Have you ever performed a procedure, when suddenly, you are overcome by a sinking feeling that something just is not right? A mix of fear, guilt, and anger: Fear that you endangered a patient, guilt that you missed an important step in the procedure, and anger at yourself for being careless. The oath we take as physicians echoes loudly: Primum non nocere. First, do no harm.
The EM Residency Match Advice Series is back with its latest installment! We put the focus on emergency ultrasound fellowships, and our sage panel walks us through some of the changes to this year’s application cycle. For the first time, Ultrasound Fellowship Programs will participate in the NRMP match program. The Society for Clinical Ultrasound Fellowships (SCUF) provides the fellowship application service (similar to the role of ERAS, but shorter!) for the residency match. Hosted by Drs. Michael Gisondi and Michelle Lin, watch the video or listen to the podcast to learn about important changes to the application process and hear tips from our experts on what to consider when pursuing a career in emergency ultrasound.
Drowning cases peak this time of year and represent a leading cause of mortality in children. For example, drowning represents the leading cause of death in boys ages 5-14 years old, and worldwide, there are 500,000 annual deaths from drowning.1 Hypoxic injury and subsequent respiratory failure represent the primary causes of morbidity and mortality. Although providers are typically taught to be aware of possible trauma (e.g. cervical spine fracture) when evaluating a drowning case, less than 0.5% of drownings are traumatic.2 The duration of immersion, volume of aspirated fluid, and water temperature dictate clinical outcomes.1 We review the presentation, pathophysiology, and management of drowning to raise awareness about this important public health issue.
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A middle-aged Asian female presents to the emergency department complaining of 2-3 days of mouth pain. She has chewed betel nut for a number of years. Which of the following is true regarding her presentation and management?
Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where point-of-care ultrasound changed the management of a patient’s care or aided in the diagnosis. In this case, a 57-year-old woman presents with chest pain and dyspnea.
The SplintER series is back with a new sub-series – Leg Day! We will review lower extremity orthopedic injuries, introduce advanced concepts, and highlight ways to implement these into your next shift. In this post, we summarize the appropriate way to evaluate, diagnose, and manage tibial plateau fractures. This post is peer-reviewed by Dr. Kori Hudson, one of our expert sports medicine colleagues! Please read below for her commentary.
Post-exposure prophylaxis (PEP) of patients who may have been exposed to HIV includes a combination HIV nucleoside analog reverse transcriptase inhibitor emtricitabine/tenofovir (Truvada) plus an integrase inhibitor. The CDC initially recommended the integrase inhibitor dolutegravir (Tivicay). However on May 18, 2018, the CDC placed an alert about the neural tube defect risk with dolutegravir.1 How does this change our ED practice?
Based on an interim analysis in an ongoing safety of dolutegraivir, the U.S. Health and Human Services announced:
The concern stems from a preliminary unscheduled analysis of an ongoing NIH-funded birth surveillance study in Botswana, which has reported an increased risk of neural tube defects among infants of women who became pregnant while taking DTG [dolutegravir]-based regimens. The study reported 4 cases of neural tube defects out of 426 infants born to women who became pregnant while taking DTG-based regimens. This rate of approximately 0.9% compares to a 0.1% risk of neural tube defects among infants born to women taking non-DTG-based regimens at the time of conception.
For men and women who are not able or likely to get pregnant, it is safe to administer dolutegravir for PEP. However for women of child-bearing age (which includes many of ED patients who are evaluated for sexual assault), these patient should instead receive raltegravir (Isentress).
Utilizing a 3-drug regimen for HIV PEP is recommended by multiple guideline committees including the CDC and WHO despite low quality evidence suggesting benefit over 2-drug regimens because of the availability of well tolerated medications. Integrase inhibitors offer a few beneficial characteristics over alternative HIV medication classes that may be included in addition to a standard nucleotide and non-nucleotide reverse transcriptase inhibitor combination (e.g. Truvada).
Because the preventative effectiveness of these medications decline over time, it is critically important to administer the first dose of each in the Emergency Department in a timely fashion. Evidence extrapolated from animal data suggests that efficacy of HIV post exposure medications decreases greatly 72 hours after exposure and should not be provided.5–7