50 YOF with acute onset of worst headache of life associated with nausea and vomiting. Patient is somnolent, will rouse to noxious stimuli and complains of a headache as well as decreased vision.
Idiopathic osteonecrosis of the femoral head
Children as young as 2 or as old as 12 but generally 4 to 8 (worse in older children)
Fare better than adults with osteonecrosis of femoral head
1 in 10,000
4-5x more common in males, much less common ini African Americans
Unilateral femoral head involvement 90% of the time (Bilateral 10% of the time)
Long term consequences are deformity and arthritis
Typical presentation: Subacute limping for weeks (Painless)
As activity worsens limp, it is maximal at the end of the day (Intermittent)
As in adults with hip pathology, IF pain is reported, it is located at the upper anterior thigh and groin
On examination, look for restriction in range of motion of the hip (compare with contralateral side)
May only present with mild to moderate decreased range of motion of the hip
30 versus 60 degrees for example
ABduct both legs with pelvis in neutral OR Place one hand on contralateral pelvis and ABduct affected leg with other hand.
Cholera is an acute diarrheal disease that can kill within hours if left untreated.
Rising cholera, diarrhea and malnutrition is a deadly combination in war torn countries, such as Yemen, South Sudan, Somalia and Sudan, especially for children.
Yemen currently has the worst outbreak globally, with over 260,000 suspected cases and over 1,600 deaths. In Yemen:
o Half the suspected cases are children
o A quarter of the deaths are among children
Bottom Line:
Cholera remains a major cause of morbidity and mortality globally, especially in areas of conflict.
When you are working up an elderly patient for trauma look for patterns such as circumferential bruising on the wrists that have the pattern of fingers the same way you would look at the injuries of a child. Remember that the person who is sitting next to them is frequently the person that is abusing them. Therefore, it is important to interview the patient alone.
When you look up dosing for levofloxacin for community acquired pneumonia (CAP), you will find that both of the following options are approved:
This is based on a multicenter, randomized, double-blind, active treatment trial comparing these two regimens in CAP (mild to severe). This non-inferiority trial shows that the 750 mg dose of levofloxacin for 5 days is "at least as effective and well tolerated" as the 500 mg dose of levofloxacin for 10 days.
So why should you choose the 750 mg daily x 5 day regimen?
As alway with levofloxacin, don't forget to renally dose adjust subsequent doses when writting a script or scheduled inpatient order for patients with reduced creatinine clearance!
Black widow spiders belong to the genus Latro dectus which include 31 species of widow spiders found throughout world. Approximately 1500-2500 black widow bites are reported to American poison control centers annually. A black widow can be identified by their hourglass pattern (red or orange) on the ventral aspect of their shiny globular abdomen. Fortunately, envenomation is rare but when it does occur it causes severe pain, muscle cramping, abdominal (may mimic acute abdomen) often refractory to traditional analgesics and antivenom (Antivenin Latrodectus mactans) is available and effective . Alpha-latrotoxin is the potent toxin causing presynaptic cation channels to open (calcium) and release of neurotransmitters such acetycholine. The neurological signs and symptoms caused by predominantly autonomic and include tachycardia and hypertension. The antivenom is equine based and infused over 20-30 minutes with pain relief in 20 minutes.
Ventilation During Cardiopulmonary Resuscitation
Adhesive Capsulitis aka Frozen Shoulder
Spontaneous gradual onset stiffness and pain of the Glenohumeral joint
Shoulder capsule becomes thickened and contracted
Often affects patients between 40 and 60 years old
Left> Right shoulder
Women> men
Association with diabetes and thyroid disease
3 clinical stages
1) Pain – gradual onset, diffuse, severe, disabling, often worse at night
2) Stiffness – decreased ROM, affects ADLs, improved pain
3) Thawing – gradual return of motion
Physical examination: Painful and decreased ROM. Evaluate active and passive movement, external rotation and ABduction of the shoulder most affected
Surgical or post traumatic shoulder stiffness usually resolves within 12 months.
Adhesive capsulitis is generally self-limiting lasting an average of 18-36 months.
DDX: Chronic locked posterior shoulder dislocation (VERY IMPORTANT), tumor.
Treatment: NSAIDs, Physical therapy, Intra articular steroids
If this fails, manipulation under anesthesia and/or arthroscopic surgical release
Every year in the U.S., preventable poisonings in children result in more than 60,000 ED visits and around 1 million calls to poison centers. Calls relating specifically to pet medication exposure and children have been on the rise.
A recent study in Pediatrics was the first was kind to characterize the epidemiology of such exposures.
This study is a call to arms for an increased effort on the part of public health officials, pharmacists, veterinarians, and physicians to improve patient education to prevent these exposures from occurring.
Summary of major findings:
Most commonly Implicated exposures:
Key contributors to exposure risk:
Take home point: Make sure your pet's medications are appropriately stored for safety!
Chest injuries represent the second most common cause of pediatric trauma related death. ATLS guidelines recommend CXR in all blunt trauma patients. Previous studies have suggested a low risk of occult intrathoracic trauma; however, these studies included many children who were sent home.
Predictors of thoracic injury include: abdominal signs or symptoms (OR 7.7), thoracic signs of symptoms (OR 6), abnormal chest auscultation (OR 3.5), oxygen saturation < 95% (OR 3.1), BP < 5% for age (OR 3.7), and femur fracture (OR 2.5).
4.3 % of those found to have thoracic injuries did not have any of the above predictors, but their injuries were diagnosed on CXR. These children did not require trauma related interventions.
Bottom line: There were still a number of children without these predictors that had thoracic injuries, so the authors suggest that chest xray should remain a part of pediatric trauma resuscitation.
Street names for illicit substance are diverse and unique. Knowing what your patient used prior to ED presentation can help with the management of their intoxication.
DEA recently released 7 page list of common street names for drugs of abuse.
https://ndews.umd.edu/sites/ndews.umd.edu/files/dea-drug-slang-code-words-may2017.pdf
But keep in mind that what our patients purchase and use may not actually contain the drug that they intended to purchase (e.g. fentanyl being sold as heroin).
What is the role of EEG for first-time seizures in the ED?
Take Home Point: A 30-minute routine EEG in the ED in adults with an uncomplicated first-time seizure revealed a substantial number of epilepsy diagnosis and can change ED management with immediate initiation of antiepileptic medication.
In patients with persistent VT/VF cardiac arrest, giving epinephrine before the 2nd defibrillation attempt (which should follow initial shock and 2 minutes of CPR) is associated with decreased ROSC, decreased hospital survival, and decreased functional outcome.
Take Home Point:
"Electricity before Epi" in patients with persistent VT/VF arrest, at least for the initial epinephrine dose.
Shin Splints
Medial tibial stress syndrome (MTSS) aka shin splints is an overuse injury of the tibia
Very common
-10 to 15% of running injuries and over 50% of leg pain syndromes
3 Characteristics
1) Pain along the posteromedial border of the tibia
2) Diffuse pain
3) Pain that is activity related
Risk Factors
Female sex, increased weight, previous running injury, and
Higher navicular drop (amount of foot pronation) and
Greater hip external rotation with the hip in flexion
Differential Diagnosis
Tibial stress fracture, compartment syndrome, nerve entrapment (sural), lumbar radiculopathy and popliteal artery entrapment.
A patient presents with altered mental status for unclear reasons- could it be anticholinergic syndrome?
There are many medications (e.g. Beers Criteria, see pearl from March 5, 2017) and plants (e.g.: certain mushrooms) that can cause this life-threatening toxidrome.
The quick mnemonic for anticholinergic poisoning is:
· Hot as a hare (hyperthermia)
· Red as a beet (flushed)
· Cry as a bone (decreased secretions)
· Blind as a bat (mydriasis)
· Mad as a hatter (delirium)
· Full as a flask (urinary retention)
Bottom line: Keep anticholinergic syndrome within your differential for a patient with altered mental status without a clear cause.
Note: An earlier version of this pearl incorrectly listed organophospahtes, which cause cholingeric toxicity.
The poor sensitivity of bedside echocardiography to identify all-comers with pulmonary embolism is well documented. Most series cite a sensitivity and specificity of 31% to 72% and 87% to 98%, respectively (1,2). But as Nazerian et al demonstrate in their recent publication in Internal and Emergency Medicine, the diagnostic performance of bedside echocardiography is far more reliable in the subset of patients presenting in shock (3).
Of the 105 patients included in the final analysis, in 43 (40.9%) PE was determined to be the etiology of their shock. Bedside echo demonstrated notable diagnostic prowess when employed in this subset of patients, sensitivity (91%), specificity (87%), –LR (0.11), +LR (7.03). The sensitivity and –LR were further augmented when the venous US of the LE was included (sensitivity of 95% and –LR of 0.06) in the diagnostic workup.
Older patients with acute coronoary syndrome (ACS) are less likely to present with typical ischemic chest pain (pressure-like quality, substernal location, radiating to jaw, neck, left arm/shoulder and exertional component) compared with younger counterparts.
Typical angina symptoms predictive of acute myocardial infarction (AMI) in younger patients were less helpful in predicting AMI in the elderly population.
Autonomic symptoms such as dyspnea, diaphoresis, nausea and vomiting, pre-syncope or syncope are more common accompaniments to chest discomfort in elderly ACS patients.
Symptoms may also be less likely to be induced by physical exertion; instead, they are often precipitated by hemodynamic stressors such as infection or dehydration
Bottom Line: Keep a high index of suspicion for ACS in older patients as they present atypically.
