January 18, 2016

Background: CT scans are frequently done after minor head injury to evaluate for intracranial hemorrhage. While CT scans are an excellent tool for diagnosing or ruling out this disorder, they are not without harms including radiation exposure, cost and department delays. Much of the time, CTs are negative, or find injuries for which no intervention is ever done and do not clinically affect the patient. Clinical Decision Instruments may aid clinicians in determining which patients are higher risk and require imaging and which do not.

December 14, 2015

Background: Fingertip amputations are not an uncommon injury seen in the emergency department. Treatment options range from healing by secondary intention to flap coverage or replantation. Selection of the appropriate treatment modality depends on the nature of the injury, the physical demands of the patient, and the patient’s co-morbidities. Prophylactic antibiotic use in patients with fingertip amputations is controversial. The routine use of prophylactic antibiotics is universally recommended on grossly contaminated wounds, in immunocompromised patients, and in injuries with extensively destroyed/devitalized tissue as it is thought the infection risk is high in these circumstances. However, many reflexively prescribe antibiotics prophylactically in all distal tip amputations. Moreover, there is often an underlying tuft fracture and we reflexively give these patients antibiotics because we were all taught that any open fractures require antibiotics in addition to usual fracture care. Prior studies on distal fingertip amputations and the use of prophylactic antibiotics suggest no change in infection risk with the routine use of antibiotics but these studies were small and have done little to inspire an antibiotic-restrictive approach universally.

October 8, 2015

Welcome to the October 2015 REBELCast, where Swami, Matt, and I are going to tackle a couple of topics in the world of Trauma, specifically ED Thoracotomy. Now we all know that ED thoracotomy is a last ditch salvage effort, performed under specific clinical circumstances, during a traumatic arrest. The purpose of the ED thoracotomy is to evacuate pericardial tamponade, control hemorrhage, improve coronary/cerebral blood flow, and if needed internal cardiac massage. The purpose of this podcast is to discuss specific indications where this already low yield procedure may have some benefit.
  • Topic #1: FAST US Examination as a Predictor of Outcomes After Resuscitative Thoracotomy
  • Topic #2: Blunt Trauma Thoracotomy

September 10, 2015

“I’ve been in this game for years, it made me an animal There’s rules to this sh*t; I wrote me a manual” -- Notorious BIG You know, whether you sling crack rocks or not, there are some sage words of wisdom in the late Notorious BIG’s Ten Crack Commandments. Life pearls like “Never let ‘em know your next move” and “Never keep no weight on you” have helped guide me through some challenging life decisions. 1. Never let no one know how much dough you hold 2. Never let ‘em know your next move 3. Never trust nobody 4. Never get high on your own supply 5. Never sell no crack where you rest at 6. That Goddamn credit, forget it 7. Keep your family and business completely separated 8. Never keep no weight on you 9. If you ain’t getting bags stay the f*ck from police 10. A strong word called consignment; If you ain’t got the clientele say hell no Table 1. The ten crack commandments. While not much is new in the world of hustlin’, when it comes to trauma resuscitation, the game done changed*. It was easier in the old days: 2L of crystalloid for a hypotensive patient, and then blood. While new science on trauma resuscitation has helped us understand how flawed that paradigm is, the new school can be some tricky water to navigate. From damage control to fibrinogen, from TXA to thromboelastometry, there is no doubt that resuscitating a bleeding trauma patient is a more nuanced endeavor than we originally envisioned it. So, inspired by Biggie’s Descartesian ten-point discourse on method, I present the ten rules of the contemporary trauma resuscitation game as I see them – backed by science, and occasionally editorialized with personal opinion. * Some academics have argued that the game has in fact not changed, but has just become more fierce; see Slim Charles vs. Cuddy

September 3, 2015

You are working as an EM resident and have just evaluated a patient with a right long finger DIP joint dislocation. You perform a digital nerve block with 1% lidocaine with 1:100,000 epinephrine, and go to present to your attending before attempting the reduction. Your attending, on hearing about the epinephrine use goes berserk, and says “don’t you know that you shouldn’t use epi in fingers, noses, ears and toes?”. When confronted with this situation we all like to have a one stop valid literature review to produce that validates our practice. Several social media authors have weighed in on this topic, however blogs sometimes don’t cut it for those unfamiliar with the current quality of peer reviewed online content. The use of epinephrine in digital nerve blocks has been shown to increase duration of action for the anesthetic, and to allow the avoidance of bupivacaine, thereby decreasing the pain of the injection. (REBEL flashback)