Category: Critical Care
Keywords: ARDS (PubMed Search)
Posted: 3/1/2016 by Feras Khan, MD
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Category: Visual Diagnosis
Posted: 2/29/2016 by Haney Mallemat, MD
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19 year-old male complaining of left arm pain one week after injecting anabolic steroids into his shoulder. What's the diagnosis?
Myositis of the deltoid muscle
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Category: Orthopedics
Keywords: Achilles tendon rupture (PubMed Search)
Posted: 2/27/2016 by Brian Corwell, MD
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Achilles tendon rupture
More common in
men, ages 30 - 40yo, s/p steroid injections, fluoroquinolone use, and episodic athletes "weekend warriors
Mechanism: usually during an athletic endeavor, sudden forced planar flexion or violent dorsiflexion of a plantar flexed foot
Location: Usually occurs 4 to 6 cm ABOVE the Achilles calcaneal insertion (hypovascular region)
Patient will report a sudden pop, gunshot like sound
History: Will report heel and calf pain and weakness/inability to walk
Physical examination: Palpable gap, weakness with plantar flexion, + Thompsons test
https://www.netterimages.com/images/vpv/000/000/007/7714-0550x0475.jpg
Consult orthopedics and splint in resting equinus
http://img.medscape.com/fullsize/migrated/408/535/mos0216.01.fig5b.jpg
Category: Pediatrics
Posted: 2/26/2016 by Mimi Lu, MD
(Emailed: 2/27/2016)
(Updated: 2/27/2016)
Click here to contact Mimi Lu, MD
Perianal Group A Strep is an infectious dermatitis seen in the perianal region that is caused by Group A beta-hemolytic Strep. Children will have a characteristic rash with a sharply-demarcated area of redness, swelling, and irritation around the perianal region. There may be associated swelling and irritation of the vulva and vagina (in girls) and penis in boys. Patients can have bleeding or itching during bowel movements.
The age range is often <10 years of age. There is often an absence of fever or other systemic symptoms.The diagnosis can be confirmed by obtaining a Rapid Strep swab from the area of interest. You can also collect a bacterial culture of the area.
Treatment requires a 14 day course of penicillin. Amoxicillin (40 mg/kg/day divided TID) and clarithromycin are alternative treatments. The additional of topical bactroban (mupirocin) can be effective, but it should not be used as monotherapy. Re-occurrence is common, so close follow-up is key.
Category: Neurology
Keywords: pseudoseizures, EEG, somatoform, psychiatric (PubMed Search)
Posted: 2/24/2016 by Danya Khoujah, MBBS
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Chen DK and LaFrance WC. Diagnosis and Treatment of Nonepileptic Seizures. Continuum 2016;22(1):116 131
Category: Critical Care
Posted: 2/24/2016 by Mike Winters, MBA, MD
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Sepsis-3
Singer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:801-10.
Category: Toxicology
Keywords: colchicine toxicity (PubMed Search)
Posted: 2/19/2016 by Hong Kim, MD
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Colchicine is an alkaloid compound found in Colchicum autumnale that is often mistaken by foragers as wild garlic (Allium ursinum). Unintentional ingestion wild garlic or therapeutic misadventures among elderly population with history of gout often result in unintentional toxicity.
It is a potent inhibitor of microtubule formation and function involved in cell division and intracellular transport mechanism. Thus toxicity is related to diffuse cellular dysfunction of all major organs and results in significant morbidity and mortality.
Colchicine toxicity occurs in three phases:
Phase | Time | Signs and symptoms | Therapy |
I | 0 – 24 hr | · Nausea, vomiting, diarrhea · Salt and water depletion · Leukocytosis | · Antiemetic · GI decontamination · IV fluids · Observation for leukopenia |
II | 1 – 7 days | · Sudden cardiac death (24 – 48 hr) · Pancytopenia · Acute kidney injury · Sepsis · Acute respiratory distress syndrome · Electrolyte imbalance · Rhabdomyolysis | · Resuscitation · G-CSF · Hemodialysis · Antibiotics · Mechanical ventilation · Electrolyte repletion |
III | >7 days | · Alopecia (2-3 weeks later) · Myopathy, neuropathy, myoneuropathy. |
|
Management
Category: Pediatrics
Keywords: UTI, fever, infant (PubMed Search)
Posted: 2/19/2016 by Jenny Guyther, MD
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There is not much data published on susceptabilities of urinary pathogens in infants. What resistance patterns are seen in infants < 2 months in gram negative uropathogens?
A retrospective study of previously healthy infants diagnosed with urinary tract infections in Jerusalem over a 6 year period examined this question. The standard treatment at this hospital included ampicillin and gentamycin for less than 1 month olds and ampicillin or cefuroxime for 1-2 month olds.
306 UTIs were diagnosed
74% were resistant to ampicillin
22% were resistant to cefazolin and augmentin
8% were resistant to cefuroxime
7% were resistant to gentamycin
Of the organisms cultured, 76% were E. coli and 14% were Klebsiella.
Bottom line: Know your local resistance patterns.
Segal Z et al. Infants under two months of age with urinary tract infections are showing increasing resistance to empirical and oral antibiotics. Acta Paediatrica. Dec 2015. Epub ahead of print.
Category: International EM
Keywords: Dengue, Hemorrhagic Fever, arbovirus, flavivirus (PubMed Search)
Posted: 2/18/2016 by Jon Mark Hirshon, PhD, MPH, MD
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What are the criteria for dengue hemorrhagic fever?
Category: Orthopedics
Keywords: back pain, sports injury (PubMed Search)
Posted: 2/14/2016 by Brian Corwell, MD
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Spondylolysis
Prevalence 3-6% in the general population (Higher in athletes)
Location: L4 (5-15% of cases) & L5 (85-95% of cases)
Population: More likely in the skeletally immature athlete due to the vulnerability of the immature pars interarticularis to repeated stress
Symptoms: Lumbar pain worse with extension
Higher risk sports: Gymnastics, diving, weightlifting, wrestling
Treatment: Bracing and activity modification, physical therapy
- Good results in 80% with conservative management allowing return to play.
- Those who fail benefit from iliac crest bone grafting and posterolateral fusion.
-Return to play is controversial in this group
Please review th images below for anaomy and imaging appearence
http://orthoinfo.aaos.org/figures/A00053F01.jpg
http://www.sonsa.org/images/spondylolysis.jpg
http://www.physio-pedia.com/images/2/22/Spondylolysis_x_ray_.docx.jpg
Huang P.et al.Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries: A Comprehensive Review. Sports Health2016 Jan;8(1):19-25.
Category: Infectious Disease
Posted: 2/10/2016 by Michael Bond, MD
(Emailed: 2/13/2016)
(Updated: 2/13/2016)
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Borrella mayonii a new species
There is a new bacteria that is causing Lyme disease. Borrella burgdorferi is the typical bacteria associated with lyme disease, but now several cases of Borrelia mayonii have been isolated from patients and ticks that live in Minnesota, Wisconsin and North Dakota. What is unique about this new species is that it is associated with nausea, vomiting, diffuse macular rashes, and neuro symptoms [e.g.: confusion, visual disturbance, and somnolence) along with the typical lyme disease symptoms of arthralgias and headaches.
Current lyme tests should detect this new species and treatment is the same as Borrella burgdorferi. The take home pearl is that we may see patients with "atypical" lyme disease symptoms so this should be on our differential for patients presenting with rashes, nausea, vomiting and neurologic complaints.
Category: Toxicology
Keywords: lipid, intralipid, poisoning, local anesthetic, non-local anesthetic (PubMed Search)
Posted: 2/10/2016 by Bryan Hayes, PharmD
(Emailed: 2/11/2016)
(Updated: 4/2/2016)
Click here to contact Bryan Hayes, PharmD
In September 2013, an international group representing major societies in toxicology and nutrition support began collaborating on a comprehensive review of lipid use in poisoning. Six total papers will be published, with the most recent two made available online this week. Here are the available (and forthcoming) papers:
Gosselin S, et al. Methodology for AACT evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol 2015;53(6):557-64. [PMID 26059735]
Grunbaum AM, et al. Review of the effect of intravenous lipid emulsion on laboratory analyses. Clin Toxicol 2016:54(2):92-102. [PMID 26623668]
Levine M, et al. Systematic review of the effect of intravenous lipid emulsion therapy for non-local anesthetics toxicity. Clin Toxicol. 2016;54(3):194-221. [PMID 26852931]
Hoegberg LC, et al. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol. 2016;54(3):167-93. [PMID 26853119]
Hayes BD, et al. Systematic Review of Clinical Adverse Events Reported After Acute Intravenous Lipid Emulsion Administration. Clin Toxicol. 2016 Apr 1. [Epub ahead of print] [PMID 27035513]
The final paper, which is in process, is the consensus recommendations from the workgroup based on the 4 systematic reviews.
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Category: Neurology
Keywords: cerebral venous thrombosis, CVT, venography, CTV, MRV (PubMed Search)
Posted: 2/10/2016 by WanTsu Wendy Chang, MD
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Bottom Line: CT venography is good for diagnosing CVT, but MRI/MRV is superior for detection of isolated cortical venous thromboses and assessing parenchymal damage.
Bonneville F. Imaging of cerebral venous thrombosis. Diagn Interv Imaging. 2014;95:1145-1150.
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Category: Critical Care
Posted: 2/9/2016 by Haney Mallemat, MD
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Category: Pharmacology & Therapeutics
Keywords: succinylcholine, rocuronium, mortality, traumatic brain injury, RSI (PubMed Search)
Posted: 2/4/2016 by Bryan Hayes, PharmD
(Emailed: 2/6/2016)
(Updated: 2/6/2016)
Click here to contact Bryan Hayes, PharmD
An interesting new study was published looking at in-hospital mortality in TBI patients who received succinylcholine or rocuronium for RSI in the ED.
What They Did
What They Found
Application to Clinical Practice
Patanwala AE, et al. Succinylcholine is associated with increased mortality when used for rapid sequence intubation of severely brain injured patients in the emergency department. Pharmacotherapy 2016;36(1):57-63. [PMID 26799349]
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Category: Toxicology
Keywords: Activated Charcoal, Gastric decontamination, Antidote (PubMed Search)
Posted: 2/4/2016 by Kathy Prybys, MD
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Throughout medical history one of the basic tenets of poisoning therapy is to remove the poison from the patient. For hundreds of years, gastric decontamination has been the cornerstone treatment for acute poisonings by ingestion. This commonsense approach endeavors to remove as much of the the ingested toxin as possible before systemic absorption and organ toxicity occurs. Multiple GI decontamination methods have been utilized including gastric emptying by lavage and ipecac, toxin binding by activated charcoal, and increasing GI transit time with cathartics and bowel irrigation. Numerous studies have been conducted to assess the effectiveness of GI decontamination including measurement of amount of toxin removed by gastric retrieval, reduction of bioavailability by measuring blood levels, and finally comparison of clinical outcomes of patients treated with and without GI decontamination. Controlled studies have failed to show conclusive evidence of benefit and have even demonstrated resultant harm especially with use of gastric lavage. Activated charcoal has a tremendous surface area capable of binding many substances. Although viewed as relatively safe it does have risks in certain subsets of patients, pulmonary aspiration the most common, and is no longer routinely recommended.
Considerations for use of Activated charcoal (AC) use in acutely poisoned patients:
The decision to use activated charcoal is no longer standard of care but should be individualized to each clinical situation weighing the risk versus clinical benefits.
Olson KR. Activated Charcoal for Acute Poisoning: One Toxicologist’s Journey. J Med Toxicol 2010;6:190-198. Activated charcoal for acute overdose: a reappraisal.
Juurlink D. Br J Clin Pharmacol 2015 Sep 26
Chyka PA, Seger D, Krenzelok EP, Vale JA. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position paper: single-dose activated charcoal. Clin Toxicol (Phila) 2005;43(2):61–87.
Lapus RM, Activated charcoal for pediatric poisonings: the universal antidote? Curr Opin Pediatr. 2007;19:219-222.
Category: International EM
Keywords: Zika virus, public health emergency, infectious disease, WHO (PubMed Search)
Posted: 2/3/2016 by Jon Mark Hirshon, PhD, MPH, MD
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On February 1st, the World Health Organization declared that Zika was an international public health emergency. As noted in the Pearl from January 20th, 2016, Zika is a mosquito-borne RNA flavivirus that is usually asymptomatic. However, congenital malformations have been seen in pregnant women infected with Zika.
While it is clear that the decision to declare an international public health is a judgement call, what are the criteria for considering this declaration?
Per the WHO, the term Public Health Emergency of International Concern is defined in the IHR (2005) as “an extraordinary event which is determined, as provided in these Regulations:
· to constitute a public health risk to other States through the international spread of disease; and
· to potentially require a coordinated international response”. This definition implies a situation that: is serious, unusual or unexpected; carries implications for public health beyond the affected State’s national border; and may require immediate international action.
The responsibility of determining whether an event is within this category lies with the WHO Director-General and requires the convening of a committee of experts – the IHR Emergency Committee.
For Zika, the sequalae of concern are the clusters of microcephaly and Guillain-Barré syndrome suspected to have resulted from Zika infection.
http://www.who.int/ihr/procedures/pheic/en/
Category: Critical Care
Keywords: aki, renal failure, acute kidney injury (PubMed Search)
Posted: 2/2/2016 by Feras Khan, MD
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KDIGO Clinical Practice Guidelines, 2012.
Category: Misc
Keywords: Diverticulitis, antibiotics. (PubMed Search)
Posted: 1/30/2016 by Michael Bond, MD
(Updated: 1/31/2016)
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Diverticulitis
It seems like the standard treatment course for patients with suspected diverticulitis in the ED is to obtain a CT of the Abdomen and pelvis and then to start antibiotics. A CT scan is really only needed if you suspect that they have an abscess, micro perforation, are not responding to conventional treatment, or you suspect an alternative diagnosis.
However, what should the conventional treatment be? Several recent studies from Sweden, Iceland and the Netherlands have shown that patients treated with antibiotics did not fair any better then patients who were just observed. There was no difference in time to resolution of symptoms, complications, recurrence rate, or duration of hospitalization.
Several national societies (Dutch, Danish, German, and Italian) now recommend withholding antibiotics in patients free of risk factors who have uncomplicated disease, but these patients will need close follow up.
TAKE HOME POINT: Patients with diverticulitis can be treated supportively and probably do not require antibiotics unless you suspect they have complicated disease or are immunosuppressed.
Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532-539.
Daniels L, Ünlü Ç, de Korte N, et al; A randomized clinical trial of observational versus antibiotic treatment for a first episode of uncomplicated acute diverticulitis. BMC Surg. 2010 Jul 20;10:23
Category: Neurology
Keywords: airway, intubation, intracranial hemorrhage, ketamine, opiates, RSI (PubMed Search)
Posted: 1/27/2016 by Danya Khoujah, MBBS
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Airway management is an integral part of caring of critically ill patients, but is there anything that should be done differently in the neurologically injured patient?
Bucher J, Koyfman A. Intubation of the Neurologically Injured Patient. JEM 49 (6) 920-7