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Succinylcholine in Myasthenia Gravis


45yoF with myasthenia gravis presents in respiratory distress.  She requires urgent intubation.  Which paralytic will you use?

 Myasthenia gravis is an autoimmune neuromuscular disorder in which antibodies target nicotinic acetylcholine receptors at the neuromuscular endplate, preventing excitation/depolarization and subsequent muscle contraction.

Respiratory compromise or failure may occur due to weakening of diaphragm/accessory muscles.  In the ED this will be a clinical diagnosis, however on the INSERVICE you will identify spirometry, or more specifically, the negative inspiratory force, as the “next step” in management for pts with MG.

When intubating, we know one paralytic is supposedly contraindicated, but why? And is there data to support this contraindication?

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You are working in the resus room, when a 65yoM h/o CAD, severe aortic stenosis, dilated cardiomyopathy (EF 15%), presents short of breath in extremis.

VS: 75/60, HR 119 RR 24, T98.0, Sp02 94% on NRB

He has rales to the apices of the lungs bilaterally.

Loud systolic murmur radiating to his carotids.

He is pale and diaphoretic.  Hypotensive with flash pulmonary edema, underlying poor cardiac contractility, with an obstruction to cardiac output.

You are concerned.

As you are formulating your approach to this patient, an intern urgently asks what tubes he needs to send for a paracentesis at Sinai.

Your response?

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August Q-tips

  • Patients with lower quadrant pain should typically have gonadal examinations. There are relative exceptions–such as virginal women without history of pelvic examinations or IBD patients with symptoms very typical of previous IBD flairs–but gonadal examinations should still be considered in these patients. Ideally, these examinations should take place before CT imaging.


  • Patients with previous tracheostomies are likely to be difficult intubations. Tracheostomy history may be an indication of distorted anatomy or a previously failed endotracheal intubation.  Awake intubation, preparation of a fiberoptic intubation, or preparation for repeat surgical airway should be considered ahead of time.


  • When bagging a cardiac arrest patient, use “squeeze release release release release release” to shoot for ~8 breaths per minute.


  • Use of librium in alcoholics continues to be controversial and management of these patients is plagued by significant practice variability. One approach stipulates that all alcoholics who are not discharged/allowed to walk out as soon as they are sober enough to do so (e.g. are to be seen by psychiatry) should get 50-100 mg librium and reassessed specifically for withdrawal symptoms every 2 hours; if hyper-dynamic but well should receive 100-200 mg librium. The purpose is to prevent a medicine admission for withdrawal, which serves nobody’s interests. This practice is not to be confused with discharging patients with a librium prescription, which is less likely to be effective (though there is still a role for outpatient librium in selected motivated patients).


  • Although pelvic exams are uncomfortable and usually non-contributory, it is difficult to defend not performing a pelvic exam in the relevant context; if it turns out the pelvic exam would have been contributory but it was omitted, that is an important error. The threshold to perform a pelvic exam should therefore be low.


  • Set patient expectations low with regard to wait times for tests, consultation, admission. Consider not having ENT scope patients with allergic reaction; there is much practice variation on this point.


  • Don’t forget to introduce yourself to patients.


  • Urine beta is a fallible test, repeat or send serum quantitative beta when negative result is discordant with clinical circumstance.

Spilled Teacup

A 28 yoM comes in with hand pain after falling on an outstretched hand.

His xray is as follows.

Lunate Pic


What is the diagnosis?

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Physical Exam in Septic Arthritis


40yoM no PMHX with a swollen, painful right hip joint.  Worsening x5 days. No history of prior episodes, no other joints involved, no fever, no trauma, no GU symptoms, no rash, no vision changes, no IVDU.

On exam, pt is afebrile, nontoxic appearing.

The hip is warm. You are able to range his hip, with moderate pain.  There is tenderness when compressing the joint space.  Strength exam limited by pain.

Sensation and pulses are intact distally.

Plain films are unremarkable. CT of hip unremarkable.

You consult your friendly orthopedist for further evaluation and to assist with a tap of the hip to rule out septic arthritis. The consultant comes down to examine the patient, ranges the hip (with pain), and gladly tells you, “nope, it’s not septic if it ranges”.  End of story?

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