Real time, high sensitivity serum biomarkers have played an enormous part in the timely identification and intervention on of cardiac pathology in the Emergency Department. These biomarkers have sufficient sensitivity to identify cardiomyocyte injury even in the absence of physical exam, radiographic, or electrocardiographic findings. Unfortunately, the utility of these studies may be limited or obfuscated in certain clinical contexts. This article will discuss the possible pitfalls and obstacles physicians may encounter in interpreting cardiac biomarkersRead More
Ever have a patient present with foot or ankle pain? In case you have, here is a refresher on the radiographic anatomy of the foot as well as the test characteristics and viability of the use of the Ottawa Rules in the ED setting by Dr. Golden.Read More
Paracentesis and thoracentesis are relatively common procedures in the Emergency Department but the analysis of the fluid can always but a touch confusing. In this post, PGY-1 Dr. Michael Klaszky walks us through the analysis of pleural fluid and ascitic fluid.Read More
Have you ever wondered what is actually being measured when you order a renal panel/BMP/serum electrolytes? Well grab your nearest pumpkin spice latte and put your Gilmore Girls Netflix binge on pause because we are about to get a little basic . . . science!Read More
Viral hepatitis is a commonly encountered and increasing problem thanks in part to the rise in injection drug use. Here I review the screening recommendations and interpretation of hepatitis B and C serology. Screening recommendations are based on CDC and US Preventative Task Force guidelines. Prevalence of viral hepatitis is much higher in the ED setting and may warrant expanded screening. This is an active area of research and there are as of yet no formal professional recommendations regarding expanded screening. In this post we will explore the current screening recommendations for HBV and HCV and detail the interpretation of the test findings.Read More
All bleeding stops eventually... Even in your anticoagulated patients? What about that INR of 1.4? On rivaroxaban? To better know the state of anticoagulation we first must understand the tests we use to define them. Take a dive with Dr. Murphy-Crews through our anticoagulation studiesRead More
Not all swollen joints are the same and our dogmatic definitions of septic joints are changing with each new study, so how do we use synovial fluid to define our differential of the swollen joint? Join Dr. Harty in delving through the latest in synovial fluid studies in his asynchronous intern diagnostics post on joint fluid analysis.Read More
Working in the ED one day you seem to hit a run of patients in whom consultants have asked you to order an ESR, CRP. First, podiatry asked for them for a patient with 1st metatarsal osteomyelitis. Spine surgery wanted the same for a patient with diskitis. And, ortho wanted them for a possible septic. You think to yourself, “what am I or my consultant going to do with these test results?” “What are these inflammatory markers anyhow?” And, “what patient’s should I be ordering them in.”Read More
Hand and wrist radiographs are some of the most common and most challenging x-rays to read. Take 10 minutes to watch a video and freshen up on both the anatomy and technical factors associated with wrist radiographs.Read More
Early in the morning, you begin your day in your local emergency department. After getting yourself situated, a slow trickle of patients begin to appear on the board. It appears to be a normal morning, all except for the fact that five patients appear, one after the other, who have the same chief complaint: “Knee pain”. It is a good thing you brushed up on reading knee x-rays recently!Read More
A 45 yo Female presents to the ED with sudden onset of chest pain, described as worse when taking a deep breath. She is significantly short of breath and appears distressed. She recently underwent a total right knee arthroplasty and reports having been bedridden secondary to pain. Physical exam is remarkable for a right lower extremity with surgical incisions that clean, dry, intact; however, her left lower extremity is swollen with significant tenderness along the popliteal fossa and calf.
Vitals: Temp 99.2HR 120RR: 28 BP: 130/80 SpO2 90% on RA.
A CTPA is ordered...Read More
Your patient is a well appearing, otherwise healthy 22 year old female who presents with lower abdominal pain x3 days. She is unsure of her LMP, but thinks she had some spotting about a month ago. Vital signs: Temp 99.3F, HR 92, BP 102/70, RR 20, 98% on RA. She has a benign, non-gravid abdomen. Urine pregnancy is positive. You fire off a quantitative hCG and don’t expect that result to come back for a while. What do you do next?Read More
Elbow injuries account for 2-3% of all emergency department visits across the nation (1). Yet, because of the elbow’s complex anatomy and the presence of numerous ossification centers in children, elbow fractures are the third most commonly missed fracture group in the ED (1). Here are some tools to help ED physicians read elbow x-rays more effectively and hopefully identify abnormalities more easily...Read More
Both the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.
It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.
US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1) Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.Read More
Think about gravity: fluid will collect in most dependent region (down); air tends to collect towards the least dependent regions (up)
Air does not reflect sound waves well. Lungs are filled with air. Rather than getting most of our information from visualizing the anatomy (as in a RUQ ultrasound, for example), much of our information comes from “artifact” or ultrasound waves being affected by phase changes.Read More