Top Blogs of 2021

Congratulations to all of the authors with the most popular posts of 2021!

1. Pill in the Pocket (23,646 views)

The runaway favorite of this year was Dr. David Feiger’s (NUEM ’22) and Dr. Jon Andereck’s (NUEM ’19) post reviewed by Dr. Kaustubha Patel of Northwestern's Bluhm Cardiovascular Institute about the “pill-in-the-pocket” approach to treating atrial fibrillation. 

Take-Home Point: In select patients, the “pill-in-the-pocket” approach is a safe and effective way to treat infrequent but symptomatic paroxysmal atrial fibrillation that reduces ED visits and improves patients’ quality of life. 

2. Peripheral Vasopressors: Do I need that central line? (8,683 views)

In the second most popular blog of the year, Dr. Saabir Kaskar (NUEM '23) and Dr. Abiye Ibiebele (NUEM '21), with commentary by Northwestern pulmonologist/intensivist, Dr. Marc Sala, summarize the current literature on the peripheral infusion of vasopressors, which is becoming more and more commonplace as the evidence evolves to support earlier initiation of pressors and more judicious use of crystalloid for many forms of shock.

Take-Home Point: While the evidence at this time is limited, clinicians should feel comfortable administering peripheral vasopressors as a bridge to central infusion for a limited time. Peripheral vasopressors have a lower risk of complications than previously thought and allow clinicians to minimize delays in administering vasoactive medications that may have a mortality benefit. 

3. Pericardiocentesis (2,553 views)

Rounding out the top three is Dr. David Feiger's (NUEM '22) and Dr. Abiye Ibiebele's (NUEM '21) post on emergent pericardiocentesis, a potentially life-saving procedure in a patient with hemodynamically significant cardiac tamponade, with expert commentary by Northwestern interventional cardiologist, Dr. Dan Schimmel. 

Take-Home Point: Bedside pericardiocentesis is a rare but important procedure that can be performed emergently using ultrasound or landmark guidance. While a subxiphoid approach is commonly performed, an apical or parasternal approach may be considered to minimize potential complications. Consider exchanging the needle for a drain once the pericardium is accessed to bridge to definitive therapy.

4. Hanging Injury (959 views)

Dr. Vytas Karalius (NUEM '22), Dr. Nery Porras (NUEM '21), and expert commentator Dr. Kevin Emmerich describe the mechanisms of injury and management of patients presenting with hanging injuries, an unfortunate but all-too-common method of self-harm worldwide. 

Take-Home Point: Hanging injuries can have wide-ranging immediate and delayed complications on multiple organ systems and clinicians should evaluate for cervical spine and cerebrovascular injury and anticipate a difficult airway due to evolving airway edema. Clinicians should have a high index of suspicion for polytrauma or toxic ingestion. Even with an initial negative workup, all patients should be admitted for observation (with a low threshold to transfer to a trauma center) and ultimately a psychiatry consult. 

5. Paronychia (623 views)

In one of two procedural infographics to make the top ten this year, Dr. Richmond Castillo (NUEM '23), Dr. Andra Farcas (NUEM '21), and Dr. Matthew Kippenhan provide a visual guide to diagnosing and treating a common "fast-track" complaint. 

Take-Home Point: Paronychia is a common infection of the nail fold that often requires an incision and drainage procedure if a purulent fluid collection is present. Be wary of several other "can't miss" visual diagnoses on the differential, such as herpetic whitlow, felon, and proximal onychomycosis. 

6. Antiemetics/Gastroparesis (572 views)

With expert commentary by NUEM faculty Dr. Howard Kim, Dr. Nery Porras (NUEM '21) and Dr. Terese Whipple (NUEM '20) provide an overview of the role of antipsychotics in the treatment of gastroparesis and other cyclic vomiting syndromes. These conditions can be difficult to treat, frustrating for both patients and providers, and refractory to traditional antiemetic therapies. 

Take-Home Point: Antipsychotic medications such as haloperidol and droperidol are effective therapies for nausea, vomiting, and abdominal pain associated with gastroparesis. Despite previous black box warnings on droperidol causing it to fall out of favor, it is safe and well-tolerated at the doses typically used in an emergency department setting. 

 7. Basic Capnography Interpretation (560 views)

Dr. Shawn Luo (NUEM '22) and Dr. Matthew McCauley (NUEM '21) review the basics of interpreting continuous waveform capnography, a versatile tool with multiple uses in both the emergency department and critical care settings. Dr. Seth Trueger, NUEM faculty, provides expert commentary. 

Take-Home Point: Continuous waveform capnography (otherwise known as end-tidal CO2) is a valuable tool that can inform real-time management decisions in both intubated and non-intubated patients. Recognizing several common patterns can guide providers during several use-cases such as confirming endotracheal tube placement, cardiac arrest, and procedural sedation. 

8. Knee Dislocation (436 views)

Knee dislocations are a rare but highly morbid condition for which Dr. Andrew Rogers (NUEM '22) and Dr. Amanda Randolph (NUEM '21) provide a streamlined approach to diagnosing and treating. NUEM's own emergency orthopedic guru, Dr. Matthew Levine, provides expert commentary. 

Take-Home Point: Knee dislocations are time-sensitive injuries that require rapid diagnosis and treatment because of the high rate of vascular complications. Emergent closed reduction is key, with a thorough neurovascular exam before and after. All patients require ABIs (with CT angiography if the ABI is abnormal) and admission for neurovascular checks. Speak with your consultants early.

9. TPA in Frostbite (422 views)

For those who practice in colder climates, Dr. Patrick King's (NUEM '23) and Dr. Nery Porras's (NUEM '21) review of the current literature on the role of tPA in frostbite is timely as we enter into the winter season. Expert commentary is provided by Dr. Anne Lambert Wagner, medical director of the Burn and Frostbite Center at the University of Colorado Health. 

Take-Home Points: While literature continues to evolve, current evidence supports the use of tPA in select patients with severe frostbite injuries in multiple digits, multiple limbs, or proximal limb segments presenting within 24 hours of injury. Combined with active rewarming strategies, tPA use results in significantly improved outcomes. 

10. Felon (381 views)

Rounding out the top 10 for 2021 is the second procedural infographic, which is closely related to our Paronychia post. The expert review of Dr. Matthew Levine, Dr. Daniel Levine (NUEM '23), and Dr. Will LaPlant (NUEM '20) illustrate the diagnosis and management of felons in the emergency department.
Take-Home Point: Understanding finger anatomy is key to understanding felons, which present as tense, throbbing, purulent infections of the distal finger pad. Incision and drainage is the mainstay of therapy for felons, with a course of oral antibiotics and mandatory hand surgery follow-up to avoid complications such as flexor tenosynovitis or osteomyelitis of the distal phalanx. 

Top Blogs of 2020

Congratulations to all of the authors with the most popular posts of 2020! Here is the 2020 rundown:

1. Oral Nerve Blocks (5,904 views)  

The most popular post of 2020 is this useful review of oral nerve blocks by Vytas Karalius, 2019 grad Andrew Cunningham, and Cincinnati faculty Jeff Hill - a great tool that can help make some of the most frustrating ED cases much better for everyone involved. Special note that this is part III in the Nerve Blocks of the Head & Neck series - all of which are in the top 10.

Take home point:

For oral nerve blocks, use bupivacaine with epinephrine when available. Oral/dental pain can be immensely painful and compromise a patient’s quality of life. The longer you can provide pain relief until they receive definitive care, the better off they will be.

 2. Clinical Question: are we impeding our patients’ fracture healing by giving them NSAIDs? (3,851 views)  

No clear answer but a strong discussion of the available evidence in this physiology vs outcomes-based data question by Andra Farcas, 2019 grad Jessica Bode, and local EM trauma guru Matthew Levine. 

Take home point:

The evidence isn’t slam-dunk in either direction on whether using NSAIDs impedes the fracture healing process. My takeaway: if my patients have no other contraindications to using NSAIDs and if their pain is well-controlled with said medication, then I’m going to advise they can use it for a short term and advise them to seek medical attention if they’re still needing to use NSADs regularly a few weeks out.

3. Little Lungs, Little Differences: Initiating Emergency Department Mechanical Ventilation in the Pediatric Patient (2,573 views)  

Kids aren’t little adults but their lungs are little; Matt McCauley, 2019 grad and current NorthShore attending Jacob Stelter, and Lurie PICU attending Katie Wolfe review on mechanically ventilating kids.

Take home point:

In choosing initial ventilator settings, the key is decision and reassessment. Most modes of ventilation will work in most children. However, careful attention to what support you’re providing your patient with and what the results of that support are, is vital.

4. Facial Nerve Blocks (1,380 views)

The first entry in the Nerve Blocks of the Head & Neck series by Vytas Karalius, 2019 grad & current faculty Aaron Quarles, and Boston Children’s attending Ashley Foster. In this post we review anesthetizing the face - a great tool for some terrible situations.

Take home point:

 Viscous lidocaine should be used prior to oral nerve blocks – this will greatly increase the patients’ comfort, their ability to remain still, and ultimately, your success.

5. Occipital Nerve Block (1,210 views)

Andrew Rogers, 2019 grad and current faculty Aaron Quarles, and Montefiore EM headache expert Ben Friedman (COI: his brother was in my residency class) review one of my favorite nerve blocks, which I offer to any headache that could possibly be occipital neuralgia and am constantly impressed by how well it works.

Take home point:

Occipital nerve blocks using local anesthetics are particularly useful for occipital neuralgia or migraines. Remember to aspirate before injecting to ensure no blood or CSF is seen. Fanning while injecting will help to improve success with this procedure. 

6. A Practical Approach to Abdominal Imaging (899 views)  

Zach Schmitz, 2020 grad David Kaltman, and NU radiologist Samir Abboud review key questions in ED abdominal imaging.

Take home point:

When both appendicitis and kidney stone are reasonably high on the differential, CT with IV contrast is warranted as stones >3mm can often still be seen and missing an appendicitis could have worse repercussions for a patient than a small stone. When considering biliary pathology, right upper quandrant ultrasound should be the first line imaging and is much more sensitive than CT for seeing gallstones, though sensitivity for cholecystitis is somewhat limited for both forms of imaging. Finally, pelvic ultrasound is considered first line imaging for female pelvic pain, but when intra-abdominal and ovarian pathology are of equal concern, a CT with contrast may be appropriate.

 7. The Timing of Antibiotics in Sepsis (526 views)

Jordan Maivelett, 2019 grad and current faculty Andrew Berg, and faculty/Lake Forest Hospital med director Tim Loftus dig into the data on time-to-antibiotics in sepsis, finding much less clarity than I expected.

Take home point

Early antibiotic initiating appears to improve mortality in sepsis and particularly in septic shock. However, not all patients meeting SIRS criteria are septic and some are sick from viral illness making it challenging to discern exactly when to start antibiotics. More data is needed to determine the right balance between early broad antibiotics and antibiotic stewardship.

 8. ED Boarding (491 views)

Julian Richardson, 2020 grad and admin fellow Luke Neill, and Tim Loftus review the intractable issue of ED boarding. It’s a big problem with a lot of issues, and more than anything, it is not an ED problem but rather a systemic problem that creates symptoms in the ED.

Take home point:

This is a complex medical issue. The most important factor leading to ED boarding is a lack of access to inpatient beds and there are multiple strategies we implement to try to solve this problem (fast tracks, observation units, etc.). Simply expanding an emergency department capacity is not effective. Boarding leads to adverse patient outcomes. Fixing this will involve collaboration among ED physicians, other specialties, hospital leadership and executives.

9. Marathon: the Collapsed Athlete (409 views)

Zach Schmitz, Andrew Berg, and sports fellowship-trained Jake Stelter summarize how to approach the collapsed distance runner.

Take home point:

While a relatively healthy cohort, endurance events can lead to a variety of life threatening scenarios. For a pulseless collapsed patient, ACLS should be initiated. Remember that a patient collapsing during exercise is typically more serious than after. For altered or syncopal patients, checking an EKG, sodium, glucose, and temperature are important first steps to rule out deadly pathology.

10. D-dimer How To (385 views)

Pete Serina, Laurie Aluce, and Timothy Loftus review the lab everyone loves to hate.

Take home point:

There are multiple different d-dimer assays, know which one your institution uses! You can use the PERC rule in low risk patients to rule out PE, but remember this test has its own pitfalls. If the patient is not PERC negative, Well’s criteria or other clinical scores can next be utilized to risk stratify. A d-dimer is appropriate for moderate risk patients. Remember that other etiologies can result in an elevated d-dimer other than PE and d-dimer can be adjusted based on a patient’s age.

The Top NUEM Blog Posts of 2019

Edited by: Maury Hajjar, MD (NUEM PGY-2), Niki Patel, MD (NUEM PGY-2), Vytas Karalius, MD, (NUEM PGY-2), Justine Ko (NUEM PGY-3)  Expert commentary by:  Seth Trueger, MD

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Happy New Year, Everyone!

Let’s take a look back at the 2019 NUEM Blog!

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The Top Ten NUEM Blog Posts of 2019

10. REBOA

Recent grads Andew Cunningham, Bill Burns, and Trauma/EM doc Zaffer Qasim walk us through the ever-popular and sublimely named REBOA.

9. The Seriousness of Deliriousness

Thorough discussion of the important but easy to overlook issue of delirium in the ED by Nery Porras, recent grad and current neuro critical care fellow Katie Colton and geriatrician Lee Lindquist.

8. Pelvic Fractures

Justine Ko, Terese Whipple, and Matt Levine walk is through pelvic fractures and the important associated injuries.

7. Verbal Deescalation in the ED

Vidya Eswaran, Zach Schmitz, Abiye Ibiebele, NUEM-blog-founder Michael Macias, recent grad Arthur Moore, and John Bailitz review the complex but important topic of verbal deescalation in the ED.

6. Visual Guide to Splinting

Recent grad and current Stanford med ed fellow, recentish grad John Sarwarkand remote grad Matthew Pirotte provide a surprising amount of information in a small amount of words & images.

5. Post-Intubation Management

It’s easy to fall into the trap getting the tube & high-fiving and walking away; Andra Farcas, recent grad and current Air Force doc Paul Trinquero and recentish grad Andrew Pirotte walk is through the steps to post-intubation management.

4. Flexor Tenosynovitis

Thorough and concise review of flexor tenosynovitis by Kevin Dyer and recent grad Adnan Hussain, featuring expert commentary hand surgeon Avi Giladi (who also had the #4 post in 2018).

3. Tetracaine

Nice review by Jonathan Hung and recent grad and current med ed fellow Matt Klein of an Annals study showing a safe approach to tetracaine for corneal abrasions. Won’t solve the controversy but does include an expert commentary by @DGlaucomflecken

2. Intubation Positioning: Beyond the Sniffing Position

Unfortunately, optimal positioning is not always optimally executed in the ED; this post reviews both “standard” sniffing position and ramping, which, if nothing else, will help push us to better position our patients. Very nice work by recent grad and current neuro critical care fellow Katie Colton, and recent grad Charles Caffrey, and recentish grad Andrew Pirotte!

1. Unstable C-Spine Fractures

The top spot goes to a very nice succinct review by recent grads Sarah Sanders and Alison Marshall featuring beautiful images and a commentary by NLFH faculty Steve Hodges.

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 How to cite this post

[Peer-Reviewed, Web Publication]  Hajjar M, Patel N, Karalius V, Ko J, (2019, December 30 ). The Top NUEM Blog Posts of 2019.  [NUEM Blog. Expert Commentary by Trueger S ]. Retrieved from http://www.nuemblog.com/blog/top-ten-2019.

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