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.

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

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:

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.