Keywords: Wrist fracture, splinting (PubMed Search)
High energy mechanism in younger patients
Falls more common in older patients
Higher incidence in older women due to osteoporosis
May indicate overall poor bone health
Avoid splinting in positions of flexion (palmer) and ulnar deviation
Palmer flexed positions may have a higher rate of displacement
Extra-articular fx, less than 5mm shortening of radius, Less than 5 degrees of dorsal angulation.
Consider fractures than are only stable in extreme positions to be unstable
If fx involves the ulnar styloid or DRUG (distal radial ulnar joint) place in long area posterior splint with arm in mid supination (anatomic position of forearm)
Keywords: foodborne botulism (PubMed Search)
Botulism is a rare neurologic condition characterized by GI symptoms that progressed to cranial nerve dysfunction and symmetric descending paralysis. Foodborne botulism is due to ingestion of botulinum toxin that is produced by clostridium botulinum, an ubiquitous bacterium in our environment.
Maryland Department of Health and Mental Hygiene
CDC Emergency Operations Center: 770-488-7100
Foodborne botulism is characterized by
Keywords: syncope, vasovagal, orthostatic, blood pressure (PubMed Search)
Vasovagal syncope is a subtype of neurally mediated syncope, and it is distinctly different from orthostatic hypotension.
Patients with orthostatic syncope have severe orthostatic hypotension that results in transient loss of consciousness immediately or within moments of standing up. This is different from neurally mediated syncope, which develops gradually under conditions of prolonged orthostatic stress such as standing for several minutes. Tilt table testing is useful for true orthostatic syncope, but not for neurally mediated syncope. In addition, checking for “orthostatic hypotension” may not capture patient with orthostatic syncope, because the hypotension occurs so quickly after standing up. Of note, patients may still have orthostatic tachycardia or intolerance with neurally mediated syncope.
Category: Critical Care
Antibiotics in Sepsis
Leisman D, et al. Delayed second-dose antibiotics for patients admitted from the emergency department with sepsis: prevalence, risk factors, and outcomes. Crit Care Med. 2017; 45:956-65.
Keywords: Reverse Segond Fracture (PubMed Search)
It is common teaching that a Segond Fracture is associated with ACL tears. A reverse Segond fracture, avulsion fracture of the knee due to avulsion of the deep fibers of the medial collateral ligament, has also been described that was initially reported as associated with PCL tears. However, a more recent study has not been able to collaborate the PCL connection, but has shown that a reverse Segond fracture is associated with multiple ligamentous injuries to the knee.
Take home point: If you note a Reverse Segond fracture on your plain flips have the patient followup with orthopedics for a possible MRI, as they probably have other ligamentous injuries that might need treatment.
In the study by Peltola et al they looked at 11 years of patients who had CT of their knee and found 10 patiens with a reverse Segond fracture. They found "Reverse Segond fracture is a rare finding even in a level 1 trauma center. Cruciate ligament injuries appear to be associated with avulsion frac- ture, but every patient does not have PCL injury, as previously reported. Our results do not support the association of knee dislocation with reverse Segond fracture."
For a detailed discussion of Segond Fractures please visit Radiopaedia at https://radiopaedia.org/articles/segond-fracture
For Reverse Segond Fractures please visit https://radiopaedia.org/articles/reverse-segond-fracture
Keywords: Psychiatric, agitation, pediatric (PubMed Search)
IM ziprasidone (Geodon) has a relatively quick onset of action with a half-life of 2-5 hours. Although commonly used in adults, there has not been a study looking at an effective dose in pediatrics. Based on the study referenced, the suggested pediatric dose of ziprasidone is 0.2 mg/kg (max 20mg).
This is the first study looking at ziprasidone in the pediatric emergency department population. This was a retrospective observational study of children 5-18 years old who were treated with IM ziprasidone. 40 patients received IM ziprasidone in a tertiary care pediatric emergency department between 2007-2015. 2/3 of the patients had ADHD and 1/3 had autism spectrum disorder. Other diagnosis included post-traumatic stress disorder, bipolar disorder and intellectual disabilities.
68% of patients responded to the initial dose. The initial dose was 0.19 +/- 0.1 mg/kg in the responder group and 0.13 +/- 0.06 mg/kg in the non-responder group. Single doses ranged from 2.5 mg to 20 mg total.
No patients had respiratory depression. Two patients had potential extra-pyramidal symptoms, but one was prior to ziprasidone administration and the other patient had baseline facial twitching with no documentation if there was a change after ziprasidone administration.
Nguyen T, Stanton J and Foster R. Intramuscular Ziprasidone Dosing for Acute Agitation in the Pediatric Emergency Department: An observational Study. Journal of Pharmacy Practice 1-4. 2017.
Category: International EM
Keywords: Meningitis, infectious disease (PubMed Search)
Currently, Nigeria is having the worst outbreak of bacterial meningitis in almost 10 years, involving 23 states, 13,420 suspected cases, and 1,069 deaths, as of May 9.
Bacterial meningitis outbreaks frequently occur in West Africa. The area most frequently struck by epidemics of bacterial meningitis is in the sub-Saharan region of Africa. This includes 26 countries and over 400 million people. Epidemics most often occur in the dry season from December-June. Neisseria meningitides serogroup A historically accounts for approximately 90% of the cases.
The U.S. Centers for Disease Control and Prevention recommends quadrivalent vaccines (protects against four serogroups A, C, W, and Y) for individuals traveling or living in countries in which meningococcal disease is hyperendemic or epidemic.
https://www.osac.gov/pages/ContentReports.aspx?cid=3 (Accessed 5/17/2017)
Category: Critical Care
High flow nasal cannula (HFNC) is a valid option in the management of acute hypoxic respiratory failure (AHRF) without hypercapnia, as evidenced by multiple studies including the FLORALI trial. Failure of HFNC, however, may result in delayed intubation and worsened clinical outcomes.
Factors predicting HFNC failure and subsequent intubation include:
Consider whether or not HFNC is appropriate in your patient with AHRF, and if you use it, reevaluate your patient to ensure improvement, or escalate their respiratory support.
For patients with acute hypoxic respiratory failure without hypercapnia, the FLORALI trial demonstrated that high flow nasal cannula (HFNC) therapy increases ventilator-free days, reduces 90-day mortality, and is associated with better comfort and lower dyspnea severity when compared to conventional oxygen therapy and non-invasive ventilation (NIV). Failure of HFNC, however, may result in delayed intubation and worse clinical outcomes in patients with acute hypoxic respiratory failure. So how do we predict in the ED which patients are going to fail?
Sztrymf et al. evaluated patients placed on HFNC for nonhypercapneic acute hypoxic respiratory failure, who later went on to require endotracheal intubation. The cohort who failed HFNC had significantly:
- higher RR at 30 & 45 minutes after initiation of HFNC
- lower SpO2% at 15, 30, and 60 minutes
- higher incidence of paradoxical breathing (thoracoabdominal dyssynchrony) at 15, 30, 60, and 120 minutes
In an observational study of patients with ARDS,* Messika et al. found that factors predicting HFNC failure included:
- a higher Simplified Acute Physiology Score II (SAPS II; 46 v. 29, p=.001)
- additional organ system failure (mostly hemodynamic or neurological)
- trends towards lower PaO2:FiO2 ratios and higher RR
So don’t set it and forget it! Consider a different method of respiratory support if your patient has multi-organ system failure, especially if they are in shock or have altered mental status. If you do use HFNC, reevaluate your patient at 15 minutes and again at 30 minutes to make sure their respiratory rate and SpO2 have improved and that there is no paradoxic breathing (or it is resolving). If not, move on to NIV or invasive mechanical ventilation.
*acute respiratory failure occurring within 1 week of known clinical insult with PaO2:FiO2 <300mmHg and bilateral opacities on chest x-ray not attributable to cardiac failure/volume overload
1. Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372:2185–96.
2. Sztrymf B, Messika J, Bertrand F, et al. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med. 2011;37:1780–6.
3. Messika J, Ben Ahmed K, Gaudry S, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respir Care. 2015;60(2):162-9.
4. Hernandez G, Roca O, Colinas L. High-flow nasal cannula support therapy: new insights and improving performance. Crit Care. 2017;21(1):62.
Keywords: Lateral knee pain (PubMed Search)
Iliotibial band tendonitis
IT band is the continuation of the tensor fascia lata and inserts on the tibia at Gerdy's tubercle
Common cause of lateral knee pain seen in Primary care/Sports med clinics
Mechanism: May be due to excessive friction between the IT band and the lateral femoral condyle
Second most common overuse injury of the knee (PF syndrome). Not an acute event.
Affects up to15% of active individuals
Impingement zone is at 30 degrees of knee flexion
Most common in runners and cyclists
Pain localized over the lateral femoral condyle. Better w/ rest. Often occurs at a predictable distance into the run and not at onset.
Exacerbated with changes to mileage or running terrain.
Additional risks include poor shoes (best to change every 300 to 500 miles), excessive foot pronation (pes planus), quad versus hamstring strength asymmetry, weak hip ABductors, leg length discrepancy, tight IT band.
Keywords: syncope, vasovagal, seizures, orthostatic, blood pressure (PubMed Search)
Cheshire WP. Syncope. Continuum 2017;23(2):335–358.
Keywords: Lisfranc Fracture (PubMed Search)
Lisfranc Fracture: Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.
Click below see image of fracture
Common current mechanism of injury is when a person steps into a hole and twists the foot. The original mechanism of injury that was described was when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficultly weight bearing with pain on palpation over the 2nd and 3rdmetatarsals with an appropriate mechanism.
Keywords: analgesics, Ultram, (PubMed Search)
Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.
A summary statement from the American Hospital Association (AHA) is posted below.
FDA RESTRICTS USE OF CODEINE AND TRAMADOL
MEDICINES IN CHILDREN, RECOMMENDS AGAINST USE IN BREASTFEEDING MOTHERS
The Food and Drug Administration (FDA) today announced that it is restricting the use of codeine and tramadol medicines in children, as well as recommending against using codeine and tramadol medicines in breastfeeding mothers due to possible harm to their infants.
Codeine is approved to treat pain and cough, and tramadol is approved to treat pain. These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years, and should not be used in these children. These medicines also should be limited in some older children.
The FDA is requiring several changes to the labels of all prescription medicines containing these drugs. These new actions further limit the use of these medicines beyond FDA's 2013 restriction of codeine use in children younger than 18 years to treat pain after surgery to remove the tonsils and/or adenoids. The agency is now adding:
The FDA is urging health care professionals and patients to report side effects involving codeine-and tramadol-containing medicines to the FDA MedWatch program, through its online form.
Keywords: Dextromethorphan, Robotripping (PubMed Search)
Dextromethorphan Abuse in Adolescence. Bryner JK, Wang K, et al. Archives of Pediatrics & Adolescent Medicine. 2006;160(12):1217-1222. doi:10.1001/archpedi.160.12.1217.
Dextromethorphan abuse. Antoniou T, Juurlink DN. CMAJ?: Canadian Medical Association Journal. 2014;186(16):E631. doi:10.1503/cmaj.131676.
Category: Pharmacology & Therapeutics
Haloperidol has a higher D2 receptor antagonist effect than standard antiemetic treatment agents such as metoclopramide. In addition, newer antipsychotic agents such as Olanzapine have a high affinity at multiple antiemetic sites such as the dopamine and serotinergic receptors.
While formal RCT's are still in the works, multiple sources including palliative care, emergency medicine, and pain journals support their use in refractory emesis.
Consider Haloperidol 3-5 mg IV.
Check an EKG for long QTc prior to use. Consider dose reduction of haloperidol in those with hepatic impairment. Also consider dose reduction in patients taking carbamazepine, phenytoin, phenobarbital, rifampicin, or quinidine due to that pesky CYP3A4 inhibition.
Consider Olanzapine 2-5 mg IV.
Several case reports have shown a higher rate of success with olanzapine for refractory emesis. Olanzapine has similar precautions as those to haloperidol (EKG, hepatic impairment), although it's CYP drug interactions are less common. Additionally, use olanzapine cautiously in hyperglycemic patients as there are several case reports of olanzapine prompting episodes of DKA. Consider frequent blood sugar checks or small doses of insulin in hyperglycemic patients.
Take Home Points:
Consider the antipsychotic agents Haloperidol or Olanzapine for patients with refractory emesis, they may be more effective than traditional antiemetics.
Get an EKG prior to administration to check for QTc prolongation. As the classical and atypical antipsychotic agents are sedating, use caution in conjunction with other sedating medications (such as benzodiazepines).
Keywords: vasogenic cerebral edema, white matter, blood-brain-barrier, steroids (PubMed Search)
Case image courtesy of Dr David Cuete, Radiopaedia.org, rID: 23178
Follow me on Twitter @EM_NCC!
Category: Critical Care
Ventilator Settings for the Post-Arrest Patient
Jentzer JC, et al. Recent developments in the management of patients resuscitated from cardiac arrest. J Crit Care. 2017; 39:97-107.
Keywords: Hip, pediatrics, arthritis (PubMed Search)
Septic Arthritis in Children
Classic presentation: Pain, fever (may not always be present)
Limited range of motion of joint or refusal to bear weight,
Joint swelling (difficult to visualize in hip or shoulder),
Limb held in position that allows greatest capsular volume (elbow held in 30° flexion for example)
Diagnostic testing may include diagnostic markers (ESR, CRP) or imaging (US/MRI)
Most common organisms: Staph and Strep, Neisseria (adolescents), HACEK organisms, consider gram negatives in immunocompromised children
DDX: Transient synovitis, osteonercrosis or osteomyelitis, Psoas abscess, acute leukemia, Lyme disease
A common ED presentation is the child with the painful limp
35% of all cases of septic arthritis
>50% of cases occur in children younger than 2yo
Hip held in flexion, Abduction, external rotation
Fever and inflammatory markers are more sensitive than WBC count and refusal to bear weight
1) Refusal to weight bear on affected side
2) Sed rate greater than 40mm/hr
3) Fever (>38.5°C
4) WBC count of >12,000 mm3
- 4/4 criteria are met, there is a 99.6% chance of septic arthritis;
- when 3/4 criteria are met, there is a 93% chance of septic arthritis;
- when 2/4 criteria are met, there is a 40% chance of septic arthritis;
- when 1/4 criteria are met, there is a 3% chance of septic arthritis;
CRP can also be incorporated into a diagnostic algorithm
CRP>2.0 (mg/dl) in a child who refuses to bear weight yields a 74% probability of septic arthritis
Keywords: Bronchiolitis, asthma (PubMed Search)
Predictive factors of asthma development in patients diagnosed with bronchiolitis include:
- Male sex (OR 1.3)
- Family history of asthma (OR 1.6)
- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)
- More than 2 episodes of bronchiolitis (OR 2.4)
- Allergies (OR 1.6)
This was a retrospective study of 1991 children younger than 2 years that presented between 2000-2010 who were diagnosed with bronchiolitis. Primary care records were reviewed 1 year after their visit to the ED to see if the patient had a primary care diagnosis of asthma.
Of the initial study population, 817 patients had received a diagnosis of asthma at 1 year.
Since these patients were only followed up at 1 year, the amount of children who were later diagnosed with asthma may be underestimated.
Waseem et al. Factors Predicting Asthma in children with Acute Bronchiolitis. Pediatric Emergency Care. March 2017. Epub ahead of print.
Keywords: lactic acidosis (PubMed Search)
Lactic acids are often elevated in critical care patients (e.g. septic shock). It can be also elevated in setting of drug overdose or less frequently in therapeutic use due to interference of oxidative phosphorylation. Some of the agents include:
Kraut JA, Madias NE. Lactic acidosis, N Engl J Med 2014;371:2309-19.
Category: International EM
Keywords: CDC, Shigella, antibiotic, health advisory (PubMed Search)
The Centers for Disease Control and Prevention (CDC) just released an official health advisory through the Health Alert Network entitled: “CDC Recommendations for Diagnosing and Managing Shigella Strains with Possible Reduced Susceptibility to Ciprofloxacin”
Concerning treatment, one key point is:
Do not routinely prescribe antibiotic therapy for Shigella infection. Instead, reserve antibiotic therapy for patients for whom it is clinically indicated or when public health officials advise treatment in an outbreak setting.
o Shigellosis is generally a self-limited infection lasting 5-7 days.
o Unnecessary treatment with antibiotics promotes resistance.
o Treatment can shorten the duration of some illnesses, though typically only by 1-2 days
This Health Advisory describes the identification of emerging Shigella strains with elevated minimum inhibitory concentration values for ciprofloxacin and outlines new recommendations for clinical diagnosis, management, and reporting, as well as new recommendations for laboratories and public health officials. There are more details available on the website: https://emergency.cdc.gov/han/han00401.asp
RECOMMENDATIONS FOR CLINICIANS
· Order stool culture for patients suspected of having a Shigella infection to obtain isolates for antimicrobial susceptibility testing.
· Order antimicrobial susceptibility testing when ordering stool culture for Shigella.
· Do not routinely prescribe antibiotic therapy for Shigella infection. Instead, reserve antibiotic therapy for patients for whom it is clinically indicated or when public health officials advise treatment in an outbreak setting.
· When antibiotic treatment is indicated, tailor antibiotic choice to antimicrobial susceptibility results as soon as possible with special attention given to the MIC for fluoroquinolone antibiotics.
· Obtain follow-up stool cultures in shigellosis patients who have continued or worsening symptoms despite antibiotic therapy.
· Consult your local or state health department for guidance on when patients may return to childcare, school, or work.
· Counsel patients with active diarrhea on how they can prevent spreading the infection to others, regardless of whether antibiotic treatment is prescribed.