By Perry Lee, MD (PGY-3)
Advanced airway management is a mainstay of an emergency physician’s armamentarium. Many practitioners establish a routine with personal nuances established either by their training or from prior experiences. Here we examine common techniques and their effectiveness.
The studies selected are not meant to drastically change your systematic practice, but give recognition to the variability in routine that can still achieve a successful intubation. In addition to technique, intubation success also relies on muscle memory from repetitive practice, operator confidence from successful mental visualization, and the ability to calmly troubleshoot a difficult airway.
By Perry Lee, MD (PGY-3)
Tranexamic Acid (TXA) is an antifibrinolytic that inhibits the enzymatic breakdown of fibrin by plasmin.[i] It was first developed in 1962 by Japanese wife and husband researchers, hoping to find an effective treatment for post-partum hemorrhage which was a leading cause of maternal death in Japan at that time.[ii] Given its effectiveness and relative cheap cost, TXA has routinely been included on the World Health Organization’s List of Essential Medicines.[iii] Below is a list of uses for TXA commonly encountered in the emergency department (ED) with supporting research.
By Emerson Posadas, MD, MBA PGY-3
The use of thrombolysis in the management of pulmonary embolism is controversial. While many physicians will give thrombolytics in patients with massive pulmonary embolism, I have found that many physicians are much more hesitant to utilize thrombolysis for sub-massive pulmonary embolism. While there has been significant evidence behind the use of thrombolysis in CVA and cardiac ischemia, the evidence behind its use in pulmonary embolism is much less clear. Yet, pulmonary embolism represents a significant disease process that is associated with high morbidity and mortality. The AHA and American Cardiology Association in the past year has advocated for the use of thrombolytics in both massive and sub-massive pulmonary embolism in select patients.1However, ACEP has yet to release a clinical policy regarding the use of thrombolysis in sub-massive pulmonary embolism. In this review, I will discuss the evidence behind the use of thrombolysis in pulmonary embolism, specifically in sub-massive pulmonary embolism.
By Emerson Posadas, MD, MBA (PGY-3)
Thromboelastography (TEG) is a tool that measures in real-time clot development, stability, and dissolution. It not only measures the coagulation cascade, but also shows the interaction of platelets in clot formation. It is a dynamic measurement, that has in recent years, become more readily available in the emergency department. This blog will review the evidence behind its use in the Emergency Department in the setting of shock in both trauma and medical patients.
Recent Publication by Chief Resident Emerson Posadas:
The presentation of bacterial meningitis can overlap with viral meningitis and other conditions, and emergency clinicians must remain vigilant to avoid delaying treatment for a child with bacterial meningitis. Inflammatory markers, such as procalcitonin, in the serum and cerebrospinal fluid may help distinguish between bacterial meningitis and viral meningitis. Appropriate early antibiotic treatment and management for bacterial meningitis is critical for optimal outcomes. Although debated, corticosteroids should be considered in certain cases. This issue provides evidence-based recommendations for the early identification and appropriate management of bacterial meningitis in pediatric patients.
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By Elizabeth Chen MD PGY-3
Acute Ischemic Stroke (AIS) in the pediatric population is extremely rare, has many mimics, and often presents with signs and symptoms that differ from a typical “adult” stroke. Because the goal for diagnosis and treatment of AIS in adults is 4 hours, these differences often lead to delayed recognition and treatment. In a Canadian study, median interval from time of onset to diagnosis was 22.7 hours. When a stroke occurred in hospital, it still took 12.7 hours to diagnose. When a child had a stroke out of the hospital, it took on average 1.7 hours for patients to present to the hospital, indicating that the time delay to diagnosis was often on the part of the medical staff. Currently, only a handful of large, dedicated pediatric centers have pediatric stroke teams similar to the typical adult “code stroke” teams found in most communities. These pediatric teams are equipped to diagnosis and potentially treat children with AIS quickly but most hospitals are not. The key to improve care for children in the community is for all emergency physicians to be well trained on how to recognize and evaluate children for stroke.
By Emerson Posadas MD MBA PGY-2
This is the first of a series of blog posts about administrative and management aspects of the Emergency Department. The first blog in this series describes the transition from one electronic medical record (EMR) system to a new one in our own Emergency Department and all the challenges we faced.
As part of the American Recovery and Reinvestment Act, all pubic and private healthcare providers were required to adopt electronic medical records in 2014. There have been multiple articles on the transition from paper charting to EMR. However, not much has been discussed regarding the transition from one EMR system to another one. With an ever-increasing amount of electronic platforms available, EMR transitions are a common challenge faced by many hospital systems. At University Medical Center of Southern Nevada (UMC) we recently transitioned from McKesson software to EPIC software as our primary EMR system. With this, there were multiple opportunities to improve our workflow and operations in the emergency department. However, as with all transitions this was not as seamless as envisioned.
Baby It’s Cold Outside: Review of Current Literature and Protocols of Resuscitation of the Accidental Hypothermic Patient
By M. Subramanian, MD and J. Haber, MD
With Punxsutawney Phil predicting another 6 weeks of winter, it’s time for a review of literature on resuscitation of the hypothermic patient. Hypothermia can be a source of anxiety for the emergency physician. The risk of malignant arrest or arrhythmia is very high (and should be expected to occur) in any patient with a core body temperature under 32 degrees Celsius, despite rewarming and resuscitation; this is due to a phenomenon called Rescue Collapse or Afterdrop. Morbidity and mortality are very high in these patients, with less than 50-60% of patients survive neurologically intact after experiencing hypothermic arrest. While there are very few studies on hypothermia resuscitation, there exists some interesting opinions on protocols.
Let’s start at the beginning….
By Schon Roberts MD PGY-3
61yo M with h/o of metastatic adenocarcinoma p/w numbness, tingling, and weakness in B/L UE and LE X 3 weeks. This has worsened in the past 3 days. He is now unable to walk or feed himself. He denies bowel/bladder incontinence, HA, fevers, chills, N/V/D, abdominal pain. He denies any IVD. He was 3 weeks ago able to work full time as an electrician. He complains also of chronic neck and back pain.
Vital Signs are unremarkable. Back is normal appearance. Pt has 4/5 strength in B/L UE and LE. He has rigidity of R arm with spasm. Decreased sensation B/L UE and LE R>L. What is the best treatment option for this pt?
A. Discharge home. This is chronic back pain.
B. Refer patient to both pain management and a spinal surgeon to evaluate for disc herniation
C. Obtain consults from nuclear medicine, spinal surgery, and admit pt. Give steroids
D. Place pt in a TLSO brace and admit to the hospital
E. Start broad spectrum antibiotics: pt has an epidural abscess
By Schon Roberts MD PGY-3
14 mo F, seen 3 days ago in ED with fever and possible UTI p/w new onset rash. She was placed on Omnicef and followed up with her regular doctor today. He sent her for evaluation. Parents state that she has had swelling of her hands and feet. Mother states that she has had a fever for 5 days. Fever was TMax 103 F. She has had adequate PO intake with good urine output and stooling. Parents deny URI Symptoms, N/V/D, or recent travel. Vital Signs show a pulse of 179, RR of 28, Temperature of 102.1 F, and patient has a spO2 of 99% on RA. Physical exam is remarkable for injected sclera, swelling of her hands and the dorsum of her feet. She has an erythematous rash on her trunk and extremities that blanches. It spares the palms and soles. Lungs are CTABL and cardiac exam is unremarkable. What is the best treatment option for this child?
A. Broaden antibiotic coverage for meningitis to include listeria coverage, LP, and admit to the hospital
B. Discharge home; Pt has a URI
C. PO Tylenol, wait for defervescence, and D/C if improved
D. Obtain an echocardiogram, start on high dose ASA, IVIG, and admit
E. Start on steroids and admit with nephrology consult
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