POTD: Straight leg test. A leg up on clinical testing!

A little background:

Lumbar disc herniation is the most common cause of lumbar radiculopathy, or sciatica, a shooting or burning pain from the low back radiating down the posterior leg distal to the knee.

Two tests used to evaluate these symptoms are

The straight leg raise.

·       The straight leg raise test is highly sensitive but not very specific for disc herniation.

·       This is performed by lifting the leg affected by the radiating pain.

·       The patient lies supine with one leg either straight or flexed at the knee with the sole of the foot flat on the stretcher.

·       The examiner then raises the affected leg up, extended, to 30 to 70 degrees.

·       Reproduction of low back pain that radiates down the posterior affected leg at least past the knee is considered a positive result. Not just pain to the lower back, which is a common misconception.

·       The SLR test can also be performed with the patient in a sitting position, by stretching the sciatic nerve by extending the knee; the test is positive if pain radiates to below the knee.

The crossed straight leg raise.

·       It is highly specific (90%) for disc herniation

·       You perform the same test as the straight leg but on the unaffected leg.

·       A positive test: reproducing both the back pain + the radiation down the affected leg.

Sources: Peer IX, Tintinelli’s, Dr. Sergey Motov, Uptodate

POTD: Chest Tube/Pig Tail Drain Suturing

There are several different techniques, so I wanted to illustrate a few of them. The common theme is start from above or below the chest tube and throw your first knot to the skin:

1) Wrapping technique (this is my go-to technique)

- begin by throwing your first knot into the skin above the tube, then wrap the suture material around the base of tube (at the level of the tube insertion site)multiple times and then tie into place

- this can be repeated from below the tube for extra security

- video: https://www.youtube.com/watch?v=v2y-g0RAImw

2) The “ps and qs” technique (here called the easy L)

- essentially throw your first stitch in the skin and then perform 3 “p” stitches or 3 “q” stitches and vice versa

- finish by performing hand ties

- video: https://www.youtube.com/watch?v=Qsq1fPxYNrQ

3) The “big S” technique

- similar to a nautical knot, called the clove hitch

- essentially form an “S” shape underneath the chest tube (after you throw your first stitch)

- video: https://youtu.be/4lkyq7U6fpg

Other techniques include purse string sutures or horizontal mattress sutures.

Targeted Temperature Management

Targeted Temperature Management

What is it: the purposeful cooling of a patient post-cardiac arrest. Target of 32°C to 34°C (Some studies say 36, but debatable and prevent any hyperthermia) for at least 24 hours. 

Why: To improve the chance of survival and neurologic recovery, international guidelines recommend use of targeted temperature management (TTM), together with urgent coronary angiography and percutaneous coronary intervention when appropriate

Who: 

• Post cardiac arrest (any cause but most evidence supports from VF/VT shockable causes of cardiac arrest)

• ROSC < 30 mins from team arrival

• Time < 6 hours from ROSC

• Patient is comatose, GCS <8 (this is try and improve neurological outcome, so someone who is neurologically intact does NOT need TTM)

• MAP >= 65mmHg

• depends on your hospital protocol

When: Initiate within 6 hours of ROSC and maintain for 24 hours

How: 

• cold IVF at 2-3 mL/kg stat

• cooling vest and cooling machine

• sedation and paralysis

Complications:

Shivering, electrolyte abnormalities, cold diuresis, infection. 

So, for post cardiac arrest patients with depressed neurological function - Keep this in mind, but consult your ICUs and plan this patient's care together for best management. TTM needs an ICU level care admission. 

Happy Learning!

References:

https://jamanetwork.com/journals/jama/fullarticle/2645105

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4578199/
https://lifeinthefastlane.com/ccc/therapeutic-hypothermia-after-cardiac-arrest/

http://www.ijccm.org/article.asp?issn=0972-5229;year=2015;volume=19;issue=9;spage=537;epage=546;aulast=Saigal