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Bleeding AV Access

Bleeding AV Access

Background

  • Most often occurs at dialysis center after fistula site is accessed
  • Presents as punctate bleed overlying fistula. Can be slow oozing bleed from uremia or high-pressure bleed similar to arterial bleed
    • Slow oozing bleed is less common in ED as hemostasis is often achieved at dialysis center
  • Ask the patient what type of AV access they have just in case you’re required to suture into the site
    • AV Fistula:  direct connection between the patient’s artery and nearby vein. Because it is the patient’s own tissue, it is less prone to clotting or infection. It takes 2-3 months for a fistula to mature. If it fails to mature, the procedure may be repeated
      • AV fistula.jpg
    • AV Graft:  indirect connection between artery and vein. Most commonly via a plastic tube, but also can be donated cadaver arteries or veins
      • AV Graft

How to Fix Most bleeds

  • First thing’s first, these patients are typically presenting from their dialysis clinic, therefore, someone already has held pressure and wrapped the site. If there is oozing or bleeding from around the dressing, then need to unwrap the site to visualize where the bleed is occurring from (recommend face shield, surgical gown)–nothing worse than starting your shift with an exposure visit
    • Bulky dressings allow for continued bleeding. Need to unwrap to see what you’re dealing with
  • Bleeding will often be from a small punctate site, therefore, once site of bleeding is visualized, then can apply firm pressure directly to this area to stop bleeding
    • This is a high pressure bleed so often will have to hold direct pressure for 10-20 minutes.
    • Taping gauze or wrapping in ACE bandage will often not be enough pressure to stop bleed, and will often prolong time to final hemostasis
  • Prior to holding pressure above, can spray topical TXA over bleeding site and place gelfoam (or surgicel) overlying punctate bleeding area
    • Gelfoam is a water-insoluble sponge prepared from purified porcine skin, gelatin granules, and water, which when applied to bleeding site acts as a mechanical matrix facilitating clot formation

PECARN Head CT and Pericarditis vs. STEMI… in a Rush

5-Minute Journal Article (PECARN Head CT Rule)

Dr. Brian Yu did a great 5-minute summary on the PECARN head CT Rule that was published in 2009. It’s an ambitious study that involved 25 emergency departments and included 42,412 patients under the age of 18 years who presented with blunt head trauma. It further risk stratified these patients into 2 major cohorts of <2 years of age and 2-18 years of age. It excluded patients with trivial injury, penetrating trauma, neurologic history, and those with prior imaging. The outcomes this study aimed for were clinically important findings including death, need for neurosurgical intervention, intubation >24 hours, and admission >2 nights. 

Bioterrorism… in a Rush

Dr. Somy Thottathil did an awesome lecture on bioterrorism this past week. And although it is hopefully something we never have to see, as one of the major hospitals designated as a bioterrorism site in Chicago, it is something that we should be prepared to recognize and treat. It’s also good review for all the med school knowledge we haven’t needed (thankfully) for some time now. The main topics we’ll focus on are the Category A agents:  Botulism, Plague, Anthrax, Smallpox, and Viral Hemorrhagic Fevers (which includes Ebola, Marburg, Lassa Fever, and Crimean-Congo Hemorrhagic Fever). We are only going to discuss Ebola as current outbreaks are still occurring.

Preeclampsia… In a Rush

You stroll into work, coffee in hand, and you’re feeling great today. Your first patient is being escorted to her room. She’s young, maybe in her early 30s, walking without difficulty, chatting with the person showing her the room. You think to yourself, why is she here? You sign into the computer and you see the chief complaint: elevated blood pressure. But she’s so young you say to yourself. You wait for the nurse to load the blood pressure in the computer and take a sip of your coffee. It loads: 162/98.  You ask if the patient has any other symptoms. The nurse says no and lets you know that the patient has no past medical history. You smile to yourself thinking easy discharge! You take another sip of coffee (well deserved).

Thyroid Emergencies… in a RUSH

Thyroid emergencies are an interesting class of disorders. They’re rare, but are an acute, life-threatening group of syndromes. This is in contrast to the vast majority of thyroid cases that often present with minor symptoms (or found on routine labs), only requiring outpatient treatment and medications. Thyroid emergencies are the extreme versions of these thyroid disorders.  They fall into two categories:  “too low” of thyroid hormone (myxedema coma) and “too high” of thyroid hormone (thyroid storm). The post starts with some background anatomy and physiology, and then dives into each disorder separately. Also briefly discusses Levothyroxine overdose.