Sound Waves for Shoulder Dislocations

/
Sound Waves for Shoulder Dislocations

Shoulder injury and dislocations are common reasons for patients to present to the emergency department (ED) for evaluation. As ED physicians we often must determine whether the shoulder is fractured, dislocated, or both. Most of the time this is done through the use of physical examination in addition to the use of a plain film radiograph of the shoulder.

 The use of ultrasound in the diagnosis and management of musculoskeletal injuries is becoming more common. While it currently does not supplant the use of radiographs, it can be a useful adjunct to the management of these patients.

Read More

The Lever Test for Diagnosing ACL Injuries

/
The Lever Test for Diagnosing ACL Injuries

The anterior cruciate ligament (ACL) is one of the most commonly injured knee ligaments, with nearly 200,000 injuries annually in the US, with ~100,000 requiring reconstruction. The ACL prevents anterior translation of the tibia relative to the femur and is a secondary restraint to tibial and varus/valgus rotation. Accurately diagnosing ACL injuries in the ED after an acute knee injury remains difficult. The diagnosis is complicated because clinical tests are performed on an acutely injured knee, which is likely swollen and painful, leading to muscle contractures and patient apprehension. As Emergency Medicine physicians, we must have some confidence in suspicion of an ACL tear because not all patients can or should be referred for prompt orthopedic follow-up. 

Read More

Has Video Finally Killed DL?

/
Has Video Finally Killed DL?

More than 1.5 million adults undergo tracheal intubation outside of the operating room each year in the United States. Traditionally, this has been performed with direct laryngoscopy, where a clinician displaces the patient’s tongue and epiglottis with a laryngoscope blade to visualize the vocal cords through the mouth, allowing for direct visualization of the passage of an endotracheal tube. An alternative method for tracheal intubation is video laryngoscopy, where a camera on the distal half of the blade transmits an image to a screen allowing for indirect visualization of the vocal cords and passage of an endotracheal tube without direct line of site.

Read More

Induction Reduction?

/
Induction Reduction?

Rapid sequence intubation (RSI) is frequently performed under emergent conditions in acutely ill patients. RSI is a technique for managing the emergency airway that induces immediate unresponsiveness (induction agent) and muscular relaxation (neuromuscular blocking agent). In properly selected patients, it is a quick, safe, and effective approach that results in optimal intubating conditions. However, one of the feared complications of RSI is post-intubation hypotension leading to cardiovascular collapse. Although there are multiple possible reasons for hypotension post-intubation, the choice and dosing of induction agents has been implicated.

Read More

Hunting for Invasive Bacterial Illness in Infants with a Positive UA

/
Hunting for Invasive Bacterial Illness in Infants with a Positive UA

The workup of febrile infants (<60 days) can be extensive and invasive. This post and podcast covers a recent paper by the PECARN research group that sought an answer to the question: What is the prevalence of bacteremia and/or bacterial meningitis (“invasive bacterial illness”, ISI) in febrile infants ≤60 days of age with a positive urinalysis (UA) result?

Read More

EtCO2 vs. Standard Triage Vitals in Predicting In-Hospital Mortality and ICU Admission

/
EtCO2 vs. Standard Triage Vitals in Predicting In-Hospital Mortality and ICU Admission

Boarding of admitted patients in the ED and subsequent overcrowding of ED’s continues to plague hospitals in the United States and Internationally.  The Covid-19 pandemic exacerbated an already growing problem regarding capacity management and patient flow. In this current climate, the Emergency Physician’s responsibilities continue to shift toward the front-end of the process, mainly patients waiting to be seen in the lobby.  As such, identifying sick patients in a timely manner and utilizing additional resources to predict patients at risk of clinical deterioration will be paramount moving forward.

Read More

The CLOVERS Trial

/
The CLOVERS Trial

Sepsis, including severe sepsis and septic shock, is a frequently encountered condition in the emergency department and carries a high mortality rate. One of the primary pathophysiologic mechanisms involves complex cascade of host dysregulation in response to an infectious stimulus (Evans, Rhodes et al. 2021, Jarczak, Kluge et al. 2021). Recent meta-analyses and systematic reviews evaluating mortality in patients with septic shock reported mortality as high as 35% and 38% at 30 and 90 days, respectively (Vincent, Jones et al. 2019, Bauer, Gerlach et al. 2020). Despite the complexity and heterogeneity of patients with sepsis, there have been few interventions which have been demonstrated to decrease mortality: early antimicrobial and fluid administration (Levy, Evans et al. 2018, Kuttab, Lykins et al. 2019, Evans, Rhodes et al. 2021, Im, Kang et al. 2022), ideally with antibiotics administered within one hour of sepsis recognition by the treating provider (Evans, Rhodes et al. 2021). Each subsequent one-hour delay in antimicrobial administration increases mortality by 35% in patients with septic shock (Im, Kang et al. 2022).

Read More

IV Metoprolol vs Diltiazem for A fib with RVR and Concomitant Heart Failure

/
IV Metoprolol vs Diltiazem for A fib with RVR and Concomitant Heart Failure

The management of atrial fibrillation with rapid ventricular response is often complicated by the presence of heart failure with reduced ejection fraction. The presence of HFrEF limits pharmacologic options for rate control. This podcast will cover a retrospective study looking at the use of metoprolol vs diltiazem in patients with A fib with RVR and concomitant heart failure

Read More

Diastolic Shock Index: A clinically relevant predictor of poor outcome in septic shock?

/
Diastolic Shock Index: A clinically relevant predictor of poor outcome in septic shock?

Early recognition and resuscitation of patients in septic shock are critical skills for an emergency medicine physician. Many clinical decision-making tools have been developed and validated in their use to identify and define those who are in sepsis or septic shock, as well as predict a patient’s overall risk of morbidity and mortality, including tools like the SIRS criteria and SOFA score. The diastolic blood pressure is determined by vascular tone, and thus it can be assumed that a decrease in the diastolic blood pressure should correlate with the pathologic vasodilation in septic shock. As a result, the authors of this study hypothesized that the relationship between heart rate and the diastolic blood pressure (i.e. the diastolic shock index) could provide providers a tool to quickly identify patients that are at risk for unfavorable outcomes.

Read More

CTs for SAH - Does Time Even Matter?

/
CTs for SAH - Does Time Even Matter?

Spontaneous subarachnoid hemorrhage (SAH) is a can’t miss diagnosis for patients presenting to the emergency department with a headache. The diagnosis is associated with a 30% mortality at 30 days, and approximately 30% of survivors may have long-term neurocognitive deficits (Rincon et al., 2013). The majority of spontaneous SAH are secondary to a ruptured arterial aneurysm (80%) while non-aneurysmal SAH are often due to low pressure venous bleeds, arteriovenous malformations, and other more rare causes. This post will recap the existing literature on the diagnosis of aSAH and will focus on breaking down a recently published paper by Vincent, et al which may inform our future practice.

Read More

What Drip to Use After the Drop - Post-Cardiac Arrest Hypotension

/
What Drip to Use After the Drop - Post-Cardiac Arrest Hypotension

During a cardiac arrest resuscitation, finally palpating a pulsatile flow beneath your gloved fingertips brings a sense of satisfaction like no other. But just as you go to finally breathe a sigh of relief and wipe the beading sweat off your brow, your now widening pupils focus on the patient’s steadily plummeting blood pressure. As you begin to sense your own heart palpitating, you think about medications to utilize in hopes of staving off another round of chest compressions. Since you’ve already given four doses of code-dose epinephrine, maybe an epinephrine infusion is best? You also recall that norepinephrine seems to be a popular choice in patients with shock, so maybe you should start that instead?

Read More

Family Presence in Cardiac Arrest Resuscitations

/
Family Presence in Cardiac Arrest Resuscitations

Cardiac arrests are an inevitable reality for emergency medicine providers. There is often a debate on whether family members presence during CPR will lead to more emotional burdens on the family members who witnessed these resuscitations. This study aimed to determine if there are increased rates of PTSD-related symptoms of close relatives who witnessed CPR of a family member.

Read More