In terms of airway management, cricothyrotomy is one of the most advanced airway procedures an ED physician will perform. It is a last resort procedure when a patient is not able to be ventilated/oxygenated and/or intubated. Typically, this procedure requires the identification of certain landmarks such as the cricothyroid membrane, but what if you can’t identify any landmarks? What do you do? We got Rob Bryant on the show to discuss some aspects of a recent nightmare airway case he had. Read more →
Background: Administration of a neuromuscular blocker (NMB) is an essential part of Emergency Department (ED) airway management for facilitating ideal airway conditions and is most commonly performed with either succinylcholine or rocuronium. Despite extensive debates between providers, one agent has not been shown to be superior to other. Limited anesthesia literature has shown that succinylcholine may provider better intubating conditions but it has a number of contraindications (which may not be initially apparent)(Shoenberger 2018). Rocuronium at high doses has a similar onset of action to succinylcholine and may provider longer safe apneic times (Swaminathan 2018). This study seeks to add more information to the clinical discussion. Read more →
Many of us have heard the saying that emergency medicine is the best 15 minutes of every other specialty. This, is in part, due to the wide breadth of disease and knowledge one must have to take care of patients. In emergency medicine we typically focus on acute disease specific problems and life sustaining treatments, but as the population gets older we are also having to deal with chronic conditions as well. This was not an area that I was trained in residency, but certainly one that I am seeing more and more often. There was a great review article published in the Journal of Emergency Medicine in January of 2018 titled, Palliative Care Symptom Management in the Emergency Department: The ABC’s of Symptom Management for the Emergency Physician. The lead author of this paper is Mari Siegel, MD, who I had the pleasure of interviewing for this episode.
Background: I received a text message from one of my colleagues inquiring about discharging a patient home with isolated traumatic subarachnoid hemorrhage and to be honest I had heard about this practice, but was not completely aware of the literature around it. Turns out from a PubMed search there was a meta-analysis published just this past year trying to answer this very question. When I was a resident, which is not that long ago, the standard practice was for patients to be assessed by neurosurgery for management which usually involved ICU admission or a trip to the OR with ICU admission. Isolated traumatic subarachnoid hemorrhage (itSAH) is typically defined as the presence of a SAH in the absence of any other traumatic radiographic intracranial pathology. So the question is, is it safe to discharge patients home with itSAH? Read more →
Background: Alteplase is a tissue plasminogen activator that is approved for use prior to thrombectomy in ischemic strokes with the goal of reperfusion to ischemic areas of the brain. Tenecteplase is a recombinant enzyme derived from alteplase that is more specific to fibrin and more resistant to inactivation by alteplase inhibitors. Tenecteplase is less expensive, can be administered at a faster rate than alteplase and has a longer half-life allowing for bolus dosing. Prior studies have shown similar to better outcomes with use of tenecteplase versus alteplase in patients with ischemic stroke. Read more →