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The last two weeks, Dr. Cash taught us about bradycardia and transcutaneous pacing. This week, we dug back years into the archives and pulled out Dr. Pelletier-Bui’s famous post on transvenous pacing.
A timeless classic! Just be sure to know what supplies are available in your department, where to find them, and alternate options if your supplies differ.
References:
Bessman, E. (2019). Emergency cardiac pacing. In Roberts et al (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (pp. 288-308). Elsevier, Inc.
Bohanske. (2013, November 4). Transvenous pacemaker placement – Part I: The walkthrough. Taming the Sru. https://www.tamingthesru.com/blog/procedural-education/transvenous-pacemaker-placement-part-1-the-walkthrough
Mason, J. [EM:RAP Productions] (2018, October 11). Placing a transvenous pacemaker [Video]. YouTube. https://www.youtube.com/watch?time_continue=24&v=00-T8PcbStE&feature=emb_title
Additional Considerations
· Any patients with concerns of airway burns should be considered for intubation.
· Calculate total surface area burned.
Rules of Nine or Lund-Browder
· After initial fluid resuscitation, use Parkland formula to calculate fluid resuscitation over first 24 hours.
· Provide appropriate analgesia.
· Address tetanus vaccination.
· Wound care is highly dependent on local burn center protocols and guidelines.
Revamped from our archives, the fabulous Dr. Alexis Pelletier-Bui teaches us how to use a slit lamp! This comprehensive post reviews all the knobs and buttons of the equipment, then shows how to use it to perform the exam.
COMPONENTS OF THE SLIT LAMP
(These photos are based on a Weiss SL 120 Slit Lamp – other models might be slightly different but the ideas are the same!)
THE VIEWING ARM:
Think of this part as a microscope.
#1 – Oculars – Adjust for your personal interpupillary distance
#2 – Magnification Dial – Can set to 5x, 8x, 12x, 20x, or 32x
#3 – Focusing Ring – Accounts for your personal refractive error. If you have 20/20 vision or correction lenses, it should be set to 0.
THE ILLUMINATION ARM:
This part is your light source. It can be swung 180 degrees side to side to allow for examination from the temporal or nasal side.
#4 – Beam height – Move to the right of examiner > shorter.
#5 – Beam widgth – Move to the right of the examiner > smaller
#6 – Color of light – 3 options: White (used for most of the exam), Cobalt blue (used with fluorescein exam), Green (aka red free filter; allows blood vessels to appear black; rarely used by ED doc)
THE PATIENT POSITIONING FRAME:
#8 – Forehead Strap
#9 – Chin Rest
#10 – Height Adjustor – twist this to raise or lower the chin rest
THE BASE:
#11 – Joystick – Allows movement of the viewing & illumination arms in tandem. Large movements forward & backward are often required to obtain initial focus which will require pressure on the joystick to move the entire base. Smaller microadjustments can be made with smaller movements of the joystick (without moving the base). Movement side to side and up & down (the latter performed by twisting the joy stick) allow for you to examine different aspects of the eye (temporal to nasal, upper to lower lid, etc).
#12 – Light Brightness Knob – Most models have this component on the illumination arm but the Weiss SL 120 has this on the base. Turn right > brighter
#13 – Locking Knob – May need to unlock to move the base. Put the lock on if you are moving the whole slit lamp (i.e. in and out of the patient’s room)
PREPARING/POSITIONING
#14 – Table Height Adjustor – To increase patient comfort (and therefore compliance), lower or elevate the table as needed. You may need to adjust your own chair height accordingly so try to use a stool.
#15 – Power Button – Make sure you’re plugged in!
PERFORMING A SLIT LAMP EXAM:
Step 1: Positioning your patient
Step 2: Position yourself
Step 3: Performing Diffuse Illumination
Step 4: Perform Direct Focal Illumination
Photo source: Vislisel, J & Critser, B. Normal cornea. https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Normal-Cornea/index.htm. Published June 2, 2015. Accessed July 3, 2020.
Photo source: Root, T. “Cell and flare” in the eye (video). https://timroot.com/cell-and-flare-in-the-eye-video/. Accessed July 3, 2020.