Core Emergency Medicine

This post discusses the presentation, diagnosis and management of abdominal aortic aneurysm.

Anaphylaxis is a severe, life-threatening reaction requiring rapid recognition and treatment.

Core Podcast See More →

This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic.

This week we discuss the recognition, diagnosis and treatment of severe decompensated hyperthyroidism or thyroid storm.

Core Procedures See More →

Effective defibillation requires defibrillation of 95% of the cardiac muscle. This video reviews proper pad placement to maximize efficacy.

Read more

Ankle injuries are common and performing a stress view can help determine whether a patient has an unstable ligamentous injury.

Read more

Core Blog See More →

Aug122016
keep-calm-and-rock-intern-year

I love sports; I’m the type of guy who opens up ESPN.com on his laptop before The New York Times or CNN every morning. I can most definitely name the last ten NBA MVPs faster than all of the PERC criteria. That being said, I am probably more parts “mathlete” than athlete. But that doesn’t mean I haven’t thought about which fellow stars would make up my entourage,
Read More

Jul302016
Screen-Shot-2012-12-29-at-6.08.14-PM

Earlier this week, I got a text from one of my mentors, Rob Rogers (@EM_Educator):

This would be at least a slightly anxiety provoking EKG on a shift but was much more worrisome when I saw the name at the top. Fortunately, Rob was quickly taken to a cardiac catheterization lab and PCI was successfully performed.
Read More

Jul012016
LG Image

On Monday, June 20th, Dr. Goldfrank delivered his graduation remarks to the 22nd graduating class from the NYU/Bellevue EM Residency program. As graduation always is, it was an emotional night. Dr. Goldfrank’s words resonated deeply with all of the residents and their families. Below are his thoughts:

I learned that
Read More

Core Journal Club See More →

:

Tissue Plasminogen Activator for Acute Ischemic Stroke: The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group NEJM, 1977

Each year, 22 million people worldwide will experience a stroke. 50% of these are ischemic strokes. For years, there were no effective treatments for these patients.
Read More

:

Intensive blood-pressure lowering in patients with acute cerebral hemorrhage (ATACH-2 Trial) NEJM, 2016

Hemorrhagic stroke accounts for only 11-22% of all strokes but up to 50% of all stroke mortality. Additionally, there is significant disability associated with the disease in survivors.
Read More

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,
Read More