All bleeding stops eventually... Even in your anticoagulated patients? What about that INR of 1.4? On rivaroxaban? To better know the state of anticoagulation we first must understand the tests we use to define them. Take a dive with Dr. Murphy-Crews through our anticoagulation studies
Read MoreNot all swollen joints are the same and our dogmatic definitions of septic joints are changing with each new study, so how do we use synovial fluid to define our differential of the swollen joint? Join Dr. Harty in delving through the latest in synovial fluid studies in his asynchronous intern diagnostics post on joint fluid analysis.
Read MoreWorking in the ED one day you seem to hit a run of patients in whom consultants have asked you to order an ESR, CRP. First, podiatry asked for them for a patient with 1st metatarsal osteomyelitis. Spine surgery wanted the same for a patient with diskitis. And, ortho wanted them for a possible septic. You think to yourself, “what am I or my consultant going to do with these test results?” “What are these inflammatory markers anyhow?” And, “what patient’s should I be ordering them in.”
Read MoreHand and wrist radiographs are some of the most common and most challenging x-rays to read. Take 10 minutes to watch a video and freshen up on both the anatomy and technical factors associated with wrist radiographs.
Read MoreEarly in the morning, you begin your day in your local emergency department. After getting yourself situated, a slow trickle of patients begin to appear on the board. It appears to be a normal morning, all except for the fact that five patients appear, one after the other, who have the same chief complaint: “Knee pain”. It is a good thing you brushed up on reading knee x-rays recently!
Read MoreA 45 yo Female presents to the ED with sudden onset of chest pain, described as worse when taking a deep breath. She is significantly short of breath and appears distressed. She recently underwent a total right knee arthroplasty and reports having been bedridden secondary to pain. Physical exam is remarkable for a right lower extremity with surgical incisions that clean, dry, intact; however, her left lower extremity is swollen with significant tenderness along the popliteal fossa and calf.
Vitals: Temp 99.2HR 120RR: 28 BP: 130/80 SpO2 90% on RA.
A CTPA is ordered...
Read MoreYour patient is a well appearing, otherwise healthy 22 year old female who presents with lower abdominal pain x3 days. She is unsure of her LMP, but thinks she had some spotting about a month ago. Vital signs: Temp 99.3F, HR 92, BP 102/70, RR 20, 98% on RA. She has a benign, non-gravid abdomen. Urine pregnancy is positive. You fire off a quantitative hCG and don’t expect that result to come back for a while. What do you do next?
Read MoreElbow injuries account for 2-3% of all emergency department visits across the nation (1). Yet, because of the elbow’s complex anatomy and the presence of numerous ossification centers in children, elbow fractures are the third most commonly missed fracture group in the ED (1). Here are some tools to help ED physicians read elbow x-rays more effectively and hopefully identify abnormalities more easily...
Read MoreBoth the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.
It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.
US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1) Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.
Read MoreThink about gravity: fluid will collect in most dependent region (down); air tends to collect towards the least dependent regions (up)
Air does not reflect sound waves well. Lungs are filled with air. Rather than getting most of our information from visualizing the anatomy (as in a RUQ ultrasound, for example), much of our information comes from “artifact” or ultrasound waves being affected by phase changes.
Read MoreWe are all guilty of ordering them in the ED, but do we really know what we’re ordering?
1 literature review looked at 7 different retrospective studies describing a total of 1,405 patients and found the urine drug screen did not affect the management of any of these patients while in the emergency department. However, the data from the UDS can affect a patient’s clinical care outside of the Emergency Department. For example, if a patient requires psychiatric inpatient care, initial knowledge of drug abuse could affect this patient’s etiology of illness or rehabilitation plan.
Read MoreThe first snowflakes of the year are falling as you head into your midday Minor Care shift. Slipping on an icy patch of compacted snow and nearly falling as you head from your car to the ED entrance, you have a sneaking suspicion what the day will bring: falls, slips, and trips. Indeed, you settle down to the computer, log in to your EMR and pull up the minor care screen to see 2 unseen patients with the chief complaint of “Fall”...
Read MoreTraditional teaching is that a positive tap is Xanthochromia or blood in the CSF
The word xanthochromia is simply Greek for “yellow color.” It refers to the yellow color that CSF can take in certain situations. Some of these situations are listed below:
What we are especially interested in when evaluating for subarachnoid hemorrhage is bilirubin and oxyhemoglobin.
Read MoreBoth pulse oximetry and capnometry rely on the Beer-Lambert Law.
There are many risk factors for septic arthritis including age >80, Diabetes, Rheumatoid Arthritis, recent joint surgery, prosthesis, cellulitis. The absence of risk factors does not make septic arthritis less likely in an acute monoarticular arthritis
Monoarticular arthritis is often characterized as a warm, painful, swollen joint with limited range of motion. No studies to date have quantified specificity data on the physical exam. Therefore, clinicians must use their own clinical gestalt when interpreting physical exam findings.
Read MoreSRU (pronounced "shrew") = Shock Resuscitation Unit
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
