Latest Updates

Competency-Based Surgical Care: Bedside Procedures for General Surgeons: Part 2

Thomas H. Cogbill, MD, Basem S Marcos, MD
    • Prevention of tube thoracostomy complications during insertion relies on three maneuvers: avoiding the neurovascular bundle by entering the pleura above the rib; performing a 360° finger sweep before placing the tube into the pleural space to ensure that there are no adhesions to the lung and to confirm the position of the thoracostomy above the diaphragm; and using a controlled pleural entry.
    • Pigtail catheter thoracostomy is equivalent to larger chest tube thoracostomy for treating uncomplicated pneumothorax. Insertion-site pain is much reduced with pigtail catheters when compared with larger chest tubes.
    • Pericardiocentesis for trauma has a very limited role in nontrauma centers where definitive surgical management of cardiac tamponade is not immediately available and transport time to a facility with a higher level of care would support use of temporary pericardial decompression in this manner.
    • Temporal artery biopsy remains important to confirm the diagnosis of giant cell arteritis because the sensitivity and specificity of diagnosis based on clinical criteria alone are only 68.5% and 58%, respectively.
    • Skeletal muscle biopsy specimens should be immediately submitted to Pathology fresh and wrapped in dry gauze, and the precise muscle biopsied must be recorded as there is variability in the type of collagen present in different muscle groups that may affect interpretation.

Competency-Based Surgical Care: Bedside Procedures for General Surgeons: Part 1

Thomas H. Cogbill, MD, Basem S Marcos, MD
    • Percutaneous tracheostomy can be performed with perioperative morbidity and mortality rates equal to open tracheostomy. The risk of surgical site infection is considerably less with percutaneous tracheostomy.
    • Intraosseous access is recommended for patients in extremis for whom a peripheral venous catheter is not readily established; blood, fluids, and medications can be effectively administered via this route until reliable venous access is obtained.
    • The success rate of central venous catheterization is significantly enhanced with the use of ultrasonography, especially when accessing the internal jugular vein.
    • The fourth to fifth intercostal space, anterior axillary line, is the preferred site for needle chest decompression of tension pneumothorax. Decompression is more likely to be successful due to less chest wall thickness at this site when compared with the traditional second intercostal space, midclavicular line.

Cardiovascular: Interpretation of Noninvasive and Invasive Information

Erik P Anderson, MD, Borzoo Farhang, DO, MS, Mark P Hamlin, MD, MS, FCCM
    • Arterial line as an essential tool in determination of volume status and response to fluid therapy
    • Transesophageal Doppler technology for continuous estimation of multiple physiologic parameters to facilitate early recognition of hypovolemia and guiding intravascular volume replacement
    • The efficacy of pulse contour analysis devices based on available data
    • Thoracic electrical bioimpedance and bioreactance devices as well as partial rebreathing technique in assessment of patients in shock 

Ultrasound: Critical Care Ultrasonography

S Patrick Bender, MD, Joshua Farkas, MD, Thomas R Pace, MD
    • Focused bedside echocardiographic examination, including assessment of ventricular function, volume status, and various cardiac pathologies
    • Pulmonary ultrasonography, including pleural effusions and thoracentesis, assessment of lung parenchyma, and pneumothorax 
    • Abdominal ultrasonography, including focused assessment with sonography in trauma examination, paracentesis, and pneumoperitoneum
    • Ultrasound-guided arterial and venous line placement 

Hepatic Disorders 

Andrew Goldsmith, MD, MBA
    • Advanced liver disease results in a decrease in cardiac output secondary to a decrease in systemic vascular resistance, leading to hypervolemic hyponatremia, renal failure, edema, and ascites.
    • A diagnostic paracentesis to rule out spontaneous bacterial peritonitis should be performed in all emergency department patients who present with ascites and fever or abdominal pain.
    • Since serum ammonia levels and the severity of hepatic encephalopathy (HE) do not correlate well, patients with known or suspected HE should be treated for hyperammonia regardless of the measured level.
    • Hepatitis B virus immune globulin effectively prevents transmission if administered within 72 hours of exposure.
    • Pyrogenic liver abscesses are best treated with a combination of antibiotics and percutaneous drainage. 

Surgical Oncology: Anal Neoplasms, Presacral Tumors, and Rare Malignancies

David E. Beck, MD, FACS, FASCRS
    • Chemoradiation therapy for epidermoid carcinoma of the anal canal
    • CT or MRI for preoperative evaluation of presacral tumors
    • Distal presacral tumors (below S3) can be removed with a perineal approach, whereas proximal lesions are managed with an abdominal approach

Opioid-Sparing Analgesics in Chronic Pain Management

Michael Fitzsimons, MD, Maricela Schnur , MD, MBA, Fangfang Xing, MD

    Approach to the Patient with an Abnormal Drug Screen

    Magdalena Anitescu, MD, PhD, John Henry Harrison, MD, Jeffrey Hopcian, MD
      • Understanding the new diagnostic terminology for substance misuse conditions as defined by the newest DSM-5
      • Identifying risk factors for substance misuse disorders and subsequently understanding clinical and social factors involved in this condition
      • Understanding various laboratory techniques used in routine urine drug tests performed in clinical practice
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