Core Emergency Medicine

Orogastric lavage is rarely used but remains an important intervention in specific situations.

This post discusses recognition and treatment of cholangitis; a life-threatening disorder.

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This week we dive into a recent article on pain control in renal colic and how it affects our management.

This week we look at the rarely used, but potentially life-saving, procedure of gastric lavage.

Core Procedures See More →

How to Reduce a TMJ Dislocation - Internal Reduction and the "Syringe" Technique

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Review of the Bed-Up-Head-Elevated position for intubation.

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Jun242016
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Editor: Christie Lech

Background: 

The prevalence of adult alcohol abuse and dependence in the United States ranges from 7% to 16% (Muncie 2013). There are an estimated 500,000 cases of alcohol withdrawal syndrome (AWS) requiring pharmacologic intervention every year (Hoffman 2015).  In addition, alcoholism has a large economic burden with annual health related costs estimated to be over $220 billion (Bouchery 2006).
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Apr012016
medstudentbooks.com

Like many other young professionals in Manhattan, I grew up out in the suburbs on Long Island hoping to one day make it to the big city.  As I maneuvered through the maze of my adolescence, I vividly remember being mesmerized by the bright lights and the unrelenting energy of the concrete jungle; it was where I needed to be.
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Jan052016
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This post was previously published on iTeachEM on 9/22/14 here.

A 44-year-old healthy man presents with dull chest pain for 3 hours. His EKG is unremarkable. What’s his risk for acute coronary syndrome? Should he get a troponin? Two troponins? Observation and a stress test?

Emergency Medicine is an inherently risky specialty.
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The “Syringe” technique: a hands-free approach for the reduction of acute non traumatic temporomandibular dislocations in the Emergency Departmen J Emerg Med, 2001

Acute nontraumatic temporomandibular joint (TMJ) dislocations are uncommon presentations in the ED that occur after excessive mouth opening. Common circumstances include laughing,
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Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multi group, randomized controlled trial Lancet, 1974

Ureteric colic is a common cause of severe pain. Anecdotally, many patients describe it as “the worst pain” they’ve experienced.
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Core Case of the Month More Cases →

CC

"a piece of turkey stuck in my throat"

HPI

39 yo F with no PMH presented with “a piece of turkey got stuck in my throat” during dinner. Immediately afterwards, reports non-bloody, non-bilious vomiting with relief of foreign body sensation. Now unable to swallow saliva. Denied any fever, throat pain, chest pain, shortness of breath, trouble breathing, voice changes, cough, nausea, abdominal pain, back pain. Currently has no pain.

Physical Exam

AF, HR 86 ,BP 109/87, RR 18, 100%RA
Well-developed, well-nourished, alert, not toxic, NAD, spitting clear saliva into cup
NCAT, EOMI, PERRL, OP clear, MMM
FROM of neck, no TTP
RRR, nml S1/2, no m/r/g
CTA b/l, no w/c/r, speaking in full sentences, no accessory muscle use
Soft, ntnd, no r/g

Questions

  1. 1) What are the key features of this history and physical?

    The patient denied any choking, coughing or trouble breathing, which suggests that there is no respiratory compromise. The patient’s inability to swallow her saliva suggests a complete esophageal obstruction and is an indication for consultation for emergent endoscopy as she likely has a complete obstruction of her esophagus. If the patient is handling secretion but a food bolus is suspected urgent upper endoscopy is acceptable within 24 hours. Of note, approximately 85% of food impactions are meat (Longstreth, 2001). Food impactions most often occur at areas of esophageal narrowing such at the upper esophageal sphincter, diaphragmatic hiatus, the level of the arch of the aorta or another pathological narrowing.

  2. What are the next steps in managing this patient?

    As with all patients, first start with the ABC’s. You will also need to get pre-operative labs for preparation for endoscopy and chest radiograph for evaluation of possible radio-opaque foreign body, mediastinal air, and suggestion of aspiration. Some specialists recommend the use of intravenous glucagon to promote passage of the food bolus; however this is controversial. Two studies looking at the the efficacy of glucagon versus placebo found no difference in the two groups; however, these data suggest glucagon may promote bolus passage in patients with previous solid food bolus dysphagia (Al-Haddad 2006; Tibbling 1995). Additionally, meat tenderizes (i.e. papain) are ineffective and potential damage esophageal mucosa so they should never be used (Golder 1985).

More Info

Common causes of food bolus include eosinophilic esophagitis, reflux disease with or without peptic stricture, carcinoma, Schatzki ring, or neurological impairment. Up to half of all causes can be attributed to eosinophilic esophagitis. In fact, food bolus can be the initial presenting feature of eosinophils esophagitis as in the case of the patient above. Therefore,
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