Tips for Management and Bedside Procedures in Critically Ill Patients with COVID Pneumonia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Emergency Procedures, Endotracheal Intubation, Featured, Gastrointestinal diseases, Glidescope Intubation, Mechanical Ventilation, Medical General, medical procedures, Procedural Sedation, Respiratory diseases
More Tags – Arterial line insertion, asystole, cardiac arrest, Central line insertion, COVID pneumonia, CPR, featured, Glidescope intubation, HPC updates, intubation, mechanical ventilation, PEA, push dose pressors, video laryngoscopy
The SARS-COV-2 pandemic started in January 2020 and has decimated the majority of U.S. hospitals for the past 18 months. The impact of COVID-19 has not only affected available hospital beds, but has limited the ability of hospitals to perform…
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Informed Consent and Ethical Challenges During the COVID-19 Pandemic

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hospital Procedures, Medical General, medical procedures, Respiratory diseases
More Tags – COVID, CPR, featured, HPC updates, Informed consent
Informed consent can be challenging during “normal” times, but it has become increasingly complicated during the COVID-19 pandemic. The informed consent process ensures that a patient or their surrogate decision-maker understands the benefits, potential risks and any alternatives of a…
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Safety of Thoracentesis and Tube Thoracostomy in Patients with Uncorrected Coagulopathies

Tube Thoracostomy Insertion Procedure
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Chest Tube, Endotracheal Intubation, Featured, Hematology, medical procedures, Thoracentesis
More Tags – anticoagulation, antiplatelets, chest tube placement, coagulopathy, featured, HPC updates, thoracentesis, tube thoracostomy
Traditionally, it was felt that the INR had to be less than 1.5 and platelets had to be at least 50,000/µL to perform most bedside procedures. With more clinical evidence, we now know that low-risk bedside procedures can be performed…
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Pediatric Procedural Sedation is Safe for Emergency Department Procedures without Fasting

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured, Procedural Sedation
More Tags – conscious sedation, featured, HPC updates, procedural sedation, Sedation
The American College of Physicians (ACEP) has previously published guidelines in October 2013 about Procedural Sedation and Analgesia. In these guidelines, they provided Level B recommendations that state, “Do not delay procedural sedation in adults or pediatrics in the ED…
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Management of Pleural Infections

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Chest Tube, Featured, Infections, King Tube, medical procedures, Respiratory diseases, Thoracentesis
More Tags – chest tube, empyema, featured, HPC updates, parapneumonic effusion, pleural effusion, thoracentesis, tube thoracostomy
Complicated parapneumonic effusions frequently represent pleural space infections. Approximately 1 in 7 cases of pneumonia have an associated parapneumonic effusion (PPE) on chest x-ray. Most of these effusions are small and usually resolve spontaneously with prompt antibiotic administration. However, moderate-to-large…
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Summary of Difficult Airway Management in COVID-19 Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Endotracheal Intubation, Featured, Glidescope Intubation, King Tube, Laryngeal Mask Airway, Mechanical Ventilation
More Tags – awake intubation, COVID-19, difficult airway management, Difficult Intubation, endotracheal intubation, featured, HPC updates, intubation, video laryngoscopy
The Society of Airway Management recently issued guidelines for Difficult Airway Management in COVID-19 patients.  The SARS CoV-2 (COVID-19) virus is extremely contagious via respiratory droplets and therefore extra precautions are needed for airway management in severe COVID-19 infection.  Airway…
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Incidence of Spinal Hematoma from Lumbar Punctures in Patients with a Coagulopathy or Thrombocytopenia

Lumbar Puncture CME
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – coagulopathy, epidural hematoma, featured, HPC updates, lumbar puncture, thrombocytopenia
A recent cohort study using the Danish nationwide medical registry demonstrates that the incidence of a spinal or epidural hematoma from lumbar punctures in patients with pre-existing thrombocytopenia (Platelets<150 K) or coagulopathy (INR>1.4 or aPTT>39 seconds) is not significantly higher…
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Intraosseous Lines: Expanding Indications

Dr. Rick Rutherford, M.D., FAAFP
More Articles – Cardiovascular diseases, Central line, Emergency Procedures, Featured, Intraosseous line, medical procedures
More Tags – EZ-IO, featured, HPC updates, intraosseous drill, intraosseous line, io line, Vascular access
Intraosseous line use has increased significantly since the advent of the battery powered intraosseous drill.  In surveying providers at courses over the years, we have seen a steady rise in the number of providers with access to the intraosseous drill. …
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Risk of Epidural Hematoma from Lumbar Puncture in Patients with a Coagulopathy

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – coagulopathy, epidural hematoma, featured, HPC updates, lumbar puncture, thrombocytopenia
Class 1 evidence to inform decisions about the safety of lumbar punctures in patients with a coagulopathy are lacking. The only guidance we have regarding the safety of lumbar punctures is based on clinical guidance from organizations such as the…
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Management of Vasopressor Extravasation Injuries

norepinephrine extravasation
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured, Hospital Procedures, Ultrasound-Guided Peripheral IV
More Tags – antidote for norepinephrine, central lines, extravasation injuries, extravasation injury, featured, HPC updates, levophed infiltration treatment, norepinephrine, norepinephrine antidote, norepinephrine extravasation, phenylephrine, treatment of norepinephrine extravasation, Vasopressor
Peripheral vasopressor infusions are generally safe at low-moderate doses and for short durations, but you must watch the patient carefully for extravasation that can cause serious tissue injury. Traditionally, central lines were placed for administration of vasopressor infusions at any rate. We…
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In-person Procedural Education in the Era of COVID19

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Chest Tube, Emergency Procedures, Featured, Glidescope Intubation, Lumbar Puncture, Paracentesis, Thoracentesis
More Tags – chest tube placement, emergency procedures course, featured, hospital procedures course, HPC updates, intubation, lumbar puncture, medical procedures course, paracentesis, POCUS, thoracentesis, Vascular access
Medical procedural education in the era of COVID19 is still best conducted via HANDS-ON simulation-based procedural training. Procedural skills can NOT be attained via remote education, but in-person training must be conducted safely. There are many topics and skills that can be successfully be taught online,…
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Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Cardiovascular diseases, Central line, Featured, Gastrointestinal diseases, Hospital Procedures, Lumbar Puncture, medical procedures, Paracentesis, Ultrasound-Guided Peripheral IV
More Tags – Arterial line placement, central line placement, chest tubes, cirrhosis, featured, HPC updates, lumbar puncture, paracentesis, thoracentesis, tube thoracostomy
This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.  Unfortunately, there are no strong evidence-based guidelines for hospital procedures dedicated to the study of patients with decompensated cirrhosis.…
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Safety of Draining Patients Dry During Large Volume Thoracentesis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Featured, medical procedures, Respiratory diseases, Thoracentesis
More Tags – featured, HPC updates, pneumothorax, re-expansion pulmonary edema, thoracentesis
A historical myth in procedural medicine is the operator should limit removal of pleural fluid to 1.5 L during thoracentesis because of the risk of re-expansion pulmonary edema or pneumothorax.  New evidence supports safety of large volume thoracentesis until no…
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Does the Location of the Central Line Tip Make a Difference?

Ultrasound-Guided Central Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured, medical procedures
More Tags – central lines, central venous catheters, featured, HPC updates
Based on several studies, central line malposition occurs between 3.3-6.7% of the time.1  The historical recommendation is that malpositioned central lines should not be used for long periods of time, if at all.  The basis for these recommendations is based…
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Where Should I Place My Central Line?

Ultrasound-Guided Central Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured, Medical General, medical procedures
More Tags – central lines, central venous catheters, featured, femoral lines, HPC updates, IJ lines, subclavian lines
The internal jugular or subclavian veins have fewer combined mechanical or infectious complications for central venous catheter insertions compared with femoral vein CVC placements.  Numerous organizations have proposed guidelines or central line bundles that have advocated preferential use of the…
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