Core Emergency Medicine

This post delves into local anesthetic systemic toxicity (LAST) syndrome with a focus on recognition and management.

This post reviews the common intertrochanteric hip fracture focusing on diagnosis and management.

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This week we drop into some of the nitty gritty on PSA including preparation and patient assessment as well as discuss some common pitfalls.

This week we dissect a JAMA article on the whether it's necessary to add TMP-SMX to cephalexin in the treatment of uncomplicated cellulitis

Core Procedures See More →

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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Jun302017

“Just cut. He’s dead”, my senior resident calmly whispered behind me. I had walked through the crash chest tube hundreds of times in my head. I knew the steps like the back of my hand – fourth or fifth intercostal space, mid-to-anterior axillary line, cut above the rib, bluntly dissect with the Kellys, pop through the pleura,
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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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Core Journal Club See More →

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Impact of thrombolytic Therapy on the Long-Term Outcome of Intermediate-Risk Pulmonary Embolism J Am Coll Cardiol, 2017

There is scant evidence published on the long-term outcomes of systemic thrombolysis in acute submassive PE.  Many advocate for the use of systemic thrombolysis to reduce morbidity (complications from chronic pulmonary hypertension) and mortality.
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Fever in the emergency department predicts survival of patients with severe sepsis and septic shock admitted to the ICU Crit Care Med, 2017

Sepsis remains a condition with a high mortality rate, and prompt recognition of the condition is essential. The presence and severity of fever raises suspicion for infection and is frequently a significant factor in medical decision making in the Emergency Department (ED).
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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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