Core Emergency Medicine

Acute Pancreatitis

This post explores the diagnosis and critical steps in the management of pancreatitis.

Abdominal Cutaneous Nerve Entrapment Syndrome (ACNES)

This post explores an unusual and likely under-diagnosed condition.

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Digital Nerve Block

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

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How to Apply a Pelvic Binder

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

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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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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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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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: Apneic Oxygenation in the ICU

Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill Am J Respir Crit Care Med, 2015

Hypoxemia is the most common complication of endotracheal intubation in the critically ill and the strongest risk factor for periprocedural cardiac arrest and death.
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: Performance of the Ottawa Heart Failure Risk Score

Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP Acad Emerg Med, 2017

In the United States, heart failure affects 5.7 million people. Acute heart failure exacerbation is a common ED presentation and 1 in 9 deaths in the US included heart failure as a contributing cause.
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Chest pain


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.


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
ABD: soft, non-tender, non-distended
NEURO: no focal deficits, moves all extremities equally


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


  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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