Category: Neurology
Keywords: autoimmune, cancer, encephalopathy (PubMed Search)
Posted: 6/28/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Category: Critical Care
Keywords: CPR, ventilation, respiratory rate, PaCO2 (PubMed Search)
Posted: 6/27/2017 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Ventilation During Cardiopulmonary Resuscitation
Chang MP, Idris AH. The past, present, and future of ventilation during cardiopulmonary resuscitation. Curr Opin Crit Care 2017; 23:188-192.
Category: Orthopedics
Keywords: Adhesive Capsulitis (PubMed Search)
Posted: 6/24/2017 by Brian Corwell, MD
(Updated: 11/13/2024)
Click here to contact Brian Corwell, MD
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
Category: Pediatrics
Keywords: overdose, poisoning, veterinary medications (PubMed Search)
Posted: 6/24/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD
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!
Methods involved reviewing regional Poison Control Center data from 1999 thruh 2013, during which 1431 calls regarding exposures of children less than or equal to age 19 or exposed to a veterinary medication.
While the authors concluded that most exposures did not result in major adverse outcomes, 14.1% of exposures resulted in at least minor health effects.
A broader range of more highly toxic medications are increasingly being prescribed for animals, including anti-neoplastic drugs such as cyclophosphamide and chlorambucil.
Treatment of chronic health conditions and pets, such as osteoarthritis, hypothyroidism, or anxiety is also increasingly common.
Tomasi S, Roberts KJ, Stull J, Spiller HA, McKenzie LB. Pediatric Exposures to Veterinary Pharmaceuticals. Pediatrics. 2017;139(3)
Category: Pediatrics
Keywords: Blunt thoracic trauma, pediatric trauma, chest xray (PubMed Search)
Posted: 6/16/2017 by Jenny Guyther, MD
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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.
This was a retrospective review of children aged 0-17 with blunt trauma requiring trauma team activation who had a chest xray preformed. 483 eligible children were included, all of whom were admitted to the hospital. 108 children had their thoracic injury detected on chest xray, 110 on chest CT and 76 on abdominal CT. Pneumothorax, pulmonary contusion and multiple rib fractures were the most commonly found thoracic injuries. All children also had other injuries.
Weerdenburg et al. Predicting Thoracic Injury in Children with Multi-trauma. Pediatric Emergency Care. Epub ahead of print. 2017.
Category: Toxicology
Keywords: drugs of abuse, street name (PubMed Search)
Posted: 6/5/2017 by Hong Kim, MD
(Updated: 6/15/2017)
Click here to contact Hong Kim, MD
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).
Category: Neurology
Keywords: seizure, electroencephalogram, EEG, epilepsy, antiepileptic (PubMed Search)
Posted: 6/14/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
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.
Background:
Follow me on Twitter @EM_NCC
Category: Critical Care
Keywords: ACLS, cardiac arrest, resuscitation, epinephrine (PubMed Search)
Posted: 6/13/2017 by Kami Windsor, MD
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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.
Background Info:
While the ACLS algorithm does recommend initial defibrillation followed by 2 minutes of CPR and repeated shock if the shockable rhythm persists, the 2015 AHA Guidelines update admits that there is insufficient evidence to comment on “optimal timing” of epinephrine administration in these patients.
A 2016 study of 2794 patients across 310 hospitals looked at patients with cardiac arrest with initial shockable rhythm and found that compared to patients who received epinephrine after the second defibrillation attempt, patients who received epinephrine in the first 2 minutes before the 2nd shock had:
The benefit of 2nd-shock-first was maintained when groups were matched using a propensity score accounting for baseline characteristics of the patients, events, and hospitals.
References:
Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Link MS, Berkow LC, Kudenchuk PJ, et al. Circulation. 2015;132(18 Suppl 2):S444-64.
Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis. Andersen LW, Kurth T, Chase M, et al. BMJ. 2016;353:i1577.
Category: Orthopedics
Keywords: Runner, injury (PubMed Search)
Posted: 6/10/2017 by Brian Corwell, MD
(Updated: 11/13/2024)
Click here to contact Brian Corwell, MD
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.
Category: International EM
Keywords: Anticholinergic, Beers Criteria, mushrooms (PubMed Search)
Posted: 6/7/2017 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
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 clinical manifestations of anticholinergic syndrome can be extensive. Additional symptoms can include:
· “Sinus tachycardia
· Decreased bowel sounds
· Functional ileus
· Urinary retention
· Hypertension
· Tremulousness
· Myoclonic jerking
Patients with central anticholinergic syndrome may present with the following:
· Ataxia
· Disorientation
· Short-term memory loss
· Confusion
· Hallucinations (visual, auditory)
· Psychosis
· Agitated delirium
· Seizures (rare)
· Coma
· Respiratory failure
· Cardiovascular collapse”1
1) http://emedicine.medscape.com/article/812644-overview
2) http://www.uptodate.com/contents/anticholinergic-poisoning
Category: Critical Care
Keywords: POCUS, Massive PE (PubMed Search)
Posted: 6/6/2017 by Rory Spiegel, MD
(Updated: 11/13/2024)
Click here to contact Rory Spiegel, MD
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.
1. Dresden S, Mitchell P, Rahimi L, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014;63(1):16-24.
2. Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957.
3. Nazerian P, Volpicelli G, Gigli C, Lamorte A, Grifoni S, Vanni S. Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism. Intern Emerg Med. 2017;
Category: Geriatrics
Keywords: Geriatric, cardiology, symptoms, atypical, angina (PubMed Search)
Posted: 6/4/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
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.
Category: Pharmacology & Therapeutics
Keywords: MSSA, MRSA, bacturia, bacteremia, Staph aureus, Staphlococcus aureus (PubMed Search)
Posted: 6/4/2017 by Jill Logan
(Updated: 11/13/2024)
Click here to contact Jill Logan
Risk factors associated with S. aureus bacturia include:
Al Mohajer M, Darouiche RO. Staphylococcus aureus bacteriura: source, clinical relevance, and management. Curr Infect Dis Rep. 2012;14:601-6.
Category: International EM
Keywords: Tranexamic acid, Post-Partum Hemorrhage (PubMed Search)
Posted: 5/31/2017 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
Post-partum hemorrhage results in approximately 100,000 deaths annually and is the leading cause of maternal death globally.
In a just published study in the Lancet, among approximately 20,000 women from 21 countries enrolled in the WOMAN study, death due to bleeding was significantly reduced in women given tranexamic acid (1.5%) compared to those in the placebo group (1.9%) {RR 0.81, 95% CI 0.65–1.00; p=0.045)}. This was especially true in women given tranexamic acid with 3 hours of giving birth (1·2%) vs in the placebo group (1·7%) {RR 0.69, 95% CI 0.52–0.91; p=0·008)}.
Bottom line:
The authors’ interpretation “Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext
Category: Orthopedics
Keywords: Wrist fracture, splinting (PubMed Search)
Posted: 5/27/2017 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
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)
Category: Toxicology
Keywords: foodborne botulism (PubMed Search)
Posted: 5/25/2017 by Hong Kim, MD
Click here to contact Hong Kim, MD
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.
Bottom line:
Maryland Department of Health and Mental Hygiene
CDC Emergency Operations Center: 770-488-7100
Foodborne botulism is characterized by
Category: Neurology
Keywords: syncope, vasovagal, orthostatic, blood pressure (PubMed Search)
Posted: 5/24/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
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
Posted: 5/23/2017 by Mike Winters, MBA, MD
(Updated: 11/13/2024)
Click here to contact Mike Winters, MBA, MD
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.
Category: Orthopedics
Keywords: Reverse Segond Fracture (PubMed Search)
Posted: 5/21/2017 by Michael Bond, MD
(Updated: 11/13/2024)
Click here to contact Michael Bond, MD
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
Category: Pediatrics
Keywords: Psychiatric, agitation, pediatric (PubMed Search)
Posted: 5/19/2017 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
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.