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. [...]

For the patients when you either suspect thrombocytopenia based on exam/history or when the CBC returns with a surprisingly low platelet count...

Ectopic pregnancy is a common and potentially fatal emergency in early pregnancy. Its prevalence is about 2% in the general population, but is as high as 16% in women presenting to the emergency department with concerning symptoms. Ectopic pregnancy is a cause of pregnancy-related death and can also lead to chronic pelvic pain, need for blood transfusions, and long-term infertility. Because of the potentially devastating outcomes, it is imperative that emergency physicians diagnose ectopic pregnancy early and refer patients to the proper specialist care. [...]

As Emergency Physicians, we are always looking for ways to improve the care we provide to our patients. Based on clinical data which have come to light over the past several years, tranexamic acid (TXA) displays considerable promise toward reducing mortality in hemorrhagic trauma. It’s widely available, cost-effective, and an easy way to save lives. Let’s take a look at the evidence and discuss the potential benefit of TXA use in trauma. [...]

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? [...]

Whether we are working with a medical student, an off-service resident, or even one of our own, most of us involved in the education of emergency medicine have described the mindset of emergency medicine as different from most other specialties. But are we really unique in our approach to patient care and how we think? And if so, can one develop this “EM Mindset?” [...]