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M2E Too! Mellick's Multimedia EduBlog
The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Friday, January 30, 2015

Shoulder dislocations are fairly common orthopedic emergencies presenting to the emergency department. And anterior to the glenoid fossa and labrum is far and away the most common final resting location of the humeral head. Consequently, most emergency physicians develop their own favorite technique for reducing anterior dislocations.

 

Factors such as the dislocation duration, patient comorbidities, prior dislocation events, and associated fractures or bony lesions will determine the specific technique used and whether procedural sedation is utilized. Posterior and inferior shoulder dislocations, however, are relatively rare. Moreover, the associated injuries differ (e.g., reverse Hill-Sachs lesion with posterior dislocations and neurologic dysfunction with inferior dislocations), and the technique for reduction changes. These three videos demonstrate the three different types of shoulder dislocations, their associated reduction techniques, and their unique injuries.

 

 

Click here to watch reduction of an inferior shoulder dislocation.

 

 

Click here to watch the reduction of a posterior shoulder dislocation.

 

 

Click here to watch the external rotation technique for a dislocated shoulder.

 

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Friday, January 09, 2015

EPs frequently discuss the issue of low-volume, high-acuity procedures that we must be ready to perform, and there is no higher stress or professionally memorable procedure than the open thoracotomy. This is one of the most time-sensitive procedures, and is unquestionably the most invasive procedure in emergency medicine. Hesitating for even seconds will guarantee failure or a poor patient outcome. Nevertheless, no matter how grisly and stressful this procedure may be, it has real potential for saving lives.

 

Controversies continue to surround this procedure. It is relegated to the trauma team in most Level I trauma centers. Emergency medicine residents must compete with surgery residents for opportunities to learn the procedure. Unfortunately, the physicians who will be doing the majority of these procedures in the real world (emergency physicians, not the surgeons) often don’t get first billing when it comes to training.

 

Other procedural controversies include the risk of injuries to health care providers (exposure to contaminated blood products and lacerations from broken ribs or scalpel blades) and whether to write off all blunt trauma cardiac arrest patients (even though a number of case series show a small success rate). There is also controversy about the value and associated complications of cross-clamping the aorta.

 

These videos demonstrate the real-life tension and the common opportunities for improvement associated with this procedure.

 

Click here to watch an open thoracotomy following blunt trauma.

 

Click here to watch an open thoracotomy from penetrating trauma.

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Friday, December 05, 2014

The alveolar and other oral nerve blocks are technically more difficult than most of us realize or admit. In fact, I have heard several emergency physicians admit over the years that they have given up trying to do inferior alveolar nerve blocks because of their failure rate.

 

It’s actually understandable when you peruse the literature. The reported failure rate for inferior alveolar nerve blocks can range as high as 30-45 percent of cases, depending on the study.

 

An obvious and critical first step is to make sure you have the correct techniques down. These two videos show a dental colleague performing expert step-by-step demonstrations of the inferior alveolar, lingual, and buccal nerve blocks.

 

Click here to watch a video of a patient receiving an alveolar nerve block.

 

Click here to watch a video of a patient receiving an oral nerve block.

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Thursday, October 30, 2014

The three videos presented this month demonstrate the technique for mixing and administering pulse dose epinephrine with actual patients. Particularly helpful is the one that demonstrates the administration of pulse dose epinephrine to a pediatric patient. What I really like about the demonstrated pediatric technique (first discussed in my Emergency Medicine News blog on anaphylaxis: http://bit.ly/1CHsX6h) is that it uses the same 1:100,000 concentration used for adults. And, the 0.1 mL/kg is easily remembered because it is the same mL/kg recommendation for the ACLS concentration of epinephrine. There is essentially nothing new to learn.

I first learned about the concept of pulse dose pressors, or as I call them, “push dose pressors,” from the EMCRIT blog by Scott Weingart, MD. (http://bit.ly/10mvXHc.) The value of push dose pressors for treating anaphylaxis presenting with hypotension was immediately apparent to me. It is stressful to treat hypotensive patients with anaphylaxis who are unresponsive to intramuscular epinephrine. Most of us cringe just a little at the thought of giving intravenous epinephrine outside cardiopulmonary arrest. Having a technique for giving well calibrated and exact doses of epinephrine makes the administration of intravenous epinephrine much more palatable. But if giving intravenous epinephrine to an adult is stressful, the angst associated with the pediatric patient is compounded. Viewing these videos should give peace of mind for treating adults and children with intravenous pulse doses of epinephrine.

 

Don’t cringe when you think of giving epinephrine outside of cardiac arrest. This first video shows pulse dosing during intubation.

 

 

This second video shows how to mix epinephrine for pulse dosing.

 

Pediatric pulse dosing employs the same concentration used for adults. This third video shows how to administer it to a child.

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Friday, October 10, 2014

Diseases and complications associated with intravenous drug use are many and varied. These three videos demonstrate three skin findings associated with drug addiction and IV drug use: the track marks associated with repeated intravenous injection, the piloerection that accompanies withdrawal, and the diffuse petechiae from septic emboli of life-threatening infective endocarditis.

 

Click here to see the track marks associated with repeated intravenous injection.

 

 

Click here to see the piloerection that accompanies withdrawal.

 

Click here to see the diffuse petechiae from septic emboli of life-threatening infective endocarditis.

 

 

About the Author

Larry Mellick, MD
Dr. Mellick is a professor of emergency medicine and pediatrics at Georgia Regents University in Augusta, the former chairman of emergency medicine at Georgia Regents Health System, and a professor of emergency medicine and pediatrics at Georgia Regents Medical Center and Children’s Hospital of Georgia.