Contributor: Adam Barkin, MD Educational Pearls: Multi-center open-label non-inferiority trial looked at treatment of pneumothorax with a small-bore chest tube versus conservative management with exceptional follow up 316 patients ages 14-50 with moderate to large pneumothorax (>32% measured on CXR) were randomized into one of the two treatment arms 15% of the conservative group required further intervention as determined by prespecified protocols 94.4% of the intervention group had resolution a...
Aug 16, 2021•5 min
Contributor: Randi Libbon, MD The Core features of trauma-informed care include: Patient empowerment, choice and collaboration. This means educating patients and allowing patients to make choices about their care when possible. Collaboration helps to level the power differential between patients and providers through shared decision making. Safety and sensitivity: Developing health care settings and activities that ensure patients’ physical and emotional safety taking into account their diverse ...
Aug 11, 2021•9 min
Contributor: Neil Cella, MD Educational Pearls: 10% of patients 100.4) have an serious bacterial infection Most of these are UTIs, but also consider pneumonia and meningitis Requires CXR, LP, labs, and UA to work up cause of fever 29-60 day old well-appearing febrile infant: Can discharge without abx if CXR, lumbar puncture, labs and UA without signs of bacterial infection If UA is positive for UTI a LP is still indicated for febrile infants References Hamilton JL, Evans SG, Bakshi M. Management...
Aug 10, 2021•5 min
Contributor: Aaron Lessen, MD Educational Pearls: Known risk factors for being awake and paralyzed in the OR include only receiving IV medications, long-acting paralytics, and no formal monitoring system for being awake The ED-AWARENESS study, a prospective single-center study found 2.6% of patients with induced paralysis during mechanical ventilation were aware Rocuronium was a risk factor for developing awareness while paralyzed in this study Ensure adequate sedation during paralysis for mecha...
Aug 09, 2021•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Recent retrospective cohort study looked at elevated BP readings in the ED and correlation to underlying hypertension Large cohort of over 30,000 patients found that nearly 50% had an elevated blood pressure reading in the ED Less than 15% of patients with elevated BP readings in the ED were diagnosed with hypertension within 2 years Only 25% of patients with BP readings >160/100 were diagnosed with hypertension within 2 years Patients with an el...
Aug 03, 2021•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Recent RCT compared pain relief in patients receiving five medications for acute musculoskeletal pain Acetaminophen 1000mg/ibuprofen 400 mg Acetaminophen 1000mg/ibuprofen 800 mg Acetaminophen 300 mg/codeine 30 mg Acetaminophen 300mg/hydrocodone 5mg Acetaminophen 325mg/oxycodone 5mg No significant difference in pain relief at 1 and 2 hours between all of 5 groups References Bijur PE, Friedman BW, Irizarry E, Chang AK, Gallagher EJ. A Randomized Tr...
Aug 02, 2021•2 min
Contributor: Aaron Lessen, MD Educational Pearls: Traditionally, fingernails were replaced after avulsion using sutures Sometimes artificial material was placed when the fingernail was not available Recent study evaluated treatment of fingernail avulsions pediatric patients by replacing the nail versus cleaning and putting a non-adhesive dressing No difference in the aesthetics or patient satisfaction with the new fingernail between the two treatment groups References Seiler M, Gerstenberg A, Ka...
Jul 28, 2021•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Survey of EM physicians to self-report empathy and burnout levels and correlated with patient satisfaction scores Patient satisfaction was not affected by what the physicians thought about their level of empathy or burnout Patient satisfaction was affected by the patient’s perception of empathetic behavior by the physician References Byrd J, Knowles H, Moore S, et al. Synergistic effects of emergency physician empathy and burnout on patient satis...
Jul 27, 2021•3 min
Contributor: Aaron Lessen, MD Educational Pearls: Kounis syndrome is an allergic acute coronary syndrome Triggers include medications (antibiotics), insect bites, or other common allergens Believed to be due to mast cell activation, inflammatory cytokines, and platelet activation causing coronary vasospasm or plaque rupture in setting of existing atherosclerosis Consider Kounis syndrome in the setting of chest pain in anaphylaxis Treatment involves treatment of allergic reaction, although epinep...
Jul 26, 2021•3 min
Contributor: Peter Bakes, MD Educational Pearls: ST elevation clinical guidelines for myocardial infarction include: 2.5 mm elevation for males 2 mm elevation in males >40 in V2 and V3 1.5 mm elevation for females in V2 and V3 1 mm elevation in 2 or more contiguous leads (not V2 or V3) Differential diagnosis of ST elevation includes, but is not limited to: STEMI Electrolyte abnormalities Pericarditis/myocarditis Brugada syndrome LVH Bundle branch blocks Ventricular aneurysm References de Bliek E...
Jul 21, 2021•5 min
Educational Pearls: Albert Einstein had chronic abdominal pain as a middle-aged man Dr. Rudolph Nissen, founder of the Nissen fundoplication, performed exploratory surgery for this pain and found an abdominal aortic aneurysm (AAA) The only treatment for an AAA at that time was to wrap the vessel in cellophane, causing a fibrotic response to prevent rupture Einstein died 7 years after this surgery, likely from his leaking abdominal aortic aneurysm References Cervantes Castro J. Albert Einstein y ...
Jul 20, 2021•3 min
Contributor: Nick Hatch, MD Educational Pearls: Complete heart block or 3rd degree atrioventricular (AV) block is diagnosed via EKG and occurs when electrical signals from the sinoatrial (SA) node are blocked from reaching the ventricles via the AV node and AV bundles P waves and QRS complexes are independent Often QRS rate is around 40 The rate is slow because the ventricular purkinje fibers have an intrinsic rate of 20-40 bpm, whereas the SA node has an intrinsic rate of 60-100 bpm Treatment i...
Jul 19, 2021•5 min
Contributor: Nick Tsipis, MD Educational Pearls: Humerus fractures can be characterized as proximal, midshaft, and distal fractures Proximal humerus fracture is the second-most common fracture in elderly patients Primary complication is with the axillary nerve and axillary artery Vast majority are managed nonoperatively with a sling, reduction usually not indicated Women comprise 70% of proximal humerus fractures, often secondary to fall with osteoporosis Midshaft humerus fractures are more ofte...
Jul 14, 2021•8 min
Contributor: Peter Bakes, MD Educational Pearls: Pelvis is comprised of the iliac, ischium, and sacrum Three mechanisms for pelvic fractures by Young-Burgess Classification Anterior-posterior compression causing open-book pelvic fractures that can be complicated by retroperitoneal bleeding or urethral injury Lateral compression causing rami fractures Vertical sheer causing offset of sacroiliac joint or sacrum Mechanically stable pelvic ring fractures can be conservatively treated with weight bea...
Jul 13, 2021•4 min
Contributor: Ricky Dhaliwal, MD Educational Pearls: CRASH 3 Trial looked at over 12,000 patients with traumatic intracranial bleeds, randomizing patients to a therapy with TXA or standard of care without TXA Dosing was 1 gram over 10 min for loading dose and then an infusion of 1 gram over 8 hours Found Improvement in survival and neurologic outcomes when patient received TXA within 3 hours References CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusiv...
Jul 12, 2021•3 min
Contributor: Chris Holmes, MD Educational Pearls: In the 1700s, boxes lined the River Thames to pump smoke up the rectum to resuscitate people who had been found unconscious in the river Sea cucumbers can extract oxygen through their rectum Perflourocarbon, a liquid that can become oxygenated, provided rectally was able to oxygenate pigs and mice in a recent study References Okabe R, Chen-Yoshikawa T, Yoneyama Y, et al. Mammalian enteral ventilation ameliorates respiratory failure. Clinical and ...
Jul 07, 2021•4 min
Contributor: Ricky Dhaliwal, MD Educational Pearls: Hypotension in patients requiring intubation should be resuscitated as much as possible While intubating, the negative inspiratory pressure goes away decreasing cardiac preload and worsening hypotension Phenylephrine can be given via push doses to increase blood pressure from alpha agonism For sedation, avoid propofol with hypotension and opt for etomidate or ketamine References April MD, Arana A, Schauer SG, et al. Ketamine Versus Etomidate an...
Jul 06, 2021•4 min
Contributor: Aaron Lessen, MD Educational Pearls: DEVT Trial, a recent non-inferiority study, looked at giving tPA prior to endovascular thrombectomy and was stopped early because there was no benefit shown to giving tPA before this intervention Coupled with the SKIP and DIRECT MT trials corroborating these findings, it appears that giving tPA prior to thrombectomy is not indicated Whether patients should receive tPA prior to transfer for thrombectomy (i.e. they are in a rural healthcare setting...
Jul 05, 2021•3 min
Contributor: Jared Scott, MD Educational Pearls: PID (pelvic inflammatory disease) occurs when the infection ascends into the uterus Tubo-ovarian abscess occurs when the infection ascends to the fallopian tubes Fitz-Hugh-Curtis syndrome occurs when the infection enters the peritoneum and causes peritoneal inflammation with peri-hepatic inflammation These conditions require GYN consultation and often more robust antibiotic therapy for treatment References Lareau SM, Beigi RH. Pelvic inflammatory ...
Jun 30, 2021•5 min
Contributor: Jared Scott, MD Educational Pearls: Recent study evaluated vaginal self swab testing for STIs to determine if they are equally sensitive to provider-obtained swab 515 patients consented to both tests and 95% agreement was found between the two methods of obtaining samples 75% of participants who preferred this over the pelvic exam, although some patients were concerned they did not perform the self swab correctly Consider vaginal self swab with proper coaching as an option for patie...
Jun 29, 2021•3 min
Contributor: Dr. Nick Gorton, MD Educational Pearls: Use transgender people’s correct names and pronouns, the Russell study found a 56% reduction in suicide behavior with chosen name usage ⅕ to ½ of transgender people report they avoided seeking care in the ED because of fear of transphobic treatment Understanding the definitions of gender identity, gender expression, assigned sex at birth, physical attraction, and emotional attraction are necessary for improving treatment of the LGBTIQ+ communi...
Jun 28, 2021•10 min
Contributor: Nick Tsipis, MD Educational Pearls: pH 7.45=alkalemia If pH low and pCO2 high, indicates a respiratory acidosis If pH low and pCO2 low, indicates metabolic acidosis After determining type of acidosis, check bicarb to determine compensation for acidosis and check electrolytes to calculate anion gap Metabolic acidosis can present with tachypnea (Kussmaul breathing) and hypotension due to loss of catecholamine function and suboptimal cardiac function at low pH Treat with IV fluids and ...
Jun 23, 2021•6 min
Contributor: Jared Scott, MD Educational Pearls: Around 30 patients with cannabinoid hyperemesis syndrome (CHS) randomized treatment in three arms with 8mg Zofran, Haldol 0.05 mg/kg, and Haldol 0.1 mg/kg Haldol arms performed better on all measures compared to Zofran Extrapyramidal symptoms were significantly higher in the Haldol group than Zofran, especially the high-dose Haldol group References Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus...
Jun 22, 2021•5 min
Contributor: Gretchen Hinson, MD Educational Pearls: Pit vipers include cottonmouths, rattlesnakes, and copperheads All have folding long fangs, triangular face, and elliptical pupils About 5,000 snakebites per year reported to Poison Control Initially develop a local reaction (swelling, bruising, pain, bullae) Complications can include 25% of snake bites result in no envenomation (dry bites) 20% of bites have serious side-effects, which can include hematologic, cardiovascular, neurologic and, m...
Jun 21, 2021•7 min
Contributor: Adam Barkin, MD Educational Pearls: Internal hernias, when bowel herniates through iatrogenic or congenital defect in mesentery, represent 1-6% of all small bowel obstructions Mortality of strangulated internal hernias is over 50% due to bowel necrosis and sepsis Intermittent symptoms presenting with nausea, vomiting, abdominal pain, abdominal distension Increased risk in patients with gastric bypass, liver transplant, or laparascopic surgery CT is very >90% sensitivity and specific...
Jun 16, 2021•5 min
Contributor: Adam Barkin, MD Educational Pearls: Spontaneous coronary artery dissection (SCAD) is the most common cause of acute MI in women under 50 years old Risk factors include fibromuscular dysplasia, extreme exercise, stress, pregnancy, and recent birth Diagnosed in cath lab but medically managed and usually do not get a stent Treated with dual antiplatelet therapy and beta-blockers References Yip A, Saw J. Spontaneous coronary artery dissection-A review. Cardiovasc Diagn Ther. 2015;5(1):3...
Jun 15, 2021•4 min
Contributor: Peter Bakes, MD Educational Pearls: Community-acquired pneumonia (CAP) is normally stratified into outpatient-candidates vs. inpatient candidates for treatment For outpatient treatment, antibiotic selection is driven by presence or absence comorbid health conditions (chronic lung/kidney/liver disease, DM, immunocompromised state, alcoholism, asplenia) No comorbidities: High dose amoxicillin, doxycycline, azithromycin Comorbidities: augmentin, cephalosporin, doxycycline, macrolide wi...
Jun 09, 2021•7 min
Contributor: Aaron Lessen, MD Educational Pearls: Refractory ventricular fibrillation, defined as 3 defibrillation shocks without resolution, was studied via RCT looking to compare ECMO with cardiac cath vs. typical resuscitation After 30 patients (15 each arm), the trial was stopped because such a significant benefit seen in the ECMO arm 6 patients survived and 3 had good neurological outcomes at 6 months with ECMO This is compared to 1 patient surviving initially and none surviving at 6 months...
Jun 08, 2021•4 min
Contributor: Jared Scott, MD Educational Pearls: Hand eczema is present in about 10% of the population and has a great prevalence in hairdressers, healthcare workers, and food service employees Using 1% oatmeal cream instead of a base cream showed statistically significant improvement in outcomes of HE in healthcare workers in a double-blind study References Sobhan M, Hojati M, Vafaie SY, Ahmadimoghaddam D, Mohammadi Y, Mehrpooya M. The Efficacy of Colloidal Oatmeal Cream 1% as Add-on Therapy in...
Jun 07, 2021•4 min
Contributor: Sam Killian, MD Educational Pearls: Patients with cirrhosis and ascites are frequently evaluated for spontaneous bacterial peritonitis, an infection of the ascites fluid that is not from a surgically treated source Fever, abdominal pain, and altered mental status should all raise clinical suspicion in a patient with ascites Fluid from paracentesis may show increased WBCS (polys and neutrophils), high LDH, high amylase, and decreased glucose Outcomes are very poor in these patients w...
May 31, 2021•4 min
