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Here you will find information regarding rotation schedules, academic resources, wellness and facts about our program and residents. Check out our bios and photos. Please also visit the Emergency Department's official residency website. This site is intended for Mount Sinai EM residency purposes only, and no information on these pages is intended or should be construed as medical advice. Read more.

How to Tap a Knee…no Not with a Reflex Hammer

42 year old M presents with R knee pain, no PMH, c/o subjective fevers at home but no other associated symptoms.

On exam vitals signs stable except temperature of 100.4, also found to have tenderness to palpation, mild erythema, and significant swelling to knee.  Able to range about 20 degrees.  No other affected joint.

Concern for a septic joint.

To build off of Dr. Bell’s septic arthritis pearl, on this busy Monday we will keep it short but sweet with a quick refresher on knee arthrocentesis.

 

Indications:

Diagnosis of septic or crystal induced arthritis

Administration of medications or analgesia for acute or chronic arthritis

Relief of pain of acute hemarthrosis

Determination of laceration communicating with joint space

 

Contraindications:

Overlying cellulitis (absolute)

Bleeding diathesis (relative)

 

Procedure:

Landmark – medial or lateral patella, superior/middle portion; approach may be lateral or medial

Position your patient with knee flexed about 15 degrees in order to open the joint space, prop up knee with pillows or sheets

Insert your 18 gauge needle at the mid to superior region of the medial (or lateral) patella, direct your needle under the patella and between the femoral intercondylar notch, as much as possible keep needle parallel to bed, aspirate while inserting needle until you observe synovial fluid in your syringe.

 

Arthro_anatomy

 

 

Of note, for those of you who prefer movies, there are a plethora of youtube videos that will aid in your knee tapping education.

 

Clinical Procedures in Emergency Medicine.  5th ed.
Roberts, James R.; Hedges, Jerris R. (2010)

http://www.anwresidency.com/simulation/guide/arthro.html

 

 

Succinylcholine in Myasthenia Gravis

Case:

45yoF with myasthenia gravis presents in respiratory distress.  She requires urgent intubation.  Which paralytic will you use?

 Myasthenia gravis is an autoimmune neuromuscular disorder in which antibodies target nicotinic acetylcholine receptors at the neuromuscular endplate, preventing excitation/depolarization and subsequent muscle contraction.

Respiratory compromise or failure may occur due to weakening of diaphragm/accessory muscles.  In the ED this will be a clinical diagnosis, however on the INSERVICE you will identify spirometry, or more specifically, the negative inspiratory force, as the “next step” in management for pts with MG.

When intubating, we know one paralytic is supposedly contraindicated, but why? And is there data to support this contraindication?

Continue reading “Succinylcholine in Myasthenia Gravis” »

Paracentesis

Case:

You are working in the resus room, when a 65yoM h/o CAD, severe aortic stenosis, dilated cardiomyopathy (EF 15%), presents short of breath in extremis.

VS: 75/60, HR 119 RR 24, T98.0, Sp02 94% on NRB

He has rales to the apices of the lungs bilaterally.

Loud systolic murmur radiating to his carotids.

He is pale and diaphoretic.  Hypotensive with flash pulmonary edema, underlying poor cardiac contractility, with an obstruction to cardiac output.

You are concerned.

As you are formulating your approach to this patient, an intern urgently asks what tubes he needs to send for a paracentesis at Sinai.

Your response?

Continue reading “Paracentesis” »

August Q-tips

  • Patients with lower quadrant pain should typically have gonadal examinations. There are relative exceptions–such as virginal women without history of pelvic examinations or IBD patients with symptoms very typical of previous IBD flairs–but gonadal examinations should still be considered in these patients. Ideally, these examinations should take place before CT imaging.

 

  • Patients with previous tracheostomies are likely to be difficult intubations. Tracheostomy history may be an indication of distorted anatomy or a previously failed endotracheal intubation.  Awake intubation, preparation of a fiberoptic intubation, or preparation for repeat surgical airway should be considered ahead of time.

 

  • When bagging a cardiac arrest patient, use “squeeze release release release release release” to shoot for ~8 breaths per minute.

 

  • Use of librium in alcoholics continues to be controversial and management of these patients is plagued by significant practice variability. One approach stipulates that all alcoholics who are not discharged/allowed to walk out as soon as they are sober enough to do so (e.g. are to be seen by psychiatry) should get 50-100 mg librium and reassessed specifically for withdrawal symptoms every 2 hours; if hyper-dynamic but well should receive 100-200 mg librium. The purpose is to prevent a medicine admission for withdrawal, which serves nobody’s interests. This practice is not to be confused with discharging patients with a librium prescription, which is less likely to be effective (though there is still a role for outpatient librium in selected motivated patients).

 

  • Although pelvic exams are uncomfortable and usually non-contributory, it is difficult to defend not performing a pelvic exam in the relevant context; if it turns out the pelvic exam would have been contributory but it was omitted, that is an important error. The threshold to perform a pelvic exam should therefore be low.

 

  • Set patient expectations low with regard to wait times for tests, consultation, admission. Consider not having ENT scope patients with allergic reaction; there is much practice variation on this point.

 

  • Don’t forget to introduce yourself to patients.

 

  • Urine beta is a fallible test, repeat or send serum quantitative beta when negative result is discordant with clinical circumstance.

Spilled Teacup

A 28 yoM comes in with hand pain after falling on an outstretched hand.

His xray is as follows.

Lunate Pic

 

What is the diagnosis?

Continue reading “Spilled Teacup” »


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