Massive Hemorrhage Post-Tonsillectomy

The initial emergency medicine management of post-tonsillectomy bleeding


A ten year old boy presents with significant bleeding from his mouth and nose. He is learning forward, and although blood is rapidly pouring onto the stretcher, he is able to tell you his name. Two very anxious appearing parents are at the bedside, and are able to tell you that he had a routine tonsillectomy performed 5 days ago…

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Respiratory distress in the patient with a tracheostomy (update)

A summary of the emergency medicine approach to respiratory distress in the patient with a tracheostomy

This is an update of a previous version of this post. I am reposting to coincide with the release of a new textbook that I am pretty excited about. The textbook is the Resuscitation Crisis Manual. It provides very succinct action scripts for the major emergencies that we see. It is exactly the textbook that I always wanted in residency, but didn’t exist. The absence of this kind of resource was exactly the reason that I started First10EM. (Perhaps, in the future, Scott can just keep me up to date on his projects. If I had just waited a couple years, I could have had the textbook without feeling like I had to write it by myself.) I wrote the “Tracheostomy Emergencies” chapter of the book – hence the decision to repost this topic. (I guess I should note that I don’t get anything for writing that chapter, so I don’t have any financial conflicts of interest – just intellectual biases.)

If you want to hear more about the book, check out this EMCrit podcast.


A 45 year old man, well known to your department because of a prior anoxic brain injury and multiple complications including a permanent tracheostomy, is brought in by ambulance from home in respiratory distress. You know from prior conversations with the family that the patient is to receive full, aggressive medical management. He is using every accessory muscle that you can see, his respiratory rate is 55, and his oxygen saturation is 87% on room air…

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Paramedic 2: Epinephrine harms/helps in out of hospital cardiac arrest

A critical appraisal of the PARAMEDIC 2 trial (epinephrine in out of hospital cardiac arrest)

After years of waiting, PARAMEDIC 2, the large RCT of epinephrine for out of hospital cardiac arrest, has finally been published. So we can now definitively say that epinephrine is harmful. Wait, maybe it helps? Can a positive study demonstrate harm? Maybe this EBM stuff isn’t so easy after all

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Articles of the month (July 2018)

A monthly (ish) summary of the emergency medicine literature

You will probably notice a new format to the articles of the month. I was getting sick of not being able to find papers that I knew I had previously commented upon. Having them listed as one 10 papers in the articles of the month made them very difficult to search for. Therefore, on bigger, more important papers, I have started writing stand alone blog posts. I will still include those papers in the articles of the month, but the summary will be truncated, with a link to the blog for all the details. The articles of the month will probably still contain extra articles, including papers that don’t warrant their own post and my usual “just for fun” kind of papers. Let me know what you think. Continue reading “Articles of the month (July 2018)”

I said “quiet”

Does saying “quiet” really cause chaos?

I did it again. I was at the nursing station in our resuscitation area and I commented on how quiet the night had been so far. Of course, all hell broke loose. Continue reading “I said “quiet””

Tamsulosin for kidney stones: The STONE trial

Another randomized control trial of “medical expulsive therapy”

This again? I know I’ve covered tamsulosin for nephrolithiasis a number of times before. I image most people can predict the results of this study. It may seem a bit repetitive, but I think there is an important EBM lesson in this data. Continue reading “Tamsulosin for kidney stones: The STONE trial”

IV fluids do not cause cerebral edema in pediatric DKA (Kuppermann 2018)

Does IV fluid rate or tonicity contribute to the rate of cerebral edema in pediatric DKA?

Some children with diabetic ketoacidosis develop cerebral edema and have bad neurologic outcomes. Unfortunately, when this happens, fingers are frequently pointed at emergency physicians for our overzealous use of intravenous fluids. Children are not little adults, we are told, and cannot tolerate the same volumes of fluids. Or perhaps it is the use of hypotonic fluids. Either way, we are given very strong recommendations to avoid “aggressive” IV fluids, and to avoid hypotonic fluids. (TREKK 2014; Dunger 2004) However, the evidence base for these recommendations is very weak, relying entirely on observational data. (Hom 2008) This observational data indicates an association, but that does not translate to causation. Children receiving more fluids tend to be sicker and more likely to develop cerebral edema in the first place, meaning the association with fluids could be entirely based on confounding. A case control study done in 2001 found no association with volume of fluid resuscitation, but instead with acidosis and renal failure (markers of disease severity). (Glaser 2001) To date, there has been a lot of conjecture, but not a lot of answers. Finally, we have a large, randomized trial to guide our management…

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