EM Thinker: Pearls from the Frontlines

Authors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome back to The EM Thinker series. This series will provide important considerations for the practice of emergency medicine.

1a) Cellulitis is typically a straightforward diagnosis. It’s unusual for it to be bilateral, so also consider other conditions (ie, venous stasis). For any common ED diagnosis, build a list of emergent/urgent mimics and stop to think about them when something doesn’t quite fit (extreme pain/pain out of proportion -> necrotizing soft tissue infection).

1b) Bedside ultrasound can help you when differentiating cellulitis and abscess, but it can fool you. If you see what looks like a fluid collection, use doppler and look for flow. If present, do not cut.

2) Intubating a patient isn’t a single activity, it’s a package of care. Be systematic each time, and use a checklist. Items to consider: vent settings; OGT placement; foley catheter placement; initial blood gas and radiograph; analgesic bolus + drip; sedative bolus + drip; restraints; additional access PRN; etc. If the radiograph is delayed, use US to visualize the ETT in the trachea and bilateral lung sliding. Be an active learner of each element and finetune for the next patient.

3) In the setting of a urinary tract infection with sepsis or acute kidney injury, stop and consider whether an obstruction exists; bedside ultrasound is your friend. This would necessitate timely drainage.

4) Infectious disease pathology is problematic for emergency clinicians. Many infectious conditions have sneaky presentations and high morbidity/mortality if unrecognized. Once suspected or identified, give one dose of antibiotics. Master antibiotics for each organ system; discuss nuances with pharmacist or ID consultant. Pause and look at old culture data, as giving an antibiotic that patient is resistant to isn’t clinically stellar.

5) Documenting that a patient is a poor historian doesn’t help to move a case forward. Is the clinician a poor history-taker? What’s the driver for the patient’s visit today?

6) For the patient with his/her first ED presentation for change in behavior, this is your chance to make a real impact. Don’t anchor on diagnoses of exclusion like substance abuse, psychiatric disease, etc. Go digging for organic causes and don’t overthink this (in a patient with unreliable history and/or exam, more work-up is required).

7) For syncope, the answer lies in the history, exam, ECG, or telemetry monitoring. Move away from formal orthostatic vitals; is the patient symptomatic when you stand them up or ambulate them? Consider syncope mimics and vascular causes of syncope when appropriate.

8) A single-digit bicarbonate result is bad. Differential diagnosis is quite narrow: severe ketoacidotic syndromes; sick toxic alcohol patient; metformin toxicity; severe renal failure; sick salicylate toxicity patient. Master the interpretation of lab results you request each shift and put them in the context of the patient’s presentation.

9) The patient with a negative urine pregnancy test may still be pregnant. The patient with a positive urine pregnancy test may not be pregnant. With each test you order consistently, know the limitations and interpret it in the context of the clinical information you collected.

10) VL versus DL debate should be eliminated. Remember, the intubator doesn’t have to utilize the camera screen if they want to learn technique without technology. Terminology change: standard-geometry blade versus hyperangulated blade. Ability to visualize procedure in real-time benefits troubleshooting and teaching. Optimizing experience is best for patient care.

References/Further Reading:

EM Mindset

emDocs – Cellulitis mimics

emDocs – Post intubation analgesia and sedation

emDocs – Antimicrobial use in the ED

emDocs – Low risk syncope

Sinai EM – Pregnancy test result