Friday, May 11, 2018

Delayed Sequence Intubation

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Image Source: Wikimedia

Author: Timothy Montrief, MD MPH
Jackson Memorial Hospital

A 55-year-old man is brought in to the emergency department by ambulance with a chief complaint of shortness of breath with associated fevers, chills, and productive cough over the past three days. On arrival, he is agitated, anxious, and repeatedly takes off his non-rebreather, stating that he is becoming increasingly dyspneic. He has an oxygen saturation (SpO2) of 85%, is tachycardic to 115 beats per minute, tachypneic to 24 respirations per minute, and has a blood pressure of 145/90 mm Hg.

Thursday, April 5, 2018

Applications, Barriers, and Future of Point of Care Ultrasound in Limited Resource Communities

Image Source: Wikimedia
Author: Janette Magallanes, MS4
Medical Student
Indiana University School of Medicine

The most common use of point-of-care ultrasound (PoCUS) in the emergency department (ED) is in evaluating trauma patients by assessing for pericardial effusion, pneumothorax, and intra-abdominal hemorrhage. The advantage in such acute settings primarily lies in ultrasound’s ability to minimize delays and quickly narrow down a differential diagnosis. Although there is minimal data on the impact of ultrasound (US) findings on patient outcomes in underserved rural communities, there is data showing that portable ultrasound findings have led to changes in patient management in up to 70% of cases.[1]

Applications of PoCUS
Other relevant applications have been found for PoCUS throughout the world. It has been found to have utility in diagnosing empyema, intussusception, retinal detachment, and fractures, as well as in verifying endotracheal tube placements in neonates and in cardiopulmonary resuscitation.[1] More relevant to developing countries, protocols have been developed to include PoCUS in risk stratifying patients with malaria, predicting progression of dengue fever, and even assessing lymphatic filariasis.[1] There is no question that there is enormous potential in the utility of PoCUS all over the world.

Sunday, March 25, 2018

Emergency Departments: Primary Care of the New Century?

Author: Kenneth K. Chang, MS III
Western University of Health Sciences
AAEM/RSA Education Committee

As aspiring emergency medicine (EM) physicians, what is it that motivates us? Perhaps it was from working as a first responder or in emergency medical services? Or maybe even from shadowing at a busy trauma center or watching a TV show come to life as the ED team rush to diagnose a complex pediatric poisoning? Or maybe, it was a poignant personal experience with serious disease or injury? While these challenging and adrenaline-rush cases provide variety and excitement to the profession, one must always remember that the core of EM is often times primary care medicine. According to the 2014 CDC data, while there were 141.4 million ED visits in the year, only 7.9% of those were critical cases requiring hospital admission.[3] As many as one-third of ED visits are thought to be for primary care complaints.[5] Although there is not a set definition, most of these are defined as non-urgent ED visits, conditions in which a delay of several hours of care would not increase the likelihood of adverse outcomes. In retrospective medical record reviews, non-urgent visits were defined by diagnoses, whether hospital admission was an endpoint, symptoms, and vital signs to name a few. However perceived seriousness of condition by the patient may also be a subjective factor. With changing healthcare policies of our new era, it is inevitable that access to healthcare, especially primary care, will be a significant concern for the younger uninsured and Medicaid population.[4] It is evident that the greatest increase in ED visits between 2006 and 2014 were from the Medicaid population. In that time period, with the exception of injury as the first-listed diagnosis, there has been an increased percentage in medical, mental health/substance abuse, and maternal/neonatal conditions that were managed on an outpatient disposition. From the EM profession’s standpoint, the questions arises: should there be more policy changes and interventions to decrease use of the already overextended ED’s? Or should the EM profession embrace this inevitable change and adapt to care for primary care issues?

Thursday, March 22, 2018

EKG Case Study: Is There More to This Chest Pain?

Author: Ashley Grigsby, DO, PGY-4
Combined Emergency Medicine/Pediatrics
Indiana University


A 32-year-old previously healthy African American male presents via emergency medical services (EMS) for evaluation of chest pain. An ST elevation myocardial infarction (STEMI) code had been activated by EMS based on pre-hospital electrocardiogram (EKG) that had been interpreted as ST elevation in the anterior leads with reciprocal ST depression in the lateral leads. On arrival to the emergency department (ED), the patient appears ill and reports severe crushing chest pain radiating to the arm and down into the abdomen. He is diaphoretic and clutching his chest. His heart rate is 123 beats per minutes, respiratory rate 16 breaths per minute, and blood pressure 210/110 mmHg. He is afebrile. Initial ED EKG is shown below.

Sunday, March 18, 2018

Just a Nick?: Mitigating and Identifying Paracentesis Complications

Image Credit: Wikimedia
Author: Mitchell Zekhtser, MS III
Western University of Health Sciences
AAEM/RSA Vice-Chair of Education Committee

A 60-year-old female with a past medical history of alcoholic cirrhosis presented to the emergency department (ED) with abdominal pain and distension seven hours after undergoing a paracentesis. The patient noted that she routinely had the procedure done at her primary care office, but today she started feeling distended again at an accelerated rate. On exam, the patient was hypotensive with a pressure of 98/57, tachycardic with a heart rate of 110, and had diffuse abdominal tenderness worst in the left lower quadrant (LLQ). A computed tomography (CT) scan revealed blood between the abdominal wall and parietal peritoneum, and complete blood count (CBC) showed an acute drop in hemoglobin. Several hours after presentation, the patient underwent an emergent exploratory laparotomy, which revealed a lacerated left inferior epigastric artery (IEA), likely a result of her recent paracentesis. The patient lost four liters of blood throughout the operation. During her stay, she received a total of five units of packed red blood cells and three units of fresh frozen plasma. While the patient survived the surgery, unfortunately, she passed away two weeks later due to exacerbation of her chronic conditions.