Core Emergency Medicine

Severe hyperthermia is life-threatening but easily managed if it is identified rapidly and the patient is aggressively cooled.

This post discusses the evaluation, differential and approach to dyspnea.

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This week we talk about priapism focusing on emergency department management.

This week we welcome Andy Little onto the show to discuss the modified Valsalva maneuver for breaking SVT.

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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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Jun232017

June marks graduation for thousands of medical residents around the country. This is a special time for residents and educators alike as it marks a major transition point. It’s a good time to reflect on who we are, what we do and, where we are going. Every year, Dr. Lewis Goldfrank gives an address to the residents,
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Jun092017

Teaching on a clinical shift can sometimes be difficult: it’s busy, everyone’s running around and it’s hard to capture a trainees attention. Recently, on twitter, Amal Mattu (@amalmattu) has been posting pictures of his white board teaching: discrete pearls written down and shared with anyone who walks by. The pearls are often prompted by patients presenting during that shift but they don’t have to be.
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May222017

SIMWars is a competitive learning environment held every year at the ACEP Scientific Assembly in October and the SAEM Annual Meeting every May. It pits residency teams from across the country against each other as they manage complex patients. This year, the NYU/Bellevue EM Resident team of Allan Guiney (PGY3), Joe Levin (PGY2), Magdalena Robak (PGY1) and Kristen Ng (PGY1) took home the championship!
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European Group for Validation of the Step-by-Step Approach in the Management of Young Febrile Infants Pediatrics, 2016

Fever without source in infants less than three months old presents a difficult diagnostic dilemma for ED physicians.  Over the past 25 years several algorithms have been developed to help guide clinicians,
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Observation Status or Inpatient Admission: Impact of Patient Disposition on Outcomes and Utilization Among Emergency Department Patients with Chest Pain Acad Emerg Med, 2017

Within the US, chest pain is the most common etiology for observation and short inpatient stays.  Patients are admitted to assess for the presence of serious pathology including acute coronary syndrome (ACS).
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Core Case of the Month More Cases →

Case:

CC

Cyanosis

HPI

83yF PMH HTN, HLD p/w fatigue and cyanosis. Reports that all day she has been feeling fatigued and was noted to have a blue color so her son called 911. On arrival she is cyanotic and hypoxic to 80-85% on NRB. Denies fevers, chills, chest pain, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria. Patient denies any toxic ingestions or recent medication changes.

PMH / PSH

PMH: HTN, HLD
PSH: None
Medications: Celebrex, Meloxicam, Cyclosporine 0.05% 1 drop BID, Tolterodine, Pitvastatin, MVI, Omega 3

Physical Exam

VS: 36.6, 90, 122/59, 25 80% on NRB
Gen: NAD
HEENT: NCAT, +periorbital and perioral cyanosis, OP clear, neck supple
Cardiovascular: RRR, no m/r/g
Pulmonary/Chest: Effort normal. No respiratory distress. No w/r/r
Abdominal: Soft, nt/nd, no r/g, normal BS
Extremities: Cyanosis to b/l hands and feet, warm to touch, no edema
Neurological: AAOx3, CN II-XII intact, strength and sensation intact

Labs

ABG: pH 7.484, PC02 32.8, P02 307, HC03 24.3 Lactate 1.8
Troponin: 0.02
WBC: 8.2, Neut 89%, Hgb 10.5, MCV 93.7, Hct 31.1, Plt 218
Na 141, K 4.7, Cl 103, BUN 35, Cr 1.0, Glucose 120, Ca 8.9, AG 12,
Bili Tot 0.4, Bili conj 0, Alk P 65, AST 18, ALT 22, Alb 3.4, Protein 6.1

CXR: No evidence for acute pulmonary pathology

Questions

  1. What laboratory test will confirm your diagnosis?

    A Co-Oximeter (Co-Ox) panel should be ordered which will report the percentages all the different types of hemoglobin currently present in the blood including MetHb (see More Info)

  2. What is the treatment?

    Methylene Blue given at 1-2mg/kg intravenously is the treatment for acquired MetHb (see More Info)

More Info

In this patient with acute onset cyanosis, hypoxemia on pulse oximeter without improvement on supplement oxygen, and a normal P02 on arterial blood gas analysis, suspicion for methemoglobinemia (MetHb) should immediately be raised. MetHb occurs when the iron in hemoglobin is oxidized from the ferrous (Fe2+) state into the ferric (Fe3+) state, thus making the heme molecule unable to bind new oxygen.
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