Welcome to the 60th edition of the #FOAMed Review! 

The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world, including interesting and relevant evidence based medicine, that you can fit into your busy weekly schedule.

Supraglottic Airways: Their Evolution as Tracheal Tube Introducers

Anesthesiology News

Troubleshooting the clotted PEG tube

Procedurettes

The Interscalene Block

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Have a large abscess you have to drain on the upper extremity? Consider the interscalene block to provided dense anesthesia for expedient & painless drainage. Use a high frequency linear probe in a transverse plane at the level of the larynx and slide the transducer laterally until you identify the lateral border of the sternocleidomastoid. Here you can then identify the anterior and middle scalene muscles just deep to the SCM, with the nerve roots of C5-C7 running in between in a vertical fashion giving us a "traffic light" appearance. This will be your target.  Learn more about this procedure here. 

LITERATURE OF INTEREST 

• An Age-Adjusted D-dimer Threshold for Emergency Department Patients With Suspected Pulmonary Embolus: Accuracy and Clinical Implications. PMID: 26320520
• A Report of Adverse Drug Reactions in Pediatric Emergency Medicine PMID: 26324354
• Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock PMID: 26323041
• Bivalirudin or Unfractionated Heparin in Acute Coronary Syndromes PMID: 26324049
• Conservative Versus Liberal Oxygenation Targets for Mechanically Ventilated Patients – a Pilot Multicenter Randomized Controlled Trial PMID: 26334785

MORE FOAMED

THE UNDIFFERENTIATED SICK INFANT [PODCAST]: Pediatric Emergency Playbook is a new kid on the blog block, putting out excellent content so far. Listen to the podcast here on how to approach the undifferentiated sick infant. 

THE PROBLEM WITH CALF CLOTS [PODCAST]: The management of isolated calf DVT in the ED has become quite an enigma. Rob Orman breaks down this topic on ER Cast to help us better understand the evidence and demystify this issue. 

CUTTING EDGE ACUTE ISCHEMIC STROKE CARE [LECTURE]: Dr. Melissa Motta, a neuro-critical care expert breaks down current best practice in acute ischemic stroke in an excellent talk at Maryland CC Project. 

EPIGLOTTITIS [BLOG]: While uncommon, this is a disease process we must be able to recognize. Learn the presentation and management of this disease process in the core content post at Core EM. 

SEE YOU NEXT WEEK

Online Advanced Ultrasound Education

Northwestern EM Residency Education Coming soon...

Welcome to the 59th edition of the #FOAMed Review! 

The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world, including interesting and relevant evidence based medicine, that you can fit into your busy weekly schedule.

CORE CATEGORIES

Airway Preparation

EM in 5

Ultrasound Case

 56 year old male presents with right sided hemiparesis and expressive aphasia. 

Ultrasound of the Week

Procedure Pearl

Ear foreign body removal with modified suction setup.

ALiEM

LITERATURE OF INTEREST 

• Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomized controlled trial Open Access
• Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation PMID: 26095867
• Noninvasive regional cerebral oxygen saturation for neurological prognostication of patients with out-of-hospital cardiac arrest: A prospective multicenter observational study PMID: 24606889
• Does Albumin Infusion Reduce Renal Impairment and Mortality in Patients With Spontaneous Bacterial Peritonitis? PMID: 26234193
• Vasopressors for the Treatment of Septic Shock: Systematic Review and Meta-Analysis PMID: 26237037

MORE FOAMED

ASTHMA MANAGEMENT [BLOG]: Excellent post describing the evidence behind 3 very frequently used treatments in the management of asthma. EM Lyceum

CARDIAC TAMPONADE & CARDIOMYOPATHIES [LECTURE]: Dr. Lorrel Brown discusses cardiac tamponade physiology as well as a variety of cardiomyopathies in an excellent talk from Louisville Lectures. 

NEUROTRAUMA [PODCAST]: This talk focuses on traumatic brain injury, particularly on traumatic subarachnoid hemorrhage and transfusion threshold in traumatic brain injury. Intensive Care Network

NICOTINE TOXICITY, A NEW TREND IN TOX [BLOG]: Nicotine toxicity is becoming more common in light of the era of e-cigarettes and other nicotine replacement. Learn about this evolving toxidrome that may end up in your ED. Boring EM 

SEE YOU NEXT WEEK 

Welcome to the 58th edition of the #FOAMed Review! 

The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world, including interesting and relevant evidence based medicine, that you can fit into your busy weekly schedule.

CORE CATEGORIES

Successful Tracheal Intubation In Children With Difficult Airways: Seven Secret Techniques

Anesthesiology News

Ultrasound Cases:

Not your Normal Cystitis

CMT = PID...Not Always

10 Ways to Reduce a Shoulder Dislocation: Video How-To

Larry Mellick

EMERGENCY MEDICINE/CRITICAL CARE LITERATURE OF INTEREST

• Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assay PMID: 26260100
• More Than One Third of Intubations in Patients Transferred to Burn Centers are Unnecessary: Proposed Guidelines for Appropriate Intubation of the Burn Patient PMID: 26284640
• The Early Repolarization Pattern: A Consensus Paper PMID: 26205599
• Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography PMID: 26204274
• Electrolyte and Acid-Base Disturbances in Patients with Diabetes Mellitus PMID: 26244308

MORE FOAMED 

THE EVOLUTION OF PAIN MANAGEMENT IN THE ED [PODCAST]: Listen to the full-length Grand Rounds recording of Sergey Motov, a pain expert, who discusses the evolving treatment of pain management in the ED hosted by Core EM. 

SHORTNESS OF BREATH AND ST SEGMENT ELEVATION [BLOG]: A middle aged man with history of MI presented by EMS for the sudden onset of difficulty breathing. Read more, here at Dr. Smith's ECG Blog.

EARLY VENT WEANING TO HFNC IN HYPOXEMIC RESPIRATORY FAILURE [BLOG]: A proposal for extubation to HFNC in patients with hypoxic respiratory failure from Josh Farkas at Pulm Crit. While this may not yet be ready for primetime it has promising appeal. 

RESUSCITATIONIST'S TOOLBOX:

What you need for an ED Thoracotomy

By Scott Weingart

Mechanical Circulatory Support for the Emergency Physician

By Felipe Teran

SEE YOU NEXT WEEK 

Welcome to the fifty-seventh edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed 

THE AIRWAY MANAGEMENT ROUNDTABLE [ARTICLE]: Read a great piece from the anesthesia world regarding 7 questions on the current state of airway management answered by 6 airway experts. Anesthesiology World

RIGHT HEART ULTRASOUND PEARLS [PODCAST]: The guys from Ultrasound Podcast sit down with Haney Mallemat to discuss key questions in right heart ultrasound. Make sure to also listen to Part 1 of this series here. 

EM/CC LITERATURE OF INTEREST

• Repeated emergency department visits among children admitted with meningitis or septicemia: a population-based study

PMID: 25458981

• Idarucizumab for Dabigatran Reversal

PMID: 26095746

• The influence of music during mechanical ventilation and weaning from mechanical ventilation: A review

PMID: 26227333

• Sexually Transmitted Disease Guidelines 2015

Guidelines: CDC.gov

• The ultrasound-guided "peripheral IJ": internal jugular vein catheterization using a standard intravenous catheter

PMID: 22579025

INCISION & LOOP DRAINAGE [BLOG]: A novel technique for abscess I&D that you may want to check out for yourself, featured at Laceration Repair.  

More FOAMed

NIGHT SHIFT WOES [PODCAST]: Two of your favorite podcast voices, Rob Orman & Haney Mallemat, sit down in a heart to heart to discuss managing finding your niche in EM, the issues we face with nightshifts and more. ER Cast 

STATUS EPILEPTICUS [PODCAST]: Scott Weingart discusses key clinical questions regarding management of status epilepticus with Tom Bleck, a neurointensivist from Rush Medical College. A must listen here at EM Crit. 

SEVERE COMMUNITY AQCUIRED PNEUMONIA [BLOG]: Pulm Crit discusses the evidence behind advanced treatment of severe community acquired pneumonia. Check out the post here to optimize your treatment strategy. 

TUBO-OVARIAN ABSCESS [BLOG]: Failure to recognize this PID complication can lead to irreversible damage to the tubal and ovarian structures. Read about the pearls and pitfalls here at EM Docs. 

See you next week 

Welcome to the fifty-sixth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

PLAN A [BLOG]: Free high yield airway resources from the CCAM airway course on approach to laryngoscopy. 

ULTRASOUND CASES OF THE WEEK [BLOG]: 

• A Case of Spontaneous Miscarriage Hennepin Ultrasound
• A 48 y/o with Leg Pain and Shortness of Breath Ultrasound of the Week

EM/CC LITERATURE OF INTEREST

• Can Vasopressors Safely Be Administered Through Peripheral Intravenous Catheters Compared With Central Venous Catheters?

PMID: 26210381

• Mechanical Ventilation and ARDS in the ED: A Multicenter, Observational, Prospective, Cross-sectional Study

PMID: 25742126

• Gestational Age and D-Dimer Levels

PMID: 24828148     FOAM: EM Lit Of Note 

• Adnexal torsion in adolescents: update and review of the literature

PMID: 26204167

• Prevalence and predictors of bacterial meningitis in young infants with fever without a source

PMID: 25461476

OWN THE BACKSLAB! [BLOG]: A practical guide to pediatric and adult splinting including excellent video tutorials. Check out this resource here.

More FOAMed 

POST INTUBATION SEDATION FOR PREGNANT PATIENTS [BLOG]: You've intubated the seizing eclamptic patient now what? Rebel EM discusses the literature on post intubation sedation for this patient whom you will hopefully never have to encounter. 

UTILITY OF PRE-4 HOUR ACETAMINOPHEN LEVEL IN ACUTE OVERDOSE [BLOG]: Should we check the acetaminophen level right when our acute overdose patient's present? Bryan Haynes at ALiEM discusses the literature on this topic here. 

CONGESTIVE HEART FAILURE [BLOG]: Core EM brings us an excellent summary of the diagnosis and management of congestive heart failure in the ED in its rapidly growing core content section. 

STEMI, BRUGADA OR NEITHER? [BLOG]: An excellent ecg case that will teach you to always keep your differential open when reviewing ECGs. Make sure to apply your findings to the clinical situation at hand. Dr. Smith's ECG Blog 

See you next week

Welcome to the fifty-fifth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

RICH LEVITAN AIRWAY MANAGEMENT [VIDEO LECTURE]: A fantastic airway lecture discussing novel ideas about management of the difficult airway. You must watch this video here! 

REGIONAL WALL MOTION ABNORMALITIES  [VIDEOCAST]: 

EM/CC LITERATURE OF INTEREST

• Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults.

PMID: 26172429

• Ultrasound guided distal peripheral nerve block of the upper limb: A technical review

Free Access: Article

• Six Months vs Extended Oral Anticoagulation After a First Episode of Pulmonary Embolism: The PADIS-PE Randomized Clinical Trial

PMID: 26151264

• Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission

PMID: 25985100

• A novel, simple method for achieving hemostasis of fingertip dermal avulsion injuries

PMID: 25886984

LET'S BE BLUNT ABOUT ED THORACOTOMY [BLOG]: St. Emlyn's Blog reviews the new EAST guidelines regarding the ED thoracotomy. While it can be a life saving procedure, make sure your intentions are honorable. Read on here. 

More FOAMed

THE FEBRILE CHILD 

THE CHALLENGE OF FEVER IN KIDS [BLOG]: Pediatric fever in the ED can be difficult and frustrating. Rebel EM brings us some pearls to managing both the patient, as well as parents expectations. 

TO CLEAN OR NOT TO CLEAN

AN EVIDENCE BASED APPROACH TO WOUND IRRIGATION [BLOG]: EM Docs explores the evidence and techniques surrounding modern wound irrigation. 

CRITICAL CARE MYTHBUSTING

DOES CENTRAL LINE POSITION MATTER? [BLOG]: Does your central line really need to lie in the lower portion of the superior vena cava? PulmCrit explores the evidence behind this previously held belief. Check it out here. 

TOXICOLOGY 101

CALCIUM CHANNEL BLOCKER OVERDOSE [BLOG]: First10EM with an excellent guide to the initial management of calcium channel blocker overdose in the ED. 

See you next week 

Welcome to the fifty-fourth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

MECHANICAL VENTILATION TUTORIALS [VIDEOS]: If you want a refresh on mechanical ventilation principles, check out Respiratory Reviews multitude of brilliant videos on this topic. 

NO RESPECT FOR THE RIGHT VENTRICLE [PODCAST]: The boys from Ultrasound Podcast sit down with critical care guru, Dr. Haney Mallemat, to discuss the assessment of the right ventricle with ultrasound. Part 1 is here, look out for Part 2 in the coming weeks. 

EM/CC LITERATURE OF INTEREST

• Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial

PMID: 25998582

• Risk-benefit analysis of lumbar puncture to evaluate for nontraumatic subarachnoid hemorrhage in adult ED patients

PMID: 26189054

• Novel vagal maneuver technique for termination of supraventricular tachycardias

PMID: 26209466

• Prothrombin complex concentrate for reversal of vitamin K antagonist treatment in bleeding and non-bleeding patients

PMID: 26151108

• A Preprocedural Checklist Improves the Safety of Emergency Department Intubation of Trauma Patients

PMID: 26194607

PROCEDURAL SEDATION RESOURCES [BLOG]: Core EM with an excellent resource page on procedural sedation medications and other useful links to pitfalls and pearls of this common emergency department skill. 

More FOAMed

THE AORTA WILL F*&% YOU UP 

AORTIC DISSECTION [SCREENCAST]: EM Basic brings us a high yield review of aortic dissection, including both common and uncommon presentation, imaging, treatment and more. Download the screencast here. 

MYTHBUSTING

AZITHROMYCIN DOES NOT CAUSE TORSADES OR INCREASE MORTALITY [BLOG]: Since the 2012 NEJM article on azithromycin we have become quite fearful of the potential life threatening cardiac side effects. Josh Farkas explores the evidence behind this correlation in depth and points out the lack of further studies able to replicate the earlier findings. Read on here. 

S-E-P-S-I-S 

A SEPSIS SMACC-BACK [PODCAST]: If you were at SMACC 2015 you may have been confused after the sepsis expert panel discussion. If you weren't there, you still should listen to this discussion on sepsis 3.0. 

(MEDICAL) EXPLUSION THERAPY

THE ADVENTURE OF THE IMPASSABLE STONE [BLOG]: The ongoing debate for alpha-blockers in large ureteral stones rages on. Should we just dump this treatment into our "pile of medical impotencies" or should we reconsider this therapy until further evidence bears out an answer. Read the post from EM Nerd here. 

See you next week 

Hey Clubhouse!  Sorry we've been out of the loop lately.  We all just flew back in from San Diego, and boy are our arms tired.

One of our beloved colleagues from the community has recently declared to us his love of ultrasound guided nerve blocks--a skill that is established in the anesthesia world but is quickly gaining traction in our realm.  Some programs are training their residents in this skill, and some aren't.  But we've been inspired to talk about it!  That said we will now be featuring a series of posts on this very subject.  Our inaugural post today: femoral nerve blocks.

The Case 

Let's say we do a little time warp, and we are unfortunately six months into the past, stuck in the dredges of frigid winter.  EMS appears with a patient who just wiped out big time on the ice.  He's gripping his thigh with his hands, and he is screaming.  Maybe he's broken his hip?  Maybe it's dislocated?  Maybe he cracked the shaft of his femur?  For this exercise, let's say that it doesn't matter.

What does matter is that it looks like this might need a little pushing and pulling, either to get it reduced or maybe just for re-positioning for imaging.  Procedural sedation?  I mean, we're always down for that, but is there a better way?

Turns out there is!  Specifically we will discuss the femoral 3-in-1 block--so titled as it knocks out the lateral cutaneous, obturator, and femoral nerves.  This will completely anesthetize the femoral shaft, with some coverage of the proximal end of the femur.  This can be done blind, but adding U/S greatly increases the chance of success--the evidence that's out there has shown that using a probe gets you blockade faster and has a higher rate of complete blockade.

How it's done 

You'll need the following for your setup:

• U/S machine with a linear probe
• 21 G spinal needle with attached syringe 
• Vial of 0.5% bupivacaine or 1% lidocaine 
• Sterile gloves
• A sterile probe cover
• Sterile gel

Essentially your goal is to infiltrate the area inferior to the fascia illiaca, allowing for the rapid distribution of anesthetic to the above mentioned nerves.  And to properly do this procedure, you'll need a LOT of local anesthetic--our sources recommend up to 30 mL of bupivacaine or lidocaine, depending on how long a duration of anesthesia you are attempting to achieve. 

When done blind, to confirm you'll either feel a gratifying "pop", your patient will get a paresthesia, or you will feel the pulsations of the femoral artery pushing your needle laterally.  But we can do it better!  For this jobby, prep and drape the area.  Place your probe per convention in the transverse plane, starting at the inguinal ligament.  Slide down until you can see the femoral vein and artery (about 2 cm caudad).  You shouldn't miss these guys.  Just lateral to them is the femoral nerve, which appears as a hyperechoic triangular structure. Review the images below for anatomy of interest:

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After you are comfortable with your anatomy, make a wheal for entry just lateral to the probe. Identify the triangle shaped femoral nerve, lateral to the femoral artery, as well as the iliopsoas muscle and the fascia illiaca running over its surface. The nerves run under this fascia so your goal will be to guide your needle into that space. Now advance your spinal needle directed medially at a 30 degree angle. Get your tip as close as possible to the nerve, and under the fascia illiaca, then inject (well, after aspirating first, of course). You should see the local anesthetic spread the fascia away from the muscle tissues in a cephalad direction.  You'll want to hold pressure distally during all of this, and then 5 minutes after injection.

Here's a fantastic demonstration from the fine people at SonoSite:

Here's the usual video (with the usual unconventional hilarity) from Whit Fisher.  It's a bit of a departure from what we've described above--he mainly goes right at a shaft fracture--but it's the same general idea:

As always, these posts are for EDUCATIONAL PURPOSES ONLY.  These nerve blocks have the potential to be huge for us as emergentologists, but don't take our word for it.  Sure, it feels good to be a trailblazer, but it definitely doesn't feel good to be a lawsuit prone bumbler.  Do your research, and always be safe.

jps

Sources

• Roberts and Hedges Clinical Procedures in Emergency Medicine. Saunders 2014, Chapter 31
• Beaudoin, F. L., Haran, J. P., & Liebmann, O. (2013). A Comparison of Ultrasound-guided Three-in-one Femoral Nerve Block Versus Parenteral Opioids Alone for Analgesia in Emergency Department Patients With Hip Fractures: A Randomized Controlled Trial. Academic Emergency Medicine, 20(6), 584–591. doi:10.1111/acem.12154
• Cristos, S., Chiampas, G, Offman, R, & Rifenburg, R. (2010).  Ultrasound-Guided Three-In-One Nerve Block for Femur Fractures.  Western Journal of Emergency Medicine.  11(4), 310-313
• Turner, A. L., Stevenson, M. D., & Cross, K. P. (2014). Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. Pediatric Emergency Care,30(4), 227–229. 
• Reid, N., Stella, J., Ryan, M., & Ragg, M. (2009). Use of ultrasound to facilitate accurate femoral nerve block in the emergency department. Emergency Medicine Australasia,21(2), 124–130. doi:10.1111/j.1742-6723.2009.01163.xdoi:10.1097/PEC.0000000000000101
• Fletcher, A. K., Rigby, A. S., & Heyes, F. L. P. (2003). Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: A randomized, controlled trial. Annals of Emergency Medicine, 41(2), 227–233. doi:10.1067/mem.2003.51
• SonoSite YouTube Page
• Whit Fisher's YouTube Page

Welcome to the fifty-third edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed 

UNDERSTANDING THE BAG VALVE MASK [VIDEO]: If you use a bag valve mask, you need to know how it works. Excellent teaching videos from George Kovacs. Check you his Youtube page for more content. 

ULTRASOUND CASE OF THE WEEK [BLOG]: A 38 year old male presents from jail with the pathology seen below. Which nerve block will facilitate drainage? Find out here at Ultrasound Of The Week.

EM/CC LITERATURE OF INTEREST

• Emergency Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk

PMID: 25863772  

• Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach

PMID: 25800524

• Safety of peripheral intravenous administration of vasoactive medication

PMID: 26014852

• Liquid Nicotine Toxicity

PMID: 26148101           FOAMED: EM Lit Of Note

• Mechanical ventilation of acute respiratory distress syndrome

PMID: 26045965

• Ultrasonography for the prediction of urological surgical intervention in patients with renal colic

PMID: 26177650

STABILIZING SUBLUXED TEETH [VIDEO]: None of us enjoy dealing with dental emergencies and we could always use a refresh. Check out the video below from The Dental Box on stabilizing a subluxed tooth. Be sure to also check out their Youtube page for more content. 

More FOAMed 

TWO STEPS FORWARD, ONE STEP BACK 

2015 ACEP TPA POLICY [PODCAST]: After some revisions to the 2015 ACEP tPA draft, the final version is in with some minor changes that you may or may not enjoy. Listen to a breakdown of the new policy here at FOAMCast. Be sure to also listen to Dr. Jerome Hoffman, an expert in clinical guidelines, as he sits down to discuss his thoughts on the matter. 

MINOR HEAD TRAUMA + ANTICOAGULATION

MINOR HEAD TRAUMA IN ANTICOAGULATED PATIENTS: [BLOG]: Should they stay or should they go after a negative head CT? Read on here at Rebel EM. 

INFECTIOUS DISEASE TRIO

MUCORMYCOSIS, WEST NILE VIRUS & ROCK MOUNTAIN SPOTTED FEVER: [BLOG]: Clinical practice updates that you should know about regarding these uncommon but cannot miss diagnoses. EM Docs 

• Mucormycosis
• West Nile Virus
• Rock Mountain Spotted Fever 

WHO NEEDS A KNEE X-RAY?

THE OTTOWA KNEE RULES [VIDEO]: Keep it simple, use this rule as a guide to deciding who needs a knee x-ray in the emergency department. A walkthrough with Dr. Ian Stiell.  

See you next week 

Welcome to the fifty-second edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the Foamed 

AIRWAY MANAGEMENT IN  THE CRITICALLY ILL [PAPER]: If you intubate patients this is a must read for management of the airway of sick patients. Check it out here at Critical Care Horizons, a relatively new free online peer reviewed journal.  .

MOUTH WATERING ULTRASOUND CASES

• A pregnant female with right lower quadrant pain ALiEM
• A hypotensive patient who needs intervention now UOTW
• Decreased appetite and hypotension Hennepin US

EM/CC LITERATURE OF INTEREST

• A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department

PMID: 26048068     FOAM: EM Lit of Note

• Immediate Discharge and Home Treatment With Rivaroxaban of Low-risk Venous Thromboembolism Diagnosed in Two U.S. Emergency Departments: A One-year Preplanned Analysis

PMID: 26113241    FOAM: The SGEM

• Sepsis Associated Hyperlactatemia 

PMID: 25394679

• Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

PMID: 25694274 

THOU MUST OBTAIN ACCESS 

• Large bore IV access showdown ETM Course
• A better central line technique EM Updates 
• Engorging a vein prior to proximal PIV placement Scan Crit

More FOAMed 

APPENDICITIS ON THE BRAIN

THE CASE OF NON-INFERIOR INFERIORITY [BLOG]: While once a 'straight to the OR' diagnosis, appendicitis has become a hot topic today with increasing studies on antibiotic therapy for uncomplicated appendicitis. EM Nerd discusses a recent study on just this topic, which found antibiotic therapy to be inferior. Is this it the end for antibiotics for appendicitis or should we remain skeptical?

TOXICOLOGY TIPS

APPROACH TO THE POISONED PATIENT [BLOG]: Some great tidbits on the basics of initial identification, management and stabilization of patients with suspected toxic exposures including several common toxidromes. EM Docs

PNEUMONIA (Noo-mohn-Yuh)

PNEUMONIA ALPHABET SOUP [AUDIO LECTURE]: Excellent talk on variation in the common disease entity we call pneumonia, from VAP to CAP, covering the history of the disease and other relevant topics including diagnosis and management. ICN 

HARDER, FASTER, STRONGER, CATH LAB

BEYOND ACLS [BLOG]: Rebel EM breaks down a new paper that has created an post arrest algorithm for us to risk stratify who would likely benefit from immediate cath after ROSC which I am sure you will find very useful. Check it out here. 

See you next week 

The Case 

A 32 y/o male presents with wrist pain after being involved in a motor vehicle collision this afternoon. He was holding onto the steering wheel with both hands while at a stop light when his vehicle was struck from behind at approximately 30 miles per hour. His x-ray imaging is seen below:

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Diagnosis: Volar Lunate Dislocation

Lunate dislocation is an uncommon traumatic wrist injury that is often a result of high energy trauma from loading of a dorsiflexed wrist along with forced ulnar deviation (i.e holding onto the steering wheel in a rear-end mechanism MVC or falling onto an outstretched hand). The lunate is displaced and rotated volarly (less commonly dorsal rotation), while the remainder of the carpal bones remain in normal alignment relative to the radius. Up to 25% of these injuries can be missed on initial presentation and if left untreated or missed, the function outcome will not be good. 

Imaging 

AP & lateral wrist x-ray images are useful for making this diagnosis. 

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On lateral imaging, alignment is lost between the radius, lunate and capitate which can be appreciated by drawing a straight line through these structures. Often, the lunate is seen displaced and angulated volarly, appearing as a 'spilled teacup.'

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On AP imaging, there is disruption of both smooth lines tracing the proximal articular surfaces of the scaphoid/lunate and hamate/capitate respectively. The lunate is seen overlapping the capitate, triangular (or 'piece of pie') in appearance. 

Clinical Exam

Lunate dislocation will commonly present with volar swelling of the wrist and decreased 2-point discrimination to the median nerve distribution. Approximately 25% of patients will display sensory and/or other median nerve symptoms. This is due to acute carpal tunnel. Besides grip strength, be sure to assess the median nerve hand muscle innervation for signs of significant injury:

• L- Lumbricals 1 & 2: Flex MP joints and extend IP joints of thumb and index finger 
• O- Opponens pollicis: Allows tip of thumb to touch other fingertips
• A- Abductor pollicis brevis: Allows movement of thumb anteriorly away from palm 
• F- Flexor pollicis brevis: Flexes thumb at the MP joint 

Management

This injury requires prompt reduction and immobilization in the emergency department. The reduction can be performed with volar pressure and extension of the wrist. After successful reduction, the wrist should be placed in a volar splint. Orthopedic consultation should be obtained from the emergency department as most of these injuries will require surgical repair of the disrupted ligaments. Without surgical intervention, functional outcomes are poor and recurrent dislocation is common. Worst case scenario, avascular necrosis of the lunate can occur, also known as Kienbock disease. Unfortunately even with treatment, many of these patients will still experience future degenerative arthritis. 

Important Points

• Lunate dislocation can result in significant chronic pain and loss of function; immediate reduction and orthopedic consultation is warranted in the emergency department. 
• This is injury that is often missed by both clinicians and radiologists. Be sure to look at your own films; the lateral wrist x-ray may be the key to your diagnosis.
• Do not confuse this diagnosis for a perilunate dislocation where the radiolunate articulation is preserved and the rest of the carpus is displaced dorsally. 
• Given that both lunate and perilunate dislocations are associated with high energy trauma; be vigilant of associated fractures. 

References:

• Sherman, S. 2014. Emergency Orthopedics 7th Ed. New York: McGraw-Hill Education
• http://radiopaedia.org/articles/lunate-dislocation
• http://www.orthobullets.com/hand/6045/lunate-dislocation-perilunate-dissociation
• http://www.wheelessonline.com/ortho/perilunate_dislocations

Welcome to the Ultrasound Leadership Academy (ULA) summary blog series. This week, we discuss the basics of shoulder ultrasound. The ULA is essentially an online advanced ultrasound education experience put on by the team from Ultrasound Podcast which brings cutting edge learning to emergency medicine personnel through a variety of interactive platforms including video lectures, google hangouts with experts, simulation, live conferences and real time scanning with a pocket-sized ultrasound device known as a Vscan.

Over the next year I will be posting summaries of the key learning points from my experience. If you want to learn more about the program you can visit Ultrasound Leadership Academy or Ultrasound Podcast to see more from the hosts of this awesome program.

INTRODUCTION

Evaluation of the shoulder with ultrasound may appear like a daunting task in the emergency department, however with a strong understanding of the anatomy and an organized approach, the technique will rapidly become more within your realm of comfort. Furthermore, there is good evidence in the literature to support the use of ultrasound to accurately identify multiple shoulder pathologies including shoulder dislocation, rotator cuff tear, clavicle fracture and AC joint separation. For example, a systematic review of the accuracy of ultrasound for rotator cuff tear found it to be up to 96% sensitive for full thickness injuries and 84% sensitive for partial thickness injuries.

Point of care ultrasound is available to us immediately and at little cost, making this an exam that is definitely worthwhile to master in order to assist not only with diagnosis in shoulder complaints but also to allow you to provide patients with more information rather than saying their x-ray imaging is normal and they may need an outpatient MRI. 

Let's get started. 

The Anatomy 

When evaluating the shoulder an organized approach will be essential, utilizing systematic identification of key shoulder structures. Our main region of interest will be the rotator cuff but will also include evaluation of the biceps tendon, the gleno-humeral articulation, the AC joint and the clavicle.

As seen above the rotator cuff is made up of four tendons that attach to the proximal head of the humerus to assist with holding it firmly within its articulation with the glenoid. 

• Supraspinatus (SS): Located in the suprascapular fossa with attachment at the greater tuberosity of the proximal humerus.
• Subscapularis (S): Located anteriorly with attachment at the lesser tuberosity of the proximal humerus.
• Infraspinatus (IS): Located posteriorly, inferior to the spine of the scapula, attaching to the posterior aspect of the greater tuberosity.
• Teres Minor (Tm): Located just inferior to the infraspinatus, also attaching to the posterior aspect of the great tuberosity.

Other structures of interest that we will be examining include:

• Biceps Tendon (B): Located anteriorly, coursing in a groove between the greater and lesser tuberosities of the humerus.
• AC Joint: This synovial articulation lies superiorly and is usually palpable on clinical exam.
• Subacromial Bursa: Usually located above the supraspinatus tendon and below the coracoid process. It is usually not seen or is very thin but enlarges visibly with pathology.
• Clavicle: Prominent anterior bony structure connecting the scapula to the axial skeletal structure.

The Technique

Scanning Protocol:

1. Supraspinatus/Subacromial Bursa
2. Subscapularis
3. Biceps tendon
4. Infraspinatus/Gleno-humeral Articulation 
5. AC joint/Clavicle

Probe: Linear high frequency 

Positioning: Have the patient sit upright with injured shoulder exposed. It is useful to use a stool with wheels to sit next to the patient to be able to maneuver from anterior examination of the shoulder to posterior examination. 

1. The Supraspinatus/Subacromial Bursa

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The supraspinatus lies directly under the acromion, so to expose it have the patient place their hand behind their back (Crass maneuver) in order to hyperextend and internally rotate the humerus. This can be uncomfortable for the patient, so a modified Crass maneuver can be also used which involves the patient placing their hand on the ipsilateral hip or buttock region. 

Place the probe along the long axis of the tendon as seen above (if in modified crass position the probe will essentially be pointing towards ipsilateral ear). The tendon appears hyperechoic compared to the deltoid muscle superiorly. You may appreciate what is called the 'birds beak' view which shows the supraspinatus tendon tapering off to a sharp point where it attaches to the greater tuberosity of the humerus. You are looking for a smooth contour of the tendon. While you do see some thin black stripes medially on the left image above, remember that tendons display a phenomenon called anisotropy which refers to differing appearance depending on what angle the ultrasound beam is with regard to the tissue. For this reason you must scan through the entire tendon at various angles to ensure these are indeed artifact and not signs of tendon injury. 

On this view you will often be able to visualize the subacromial bursa (or lack off). It will lie in the space just superior to the supraspinatus tendon and just inferior to the deltoid. In a normal shoulder it is not visible or is seen as a very thin black stripe. Enlargement of this space will suggest inflammation and pathology. 

Remember that after viewing a tendon in long axis, rotate your probe 90 degrees and fan through the entire tendon in short axis. A complete exam will consist of both long and short axis views of each structure of interest.

2. The Subscapularis 

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The subscapularis is directly anterior so have the patient relax the arm down by their side and place their ipsilateral hand on their lap with palm facing upward. Place the probe slightly more inferior and anterior than you would when viewing the supraspinatus, as shown above. You should be able to visualize the lateral aspect of the subscapularis tendon attaching to the lesser tuberosity of the humeral head. After you identify this, rotate the shoulder externally to allow you to visualize the most medial aspects of the subscapularis which can hide beneath the coracoid process. Rotate your probe 90 degrees and examine the entire tendon from lateral (lesser tuberosity of humeral head) to medial (corocoid process). The subscapularis often demonstrates significant anisotropy so don't be fooled! 

3. The Biceps Tendon

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The biceps tendon sits right in the groove between the greater and lesser tuberosity. After assessing the subscapularis, move your probe slightly lateral to view the biceps tendon in the short axis (as seen above). The arm will usually need to be slightly externally rotated. You will appreciate a circular structure between the two hyperechoic bony surfaces surrounding it. Since the tendon dives deep to the skin surface, you may appreciate it appearing hypoechoic due to anisotropy. It should normally appear hyperechoic and fibrillar so be sure to fan your probe up and down in order to eliminate this artifact. Assess the tendon proximally until the bicipital groove becomes shallow and distally until your visualize the pectoralis major tendon. Then turn the probe 90 degrees to assess the tendon in long axis. It is important to note that the the biceps tendon communicates with the glenohumeral joint so if you notice fluid surrounding the tendon this can be an indicator of injury within the joint. 

4. The Infraspinatus/Gleno-humeral articulation

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Place the probe on the posterior aspect of the shoulder just inferior to the spine of the scapula. Your orientation should be oblique, pointing in the same direction as the scapular spine. Laterally your should visualize the smooth hyperechoic contour of the humeral head, articulating medially with the hyperechoic glenoid labrum. The infraspinatus tendon will run just superior to these structures.  Note that this view will be useful when assessing for shoulder dislocation as you will be able to clearly appreciate abnormal articulation of the humeral head with the glenoid. If you find it difficult to visualize the distal aspect of the infraspinatus tendon, you can have the patient place their ipsilateral hand on their contralateral shoulder to move the tendon away from shadowing created by the acromion. After long axis assessment, be sure to turn your probe 90 degrees to assess the infraspinatus in short axis.  

5. The AC Joint/Clavicle

This last step should be fairly quick and only focused on directly if you are concerned about AC separation or clavicle fracture. Identifying the clavicle is easy, place the probe on top on this palpable bony structure either in short on long axis to visualize any cortical disruption. Start medially and then follow the clavicle laterally until you come to the AC joint. Here you will see the bony cortex of the clavicle, separated by a small hypoechoic space, connecting to the acromion (as seen above). You are looking for widening of this space in AC separation. The joint should be approximately 5 mm in width however it is useful to use the other side for comparison if you are concerned for pathology. 

LEARN MORE:

• Ultrasound of the Shoulder [VIDEO]
• 1 Minute Ultrasound: Shoulder Dislocation [VIDEO] 
• Web Based US Simulation of the Shoulder [INTERACTIVE MODULE]

THAT'S IT FOR THIS WEEK

If you are interested in learning more about the ULA learning experience, visit their website below:

More on MSK ultrasound can be found in "Introduction to Bedside Ultrasound," Volume 1 & 2, from Dr. Mallin and Dr. Dawson. If you are interested in purchasing these ebooks for less than $1, visit Ultrasound Podcast Consumables.

References 

• Ultrasound Leadership Academy Online Course

• Ultrasound assessment of most frequent shoulder disorders

• Shoulder US: Anatomy, Technique, and Scanning Pitfalls

• Ultrasoundcases.info: Shoulder

• EM Docs: Shoulder Ultrasound: Intra-articular Injection & Reduction  

Welcome to the fifty-first edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

THE TRAUMA AIRWAY [BLOG]: Excellent discussion of optimizing your trauma airway assessment and management, based on the EAST guidelines and relevant literature, here at EM Docs. 

ULTRASOUND GOODIE BAG 

ULTRASOUND FOR LATE PREGNANCY [PODCAST]: While not a routine exam we perform other than confirming fetal heart tones, definitely some great pearls on more advanced US topic. Part 1 here. 

US GUIDED ULNAR NERVE BLOCK [BLOG]: Boxer's fracture need a reduction? Consider an ultrasound guided ulnar nerve block. Check out the case here and be sure to watch the video tutorial from 5minsono. 

EM LITERATURE OF INTEREST 

• Safety and efficacy of antihypertensive prescription at emergency department discharge PMID: 25904073

• Outcomes Of Patients Resuscitated From Cardiac Arrest in the Setting of Drug Overdose PMID: 26126505

• Over treatment of gonorrhea and chlamydial infections in 2 inner-city emergency departments PMID: 26119905

• Periprosthetic joint infection PMID: 26135702

• Thromboembolic Events After Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate: Exploratory Analyses of Two Randomized, Plasma-Controlled Studies PMID: 26094105

DIY FINGER TRAPS: [BLOG]: If you find yourself finger-trapless with a distal radius fracture in your ED, remember this blog post to assist you with a make shift solution. 

More FOAMed 

INFECTIOUS DISEASE SMORGASBORD

CORE EM PODCAST EPISODE 3 [PODCAST]: Swami sits down to run over some high yield EM topics in the arena of infectious disease, from antibiotic choice in HCAP, to new paradigms in soft tissues infectious. With a bonus brief on disaster management. Enjoy here. 

CARDIOLOGY NUGGETS 

CASE OF A 59 Y/O M APPEARING UNWELL [BLOG]: You must learn to recognize these ecg patterns, and have a practical ecg reading algorithm. Read the case here and then the conclusion once you have it all figured out. 

BENIGN EARLY REPOLARIZATION [BLOG]: Have a quick skill brush-up on this common ECG finding that could be looking quite concerning if you are not familiar with it.

LACTATE KNOWLEDGE BOMB

UNDERSTANDING LACTATE IN SEPSIS [BLOG]: Raise your hand if you think elevated lactic acid in sepsis is from anaerobic metabolism? Well, this may not be completely true. Very relevant and timely to the recent SMACC CHICAGO  smaccdown on this myth, Josh Farkas discusses what lactate really means and how we can better use this marker in our management of these patients. Read on here. 

See you next week 

Welcome to the fiftieth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

WEINGART ON HFNC [PODCAST]: The new oxygen wonder child is taking critical care by storm. Should we all be jumping on board? Weingart discusses some background, the evidence and his opinions here. 

ULTRASOUND IN CHEST PAIN: [BLOG]: It is never a bad idea to throw an ultrasound probe on your patient with chest pain. Ben Smith at USOTW with a excellent exemplary case here.

LITERATURE THAT MAY INTEREST YOU [JOURNALS]: 

• Should we be looking for and treating isolated calf vein thrombosis?

• The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients

• Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension

• Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort

• Comparing biomarkers of traumatic shock: the utility of anion gap, base excess, and serum lactate in the ED

TONGUE BLADE TEST: [VIDEO]: Does every patient with potential jaw fracture need a CT? Check out this video at the new CORE EM website regarding the tongue blade test to assist with your decision making. 

More FOAMed 

HARDWARE MALFUNCTION

PACEMAKER AND AICD MANAGEMENT IN THE ED [BLOG]: EM Docs brings us some well needed cardiac hardware meducation on the patient with AICD/pacemaker issues presenting to the ED. I would definitely give it a read. BONUS: User this article to identify what type of device your patient has if in the rare circumstance they don't know. 

ECG PATTERN RECOGNITION 

CARDIAC ARREST AND ST ELEVATION: [BLOG]: Dr. Smith features a brief cardiac arrest case with an ECG pattern that you must know and be able to recognize! Check out his post here. Dr. Smith's ECG Blog 

CHRONIC PAIN IS REAL PAIN

CHRONIC PAIN MANAGEMENT [PODCAST]: Rob Orman sits down with an expert to discuss the predominate issues regarding chronic pain, how opiates really aren't making anything better, and how we can begin to address this highly complicated and serious issue. ER Cast 

• Part 1
• Part 2

SMACC-stalgia 

SMACC CHICAGO 2015 PEARLS [PODCAST]: Missed SMACC Chicago and want to hear what all the buzz was about? Or maybe just want to reminisce on the great time you had at the conference? Listen to the 3 part series from FOAMcast on SMACC Chicago highlights:

• Part 1
• Part 2
• Part 3

See you next week

Welcome to the forty-ninth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

DIRECT VS INDIRECT LARYNGOSCOPY [VIDEO]: It's all about blade geometry. Rueben Strayer discusses some terminology and misunderstandings in the ongoing DL vs VL debate. Watch this 10 minute video here. EM Updates 

DVT ULTRASOUND DELUX [PODCAST]: Sometimes two point compression ultrasound may not be enough. Ultrasound Podcast brings us whole leg DVT ultrasound education...from a hotel room. 

LOW RISK CHEST PAIN [VIDEO]: The evidence continues to build on the unnecessary admission of low risk chest pain after initial ED evaluation. Listen to Amal Mattu discuss a brand new JAMA article to further justify your decision to send a low risk chest pain patient home. ECG Weekly

More FOAMed 

CORE EM CONTENT 

NON PREGNANT VAGINAL BLEEDING [PODCAST]: EM Basic continues to put out great content on core EM topics, listen to the podcast here discussing the workup and initial management of non pregnant vaginal bleeding in the ED. 

FUEL FOR THE PE FIRE

PE IN COPD: [BLOG]: How often do you think about PE in a clear COPD exacerbation? EM Crit features a new article on the prevalence of PE in COPD exacerbations which found it to be an astounding 18%(N=49). Be sure to check out the on-going discussion in the comments section. 

KIDNEY LOVE 

AIR SERIES- GU/RENAL [COLLECTION]: Yes, this is a link to more links, full of FOAMEd goodness! The AIR (Approved Instructional Resources) series at ALiEM brings us its 8th module of curated content, this month focusing the on GU/renal system. Topics include ultrasound for renal colic, testicular torsion, and more. 

HEROIC EFFORTS

THE CRASHING ASTHMATIC [PODCAST]: The crashing asthmatic is a frightening scenario and a patient whom we definitely do not want to intubate unless we ABSOLUTELY have to. Swami brings us some heroic pearls on management of this patient, what tools we have under our belt and how to manage them if we do have to pull the trigger and intubate. Rebel EM 

UNNECESSARY TESTING

ROUTINE LABORATORY SCREENING IN PSYCHIATRIC PATIENTS IN THE ED [PODCAST]: Is it needed? It probably doesn't change our management and is rather low yield. Listen to the journal club review at Wash U EM. 

See you next week

Welcome to the forty-eighth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

KETAMINE AND ROCURONIUM: [BLOG]: Is the jury still out about the optimal RSI meds or has a true superior choice risen to the top? Nice post EM Docs post discussing the pro ketamine/rocuronium camp. 

THE SUPERIOR CERVICAL PLEXUS BLOCK [VIDEO]: AKA THE SCP Block, a useful nerve block technique for your ear laceration, central line placement and even a clavicle fracture. 5 Min Sono 

PNEUMONIA AND HFNC [BLOG]: As mentioned last week, my prophecy of a FOAMed analysis regarding the recent NEJM article has been fulfilled. Josh Farkas discusses the argument of HFNC versus BiPap in pneumonia in light of current evidence. Pulm Crit 

CIRRHOSIS, FFP & PROCEDURES : [BLOG]: Is there a true benefit to give FFP to liver patients prior to a procedure? How well do you think the INR is as an indicator of coagulopathy in these patients? Read on here at Boring EM. 

More FOAMed 

THINGS THAT WILL MAKE YOUR LIFE EASIER 

PEDIATRIC ED HACKS [BLOG]: Rebel EM with an outstanding post on pediatric ED management hacks that will make you a more efficient, kind and creative ED doc. Check out these 7 pearls here. 

WHEN THE HEART FAILS

CARDIOGENIC SHOCK: [BLOG]: We don't normally refer to the same blog twice in one week but these posts are just too good. This post features a guest author, from the soon to be released Core EM FOAMed website, on management of cardiogenic shock in the ED. Read on here. Rebel EM

FLUID IS A DRUG

FLUIDS BY MYBURGH [PODCAST]: This is one podcast you really cannot miss. We give fluids every day, and we often forget that what type of fluid we give, and how much, matters, just like any other drug. Listen to Myburgh discuss the history of fluid therapy and where we currently stand in this day and age. Intensive Care Network 

HONE YOUR ECG SKILLS 

T WAVE INVERSION [VIDEOCAST]: The all to well known ECG expert Dr. Steve Smith with another great video lecture on the T wave inversion, both normal, abnormal, and when we should be really concerned for badness. Check it out here. Dr. Smith's ECG Blog 

See you next week

Welcome to the forty-seventh edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

AIRWAY TIPS: [BLOG]: EM Didactic sums up some nice pearls from the CRASH Airway Course in a two part post:

• Part 1
• Part 2

NEEDLE TO THE FOOT: [BLOG]: Ben Smith brings us a great case highlighting the utility of ultrasound in both foreign body identification and regional anesthesia in case #47 of Ultrasound of the Week. 

HIGH FLOW NASAL CANNULA IN ACUTE HYPOXIC RESPIRATORY FAILURE: [ARTICLE]: More evidence for the use of high flow nasal cannula in acute hypoxic respiratory failure. No change in rate of intubation, but a significant improvement in 90 day mortality. NEJM

More FOAMed

OH YOUR BLOOD PRESSURE IS HIGH? 

HYPERTENSIVE EMERGENCY TREATMENT [VIDEO]: Management of all of your hypertensive emergencies in five minutes. Simply awesome. Watch here @ EM in 5.

ENDOCRINE EMERGENCY

THYROID STORM: [PODCAST]: Fever, altered mental status, tachycardia and GI issues are just some manifestations that can clue you in to this uncommon endocrine emergency. Weingart discusses the ED management of thyroid storm, a need to know entity. EM Crit

SILVER LINING?

MINOR BURNS AND SILVER SULFADIAZINE [BLOG]: What constitutes a minor burn and when should you consier transferring a patient to a burn center? If you don't, how do you manage them and is silver sulfadiazine really the best topical option? Read on here. EM Docs

AGITATION ARMAMENTARIUM

KETAMINE FOR EXCITED DELIRIUM SYNDROME [BLOG]: Bryan Hayes at ALiEM reviews the literature for the use of ketamine in agitation and while it looks promising, it may not be ready to become numero uno in cases where immediate chemical restraint is necessary. 

MEDICAL EDUCATION 

SCOTT WEINGART ON THE STATE OF THINGS [PODCAST]: Rob Orman sits down with Scott Weingart in a charming show to discuss randoms topics from beer choice, to medical education, to the state of the FOAMed movement. A must listen here @ ER Cast. 

See you next week. 

Welcome to the forty-sixth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

USING ULTRASOUND TO IDENTIFY THE CRICOTHYROID MEMBRANE: [VIDEO]: Thank you PHARM for finding this excellent instructional video by AirwayOnDemand on ultrasound anatomy of the trachea for surgical airway planning. 

B-LINES USING ULTRASOUND FOR HEART FAILURE [PODCAST]: Are B-lines identified by ultrasound of the lungs useful for diagnosing heart failure? The breakdown on the evidence @ The SGEM. 

THE P-VALUE [BLOG]: 3 weeks ago we featured the Pulm Crit post discussing the issues currently faced with the p-value as the prototype of statistical prowess. This week EM Nerd brings us a side dish of skepticism with his take on our p-value obsession. 

THE EXTERNAL JUGULAR IV [VIDEO]: This is a life saving peripheral line I find extremely useful in difficult access patients. Dr. Whit Fisher brings you some Procedurettes pearls on optimizing your technique. 

More Foamed

YES, MORE DISCUSSION ON SAH

THE SUBARACHNOID ENIGMA: [PODCAST]: An enticing title for a worthy podcast with Rob Orman discussing the continuously evolving literature on subarachnoid hemorrhage. Is CT only in 6 hours is ready for prime time? Listen here. ER Cast

BURN THIS INTO YOUR MEMORY

BLOATED & UPSET [BLOG POST]: An excellent imaging case regarding x-ray findings that should concern you in a patient presenting with abdominal pain, bloating and vomiting. Sinai EM

HEMOGLOBIN HAZARDS

TOXIC HEMOGLOBINOPATHIES [VIDEO]: A fine review of two classic hemoglobinopathies, by Dr. Hong Kim. Do you know the causes of methemoglobinemia? How do you manage carbon monoxide poisoning? Watch this lecture here @ Maryland CC Project. 

HOT, RED, AND TENDER

SEPTIC JOINT [BLOG]: EM Docs brings us a well versed update on the septic joint, including key history and background, diagnostic work up strategy, and management. Check this post out right here. 

See you next week

Welcome to the forty-fifth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

CRITICALLY ILL AIRWAY PRECOURSE [VIDEO]: Over at EM Curious we can never get enough airway education so we would like to recommend these excellent videos on airway management over at @ The Intensive Blog from a variety of airway experts.

DVT ULTRASOUND CONTROVERSY [PODCAST]: There has been an emerging collection of literature that two-point compression ultrasound may be inadequate to rule out DVT. Check out the podcast here @ Ultrasound Podcast. 

IS IT TIME TO START USING THE HEART PATHWAY IN THE EMERGENCY DEPARTMENT? [BLOG]: The ongoing struggle with low risk chest pain disposition in the ED rages on while the HEART pathway continues to show promise, now with an RCT in its favor. Read on here @ Rebel EM.  

ROCKET LAUNCHER- A NOVEL TECHNIQUE FOR POSTERIOR HIP DISLOCATION [ARTICLE]: The EMA Journal reviews literature regarding techniques for posterior hip dislocation and proposes a new approach that you may find useful. Check it out here.

More FOAMed 

AGE ADJUSTED D-DIMER

I HOPE YOU HAD A NEGATIVE D-DIMER: [PODCAST]: The false positive rate of d-dimer in the elderly is high and it may be time for age adjustment in light of the ADJUST-PE study. Listen to the review here @ The SGEM. 

TOXICOLOGY 

CYANIDE POISONING [VIDEO]: EM in 5 brings you a visually pleasing 5 minute video lecture on cyanide toxicity. You should be able to know when to suspect it, how to recognize it and what your go to treatment should be. Watch here. 

FOAMCASTIN 

NEUROLEPTIC MALIGNANT SYNDROME, SEROTONIN SYNDROME, & MALIGNANT HYPERTHERMIA [PODCAST]: Foamcast covers some of the toxicologic syndromes we may see in the ED that present with altered mental status and fever. Remember that not all fever is infectious so don't forget about tox! Listen here. 

TISSUE ADHESIVE UTILITY

FINGERTIP AMPUTATION TREATED WITH CYANOACRYLATE TISSUE ADHESIVE [VIDEO]: We are finding that tissue adhesives continues to find their way into more and more procedures as physicians become more comfortable with this treatment. Larry Mellick with an excellent demonstration of using tissue adhesive to stop finger tip amputation bleeding. 

See you next week 

Welcome to the forty-fourth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.

Onto the FOAMed

AIRWAY DECISIONS & ONLINE ETIQUETTE [PODCAST]: Last week EM Crit posted a real case regarding a life saving cricothyrotomy on a post arrest patient which received quite a bit of online buzz, some of which was not so nice. This week he delves further into the airway decisions made in this case and also points out that FOAM is really about the discussion and not about playing the shame game. Listen here @ EM Crit.

VIRTUAL TRANSTHORACIC ECHO [SIMULATION]: One of the best interactive virtual TTE simulators out there, this free website will help you hone your cardiac anatomy and technique. You can view the TTE recordings for each of the 20 standard views used in a full cardiology exam and see the corresponding 3D model of the probe, ultrasound plane, heart and rib cage for that view.

TOP 10 TRAUMA PAPERS OF 2014-2015 [PODCAST]: It's been a huge year in trauma literature with big changes and a large volume of dogma smashing evidence. Listen to a great review of the top 10 trauma papers in 2014-2015 @ St. Emlyns Blog. 

SMALL JOINT ARTHROCENTESIS [VIDEO]: From our very own Dr. John Sarwark for your viewing pleasure. 

More FOAMed

AVOIDING ERRORS

HYPERKALEMIA MANAGEMENT- PREVENTING HYPOGLYCEMIA FROM INSULIN: [BLOG]: Normoglycemic patients need more than a single amp of D50 to prevent hypoglycemia after insulin therapy for hyperkalemia. Read on here @ ALiEM.

WHEN KIDS FALL OUT 

PEDIATRIC SYNCOPE [PODCAST]: An in depth look into pediatric syncope, delving into etiologies of sudden cardiac death in children and who should get further work up. Listen to the two part podcast featuring Dr. Andy Sloas & pediatric cardiology expert Dr. Buck Kyle @ PEM ED.      

Part 1       Part 2

DONT STOP COMPRESSING 

HANDS ON DEFIBRILLATION [BLOG]: Minimizing time off the chest during CPR? Put some gloves on and keep on pressing through defibrillation. Don't believe me? Read on regarding some recent evidence on this subject here @ Rebel EM. 

INTOXICATED PATIENTS HAVE MEDICAL PROBLEMS TOO

JUST ANOTHER INTOXICATED HEAD INJURY [BLOG]: A great case highlighting the importance of monitoring your agitated and/or intoxicated patients that require chemical sedation. Read on here @ LITFL. 

See you next week