Core Emergency Medicine

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This week, we sit down with Billy Goldberg - senior faculty at NYU/Bellevue, to discuss some nuances of hip dislocation management.

This week we talk about the subacute headache and the dangerous, can't miss diagnoses of cerebral venous thrombosis and IIH

Core Procedures See More →

This is a brief video detailing how to do regional anesthesia for the fingers.

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This post discusses the application of both a commercial pelvic binder as well as a sheet for pelvic stabilization.

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Nov172017

The Paradox

“Go take a break.” “Let me quickly pick up these two patients.” “Go grab some food and come back.” “I’m fine, I’ll just…” “Sanjay, get the hell out and don’t come back for fifteen minutes.”

It was my sixth overnight in a row. After having struggled for over 15 minutes with trying to place an ultrasound guided IV in a sickle cell patient,
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Oct062017

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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Sep122017

The MDCalc Fellows program is a 2-year longitudinal engagement for residents and medical students passionate about EBM and knowledge translation. 
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Core Journal Club See More →

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Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial JAMA, 2017

Since 2000, there have been over 500,000 opioid related overdose deaths in the US. (Burke 2016).  Despite the epidemic of opioid deaths,
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Coronary computed tomography angiography versus traditional care: comparison of one-year outcomes and resource use Ann Emerg Med, 2016

Cardiac CT Angiography (CCTA) is a promising imaging technique that detects stenosis of the coronary arteries quickly and accurately. It can also detect other causes of chest pain when patients present to the emergency department (ED).
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Core Case of the Month More Cases →

CC

Chest pain

HPI

50yM no PMH, active smoker presents by ambulance with chest pain. Six hours ago he developed substernal chest pressure and nausea, no vomiting. Pain was moderate and constant, but he had a presyncopal episode 1hr prior and severe worsening of chest pain which led him to call 911. He was given ASA en route.

PMH / PSH

No medications or known PMH

Physical Exam

BP 109/44 | HR 95 | RR 18 | T 98.5F | SpO2 92% RA → 97% 4L NC
GEN: diaphoretic, pale, grimacing, clutching his chest in pain, speaking in incomplete sentences
CV: tachycardic, regular, 3/6 systolic ejection murmur
PULM: CTAB
ABD: soft, non-tender, non-distended
NEURO: no focal deficits, moves all extremities equally

Labs

CBC: 17.6 > 15.4 / 43.9 < 189
BMP: 140 / 4.4 / 107 / 23 / 21 / 1.4 < 139
LFT: 91 / 37 / 90 / 1.6 / 0.0 / 4.2 / 7.5
Troponin: 4.33
VBG: 7.50 / 34.3 / 26.7 Lact 2.95

Questions

  1. What are your next steps in management of this patient?

    STEMI team was activated and the patient was started on heparin and promptly taken for cardiac catheterization. He had normal coronary arteries but was noted to have severe aortic insufficiency and a dissection flap in the ascending aorta consistent with type A aortic dissection.

  2. What additional therapies would you consider administering?

    He was started on labetalol and as the patient was being consented for emergent operative repair by CT surgery, he admitted to longstanding and recent crystal meth use. Intraoperatively, an intimal tear was noted 2-3cm above the sinotubular junction with the intimal flap dissecting through the aortic valve; graft repair was performed with good outcome.

More Info

Aortic dissections have a highly variable presentation, which makes diagnosis challenging.  It is much rarer than ACS, with an incidence of 5-30 cases per million people, and a high risk of mortality (classically 1-2% increase in mortality with each passing hour) (Hagan 2000).  There is no information in the literature regarding the incidence of aortic dissection among cases that present as myocardial infarctions. 
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