Our ongoing intern report series is the product of first-year EM residents at UT Southwestern exploring clinical questions they have found to be particularly intriguing. For med students & junior residents – if you haven’t encountered these issues yet, you will!
What to consider and keep in mind when confronted with the all-too-common violent patient in the ED...
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** […]
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.
How ultrasound can help you win your fantasy football championship
A minute-by-minute Jack-Bauer-24-type walkthrough for approaching the unstable upper GI bleed Tintinalli's - Upper GI Bleed link
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 [...]
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. [...]
