Top 10 Most Read Posts of 2015

Flickr: Epic Fireworks

I would like to take a moment to recognize our Top 10 articles of 2015 and congratulate the authors (see below).

Additionally, I would like to thank each of the AAEM/RSA Blog authors, reviewers, mentors, and editorial staff members for a wonderful and successful 2015.

We are accepting articles for 2016 and we welcome additional faculty mentors; contact us at info@aaemrsa.org with questions. Have a safe and happy holiday season!

Sincerely,
Gregory Wanner, DO
Editor-in-Chief
AAEM/RSA Blog
@gregwanner

1. Osteopathic Emergency Medicine Match by the Numbers
Author: Muhammad Alghanem, MSIV
Medical Student, Midwestern University - Chicago College of Osteopathic Medicine

2. In-Flight Emergencies
Author: Kenneth Young, MD
Emergency Medicine Resident, University of Chicago 

3. Be a Non-Terrible Intern in Ten Easy Steps
Author: Gregory Wanner, DO PA-C
Thomas Jefferson University Hospital

4. Free Resource! 50 Drugs Every EP Should Know 
Authors: Steve Elsbecker, DO and Aryan J. Rahbar, PharmD BCPS
University Medical Center of Southern Nevada

5. Cardiac Infarctions Under Disguise

Author: Joshua Bowers, DO 

Emergency Medicine Resident, Adena Regional Medical Center

6. “A Whole Herd of Zebras:” Anti-NMDA Receptor Encephalitis
Author: Jonathan Morgan, OMSIII
Medical Student, Lake Erie College of Osteopathic Medicine-Bradenton

7.  ACE-Inhibitor Induced Angioedema
Author: Kaylinn Dokken, MSIII
Medical Student, Western University of Health Sciences

8. Updates on LBBB and STEMI
Author: Meaghan Mercer, DO
Emergency Medicine Resident, University of Nevada School of Medicine
AAEM/RSA Immediate Past President

9.  Management of Open Fractures in the Emergency Department 
Author: Bill Mulkerin, MD
Stanford/Kaiser Emergency Medicine Residency

10. Ocular Emergency: Globe Injury, A Non-Ophthalmologist Approach to Initial Treatment and Referral
Author: Fernando Pellerano, MS-4
Medical Student, Universidad Iberoamericana (UNIBE)

A FOAM Favela

Photo Credit: Flickr Dany13

Author: Sean Weaver, DO MPH and Nathan Cleveland, MD MS
University of Nevada School of Medicine

Originally Published: Common Sense, November/December 2015

Favela is a term from Brazilian Portuguese that refers to a heavily populated, urban, informal settlement. In other words, a shanty town. Born out of necessity, favelas look disorganized, haphazard, temporary, and chaotic. To its inhabitants, however, the favela represents a vibrant and constantly evolving community built on cooperative living. This vibrancy has led to some of Brazil’s most famous cultural contributions. Samba, capoeira, and funk all came from favelas.[1]

Free Open-Access Meducation (FOAM) is the favela of medical education. Early adopters of social media in emergency medicine and critical care began sharing information through Facebook, Twitter, podcasts, and blogs. As connections were made, experts began spontaneously discussing ideas and practice habits. These conversations were open to the public and anyone could participate. Over time, a structure began to develop and the number of participants increased.[2] In 2012, over a pint of Guinness, emergency physicians Sean Rothwell and Mike Cadogan named this informal online community “FOAM.”[3]

Retinal Detachment: What You Need to Know

Image Credit: Subhadra Jalal - Flickr

Author: Stephanie Cihlar, MSIII
Medical Student
Loyola University Chicago Stritch School of Medicine
AAEM/RSA Publications Committee Member

This post was peer reviewed.
Click to learn more.

Introduction
Retinal detachment is one of the most common ophthalmic emergencies, affecting approximately 1 in 10,000 people per year.[1] Because of the risk of permanent vision loss, it is important that emergency physicians are able to identify a retinal detachment and consult a retinal specialist as soon as possible.

Pathophysiology
Retinal photoreceptors (rod and cones) are metabolically highly active cells. In fact, the choroidal circulation responsible for nourishing these cells has the highest blood flow per cubic centimeter of tissue found in the human body.[2] In a retinal detachment, the neurosensory layer of the retina is peeled away from its underlying supporting tissues, the retinal pigment epithelium and choroid. The photoreceptors undergo ischemic damage, which can lead to vision loss and blindness in a matter of hours.[3]

Board Review: Hypothermia/Cold Water Submersion

Author: Kevin P. Beres, DO PGY-1
UTHealth Emergency Medicine Resident

Originally Published: Modern Resident, April/May 2015 

Growing up in Wisconsin, one of the beloved New Year’s traditions was the polar bear plunge, which translates to a group of people jumping into the cold lakes on New Year’s Day. This event brings up two important concepts: cold water submersion and accidental hypothermia. Risk factors for accidental hypothermia include alcohol, AMS, behavior, extreme ages and certain comorbidities including peripheral vascular disease, trauma and diabetes mellitus.[1,2]

Cold Water Submersion:
When the body comes into contact with cold water, it leads to activation of the Mammalian diving reflex, resulting in bradycardia, shunting of blood to the CNS system and slow metabolism and may actually prolong survival.[1] This reflex affects children more efficiently than adults. Alcohol has been shown to reduce this reflex.[3]

Chilblains:
Chilblains are red and/or blue edematous plaques and papules that appear on the distal extremities that occur secondary to prolonged cold exposure. A variety of sensory symptoms such as itching or burning can accompany the skin changes.[1]

Maisonneuve Fracture - A can’t miss diagnosis!

Author: Benjamin Lindquist, MD

This post was peer reviewed.
Click to learn more.

Chief Resident
Stanford/Kaiser Emergency Medicine Residency

A 50 year-old male pedestrian presented to the emergency department by ambulance after having his left foot struck by a bicyclist while the foot was firmly planted on the ground. He complained of severe pain to his medial ankle but denied knee or hip pain. He had no other injuries. On examination, he had slight eversion at the ankle with significant tenderness over the medial malleolus. He also had tenderness over his proximal fibula. He had normal strength, sensation and pulses.

X-ray showed widening of the medial tibiotalar joint space (Image A) and a comminuted fracture of the proximal fibula (Image B). These findings are suggestive of a Maisonneuve fracture with syndesmotic ligament disruption. He was placed in a splint and referred to orthopedic surgery. Ten days later, he underwent operative fixation of his syndesmotic ligament injury.

In evaluating patients with ankle injury, it is imperative to assess for concomitant proximal fibular fractures. As in this case, it is common for patients to complain only of ankle pain and not pain around the proximal fibula. However, Maisonneuve fractures are often unstable and require surgical fixation, whereas isolated fibular fractures or deltoid ligament sprains are managed nonsurgically.

Image A: Anteroposterior view L ankle

Image B: Anteroposterior view L tibia-fibula

References:

Taweel NR, Raikin SM, Karanjia HN, Ahmad J. The proximal fibula should be examined in all patients with ankle injury: a case series of missed maisonneuve fractures. J Emerg Med. 2013;44(2):e251-5. PMID: 23079149

Five Things to Keep in Mind When Treating an Asthmatic

Image from Alan Levine

This post was peer reviewed.
Click to learn more.

Author: Puja Gopal, MD
Emergency Medicine Resident
University of Illinois at Chicago
AAEM/RSA Publications Committee Member

Asthmatic patients present along a broad spectrum of severity. There are those who present with mild wheezing, have complete resolution with a single neb treatment, and go home with a refill of their albuterol inhaler. And then there are those patients who present unable to speak or breathe and become increasingly agitated and altered. Though presentations of asthmatic patients may vary greatly, there are some key things you can keep in mind with the asthmatics you see.

1. Monitor the patient and the 5 key vital signs closely – temperature, pulse, respiratory rate, blood pressure and oxygen saturation. Heart rate above 120 and respiratory rate above 30 are concerning for a severe asthma exacerbation. Also note that a decreasing respiratory rate can be concerning for the inability to maintain respiratory effort and possible decompensation. An oxygen saturation <90% is hypoxemia and requires your attention. Monitoring your patient’s mental status is of utmost importance to ensure they don’t become agitated or altered – both of which can occur with hypoxia and/or hypercapnia.[1]
   

Pre- and Post-Intubation Issues and Solutions

Photo Credit: Borls Ott - Flickr

This post was peer reviewed.
Click to learn more.

Author: Andrew V. Bokarius, MD
Emergency Medicine Resident
University of Chicago




There are a number of issues that may come up prior to, during, and after successful intubation. Let’s take a look at a few common problems and possible solutions.


 Pre-intubation:

• Can’t mask ventilate:
• Turn head to the side, consider oral/nasal airway or LMA.2 

• Can’t intubate, patient has a Grade 4/Mallampati Class 4 view:
• Change position or equipment, i.e., ear to sternal notch, B.U.R.P. maneuver (backward-upward-rightward-pressure or modified cricoid pressure), change blades, or consider a bougie, Glidescope, or other fiberoptic device.[1]  

A Cannot Miss Cause of Bradycardia

This post was peer reviewed.
Click to learn more.

Author: Daniel Balk, MD
Emergency Medicine Resident
Drexel University College of Medicine

The Case:

The tech hands the physician this EKG:

It’s slow with a rate of 37, it’s irregular, it’s wide with a QRS of 130, it’s scary, and there is no previous EKG. The tech doesn’t know the patient’s story as “he speaks only Portuguese” and his chief complaint is hypoglycemia.

Glancing at the monitor as the physician rushes towards the room, the blood pressure is 138/71. This elderly Brazilian traveller (with a prior history of two cardiac stents, hypertension and diabetes) is discussing with his family whether his two days of diarrhea caused his sugar to be low all day despite foregoing his insulin. His blood glucose was 40 this morning; it’s 135 now after eating normally all day and skipping his long acting and mealtime insulin doses. The review of systems is entirely negative other than for diarrhea and hypoglycemia. Other than marked bradycardia, the exam is unremarkable.

Acute Aortic Syndrome

Photo Credit: Charlotte Astrid

Author: Nathan Haas, MD PGY-1
University of Michigan

Originally Published: Modern Resident, February/March 2015

The acute onset of severe, ripping chest pain radiating to the back quickly brings to mind the diagnosis of aortic dissection. However, dissection is just one potential etiology of Acute Aortic Syndrome (AAS) which includes the acute presentation of aortic dissection, penetrating atherosclerotic ulcer, intramural hematoma, aneurismal leak and traumatic transection. Overlap frequently exists between these processes, and the various etiologies within AAS in some ways represent more of a spectrum of disease than distinct entities.

Aortic dissection results from an intimal tear penetrating the aortic media, with progressive dissection of the media creating a false lumen. Contrarily, a penetrating atherosclerotic ulcer occurs at the site of a preexisting atherosclerotic plaque and is the result of intimal erosion through to the media. Intramural hematoma is defined as a blood collection in the media without the presence of an intimal flap and physiologically is driven by the rupture of vasa vasorum. Aneurismal leaks are related to the acute expansion of a preexisting aortic aneurism. Traumatic transection most frequently occurs secondary to a rapid deceleration injury and classically occurs immediately distal to the left subclavian artery at the ligamentum arteriosum.