Core Emergency Medicine

This post reviews the presentation and management of patients with acute methamphetamine intoxication.

Air embolism is a rare, but potentially lethal iatrogenic complication. We discuss identification and treatment in this post.

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This week we discuss the diagnosis and management of pericarditis with a focus on not missing the hidden STEMI.

This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation.

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A brief video on how to perform and incision and drainage of a cutaneous abscess.

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This video discusses how a magnet helps you in the management of pacemaker mediated tachycardia + inappropriate shocks

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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,
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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.
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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
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Core Journal Club See More →

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Validation of the Modified Sgarbossa Criteria for Acute Cornoary Occlusion in the Setting of Left Bundle Branch Block: A Retrospective Case-Control Study Am Heart J, 2015

It has been recognized since the 1940s that the presence of a Left Bundle Branch Block (LBBB) obscures the EKG diagnosis of myocardial infarction (MI).
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Randomized Comparison of Intravenous Procainamide vs. Intravenous Amiodarone for the Acute Treatment of Tolerated Wide QRS Tachycardia: the PROCAMIO Study Eur Heart J, 2016

The current ACLS guidelines give both procainamide and amiodarone a class II recommendation as chemical therapy for the treatment of patients with stable ventricular tachycardia.
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Core Case of the Month More Cases →

CC

Bizarre, disorganized behavior

HPI

23 yo M with unknown pmh sent from Rikers c/f psychosis and med/psych evaluation in light of “bizarre, disorganized behavior.”  Per records sent from Rikers, patient has history of cannabis and alcohol abuse and tested positive for benzos at Rikers.  No known prior psychiatric history.  Initially sent to CPEP but was brought to ED after witnessed seizure-like activity, though patient responded to sternal rub and did not appear to have have postictal state.

Patient was reportedly yelling and talking to himself in his cell, stating people are “plotting to kill me” and appeared scared and paranoid.  He answers some questions but continues to yell “turn the music off” and intermittently fights against restraints, yells, kicks, and screams at cops begging them to remove handcuffs. Reports benzodiazepine use one month ago. Denies any additional past medical history.

On ROS states his throat hurts a little, unable to state when this started.  Denies any HA, n/v, pain, sob, cp, abd pain, f/c, neck stiffness.

PMH / PSH

PMH: denies
PSH: denies
Meds: denies
NKDA
Social: Rikers Island x4 days. Reports occasional etoh, cannabis, and benzodiazepine use

Physical Exam

BP 109/61, HR 96,  RR 24, O2 99% (RA) Temp 99, BG 146

GEN: Becoming increasingly more agitated initially distractable now screaming, kicking. Non-toxic
HEENT: NC/AT, neck supple. Normal ROM. No tonsillar exudate. Uvula midline.
CV: RRR, S1/S2, no mm. Strong and equal peripheral pulses
Pulm: Tachypneic but CTAB, unlabored, no wheezing
Abd: Soft, thin, nt/nd
Ext: No LE edema, wwp
Neuro: Moving all extremities spontaneously. No focal neuro deficit. CN intact. A&O person, month, year, president. Not name of hospital or date. Pt also cannot remember that he is arrested.
Psych: Responding to external stimuli, disorganized thought process.

Labs

VBG: pH 7.32, pCO2 43, pO2 111, Lact 0.6
CBC: 18.3>14.9/44.8 BMP: 138/4.3 104/22 17/0.9 Gluc: 121 Ca: 10.0
LFT: AST 54, ALT 39, AlkP 67, Tbil 1.7, Dbil 0.7, Prot 8 , Alb 4.9
EtOH: <10
TSH: 2.5
No utox or UA obtained

CSF:
Cell Count: RBC 0, WBC 1, Lymph 2%, Mono 1%
Gluc: 87 (range 40-80)
Protein: 21.4
Gram Stain: Rare WBC, no organisms

Questions

  1. What diagnosis can you make from these images alone?

  2. What do you suspect was the underlying cause of this diagnosis?

  3. What imaging do you want next?

  4. What are your next steps in management?