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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Alternative Tests to Differentiate Pleural Effusion Exudates from Transudates

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, Mechanical Ventilation, medical procedures, Thoracentesis
More Tags – featured procedure, HPC updates, Pleural cholesterol, pleural effusion, pleural exudate, pleural transudate
How to Differentiate Pleural Effusion Exudates from Transudates   Historically, Light’s criteria have been used to classify pleural effusions into transudates or exudates.  Light’s criteria were established by Dr. Richard Light in 1972.[1]  These criteria maximize sensitivity but have a…
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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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In plane ultrasound-guided central line placement is preferred over out-of-plane technique

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Arterial line, Central line, medical procedures
More Tags – central line, HPC updates, internal jugular line, subclavian line, ultrasound-guided procedures
A study from an urban EM residency program determined that in-plane ultrasound-guided central venous catheterization is superior to out-of-plane ultrasound-guided central line placement. This study was only a single center study that was a randomized crossover study of ER residents…
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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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In plane ultrasound-guided central line placement is preferred over out-of-plane technique

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured Procedure, medical procedures
More Tags – central line, featured procedure, HPC updates, internal jugular line, subclavian line, ultrasound-guided procedures
A study from an urban EM residency program determined that in-plane ultrasound-guided central venous catheterization is superior to out-of-plane ultrasound-guided central line placement. This study was only a single center study that was a randomized crossover study of ER residents…
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Which cirrhotic patients are at high risk for bleeding during hospital procedures?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Central line, Featured Procedure, Hospital Procedures, Lumbar Puncture, medical procedures, Paracentesis, Thoracentesis
More Tags – Bleed risk, central line, HPC updates, paracentesis, Procedures in Cirrhotic Patients, thoracentesis
How do we assess a cirrhotic patients bleed risk prior to a planned bedside procedure?  Can our standard platelet count and coagulation studies, prothrombin time (PT/INR) and partial thromboplastin time (aPTT), accurately predict bleed risk in cirrhotic patients?  The quick…
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Review of the Management of Hepatic Hydrothorax

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured, Gastrointestinal diseases, medical procedures, Thoracentesis
More Tags – ascites, cirrhosis, featured, hepatic hydrothorax, HPC updates, pleural effusion, thoracentesis
This blog summarizes a recent update reviewing current management recommendations for hepatic hydrothorax (HH).  Hepatic hydrothorax is a complication of decompensated cirrhosis with portal hypertension.  Sixty percent of patients accumulate both ascitic fluid and pleural fluid as a result of portal…
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Transfuse Plasma, Platelets and Red Blood Cells in a 1:1:1 Ratio in Severely Injured Trauma Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, medical procedures, Traumatology
More Tags – HPC updates, massive transfusion protocol, transfusions, trauma
In recent years, the dogma regarding large-volume crystalloid resuscitation in trauma patients has changed, with increased emphasis on including plasma and platelets in addition to red blood cells in the immediate resuscitation protocol. The long-awaited PROPPR trial compared the safety and…
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Video Laryngoscopy after Failed Intubation Attempt in the ER

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured Procedure, Glidescope Intubation, medical procedures, Respiratory diseases
More Tags – direct laryngoscopy, featured procedure, HPC updates, intubation, video laryngoscopy
Video Laryngoscopy Is Superior to Direct Laryngoscopy for Failed Intubation Attempts in the ER Although video laryngoscopy has repeatedly been shown to be superior to direct laryngoscopy, there has not yet been any specific directive instructing emergency department (ED) intubators…
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Summary of New Difficult Airway Society Awake Intubation Guidelines

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, Featured, Glidescope Intubation, King Tube, Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – awake intubation, difficult airway management, featured, HPC updates, intubation, video laryngoscopy
The Difficult Airway Society (DAS) has recently published new guidelines for awake tracheal intubation (ATI) in adults.  When performed correctly, ATI has a favorable safety profile for patients with an anticipated difficult airway.  The guidelines cover the indications for ATI,…
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Summary of AASLD Practice Guidelines on Cirrhotic Ascites – Paracentesis Indicated for all Hospitalized Patients

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured Procedure, Infections, Medical General, medical procedures, Paracentesis
More Tags – Cirrhotic ascites, featured procedure, Guidlelines, HPC updates, paracentesis, SBP, spontaneous bacterial peritonitis
According to AASLD Practice Guidelines, all patients with cirrhotic ascites admitted to the hospital should have a diagnostic paracentesis to rule out spontaneous bacterial peritonitis (SBP). Treatment of SBP requires cefotaxime plus albumin 1.5 gm/kg on the first day and…
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Summary of EASL Guidelines on Ascites, SBP and HRS Management in Cirrhosis

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Featured, Gastrointestinal diseases, Infections, medical procedures, Paracentesis
More Tags – ascites, featured, HPC updates, paracentesis, spontaneous bacterial peritonitis
This blog summarizes the recent European Association for the Study of the Liver (EASL) guidelines on the management of ascites, spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS) in patients with cirrhosis. Cirrhotic ascites occurs as a consequence of portal…
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Bedside Ultrasound Increases the Success Rate for Difficult Lumbar Punctures

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured Procedure, Lumbar Puncture, medical procedures
More Tags – featured procedure, HPC updates, lumbar puncture, Ultrasound-Guided Lumbar Punctures, ultrasound-guided procedures
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 – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – anticoagulation, antiplatelets, epidural hematoma, featured, HPC updates, lumbar puncture
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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