Core Emergency Medicine

Digoxin Toxicity

We take a look at one of our favorite cardiac glycosides.

Retropharyngeal Abscess

A review of this rare and life-threatening pediatric illness.

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Push-Dose Pressors

A brief video reviewing how to prepare and administer push-dose epinephrine and push-dose phenylephrine.

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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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Core Blog See More →

Jun252019

The new 2019 PEM Guide has been released! 183 PEM topics covered concisely in this free, point of care reference.

Download the PDF

Access the Apple Book

“PEM (Pediatric Emergency Medicine) Guides was developed as an online, point of care resource for the residents and medical students who work with us in our pediatric emergency departments.
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Jun132019

Graduation Speech

Lewis R. Goldfrank, MD

(June 12, 2019)

Congratulations on your graduation.  This milestone and the commencement of your increased independence are a tribute to your fine work.  Your future accomplishments will be substantial.

Your team

You as a class will have developed immensely profound bonds.  
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Jun122019

“Take one more look. Surgery will prep the neck in the meantime.”

Emergency medicine is a cruel field. The more I learn, the more I realize my deficiencies, my weaknesses, my fears. As I uncover the intricacies and nuances of this specialty, questions continue to arise. The scope of practice is ever growing and self-doubt seems to only grow with experience.
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Core Journal Club See More →

: Apneic Oxygenation Reduces Hypoxemia During Endotracheal Intubation in the Pediatric Emergency Department

Apneic Oxygenation Reduces Hypoxemia During Endotracheal Intubation in the Pediatric Emergency Department Am J Emerg Med, 2019

Oxygenation is particularly important in children undergoing endotracheal intubation. They have higher oxygen consumption than adults and become hypoxemic more quickly with rapid sequence intubation.
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Core Case of the Month More Cases →

Case: July 2018

CC

Aphasia and R-sided hemiparesis

HPI

29yo FTM on testosterone cypionate, no other sig pmh, presents with worsening headache, expressive aphasia, and R sided hemiparesis. Pt had been having moderate L sided headache x 1 week prior to this presentation. No hx of headaches or migraines. Pt was at the theater with his sister, noticed some R sided hand weakness, but then was noted to have expressive aphasia by sister and brought to ED.

In ED pt had aphasia, R sided hand numbness, clumsiness, initial head CT negative, given tPA, and admitted to stroke unit. Over next 24 hours, pt had CT angiogram, MRI brain, MRV brain without evidence of ischemia, mass, or bleed. By this time aphasia and motor symptoms had resolved, although still with some headache.

Physical Exam

HR 45 BP 164/87 RR 22 SpO2 100% T 101.2˚
General Appearance: Alert, in no acute distress
ENMT: Atraumatic, moist mucus membranes
Cardiovascular: RRR no RMG
Pulmonary: CTABL
GI: No tenderness or guarding, no masses or hepatosplenomegaly on palpation
Extremities: Palpable pulses.  No edema, clubbing, or cyanosis
Skin: No evident rash or skin breakdown, normal temperature on palpation
Psych: Appropriate affect
Neurologic: AAOX3,  PERRLA, EOMI, Visual fields are intact to finger counting. There is no dysarthria.  Hesitation with word finding, naming (able to say knuckle, not watch or pen), Difficulty following complex commands. Facial strength and sensation are symmetric and intact.  Strength is 5/5 throughout without pronator drift. Sensation to temperature is symmetric. Finger-nose-finger is intact. There is no neglect.

Labs

CBC 9.7> 11.5/38<376 BMP 144/4.5/107/26/18/0.94<113 LFT 7.7/0.2/4.5/36/49/0.4/29 INR 1.1 Troponin 0.0 VBG: 7.325/51/37/26 lactate 4.37 CT head without IV contrast: No acute intracranial findings CT angio head and neck: no evidence of aneursym MRI brain with and without IV contrast: No evidence of acute infarction, intracranial hemorrhage or mass, no abnormal intracranial enhancement. MRI head: great cerebral veins, vein of galen, major dural sinuses are patent

Questions

  1. What is your differential?

  2. What other labs or studies would help you confirm this diagnosis?