Core Emergency Medicine

Recent-onset AF is a common presentation in the ED. In this post we discuss management options, anticoagulation + disposition.

This post reviews the basics of ED cellulitis diagnosis and management

Core Podcast See More →

This week we delve into the anticholinergic toxidrome with a focus on management and the use of physostigmine.

This week we review mandible dislocations and reduction approahces focusing on the new "syringe" technique.

Core Procedures See More →

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

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In this video we review all of the steps in setting up an arterial line.

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Core Blog See More →

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
Screen Shot 2015-12-14 at 3.36.49 AM

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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Dec222015
medstudentbooks.com

Program Director – “So what are you looking for in a residency program?” Interviewee – “Well let’s begin by discussing the lunch spread during Wednesday conference.” NOTE: do not say this during your actual interview.

Having completed about half my interviews at this point, I still struggle when program directors ask me this question.
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Core Journal Club See More →

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Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit Anesth Analg, 1994

Emergent endotracheal intubation has risks of complications including hypoxia, pulmonary aspiration, and prolonged time to intubation. Previous studies from the anesthesiology literature suggests that bed-up head-elevated (BUHE) positioning is associated with improved glottic views and prolonged apnea time.
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Irrigation of cutaneous abscesses does not improve treatment success Ann Emerg Med, 2015

Irrigation after incision and drainage (I+D) of an abscess in the ED is considered by some sources to be standard care but local practice varies considerably.
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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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