The use of vasopressors and inotropes to treat hypotension is common in the emergency department.  It is now standard to start off with norepinephrine as your 1st line agent to treat shock in the ED.  But is norepi always that best choice?   What if you need a second agent?   Treatment of hypotension shouldRead more

Non-invasive Ventilation Basics

You have received a notification, EMS has a patient with “APE” or acute pulmonary edema.  The patient arrives in respiratory distress and if you do nothing, she will require intubation.  However, you are well practiced in the use of noninvasive ventilation and will prevent intubation today.  You put the mask on the patient and start them onRead more

Abscess Innovations

Todays pearl was inspired by the amazing and innovative Dr. Vella and Dr. McVane.   We all have had the joy of draining a large pilonidal abscess.  You know the second that abscess opens white pus will flow freely creating mountains of dirty 4x4s and an aroma that may inspire you to vomit.  But whatRead more

Ventilator alarms

You are working resus at 3 am when you hear an alarming vent.  It’s the patient in room “E” who is intubated and has been admitted for 36 hours waiting for a stepdown bed.  The patient is satting 99% and you are tempted to just hit the silent button and walk away since this patientRead more

Therapeutic Hypercapnia

Ventilator management can be very simple or complex. As boarding continues to plague the emergency department, ventilated patients become more commonplace. The emergency physician should be well versed in ventilator settings as well as active trials regarding ventilator management.   Permissive hypercapnia was born out of ARDSnet protective lung strategies. However permissive hypercapnia does leadRead more

Sepsis 2.0 vs 3.0

A 65 yo M is bibems tachycardic and hypotensive with one week of worsening cough and sob.  Large LLL infiltrate is present on XRay.  You begin treating your patient for severe sepsis and begin to wonder what has been happening in the world of sepsis recently. October 1st, 2015: CMS published a new sepsis bundleRead more

LVADs for Emergency Physicians

This pearl is based off a question on our in-service yesterday.   You are working resus and a 63 yo M presents with altered mental status. He has a LVAD. His EKG is below: Time to call the LVAD team right? Well what if you can’t reach them or you receive this patient in aRead more

Unstable Cervical Fractures

Last pearl before our inservice tomorrow. Good luck to everyone. Hopefully this will buy you an additional point.   Jefferson Bit Off A Hangman’s Tit = Unstable cervical spine fractures   Jefferson Fracture A burst fracture of the ring of C1 Typically caused by an axial loading force to the occiput (think diving injury) TypicallyRead more


This pearl was created in light of our impending in-service exam this Wednesday.  Hopefully reading this will give you at least 1 point on the exam. A 19 yo F ingested 150 pills of Tylenol four hours ago and is presenting now because she does not want to die.  As your nurse is drawing labs yourRead more

A Novel Idea for Airway Management

A 65 yo M is rushed into the resus room. He is pale and is vomiting a mixture of coffee ground emesis and bright red blood. His vitals are stable currently but he is continuing to vomit in the emergency department. This patient requires a definitive airway. You have studied the emcrit guidelines for intubatingRead more