55 year-old male presents with chest pain. You take a look at his cardiac function with ultrasound and here's the patient's apical four-chamber view. What's in his right ventricle and why would it be there?
Ebstein's Anomaly
Pediatric patients with an isolated skull fracture and normal neurological exam have a low risk of neurosurgical intervention and outpatient follow up may be appropriate (assuming no suspicion of abuse and a reliable family). In a study published in 2011, a retrospective review over a 5 year period at a level 1 trauma center showed that 1 out of 171 admitted patients with isolated skull fractures developed vomiting. This patient had a follow up CT showing a small extra-axial hematoma that did not require intervention. 58 patients were discharged from the ED within 4 hours.
You can also check out another recent article published in Annals of Emergency Medicine on the same topic this month!
Drugs that cause hearing loss:
Reversible - Chloroquine, erythromycin, quinine, CO, loop diuretics, NSAIDS, ASA
Irreversible - aminoglycosides, bleomycin, vincristine, vinblastine, cisplatin, lead, mercury, arsenic
General Information:
Trachoma is the leading cause of preventable blindness caused by an infectious disease. It is spread by direct contact with people, objects, or flies carrying Chlamydia trachomatis. Blindness occurs due to corneal scarring with repeated infections (severe scaring of the eyelid-->eyelid inversion-->repeated corneal abrasions).
Clinical Presentation:
-Mild: Hypopigmented follicles on the inner eyelid; Moderate: inner eyelid scarring/eyelash inversion; Severe: corneal scarring/blindness (irreversible)
Diagnosis:
- Clinical: eyelid eversion and careful examination looking for the above
Treatment:
- Azithromycin 20mg/kg ONE TIME DOSE (preferred)
- 1% Tetracycline ointment bid x6 weeks
- If scarring or eyelid inversion is present, surgery is needed.
Bottom Line:
Trachoma is a clinical diagnosis and easy to treat early with a single dose of antibiotics. Patients with late findings should be referred for surgery.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
There have been so many great talks at ACEP 2013, but Dr. Michael Winters' talk "The ICU is NOT Ready for Your Patient" was chock full of great critical care pearls. Here are just a few:
A 23 year-old male presents with the rash below. He originally presented to his primary care doctor for a sore throat and was given a prescription for a medication; this rash subsequently broke out. What's the diagnosis and which medication did he receive?
A 48 year-old female presents to the ED with progressive dyspnea and chest discomfort over the past 3 months. HR = 105, BP = 100/60 mmHg, with mild JVD on exam. Her ECG is shown below. What ECG abnormalites are present? What does your differential diagnosis include? What is the best initial diagnostic test?
Toxicologists should be aware of non-toxicological mimics of delirium, including anti-NMDA receptor encephalitis. It is an under-recognized progressive neurological disorder caused by antibodies against NMDA receptors.
Cases often present with altered mental status, autonomic instability, increased muscle tone, and movement disorders. It can easily be mistaken for neuroleptic malignant syndrome (NMS). A new case series describes two such patients for which toxicologists were consulted.
Must read links:
Dr. Leon Gussow provides a great review of the case series on his Poison Review blog.
Dr. Chris Nickson reviews the basics of the disease on the Life in the Fast Lane blog.
General Information:
Area of the world affected:
Relevance to the US physician:
Bottom Line:
Suspect Salmonellosis in patients with appropriate exposure and symptoms, give supportive care for most, only give antibiotics to severely ill patients after sending blood and stool culture and sensitivities.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
Want to improve your chances of success in the resus room? Download a metronome app on your smartphone and set it to a rate of 100-120 beats per minute. There are a number of cheap (usually free) metronome applications for both iOS and Android devices.
A recent review looked at the evidence behind CPR feedback devices and found:
So instead of going to iTunes and downloading the Bee Gees, go over to the App store and download a free metronome. Your resus team will be able to stay on track with their compressions and even better - they won't have to hear you sing!
25 year-old female struck in the left hand by a football. Presents with pain, visible deformity, and the Xray below. What are the next step(s) in management?
Acute Aortic Syndromes
Classically, aortic dissection is considered the primary culprit in patients with chest pain that radiates to the back (aortic pain) or chest pain combined with ischemia (cerebral, cardiac, peripheral), syncope, or cardiac arrest. However, it should not be your only concern: the rate of aortic rupture is much higher in penetrating atheromatous ulcer (42%) and intramural hematoma (35%) than in aortic dissection (types A 7.5% and type B 4.1%).
Chest pain with concomitant ischemic symptoms and acute decompensation should prompt consideration of several etiologies under the umbrella of aortic syndromes and not limited to dissection :
Treatment of patients with HIV/AIDS can frequently mean consideration for, and need to treat cryptoccocal meningitis.
Since 1997, studies have demonstrated that high-dose Amphotericin B combined with flucytosine has improved outcomes compared to low dose treatment or monotherapy.
A recent 2013 study reiterated this approach, showing significant decrease in deaths at 70 days post-treatment and increased rates of yeast clearance with combination therapy of Amphotericin B plus flucytosine.
Recommendation:
Antifungal treatment of cryptococcal meningitis should start with Amphotericin B at 0.7-1 mg/kg IV daily plus concurrent flucytosine 25 mg/kg orally q6 hours. Fluconazole can be substituted in place of flucytosine if it is not available or not tolerated.
Should you be concerned about erythema around the umbilical stump?!
Yes!
Often parents will bring their neonate to the ED with concerns about the umbilical cord and it is just a simple granuloma or normal detachment. But is it omphalitis???
Omphalitis incidence is low in developed countries, but that means it’s easier, and no less catastrophic, to miss!
Omphalitis is a superficial cellulitis of the umbilical cord, but 10-16% progress to necrotizing fasciitis of the abdominal wall!!!
Always ADMIT and consider consulting surgery early in case of rapid progression…
Most often polymicrobial and should be treated with:
Should notice improvement within 12-24 hours, so if don’t or begin to observe
CONSULT SURERY for concern of necrotizing fasciitis which has a mortality rate of close to 60%!!!
ACLS recommendation for procainamide in tachycardic rhythms is:
Loading dose 20 mg/minute (up to 50 mg/minute for more urgent situations) until:
Maintenance infusion is 1 to 4 mg/min.
An easier method for dosing acute onset atrial fibrillation in stable patients was used in the Ottawa Aggressive Protocol, in which they administered 1 gm over 60 min, which was interrupted if BP < 100 mmHg; if corrected by a 250 ml IV bolus, the infusion was resumed. This was not used, however if the patient was to be admitted.
A strategy for treating stable monomorphic VT with procainamide used:
100 mg IV over 1-2 minutes, repeat as necessary until an endpoint of
If no slowing of the tachycardia occurred with a dose of 400 mg, the administration was ceased.
Case Presentation:
You are working in an ED in Houston when a 2 year old girl presents with fever for one day and decreased po intake. On arrival her temp=103, HR=180, and RR=50 SaO2=100%. She was born in the US and is up to date on all of her vaccinations, but has just returned from a trip to Liberia where she was visiting her extended family and received multiple mosquito bites. Physical exam, CXR and urinalysis are otherwise unremarkable and you suspect malaria, based on her history. You start quinine IV while you are waiting for the smear when suddenly the child becomes unresponsive.
Clinical Question:
What is the next investigation you should perform?
Answer:
Rapid blood glucose!
This patient has at least 4 reasons to be hypoglycemic:
1. fasting (Kids can become hypoglycemic from fasting alone in ~24hrs)
2. infection (any infectious disease can cause it, esp in kids <3 yrs old)
3. malaria (thought to be due in part to increased consumption by parasite)
4. quinine (stimulates insulin release)
Bottom Line:
Kids can become hypoglycemic fast—check a blood glucose in all pre-pubertal sick children.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
The efficacy of epinephrine during out-of hospital cardiac arrest has been questioned in recent years, especially with respect to neurologic outcomes (ref#1).
A recent study demonstrated both a survival and neurologic benefit to using epinephrine during in-hospital cardiac arrest when used in combination with vasopressin and methylprednisolone.
Researchers in Greece randomized 268 consecutive patients with in-hospital cardiac arrest to receive either epinephrine + placebo (control group; n=138) or vasopressin, epinephrine, and methylprednisolone (intervention arm; n=130)
Vasopressin (20 IU) was given with epinephrine each CPR cycle for the first 5 cycles; Epinephrine was given alone thereafter (if necessary)
Methylprednisolone (40 mg) was only given during the first CPR cycle.
If there was return of spontaneous circulation (ROSC) but the patient was in shock, 300 mg of methylprednisolone was given daily for up to 7 days.
Primary study end-points were ROSC for 20 minutes or more and survival to hospital discharge while monitoring for neurological outcome
The results were that patients in the intervention group had a statistically significant:
probability of ROSC for > 20 minutes (84% vs. 66%)
survival with good neurological outcomes (14% vs. 5%)
survival if shock was present post-ROSC (21% vs. 8%)
better hemodynamic parameters, less organ dysfunction, and better central venous saturation levels
Bottom-line: This study may present a promising new therapy for in-hospital cardiac arrest and should be strongly considered.
65 year-old diabetic patient presents with abdominal pain. What's the abnormality on Xray?
The primary goal in management of STEMI is rapid coronary revascularization. STEMI's are occasionally complicated by ventricular fibrillation (VF) arrest. High quality chest compressions and early defibrillation will improve survival. But what can be done in cases where conventional ACLS measures fail and patients have shock-refractory VF?
Some have suggested that emergent PCI with ongoing CPR en route may be beneficial. This option may be considered in close consultation with cardiology if the arrest is thought to be driven by ongoing ischemia and infarction. However, definitive data is lacking and this has only been described in a handful of case reports.
There may also be a role for venoarterial ECMO to aid in perfusion of vital organs and limit the risk of multisystem organ failure. The ECMO circuit can also help facilitate therapeutic hypothermia after the culprit vessel(s) is revascularized and rhythm is restored.
Chances for survival are highest in younger patients, those that do not have chronic illnesses, and those who received immediate CPR after arrest.
Summary:
Consider emergent consultation for salvage PCI and ECMO in select cases of shock-refractory ventricular fibrillation associated with STEMI
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