Tracheoinnominate Fistula
One of the most dreaded days in the ED, a post-trach patient presents with a small bleed that stopped, is this one of 50% of patients with a TI fistula waiting to unleash?
Once the patient starts massively bleeding - what's your next move hotshot?
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 MoreImagine: you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria. You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics. Your clinic does not have any power. Your diagnostics include: urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria. You have 2 nurses, one of whom acts as a translator (from Swahili to English). You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.
Read More1. Find your Tonopen. At our shop the Tonopen lives in the cabinet in the attending office.
2. Adequate corneal analgesia is key. Instill tetracaine in both eyes prior to using the Tonopen.
3. If you are assessing the patient for corneal abrasions, perform the fluorescein exam prior to using the Tonopen as the Tonopen may inadvertently cause small abrasions.
4. Place a cover over the tip. It slides on like a condom and then roll the ridge into the grove.
Read MoreThe patient is a male in his 40s who presents after sustaining an injury to his right eye with a fishing hook. He states that a three-barbed hook pierced his eye while fishing with his friend. On gross inspection, the hook was noted to have pierced the inferior eyelid causing an obvious right open globe and there was a large hyphema. While he was initially able to count fingers at four feet in his superior visual field, his visual acuity quickly deteriorated to light perception only. Extraocular movements were intact and caused movement of the hook. Ophthalmology was consulted and a CT was obtained. The patient was then taken to the OR for anterior chamber washout, open globe repair, and removal of the fish hook. He was discharged following the surgery with next day follow-up with ophthalmology.
Read MoreEKG Changes
The patient is a female in her 60s who presents by EMS after a fall in a parking lot approximately one hour prior to arrival. She fell forward and landed on her face. She believes she simply tripped and fell, but she did lose consciousness and does not know how she ended up on the ground. Per family, she is unsteady on her feet and falls frequently, requiring a cane at baseline. She reports feeling “weak” but no other symptoms preceding her fall. She presents with significant right-sided facial trauma and is unable to open her right eye. She has no complaints of blurry vision in her left eye. She has no headache or other areas of pain or trauma.
Read MoreWe will all have the experience of taking care of a patient in the emergency department who is acting…different than they normally do. Sometimes, the change can be subtle, maybe a family member will be the first to notice and bring the patient to be evaluated. Sometimes the patient makes the change abundantly clear. In either case it is essential to identify the underlying cause and treat any emergent conditions precipitating this dysfunction of the brain. This month we hear from Dr. Erin McDonough on her approach to the patient with altered mental status (AMS).
Read MoreRemember the "I's" when looking for cause of DKA/HHS: Infection, Insulin lack, Infarction (MI, CVA, Ischemic gut), Indiscretion (EtOH, cocaine), Infant (pregnancy).
After 2L NS fluid bolus in the hemodynamically stable patient, the corrected sodium should guide fluid choice for further therapy.
Venous pH, HCO3 and base excess have sufficient agreement to be interchangeable with ABG in the ED.
Read MoreCC: Laceration to Upper Lip
HPI: 23 year old male presents to the ED with laceration to his upper lip. Patient states he was “Minding his own business” when all of the sudden the ground came up and hit him in the face. His friend alcohol might have been there. Patient states he now has a cut on his lip and a bruise on his pride.
Physical Exam: Physical exam demonstrates a 2 centimeter full thickness laceration of the left upper lip that crosses the vermillion border.
Read MoreDr. Hinckley - Air Medical Resource Management
Familiarity and complacency can lead to mistakes. Stay uncomfortable. A policy for preflight walk-a-rounds will be released shortly.
E-poc blood gas analyzer is now on AirCare. Think about using it for all patients, but particularly those who are intubated or may be in a state of shock.
Dr. Powell - Minnesota Tube is coming to AirCare
Everything you need will be in the Critical Care bag. You can bring all the gear with you into the hospital without having to gather supplies there. No football helmet required.
Read MoreTraditional teaching is that a positive tap is Xanthochromia or blood in the CSF
The word xanthochromia is simply Greek for “yellow color.” It refers to the yellow color that CSF can take in certain situations. Some of these situations are listed below:
What we are especially interested in when evaluating for subarachnoid hemorrhage is bilirubin and oxyhemoglobin.
Read MoreThis week we recap the latest IOM recommendations on cardiac arrest management, evidence-based update on anaphylaxis management, management of the morbidly obese code and discuss the ins and outs of immunosuppressive agents.
Read MoreThis the recap of the 2nd of our 2 "Sepsis Smackdown" cases. Several weeks back, we presented to you the case of Lucy, a 79 yo female resident of a nursing facility presenting to your busy community ED with reported altered mental status. She's unable to provide you with a meaningful history but you piece together she's been acting abnormally at the nursing facility over the course of the past several days at the nursing facility and is now febrile, tachycardic, and hypotensive. In your testing, you find her to have a UTI, begin her resuscitation and admit her to the hospitalist and MICU. While waiting for a bed, she continues to be poorly responsive to your resuscitation...
Read MoreBelow you will find the recap of the 1st case in our Sepsis Smackdown case series. Several weeks ago, we posed a clinical scenario followed by a series of questions. As a refresher the case was that of Linda, a 79 yo female resident of a local nursing facility who arrives to your busy community ED with altered mental status, hypothermia, tachycardia, hypotension, and along history of multiple complicated UTI's. You begin your work up and find her to again have a likely UTI with a urine dipstick with large leukocyte esterase, pH 5.5, 20 protein, negative nitrite.
Read MoreSRU (pronounced "shrew") = Shock Resuscitation Unit
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
