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
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
The first snowflakes of the year are falling as you head into your midday Minor Care shift. Slipping on an icy patch of compacted snow and nearly falling as you head from your car to the ED entrance, you have a sneaking suspicion what the day will bring: falls, slips, and trips. Indeed, you settle down to the computer, log in to your EMR and pull up the minor care screen to see 2 unseen patients with the chief complaint of “Fall”...Read More
There isn't a day that goes by in the ED that a patient does not get a chest x-ray. Whether the indication is chest pain, shortness of breath, cough, or line placement or intubation, interpreting chest radiographs is a critical, necessary skill for anyone working in the Emergency Department. Here you will find a brief video explaining how to interpret CXRs and 6 practice cases.Read More
1. The ACC/AHA Criteria (1) (2)
ST-elevation in 2 contiguous leads that is:
Men < 40: 2.5 mm ST-elevation in V2 or V3, 1 mm in any other lead
Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead
Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead
STEMI's have a 90-minute door-to-balloon time mandate from the Center for Medicare Services (CMS). To be good stewards of our resources we need to be familiar the false positive STEMI patterns. Ultimately, however, some degree of over triage and activation for false positives is expected and (potentially even) desirable.Read More
It's 6pm in the ED on a sunny summer afternoon- you're working as a single coverage physician at a level 3 trauma center. You are noticing an uptrend in the trauma patients being brought in over the past few hours. While log rolling yet another patient, an EMS provider tells you that they have been making runs nonstop- all of the hospitals downtown are overloaded, and it doesn't look like it will slow down anytime soon. Your modest trauma bay is already full, and you're starting to sweat about the state of the department- there are 4 patients in the pod you haven't even seen yet, 2 with abnormal vital signs.Read More
After a long shift in the adult ED, jam packed with patients presenting with abdominal pain, your looking forward to a brand new day in the Peds ED. Your first patient, however, gives you PTSD-like flashbacks to the previous days shift.
Alice is a 8 year old girl who developed abdominal pain last night. Her parents thought that she would be okay waiting until morning, that the pain would pass in the night. On waking this morning, however, the pain was still there.Read More
It's weird how you get runs of patients in the ED. Some days it seems like it's nothing but wall-to-wall low risk chest pain, altered mental status, or back pain. Today (and a lot of other days), it's abdominal pain. Scanning the board you see seemingly nothing but Level 3 acuity patients with the chief complain of "Abdominal pain." Out of the scores of patient's, you seen so far, the last 2 worry you the most:
Andrea is a very pleasant 20 year old student from a local college. She came in after having symptoms of right lower quadrant pain over the course of the past 8-12 hours. She didn't recall any migratory symptoms but does endorse a lack of appetite, nauseousness, 2 episodes of vomiting (started after the pain), and steadily worsening pain.Read More
It's a frosty Easter morning and the ED is "q!&%t," all except for the 2 patient's turned over to you by the night ranger. You greet the first patient, a 75 yo M complaining of flank pain - probably a kidney stone you think to yourself as you walk in to the room. Walking into the room, you see the patient rolling around on the stretcher (as one would expect from those with a stone jammed in the UVJ), but something about his presentation strikes you as odd - a bit of diaphoresis, clammy pale skin. It could just be pain, but the specter of a ruptured abdominal aortic aneurysm still looms large in your differential diagnosis. You quickly exit the room, grab the ultrasound machine and head back in to take a look at his aorta...Read More
The soft-tissue neck radiograph can be an extremely useful tool in a variety of clinical situations. These include: epiglottitis, croup, retropharyngeal abscesses, and localization of airway foreign bodies.
However, like any diagnostic tool, the soft tissue neck x-ray’s usefulness depends on knowledge of the relevant anatomy — particularly the normal size and appearance of various airway structures — as well as a systematic approach to each radiograph. We will discuss both the anatomy and radiographic approach in this blog post.Read More
Any way you slice it, foot x-rays are a pain to read. Complicated by a number of overlapping bones, joints, the presence of multiple sesamoid bones, and multiple radiographic views, it's easy to get lost in the weeds trying to sort out normal variant from pathology. Take a look at this short Blendspace module by PGY-1 Lauren Titone, MD and get a better understanding of the normal anatomy and a systematic approach to reading foot x-rays.Read More
It's another back pain type of day in Minor Care. 3 hours into your shift and you've seen 6 patient's with back pain. You quickly evaluate them asking them about red flag symptoms, searching for signs of neurologic injury on your physical exam. As you talk to Jane, your next patient, you get worried she doesn't have simple musculo-ligamentous back pain. Jane has a history of IVDU and states her last use was 3 months ago. She cites some subjective fever and chills over the past several days along with aching low back pain which has been getting steadily worse. On exam, you find she is febrile with a temperature of 101.4, tachycardic to 110, with a normal blood pressure. She has midline upper lumbar and lower thoracic spinal tenderness to palpation.Read More
You are talking to your new patient, John. He's a pleasant 30 year old man who, by your estimation appears to be a victim of HGS... Holiday Gluttony Syndrome. John presented to you in the ED with abdominal pain, nausea, and vomiting. He goes on to tell you all this started after he chowed his way through a few too many Buckeyes. You see every Christmas, his mom sends him a far too large tin of Buckeye candies, which John had eagerly eaten and eaten and eaten, until the belly pain hit.Read More