By Elizabeth Rozycki PharmD, BCPS, Specialty Practice Pharmacist, Emergency Medicine, Ohio State University) // Edited by Michael Barrie MD @MikeBarrieMD, OSUEM Assistant Professor // Zach Adams MD, OSUEM PGY1 Resident
A 61 year old female patient presents after a fall and possible seizure activity witnessed by family members. The patient has no history of seizures. On exam the patient has a tongue laceration and apparently lost control of their bladder during the event. The patient has a GCS of 8 and is waxing and waning so the decision is made to intubate for airway protection. Blood pressure is 168/98, hear rate 112 and patient has good oxygen saturation on a non-rebreather. Your friendly and helpful pharmacist inquires about which medications you would like for induction and paralysis. Etomidate? The patient seized… will etomidate lower their seizure threshold?
The Bottom line: Maybe, but the evidence is not great. If possible, use an alternative RSI agent such as propofol or ketamine.
By Chris Paul MD, OSU EM Assistant Professor // Edited by Michael Barrie MD, OSU EM Assistant professor
54 yo F presented with chest pain and shortness of breath for two days
past medical history included prosthetic aortic valve, endocarditis, MI, DM, HTN, HLD, cough variant asthma and stroke
Vital signs -HR 130’s, bp – 110’s, spO2 – low 90s/high 80’s
What’s your interpretation? Plan for management?
By Dr. Daniel Zach Adams, OSUEM resident // edited by Michael Barrie OSUEM Assistant Professor
Out of all the various procedures we’re expected to be able to perform in the ED, a resuscitative thoracotomy (EDT) has to be the most intense but least common, depending on your demographic. EM:RAP did a great job this past month on going through indications, contraindications, and some of the finer details (EM:RAP January Edition – Trauma Surgeons Gone Wild: When to Crack the Chest). My summary:
- Use of bedside US can determine who may benefit from a thoracotomy – i.e. those without evidence of cardiac motion have a survival rate of ZERO (the skinny).
- EAST trauma and the Western Trauma Association guidelines differ:
- Pulseless thoracic penetrating injury WITH signs of life – strong recommendation for EDT
- Pulseless thoracic penetrating injury WITHOUT signs of life – conditional recommendation for EDT
- Pulseless EXTRA-thoracic penetrating injury (not including isolated cranial injuries – obviously) WITH signs of life – conditional recommendation for EDT
- Pulseless EXTRA-thoracic penetrating injury WITHOUT signs of life – conditional recommendation for EDT
- Pulseless BLUNT trauma WITH signs of life – conditional recommendation
- Pulseless BLUNT trauma WITHOUT signs of life – DO NOT PEFORM EDT
- Western Trauma Association
- CPR is utilized as a time marker for performance – check out the algorithm
- Blunt trauma, CPR >10 minutes – no go
- Penetrating trauma, CPR >15 minutes – no go
In our center we rarely do EDT, likely because we see less penetrating thoracic injury than other settings. That said, there’s some good resources out there to stay sharp on this potentially life saving procedure. Something worth watching by Dr. Raul Comibra on YouTube – link – if you’re bored and looking for some more insight. Pretty long, but it goes through a lot to include some technique and covers the Western Trauma Association guidelines in some more detail. As with anything, mental preparation and a solid understanding of the indications, contraindications and how to proceed is key. The details of how to proceed after you get into the chest seems to be the more difficult task – glad we have great trauma colleagues!
A middle-aged African American female presents to your emergency department with two days of diffuse abdominal pain, distention, nausea, emesis and watery diarrhea. She has a history of asthma and hypertension, for which she was recently started on amlodipine/benazeprilat. On physical exam she is mildly tachycardic with non-peritoneal mid-epigastric and LLQ abdominal pain. Initial laboratory investigation is unremarkable other than for mild hypokalemia. An acute abdominal series is ordered demonstrating a non-specific bowel gas pattern. You suspect a small bowel obstruction, but what might you consider given the patient’s history? Surgical adhesions? Diverticulitis?
A CT of the abdomen and pelvis is ordered demonstrating marked small bowel wall thickening. The WBC was normal. Could this be infectious? Lactate – normal, certainly unlikely ischemic. What in the patient’s history could point you towards the cause?
LEARNing Rounds: Learn, Evaluate, Adopt Right Now…
I Think I Have a Fish Bone Near My Wish Bone!
By Colin Kaide MD, OSU EM Assoicate Professor // Edited by Michael Barrie MD, OSU EM Assistant Professor
Chief Complaint: Foreign Body in throat
This patient is a 57 y.o. female with no related past medical history who presents with foreign body sensation in her throat. Patient states this started approximately one hour ago. She was eating fish, and says that she has a fish bone stuck in her throat. She has not had anything to eat or drink since that time. She denies chest pain, shortness of breath. She states that the foreign body sensation has not moved since that time and is located in the left side of her anterior lateral neck, above the sternal notch. Denies fevers. Denies history of similar. No issues with swallowing prior to the sensation.
By Michael Barrie, OSU EM Assistant Professor
As Emergency Physicians we are experts in evaluating acute chest pain. In our sleep we can recite the dangerous causes of chest pain such as acute coronary syndrome, aortic dissection, pulmonary embolism, myocarditis, pneumothorax, etc, etc. In medical school and residency we spent a huge amount of brain power devoted to learning how to diagnose and manage dangerous causes of chest pain. But as a practicing ED doc what I actually see a majority of the time is atypical chest pain.
While we always think “worst first”, it’s worth your time to remember some of the more benign causes, such as reflux, musculoskeletal pain, esophageal spasm so you can give a patient a more specific diagnosis. Let’s take a moment to discuss one of my favorite presentations of atypical chest pain – Precordial Catch Syndrome.
Steroids for Hospitalized Patients with Community Acquired Pneumonia
By Zach Adams, OSU EM Resident // Edited by Michael Barrie, OSU EM Assistant Professor
Do steroids help improve mortality in Pneumonia? An article in the Annals of Internal Medicine attempted to set the record straight in the meta-analysis Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis
What did they find?