Category: International EM
Keywords: cyclospora, outbreak, international, tropical, infectious disease (PubMed Search)
Posted: 7/31/2013 by Andrea Tenner, MD
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General Information:
As of July 30th, 2013, there have been 378 cases of Cyclospora infection from multiple states in the US. Cyclospora is most common in tropical and sub-tropical regions, and is spread via fecal-oral route. While the cause of the most recent outbreak is unknown, outbreaks in the US are generally foodborne.
Clinical Presentation:
- Symptoms usually begin 7 days after exposure
- Watery diarrhea, cramping, bloating, nausea, fatigue, increased gas, vomiting, low grade temperature
- Can persist several weeks to > 1 month
Diagnosis:
- Concentrated Stool Ova and Parasites— viewed under modified acid fast or fluorescence microscopy (labs can submit photos to the CDC for “telediagnosis”)
Treatment:
- TMP-SMX DS one tab po bid x7-10 days
- No effective alternate for failed treatment or sulfa allergy
- Most will recover without treatment but S/S can persist for weeks to months
Bottom Line:
Consider Cyclospora as a cause of prolonged diarrheal illness, treat with TMP-SMX.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
www. cdc. gov/parasites/cyclosporiasis/outbreaks/investigations-2013.html
www.cdc.gov/parasites/cyclosporiasis
Category: Critical Care
Posted: 7/30/2013 by Haney Mallemat, MD
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Elderly patient who originally presented for severe pancreatitis now intubated for worsening hypoxemia. CXR is shown below, what's the diagnosis?
Acute Respiratory Distress Syndrome (ARDS)
Acute Respiratory Distress Syndrome (ARDS) is defined as hypoxemia secondary to increased pulmonary capillary permeability and non-hydrostatic (i.e., non-cardiogenic) leakage of fluid into the interstitial lung tissue and alveoli. Lung radiographs diffuse and symmetric infiltrates (see below)
ARDS may occur secondary to a primary (or pulmonary) insult (e.g., aspiration, pneumonia) or secondary (or systemic) insult (e.g., pancreatitis, trauma, etc.)
The newest classification system for ARDS no longer includes the previously known category of acute lung injury; there are three categories of ARDS determined by the PaO2 (on ABG) divided by administered FiO2 (as a fraction of 100%):
A number of interventions have been demonstrated to improve outcomes for patients with ARDS:
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Category: Visual Diagnosis
Posted: 7/29/2013 by Haney Mallemat, MD
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13 year-old female fell on right shoulder while catching a rebound during a basketball game. The patient is holding her arm in adduction and has exquisite scapular tenderness on exam. What’s the next step in management? …oh, and what’s the diagnosis?
Answer: Non-displaced scapular fracture
Treatment:
Bonus Pearls: #foam4yrdome
This installment of #foam4yrdome will focus on freeemergencytalks.net which is quite possibly the best Critical Care and Emergency Medicine FREE lecture website.
The website was founded and is maintained by Professor Joe Lex (@joelex5); the website hosts hundreds of free talks.
Check out talks from all the major conferences featuring the best speakers in Emergency and Critical care medicine today.
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Category: Cardiology
Posted: 7/29/2013 by Semhar Tewelde, MD
(Updated: 7/29/2025)
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Tight glycemic control (HbA1C<7%) has previously been recommended in CAD based on data from the United Kingdom Prospective Diabetes Study (UKPDS)
A recent study (JACC) evaluated the relationship between glycemic control, cardiovascular disease (CVD) risk, and all-cause mortality
Patients with a mean HbA1C 7-7.4% were compared to those with mean HbA1C <6%; tight glycemic control had a 68% increased risk of CVD hospitalization
Lenient HbA1C>8.5% also had significantly higher risk
CVD risk and all-cause mortality is greater with both aggressive and lax glycemic control and the optimal reference range may lie between 7-7.4%
Nichols G, Joshua-Gotlib S, Parasuraman. Glycemic Control and Risk of Cardiovascular Disease Hospitalization and All-Cause Mortality. JACC. 62: 2; 121-127. |
Category: Orthopedics
Keywords: Hand nodules, contactures (PubMed Search)
Posted: 7/28/2013 by Brian Corwell, MD
(Updated: 7/29/2025)
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Dupuytren disease is a nodular thickening and resultant contraction of the palmer fascia.
Increased in those of Northern European dissent.
One or more painful nodules located near the distal palmer crease.
Over time may result in flexion at the MCP joint.
Most commonly affects the ring finger.
Sensation is normal.
Over time affects ADLs
Tx: night splints and surgery
Category: Pediatrics
Keywords: sedation, pain management (PubMed Search)
Posted: 7/3/2013 by Mimi Lu, MD
(Updated: 7/26/2013)
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Cringing at the thought of sewing up another screaming 2 year old?
Consider intranasal fentanyl.
Who: Young, otherwise healthy pediatric patients undergoing minor procedures (laceration repair, fracture reduction/splinting, etc...)
What: Fentanyl (2mcg/kg)
When: 5 minutes pre-procedure
Where: Intranasal
Why: More effective than PO, less invasive than IV while being equally efficacious.
How: Use an atomizer, splitting the dose between each nostril.
Category: International EM
Posted: 7/24/2013 by Walid Hammad, MD, MBChB
Click here to contact Walid Hammad, MD, MBChB
General Information:
· Caused by the ameboflagellate Naegleria Fowleri
· Case fatality rate is estimated at 98%
· Commonly found in warm freshwater environments such as hot springs, lakes, natural mineral water, especially during hot summer months
· Incubation period 2-15 days
Relevance to the EM Physician:
· Clinical presentation: resembling bacterial meningitis/encephalitis
· Final diagnostic confirmation is not achieved until trophozoites are isolated and identified from CSF or brain tissue
· Treatment: Amphotericin B
Bottom Line:
· History of travel to tropical areas or exposure to warm or under-chlorinated water during summer time should raise the suspicion for Naegleria Fowleri. The amoeba is not sensitive to the standard meningitis/encephalitis therapy and amphotericin B must be added to the treatment regimen.
University of Maryland Section of Global Emergency Health
Su MY, Lee MS, Shyu LY, Lin WC, Hsiao PC, Wang CP, Ji DD, Chen KM, Lai SC. A fatal case of Naegleria fowleri meningoencephalitis in Taiwan. Korean J Parasitol. 2013 Apr
Naegleria fowleri, Kelly Fero , ParaSite, February 2010 retrieved from http://www.stanford.edu/group/parasites/ParaSites2010/Katherine_Fero/FeroNaegleriafowleri.htm
Category: Critical Care
Posted: 7/23/2013 by Mike Winters, MBA, MD
(Updated: 7/29/2025)
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HIV, ART, and the ICU
Tan DHS, Walmsley SL. Management of persons infected with human immunodeficiency virus requiring admission to the intensive care unit. Crit Care Clin 2013; 29:603-20.
Category: Visual Diagnosis
Posted: 7/22/2013 by Haney Mallemat, MD
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A 3 year-old boy was attacked by a dog and sustained the injury below. Name one injury that should be strongly considered (Hint: there are several)
Important injuries to consider (image below):
This patient had only a corneal abrasion on fluorescein exam.
Bonus Pearl: #Foam4yrDome
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Category: Cardiology
Posted: 7/21/2013 by Semhar Tewelde, MD
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Westfall M, Krantz S, Mullin C, Kaufman C. Mechanical versus manual chest compressions in out-of-hospital cardiac arrest. Crit Care Med 2013 Jul; 41(7):1782-9
Category: Endocrine
Keywords: Hypothyroidism, treatment (PubMed Search)
Posted: 7/20/2013 by Michael Bond, MD
(Updated: 7/29/2025)
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Treatment of Severe Hypothyroidism
We do not see patient's with severe hypothyroidism often, but it is important that they be treated aggressively. Some treatment pearls are
Category: Pediatrics
Keywords: lactate, sepsis, pediatric (PubMed Search)
Posted: 7/19/2013 by Jenny Guyther, MD
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Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED. Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets. Serum lactate had a negative correlation with BUN, serum bicarbinate and age. Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn. This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures. Only previously healthy children were included.
The study is limited by its small sample size and overall low lactate levels. Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis. The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications. There were no serial measurements.
Bottom line: Consider measuring serum lacate in your pediatric patient with suspected sepsis. Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.
Reed et al. Serum Lactate as a Screening Tool and Predictor of Outcome in Pediatric Patients Presenting to the Emergency Department With Suspected Infection. Pediatric Emergency Care. 2013; Vol 29: 787-791.
Category: Toxicology
Keywords: lsd, alpha-methyltryptamine, AMT (PubMed Search)
Posted: 7/18/2013 by Fermin Barrueto
(Updated: 7/29/2025)
Click here to contact Fermin Barrueto
The internet has become a wealth of information and some books have now gained internet noteriety. A chemist and author of the book - TIKHAL: Tryptamines I Have Known and Loved is an excellent example.
Tryptamines include drugs like LSD and alpha-methyltryptamine (AMT). Vivid visual hallucinations and serotonin agonism, these drugs were glamorized by this author. He would synthesize a tryptamine and then "taste it". Take a look at the link below where he first describes the biochemical synthesis he performed then describes his dose response effect when he tried the drug.
If you run into a drug or slang term in the ED you are not familiar with, the website www.erowid.org will likely have the translation.
http://www.erowid.org/library/books_online/tihkal/tihkal48.shtml
Category: Critical Care
Posted: 7/16/2013 by Haney Mallemat, MD
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COPD treatment guidelines (e.g., GOLD) recommend 10-14 days of steroid therapy following a COPD exacerbation to prevent recurrences; the supporting data is weak.
A recent noninferiority trial (here) compared patients with a severe COPD exacerbation who received either a 5-day course (n=156) or 14-day course (n=155) of prednisone 40mg.
The results were:
What you need to know:
Bottom-line: 5 days of prednisone may be as effective as 14-days for COPD exacerbations.
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Category: Visual Diagnosis
Posted: 7/15/2013 by Haney Mallemat, MD
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46 year-old female presents with a headache. The following is seen on visual inspection of the eye. What's the diagnosis?
Pterygium
Six-word Summary: Cornea, benign, UV, supportive, surgery, and sunglasses
Bonus Pearl
As a new academic year begins, I will be sharing some amazing free educational online resources/links. These free materials are known as Free Open Access Meducation (or FOAMed) and for those familiar with FOAMed this is an emerging educational revolution. If you don't know what FOAMed is, read about it here and then read this. Updates will happen every Monday and will be known as #FOAM4yourDome
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Category: Cardiology
Posted: 7/14/2013 by Semhar Tewelde, MD
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Radiation therapy is frequently utilized in the management of numerous thoracic malignancies
Cardiovascular disease is now the leading cause of nonmalignancy death in radiation-treated cancer survivors
The spectrum of radiation-induced cardiac disease is broad
The relative risk of CAD, CHF, pericardial/valvular disease, and conduction abnormalities is particularly increased
Early identification of potential cardiac complications w/cardiac MR and echocardiography provides an opportunity for regular assessment and potentially improved long term mortality
Jaworksi C, Mariani J, et al. Cardiac Complication of Thoracic Irradiation. JACC Vol 61, No 23, 2013.
Category: Orthopedics
Keywords: ulnar nerve, entrapment (PubMed Search)
Posted: 7/13/2013 by Brian Corwell, MD
(Updated: 7/29/2025)
Click here to contact Brian Corwell, MD
Tests for distal ulnar nerve entrapment
Ask patient to hold a piece of paper between the thumb and the index finger
Normally this is a fairly simple task.
With an unlar nerve palsy, the patient will substitute with the FPL (flexor pollicis longus - median nerve innervation). This causes flexion of the thumb in order to maintain the grip since the adductor pollicis cannot be used. This causes thumb flexion rather than extension.
http://www.mims.com/resources/drugs/common/CP0042.gif
http://www.youtube.com/watch?v=yJTIhm1VfSI
Category: Pediatrics
Posted: 7/12/2013 by Rose Chasm, MD
(Updated: 7/29/2025)
Click here to contact Rose Chasm, MD
Risk stratisfication score introducted by Maden Samuel in 2002.
The Pediatric Appendicitis Score had a sensitivity of 1, speciificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99
Signs:
Symptoms:
Laboratory Values:
Scores of 4 or less are least likely to have acute appendicitis, while scores of 8 or more are most likely.
Pediatric Appendicits Score. Samuel, M. J Pedia Surg.37:877-888. 2002.
Category: Toxicology
Keywords: salicylate, aspirin, toxicity, sodium bicarbonate (PubMed Search)
Posted: 7/10/2013 by Bryan Hayes, PharmD
(Updated: 7/11/2013)
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In June 2013 the American College of Medical Toxicology (ACMT) released a Guidance Document on the Management Priorities in Salicylate Toxicity. Here are some key highlights:
The full document can be accessed here.
The Poison Review blog by Dr. Leon Gussow discusses the guidance document here.
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Category: Visual Diagnosis
Posted: 7/8/2013 by Haney Mallemat, MD
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3 year-old male develops rash 5 days after starting amoxicillin for acute otitis media. What's the diagnosis?
Erythema Multiforme
Erythema multiforme (EM) is a pruritic, erythematous, and blanchable maculopapular rash; it is serpiginous or targetoid in shape, with central clearing or pallor.
EM is generally symmetric, appearing on hands, feet, groin, and extensor aspects of legs and forearms.
It is classically associated with upper respiratory infections, medications, connective tissue diseases, and malignancies.
Treatment includes:
Habif, et al, Skin Disease, 3rd Ed. 2011
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