Category: Orthopedics
Keywords: Foot, instability, dislocation (PubMed Search)
Posted: 8/24/2019 by Brian Corwell, MD
(Updated: 11/26/2024)
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Tarsometatarsal fracture-dislocation
The Lisfranc ligament is critical for stabilization of the midfoot arch and the 2nd MT
Injuries can range from mild (sprains) to severe (gross dislocation)
Injury may be purely ligamentous injuries or a fracture-dislocations
Difficult diagnosis to make
https://www.aafp.org/afp/1998/0701/afp19980701p118-f4.jpg
Mechanisms: MVAs, fall from height or athletic injuries
Common athletic mechanism: Axial load to a hyperplantar flexed forefoot
Injury severity is often underestimated
Severe pain and inability to weight bear
Plantar bruising and bruising throughout midfoot
No specific tests as exam is limited due to pain
Midfoot stress tests
-Often positive but unlikely to be allowed by patient due to pain
https://www.youtube.com/watch?v=v8SGVwz2RHs
Midfoot instability test
Grasp metatarsal heads and apply dorsal force to forefoot.
Other hand palpates the TMT joints and feels for dorsal subluxation
Category: Pediatrics
Keywords: NV exam, neurovascular, upper extremity injury, orthopedics, hand, fracture, supracondylar (PubMed Search)
Posted: 5/24/2019 by Mimi Lu, MD
(Updated: 8/23/2019)
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Category: Toxicology
Keywords: vaping, THC, e-cigarette, pulmonary injury (PubMed Search)
Posted: 8/22/2019 by Hong Kim, MD
Click here to contact Hong Kim, MD
Center for Disease Control and Prevention (CDC) recently issued alerts regarding cases of pulmonary illnesses that may be linked to "vaping" (in 15 states with 149 possible cases). These cases are still under investigation but all cases reported vaping weeks/months prior to hospitalization.
Most cases involve young adults who have been using THC-containing products
Common complaints included
Imaging studies:
Clinical course
What to do:
https://www.cdc.gov/media/releases/2019/s0821-cdc-fda-states-e-cigarettes.html
https://emergency.cdc.gov/newsletters/coca/081619.htm
Category: Critical Care
Keywords: Torsades de pointes, QT prolongation, antibiotics (PubMed Search)
Posted: 8/20/2019 by Quincy Tran, MD, PhD
(Updated: 11/26/2024)
Click here to contact Quincy Tran, MD, PhD
A new study confirmed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study found new association between amikacin and Torsades de pointes/QT prolongation.
Methods
The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).
Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS
Results
FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).
Macrolides ROR 14 (95% CI 11.8-17.38)
Linezolid ROR 12 (95% CI 8.5-18)
Amikacin ROR 11.8 (5.57-24.97)
Imipenem-cilastatin ROR 6.6 (3.13-13.9)
Fluoroquinolones ROR 5.68 (95% CI 4.78-6.76)
Limitations:
These adverse events are voluntary reports
There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.
Teng C, Walter EA, Gaspar DKS, Obodozie-Ofoegbu OO, Frei CR. Torsades de pointes and QT prolongation Associations with Antibiotics: A Pharmacovigilance Study of the FDA Adverse Event Reporting System. Int J Med Sci. 2019 Jun 10;16(7):1018-1022.
Category: Pediatrics
Keywords: GSW, mass shooting, bleeding (PubMed Search)
Posted: 8/16/2019 by Jenny Guyther, MD
(Updated: 11/26/2024)
Click here to contact Jenny Guyther, MD
Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population. The Pediatric Trauma Society supports the use of tourniquets in severe extremity trauma. The Combat Application Tourniquet (CAT) that is commonly used in adults has not been prospectively tested in children. This study used 60 children ages 6 through 16 years and applied a CAT to the upper arm and thigh while monitoring the peripheral pulse pressure by Doppler. The CAT was successful in occluding arterial blood flow in all of the upper extremities and in 93% of the lower extremities.
Bottom line: The combat application tourniquet can stop arterial bleeding in the school aged child.
Harcke et al. Adult tourniquet use for school-age emergencies. Pediatrics. 2109; 143 (6) e:20183447.
Category: Toxicology
Keywords: drug-induced liver injury (PubMed Search)
Posted: 8/16/2019 by Hong Kim, MD
(Updated: 11/26/2024)
Click here to contact Hong Kim, MD
Direct hepatotoxicity from a drug is predictable and dose-dependent.
Most commonly implicated agents include:
On the contrary, idiosyncratic prescription drug-induce liver injury is rare, unpredictable and not related to dose.
Most commonly implicated agents are:
Bottom line:
Category: Critical Care
Posted: 8/14/2019 by Caleb Chan, MD
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The Kidney Transplant Patient in Your ED
Darmon M, Canet E, Ostermann M. Ten tips to manage renal transplant recipients. Intensive Care Med. 2019;45(3):380-383.
Category: Orthopedics
Keywords: Anterior knee pain (PubMed Search)
Posted: 8/10/2019 by Brian Corwell, MD
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Plica Syndrome
-A painful impairment of knee function resulting from thickened and inflamed synovial folds
Plicae are embryologic remnant inward folds of the synovial lining present in most knees
Most plica are asymptomatic
A pathological synovial plica can become inelastic, thickened and fibrotic. It may bowstring across the femoral trochlea at 70 to 100 degrees of knee flexion
Can be a cause of anterior knee pain/mechanical Sxs
Medial patellar plica most commonly involved
Hx: Snapping sensation, pain w/ sitting or repetitive activity
Anterior knee pain, clicking, clunking, and a popping sensation on knee loading activity such as squatting/stairs or with prolonged sitting
Many present with history of blunt trauma to the anterior knee
PE: A taut band of tissue that reproduces concordant pain with palpation
Tenderness in the medial parapatellar region
Painful, palpable medial parapatellar cord
-This can be rolled and popped beneath the examiners finger
The knee may be tender to the touch, swollen, and stiff
Can be difficult to distinguish from other intra-articular conditions such as meniscal tears, articular cartilage injuries, or osteochondral lesions,
The examiner can then palpate for the plica by rolling one finger over the plica fold, which is located around the joint lines in anterior knee compartment
https://www.ortho.com.sg/wp-content/uploads/2018/04/medial-plica-syndrome-31-e1478966479644.jpg
Lee et al., 2017. Surg J. Synovial Plica Syndrome of the Knee: A Commonly Overlooked Cause of Anterior Knee Pain.
Category: Critical Care
Keywords: mechanical ventilation, respiratory failure, obstructive lung disease, asthma exacerbation, COPD (PubMed Search)
Posted: 8/6/2019 by Kami Windsor, MD
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Managing the intubated patient with exacerbation of severe obstructive lung disease, especially asthma, can be very challenging as it carries higher risks of barotrauma due to higher pulmonary pressures and circulatory collapse due to auto-PEEP and decreased venous return. When measures such as medical therapy and noninvasive positive-pressure ventilation fail to prevent intubation, here are some tips to help:
1. Utilize a volume control ventilation mode to ensure a set tidal volume delivery / minute ventilation, as pressure-targeted modes will be more difficult due to the high pulmonary pressures in acute obstructive lung disease.
2. Set a low RR in order to allow for full exhalation, avoiding air-trapping / breath-stacking and circulatory collapse due to decreased venous return. This may require deep sedation and potentially paralysis.
3. Increase your inspiratory flow by shortening your inspiratory time (thereby increasing your time for exhalation.
4. Monitor for auto-PEEP:
5. Peak inspiratory pressures will be high -- what is more important is the plateau pressure, measured by performing an inspiratory hold at the end of inspiration. Provided your plateau pressure remains <30, you don't need to worry as much about the peak pressure alarms.
6. If your patient acutely decompensates in terms of hemodynamics and oxygenation -- first attempt to decompress their likely auto-PEEPed lungs by popping them off the ventilator and manually press on their chest to assist with exhalation of stacked breaths allowing venous return to the heart.
Category: Pharmacology & Therapeutics
Keywords: DKA, SGLT2 Inhibitors (PubMed Search)
Posted: 8/3/2019 by Wesley Oliver
(Updated: 11/26/2024)
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The American Diabetes Association requires a plasma glucose concentration greater than 250 mg/dL to diagnose diabetic ketoacidosis (DKA). However, with the new diabetic agents this is not always the case. With the introduction of SGLT2 inhibitors (canagliflozin [Invokana], dapagliflozin [Farxiga], empagliflozin [Jardiance]) there have been reported cases of DKA and patients being euglycemic.
Take Home Point
Patients with a low/normal blood glucose can still have DKA. Especially if they are taking newer medications, such as the SGLT2 inhibitors.
AE Kitabchi, GE Umpierrez, JM Miles, JN Fisher. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009;32:1335-1343.
U.S Food and Drug Administration. FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood. https://www.fda.gov/media/92185/download. Accessed August 3, 2019.
Category: Toxicology
Keywords: hematologic toxicity, copperhead envenomation, bleeding (PubMed Search)
Posted: 8/1/2019 by Hong Kim, MD
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Hematologic toxicity (coagulopathy/bleeding) can occur with pit viper envenomation. Copperhead is the most commonly implicated pit viper envenomation in the U.S. However, the prevalence of hematologic toxicity from copperhead envenomation is variable, possibly due to regional variation in venom potency and species misidentification.
An observation study was performing using multi-center (Virginia Commonweath university, University of Virginia Medical Center and Eastern Virginia Medical medical center) electronic hospital/medical records (Jan 1, 2006 to Dec 31, 2016) of suspected copperhead bites. Authors state that copperhead snakes are "nearly exclusively endemic" to the VCU and UVA medical center region.
Results:
388 patients were identified but 244 met inclusion/exclusion criteria.
Hematologic toxicity: 14%
Conclusion
In a small sample of copperhead envenomation in Virginia, “subtle” hematologic abnormalities were observed but clinically significant hematologic toxicity was not observed (i.e. bleeding)
Wills BK et al. Prevalence of hematologic toxicity from copperhead envenomation: an observational study. Clin Toxicol. 2019. DOI: 10.1080/15563650.2019.1644346
Category: Critical Care
Keywords: Mechanical Ventilation, Intubation, Extubation, RSBI (PubMed Search)
Posted: 7/28/2019 by Mark Sutherland, MD
(Updated: 7/30/2019)
Click here to contact Mark Sutherland, MD
With increasing critical care boarding and the opioid crisis leading to more intubations for overdose, extubation - which was once a very rare event in the ED - is taking place downstairs more often. Prolonged mechanical ventilation is associated with a ton of complications, so it's important for the ED physician to be comfortable assessing extubation readiness. There is no single accepted set of criteria, but most commonly used are some variant of the following:
If the above criteria are met, two additional tests are frequently considered:
And don't forget to consider extubating high risk patients directly to BiPAP or HFNC!
Bottom Line: For conditions requiring intubation where significant clinical improvement may be expected while in the ED (e.g. overdose, flash pulmonary edema, etc), be vigilant about, and have a system for, assessing readiness for extubation.
1. Souter MJ, Manno EM. Ventilatory management and extubation criteria of the neurological/neurosurgical patient. The Neurohospitalist. 2013;3(1):39-45. doi:10.1177/1941874412463944
2. Thille AW, Richard J-CM, Brochard L. Concise Clinical Review The Decision to Extubate in the Intensive Care Unit. doi:10.1164/rccm.201208-1523CI
3. Ouellette DR, Patel S, Girard TD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest. 2017;151(1):166-180. doi:10.1016/j.chest.2016.10.036
Category: Orthopedics
Keywords: Bone stress reaction, fracture, overuse injury (PubMed Search)
Posted: 7/27/2019 by Brian Corwell, MD
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Bone stress injury (BSI) in Adolescents
A BSI occurs along a pathology continuum that begins with a stress reaction and may progress all the way to a stress fracture.
Difficult to diagnose clinically.
Identifying risk factors as part of the history is very important.
Common sites for BSI are most frequently in the lower extremity and include the tibia, fibula, tarsals and metatarsals, calcaneus, and femur.
When considering this in an ED setting, image the involved area and if there is no fracture, advise discontinuing the activity until time of PCP/sports medicine follow up. For those with rest pain, pain with minimal weight bearing or in whom a fracture was suspected but not present, consider providing a walking boot or crutches.
BSIs occur more frequently in young athletes than in adults.
Almost 50% of BSIs occur in those younger than 20 years of age
Primary care and sports medicine providers are seeing more of these patients due to many factors.
Year-round training, sports specialization at younger ages and increase in training intensity/duration contribute to the increase incidence in adolescents.
Not surprisingly, participation in organized sports as an adolescent is a known risk factor.
Just as a change in sporting level from high school to college is a known risk factor for BSI, young “gifted” athletes who are promoted to competing with the varsity team may be at similar risk.
Shin pain lasting more than 4 weeks may represent a unique subset of MSK pain complaints increasing risk of BSI.
A prior history of BSI is a strong predictor of future BSI.
Inquire about night pain, pain with ambulation, and pain affecting performance.
Athletes with BSIs have a significantly lower BMI than controls (<21.0 kg/m2).
Athletes with BSIs sleep significantly less than controls.
Athletes with BSIs have significantly lower dairy intake than controls.
Inquire about components of the female athlete triad (low energy availability, menstrual dysfunction and low bone mineral density)
Nussbaum et al., 2019. Identifying Factors That Contribute to Adolescent Bony Stress Injury in Secondary School Athletes: A Comparative Analysis With a Healthy Athletic Control Group. Sports Health.
Category: Critical Care
Keywords: empyema (PubMed Search)
Posted: 7/23/2019 by Robert Brown, MD
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The incidence of empyema as a complication of pneumonia has been increasing since the 1990's and source control requires removing the pus from the chest as soon as possible, but how large should the drain be? The American Association for Thoracic Surgery (AATS) released the most recent guidelines for identifying and managing empyema in June 2017 and at the time had no certain evidence to guide the choice of large-bore vs small-bore catheters. Most studies to guide us are flawed (not randomized), but no recently published randomized studies exist to provide a definitive answer.
Bottom line: a small-bore pigtail catheter is a reasonable choice to drain empyema and flushing it every 6 hours has been shown to prevent clogging.
Category: Pediatrics
Keywords: Keppra, Dilantin, status epilepticus (PubMed Search)
Posted: 7/20/2019 by Jenny Guyther, MD
(Updated: 11/26/2024)
Click here to contact Jenny Guyther, MD
-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients
-The guidelines for second line agents are based on observational studies and expert opinion
-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias
- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.
Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children. There was no difference between efficacy or safety outcomes between the two groups.
Phenytoin is the second line treatment for pediatric convulsive status epilepticus after failure of first-line benzodiazepines but is only effective in approximately 60% of cases. This study was an open label, multicenter, randomized control trial conducted in Australia and New Zealand with children aged 3 months to 16 years with status epilepticus who had failed first-line benzodiazepine treatment. Patients were randomly assigned to to receive 20 mg/kg of phenytoin or 40 mg/kg of levetiracetam with the primary outcome being seizure resolution at 5 minutes
There were 233 children included in the study and seizure activity stopped in 60% of the patients in the phenytoin group and 50% of the patients in the levetiracetam which was not a statistically significant difference.
Dalziel at al. Levetiracetam versus phenytoin for second line treatment of convulsive status epilepticus in children; an open label, multicenter, randomized control trial. The Lancet. Published online April 17, 2019.
Category: Toxicology
Keywords: naloxone, pulmonary edema, aspiration, overdose (PubMed Search)
Posted: 7/19/2019 by Hong Kim, MD
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Pulmonary complications - aspiration, pulmonary edema, etc. are frequently reported in both heroin intoxication and in reversal of opioid overdose with naloxone.
Suspected opioid overdose victims (N=1831) who received naloxone from EMS providers were studied retrospectively. Pulmonary complications were defined as pulmonary edema, aspiration pneumonia and aspiration pneumonitis.
Results
Conclusion
Higher out of hospital naloxone administration is associated with increased odds of developing pulmonary complications
Category: Critical Care
Posted: 7/16/2019 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
Click here to contact Mike Winters, MBA, MD
POCUS in the Critically Ill Pregnant Patient
Blanco P, Abdo-Cuza A. Point-of-care ultrasound in the critically ill pregnant or postpartum patient: what every intensivist should know. Intensive Care Med. 2019; epub ahead of print.
Category: Orthopedics
Keywords: shoulder, overhead athlete (PubMed Search)
Posted: 7/13/2019 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Long head of biceps tendon (LHBT) Testing
Overhead activities can cause anterior shoulder pain due to LHBT instability. A review of 3 physical exam maneuvers for bedside evaluation.
Speed test
Shoulder at 90° of flexion with arm fully supinated and elbow extended
Patient attempts to fwd. elevate arm against a downward force
Positive test is pain localized to bicipital groove.
Sensitivity 54% and specificity 81% for biceps pathology
Yergason test
Elbow at 90° of flexion with arm fully pronated and held against thoracic wall. Examiner grips patient’s hand and resists attempts at supination.
Positive test is pain localized to bicipital groove or LHBT subluxation.
Sensitivity 41% and specificity 79% for biceps pathology
Upper Cut test
Shoulder neutral with Elbow at 90° of flexion, arm fully supinated and hand in a fist. Patient moves hand toward chin in an uppercut motion like a boxer. Examiner places hand over patient’s fist and resists upward movement.
Positive test is pain localized to bicipital groove or LHBT subluxation.
Sensitivity 73%, specificity 78%, +LR 3.38 for biceps pathology
Comprehensive Examination of the Shoulder. Cotter et al., 2018. Sports Health
Category: Toxicology
Keywords: push dose pressor, phenylephrine, epinephrine, human error (PubMed Search)
Posted: 7/11/2019 by Hong Kim, MD
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“Push dose pressors” – administration of small doses of vasopressors in the emergency room has become a common practice. A recently published study investigated the incidence of human error and adverse hemodynamic events.
Push dose pressors were defined as:
Adverse hemodynamic event was defined as:
249 out of 1522 patients were identified and analyzed from Jan 2010 to November 2017
Adverse event
Errors
Conclusion
Cole JB et al. human errors and adverse hemodynamic events related to "push dose pressors" in the emergency department. J Med Toxicol. 2019 Jul 3. doi: 10.1007/s13181-019-00716-z. [Epub ahead of print]
Category: Neurology
Keywords: secondary headache, features, risk factors, red flags (PubMed Search)
Posted: 7/10/2019 by WanTsu Wendy Chang, MD
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