Management of Upper GI Bleed in the Emergency Department

Author: Aimee Almanzar, MSIV
Medical Student
Universidad Iberoamericana

This post was peer reviewed.
Click to learn more.

Introduction to Upper Gastrointestinal (GI) Bleed
Upper GI bleeding is a potentially life-threatening hemorrhage originating anywhere along the GI tract from the esophagus to the level of the ligament of Treitz. Bleeding from the upper GI tract is four times more common than bleeding from the lower GI tract and is a major cause of morbidity and mortality.[2] Upper GI bleeding is associated with non-steroidal anti-inflammatory drug (NSAID) use, and in patients with a bleeding peptic ulcer, it is associated Helicobacter pylori infections. According to a review in American Family Physician, peptic ulcer bleeding accounts for more than 60% of upper GI bleeding cases.[3] Esophageal varices, most commonly associated with liver disease, [9] make up approximately 6% of upper GI bleeding cases. Other etiologies include arteriovenous malformations, Mallory-Weiss tears, gastritis, duodenitis, and malignancy.[3]

Ocular Emergency: Globe Injury, A Non-Ophthalmologist Approach to Initial Treatment and Referral

Author: Fernando Pellerano, MS-4
Medical Student, Universidad Iberoamericana (UNIBE)

This post was peer reviewed.
Click to learn more.

Ocular emergencies are immediate threats to the visual system that can lead to permanent loss of visual function.[1] Emergency medicine physicians should be able to recognize and provide initial treatment for sight-threatening ophthalmologic emergencies, including globe injury, before referral to an ophthalmologist.

Globe rupture should always be considered as a differential diagnosis in a patient with an eye injury. Patients will complain of moderate to severe pain and decreased vision. Visual acuity may be limited to “counting fingers at 18 inches” or “light perception only.” Pupils should be examined for shape, size, light reflex, and afferent pupillary defect. A peaked, teardrop-shaped, or otherwise irregular pupil may indicate globe rupture (see Image A).[2] Hyphema (blood in the anterior chamber: see Image B) or severe conjunctival hemorrhage involving the area around the cornea are also highly suspicious for globe injury.[2] Physicians may perform the Siedel’s Test to detect aqueous humor leaking from a corneal wound. To perform the test, a fluorescein dye is applied to the affected eye and examined under slit-lamp. The test is positive when a stream of fluorescent dye is seen emanating from the affected eye.[3]

The Graduating Resident Series

Author: Meaghan Mercer, DO
Emergency Medicine Resident
University of Nevada School of Medicine
AAEM/RSA President

The following blog post appeared initially at www.lasvegasemr.com/foam-blog and is reproduced with the permission of the author.

As the year nears an end we are looking at all the residency check boxes that need to be completed but often receive little education about the next step after we leave the doors of academia.

ABEM.org
If you haven’t looked at the website, start now.

You become (board eligible) BE on your date of graduation and initial certification and application: if submitted from April 15- July 1,2015 ($420), July 2- Aug 3, 2015 ($575), and Aug 4- Oct 1, 2015 ($1295). You are able to apply for your board exams starting May 1-Nov 5th and costs $960. The qualifying exam will be available Nov Monday - Saturday, November 16 - 21, 2015. Plan ahead to have ample time to study and have access to the time to take your exam.

Once you pass your written exam you then will be given a date in the spring or fall to take your oral board exam. After you pass the oral board you will be officially board certified for ten years. To maintain your certification you will have to participate in MOC (maintenance of certification). Requirements in the first five full years of certification include the following:

• Passing four ABEM LLSA tests, completing an average of 25 AMA PRA Category 1 CreditsTM or equivalent.
  
• Completion of an Assessment of Practice Performance (APP) patient care Practice Improvement (PI) activity.
  
• Completion of an APP patient-centered communication/professionalism activity. 

Acute Aortic Syndrome

Source: Flickr

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.