My Head Hurts

35 y F presents to ED with sudden onset worst headache of life starting 3 hours ago.  Refractory to treatment with excedrin.  No history of Migraines.  Concern for SAH. What is your management algorithm to rule out SAH?  Do you CT/LP?Read more

Orthopedic Injuries

34 y M with right midfoot swelling and pain after injuring while playing football.  The patient describes a hyper-plantarflexion mechanism.  Physical exam notable for bruising to medial plantar foot and diffuse swelling to dorsal midfoot with tenderness to palpation.  XR is seen below: What is the diagnosis?Read more

Exertional Syncope

23 y M presenting to ED with episode of syncope while playing soccer this afternoon.  Endorses preceding palpitations, but denies any associated CP/diaphoresis/n/v/sob.  EKG is as follows: What is the diagnosis?Read more

A Different Approach to Central Line Placement

Today’s pearl comes to you directly from Dr. Reuben Strayer ( and I think is particularly applicable to resident learners.  The traditional teaching for CVC placement has involved needle puncture and stabilization of said needle followed by detaching the syringe and threading a wire.  Many, typically less experienced providers (i.e. residents), have a tendency toRead more

Post Cardiac Arrest Care

According to the American College of Cardiology(ACC), based on guidelines published this month, there is a shift in the post cardiac arrest care algorithm.  The prior guidelines from 2013 have a Class I recommendation for performing immediate heart catheterization for PCI for the management of comatose patients with STEMI after out of hospital cardiac arrest.Read more

I’ve Got a Lump

45 y  male with no known medical problems presents to the emergency department complaining of tender lump to left axillary region worsening over the last 2 days.  Pt notes that over the last 3 days he had also been having subjective fevers, chills, and HA.  Pt has never had similar issues in the past.  States thatRead more

Do Less

A 4 y female arrives to ED accompanied by mother after witnessed mechanical fall off out of stroller (approximately 3.5 feet high) with head hitting linoleum floor.  Mom states that the child cried immediately afterwards and never experienced LOC.  Denies n/v.  Now acting normally.  Physical exam is remarkable only for a small, left parietal scalpRead more

Respiratory Failure

As we all know, NiPPV is a well established practice and therapy of choice in patients with COPD and CHF exacerbations.  It is typically used in patients with hypercarbic respiratory failure.  But for those patients who come to the ED with pure hypoxemic respiratory failure (in say, someone with pneumonia) is there a better way toRead more

I Think I Ate Something Fishy

31 y M presents with n/v/d and altered sensation to hands and feet several hours after going out for a seafood dinner.  Pt states that he ate red snapper at the request of a work colleague and prior to tonight was in his USOH.  Later, during the hospital stay the patient notes that the railRead more

Sob in Heart Failure

A 64 yo male with a history of CHF and COPD arrives with a complaint of acute onset SOB since this morning.  Lung exam is notable for diffuse Rhonchi.  You believe the patient is having a CHF exacerbation, but you’re also concerned for COPD (as well as the multitude of other pathologies that can give youRead more