April 18, 2019

Every now and again someone raises the issue on social media about resuscitative thoracotomy.  What are the indications (we have the EAST guidelines for that), what are the risks (highlighted in this important recent paper), and of course, whether EM or surgery should be doing it in the trauma bay (guess what – it’s in the curriculum for both specialties). That’s not the point of this post.  This post is about how I think you, as the emergency medicine physician (EP), working in a system where your surgeon is not in-house, but is available in a reasonable amount of time, should proceed when faced with the patient who meets the indications.  You’ve gone through your HOTTT(T) algorithm and are now at that final “T” – you have to open the chest.

April 8, 2019

Screen-Shot-2019-03-19-at-5.32.30-AM.pngBackground: Multiple guidelines recommend tramadol or NSAIDs as 1stline treatment for patients with osteoarthritis (OA).  Tramadol is viewed as a weak opioid because it binds to the mu receptor at a significantly lower affinity than morphine.It also inhibits the reuptake of serotonin and norepinephrine.  Tramadol is converted in the liver via CYP2D6 which can cause some issues.  The big issue is that CYP2D6 activity varies among patients and this is important because you don’t know how much opiate the patient is actually receiving (i.e. the same dose of tramadol will have widely different effects from patient to patient).  Not only is tramadol potentially not giving pain relief, but patients often return to the ED for common side effects of tramadol including nausea/vomiting, dizziness, constipation, etc. Because of it’s multiple mechanisms of action, potential drug-drug interactions, and lowering of the seizure threshold, the safety of tramadol has been brought to question.

March 23, 2019

The management of the critically hemorrhaging trauma patient has seen a large amount of change over last decade, from bringing care far forward to the field to early use of blood products to civilian translation and application tourniquets to name a few. The reality unfortunately is that there is still a subgroup of patients who continue to suffer early mortality from hemorrhage, primarily because they are bleeding in the torso.  This is particularly challenging for both prehospital and in-hospital clinicians to manage as these areas do not allow control through direct compression. Enter resuscitative endovascular balloon occlusion of the aorta (REBOA) – a technique that builds on principles from vascular surgery and sees the placement of a balloon catheter into the aorta via the femoral artery.  Acting as an internal tourniquet, it temporarily occludes flow to the bleeding vessel thus providing circulatory support and precious time to get the patient to definitive care. With the alternative being death from hemorrhage, REBOA came as a breath of fresh air – a minimally invasive means of achieving hemorrhage control in these extremely sick patients. There were innovators and early adopters and reports of fantastic saves – patients were surviving who would never have survived before. 

March 6, 2019

Take Home Points:

  1. If the patient is a clear traumatic arrest, compressions aren’t indicated and, instead we should focus on the important interventions that need to be done.
  2. Ultrasound can be incredibly helpful in traumatic arrest. If you’ve got a traumatic arrest patient with neither pericardial fluid nor cardiac activity, it may be reasonable to stop resuscitation without the thoracotomy.
  3. When decompressing the chest, it’s better to place you angiocath in the 5th intercostal space in the anterior axillary line. This helps you avoid the great vessels in the as well as the thick anterior chest wall
  4. And last, if you are doing a thoracostomy, you may as well go bilaterally. You are doing invasive things to a dying patient, there is no reason to guess where the problem is. Similarly, if you have to do a thoracotomy, you could consider making it a clamshell as it space to look into and making sure the right side of the chest is accessed.

January 28, 2019

Diagnosis and management of concussion in children is part of our everyday bread and butter in the Emergency Department. Given the estimated 1.1 million - 1.9 million pediatric concussions we see annually in the United States, it is no wonder why. [1] We are well aware that pediatric concussions (more accurately termed mild traumatic brain injury, mTBI) occur most commonly from direct blunt head trauma, but they can also occur via indirect forces. Regardless of mechanism, concussions result in temporary neurologic and/or cognitive impairment that can last hours to days, with long-term sequelae potentially lasting weeks to months.