recent articles

FOAMED

Novel Tips for Airway Management

Featured on #FOAMED REVIEW 28TH EDITION – Thank you to Michael Macias from emCurious for the shout out! Author: Joe Rogers, MD (Senior EM Resident, Rutgers-NJMS) // Editor: Alex Koyfman, MD & Justin Bright, MD The following is a compilation of helpful tips for managing the airway in the emergency department. **EAR TO STERNAL NOTCH POSITIONING** […]

perspectives

The Hypotensive ED Patient: A Sequential Systematic Approach

Treat the patient, not the number. A blood pressure of 120/80 mmHg in a chronically hypertensive patient can be dangerously low. Whatever the HPI may suggest, unbiased implementation of the bedside physical examination and sonography are crucial in the workup of unexplained hypotension. This four step systematic approach of sequentially assessing heart rate, volume status, cardiac performance, and systemic vascular resistance can narrow the differential and guide management.

practice updates

Power Review: Management of the Post-Bariatric Surgery Patient

Your next 3 patients… #1: Gastric bypass pt with SIRS criteria #2: Gastric bypass pt with psychiatric complaints #3: Gastric bypass pt with nausea/vomiting The Basics -Morbid obesity continues to rise significantly (epidemic) -Increasing # of weight-loss surgeries w/ physical/psych effects => increasing ED visits for postoperative complications -Increased laparoscopic techniques; each surgical option w/ potential complications -2 main strategies of surgery: gastric restriction (early satiety) => banding / gastroplasty; intestinal malabsorption (bypass parts of small intestine) => distal gastric bypass / biliopancreatic diversion +/- duodenal switch -Hospital stays: 3-4 days Clinical Pearls -Challenging / unreliable abdominal exam => more extensive work-ups including CT abdo/pelv w/ oral + IV contrast (drink over several hours) -May not fit into CT scan -Often don’t manifest symptoms/signs of serious intra-abdominal pathology i.e. signs of peritonitis masked by large amount of intra-abdominal fat -Lack cardiopulmonary physiologic reserve => quick deterioration; get surgery involved early -Concern for band migration: need swallow study under fluoroscopy -Roux-en-Y pts are tricky b/c part of small intestine is bypassed; signs/sxs not classic and abdo XR not reliable -Fever + tachycardia + increasing abdominal / back pain in Roux-en-Y pt in 1st several weeks post-surgery, pursue anastomotic leak/intra-abdominal abscess; need UGI series vs surgical exploration -Upper endoscopy has a role in diagnosing bleeding / stricture / stenosis -Internal hernia: tough dx; many w/ normal labs / XR / UGI series / CT; surgical exploration needed [...]

practice updates

Neck Trauma: A Practice Update

The neck is a particularly tricky area of assessment and management in the trauma patient, as it is the location for many vital structures. Concern for vascular, neurologic, digestive tract, and airway injury are of paramount importance in the evaluation of these patients, as all can be life-threatening. Oftentimes, the neck trauma patient may appear stable, only to have delayed injury found later, causing increased morbidity and mortality. Neck trauma can be split into penetrating injury and blunt injury. [...]

practice updates

EKG Practice #4

Case

A 67 year old woman with metastatic squamous cell cancer presents to the emergency department having been found on the floor by a family member. She lived alone and cared for herself and was apparently given to heavily imbibing in solutions containing two carbon fragments. She was clearly quite ill, hypothermic, and confused. She was very weak and had difficulty moving her extremities. Her blood pressure was 95/55, and her temperature was 34 degrees centigrade. Her 12 lead ECG revealed this: ekg1

A closer look at leads V1 through V3 is found here:

ekg2

What is your interpretation, and what do you think that this patient’s electrolyte panel would show?