recent articles

practice updates

Peripheral Vascular Injury Management


  • Peripheral vascular injury can be life-threatening or limb-threatening.  Proper understanding of pathology and management is important in the ER.
  • Vascular injuries can be internal and may not be obvious on presentation. Patients with blunt or penetrating trauma who remain hypotensive after a fluid bolus challenge may have internal hemorrhage.
  • Incidence of penetrating and blunt trauma in the US has been rising.
  • Blunt and penetrating causes of peripheral vascular injuries are about equal in the US.
  • Low velocity gunshot wounds are the second leading cause of death in the 15- to 34-year-old age group in the US.  Peripheral vascular injury has been reported to be present in up to 50% of these cases.

intern report

Ultrasound and Respiratory Distress

Clinical Question: What is the utility of US for differentiating causes of respiratory distress and expediting treatment in the ED? As I am currently on my US rotation and learning how the FAST or focused echo can help us in our initial clinical decision-making, I am curious as to why it is not commonly utilized for respiratory complaints or acute respiratory distress. This presentation is a large population of what we see and is often hard to diagnose and work-up.  A literature search resulted in one recent article in the Lancet that attempted to address this question. [...]

intern report

ED Observation Units and Their Efficacy

I had concerns for admitting a patient to the observation unit for suspected CHF exacerbation. The specific protocols for CHF exacerbation are available on EPIC and list a very specific set of criteria that allows for admission to the 2SS observation unit. I was initially curious about the development of these criteria, and more broadly, the efficacy of observation units and their sustainability as the face of a changing environment in Emergency Medicine. My main question was: do observation units lead to equal or better outcomes for patients versus conventional admission? Are they cost-effective or do they merely delay the costs associated with admission and full work-up? [...]

intern report

Post LP Headache

On my first month in the Parkland ED, I saw multiple patients with post-lumbar puncture headaches and even iatrogenically caused one myself.  Often I found myself wondering what proven preventative measures during an LP decrease the incidence of such headaches, what could I have done better, and what literature supports treatment of post-lumbar puncture headaches in the emergency department. [...]

clinical cases

Chief Complaint: "Seizures"

Chief Complaint: “Seizures” History of Present Illness: 25-year-old male with no PMHx, BIBEMS after he had episode of tonic-clonic seizure. As per wife, who gave medical history, the patient was found down in a hotel with "his whole body shaking."  Upon EMS arrival, he was given 5mg of Valium. On arrival to the ED, patient combative, not following commands with frothy oral secretions.  Wife endorses that patient has had weakness, dizziness, and malaise x 3 days, but no other complaints. Patient had another seizure while in the ER without regaining full consciousness. [...]

intern report

Management and Dispo of Upper GI Bleed

Upper GI bleed (UGIB) is a common cause of presentation in the ED with an incidence of 102 per 100,000 hospitalizations. Mortality can range from 2-15%, with a rebleeding risk of up to 10-30%. It is important to identify high-risk patients that are candidates for early endoscopy or if monitored management is more appropriate. Low-risk patients may be identified and safely discharged from the ED. [...]

practice updates

ICP Management Update

Author: Albert Arslan, MD and Anthony Scoccimarro, MD (Resident Physicians, Lincoln Emergency Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)   Prevent and Identify – the ED’s equivalent of Search & Rescue when managing elevated Intracranial Pressures (ICP). The causes of elevated ICP are typically described in the context […]

intern report

Tranexamic Acid in the ED

A quick case: A 57 y/o F with a PMH of DM, HTN, and Afib on warfarin presents to the emergency department (ED) complaining of spitting out a blood clot when she woke up in the morning. Upon waking she felt something in her mouth, spit out a small blood clot, and continued to have slow oral bleeding over the next several hours leading to presentation in the ED. She is not able to see where the blood is coming from, denies any other symptoms and states her last INR was 2.3. All other ROS is negative. On physical exam, it is noted that the patient has a broken upper left molar that is slowly bleeding. All other physical exam and vitals were normal. The attending physician suggested using tranexamic acid (TXA) for treatment. But what’s that? I didn’t learn about that in med school. Clinical Question: What studied uses are there for tranexamic acid in the Emergency Department? [...]