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practice updates

The Evaluation of Occult Subarachnoid Hemorrhage: Why Are We Still Doing LPs? Is CTA A Better Alternative?

It’s 4pm on a Wednesday. As per usual, the chart rack is full, and you’re trying to stay positive and keep up morale of the entire team. You pick up your next chart, and as you read the chief complaint, your heart sinks into your belly. The complaint is, “severe headache,” and you’re already trying to figure out how you’re going to fit an LP into your busy patient load. Headaches are experienced in all types of ways by our patients. Many are benign – but we are in the catastrophe business. How do we know if the headache is actually a brain mass? Or what if it’s a raging intracranial hemorrhage? And if it is a brain bleed, what kind will it be? If we have a suspicion of subarachnoid hemorrhage (SAH), did our mouse click for “head CT (non-contrast)” just commit us and our patient to a lumbar puncture? [...]

practice updates

Wrist Injuries: Pearls and Pitfalls

Wrist pain is a frequent emergency department complaint. Most presentations are due to an acute traumatic injury. Furthermore, overuse or repetitive motion mechanisms cause ED visits for either an acute injury or an exacerbation of chronic pain conditions. For the purposes of this post, the wrist is going to be defined as injuries occurring to the distal radius and ulna, as well as any injury to the carpal bones. In addition, I feel it to be a poor use of this forum to simply list every conceivable form of wrist injury. Instead, I’d like to discuss the following:

  • Pertinent questions you need to ask your patient when evaluating a wrist injury
  • Pain management techniques including hematoma blocks
  • Which fractures have a higher likelihood of developing avascular necrosis
  • What type of splint is indicated for a particular injury

practice updates

Ventilator Management in COPD

Editor's note: This post was listed in the #FOAMED Review (17th Ed.) from EM Curious. It ALSO appeared in LITFL Review 154's "Best of #FOAMcc Critical Care" section.

Its 7:01am.  Your shift in your department’s high acuity area is just beginning, and you are waiting to receive sign out.  There hasn’t even been time to get your first sip of coffee.  Just as you are lifting your cup to your lips, the charge nurse grabs you and says, “Doctor, I need you!  This patient isn’t looking so good!” [...]

practice updates

Nuances in Resuscitation Part III: Diabetic Ketoacidosis

Thus far we have discussed resuscitation in trauma and sepsis.  What distinguishes those two from the resuscitation goals in DKA is timing.  In trauma and sepsis, it’s all about early recognition, aggressive and quick optimization, and understanding all the possible treatment options at your disposal.  In the management of DKA, it’s quite the opposite.  If you remember anything from this discussion, it’s that slow and steady wins the race!  In fact, overaggressive resuscitation is what leads to the most significant morbidity and mortality in DKA patients.  Patients in DKA don’t die from the disease process – they die because we kill them! [...]

practice updates

Nuances in Resuscitation Part II: EGDT In Sepsis

In November 2001, Dr. Manny Rivers and his colleagues published an article in the New England Journal of Medicine on Early Goal Directed Therapy in Sepsis.  At the time, sepsis was not a new concept, nor was the treatment of it.  Where I believe the real genius in EGDT lies is in a fanatical focus on early recognition of sepsis by utilizing SIRS criteria, as well as developing an algorithm with definable objective treatment goals to assist providers in understanding if their treatment selections are in fact working.  The basic questions in EGDT therapy are:

  1. How much fluid is enough?
  2. Are the vital organs being perfused appropriately?
  3. Is there adequate oxygen delivery and utilization by those vital organs?
Since Rivers published his article in 2001, it has been met with both acclaim and controversy.  EGDT utilizes central venous pressure monitoring, lactate trending, SvO2 monitoring, vasopressor therapy, and sometimes, blood transfusions to optimize resuscitation of the septic patient.  I believe the controversy is not in whether or not it works, as multiple studies have demonstrated a reduction in morbidity and mortality.  Instead, the controversy lies in what is the best modality to answer the basic questions of sepsis resuscitation, and whether some of the aggressive steps recommended in the initial study are necessary or even practical in many emergency departments across the country. [...]

practice updates

Practical Nuances of Resuscitation – Part I: Not All Are Created Equal

One of my colleagues likes to tell our residents, “they don’t come to the ED to die, they come here to live.”  It is our skill in identifying critically ill patients and successfully resuscitating them that defines us as emergency medicine physicians.  Resuscitation in its simplest term means to revive from unconsciousness or apparent death.  However, there are a multitude of different disease processes that cause critical illness, and the approach to resuscitation of each illness is quite different.  It is important to have a confident grasp of different resuscitation options and endpoints so you can best help your patients.  If you try to resuscitate all of your patients in exactly the same manner, you will actually end up harming many of them instead. The goal here is to understand the resuscitation technique and endpoints in trauma, sepsis, and diabetic ketoacidosis.  The tried and true methods will be summarized, and areas where controversies exist will be discussed as well.  As a result, there is a wealth of information that we need to get through.  In order to lay it out for you in smaller, digestible bites, I am going to roll this out in installments.  First up….trauma! [...]