Procedural Competency in Academic Emergency Medicine Attending Physicians

Joseph Esherick, M.D., FAAFP, FHM
More Articles – ACLS, advanced airway, Airway management, Central line insertion, central line placement, central lines, chest tube placement, cricothyroidotomy, difficult airway, difficult airway management, Endotracheal Intubation, Featured, HPC Updates, Intubation, Lumbar Puncture, Paracentesis, paracentesis, Procedural Sedation, Simulation Based Training, Simulation-based procedural training, Thoracentesis, Tube Thoracostomy
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A recent article summarizes a cross-sectional survey aimed at determining the processes in place to assess the procedural competency of academic emergency medicine attendings.[i] The survey was sent to the 39 ACGME-accredited Emergency Medicine programs in the U.S. and had…
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Periprocedural Bleeding Risk for Thrombocytopenia, Coagulopathy, Antiplatelets and Anticoagulation

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Anticoagulation, antiplatelets, central lines, Chest tube, chest tubes, coagulopathy, Featured Procedure, HPC Updates, Lumbar Puncture, Paracentesis, procedures, Thoracentesis
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This blog summarizes the 2019 Society of Interventional Radiology (SIR) for Periprocedural Management of Image-guided Procedures with regards to thrombocytopenia, coagulopathies, antiplatelets and anticoagulation.  The SIR guidelines are summarized as follows: Anticoagulation with heparin, LMWH, fondaparinux, argatroban, warfarin, DOAC, clopidogrel, ticagrelor…
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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 – coagulopathy, epidural hematoma, Featured, HPC Updates, Lumbar Puncture, thrombocytopenia
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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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Risk of Epidural Hematoma from Lumbar Puncture in Patients with a Coagulopathy

Joseph Esherick, M.D., FAAFP, FHM
More Articles – coagulopathy, epidural hematoma, Featured, HPC Updates, Lumbar Puncture, thrombocytopenia
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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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Atraumatic Spinal Needles Significantly Decrease the Risk of Post-Dural Puncture Headaches or Spinal Headaches

Joseph Esherick, M.D., FAAFP, FHM
More Articles – ATN, Atraumatic spinal needles, Featured Procedure, HPC Updates, Lumbar Puncture, PDPH, Post-dural puncture headache, TN, Traumatic needles
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According to recent studies, atraumatic needles (ATN) reduce the rate of post-dural puncture headache (PDPH) when compared to traumatic needles (TN – or bevel-tip needles such as Quincke needles) (27% vs 60%).  Also, the mean duration of PDPH from ATN…
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In-person Procedural Education in the Era of COVID19

Joseph Esherick, M.D., FAAFP, FHM
More Articles – chest tube placement, emergency procedures course, Featured, hospital procedures course, HPC Updates, Intubation, Lumbar Puncture, medical procedures course, paracentesis, POCUS, Thoracentesis, Vascular access
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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 placement, central line placement, chest tubes, Cirrhosis, Featured, HPC Updates, Lumbar Puncture, Paracentesis, Thoracentesis, Tube Thoracostomy
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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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Bedside Ultrasound Increases the Success Rate for Difficult Lumbar Punctures

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, HPC Updates, Lumbar Puncture, PROCEDURE OF THE WEEK, Ultrasound-Guided Lumbar Punctures, ultrasound-guided procedures
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The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891[1]This technique utilizes the iliac crest and the posterior lumbar spinous processes to determine the optimal sites for spinal needle introduction in either the L3-4 or…
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Guidelines for Antiplatelet and Anticoagulation Discontinuation before a Lumbar Puncture

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Anticoagulation, antiplatelets, epidural hematoma, Featured, HPC update, HPC Updates, Lumbar Puncture
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This blog summarizes the guidelines by the European Society of Anesthesiology (ESA), the American Society of Regional Anesthesia (ASRA) and the Association of British Neurologists regarding the timing of antiplatelet and anticoagulation discontinuation before a lumbar puncture.  The following table…
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Performing Procedures on Patients Who Take Dabigatran, Rivaroxaban, and Apixaban

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Anticoagulants and Procedures, Featured Procedure, HPC Updates, Lumbar Puncture
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Over the past several years, there has been a dramatic increase in the use of the new oral anticoagulants (Dabigatran, Rivaroxaban, and Apixaban).  The popularity of these medications stems not only from aggressive pharmaceutical monitoring to physicians and to the…
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Safety of Lumbar Puncture in Adults and Children with Thrombocytopenia

Joseph Esherick, M.D., FAAFP, FHM
More Articles – epidural hematoma, Featured, HPC Updates, Lumbar Puncture, thrombocytopenia
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Traditionally, it has been promulgated by anesthesiologists that you need a platelet count of 100,000 to safely perform neuraxial regional anesthesia (spinal and epidural anesthesia).  This practice pattern has continued even though Children’s Hospitals routinely perform intrathecal injections for prophylactic chemotherapy with…
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Risks for Post-Dural Puncture Headaches after Lumbar Puncture

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, Headache, HPC Updates, Lumbar Puncture, Post-dural puncture headache, spinal headache
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Diagnostic lumbar punctures aid in the diagnosis of infections and diseases of the central nervous system. Life-threatening events from lumbar punctures are rare, but post–lumbar (dural) puncture headaches (PDPH) occur in 1% to 36% of patients, depending on the needle…
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Ultrasound-Guided Lumbar Puncture More Successful than Traditional LP in Infants

Joseph Esherick, M.D., FAAFP, FHM
More Articles – HPC Updates, Infants, Lumbar Puncture, Ultrasound, Ultrasound-guided lumbar puncture
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Lumbar puncture (LP), commonly performed in infants to rule out meningitis, is often not successful in the hands of inexperienced operators. Investigators conducted a study of 128 infants younger than 6 months. They compared traditional LP to LP preceded by…
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Correction for CSF protein in traumatic lumbar punctures

Joseph Esherick, M.D., FAAFP, FHM
More Articles – HPC Updates, Lumbar Puncture, meningitis
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Traumatic lumbar puncture (LP) is fairly common and occurs when the needle causes bleeding into the subarachnoid space. Introduction of peripheral red blood cells (RBCs) in cerebrospinal fluid (CSF) increases CSF protein levels, thereby complicating diagnosis of bacterial meningitis. This…
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Differences Between Lumbar Punctures in Children Vs Lumbar Punctures in Adults

Joseph Esherick, M.D., FAAFP, FHM
More Articles – CSF Lactate Level, HPC Updates, Lumbar Puncture, Pediatric Lumbar Puncture
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Pediatric lumbar punctures can have much higher success rates when proper positioning and technique are emphasized. The position should be the lateral decubitus position with hips flexed, but the neck does not need to be flexed. The spinal cord ends…
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