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Predicting and Dealing with Difficult Peripheral Iv Access.

Nurse: Doctor, this patient is a tough stick. I tried 3 times and I got nothing. Can you help?

Doctor: Sure! I’ll grab the linear ultrasound vessel finder and get that line in for you, thereby potentially saving this non-critically ill patient from an unnecessary central venous catheter (free pearl #1).

Nurse: Ok! Do you need the special longer IV angiocatheters?

Doctor: Why yes, I do. Because I always use the special longer IV angiocaths, as they have a much better chance of not coming out later (free pearl #2).


Then you realize: It has been a little while since you last did an ultrasound guided IV.  So, you check out ultrasoundpodcast.com and watch these brief FOAM videos.




Now that you’re up to speed,

1. Name a few predictors of difficult peripheral IV access.


2. When deciding on a vein to use, which features are preferable?

a) Proximal

b) Distal

c) Shallow

d) Deep

e) combo of option a + option c

f) combo of option b + option c

g) combo of option a + option d

h) combo of option b + option d


3. What is the likelihood that an ultrasound-guided IV will survive even a few hours if the vein is >1.2cm deep?

a) 29%

b) 50%

c) 74%

d) 88%

Continue reading “Predicting and Dealing with Difficult Peripheral Iv Access.” »

Wet Read on Lateral Knee Film

Your 14 year old male patient fails the Ottawa Knee or Pittburgh Knee clinical decision tool after gettting whacked in the knee with some object of some kind or another.

He’s tender near the tibial tuberosity and he refuses to extend his leg.

You can’t tell whether this is pain limited or whether something else is going on.

Your AP knee xray shows this. The radiologist is busy interpreting a lot of CT heads that you ordered earlier. Now you must read your own film because ortho might need to be consulted. So…you do a “wet read.”

Knee Ap


You have no clue how to read this so you check out this link on How to Read a Knee Xray (peds specific)  so that you have a framework for your wet read.

Hmmm. Looks like no fractures, good femur-tibial alignment, and no significant effusions. Not too helpful so far. What about the lateral view?

Is the lateral view useful at all? Yes! One use: patellar tendon rupture.

Continue reading “Wet Read on Lateral Knee Film” »

Stroke Alert! Wait, What Does Acep Want Me to Do?

A 75-year old man comes to your Emergency Department with an acute onset of left sided weakness and a facial droop.

His NIH Stroke scale is 15.

A stroke alert is called and the stroke fellow and her team race-walks to the Emergency Department. A vigorous discussion of whether to give tPA (alteplase) as a treatment for acute ischemic stroke.

It is high noon.

1. If onset was clearly witnessed at 10am, what does ACEP’s previous (rescinded) 2012 clinical policy state should occur? And if enacted, what would the new proposed 2014 ACEP clinical policy state should occur?

2. What if onset had instead been 8am? What does ACEP’s previous (rescinded) 2012 clinical policy state should occur? And if enacted, what would the new proposed 2014 ACEP clinical policy state should occur?

Continue reading “Stroke Alert! Wait, What Does Acep Want Me to Do?” »

He Keeps Repeating Himself, Himself, Himself….

A 60 year-old male patient with a history of hypertension is BIBEMS with his spouse two hours of sudden onset memory loss. She noticed he began asking her if she wanted coffee every 3 or 4 minutes, apparently not remembering he had already asked.  He knows his name, where he is, and the date. He correctly states the name of the President of the United States. He is calm but keeps repeating himself every few minutes. His vitals are normal, and his neurologic exam is normal.

1.What is the diagnosis?

2. If imaging were to be acquired, what would be the most likely finding on a non-contrast CT?

3. What is the treatment?

4. What is the prognosis of patients with this condition?

Continue reading “He Keeps Repeating Himself, Himself, Himself….” »

Femoral Nerve Blocks for Hip Fractures

by @benazan

Fall Turtle Caption

I have been surprised by the lack of pain in some patient with hip fracture. Most I have seen seem to be fine as long as the remain perfectly still. However, how often does that happen? After x-rays, multiple attending and resident exams patient will hate you if their pain is not well controlled.

The femoral nerve block has been around for a long time and several studies have shown it to be effective and safe in the emergency department (1, 2, 3, 4). Patients who receive femoral nerve blocks achieve pain control faster, have lower pain scores and require less opoids.

The best part is, if you’ve ever done an ultrasound guided femoral central line, you already know most of the steps. There are several good resources with in depth guides, so we’ll just go over the highlights.

  • Remember the anatomy goes NAVEL (in the direction of the navel), so that’s from Lateral to Medial: Nerve, Artery, Vein, Empty Space, Lymphatics
  • Drugs: Lidocaine or bupivacaine. Lido starts working faster. Bupivicaine lasts longer. You can use both mixed together, for faster onset but decrease duration than bupivicaine alone (5). Remember to remain within allowed max per kg doses.
  • Clean with antiseptic and use sterile technique.
  • It’s 2015, use ultrasound. Guide your needle down, using a lateral approach, into the femoral nerve compartment. It is located superior-medial to the iliac muscle and lateral to the femoral artery. It is a relatively hyperechoic structure. Make sure the needle tip is below the Fascia Iliaca (fascia just above the nerve) otherwise the anesthetic will not reach the nerve.

Screen Shot 2015-01-08 at 8.52.41 Pm(Figure 1, ref)

  • Aspirate to ensure you are not a vascular structure. If no blood returns, you can inject a 1cc test dose, which will be visible on ultrasound as a hypo-echoic circle in the nerve bundle. Once you are comfortable you are in the nerve compartment, go ahead an inject the rest of the anesthetic.

Screen Shot 2015-01-08 at 8.42.58 Pm(Figure 2  ref)  

Here’s a 5 minute video review.


  1. Beaudoin, F. L., Haran, J. P., & Liebmann, O. (2013). A Comparison of Ultrasound‐guided Three‐in‐one Femoral Nerve Block Versus Parenteral Opioids Alone for Analgesia in Emergency Department Patients With Hip Fractures: A Randomized Controlled Trial. Academic Emergency Medicine,20(6), 584-591.
  2. Beaudoin, F. L., Nagdev, A., Merchant, R. C., & Becker, B. M. (2010). Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures.The American journal of emergency medicine28(1), 76-81.
  3. Fletcher, A. K., Rigby, A. S., & Heyes, F. L. (2003). Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Annals of emergency medicine41(2), 227-233.
  4. Hurley, K. (2004). Do femoral nerve blocks improve acute pain control in adults with isolated hip fractures?. CJEM6(6), 441.
  5. Cuvillon, P., Nouvellon, E., Ripart, J., Boyer, J. C., Dehour, L., Mahamat, A., … & de La Coussaye, J. E. (2009). A comparison of the pharmacodynamics and pharmacokinetics of bupivacaine, ropivacaine (with epinephrine) and their equal volume mixtures with lidocaine used for femoral and sciatic nerve blocks: a double-blind randomized study. Anesthesia & Analgesia108(2), 641-649.

Carl “Scooter” Mickman