Ultrasound-guided Central Venous Access: Are Landmarks a Thing of the Past?

Dr. Rick Rutherford, M.D., FAAFP
More Articles – Central line, Emergency Procedures, Featured Procedure, medical procedures
More Tags – central line, central venous catheter, featured procedure, HPC updates, ultrasound, ultrasound-guided procedures
Point-of-care ultrasound is one of the most rapidly evolving areas of medicine.  In addition to becoming the “stethoscope of the future” for bedside diagnostic evaluations, ultrasound has improved the safety and efficiency of a wide range of procedures.  The use…
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Emergency Department Intubations Are Increasingly Successful

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured Procedure, Gastrointestinal diseases, Glidescope Intubation, medical procedures, Respiratory diseases
More Tags – endotracheal intubation, Glidescope intubation, HPC updates, intubation, video laryngoscopy
Emergency department (ED) intubation is constantly evolving, with new devices, techniques, and medications being frequently adopted. To evaluate temporal trends, National Emergency Airway Registry (NEAR) investigators analyzed registry data on ED intubations at 13 large hospitals in the U.S., Canada,…
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Does chest tube location or size matter for tube thoracostomy in trauma patients?

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, Featured Procedure, medical procedures
More Tags – chest tube, chest tube position, chest tube size, HPC updates, tube thoracostomy
Traditional teaching is that chest tubes placed to evacuate a pneumothorax should be directed anterior and superior and to evacuate fluid should be directed posterior and inferior. A recent study examined the effect of specific chest tube position on chest…
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Ultrasound-guided Tube Thoracostomy Improves Optimal Insertion Site Selection

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Chest Tube, Emergency Procedures, Featured, medical procedures
More Tags – chest tube, featured, HPC updates, tube thoracostomy, ultrasound
The optimal insertion site for tube thoracostomy is at the mid-axillary line in the triangle of safety.  This avoids any major nerves or arteries aside from the intercostal vessels.  Ultrasound-guided localization of this site performed better than palpation. In semi-elective…
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Predictors of and Pearls for Difficult Airway Management

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, Featured, King Tube, Laryngeal Mask Airway, Mechanical Ventilation, Medical General, medical procedures, Respiratory diseases
More Tags – cricothyroidotomy, difficult airway management, endotracheal intubation, featured, HPC updates, intubation, King tube, laryngeal mask airway, supraglottic airway, surgical airway
Patients may have anatomically difficult airways or physiologically difficult airways.  Both anatomical and physiological factors can lead to peri-intubation complications.  My goal for this blog is to describe the factors that may contribute to an anatomically difficult airway and clinical…
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Bleeding Risk of Central Line Insertion in Coagulopathic Patients

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured, Hematology, medical procedures
More Tags – central lines, featured, HPC updates, thrombocytopenia
The evidence base for the safety of ultrasound-guided central line placement with thrombocytopenia or in patients with a bleeding diathesis is not robust.  Nevertheless, based on the data available most procedural experts feels that an ultrasound-guided central venous catheter insertion…
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Performing Procedures on Patients Who Take Dabigatran, Rivaroxaban, and Apixaban

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured Procedure, Hematology, Lumbar Puncture, medical procedures
More Tags – anticoagulation, bedside procedures, HPC updates, invasive procedures, Oral anticoagulants
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 – Featured, Hematology, Lumbar Puncture, medical procedures
More Tags – HPC updates, lumbar puncture, procedure, thrombocytopenia
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, Lumbar Puncture, Medical General, medical procedures, Paracentesis, Traumatology
More Tags – Headache, HPC updates, lumbar puncture, post-dural puncture headache, spinal headache
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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A Simple Checklist for Central Lines Saves Lives and Money

Ultrasound-Guided Internal Jugular Line Placement
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Central line, Featured Procedure, medical procedures, Ultrasound-Guided Peripheral IV
More Tags – central line, checklists, HPC updates
Safety checklists have been adopted by numerous industries to prevent errors and save lives.  Checklists have been used for decades by industries as diverse as the aviation industry, construction companies, and professional chefs to prevent mistakes.  In medicine, checklists have…
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Safety of Thoracentesis with Coagulopathy or Thrombocytopenia

Thoracentesis Course
Joseph Esherick, M.D., FAAFP, FHM
More Articles – Cardiovascular diseases, Featured Procedure, Hematology, medical procedures, Thoracentesis
More Tags – coagulopathy, featured, featured procedure, HPC updates, thoracentesis, thrombocytopenia
Historically, it was felt that a platelet count below 50,000 or an INR>1.5 was a contraindication to thoracentesis because of an increased bleeding risk.  These were arbitrary cut-offs that have since been challenged with newer kits and the use of…
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Remember the Laryngeal Mask Airway When You Can’t Intubate!

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Endotracheal Intubation, Featured Procedure, Glidescope Intubation, King Tube, Laryngeal Mask Airway, Mechanical Ventilation, medical procedures, Respiratory diseases
More Tags – featured procedure, HPC updates, intermediate airways, laryngeal mask airway
Remember the Laryngeal Mask Airway When You Can’t Intubate! As a hospitalist who also works in the ICU, I am often the first responder to respiratory emergencies.  Frequently under these circumstances, you have a chaotic environment and a less than…
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2018 Guidelines for Acute Ischemic Stroke Provides New Recommendations

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Emergency Procedures, Featured, Medical General, medical procedures
More Tags – featured, HPC updates, stroke
The 2018 AHA/ASA guidelines for the early management of acute ischemic stroke provides some important new evidence-based recommendations.  Some important new recommendations described in these guidelines include: The DAWN and DEFUSE 3 trials selected patients for mechanical thrombectomy within an extended time…
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Rapid Ultrasonography in Shock: A Lifesaving ED Tool

Joseph Esherick, M.D., FAAFP, FHM
More Articles – Events, Featured Procedure, medical procedures
More Tags – featured procedure, HPC updates, RUSH Exams
Rapid Ultrasonography in Shock:  Is this really useful? Caring for patients with undifferentiated hypotension, causes anxiety for most health care providers.  This is natural.  Fear, however, must not lead to hesitation or poor decision-making.  Therapies chosen early in shock disproportionately…
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