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By: Kelvy Levit, PGY3
Reviewed by: David Slattery, MD The ED thoracotomy (EDT) was originally intended as an access point for open cardiac massage to treat cardiac arrest prior to the 1960’s. Interestingly, this was the only method of providing CPR until closed chest compressions were described by Dr. Kowenhoven in 1960 (1). The ED thoracotomy, also known as a resuscitative thoracotomy (RT), is a controversial but potentially lifesaving procedure in certain patients. It involves exposure of the heart, lungs, and major vessels with the hope that the source of injury can be identified and managed. It is a temporizing measure and usually considered a last resort until definitive treatment in the operating room. Survival rates after an EDT have been shown to be as high as 35% in hypotensive patients with isolated cardiac injuries and 20% in isolated cardiac injuries presenting without signs of life. Survival rates are around 1 to 2% in blunt trauma patients (2). It’s important to know your limitations as an emergency physician performing this procedure. The most likely and most critical interventions that the EM physician can perform are:
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By: Chase Hamilton, PGY3
Reviewed by: Brian Ault, DO High-pressure injection injuries are rare injuries that are typically characterized by small puncture wounds whose severity is easily underestimated by physicians and patients. These injuries result from equipment malfunction or misuse that eject a pressurized material with enough force to penetrate human skin. The force is typically generated by the machinery is 3,000 to 10,000 pounds per square inch (PSI). A force of 100 PSI is sufficient to break the skin. Most commonly high-injection injuries occur to the non-dominant hand. These injuries are uncommon yet have high morbidity. The rate of injury is related to the material injected. Studies have shown amputation rates of the affected limb as high as 50% for organic solvents 1. Even if debridement occurs within 6 hours for paint thinner, jet fuel, petrol, or oil the amputation rate is still 38%, compared to 58% amputation rate when treatment occurs over 6 hours. High caustic agents like turpentine and paint solvents, along with higher injection pressures have an amputation rate of about 80% even with appropriate care 2. Organic solvents include paint, paint thinner, diesel fuel, jet fuel, oils, etc. By: Chase Hamilton, PGY3
Reviewed by: David Slattery, MD Acute ST-elevation myocardial infarction is a “must-not-miss” in the world of medicine. Time is myocardium. Along with that adage is the importance of early detection and prevention of myocardial injury and potential infarction. Electrocardiograms (ECGs) are not highly sensitive in detecting early signs of potential ischemia. Also, ECG reading and interpretation is physician dependent and based on experience and education. These two factors make it difficult to reliably detect potential signs of early myocardial damage without infarction or ischemia. The morphology of the T wave in V1 can be a herring for early left anterior descending (LAD) artery disease in patients with active symptoms. The normal morphology of the T wave in V1 is inverted or flat. An upright T wave with active chest pain should make the physician more seriously consider cardiac etiology and further evaluate and study the ECG and/or ensure serial ECGs are performed2. The upright T wave is considered a type of hyperacute T wave. Specifically, it should be considered hyperacute if the T wave in V1 is larger than the T wave in V6. This is described as loss of precordial T wave balance by Marriott et al. Literature has found that it was present in 36% of subtle LAD occlusion versus 16% of precordial early repolarization1,3. By: Kelvy Levit, PGY3
Reviewed by: David Slattery, MD Violence is rising at a concerning rate in emergency departments. According to a national survey by American College of Emergency Physicians’ (ACEP), almost 50% of emergency physicians and nearly 70% of emergency nurses report being physically assaulted at work. A troubling 97% of assailants were patients (1). With these staggering statistics in mind, it’s important to not only have preventative measures in place, but also a management plan when dealing with agitated, combative, and altered patients. Dealing with the agitated patient can be distressing to not only the emergency physician but also to the staff involved directly or indirectly. As providers, we are prone to cognitive errors during times of high stress. This blog will discuss the approach to the agitated patient to include verbal de-escalation techniques, options for chemical sedation, and an overview of the current literature supporting practice recommendations. By Jason David, PGY3, Aaron Johnson, PGY3, and Jerad Eldred, PGY1
Working in a county hospital, we witness healthcare disparities and the consequences of poor access to healthcare every day. Some of our residents shed light on some of the unfortunate consequences of poor healthcare access in our Las Vegas community. Hernias with loss of domain are often a consequence of poor access to surgical care and require extensive planning and management. Emergency medicine and general surgery communities should collaborate on what constitutes a need for urgent surgical intervention or the need for surgical coordination without primary care acting as an additional step/obstacle. Read the full article in EM Resident here: https://www.emra.org/emresident/article/scrotal-hernia/ By Patrick Wallace, DO PGY3 and Jordana Haber, MD
Night shift is not unique to the specialty of Emergency Medicine, but we are required to remain alert and efficient throughout the entire night. In order to have a successful career in Emergency Medicine, it is imperative that you conquer the night shift as well as the rapid transition from days to nights. What does the science say we should do to prepare for night shift and the accompanying circadian transitions? This article discusses the top ten evidence based practices that you can implement to improve efficiency, alertness, productivity, and transitions for night shifts to include the importance of light, timing of caffeine, timing your pre shift nap, and what foods you should be eating. Check out Dr. Wallace's full article in EMJ here: https://emj.bmj.com/content/37/9/562 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. |
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June 2021
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