The Dreaded Cricothyrotomy
​I'll admit it. I hate the cricothyrotomy. It's not because I haven't done one for a decade or because it is a complicated procedure. Or because I dread the thought of leaving a permanent cosmetic defect on someone's neck. Or because it is a procedure performed as a last resort under extreme time pressure on a hypoxic patient who will almost assuredly die if you fail.It has something to do with the word failed, as in failed airway. That surgical airway is there because the physician could not gain effective control of the patient's airway using all of the other airway tools at his disposal. We all understand that failure...
Source: M2E Too! Mellick's Multimedia EduBlog - January 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Numbered Pediatric Rashes Revisited
​I have been seeing a lot of second disease and fifth disease—it's that time of year. School is back in session, and winter is just around the corner.The rash-numbering system for these diseases is now a historical footnote, but fifth disease is still commonly used by physicians to refer to erythema infectiosum, a parvovirus. I suspect that this system was created as a memory device for similar names and the obscure Latin terms used for these diseases. Erythema infectiosum is also easy to confuse with the many other erythema rashes such as erythema migrans, erythema marginatum, erythema toxicum, and erythema multiforme...
Source: M2E Too! Mellick's Multimedia EduBlog - December 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Breath-Holding Spells Are More Complicated than Imagined
It never ceases to amaze me how nothing is ever as simple as it seems. Breath-holding spells are just the latest of the simple and common medical conditions that turn out to be much more complex than ever imagined.It all started during a recent shift in the pediatric emergency department with a toddler who presented after a breath-holding episode. He fell after losing his balance on a trampoline.It started as a classic pallid breath-holding spell that then manifested as crying out, stopping breathing, and rapidly losing consciousness. He then had a CNS anoxic event. The unconscious child clenched his fists and arched his b...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Three Ps of Pyloric Stenosis
​The back story of pyloric stenosis is fascinating. It is a relatively minor surgical condition today, but the disease had a mortality of 100 percent before 1904, when only five operative cases were known to have been performed in the United States. The dying process was slow and painful, and parents watched their infants slowly starve to death.The pyloromyotomy procedure currently used to treat pyloric stenosis was introduced by Conrad Ramstedt, MD, in 1911 at the Children's Hospital of Munster, and is still called the Ramstedt procedure. Before surgical management was introduced for this gastric outlet obstruction, mul...
Source: M2E Too! Mellick's Multimedia EduBlog - October 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Prepubertal Dysuria Not as Simple as a UTI
​Prepubertal boys who present to the emergency department with dysuria are uncommon. The adult with burning on urination is assumed to have a sexually transmitted disease, but of course that diagnosis should not be high on your list for boys.In fact, infectious urethritis in children is quite uncommon unless there is premature sexual activity or sexual abuse by an adult. Unfortunately, a variety of noninfectious urethral pathologies may mimic infectious urethritis in children. A urinary tract infection in a prepubertal boy is an infectious cause of dysuria. Those infections, however, rarely present with the isolated symp...
Source: M2E Too! Mellick's Multimedia EduBlog - September 3, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Heat-Related Illness Not as Simple as It Looks
​Heat-related illness should be an easy diagnosis, but it is not that simple, and there are a number of tripwires.The common pathophysiology for most heat-related illnesses is heat generated from muscular activity that accumulates faster than can be dissipated via increased skin blood flow and sweating, resulting in exertional hyperthermia. Part of the challenge for clinicians is that heat illness is a continuum with a significant overlap of signs and symptoms. Granted, heat rash, heat cramps, and heat edema aren't that confusing, but diagnostic accuracy can be a little more challenging at the other end of the spectrum.S...
Source: M2E Too! Mellick's Multimedia EduBlog - August 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Don’t Treat Kids as Tiny Adults in Needle Thoracostomy
​Pediatric needle thoracostomy is a rarely performed procedure, but one must know the technique and be prepared to perform it. It can be life-saving in the face of a tension pneumothorax. This is a simple procedure, but a few procedural fine points can guarantee success and safety.Adult Needle ThoracostomyWe have learned only relatively recently that most adult needle thoracostomies fail to accomplish their mission. A 5 cm angiocatheter inserted at the second intercostal space on the midclavicular line has been the Advanced Trauma Life Support guidelines recommendation for at least a decade. Unfortunately, we now know th...
Source: M2E Too! Mellick's Multimedia EduBlog - July 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Tactical Emergency Medicine a Possible Career Path for EPs
​The value and importance of our specialty branching out into tactical emergency medicine are not widely discussed, but it can be rewarding to work with law enforcement. Tactical emergency medicine has expanded rapidly over the past two decades. The American College of Emergency Physicians even has an active tactical emergency medicine section. (http://bit.ly/2Dt1spl.) Its goal is to provide a forum for emergency physicians with interest or expertise in tactical medicine and to share information with the college and other organizations. Fellowships in tactical emergency medicine have been developed as part of ac...
Source: M2E Too! Mellick's Multimedia EduBlog - June 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Racemic Epinephrine Deserves More Respect
​Some medications enjoyed years of glory but later ended up on the trash heap of clinical medicine, often put there by a systematic review or small case series of adverse outcomes or complications that led to black box warnings and a culture of fear and rejection. Still, the heyday lasted for years for some medication outcasts, such as acetaminophen with codeine, promethazine (Phenergan), aminophylline, droperidol, and meperidine (Demerol).Of course, a few of these medications probably deserved their bad rap, but most of them served us well for many years when we had few other options. Medications like racemic epinephrin...
Source: M2E Too! Mellick's Multimedia EduBlog - May 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Enigmatic Ganglion Cyst
​Ganglion cysts are soft tissue, fluid-filled swellings most frequently found in the hand and wrist; their origin is not exactly clear. They are common, however, and can occasionally be associated with surprising morbidity despite their benign nature. The morbidity seems to be related to their tendency to localize in highly mobile and anatomically tight quarters such as the hand and wrist. Nevertheless, they can show up almost anywhere.Cysts can also have sequelae, such as sciatica from a piriformis ganglionic cyst, compression radiculopathy from a lumbar intraspinal ganglion cyst, foot drop from peroneal nerve cyst, met...
Source: M2E Too! Mellick's Multimedia EduBlog - April 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pediatric Conjunctivitis a Simple Diagnosis Until It Isn’t
​Conjunctivitis is a common condition and easy enough to treat, but several uncommon conjunctivitis syndromes require more care and should not be missed.Conjunctivitis is either infectious (viral or bacterial) or noninfectious (allergic or nonallergic). Viral infections are more common in adults, bacterial ones in children, usually caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Adults tend to have more S. aureus infections, while the other pathogens are more common in children. An adenovirus is typically responsible for viral-associated infections in conjunct...
Source: M2E Too! Mellick's Multimedia EduBlog - March 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

TXA a Late Bloomer in Bleeding Management
​Tranexamic acid (TXA) was invented by a Japanese husband-and-wife research team in the 1960s. Years earlier, this same research team had discovered epsilon-aminocaproic acid, a derivative and an analogue of the amino acid lysine. In their search for a more potent antifibrinolytic agent, they discovered tranexamic acid, a synthetic analog of the amino acid lysine. Tranexamic acid is eight to 10 times more powerful than epsilon-aminocaproic acid.The antifibrinolytic actions of TXA result from the binding of four or five lysine receptor sites on plasminogen. This binding prevents plasmin from binding to and degrading fibri...
Source: M2E Too! Mellick's Multimedia EduBlog - February 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Distinguishing between Orbital and Preseptal Cellulitis
​Some medical conditions have signs and symptoms that significantly overlap, making a diagnosis a little more difficult. Epididymitis, testicular torsion, and torsion of the testicular appendage are examples, but orbital and preseptal cellulitis are others that can cause significant diagnostic confusion.Both conditions are more common in children than in adults, and preseptal or periorbital cellulitis is more common in children under 5. The preseptal and orbital spaces are separated by only a thin membranous septum that originates in the orbital periosteum and inserts into the tarsal plates. It is only this thin septum t...
Source: M2E Too! Mellick's Multimedia EduBlog - December 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

AAP Bronchiolitis Guidelines a Mismatch with Clinical Practice
​I recently met with a group from our children's hospital to standardize the hospital management of bronchiolitis according to the latest American Academy of Pediatrics guidelines. (Pediatrics 2014;134[5]:e1474; http://bit.ly/2QIGbMX.) Unfortunately, these guidelines seem to cause confusion for experienced and inexperienced emergency physicians alike.This confusion comes from the guidelines raising unaddressed issues and new questions, most importantly not tackling important aspects of frontline clinical practice. These guidelines were developed with the best evidence currently available, and their application mo...
Source: M2E Too! Mellick's Multimedia EduBlog - December 4, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Foreign Bodies in the Ear and Nose a True Test of EP Mettle
​Pediatric patients frequently put foreign bodies into their mouths, noses, and ears. The spectrum of foreign bodies that children place into their facial orifices are impressive. Paper, vegetable matter (such as peanuts), toys, beads, metal screws, and Play-Doh are just a few examples.The insertions are often done surreptitiously, only to be discovered days or sometimes weeks later. Occasionally, the retained foreign nasal bodies will ferment and present with a purulent, unilateral nasal drainage, accompanied by an unrelentingly repulsive odor. Sometimes an occasional cockroach wanders into the external auditory canal l...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs