The problem isn’t that we forget to consider aortic dissection, but rather that we forget that aortic dissection has an uncommon presentation. Read this week's post on this chest pain "outlier" and how to best approach diagnosis and management of this deadly clinical entity.
The Use of the Angiocatheter in Central Venous Line Insertion
There are two techniques for guide wire insertion when performing central line placement. This week we compare the evidence for the two approaches and provide support for the cathether-over-needle (CON) technique which may prove useful in specific situations.
Is High Flow Nasal Cannula Effective for Adults with Acute Respiratory Distress in the Emergency Department?
HFNC is increasing in popularity in multiple clinical environments despite limited evidence regarding its use, and the effects of HFNC on patient outcomes are still being studied. For the emergency physician, HFNC is a potential tool to be utilized in acute respiratory distress, but is there data to support the use of HFNC for acute respiratory distress in the emergency department?
Acute Compartment Syndrome
Acute compartment syndrome (CS) of the extremity is a clinical diagnosis. However, patients without the ability to convey a good history increase our reliance on objective measures. This week's post will review the characteristics of CS injuries by mechanism and location, utility of clinical symptoms, and the use of compartment pressures in the diagnosis of CS.
To Admit or Not to Admit: Initial Results from the Intermediate-Risk Syncope (IRiS) Study
There is not clear guidance on which patients presenting with syncope to the emergency department should be admitted. This week we discuss new evidence from the IRiS trial that may help with determining which patients may be safe for outpatient work up.
Double Sequence Defibrillation For Vfib
What is better than shocking someone back into rhythm? Shocking them with twice the electricity. This week we discuss the utility of dual sequential defibrillation (DSD) in refractory ventricular fibrillation.
A Visual Guide to Acute Angle Closure Glaucoma
Glaucoma is one of the leading causes of preventable blindness. While most cases are due to chronic open-angle glaucoma, acute angle-closure glaucoma is an ophthalmic emergency. This week we present a visual guide to successful management of these patients in the emergency department.
Asplenia in The Emergency Department
From an infectious perspective, asplenia poses a serious risk factor in acquiring various types of infections. The spleen plays a critical role for the immune system in having a robust response to various encapsulated organisms... Read this week's post to learn more about managing these at risk patients.
Necrotizing Fasciitis: Using EBM to Answer the Big Questions
Necrotizing soft tissue infections (NSTI) are exceedingly difficult to recognize in their early stages, and can resemble a cellulitis. A high index of suspicion must be maintained. This week we briefly summarize the evidence in diagnosis and management of this deadly condition.
Hepatic Encephalopathy In The ED
Over 600,000 adults in the United States have liver cirrhosis, and as many as 30 to 45 percent of these patients will develop overt neuropsychiatric abnormalities. This week we discuss when patients present to the emergency department with signs suggestive of hepatic encephalopathy and how to best evaluate, manage and disposition this complex group.
A Quick Look at Reversal of Novel Anticoagulants
This week we present a graphical approach to reversal of novel anticoagulants in life threatening bleeding! Check out the expert commentary for a deeper dive into the data!
HIV Counseling in the ED: Commonly Asked Questions and How to Answer Them
Testing for HIV in the emergency department (ED) has become a vital topic and policy in hospitals across the country. Early diagnosis of HIV is critical in decreasing transmission rates, in addition to providing better outcomes for patients, as early diagnosis often leads to earlier treatment. Today we discuss how to counsel patients with a new diagnosis of HIV in the ED.
Better than a shotgun approach to diagnosis: Ultrasound in Cholangitis
This week we discuss an interesting case and how bedside ultrasound can help you facilitate rapid diagnosis and disposition of patients presenting to the emergency department with right upper quadrant abdominal pain.
Nibbles and Bits: Management of Dog Bite Wounds
The classic teaching is that bite wounds should not be closed due to concern for infection; however, several studies have challenged this dogma, particularly in low-risk wounds and patients. We discuss the evidence this week on the blog.
Do It Yourself: Dental Emergencies
A simple, do-it-yourself, graphical approach to management of common dental emergencies.
Pulmonary Embolism: Don't Throw Out That EKG!
The EKG is easy to obtain and is certainly useful to potentially exclude or uncover other etiologies of chest pain. Furthermore, an EKG can aid in diagnosis or at least increase suspicion or PE as well as provide prognostic data on an already diagnosed PE. This week we dive into the data regarding EKG analysis in PE.
Infestations
Skin infestations are frequently encountered in the ED, particularly among the homeless population, though data on the number of visits are lacking. While patients with infestations may seem like pests in the middle of a busy shift, these conditions can be a public health menace, and may be markers of serious underlying pathology.
Pneumothorax Part II: Management In The ED
While spontaneous pneumothorax is a common problem encountered by emergency physicians, there remains regular controversy regarding its appropriate management. Read this weeks post to learn more.
What you didn't know about the Holiday Season. A Brief on Holiday Morbidity and Mortality
Author: Matt Klein, MD
Citation: [Peer-Reviewed, Web Publication] Klein M (2016, December 22).What You Didn't Know About The Holiday Season: A Brief On Holiday Morbidity & Mortality [NUEM Blog]. Retrieved from http://www.nuemblog.com/blog/holidazed
Santa Claus and his elves aren’t the only ones preparing for a busy holiday season. Emergency departments across the country are bracing for an influx of casualties as the most wonderful, and possibly the most dangerous, time of the year is underway.
According to an analysis of US death certificates from 1979 to 2004, more deaths occur in, or on arrival to, the ER on Christmas and New Years than on any other day. Beyond mortality, a review of the literature reveals a not-so-heavenly host of hazards threatening to maim Yuletide revelers.
Deck the Halls
National Lampoon’s Christmas Vacation features family man Clark W. Griswold hanging from his gutter while trimming hearth and home, and he’s not alone in holiday mishaps.
The US Consumer Product Safety Commission reports that holiday decorations send an estimated 15,000 injured people – roughly 240 a day during the peak – to local hospitals during the Christmas season.
In a series of patients with holiday-related fractures, one third were injured while putting up decorations, and twice as many fell while attempting to reach an attic.
Among patients presenting to a Level I trauma center with injuries sustained while installing Christmas lights, 30 percent required surgery and more than 10 percent were transferred to a rehab or long-term care facility.
O Christmas Tree
Charlie Brown’s Christmas tree may just need a little love, but it might also require a wide berth.
The National Electronic Injury Surveillance System – a treasure trove of data on what consumer products send their users to the ER – contains records on hundreds of victims of Christmas trees and their decorations.
A 12-year-old sustained second-degree burns after a power socket exploded while plugging in a string of lights, for example, while a three year-old required medical care to remove a piece of a Christmas light bulb shoved up his nose. Surgical case reports describe pediatric tracheostomy and right lower lobectomy following ingestions of decorations.
You’ll Shoot Your Eye Out
Everyone from the school teacher to a department store Santa warns A Christmas Story’s Ralphie that his coveted Red Ryder BB gun will lead him to shooting his eye out, and with good reason.
Holiday ocular trauma, including scratched corneas from gift tags and eyes poked by Christmas tree branches, is commonly reported by ophthalmologists. According to a study from the American Academy of Pediatrics, the face is the most commonly injured body part in children visiting the ER on Christmas.
Assault-related facial trauma, including broken bones and soft tissue injuries, are significantly higher at Christmas than an average non-holiday week of the year. Not surprisingly, the authors of this UK study noted that alcohol played a role in many of the cases.
Blue Christmas
Clarence the angel may never have received his wings in It’s a Wonderful Life without George Bailey’s drunken suicide attempt, but what role does an excess of holiday spirits play in self-destructive behavior?
Australian hospitals see a significant spike in intoxicated patients on the last working day before Christmas, while Finland experiences a peak in fatal alcohol poisonings around the holiday.
In the United States, a review of the National Poison Database System found that suspected intentional exposures were significantly less common on Christmas day, and multiple other studies show a decrease in suicide on December 25th.
The Holly and the Ivy
In 2010, poison centers fielded 750 calls related to poinsettia exposures, but danger of the decorative plant is grossly overstated. The urban myth stems from the unconfirmed death of a two year-old child nearly a century ago. In a review of nearly 23,000 poinsettia exposures published in 1996, zero fatalities were reported.
If you’re intent on finding a sinister Christmas plant, ingestion of holly berries and mistletoe can lead to gastrointestinal symptoms, but they’re rarely dangerous.
Reindeer Games
There are no reported cases of reindeer-induced trauma, let alone grandmothers getting run over by Santa’s favorite mode of transportation. However it may be a good idea to skip the holiday petting zoo. Myiasis, or infection with fly larva, has been described in children as the result of coming in contact with reindeer; two of whom developed ophthalmomyiasis, with one child losing vision in the affected eye.
How can you keep Christmas a time of peace and goodwill? Be careful decorating for the holiday. Keep ornaments out of the reach (and mouths) of children. Drink alcohol in moderation.
Here’s hoping your stockings are hung by the chimney with care, and without a call to 911.
References
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- Tsatsos M, Tsemetzoglou E, Triandaffilidis C et al. Christmas-related eye injuries: a prospective study. Clin Experiment Ophthalmol. 2010;38(1):85-86.
- Gordon R, Dhokia R, Eames N. Christmas related fractures admitted to the fracture department, Northern Ireland. Ulster Med J. 2013;82(3):192-196.
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- Philip J, Bresnihan M, Chambers N. A Christmas tree in the larynx. Paediatr Anaesth. 2004;14(12):1016-20.
- Lloyd B, Matthew S, Livingston M, et al. Alcohol intoxication in the context of major public holidays, sporting and social events: a time-series analysis in Melbourne, Australia, 2000-2009. Addiction. 2013;108(4):701-9.
- Poikolainen K, Leppanen K, Vuori E. Alcohol sales and fatal alcohol poisonings: a time-series analysis. Addiction. 2002;97:1037-40.
- Bergen H, Hawton K. Variation in deliberate self-harm around Christmas and New Year. Soc Sci Med. 2007;65(5):855-67.
- Beauchamp GA, Ho ML, Yin S. Variation in suicide occurrence by day and during major American holidays. J Emerg Med. 2014;46(6):776-81.
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- Evens ZN, Stellpflug SJ. Holiday plants with toxic misconceptions. West J Emerg Med. 2012;13(6):538-42.
- Krenzelok EP, Jacobsen TD, Aronis JM. Poinsettia exposures have good outcomes…just as we thought. Am J Emerg Med. 1996;14(7):671-4.
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- Kan B, Otranto D, Fossen K et al. Dermal swellings and ocular injury after exposure to reindeer. N Engl J Med. 2012;367(25):2456-7.
Cerebral Venous Sinus Thrombosis: The Forgotten Headache
Cerebral venous sinus thrombosis (CVT) is becoming recognized as a more common and treatable disorder in young patients. Unfortunately, headaches are overwhelmingly common complaints in the emergency department (ED), so CVT can be easy to miss since it has confusing clinical and imaging findings. This week we discuss this clinical entity, when to suspect it and what to order.