A 55 yo M presents to the ED w/ thumb pain following an MVC. He states his car spun out of control and he felt the steering wheel slam into the webspace between his thumb and 2nd digit. Pain and swelling have worsened since the time of the accident. An xray is done and shown below.
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EMS brings in a patient who was found down in his front lawn. They report he is dry and very hot to the touch, and has been unresponsive during transport. As you approach the resuscitation bay you quickly run down potential causes of a heat emergency and begin to think about the best way to treat this patient.....
Read moreSubmitted by Karen O'Brien, DO
How do we manage a first time seizure? Let's review the basics here
Read moreSubmitted by Lynn Manganiello, DO
Several drugs have been investigated in patients with ARDS, including epoprostenol, nitric oxide, statins, and methylprednisolone, but have not improved survival. Meduri et al. performed an RCT demonstrating that methylprednisolone was associated with a reduction in lung injury score and duration of mechanical ventilation. While not powered to evaluate mortality, this trial raised interest in the use of corticosteroid to mitigate inflammatory lung injury. The 2017 Guidelines from the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) recommend steroids for treatment of ARDS based on a meta-analysis of nine randomized controlled trials demonstrating reduction in markers of inflammation and duration of mechanical ventilation, although many of the trials had a small sample size and some were performed without lung protective ventilation. In March 2020, Villar et al. published the largest randomized control trial of corticosteroid therapy for moderate to severe ARDS investigating the impact of dexamethasone on survival and duration of mechanical ventilation.
Read moreSubmitted by Tom Sewatsky, MD
General:
- Can be Alternating Current (AC) or Direct Current (DC)
- Enormous amount of voltage
- REVERSE TRIAGE: tend to patients in arrest first
5 Mechanisms of Injury:
Read moreSubmitted by Karen O'Brien, DO
A 12 day old baby boy presents with vomiting
Read moreSubmitted by Angela Ugorets, MD
Delivering bad news, such as concern for a new cancer diagnosis, is difficult in any setting. In the ED, we are often faced with additional challenges - limited information, time constraints, lack of established relationship with patients, and many others. Yet it is crucial we learn to do this well - here is some guidance to get started.
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You admitted a 72 year old male to the ICU for septic shock from community acquired pneumonia. He required intubation and mechanical ventilation for failure to improve oxygenation with NIPPV and encephalopathy. He received broad spectrum antibiotics and a 30 cc/kg crystalloid bolus. His MAP was persistently in the 50s despite adequate fluid resuscitation and based on your exam he does not appear hypovolemic. Norepinephrine is started and despite adequate MAP he is oliguric. His only medical history is he was a previous smoker with COPD, HTN, HLD but normal renal function with a Cr of 0.8 two months prior. His Cr on admission is 2.2 and a foley is placed and his UA shows granular casts. He is not acidotic and his electrolytes are normal.
You are concerned this patient is heading towards renal replacement therapy. He is adequately fluid resuscitated and has a MAP above 65 on a vasopressor but is still not making urine and has signs of ATN on urinalysis. Renal replacement therapy is an invasive procedure and has associated risks. If a patient has a chance to have renal recovery with a more conservative approach then this should be considered. You wonder if there is a diagnostic test which can be used to assess the potential for renal recovery.
Read moreSubmitted by Tom Sewatsky, MD