Joseph Cesarine, MD

When Snow Blowers Attack: How to Use a Rongeur in Finger Amputations

Your patient in the Emergency Department has a Zone II or Zone III finger amputation which requires primary closure of the wound prior to discharge with appropriate outpatient follow up. However, a protruding piece of bone often prevents closure of the skin flap and requires trimming by using a rongeur. While this process is typically carried out by an orthopedic or hand surgical consultant, this post aims to introduce the use of a ronguer during management of finger amputation in the Emergency Department.

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Imaging Case: Answer

Answer: False. Infants present with non-bilious vomiting

Diagnosis: Pyloric Stenosis

Pathology: Pyloric stenosis is hypertrophy and hyperplasia of the pylorus with a multifactorial inheritance in families. The incidence is 5/1000 births in males and 2/1000 births in females. It is therefore more common in males; it is also more common in first-born infants, and in Caucasian infants.

Imaging Case: Six Week-Old Infant with Projectile Vomiting

Case: A six week-old previously healthy, term infant via vaginal birth is brought to pediatric ED for repeated episodes of vomiting over a one week period. Vomiting occurs 20-30 min following every episode of feeding and is described as projectile. Parents note decreased urine output over the past two days. Patient is noted to be hungry following vomiting episodes

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Recognize Dynamic Hyperinflation (Air-Trapping) at the Bedside Using the Flow Curve

Dynamic hyperinflation (autoPEEP, air trapping, etc.) is a process leading to an increase in end-expiratory lung volumes and increased airway pressures. This process may occur secondary to obstructive lung pathology and/or an increase in minute-ventilation without sufficient time for expiration. The pathologic effects of dynamic hyperinflation include an increased work-of-breathing, barotrauma, pneumothorax, and an increase in intrathoracic pressure leading to a decrease in cardiac output and possible hemodynamic collapse. Rapid identification of this process is crucial for reversing it.

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What to Do With Gonococcal Arthritis in Your Emergency Department

You have made the diagnosis of disseminated gonococcal infection in your patient presenting with history and physical exam findings suggestive of purulent arthritis, now what? Treatment for gonococcal arthritis goes beyond the one-time "shot and a pill" given for uncomplicataed gonococcal infections. A quick review of disseminated gonococcal infection:

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Is the Use of Ketamine As An Alternative to Etomidate During Rapid Sequence Intubation of Adult Trauma Patient's Safe?

The most commonly used induction agent for rapid sequence intubation in the acutely injured patient is etomidate, largely due to its rapid onset of action and hemodynamically "neutral" effects. The dose-dependent effect of etomidate in suppressing adrenal synthesis of cortisol leading to adrenal insufficiency has left the door open for ketamine to be also considered as the rapid induction agent of choice in these critically injured patients.

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Forget About Just Confirming Endotracheal Tube Placement! Ultrasound-Guided Tracheal Intubation Without Laryngoscopy?

This post aims to shine a light on a possibly emerging use of bedside ultrasound. While this is far from being recommended as a viable method of intubation during RSI in an Emergency Department, knowledge that ongoing research evaluating the use of ultrasound-guided tracheal intubation (UGTI) exists can only serve to enhance one's understanding of the progression of ultrasound in medicine.

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Imaging Case: 2 Year Old Male With Abdominal Pain

Case: A 2 year-old male with no significant PMH is brought to the Emergency Department by his mother for intermittent abdominal pain for the past two days. Mom notes that the child will crouch down into a ball when he has pain, which lasts only a few minutes at a time. He has decreased solid food intake but no vomiting or diarrhea and is otherwise well.

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