The Emergency Medicine Resident Blog

A New Home for The EM Res Podcast and Blog!

rmstuntz — Fri, 24 May 2013 08:12:27 -0400

I started the EM Res Podcast and Blog about one year ago, and things have taken off in that time. To accommodate the growth of the podcast and the blog, I am excited to announce that I have a new website: www.emrespodcast.org.

The new site offers a number of exciting advantages. First, it offers a better aesthetic and navigation across all platforms, including smartphones and tablets. It is overall much cleaner and easier to use. It is also everything EM Res in one location. You get the blog, the podcast, and the show notes all in one place. The podcast is still on iTunes, but is also hosted here for streaming from any device. The new format allows for easier commenting and interactivity between myself and readers/listeners. The search functionality is much easier, allowing you to search blog posts and podcast episodes all at the same time. I can also make more dynamic, involved posts with more capabilities than I had before. Finally, you get one click connectivity to all my social media outlets, including Facebook, Twitter, Google, Vimeo, and Tumblr.

For those of you who are die hard Tumblr fans and following that, the Tumblr site is not going away. You can still follow along there, as all future blog posts and podcasts will be pushed to Tumblr as well.

Thank you all for reading, listening, and making this such a fun and rewarding experience for me. Hopefully you get as much out of it as I do. I’m looking forward to what the next year has to bring, and please bookmark/head on over to emrespodcast.org!

Peritonsillar Abscess About a month ago, I posted a video with...

rmstuntz — Sun, 19 May 2013 08:01:50 -0400

Peritonsillar Abscess

About a month ago, I posted a video with the following history and questions. Let’s take a look at the answers:

A 23 year old male presents to the ED with 4 days of sore throat, getting much worse over the last 24 hours. You note that he has a muffled sounding voice. On exam, he has trismus, uvular deviation, L sided tonsillar asymmetry, and could seriously use a breath mint. Your attending decides to perform an intraoral ultrasound to evaluate the patient, and you see the above image.

1. What do you see?

As correctly pointed out by a few, what you were looking at was a peritonsillar abscess, noted as the anechoic circular area adjacent to the tonsillar tissue. This is the most common deep space infection of the head and neck.

2. What is the next step in management?

First, you want to make your patient comfortable. Start with some pain medicine. Steroids have been shown in some studies to potentially decrease hospitalization time, and perhaps help with symptom relief, but there is question as to the risk-benefit profile. Use your clinical discretion. Perform intramural US to confirm the presence of a PTA and distinguish from cellulitis. Once comfortable, you may proceed with needle aspiration (no significant evidence that aspiration or ID are different in terms of outcomes). I prefer ultrasound guidance. More on that in the podcast.

3. Should you start antibiotics or not?

Antibiotics are indicated, with Penicillin and Flagyl being 98-99% effective in the below referenced review. Nontoxic patient can be treated as an outpatient, while those who fail aspiration or I/D or are toxic may require surgical consultation.

Want more in depth info? Check out the podcast!

The latest episode of the EM Res Podcast talks about where new...

rmstuntz — Mon, 22 Apr 2013 10:02:03 -0400

The latest episode of the EM Res Podcast talks about where new residents should start if they are looking to get into the FOAMed world. It can be daunting to start out, but once you get into it you’ll find it a great way to learn anytime, anywhere.

This is by no means an exhaustive list, and if your blog or website was left off it is by no means a slight. There are many great resources out there. Go to www.lifeinthefastlane.com to see their full listing of EM/CC Podcasts and blogs. Remember, start with basic core content, and branch out from there. If you are a more seasoned EM resident or attending, go big from the start.

Also, check out the actual responses to my Twitter poll on the top 3 FOAMed resources for the new EM Resident here.

A Case of a Sore Throat A 23 year old male presents to the ED...

rmstuntz — Sat, 13 Apr 2013 10:01:23 -0400

A Case of a Sore Throat

1. What do you see above?

2. What is the next step in management?

3. Should you start antibiotics or not?

The Answer to Dr. Shafer's Neuro Dilemma

rmstuntz — Thu, 11 Apr 2013 22:24:16 -0400

From the last post:

A 57 y/o male presents to the ED with a chief complaint of sudden loss of memory. His wife reports that when he awoke this morning he was his normal self, had coffee and ate breakfast but while his wife was showering he suddenly told her that he felt “weird”. His wife realized that he had forgotten everything that had happened not only this morning but also the night prior and was very tearful and frightened which is unlike his normal personality. Last night he drank four beers which he usually does every weekend. His wife denies any trauma, or LOC, slurred speech or weakness. His only medical problem is hypertension. He has no significant family history, does not smoke and denies any illicit drug use. On physical examination, initially on arrival to the department he was only oriented to self but after an hour on he began to remember events from the night prior and became oriented to time and place. He was noted to persistently have trouble making new memories as he scored 0/3 when asked to recall three objects and was also noted to occasionally ask the same questions multiple times. He can easily remember past events such as his first car and his birthday. Cranial nerves are intact, he has normal sensory and muscle strength in all four extremities bilaterally, normal finger to nose testing and also has a normal gait. The rest of the physical exam is unremarkable

1) At this time, what testing should be performed?

Answer: No further testing is needed.

2) What is your diagnosis?

Answer: Transient Global Amnesia

3) What is the prognosis for this diagnosis?

Excellent prognosis. The attack typically resolves in 24 hours

Transient global amnesia(TGA) is a rare condition where there is a sudden, temporary episode of memory loss that cannot be attributed to a neurologic condition such as epilepsy or stroke. Patients do not have any focal neurologic findings before or after the attack and there is no history of recent head injury; however, 1/3 of patients have an identifiable precipitating event. Females are more likely to have an emotional precipitating event while in men the precipitating event is likely to involve physical exertion. The deficit is in short-term memory and ability to make new memories resulting in speech perseverance. Long-term memory remains intact as demonstrated in our clinical case where our patient was able to recall things such as his birthday and his first car. During the event the patient is aware of their amnesia because their consciousness is not effect often leading to anxiety. In one study, 11% of patients exhibited “emotionalism” (as our case patient experienced) and 14% “fear dying”. The average duration lasts between 2-8 hours and per diagnostic criteria resolves within 24 hours making this a rather benign disorder. The cause of TGA remains unknown at this time and about 6% of patients experience a relapse of TGA per year. These patient’s are not at an increased risk for stroke and management of these patients is simply reassurance and time.

Resources:

1) Miller, J. W.; Petersen, R; Metter, E; Millikan, C; Yanagihara, T (1987).”Transient global amnesia: Clinical characteristics and prognosis”. Neurology 37 (5): 733–7.

2) Quinette, P.; Guillery-Girard, B; Dayan, J; De La Sayette, V; Marquis, S; Viader, F; Desgranges, B; Eustache, F (2006). “What does transient global amnesia really mean? Review of the literature and thorough study of 142 cases”. Brain 129 (Pt 7): 1640–58.

3) Pantoni; Bertini, E; Lamassa, M; Pracucci, G; Inzitari, D (2005). “Clinical features, risk factors, and prognosis in transient global amnesia: a follow-up study”. European Journal of Neurology 12 (5): 350–6

A Neuro Dilemma from Dr. Shafer

rmstuntz — Thu, 04 Apr 2013 21:48:00 -0400

Welcome back Dr. Krystle Shafer, who has the following conundrum for us:

1) At this time, what testing should be performed?

2) What is your diagnosis?

3) What is the prognosis for this diagnosis?

The Importance of A Good History in Tox Patients

rmstuntz — Sat, 30 Mar 2013 00:21:46 -0400

From our last post: “EMS brings in a 22 year old male who has presented multiple times previously with suicidal gestures. Tonight, they state he took an unknown quantity of acetaminophen about 4 hours prior to arrival. You draw a 4 hour acetaminophen level, and it is 105 micrograms/mL. Feeling good that he is below the treatment threshold of 150 micrograms/mL, you are just about to call the psychiatrist when the patient tells you he actually ingested “Tylenol PM.” Does this matter? Is the patient medically clear?”

Pimpsmanship 101: if an attending asks you a question like that, the answer is not going to be “yes, the situation you presented me is the right answer with no change. Medically clear.” Unless your attending is doing some 5th level Jedi-type pimping.

Tylenol PM is a combination of acetaminophen and dihenhydramine. Diphenhydramine overdose is concerning in and of itself as it can cause the anticholinergic toxidrome. In this case, however, the diphenhydramine is cause for a different concern.

Diphenhydramine can cause delayed GI motility, potentially causing delayed acetaminophen toxicity. In fact, any agent that causes delay in GI motility (think opioids) can cause this problem. Because of this, your 4 hour level is not going to be reliable. If you are concerned that a patient may have delayed motility or gives you a history of co-ingestion of any drug that causes slowed GI motility, you should check an 8 hour level, and treat if toxic based on the Rumack Nomogram. The same goes for extended-release acetaminophen preparations (see references below)

This case and topic highlights the importance of the history in patients presenting to the emergency department with potential toxic ingestions. In particular, remember these 3 tremendously important points:

1. When did they ingest, what did they ingest, and how much? This obviously gives you the basics. It also is helpful in calculating toxic doses (do you know the toxic dose of acetaminophen in mg/kg?)

2. Were there any co-ingestants? Obviously this makes a huge difference in this case. In all cases, you want to know the full spectrum of what you may be facing, and what toxidromes you need to look for.

3. To what medications did they have access? This is a crucial historical point, and this is one of those cases where not showing up with your cynical hat can prove foolish. Remember, patients who have ingested medications often have done so with the intent to harm themselves. Now they are talking to a doctor who is trying to save them. They may not be straightforward with you. Knowing what medications were available to them may give you a hint about what they really took.

Talk to family, those who live with them, and definitely talk to your prehospital providers. This is also a big pearl for your oral boards: If anyone is available to provide extra history, they are there for a reason. Ask the question: is there anyone else who can provide me with additional history? This extra history can prove to be vital. In this case, it is the difference between treating your patient appropriately or sending them to psych to crump.

1. Ho S, Arellano M, Zolkowski-Wynne J. Delayed increase in acetaminophen concentration after Tylenol PM overdose. Am J Emerg Med 1999;17:315–7.

2. Schwartz EA, Hayes BD (@PharmERToxGuy), Sarmiento KF. Development of hepatic failure despite use of intravenous acetylcysteine after a massive ingestion of acetaminophen and diphenhydramine. Ann Emerg Med 2009;54:421–3.

3. See this post from The Poison Review (@poisonreview) reviewing an article from JEM 2012 on this very subject

4. See this post from UMEM Education Pearls on when a subtoxic 4 hour acetaminophen level may not be enough.

Want to learn about Point of Care Ultrasound?

rmstuntz — Fri, 29 Mar 2013 22:50:00 -0400

Do you want to learn about Point of Care Ultrasound (POCUS)? Have you ever wanted to learn about point of care echocardiography from Haney Mallemat (@CriticalCareNow)? Have you ever wondered what I am like in non-blog, podcast or Twitter form?

You can accomplish all of these things by attending the Wellspan York Hospital Point of Care Ultrasound Conference, June 13-14, 2013. This is a two day course that covers both basic and advanced POCUS. Didactic sessions will be mixed with hands on scanning with live models and phantoms. Two day attendees will earn 16 hours of Category 1 CME.

The course itself is located in York, Pennsylvania. We are about 45 minutes north of Baltimore, and 2 hours west of Philadelphia. For more information, including the schedule and fees, check out: http://www.yorkhospital.edu/default.aspx?program=2&type=text&content=165

If you have any further questions, please contact me here, on Twitter (@BobStuntz), or email me (bobstuntzmd@gmail.com). We hope to see you there!

What kind of Tylenol was it?

rmstuntz — Mon, 25 Mar 2013 00:44:43 -0400

EMS brings in a 22 year old male who has presented multiple times previously with suicidal gestures. Tonight, they state he took an unknown quantity of acetaminophen about 4 hours prior to arrival. You draw a 4 hour acetaminophen level, and it is 105. Feeling good that he is below the treatment threshold, you are just about to call the psychiatrist when the patient tells you he actually ingested “Tylenol PM.” Does this matter? Is the patient medically clear?

The answer later this week, unless you come up with it first!

Altered Mental Status: The Forgotten Four

rmstuntz — Fri, 15 Mar 2013 01:41:33 -0400

Altered mental status is an all too familiar complaint to emergency physicians. The differential is broad, and includes multiple life threatening diagnoses. We of course think the worst: does the patient have a head bleed or a stroke? Are they septic? Have they ingested some life threatening drug or toxin?

All too often, we get caught up in the rush to get the patient to CT without thinking about a few common, easily diagnosed, and relatively easily fixed problems that require no radiation. It is something we all do from time to time. I have noted four diagnoses that I and my residents occasionally forget to look for, and wind up kicking ourselves over later. Think about these early, and look for them routinely.

1. Glucose: In my experience this is far and away the most commonly forgotten cause of AMS. Glucose is the syphillis of AMS. It can cause seizures, mimic strokes, and make a patient look like they are having an MI. I have seen patients sent to CT for stroke and even intubated, only to later discover they have a low serum glucose. Ask EMS for a fingerstick reading on all AMS patients. If they did not check, you should. Consider D for Dextrose along with disability in your ABC’s (and remember to ask for a chem stick on your oral boards!). Treatment options range from oral glucose in the awake, to IV dextrose in those with contraindications to oral repletion (1-2 mg glucagon IM is an option if IV access is not immediately available). What you give depends on age:

Adults: 1 mL/kg D50

Kids: 2 mL/kg of D 25

Infant/newborn: 5 mL/kg D10

2. Hypoxia: You would think this is a simple one, but it does get missed. A patient is not themselves at home, and a family member brings them in. In the heat of the moment, no one tells the triage nurse they are oxygen dependent and ran out of their home O2 the day before. This one is as simple as sticking a pulse ox on and administering supplemental O2.

3. Hypercarbia: Seen frequently in COPD, and thus usually in an older, sicker population, we often forget to look for hypercarbia as we look for other causes of AMS. This is as simple as getting a screening VBG or iSTAT (an iSTAT gets you your glucose as well). As I described in a previous post, a venous pCO2 < 45 mmHg is nearly 100% sensitive in the evaluation of hypercarbia. Remember, however, that it does not correlate well to an absolute number. The interpretation: Normal pH and pCO2 < 45 mmHg on your VBG, and you are clear. If the patient is acidotic or has an elevated pCO2, get an ABG to get a true evaluation and ventilate them (invasively or non invasively as indicated).

4. Hepatic encephalopathy: You would think this would be easy: Your patient is yellow, or has a history of liver disease. But again, patients prone to hepatic encephalopathy tend to be overall sickly, and I see extensive workups to rule out ICH, sepsis, or other causes of AMS, but lack a simple ammonia. Do not forget to check that ammonia if the patient has any risk factors for hepatic encephalopathy. Treatment involves initiation of lactulose and further investigation as to the root cause.

Three of these can be checked and treatment initiated within 5 minutes of arrival (apply a pulse ox and get an iSTAT to check a sugar and screen for hypercarbia). While you always want to fully work up your patients with AMS, do not miss these oft forgotten, easily identified and fixed causes of AMS.

Good Luck!

rmstuntz — Tue, 26 Feb 2013 14:34:18 -0500

To any American EM residents who follow the blog and/or podcast, good luck on the inservice exam tomorrow. Remember to take the exam seriously. While your results do not directly help or hurt your cause to become board certified EP’s, the results will give you great insight into your knowledge base, and will help you identify areas where you need to improve.

Do whatever you normally do before big tests today. Some people don’t touch anything study related. I always feel the need to review last minute stuff the day before any big test. Just do what you normally do before a big test (you’ve taken a few at this point).

Also, if you have not yet, check out www.emergencyboardreview.com (@EMBoardReview on Twitter). There is a nice comprehensive review on the site from Dr. David Pierce from University of Buffalo. It is about 1hr 45 min, and a nice wrap up.

The last doctor gave me that "D" medicine...

rmstuntz — Fri, 15 Feb 2013 16:22:00 -0500

There has been a fair amount of discussion recently about the national epidemic of prescription drug abuse in the United States. I recently read an interesting article in EM News on the topic. I have some personal opinions on the subject, and I feel that this is an important topic for Emergency Medicine Residents and Registrars to consider.

First, I notice frequently that we refer to the medications for which we write as “narcotics.” This sends a shiver up my spine. I have been told that at one point, pharmacologically “narcotics” referred to any drug with sleep inducing properties. In the United States’ common vernacular, it has become a legal term. Narcotics by US legal definitions include cocaine and heroin. While I understand that amongst physicians we know what we mean by this, remember that our patients knows narcotics from TV (do you think when they say Narcotic on “Law and Order,” they are referring to legally obtained prescriptions?). I think when we refer to these medicines as narcotics, to the lay person we are associating ourselves with illegal drugs, making us look even more like the drug dealers inflicting this scourge on society. I am not a drug dealer. I would submit that we should avoid referring to what we prescribe as narcotics, and I try my best to do so myself. (We all slip of course!)

The question is always who is to blame for the skyrocketing abuse of these medications? I was taught that pain was the 5th vital sign, and spent residency seeing articles in how bad we are at addressing pain in the ED. Now I am told I am responsible for killing and addicting my patients. What are we to do? As a resident, you hear both sides. Every attending with whom you work will have a different opinion. It is going to be your job to synthesize those opinions and develop your own practice.

I personally rarely will write for more than 1-2 day’s worth of opioid and opioid like analgesics (obviously there are exceptions to this). I believe in this especially in the “abdominal pain NOS” and other NOS (not otherwise specified) groups, where your prescription may mask pain that should prompt their return to the ED. I know there are other EP’s who will write for more or less. I also hear blame placed on primary care providers. I think we as physicians should stop trying to blame each other as there is not one group at fault for the problem. It is clearly multifactorial. I think there are a few things we can do to address the problem from our standpoint and make our treatment of pain better and safer for us and our patients.

1. Talk with your patients. Acknowledge their pain, treat them in the ED, and discuss prescription options. We should be telling our patients of the side effects of prescriptions opioids/opioid like analgesics (constipation, overdose, addiction, impaired function, masking concerning pain). Explain your recommendations.

2. Review patient records and drug databases if available. If they are doctor shopping or shuttling prescriptions, recognize this and don’t compound the problem.

3. Try to avoid treating Press-Gainey. Remember, we are doctors and not concierge at the Bellagio. If it takes a few minutes to sit down and discuss pain management with your patient, it is worth it to avoid blindly throwing Vicodin at someone who may abuse it (or let it get in the hands of their kids) just because you feel like it will make them score you higher. This gets into the issue of people rating their doctors like a customer service industry in general, which is a debate all its own. I know this issue is not so simple, but I think it is something that is important and that we should all talk about.

4. Do not punish patients who truly need it because you think everyone asking for pain meds is a “drug seeker.” Just because the terminal cancer patient is asking for dilaudid does not mean he/she is a “drug seeker” in the classic sense. Perhaps they are seeking drugs because they are truly in pain. This leads to my last point:

5. Treat each patient as an individual with a fresh set of eyes. One day, that “drug seeker” may going to come in with something catastrophic, and you do not want to miss that. Just because your last 3 patients were scamming you does not mean the fourth one is doing the same. Take each complaint seriously. If you evaluate them and determine they do not have an emergency medical condition, by all means hit the brakes. If you do not want to be treated like an illegal drug dealer, then do not treat your patients like an illegal drug buyer.

ACEP recently released a clinical policy on the topic that I think presents reasonable recommendations. This is obviously a controversial topic, and there are no absolute right answers. As a trainee, you need to evaluate your own beliefs and learn from your supervisors. But above all, remember, your job is to do what is right for your patients. Do that, and you will never go wrong.

Turn the Oxygen DOWN!

rmstuntz — Tue, 22 Jan 2013 23:57:24 -0500

One of the most common knee jerk reactions in medicine is to give oxygen. Short of breath? Oxygen. Chest pain? O2. Abdominal pain….you get the idea. And why not, oxygen is harmless, right? While we do require oxygen to live, and it is 21% of our atmospheric pressure at sea level, oxygen in the medical setting should be considered a drug. It is a substance that you are administering to treat a medical condition, and it has been shown to have deleterious effects in the right setting.

Situation 1

A 70 year old COPD patient is brought in by EMS with a complaint of worsening shortness of breath. He was noted to have a pulse ox reading of 85% on EMS arrival, so a non-rebreather mask was placed. You order a few nebulizer treatments and some steroids before you saw him, and now his oxygen is up to 98%. You’re feeling much better about yourself, and you consult the hospitalist for admission. An hour later, the hospitalist shows up raving about admitting an unconscious patient to the floor. ”Why isn’t this guy going to the unit?” You go back to check on your patient, and he is full-on gorked. What happened? In this case, oxygen has led to hypercapnic respiratory failure.

The traditional teaching is that COPD patients depend on low oxygen to keep their reparatory rate up and blow off CO2. Thus, if you cause hyperoxia, you knock out their hypoxic reparatory drive, they retain CO2, and then they tank. Truthfully, the hypoxic reparatory drive only accounts for about 10-15% of your respiratory drive, while CO2 levels contribute most of the rest. So what does happen in these people when you give them high levels of O2?

A. The Haldane effect: When we increase blood oxygen levels, hemoglobin binds to mostly oxygen (instead of CO2), leaving CO2 by itself in the blood. As it builds up in the blood, the acute COPD patient cannot blow it off.

B. Reversal of hypoxic pulmonary vasoconstriction: In COPD, hypoxic portions of lung are vasoconstricted to match ventilation and perfusion. When you cause hyperoxia, this vasoconstriction eases, and you get vasodilation in these areas. This leads to a V/Q mismatch, and increased dead space in the lung. This again leads to poor ventilation and an increase in plasma CO2.

There is probably some effect of decreased hypoxic respiratory drive, especially when you drive the paO2 incredibly high, but it’s true effect on hypercapnea is oven overstated (1). This has been a contentious topic, especially in the prehospital setting. However, there was a nice article in BMJ in 2010 that really answered the question in my opinion (2). While it has its flaws, it showed that patients with true COPD exacerbation who received oxygen titrated to a sat of 88-92% had a significantly lower mortality rate than those who received high flow oxygen (2% versus 9%), and less incidence of hypercapnia.

So what should you do? First ask the patient if they know where they live normally in terms of a pulse ox. If they are always at 96% at their doctor’s office, 96% is fine. If they live at 88%, that’s ok. Get the non-rebreather off and titrate your oxygen to their level. I have seen some resistance to this from nursing and prehospital providers, however, this is a great opportunity to educate and engage others in the patient’s care. Get the mask off, put them on nasal cannula, and titrate their oxygen. It is easy to overlook these patients, as they may initially look better, and if you do not think about this you will have someone crash on you.

(Like COPD? Look out for an upcoming EM Res Podcast episode…)

Situation 2

You resuscitate a cardiac arrest patient. You intubated them, but you never talked with the respiratory therapist about vent settings, and you never checked an ABG to titrate your oxygen. You’re a busy man, “ain’t nobody got time for that.” Your ICU is booked, and your patient stays in the ED for a few hours. The intensivist has some choice words for you when he comes down and finds the vent to still be set to a FiO2 of 100%. What’s his problem?

This is another case where oxygen has been shown to be bad for patients. Hyperoxia following cardiac arrest has been shown to lead to increased free radical production and oxidative stress, alveolar injury and apoptosis, and increased in hospital mortality (3). With patients across the country spending more time boarding in the ED waiting for an ICU bed, we have to realize that this is not something we can ignore. Check ABG’s after intubation and titrate your vent settings.

As you can see, oxygen is not always completely benign. Titrate your oxygen in COPD patients. Check for hyperoxia and alter your vent settings to correct it in your resuscitated cardiac arrest patients. (This is where you need an ABG).

On a side note, thanks for your patience with the lack of posts and podcasts in the last month. I have been working on the Emergency Board Review Podcast series (On Twitter @EMBoardReview, and on iTunes as well!). Hopefully you have been liking that. If you don’t know about it, go check it out, 100% free Emergency Medicine US Board review. Not taking the American EM Boards? It’s still great review material for Emergency medicine no matter where you are. Look out in the upcoming weeks and months for the EM Res Podcast and Blog to be back up at normal speed. As always, I’d love to hear your feedback and suggestions!

1. New, A. Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient. Emerg Med J. 2006 February; 23(2): 144–146.

2. Austin MA et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ 2010 Oct 18; 341:c5462.

3. Kilgannon JH, et al. Association Between Arterial Hyperoxia Following Resuscitation From Cardiac Arrest and In-Hospital Mortality. JAMA Vol 303, No 21, June 2, 2010;2165-2171.

Please, don't cut it!

rmstuntz — Tue, 15 Jan 2013 10:27:04 -0500

We had some good responses, and everybody was right on.

This is an image of Herpetic Whitlow. Herpetic whitlow is an infection of the digits caused by herpes simplex virus (HSV). It can be caused by HSV 1 or two. The common pathophysiology is inoculation of the affected area through a break in the skin and subsequent exposure to bodily fluids.

Patients present with a complaint of intensely painful lesions on the digits, usually at the distal phalanx. A prodrome of severe pain is followed by eruption of vesicular lesions. The prodrome may include pain felt in the upper arm or axilla as well. The lesions appear as classic HSV, grouped vesicles on an erythematous base, and may coalesce, as in this case. This is a self resolving illness, and usually will improved within two weeks. Treatment is symptomatic care with analgesia, although in the immunocompromised, oral antivirals should be considered.

In children and healthcare workers, infection is usually secondary to oral HSV infection (the classic buzzword is a dental hygienist or dentist), while in adults exposure to genital HSV is more common.

The big take home: do not attempt to incise and drain these lesions. Doing so may lead to bacterial superinfection, delayed healing, or, the more feared complication, systemic spread. You wouldn’t want to be the one who caused herpes encephalitis, would you?

For a more detailed overview, check out this well done Medscape article.

What is that? A young female presents with complaints of left...

rmstuntz — Fri, 04 Jan 2013 00:42:00 -0500

What is that?

A young female presents with complaints of left thumb pain and swelling preceded by a few days of upper arm and axillary pain. She states she has not had any trauma, fevers, chills, or engaged in any high risk sexual behavior recently. She was told by a friend to come to the ED so that we could “cut it open and drain it.” You see the above cutaneous finding with no other notable abnormalities of the left upper extremity. Wat is this and are you going to cut it open?

Emergency Board Review

rmstuntz — Thu, 27 Dec 2012 23:29:28 -0500

Hey faithful readers, and belated Happy Holidays! Sorry for the lag in posts, but I’ve been spending time with the family, and working on this…

You may remember back a few months I started doing some board review stuff, but noted it was going to be a huge project to tackle on my own. Fortunately, Jon Schonert from EM Chatter (@EMChatter, www.emchatter.com), came to the rescue with similar interests and a keen ability to make websites. We have gotten some help from around the EM blog and podcast world (@EMBasic, Steve Carroll to name one), and are rolling out www.emergencyboardreview.com.

This is a work in progress, but our goal is to provide you with high quality, high yield, just-the-facts FREE board review material to help you pass the EM Inservice, Qualifying, and ConCert exams. My introduction video can be found here, I give an audio intro on my podcast here.

Down the road, we will be getting these on iTunes as well, and the website will be expanded. For now, find us here:

Twitter: @EMBoardReview

Facebook and Google+: Emergency Board Review

Website: www.emergencyboardreview.com

There’s already a lot of great content there. The GI videos are up along with the first cardiology and ortho videos. Keep checking back.

As promised, here are the ABEM links to the exam info and the Model of the Clinical Practice of Emergency Medicine. Looking forward to helping you prep for the boards!

Inservice exam

Qualifying Exam

ConCert Exam

Model of the Clinical Practice of Emergency Medicine

Critical care questions: Hypotensive A Fib

rmstuntz — Tue, 11 Dec 2012 23:54:00 -0500

I got a bunch of critical care questions for the Weingart-Mallemat interview for the last podcast. Of course, I did not have time to get them all answered, and I felt some of them were already well answered elsewhere. So I’m going to answer a few of them with my references for good resources already out there, starting with this question:

“I have a situation that’s come up a few times recently and I haven’t been able to find a good answer to it in my lit search. Patient with a fib and in CHF. Slightly hypotensive (SBP 100-110), but not unstable or warranting cardioversion. 2 different attendings have recommended giving calcium gluconate prior to the Ca-channel blocker to “blunt the hypotensive effect”. The best explanation I’ve gotten was that it allows AV nodal blockade to occur, but the calcium influx to the peripheral vascular system prevents vasodilation.

So: What is the pharmacokinetics for giving calcium prior to CCB in the a fib patient and is there an alternative (besides electricity) in the hypotensive patient?

In terms of the alternative to electricity and treating the crashing a fibber, I will refer you to the EMCrit Podcast, Episode 20. As usual, Weingart has a great approach to these patients. The problem is (and I hate to break this to all the electricity-heads out there): cardioversion does not work in these really sick a fib patients. These are not the younger paroxysmal a fibbers who come in for their monthly cardioversion. They are usually chronic a fib patients, and have irritable hearts and you get a few minutes of sinus rhythm, at best, before you have them flip right back into a fib with RVR. So this will take some medical finesse. Listen to his podcast, he has a fantastic approach. Make sure if there is an obvious reason they are in a fib (like being floridly sceptic), treat that source. Make sure they have a good preload (US their IVC). When the heart is beating that fast, it does not fill so you want your preload optimized. Don’t be afraid to give them fluid.

Then comes rate control and the calcium question. Many times, in the patient with borderline pressures, reducing their heart rate will actually increase their pressure (more cardiac filling time). But does calcium prevent hypotension with dilt?

The pharmacology of CCB’s is nicely reviewed here. Where people are getting this idea is actually from studies on verapamil (see this and this). There has been one RCT looking at Ca pretreatment with Diltiazem and it could not detect any statistically significant blunting of the BP drop with Ca administration. This is partially because few actually got hypotensive in the study. It is also interesting because pharmacologically, diltiazem should actually have more peripheral effect than Verapamil (Verapamil is supposed to be more cardioselective. Dilt can be used for BP but has more cardiac effects than the dihydropyridines). Yet the study did not really pan this possibility out.

My take: Ca is a safe drug to administer, and as Weingart said on his blog, it has some good inotropic/pressor activity in its own, so why not try it? Optimizing electrolytes in irritable hearts is a goal anyway. Try lower doses of dilt, and repeat. Weingart has a link to a slow infusion he sets up in the above post. I haven’t tried this, but same principle: lower and slower to slowly control HR and not tank BP. I have also used digoxin loading in a few patients (0.25 mg initial dose). Digoxin decreases chronotropy, and this does take up to 6 hours, but it also causes vasoconstriction and increased isotropy. Reliable pharmacists have told me this can be within the first hour, and anecdotally I can say I’ve seen the patients who failed low slow dilt and needed digoxin did get better within the first hour. Not fully better, but any better is good in this population.

In a related post, check out my previous post of diltiazem versus metoprolol in rate control for rapid a fib. Hope this helps, and we’ll be answering more of the left out questions as time goes on.

Episode 8: Critical Care with Scott Weingart and Haney...

rmstuntz — Sat, 08 Dec 2012 12:34:00 -0500

Episode 8: Critical Care with Scott Weingart and Haney Mallemat

I somehow tricked Scott Weingart and Haney Mallemat into sitting down and talking EM-Critical Care with me. We go over Critical Care fellowships and answer your questions about EM/CC. Should all residencies be four years? Where do the experts see our specialty in 10 years? Should we abandon the landmark technique for central line placement? What about video versus direct laryngoscopy? A ton of great stuff in just an hour of your time. Either follow the link above, or find us/subscribe on iTunes.

Miss that procedure? Good!

rmstuntz — Mon, 03 Dec 2012 09:54:11 -0500

I have had a few cases recently where, while supervising a procedure with a resident, the procedure does not go perfectly smoothly, and I have had to step in and lend a hand. This usually results in the resident beating themselves up. I’m here to talk you down off the ledge.

Remember, you are learning how to do procedures the attendings you are working with have done hundreds, or even thousands, of times. We are naturally going to be more skilled procedurally because, as has been said, practice makes perfect. If you compared my intubating skills to an EM attending who has been working for 15 years, they would probably have me beat. It is the natural progression of things.

Look at it as a learning experience. As a resident, when I missed a procedure, it usually wound up teaching me some very good lessons about what I was doing wrong and what I could do better.

So how can you turn these instances into positive learning experiences?

1. No matter how many times you have done a procedure, check your ego at the door. I vividly remember the first intubation I missed as as resident. I had had the good fortune of being successful for about 90 intubations in a row, with near half of those being on very carefully selected OR patients. I was going in a bit cocky. It was an obese status epileptics. I jokingly told someone that I had done a tough intubation on a skinny guy earlier that week I thought would be easy, so this lady would probably wind up being the opposite of what I expected and be the easiest tube of my life. It was not. I had not mentally prepared myself for the procedure, and when I got in and saw it was difficult, I panicked.

2. Ask the attending what they did differently, and make them give you a good answer. On that same tube, my attending went in calmly, visualized structures, passed a bougie, and smoothly threaded the tube over that. I asked the attending what they had done and why. The attending jokingly responded, “I took my time, visualized my structures, and it was easy.” I now use this as a joking phrase, but if you are an attending, explain to the resident what you did. What did you see? What kind of view did you get? Why did you choose the bougie, and how do you use it? What would you have done if that did not work? Debrief the resident, and residents demand an adequate debriefing.

3. Do your own mental debriefing, and review the procedure step by step. Did you position the patient appropriately? Was your equipment positioned appropriately? Did you have everything in the room that you needed? What did you attending do differently that helped them get it?

4. Identify where you went wrong, and make a mental note for the next time. Maybe you had the US machine over your shoulder instead of line of sight during that central line. Maybe the LP patient was not sitting correctly. Perhaps you forgot a crucial piece of equipment. Figure it out, note it, and don’t do it next time.

5. Take a deep breath, and relax. This is how you learn, and you will miss procedures. Murphy’s law dictates that your attending will come in and have a super easy time, leaving you to think they never miss procedures, and you are somehow incompetent because you do. Everyone, at every stage in the game misses procedures. I did an LP with a resident recently that went very smoothly for me. A few weeks before that I had done an LP on my own when I was covering our ED during resident conference that was one of the more difficult ones I have ever done, and I had to throw in the towel. We all miss sometimes.

Do not freak out about these missed procedures. Use them as a learning tool. Approach it like a mechanic: break down every step, figure out where you went wrong, and fix it for next time. Attendings, make sure that you talk your resident through your process and debrief them appropriately. Making it seem easy and not explaining yourself only makes the resident feel worse, and winds up teaching them nothing. This is a true learning opportunity. Don’t miss it!

Episode 7: Airway Tips and Tricks

rmstuntz — Fri, 30 Nov 2012 08:02:06 -0500

Well, Episode 7 is here, and I finally caved. That’s right, I’m doing an airway talk.

Obviously, airway is king. As it turns out, the A in ABC’s stands for airway and not Ativan. (I know, I was surprised when I first learned that too). There is a ton of stuff out there on airway, and I wanted to try to do the topic some justice. Part of my job is to synthesize what is out there for you, the EM Resident.

So I sat down with Tom Kehrl and we talked tips and tricks of the airway. These are pearls we have learned in going to courses, listening to lectures and podcasts, and intubating a bunch of people, and supervising a bunch more.

You can find the show notes here. I put a ton of links to podcasts, articles, and websites that go over many of the topics we discuss. Might be the most robust set of show notes yet, and you definitely want to be online when you check it out. Get it on your usual podcast apparatus or click the link below:

http://emrespodcast.libsyn.com/episode-7-airway-tips-and-tricks-i