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In the ED we often provide first line care for patients as the result of traumatic events.  Beyond attending to clinically apparent injuries, pain, and distress, we would be in a position to apply prophylactic treatment to attempt to prevent PTSD, a debilitating sequela of trauma, if such treatment were to exist and founded inRead more

A 75M presents with several days of cough, fever, and progressive lethargy. CXR demonstrates RLL pneumonia. BP 70/50. HR 130. Lactate 5. T38.0 2L bolus NS given. Antibiotics started. Bedside sono shows noncollapsing IVC, hyperdynamic LV. Recheck BP 72/50. Lactate 5.0 DX: Septic shock. Plan: Central line, start a pressor, then intubate. Question: What pressorRead more

A 55M h/o HTN presents with 5 hours of palpitations that woke him from sleep. His complaint is that the sensation of his fast beating heart is uncomfortable. There is no chest pain, no SOB. There are no other associated symptoms. Vitals: HR 145 BP 120/65 RR 12 T98.0 98% Patient is well appearing, examRead more

Pt is 54 yo M with PMH of DM, HTN, Crohn Disease presents with 2 days of worsening vomiting, had diarrhea initially that has now stopped and is no longer passing gas, also reports some slight abdominal distention. Patient has had several abdominal surgeries in the past, denies any fevers, any blood in the vomitRead more

Patient is 49 yo F who presents to ED with few days of fever (T max 102F), progressive headache, neck stiffness. Patient denies any travel, rashes, sick contacts. Pt complains she can’t be in a well lit room or go outside without pain. You have a high suspicion for meningitis and so perform an LP.Read more

Pt is 58 yo M with PMH of alcoholism, HCV with liver cirrhosis (h/o variceal GI bleeds, h/o SBP, h/o hepatic encephalopathy) presents to ED with 2-3 days of altered mental status and fever, you want to rule-out Spontaneous Bacterial Peritonitis and you send your newly minted intern over to get set up for aRead more

“Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients wit Allergic Reactions or Anaphylaxis” Grunau BE, Li J, Yi TW, et al. Annals of Emergency Medicine 2014; 63(6): 736-744   Background: Allergic or anaphylactic reactions are fairly common presentations to the ED.  After initial treatment and clinical improvement, a proportion of patients may develop aRead more

                  Appendicitis on ultrasound – the first step is to identify the appendix by finding a blind-ending tubular structure arising from the base of the cecum. The sonographic signs of appendicitis include: dilated appendix > 6mm outer diameter (left image) noncompressible distinct appendiceal wall layers due to edema (left image) target appearanceRead more

52F h/o Protein C deficiency with recent PE diagnosis started on anticoagulation 5 days ago presents with the following skin lesions.  Diagnosis?      Read more

Quantitative D-dimer is a common screening tool to rule-out pulmonary embolism in low-risk population but is there more that it can tell us?   Yes, there have been studies linking increasing d-dimers to: 1) likelihood of PE, 2) location of PE, and 3) clot burden. 1. The level of d-dimer has been shown that withRead more