Core Emergency Medicine

This posts delves into diagnosis + management of HD unstable (Massive) PE with a focus on thrombolytics.

This post reviews the multiple etiologies of angioedema and focuses on tailored management based on the underlying cause.

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This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety.

This week we dive into the PATCH trial investigating the role of platelet transfusions in patients with spontaneous ICH on antiplatelet meds

Core Procedures See More →

Starting a peripheral IV is an essential skill in Emergency Medicine. Check out this quick video detailing the procedure

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

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Jul012016
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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
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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
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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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Focused Transesophageal Echocardiography by Emergency Physicians is Feasible and Clinically Influential: Observational Results from a Novel Ultrasound Program J Emerg Med, 2016

Cardiac ultrasound is an established diagnostic modality in Emergency Medicine (EM). We use it to diagnose pericardial effusions (medical and traumatic),
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A randomized controlled noninferiority trial of single dose of oral dexamethasone versus 5 days of oral prednisone in acute adult asthma Ann Emerg Med, 2016

Acute asthma presentations account for more than 2.1 million Emergency Department (ED) visits annually. In the US, 8.4% of the population is affected by the disease.
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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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