There is so much literature to sift through each year, it becomes nearly impossible to stay abreast of it. Here is a quick summary of the 10 must-know Emergency Medicine pharmacotherapy articles from 2015, in my humble opinion.
What is the most commonly fractured carpal bone in adults? It’s the scaphoid bone. As a bonus it has the dreaded complication of avascular necrosis. So how good are the physical exam and imaging modalities in diagnosing a fracture? What is the likelihood ratio (LR) that snuffbox tenderness predicts a fracture? Bottom lines: The exam is highly sensitive but poorly specific, such that one can only confidently state that a NON-tender snuffbox and scaphoid tubercle essentially rule out an acute scaphoid fracture. Also negative x-rays for patients with scaphoid tenderness still yield a fracture post-test probability of 25%. This PV card breaks down all the LRs.1
Adapted from 1
Anterior dislocation of the mandible is a clinical scenario that is not infrequently encountered by the ED provider and requires prompt intervention. The classic technique for reduction of the mandible requires the provider to place his/her thumbs or fingers into the patient’s mouth along the lower molars and apply force inferiorly and posteriorly. However, this technique is fraught with difficulties and inefficiencies including the following:
The Case: A 5 year old girl presents to the ED with approximately 24 hours of suprapubic and RLQ abdominal pain. Vital signs are: Temp 38.2 C, HR 110, RR 19, BP 100/60, Oxygen Sat 100% on room air. She has vomited twice but has not had diarrhea. She had a history of constipation a year ago that has resolved and mother denies any urinary symptoms or history of UTI’s. The patient is quiet but nontoxic appearing. Your abdominal exam notes mild to moderate RLQ tenderness but no rebound and normal bowel sounds. You order a urinalysis, which is negative and a RLQ US which ‘does not visualize the appendix’. Your suspicion for possible appendicitis is still intermediate; however, now the patient states she is “a little hungry”. Should you order a CT of the abdomen and pelvis? Uuugh!
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Patients with 5th metacarpal fractures (commonly termed “boxer’s fracture”) are frequently treated in the emergency department (ED) with closed reduction and splinting. Obtaining analgesia and a successful closed reduction can often be challenging without procedural sedation. Severe swelling can make a hematoma block difficult, often resulting in inadequate analgesia. An ultrasound-guided ulnar nerve block provides a simple method to facilitate pain relief and allow for improved fracture site manipulation.
Case: 55-year-old restrained driver is reporting severe shortness of breath and right sided chest pain after a high-speed motor vehicle collision. Her respiratory rate is 26 breaths/min and her oxygen saturation is 96% on a 15-liter non-rebreather. She has decreased breath sounds on the right, epigastric tenderness, and an abdominal seatbelt sign. What is the diagnosis?
Your triage nurse complains of numerous patients in the waiting room complaining of nausea, retching, and emesis. They ask you “why can’t we have an antiemetic on hand in triage?” Turns out they might have had an effective antiemetic on hand, or rather in their scrub pocket the entire time. They just didn’t know about it yet.
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