Thursday, June 29, 2017

Recognizing and Treating Exertional Heat Stroke

Image Credit: Pixabay
This post was peer reviewed.
Click to learn more.

Author: Patrick M. Brown, MSIV
Western University of Health Sciences College of Osteopathic Medicine of the Pacific


An otherwise healthy 25 year old male is brought to the emergency department (ED) by emergency medical services (EMS) after witnesses saw him collapse while hiking in Arizona on a humid 38.3°C (101°F) summer day. His friends state that he was feeling well and behaving normally before hiking and add that they found his full water bottle in the car on the way to the ED. On physical exam, his temperature is 40.6°C (105.2°F), pulse is 134, blood pressure is 82/60, O2 saturation is 88% on room air and respirations are 21 breaths/min and labored. BMI is 29.3. He currently is unable to answer questions appropriately and appears restless. He is diaphoretic and hot to the touch. Eye exam reveals pupils that are 3mm and reactive to light bilaterally. Crackles are heard bilaterally on lung auscultation. Neurological exam reveals no abnormalities in tone or reflexes and the neck is supple. There are no obvious signs of trauma. His friends state that he is a regular smoker, social drinker and smokes marijuana recreationally. Labs significant for hemoglobin of 17.2, hematocrit of 51.0, WBC of 16.9, BUN of 43, creatinine of 0.9, and 2+ ketones in urine.

Sunday, June 25, 2017

Critical Care Pearl: Metabolic Acidosis: Bicarbonate Drips and Alternative Options

Image Credit: Pixabay
Authors: Victoria Weston, MD; Kevin Bajer, PharmD; and Randy Orr, MD
Northwestern University
Originally Published: Modern Resident, June/July 2013

The focus of this critical care pearl is to discuss the use of bicarbonate drips for severe metabolic acidosis, as well as alternative options, which are available. Given the current nature of medication shortages, it is valuable to learn about the alternative options available for use in some of our most critically ill patients.

When approaching a patient with metabolic acidosis, it is important to consider the cause of their acidosis (e.g., increased generation of acids as in lactic acidosis, ketoacidosis and ingestions vs. loss of bicarbonate or decreased acid excretion). As this is a relatively broad topic, this critical care pearl will focus on the treatment of lactic acidosis, as treatment of ingestions may vary with the substance ingested.

Thursday, June 22, 2017

Image of the Month (From August/September 2011 Issue of Modern Resident)

Author: Casey Grover, MD
Stanford/Kaiser Emergency Medicine
Originally Published: Modern Resident August/September 2011

A 17 month old female is brought to the ED by her mother for emesis and fever. The mother thinks that her daughter may have swallowed something last night because the child had made a "wheezing sound" while breathing and appeared uncomfortable. There was no witnessed ingestion. The child appears well with normal vital signs and is playful and interactive. Her physical exam, including pulmonary examination, is normal.

You order a PA and lateral chest X-ray. What does it show?

Image Credit: Modern Resident
  1. A coin in the esophagus
  2. A coin in the trachea
  3. A bottle cap in the esophagus
  4. A button battery in the esophagus
Click here for the answer.

Sunday, June 18, 2017

Tell Me More: The Basics of Child Forensic Interviewing

Image Credit: Pixabay
This post was peer reviewed.
Click to learn more.


Author: Michelle Mitchell, MD, PGY-1
Duke University Medical Center

Posterior rib fractures in infants. Burns on the buttocks and legs. Mechanism of injury that is not consistent with developmental age. Most physicians will recognize these potential red flags of child abuse. However, many emergency medicine physicians have received little training on how to interview children who present with injuries concerning for child abuse. As physicians, we are not expected to definitively determine if child abuse has occurred. Instead, we often report suspected cases and leave the investigation to the authorities. It is thus important to obtain and document a thorough history in the medical record as it may be used in future court proceedings.

It is imperative that physicians have general knowledge about forensic child interviewing, as the method of interviewing may greatly impact the information that a child provides. Most models of child forensic interviewing have three stages.

Thursday, June 15, 2017

Unexpected Patient Demise in the Emergency Department

Image Credit: Pixabay
Author: Victoria Weston, MD
2015-2016 RSA President
Originally published: Common Sense January/February 2016

I could hear the wails of grief coming from our trauma bay. It was the start of my shift, and the prior team had recently terminated an unsuccessful resuscitation. The patient had been chronically ill and had collapsed while checking in at our triage desk. Although the patient had cancer and had been unwell for years, his family was shocked and devastated by their sudden, unexpected loss.

Sunday, June 11, 2017

Image of the Month (From August/September 2013 Modern Resident)

Author: Michael Gottlieb, MD
Cook County Emergency Medicine Residency
Originally Published: Modern Resident August/September 2013

An 81-year-old man with PMHx of HTN, DM, HL and OA s/p right hip replacement presents to the ED with acute onset CP and SOB x 1 day. While watching TV earlier, he developed a sudden inability to catch his breath, as well as some poorly localized, pleuritic chest tightness on the right side of his chest. He initially attributed this to reflux, but when it did not improve he drove himself to the ED.

His initial vitals are: Temp: 98.2, HR: 56, BP: 132/78, RR: 28, O2 Sat: 89%. Upon examination, he is in moderate distress, appreciably tachypneic and has to stop halfway through his sentences to catch his breath. The remainder of his exam is significant only 2+ pitting edema bilaterally. Labs are pending, a chest X-ray is ordered and his ECG is shown below.

Thursday, June 8, 2017

Photo of the Month (From Apr/May 2013 Issue of Modern Resident)

Author: ENS Dylan Hendy, MSIV
Arizona College of Osteopathic Medicine
Author: LT Christopher D. Helman, DO
Naval Medical Center Portsmouth
Originally Published: Modern Resident, April/May 2013

Patient Vignette
Twenty-nine-year-old male was sent to the ED by a community clinic for a syncopal episode. The patient originally visited the clinic for a headache that resulted from a shelf falling on the back of his head while working in his garage two days earlier. The patient denies losing consciousness, amnesia, disorientation or N/V. However, upon further questioning the patient described an unwitnessed episode of “blacking out” while sitting in his car today. He states this episode may have lasted for 30-60 minutes. The clinic subsequently sent the patient to the ED for further workup. In the ED the patient explained that he has a history of chronic headaches and that his headache at present is similar with regards to onset, location and duration. However, to the best of his knowledge, today’s unwitnessed syncopal episode was a first time occurrence. Further ROS were negative. The patient has no other pertinent PMH and is taking no medications. Complete physical exam was unremarkable. A workup for a closed head injury and syncopal episode was performed. Laboratory data was WNL. Non-contrast CT head and CXR were both unremarkable. The following ECG was obtained:

Image Credit: Modern Resident

Thursday, June 1, 2017

Bark Scorpion Stings

This post was peer reviewed.
Click to learn more.

Author: Ashley Grigsby, DO, PGY-3
Indiana University combined Emergency Medicine/Pediatrics

Centruroides sculpturatus, also known as the bark scorpion, is a type of venomous scorpion found in the Southwestern United States, i.e. Arizona, Nevada, New Mexico and Texas. The majority of these stings occur in Arizona, with a reported 3,498 emergency department (ED) visits in 2010.[1] The bark scorpion’s venom is a neurotoxin that works at axonal sodium channels causing excessive acetylcholine release in the neuromuscular junction. The clinical syndrome is most pronounced in young children, especially under 10 years old, who are most susceptible to the toxin. From 2005-2015, there were 185,000 scorpion calls to the poison centers nationally, 68% from Arizona.[1] Multiple other southwestern states were included in these calls; however, Arizona had the highest rate of neurologic and respiratory symptoms, and hospital admission.