Keywords: Back Pain, Treatment (PubMed Search)
Treatment of Low Back Pain
A recent recommendation from the American College of Physicians (Internal Medicine) now recommends nonpharmacologic therapies as the first line treatment of acute or subacute lower back pain lasting 12 weeks or less. This might bring more people to our Emergency Departments so it is important that we know their current recommendations.
Some nonpharmacologic therapies recommended are:
For acute back pain they recommend:
For chronic back pain:
Keywords: unicameral bone cyst, fracture (PubMed Search)
A 12 year old with arm pain after doing push ups during gym class. What is the diagnosis?
Diagnosis: Pathologic fracture with a unicameral bone cyst
Unicameral bone cysts are benign lesions that mainly affect children and adolescents. On xray the cyst is noted to be a mildly expansile, lytic, thin walled lesion without periosteal reaction. The most common sites are the proximal humerus and femur. These lesions can resolve spontaneously, but there is a risk of pathologic fracture. If fracture is detected, then the fracture site should be treated as any other fracture in the area. These lesions can also be found incidentally in which case they should be referred to orthopedics for outpatient follow up.
Kadhim, M, Thacker M, Kadhim A and Holmes L. Treatment of unicameral bone cyst: systemic review and meta analysis. J Child Orthop. 2014 Mar; 8(2): 171-191.
Mascard E, Gomez-Brouchet A, Lambot K. Bone cysts: Unicameral and aneurysmal bone cyst. Orthop Traumatol Surg Res. 2015 Feb; 101.
Keywords: Buprenorphine, Suboxone (PubMed Search)
The current opioid epidemic is considered the worst drug crisis in American history responsible for 50,000 deaths per year in the US from overdose of heroin and opioid prescription drugs. A 200% increase in the rate of overdose deaths involving opioids occurred between 2000 and 2014. The continued rise in opioid related deaths calls for an urgent need for treatment. Three types of medication-assisted therapies (MATs) are available for treating patients with opioid addiction:methadone, buprenorphine, and naltrexone. Suboxone a combination of buprenorphine and naloxone, is emerging as one of the best choices for the following reasons:
Rudd RA, Seth P, David F, Scholl L. Increase in Drug and Opioid-involved Overose Deaths -Unted States, 2010-2015. MMWR Morb Mortal Wkly Rep. ePub: 16 December 2016.
Jones HE. Practical Considerations for the Clinical Use of Buprenorphine. Science & Practice Perspectives. 2004;2(2):4-20.
Category: International EM
Keywords: Zika, arbovirus, pregnancy, congenital (PubMed Search)
Congenital infection with the Zika virus is associated with 5 types of birth defects
· These are rarely or never seen with other infections during pregnancy
· These defects are:
1. Severe microcephaly (small head size) resulting in a partially collapsed skull
2. Decreased brain tissue with brain damage
3. Damage to the back of the eye with a specific pattern of scarring and increased pigment
4. Limited range of joint motion, such as clubfoot
5. Too much muscle tone restricting body movement soon after birth
Category: Critical Care
Long B, Koyfman A. Clinical mimics: An emergency medicine-focused review of sepsis mimics. J Emerg Med. 2017; 52:34-42.
Category: Visual Diagnosis
56 year-old male with history of hypertension presents with complaints of right scrotal swelling and pain. Denies any urinary symptoms, abdominal pain, nausea/vomiting or change in bowel habits or prior episodes. Temp was 99.0.
A scrotal ultrasound was done and an image of the right testis was seen (below). What's the diagnosis?
Answer: Right Epididymitis (and Hydrocele)
Take Home Points:
Kühn AL, Scortegagna E, Nowitzki KM, Kim YH. Ultrasonography of the scrotum in adults. Ultrasonography. 2016;35(3):180-97.
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3): 1-137.
Category: Airway Management
Keywords: Elbow, fracture, trauma (PubMed Search)
Is that a fracture or a growth plate?
Pediatric elbow x-rays are complicated to interpret due to the large number of ossification centers.
Elbow trauma is common in pediatrics.
Ossification centers of the elbow appear in a reliable chronologic pattern which aids in distinguising fractures from growth plates.
Note the age ranges are an estimate with great variability. For example, girls can develop these up to 2 years earlier than boys.
The numbers 1/3/5/7/9/11 correspond to the average age of development of each ossification center
Years of fusion shown below in ()
Radial head (14-16yo)
Medial epicondyle (16-18yo)
Lateral epicondyle (12-14yo)
Pneumonic: "Can't Resist My Team Of Lawyers"
Consider ordering films of both elbows to compare if in doubt.
How is this useful? If the trochlear center is present, but there is no medial epicondyle then you are most likely looking at a fx where the ossification center has been avulsed and displaced.
Keywords: aphasia, fluency, comprehension, repetition, Broca's aphasia, Wernicke's aphasia, conduction aphasia (PubMed Search)
Types of aphasia [Online image]. Retrieved February 8, 2017 from https://www.aphasia.org/
Follow me on Twitter @EM_NCC
Category: Critical Care
Keywords: peri-Intubation hypotension, shock index (PubMed Search)
Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.1 And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.2 In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.
1. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9-13.
2. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(6):587-93.
Category: Visual Diagnosis
Keywords: Herpes Zoster Ophthalmicus; Hutchinson's sign (PubMed Search)
24-year-old male with a history of Wagner's Granulomatosis, currently on Cellcept (Mycophenolate Mofetil) and high dose prednisolone, presented with two days of sore throat, malaise and the lesions shown in the picture. What is the diagnosis?
Answer: Herpes Zoster with Hutchinson's sign.
- This patient is presenting with a well demarcated eruptive skin lesion involving the tip of the nose and half of the lip and palate. This lesion is suggestive of Herpes Zoster with Hutchinson's sign.
- Hutchinson's sign is associated with a high rate of corneal denervation and ocular involvement. Some studies suggest that up to 100% of patients with Hutchinson's sign will present with a serious intraocular pathology.
- In addition to starting systemic antiviral therapy, all patients who present with Hutchinson's sign need an immediate and complete ophthalmologic evaluation including a complete slit lamp examination.
Adam, R. S., Vale, N., Bona, M. D., Hasanee, K., & Farrokhyar, F. (2010). Triaging herpes zoster ophthalmicus patients in the emergency department: do all patients require referral?. Academic Emergency Medicine, 17(11), 1183-1188.
Van Dyk, M., & Meyer, D. (2010). Hutchinson's sign as a marker of ocular involvement in HIV-positive patients with herpes zoster ophthalmicus. SAMJ: South African Medical Journal, 100(3), 172-174.
Keywords: physical abuse, neglect, identification (PubMed Search)
Evans CS, et al. Diagnosis of Elder Abuse in U.S. Emergency Departments. J Am Geriatr Soc 65:91–97, 2017
Category: Pharmacology & Therapeutics
Keywords: sepsis, antibiotics, vasopressors, shock (PubMed Search)
Below is a list of pharmacy-related pearls from the 2016 Surviving Sepsis Guidelines:
Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med 2017; 3. [PMID 28098591]
Follow me on Twitter @mEDPharmD
Category: Critical Care
Keywords: Sepsis, Septic Shock, Fluid resuscitation (PubMed Search)
At the Society of Critical Care Meeting (SCCM) this month, updates to the Surviving Sepsis Guidelines were released. Recommendations include:
--Initial 30mL/kg crystalloid resuscitation with frequent reassessment of fluid responsiveness using dynamic (not static) measures [goodbye CVP/ScvO2!]
--Initiation of broad-spectrum antibiotics within ONE hour of sepsis recognition [two agents from different classes]
--Further hemodynamic assessement (e.g. echo for cardiac function) if clinical assessment does not reveal the type of shock [get out the ultrasound!]
Rhodes A, Evans LE, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017 Jan 18.
Category: Visual Diagnosis
25 year-old female with hx of cerebral palsy with significant developmental delay, s/p G-tube who presented with acute hypoxic respiratory failure, hypotension and a distended, tense abdomen. A CT was done with the scout film below. What's the diagnosis?
Answer: Cecal Volvulus
Patient was subsequently intubated, had an NG tube placed with over 500cc of fluid returned. Patient had multiorgan failure and received fluids, antibiotics, pressors, blood products and went to the OR, and had a partial bowel resection.
One way to differentiate cecal volvulus from sigmoid volvulus is that sigmoid volvulus generally do not have haustra.
Tonerini M, Pancrazi F, Lorenzi S, Pacciardi F, Ruschi F, et al. (2015) Cecal volvulus: what the radiologist needs to know. Glob Surg, 1: DOI: 10.15761/GOS.1000106.
Keywords: nerve, entrapment (PubMed Search)
During a busy ED shift, your 40yo charge nurse asked you to look at his hand. He is known avid mountain biker. He has pain in his right 4th and 5th digits. . He feels a lack of coordination and a feeling of “clumsiness” of the hand. Where is his possible nerve compression and what do you expect to find on exam?
Ulnar nerve entrapment is sometimes called “handlebar palsy.”
Compression location is Guyon’s canal.
The ulnar nerve supplies the intrinsic muscles of the hand AND the extrinsic muscles for flexion of the 4th and 5th digits. This is what aids in a “power grip” and why he may have diminished grip strength on exam.
Also innervates the ADDuctor pollicis and 1st dorsal interosseous muscles (pinch)
Note the ulnar nerve also passes through the radial tunnel at the elbow. Entrapment here is called Radial tunnel syndrome or Cubital tunnel syndrome and causes forearm pain and paresthesias in the 4th and 5th digits with grossly normal motor and sensory function.
Keywords: epinephrine, auto-injector (PubMed Search)
As a follow up to Dr. Winter’s Pearl on Anaphylaxis on 1/24/2017, here’s a handy pearl for pediatric anaphylaxis (part 1).
Anaphylaxis: rapid and potentially life-threatening involvement of at least 2 systems following exposure to an antigen.
Medications (max: adult doses)
Get it?!?! Easy right? Instead of fumbling through an app or reference card during your next case of pediatric anaphylaxis, be a rock star "EM DR" by remembering the “Rule of 2’s”.
(Can't help it...ya'll know I love my mnemonics!!)
Keywords: methadone overdose, hypoglycemia (PubMed Search)
Methadone overdose produces classic signs and symptoms of opioid intoxication - CNS and respiratory depression with pinpoint pupils. However, methadone overdose has also been associated with hypoglycemia – a relatively uncommon adverse effect.
Several case reports have been published over the past years. Recently, a case of refractory hypoglycemia was reported in a woman, without a history of diabetes, after ingesting 250 mL of methadone (18.2 mg/kg).
She required, in additional to naloxone infusion for respiratory depression, dextrose infusion (initially D10 then D20) for 54 hours.
Incidence of hypoglycemia has also been observed in patient with rapid methadone dose escalation as well as in cancer patient who were started on methadone for pain control with dose-depedent association.
In a mice study, methadone induced a dose dependent hypoglycemia - 20 mg/kg methadone resulted in decrease in average glucose level of 172 +/- 7 mg/dL to 55 +/- 6 mg/dL. This effect was reversed by naloxone administration. morphine, fentanyl, oxycodone and levorphanol did not produce hypoglycemia.
However, in the case report published in Clinical Toxicology Nov 2016, naloxone infusion did not effect the hypoglycemia.
Keywords: weakness, ptosis (PubMed Search)
Patients may present to the ED with new onset weakness due to myasthenia gravis (MG). A group that is frequently missed is late-onset MG, which occurs after the age of 50. It is frequently misdiagnosed as a stroke or transient ischemic attach (TIA).
Two cardinal features:
Bonus pearl: Ocular symptoms are present in up to 85% of patients with MG, with unilateral ptosis or asymmetric bilateral ptosis being the most common presentations.
Nicolle MW. Myasthenia Gravis and Lambert-Eaton Myasthenic Syndrome. Continuum. 2016;22(6):1978–2005
Category: Critical Care
Epinephrine in Anaphylaxis
Kawano T, et al. Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications. Resuscitation 2017; 112:53-58.
Keywords: Nail bed injuries, wound closure (PubMed Search)
More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.
Nail bed injuries occur in 15-24% of children with fingertip injuries.
In 1997, medical adhesive was first used to secure the avulsed nail plate back to the nail bed instead of suturing back into place. By 2008, there were small studies looking at the utility of using medical adhesive to close the laceration of the nail bed. The studies were small, but there was a tendency towards shorter repair times and no difference between pain, cosmetic outcome or function.
A total of 6 articles were included in this review – 2 using histoacryl and 4 using demabond.
Edwards, S, Parkinson L. Is Fixing Pediatric Nail Bed Injuries with Medical Adhesives as Effective as Suturing? A Review of the Literature. Pediatric Emergency Care. 2016.