practice updates

For your Friday afternoon, here’s another batch of excellent write-ups from the EM interns at UT Southwestern. Our ongoing intern report series is the product of first-year residents exploring clinical questions they have found to be particularly intriguing, with an intended audience of med students & junior residents. Enjoy!

[Note: These are PDF files.]

• CHF Exacerbation by Meaghan Dehning, MD
• Use of Ultrasound in Endotracheal Intubation by Andrew Fredericks, MD
• Ventilator Strategy for an Acute COPD Exacerbation by Andrew Fredericks, MD
• Wernicke’s Encephalopathy by Richard Moleno, DO; edited by Larissa Velez, MD
• Serotonin Syndrome by Andrew Fredericks, MD; edited by Larissa Velez, MD
• Steroids for Sciatica by Christina Smith, MD
• Post-Partum Fever by Meaghan Dehning, MD
• Pressor Choice In Shock by Chris Chase, MD
• Procedural Sedation in the ED by Chris Chase, MD
• RSI Pharmocology for the EM Physician by Richard B. Moleno, DO
• Management of Traumatic Subungual Hematoma by Lindsay Schroeder, MD
• Leukocytosis in the Immunocompromised by John R. Corker, MD
• H&P for Ovarian Torsion by Gray Millsap, MD
• Pericarditis by Ashley Phipps, MD
• Estrogen for Uterine Bleeding by John R. Corker, MD
• Treatment of Intractable Hiccups by Ashley Phipps, MD
• Central Venous Access Site Comparisonby Kevan Beth Meadors, MD
• COPD Exacerbations and Managementby Stace Breland, D.O.
• Epistaxis by by Gray Millsap, MD
• Energy Drink Toxicityby Kevan Beth Meadors, MD
• Delayed Neuro Injury Following Electrocution: Two Case Reports by Brandon Morshedi, MD
• Compartment Syndrome by Alex Cohen, MD
• Appy In Pregnancy by Christina Smith, MD
• Benzo Resistant Alcohol Withdrawal Seizures by William Fox, MD, edited by Larissa Velez, MD
• Benzodiazepines in Alcohol Withdrawal Syndrome: Preventing “Kindling” by William Fox, MD, edited by Larissa Velez, MD
• APAP Overdose by Alex Cohen, MD

Our AMA with Dr. Mike Mallin & Dr. Matt Dawson from the Ultrasound Podcast, held on Friday, November 14th from 2-3:30pm EST.

These children are often a mixed picture of viral bronchitis/bronchiolitis PLUS an asthma exacerbation. Treatment with albuterol, ipratropium, magnesium sulfate, steroids, fluids, etc are all reasonable and prudent in this population. If they begin to clinically improve within 30 minutes then you can feel good about soothing their reactive airways. However, they still have underlying viral issues which may require non-invasive positive pressure ventilation (either high-flow nasal cannula or BIPAP). If they do not improve within 30 minutes then you should begin to plan for IMC/ICU admission as these patients will require significant monitoring and respiratory support.

Trying to predict the future is a task that is riddled with risk. There is a very high potential that I will be wrong and my thoughts will end up being complete baloney. I’m okay with this. According to Strengths Finder 2.0, I’m futuristic, meaning that I’m inspired by the future and what could be, and hopefully will inspire you. With this in mind, two quotes that I believe should frame our conversation:

“The future is already here, it’s just not very evenly distributed.”
-William Gibson

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next 10.”
-Bill Gates

With these in mind, here are some trends that I see emerging. […]

Aortic dissection is a life-threatening yet infrequent diagnosis, estimated at about three cases in every 100,000 person years (1,2). Because of its low frequency and emergency nature, large randomized controlled trials are difficult to conduct (3). Thus, the International Registry of Acute Aortic Dissection (IRAD) was established in 1996 to obtain up-to-date data on patients with acute aortic dissection. Currently, 30 large referral centers in 11 countries participate. Most novel research on aortic dissection is based on IRAD data. […]

Naloxone has been proven to reduce the incident of death in acute opioid overdoses. So why aren’t we using it more often?

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).

Editor’s note: This post was listed in the #FOAMED Review (17th Ed.) from EM Curious. It ALSO appeared in LITFL Review 154’s “Best of #FOAMcc Critical Care” section.

Its 7:01am.  Your shift in your department’s high acuity area is just beginning, and you are waiting to receive sign out.  There hasn’t even been time to get your first sip of coffee.  Just as you are lifting your cup to your lips, the charge nurse grabs you and says, “Doctor, I need you!  This patient isn’t looking so good!” […]

Editor’s note: This post was listed in the LITFL Review 153‘s “Best of #FOAMed” category.

Venous thromboembolism (VTE) (deep vein thrombosis or pulmonary embolism) has an incidence of roughly 1 in 1,000 with an incidence of PE with or without DVT of 2.3 per 10,000.

One major factor to consider is that VTE is much more common in the elderly and has a mortality highly associated with co-morbidities such as cancer and underlying cardiovascular disease.

In the distant past any diagnosis of DVT and/or PE would result in admission for heparin bridging to oral anticoagulation therapy. This was largely due to a fear that outpatient management would lead to an increase in fatal embolic or major bleeding events. However, there is a great amount of literature that has established the safety of outpatient management of “low-risk” DVT; outpatient treatment has become standard of care for these patients.

“Low-risk” patients were those with no prior VTE, no PE, no prior heparin use, and no confounding co-morbidities (cancer, infection, stroke, etc).

So what about PE?
If outpatient management is standard of care for a select group of DVT patients, then can we treat PE as an outpatient? […]