UMEM Educational Pearls

Title: Septic Arthritis in Children

Category: Orthopedics

Keywords: Hip, pediatrics, arthritis (PubMed Search)

Posted: 4/22/2017 by Brian Corwell, MD (Updated: 11/27/2024)
Click here to contact Brian Corwell, MD

Septic Arthritis in Children

Classic presentation: Pain, fever (may not always be present)

Limited range of motion of joint or refusal to bear weight,

 Joint swelling (difficult to visualize in hip or shoulder),

Limb held in position that allows greatest capsular volume (elbow held in 30° flexion for example)

Diagnostic testing may include diagnostic markers (ESR, CRP) or imaging (US/MRI)

Most common organisms: Staph and Strep, Neisseria (adolescents), HACEK organisms, consider gram negatives in immunocompromised children

DDX: Transient synovitis, osteonercrosis or osteomyelitis, Psoas abscess, acute leukemia, Lyme disease

A common ED presentation is the child with the painful limp

               35% of all cases of septic arthritis

>50% of cases occur in children younger than 2yo

Hip held in flexion, Abduction, external rotation

Fever and inflammatory markers are more sensitive than WBC count and refusal to bear weight

Kocher criteria:

1)     Refusal to weight bear on affected side

2)     Sed rate greater than 40mm/hr

3)     Fever (>38.5°C

4)     WBC count of >12,000 mm3

 

IF
                 - 4/4 criteria are met, there is a 99.6% chance of septic arthritis; 
                 - when 3/4 criteria are met, there is a 93% chance of septic arthritis; 
                 - when 2/4 criteria are met, there is a 40% chance of septic arthritis; 
                 - when 1/4 criteria are met, there is a 3% chance of septic arthritis; 

 

CRP can also be incorporated into a diagnostic algorithm

CRP>2.0 (mg/dl) in a child who refuses to bear weight yields a 74% probability of septic arthritis

 

 

Show References



Predictive factors of asthma development in patients diagnosed with bronchiolitis include:

- Male sex (OR 1.3)

- Family history of asthma (OR 1.6)

- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)

- More than 2 episodes of bronchiolitis (OR 2.4)

- Allergies (OR 1.6)

Show Additional Information

Show References



Title: Drug induced lactic acidosis.

Category: Toxicology

Keywords: lactic acidosis (PubMed Search)

Posted: 4/20/2017 by Hong Kim, MD (Updated: 11/27/2024)
Click here to contact Hong Kim, MD

Lactic acids are often elevated in critical care patients (e.g. septic shock). It can be also elevated in setting of drug overdose or less frequently in therapeutic use due to interference of oxidative phosphorylation. Some of the agents include:

 

  • Carbon monoxide
  • Cyanide
  • Propofol
  • Metformin
  • Propylene glycol
  • Salicylates
  • Beta-2 agonists
  • Thiamine deficiency/alcoholic ketoacidosis
  • Ethylene glycol/toxic alcohols
  • Nucleoside reverse-transcriptase inhibitors

 

Bottom line:

  • Although elevated lactic acid levels are often associated with underlying medical conditions, it is important to recognize drug-induced etiologies of lactic acidosis. 

Show References



Title: Reduced Shigella Susceptibility to Ciprofloxacin

Category: International EM

Keywords: CDC, Shigella, antibiotic, health advisory (PubMed Search)

Posted: 4/19/2017 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 11/27/2024)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

The Centers for Disease Control and Prevention (CDC) just released an official health advisory through the Health Alert Network entitled: “CDC Recommendations for Diagnosing and Managing Shigella Strains with Possible Reduced Susceptibility to Ciprofloxacin”

 

Concerning treatment, one key point is:

Do not routinely prescribe antibiotic therapy for Shigella infection. Instead, reserve antibiotic therapy for patients for whom it is clinically indicated or when public health officials advise treatment in an outbreak setting.

o   Shigellosis is generally a self-limited infection lasting 5-7 days.

o   Unnecessary treatment with antibiotics promotes resistance.

o   Treatment can shorten the duration of some illnesses, though typically only by 1-2 days

Show Additional Information

Show References



Title: Use Ultrasound to confirm CVC placement

Category: Critical Care

Keywords: Central venous catheter, ultrasound (PubMed Search)

Posted: 4/18/2017 by Kami Windsor, MD (Updated: 11/27/2024)
Click here to contact Kami Windsor, MD

Save time by using bedside ultrasound to confirm above-the-diaphragm central venous catheter (CVC) placement rather than waiting for chest x-ray confirmation:

1. Perform rapid push of saline (it doesn’t have to be agitated) through CVC while cardiac probe is placed with right atrium in view. Immediate visualization of bubbles (or “atrial swirl”) essentially confirms correct placement.

2. Perform the usual search for ipsilateral lung-sliding and the waves-on-the-beach to rule out procedural pneumothorax.

 

 

Show Additional Information

Show References



Question

A 50 years old male with a history of CHF, presenting to the ED with progressively worsening shortness of breath. POCUS was performed. The picture shows the left lower part of the chest. What is the diagnosis?

Show Answer

Show References



Title: Does spinal manipulation work for back pain

Category: Orthopedics

Keywords: back pain, manipulation (PubMed Search)

Posted: 4/15/2017 by Michael Bond, MD (Updated: 11/27/2024)
Click here to contact Michael Bond, MD

We all wish there was a great treatment regimen for our patients with back pain. However, most studies have shown that it really does not matter what you do, as most patients will get better in 6 weeks.

A recent study published in JAMA looked at the role of spinal manipulation to improve pain and function in adults with low back pain. They looked at 26 randomized controlled trails and found that there was modest benefit for spinal manipulation and it was similar to using NSAIDs.

So spinal manipulation may or may not work for some patients. Something to consider along with physical therapy if patients are not getting relief with home remedies.

 

Show References



Title: Does urine concentration effect the diagnosis of urinary tract infection?

Category: Pediatrics

Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)

Posted: 4/14/2017 by Jenny Guyther, MD (Updated: 11/27/2024)
Click here to contact Jenny Guyther, MD

A recent study suggests that using a lower cut off value of white blood cells in dilute urine, may have a higher likelihood of detecting a urinary tract infection in children.

In dilute urine (specific gravity < 1.015), the optimal white blood cell cut off point was 3 WBC/hpf (Positive LR 9.9).  With higher specific gravities, the optimal cut off was 6 WBC/hpf (Positive LR 10).  Positive leukocyte esterase has a high likelihood ratio regardless of the urine concentration. 

 

Show Additional Information



Title: Simplified GCS vs. Full GCS? Which One To Use?

Category: Neurology

Keywords: Glasgow Coma Scale, GCS, motor GCS, mGCS, Simplified Motor Scale, SMS (PubMed Search)

Posted: 4/12/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 
Simplified GCS vs. Full GCS?  Which One To Use?

  • The Glasgow Coma Scale (GCS) is an instrument widely used to assess level of consciousness by EMS.
  • The motor GCS (mGCS) and Simplified Motor Scale (SMS) have been proposed to simplify EMS triage.
  • A number of retrospective studies have compared these scales.
  • Chou et al. performed a systematic review and meta-analysis of 18 studies with a total number of 1.7 million patients to compare the predictive utility of these scales for identification of patients with severe traumatic injury.
  • The total GCS was slightly better than the mGCS or SMS on predicting mortality, neurosurgical intervention, severe traumatic brain injury, and emergent intubation.

Bottom Line:  The motor GCS and Simplified Motor Scale (SMS) have similar discrimination when compared with the total GCS, and may be easier to use.

Show References



Title: Avoiding Hyperoxia in Patients on Mechanical Ventilation

Category: Critical Care

Keywords: Hyperoxia, Mechanical Ventilation (PubMed Search)

Posted: 4/11/2017 by Rory Spiegel, MD (Updated: 11/27/2024)
Click here to contact Rory Spiegel, MD

The deleterious effects of hyperoxia are becoming more and more apparent. But obtaining a blood gas to ensure normoxia in a busy Emergency Department can be burdensome. And while the utilization of a non-invasive pulse oximeter seems ideal, the threshold that best limits the rate of hyperoxia is unclear.

Durlinger et al in a prospective observational study demonstrated that an oxygen saturation 95% or less effectively limited the number of patients with hyperoxia (PaO2 of greater than 100 mm Hg). Conversely when an SpO2 of 100% was maintained, 84% of the patients demonstrated a PaO2 of greater than 100 mm Hg.

 

Show References



Title: Ethnic differences in the EKG patterns of Athletes

Category: Orthopedics

Keywords: EKG, athletes (PubMed Search)

Posted: 4/8/2017 by Brian Corwell, MD (Updated: 11/27/2024)
Click here to contact Brian Corwell, MD

Most of our knowledge of the athlete’s EKG is based on white athletes.

African/Afro-Caribbean athletes are more likely to have an abnormal EKG than white athletes in multiple studies.

Different selective criteria have been developed to minimize classification of benign normal patterns as abnormal.

The 2010 ESC criteria classified 40.4% of black athletes as abnormal versus the Refined criteria which resulted in 11.5% of EKGs classified as abnormal.

This reduction was aided by the recognition that isolated anterior TWI in asymptomatic black athletes is considered a benign finding.

               Note this does NOT apply if the TWI extend to the lateral leads

For example, T-wave inversion (TWI) was present in 23% of African/Afro-Caribbean athletes vs. 3.7% of white athletes (usually in contiguous anterior leads).

Other changes included a higher prevalence of early repolarization, RV hypertrophy, and LA/RA enlargement.

Show References



Title: Sodium bicarbonate shortage Is there an alternate solution?

Category: Toxicology

Keywords: sodium bicarbonate, sodium acetate (PubMed Search)

Posted: 4/6/2017 by Hong Kim, MD (Updated: 11/27/2024)
Click here to contact Hong Kim, MD

FDA announced a shortage of sodium bicarbonate on 3/01/17.  Sodium bicarbonate is frequently used in acid-base disorder as well as in poisoning (cardiac toxicity from Na-channel blockade, e.g. TCA & bupropion, and salicylate poisoning).

 

Acetate is a conjugate base of acetic acid where acetate anion forms acetyl CoA and enters Kreb cycle after IV administration. Final metabolic products of acetate are CO2 and H2O, which are in equilibrium with bicarbonate via carbonic anhydrase activity.

 

Administration of sodium acetate increases the strong ion difference by net increase in cations, as acetate is metabolize, and leads to alkalemia.

 

Adverse events from sodium acetate infusion have been associated with its use as dialysate buffer: myocardial depression, hypotension, hypopnea leading to hypoxemia and hyperpyrexia. However, such adverse events have not been reported in toxicologic application.

 

 

Bottom line:

Sodium acetate can be administered safely in place of sodium bicarbonate if sodium bicarbonate is not available due to shortage.

Sodium acetate dose:

  • Bolus: 1 mEq/kg over 15 – 20 min
  • Infusion: 150 mEq in 1L D5%W @ twice maintenance rate   

Show References



·       In the elderly, falling is the most common mechanism of injury
·       Unavoidable Risk factors: age 85 or older, male, Caucasian, history of falls
·       Other factors: alcohol consumption, polypharmacy
·       Mechanisms of fall:  slipping, tripping, stumbling
·       Physical exam to include: gait, balance, proprioception, vision, strength and cognitive function testing
·       Must consider neglect/abuse, affects 10% of seniors per year
·       Evaluate for anticoagulant use due to increased risk of intracranial injury
·       Use advanced imaging to identify occult hip fractures when clinically suspected and plain radiographs are negative

 

Show References



Title: On your radar: methadone-linezolid drug-drug interaction

Category: Pharmacology & Therapeutics

Keywords: methadone, linezolid, serotonin syndrome, drug interaction (PubMed Search)

Posted: 4/1/2017 by Michelle Hines, PharmD (Updated: 4/3/2017)
Click here to contact Michelle Hines, PharmD

Linezolid is a weak, nonselective monoamine oxidase inhibitor (MAOI). A recent FDA Drug Safety Communication released in March 2016 noted reports of serotonin syndrome associated with certain opioids, particularly fentanyl and methadone. Development of serotonin syndrome after concomitant administration of linezolid with other serotonergic agents has been reported. Due to a potential risk of serotonin syndrome, a patient on chronic methadone should not be started on concomitant linezolid unless they will be monitored.

Show References



Title: Pediatric Sepsis (submitted by Lauren Grandpre, MD)

Category: Pediatrics

Keywords: pediatric, sepsis, infection, infants, children (PubMed Search)

Posted: 3/31/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Sepsis remains the most common cause of death in infants and children worldwide, with pneumonia being the most common cause of pediatric sepsis overall.

Strikingly, however, the mortality rate in pediatric sepsis is significant lower in children (10-20%) as compared to adults (35-50%).

The management of pediatric sepsis has been largely influenced by and extrapolated from studies performed in adults, in part due to difficulties performing clinical trial data in children with critical illness, including sepsis.

A major difference in management of children vs. adults with refractory septic shock with or without refractory hypoxemia from severe respiratory infection is the dramatic survival advantage of children when ECMO rescue therapy is used as compared to adults.

Bottom line: Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!

Show Additional Information

Show References



Title: Pediatric poisoning trends

Category: Toxicology

Keywords: Pediatric poisoning, household , fatalities (PubMed Search)

Posted: 3/30/2017 by Kathy Prybys, MD
Click here to contact Kathy Prybys, MD

Children less than 5 years of age account for the majority of poisoning exposures in the United States. As expected, accessible household items are the most frequently reported exposures and include cosmetics and personal care products, household cleaning substances, medications, and foreign bodies. Opioids are responsible for the highest incidence of hospitalizations followed by benzodiazepines, sulfonylureas, and cardiovascular drugs (beta & calcium channel blockers, and centrally acting antiadrenergic agents).  Rise in buprenorphine use has led to significant increases in pediatric exposures. The most common sources of prescription medications were pills found on the ground, in a purse or bag, night stand, or pillbox. The 2015 American Association of Poison Centers Annual report lists 28 fatalities in children less than 5 year of age. Fatalities occurred from exposures to the following: narcotics (9), disc and button batteries (5), carbon monoxide (4), and other substances (10). 

Highlighted AAPC cases include:

  •  20 month old with ingestion of 20 mm Lithuim disc battery with several previous ED visits for abdominal pain who developed an aorto-esophageal fistula 
  • 13 month old with ingestion of unknown amount of salicylate pills 4 hours earlier with nausea and vomiting
  • 2 year old with ingestion of 5 tablets of 30mg Oxycodone ER seen in ED and discharged 7 hours later. EMS called next morning found patient unresponsive and apneic
  • 11 month old with ingestion of 1 unknown strength methadone pill found unresponsive and apneic at home

Poison prevention education of patients prescribed opioids or other highly toxic "one pill killers"  who have young children in their household is recommended and could be potentially life saving.

 

 

 

 

 

 

 

 

Show References



Title: Falls in the elderly

Category: International EM

Keywords: Falls, elderly (PubMed Search)

Posted: 3/29/2017 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 11/27/2024)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

·       Falls are the second leading cause of accidental or unintentional injury deaths worldwide.

·       Each year an estimated 424 000 individuals die from falls globally of which over 80% are in low- and middle-income countries.

·       Adults older than 65 suffer the greatest number of fatal falls.

·       37.3 million falls that are severe enough to require medical attention, occur each year.

·       Prevention strategies should emphasize education, training, creating safer environments, prioritizing fall-related research and establishing effective policies to reduce risk.

Show References



DSI, Ketamine, and Apnea

  • In recent years, delayed sequence intubation (DSI) with ketamine has been used in select patients to maximize preoxygenation and dinitrogenation. 
  • Importantly, DSI is not well studied. In the only prospective trial of DSI, patients received approximately 1.4 mg/kg of ketamine.
  • Driver, et al. report the abrupt onset of apnea in a patient who received a much lower dose of ketamine (25 mg) for DSI.
  • Take Home Point: If DSI is a part of your preoxygenation armamentarium, apnea can occur even at low doses of ketamine.  Stand at the patient's bedside and be ready to immediately intubate the patient.

Show References



Title: Responsibilities of the local team physician

Category: Orthopedics

Keywords: team doctor, sports medicine (PubMed Search)

Posted: 3/25/2017 by Brian Corwell, MD (Updated: 11/27/2024)
Click here to contact Brian Corwell, MD

Question

Physicians are often called upon to serve as a team physician for a local high school in an official or unofficial capacity.

To aid in preparedness for sport-related emergencies, multiple national organizations have defined institutional best practices.

Knowledge of the following 3 best practice recommendations is important before taking on the role of “Doc covering the game”

     1)The written Emergency Action Plan (EAP) – details the standard of emergency care at the particular venue.

     2)The availability of life saving equipment: AED – where is it, charged and working?

     3)Are the coaches trained in use of the AED and CPR. You can’t be everywhere and often multiple sporting events occur on campus simultaneously. It’s imperative that your first responder (coach or athletic trainer) can perform these tasks until you are able to respond

Please investigate these best practice recommendations before agreeing to serve as the physician for the local high school.

Show Answer



Title: Blistering Distal Dactylics (submitted by Nicole Cimino-Fiallos, MD)

Category: Pediatrics

Keywords: rash, fingertip, bulla, nail disorder (PubMed Search)

Posted: 3/24/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Who- Mostly seen in children, but sometimes in immunocompromised adults
What- Peri-ungal infection of the fingerpad with pus-filled blister with erythematous base
Cause- May result from thumb or finger sucking. Staph and strep are the most common bugs, but it can be caused by MRSA.
DDx- herpetic whitlow, paronychia/felon, friction blister, insect bite
Treatment-
1. De-roof the blister
2. Send drainage for culture
3. Treat for staph and strep- no indication to treat for MRSA initially unless strong suspicion
4. 10 day course of antibiotics recommended
For additional information and image: http://www.medscape.com/viewarticle/718695_3

Show References