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practice updates

Ultrasound for Small Bowel Obstruction

Editor's note: This article was listed in EM Curious' #FOAMed Review 19th Ed.

Quicker diagnosis (vs waiting for CT), quicker treatment (IVF, NG tube, surgery), and earlier consult/admission to Surgical team. Everyone benefits: ED flow, overburdened nurses, other patients requiring attention in the ED, and most of all, the patient himself.

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

Thromboelastography (TEG®) for Trauma

Editor's note: This article was listed in LITFL Review 154's "Best of #FOAMcc Critical Care" section.

Using thromboelastography in goal-oriented algorithms, clinicians may be able to optimize targeted transfusion therapies with specific coagulation factor(s) instead of empirically administering multiple components with potentially hazardous effects.

clinical cases

Bounceback: An Unrelenting Headache

CC: Headache First visit HPI: 29 year old female with a prior history of headaches, presented with two days of gradual onset, atraumatic, right sided headache that is throbbing in nature. The patient reported heaviness about the eye but no visual changes or disturbances. No neck pain, fevers, chills. She described feeling slightly light-headed but no balance loss. She had a mechanical trip and fall yesterday without head trauma, and her headache had been present for a day prior to the fall. ROS: otherwise normal. PMH/PSH: headaches, depression, anxiety, asthma SH: no smoking, no etoh, no drugs Allergies: Penicillin (rash) Pertinent Exam Vitals: 98.6F, BP: 156/85 P: 101, RR: 16, O2: 98%RA Gen: A&Ox3, well-developed, well-nourished HEENT: normocephalic, atraumatic, conjunctiva wnl, EOM wnl, PERRL, normal fundoscopic exam, crisp optic discs, normal ROM neck/supple Chest: wnl Abd: wnl Musculoskeletal: wnl Neuro: CN2-12 intact, normal reflexes, normal muscle tone, normal coordination Labs: Serum HCG negative Imaging: None ordered ED Course: The patient was believed to be experiencing a migraine headache. She had no evidence of head trauma, no signs of infectious etiology, and had no clinical findings or hx for SAH. She was administered Toradol, IVF and Reglan, and discharged with instructions to follow up with neurology and possibly have an outpatient MRI. Discharge Dx: Headache [...]

practice updates

Don't be RASH: Emergency Physician's Approach to the Undifferentiated Lesion

Editor's note: This post was listed in both the #FOAMED Review from EM Curious AND in the LITFL Review 154 "Best of #FOAMed" section.

As an EM physician, it is difficult to have working knowledge of the hundreds of different types of rashes that exist. However, I argue that it is not the job of the EM physician to diagnose every rash that comes in the ED. That is the job of the dermatologist who has the luxury of time and biopsies. Rather, it is our duty, just like chest pain and syncope, to rule out the life-threatening causes of skin lesions, quickly identify a potentially lethal rash, and provide the appropriate initial stabilization, resuscitation and disposition (ICU, surgery).

practice updates

Left Bundle Branch Block in Myocardial Infarction: An Update

Editor's note: This article was listed in the LITFL Review 154's "Best of #FOAMed" section.

The left bundle branch arises from the Bundle of His, and subsequently is divided into the anterior and posterior fascicles. The anterior fascicle is usually supplied by septal perforators from the Left Anterior Descending artery, and the posterior fascicle typically has a dual supply from septal perforators from the Left Anterior Descending artery and the Posterior Descending artery (arising from the Right Coronary). Electrocardiographically, a LBBB is defined as QRS duration greater than or equal to 120 ms; a broad-notched or slurred R wave in leads I, aVL, V5, and V6; absent Q waves in leads I, V5, and V6; and an R peak time >60 ms in leads V5 and V6 but normal in leads V1 to V3 (1). LBBB can be transient and/or rate-related (1). These morphologic changes make it difficult to discern whether or not a patient presenting to the emergency department with chest pain is experiencing a STEMI. [...]

practice updates

How To Be A Clinical Rock Star Managing Subarachnoid Hemorrhages

A New Way to Think About Subarachnoid Hemorrhage: It is helpful to remember that while a subarachnoid hemorrhage is in fact a “bleed”, it is also a stroke.  When compared to ischemic strokes, hemorrhagic strokes tend to have an increased risk death in the acute phase, but for those patients that don’t die, their overall prognosis for return-to-baseline is somewhat better than ischemic events.  Why is this?  During hemorrhagic strokes (i.e. bleeds), an artery bursts, bathing brain cells in blood.  The cells become “stunned”, but there is rarely significant cell death surrounding these events.  If the total volume of hemorrhage is small, a patient has a chance at making a full, or near-full recovery (depending on extent of injury and any herniation symptoms). In ischemic events, lack of blood flow to brain cells causes cellular destruction, and a watershed “penumbra” effect can cause large swaths of brain cell death relative to the small area of initial ischemia.  In ischemic cell death, brain cells don’t remodel or regain function, which is why ischemic stroke patients have a high likelihood of residual neurologic deficit.  This terminal cell death is also why there is such a push for early identification of ischemic stroke, and why thrombolytics and other neurologic intervention procedures have gained such momentum. Patients presenting with headaches are worrisome because it can be difficult to sift through so many associated symptoms to determine who has benign pathology and who has a catastrophe brewing in their brain.  It is my goal to give you the needed strategy to be a rock star when it comes to evaluating headache patients. [...]