Top emDocs Posts of 2020

Authors: Brit Long, MD (@long_brit – EM Attending Physician, San Antonio, TX); Manpreet Singh, MD (@MPrizzleER – Assistant Professor of Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center); and Alex Koyfman, MD (@EMHighAK – EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) 

Thank you for all that you do; as frontline emergency clinicians, you are the true heroes. This year has been difficult, with many of us experiencing loss and severe stress with the pandemic. This new year brings hope with the vaccine.

Second, thank you for your support of our FOAMed resource this past year. We cannot do what we do without your views, feedback, and assistance. This last year saw the development of the emDocs podcast, Visual Wednesdays with Walid Malki, MD (@Wandering_ER), Policy Playbook with Summer Chavez, DO, and the growth of our editorial team, including Marina Boushra, MD; Summer Chavez, DO, MPH, MPM (@goodavocado); Andy Grock, MD; Edward Lew, MD (@elewMD); Mark Ramzy, DO, EMT-P (@MRamzyDO); and Alex Sheng, MD, MHPE (@TheShenger). Happy Holidays and Happy New Year!

Now, without further ado, here is our list of our top posts from 2020 based on viewership from you, the readers:

COVID-19: Oxygen Escalation Therapy and Noninvasive Ventilation

This post from Amber Cibrario, Zac Baker, and Brit Long covers management of hypoxia in the patient with COVID with 1) NC up to 6 LPM, 2) Venturi Mask up to 50%, 3) NC at 6 LPM + Non-rebreather at 15 LPM, 4) HFNC, 5) CPAP, 6) Intubation. HFNC has proven safe and improves patient comfort. This can improve respiratory fatigue and oxygenation. When evaluating need for intubation, do not just focus on the oxygen saturation. Consider mental status, work of breathing, and diaphoresis in your evaluation.

COVID-19: Awake Repositioning / Proning

This post from Manny Singh and Brit Long looks at patient awake repositioning or proning in those with COVID and hypoxia. Literature suggests improved oxygen saturations with this strategy, but patient selection is key. Patients should have normal mental status, can communicate, are able to move by themselves, and are otherwise hemodynamically stable (other than mild tachycardia, tachypnea, and hypoxemia). Have the patient start in prone, then move to the right lateral recumbent, sitting up 60-90 degrees, left lateral recumbent, and then back to prone. Each position is held for 30 minutes to 2 hours, after which the patient moves to the next position. Reassess the patient after each position change both through vital signs and clinical status/appearance.

Personal Protective Equipment (PPE) Pearls – COVID-19

We are experts at donning and doffing PPE during this pandemic. This post provided pearls and pitfalls for PPE use, as well as several videos. Your big takeaways include 1) Limit exposure to the patient (limited number of providers in the room) and remove watches and jewelry on the upper extremities before starting your shift. 2) Use a constructed checklist and a partner to assist in donning and doffing. 3) If no partner is available, use a checklist and don and doff in front of a mirror if able. 4) Ensure the cuff is tucked into the gloves. The gloves should cover the gown, and there should be no gaps. Longer cuffed gloves are preferable, as they allow you to remove the gown and gloves in a single motion. 5) Aerosol generating procedures are high risk. Wear a respiratory mask with hood or cap. 6) Sanitize before donning and before each step when doffing. Clean your gloved hands before doffing (We recommend in between steps of the doffing process). 7) Have a decontamination process when you leave your shift (to include cleaning your phone and badge).

Managing the Critical COVID-19 Patient – SCCM Guidelines

COVID can result in critical illness, and the Society of Critical Care Medicine guidelines provide important information concerning PPE, laboratory evaluation, fluid resuscitation, vasopressors, steroid use, supplemental oxygenation and ventilation, and specific COVID interventions. The post was updated based on new literature, specifically the RECOVERY trial published in the New England Journal of Medicine and the IDSA treatment recommendations.

Unstable Atrial Fibrillation: A Guide to Management

This post from Melodie Blackmon and Nurani Kester covers the evaluation and management of the hemodynamically unstable patient with atrial fibrillation. The authors discuss the importance of avoiding premature closure. Don’t assume that the hypotension in your patient with a-fib is due to the arrhythmia. The PIRATES mnemonic can be used to consider causes of atrial fibrillation. Perform a thorough evaluation for other causes of shock before lowering the rate. When cardioverting the unstable patient with a-fib, do it right the first time; start out at 200J and consider adding external pressure to the anterior pad. Use push dose vasopressors such as norepinephrine or phenylephrine to stabilize the BP before trying to control the rate. Consider amiodarone or esmolol as the drug of choice for rate control in the crashing patient with a-fib. Electrolytes are also key.

Posterior Circulation Strokes: Why do we miss them, and how do we improve?

Dizziness and vertigo are difficult. How can you differentiate central and peripheral causes? This post from Ava Pierce looks at posterior circulation strokes. Stroke is likely in patients with abrupt onset of neurological symptoms, but don’t rely on the NIH stroke scale for posterior circulation strokes; CT is also typically non-diagnostic. Perform a targeted exam of the visual fields, cranial nerves, and cerebellar function (gait and truncal ataxia) to help reduce misdiagnosis. Also look for skew deviation, normal HIT, and variable direction/changing direction nystagmus.

Dermatologic Findings in COVID-19

COVID affects a variety of systems, including the skin. This post from Michael Gottlieb and Brit Long covers dermatologic findings, which may occur due to diffuse microvascular thrombosis or viral exanthem. Rashes reported in COVID-19 include maculopapular rash, urticaria, vesicular rash, petechia, purpura, chilblains, livedo racemosa, and distal ischemia. Think about COVID-19 in patients with these rashes, and potentially dangerous rashes include livedo racemosa, purpura, and distal ischemia.

Diagnosing Cardiogenic Shock in the ED

Madison Daly and Skyler Lentz evaluate diagnosing cardiogenic shock in the ED. Cardiogenic shock is most commonly the result of acute MI (70%) with high mortality. Exam should focus on evaluating for pulmonary edema, systemic congestion (JVD), and hypoperfusion.  The RUSH exam can assist, and consider using left ventricular outflow tract velocity time interval (LVOT VTI).

Cervical Artery Dissection: The Elusive Diagnosis

John Riggins, Jr, and Richard Sinert evaluate cervical artery dissection, a challenging diagnosis in the ED. This disease has multiple risk factors and may present with severe neck pain, new-onset headache, and/or neurological abnormalities on exam. Think dissection in the young patient with stroke-like symptoms. With imaging, both CTA and MRA (head and neck) can be used for the diagnosis. There is no difference in efficacy between anti-platelet and anticoagulation therapy in patients with symptomatic cervical artery dissection, usually for 3-6 months.

The Storm Within: Cytokine Storm and COVID-19

Cytokine storm can result in major complications in any disease, but especially COVID. Charles Cullison covers the pathophysiology, evaluation, and therapy in this post. Etiologies of cytokine storm include COVID-19, bacterial infections, rheumatologic disorders, and cancer therapies. The Hscore can help in diagnosis, and pay close attention to markers of systemic inflammation (ie, ferritin, liver enzyme elevation, fibrinogen). Treatments of critical patients with potential for cytokine storm secondary to COVID-19 are under study, but start with resuscitation first. Patients will likely require anticoagulation and steroids.

Stay tuned for a great 2021!