Category: Orthopedics
Keywords: cervical spine injuries, football (PubMed Search)
Posted: 7/12/2014 by Brian Corwell, MD
(Updated: 11/27/2024)
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Football helmets
A review of head and neck injuries from football from 1959 to 1963 found the rates of intracranial hemorrhage /intracranial death were 2-3X higher than the rates of cervical spine fracture/dislocation or cervical quadriplegia. In contrast, a study of football injuries from 1971 to 1975, revealed a dramatic reversal in rates. Cervical injuries now exceeded the rate of ICH by 2-4X.
A 66% reduction in ICH
A 42% reduction in craniocerebral deaths
A 204% increase in cervical spine fractures and dislocations
The shift was attributed to the modern football helmet, whose superior protection promoted “spearing” (headfirst tackling technique). Spearing involves hitting with the crown of the helmet leading to axial loading of the spine. Spearing accounted for 52% of the quadriplegia injuries from 1971 to 1975. Research by Joesph Torg, M.D., resulted in rule changes that led to an immediate 50% reduction in quadriplegia in NCAA football.
As a parent, coach or team physician, teach and enforce proper form and protect our young athletes.
Category: Pediatrics
Posted: 7/11/2014 by Rose Chasm, MD
(Updated: 11/27/2024)
Click here to contact Rose Chasm, MD
Wolfe TR, Braude DA. Intranasal Medication Delivery for Children: A Review and Update. Pediatrics. 2010;126:532-7.
Mudd S. Intranasal fentanyl for pain management in children: a systematic review of the literature. J PediatrHealth Care 2011;25:316-22.
Chiaretti A, Barone G, Rigante D, et al. Intranasal lidocaine and midazolam for procedural sedation in children. Arch Dis Child 2011;96:160-3.
Category: Toxicology
Keywords: poisoning, overdose, pediatric, ICU (PubMed Search)
Posted: 7/8/2014 by Bryan Hayes, PharmD
(Updated: 7/10/2014)
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In a single academic medical center, 273 poisonings required Pediatric ICU (PICU) admission over a 5-year period. This represented 8% of total PICU admissions during that time. Key findings include:
The majority of poisonings were non-fatal and required supportive care, close monitoring, and some specific treatment. Drug classes causing poisonings have changed to a higher percentage of opioids in younger patients and atypical antidepressants in adolescents.
Even KM, et al. Poisonings requiring admission to the pediatric intensive care unit: A 5-year review. Clin Toxicol 2014;52(5):519-24. [PMID 24738737]
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Category: Neurology
Keywords: Stroke, Score, MRI (PubMed Search)
Posted: 7/9/2014 by Danya Khoujah, MBBS
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In patients presenting to the ER with a TIA (transient ischemic attack), the classic teaching has been to calculate their ABCD2 score (age, blood pressure, clinical features, duration of episode and diabetes) to determine their risk of developing a stroke.
The problem is, a moderate-to-high ABCD2 score is sensitive (86%) but not specific (35%) for a stroke in 7 days.
The solution: Combining imaging data with the scoring system!
The presence of an acute infarct on a diffusion-weighted MRI (DWI) in a patient with an ABCD2 score of 4 or more carries the highest risk of stroke, at 14.9% at 7 days. On the other hand, a negative DWI predicts a 0-2% stroke risk at 7 days irrelevant of the ABCD2 score.
Panagos P D. Transiet Ischemic Attacks (TIA): the initial diagnostic and therapeutic dilemma. AJEM (2012) 30: 794-799
Category: Critical Care
Posted: 7/8/2014 by Haney Mallemat, MD
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Editors note: The new Back 2 Basic series will review essential critical care concepts on the first Tuesday of each month. Want a specific topic reviewed? Contact us by email or Twitter.
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Category: Visual Diagnosis
Posted: 7/6/2014 by Haney Mallemat, MD
(Updated: 7/7/2014)
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10 year-old male complains of fever and rash (shown below); no other complaints. He went camping 10-days ago. What’s the diagnosis...and what medication(s) should he receive?
Rocky Mountain spotted fever (RMSF)
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Category: Cardiology
Keywords: Magnesium, cardiovascular disease, arrhythmia (PubMed Search)
Posted: 7/6/2014 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD
Role of Magnesium in Cardiovascular Disease
* Magnesium (Mg2+) is an essential element that is obtained via dietary intake of leafy green vegetables, legumes, nuts/seeds, and whole grains; it is relatively deficient in the American diet.
* Mg2+ is critical for the normal physiological functioning of the vascular smooth muscle, endothelial cells, and myocardium. Several epidemiological and clinical studies have linked Mg2+ in the pathogenesis of cardiovascular disorders (CVD).
* Mg2+ is well known for its antiarrhythmic properties via modulation of myocardial excitability and in the pathogenesis and treatment of cardiac arrhythmias (polymorphic ventricular tachycardia/torsades de pointes & digoxin toxicity).
* Mg2+ supplementation has also been shown to cause significant decrease in ventricular ectopic beats and nonsustained ventricular tachycardia in NYHA class II–IV heart failure patients.
* A recent meta-analysis by Qu et al examined the association between dietary Mg2+ intake, serum Mg2+ levels, and the risk of total CVD events; the greatest reduction in CVD events was observed for intake between 150-400 mg/d.
* Given the magnitude of CVD and Mg2+-deficient diet in the US, there is a critical need to further investigate the interrelationship between Mg2+ and CVD events. Additionally increasing Mg2+ intake in the diet to maintain high normal serum Mg2+ level is both physiologic and judicious.
Dhaval K, Krishnaswami V, et al. Role of Magnesium in Cardiovascular Diseases. Cardiology in Review. Vol22 (4) pgs. 153-192 July/August 2014
Category: Pharmacology & Therapeutics
Keywords: clindamycin, MRSA, SSTI (PubMed Search)
Posted: 7/1/2014 by Bryan Hayes, PharmD
(Updated: 7/5/2014)
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Clindamycin used to be a first-line agent for many SSTIs, particularly where MRSA was suspected. With growing resistance to staph species, the 2014 IDSA Guidelines recommend clindamycin as an option only in the following situations:
* Clindamycin may be used if clindamycin resistance is <10-15% at the institution.
Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014;59(2):e10-52. [PMID 24947530]
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Category: International EM
Keywords: Geriatric, Global, Emergency Care (PubMed Search)
Posted: 7/3/2014 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 11/27/2024)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
Background:
Relevance to the EM Physician:
Bottom Line:
University of Maryland Section of Global Emergency Health Author: Terrence Mulligan DO, MPH
Samaras N, Chevalley T, Samaras D, et al. “Older Patients in the Emergency Department: A Review” Annals of EM Vol 56:3, Sept 2010, p 261-269.
WHO Global Burden of Disease. 2010. www.who.int/healthinfo/global_burden_disease/GBD_report_2010update_full.pdf
United Nations. “World Population Ageing 1950-2050” 2011. www.esa.un.org/wpp/
Category: Critical Care
Keywords: blood, anemia, infection, blood transfusions (PubMed Search)
Posted: 7/1/2014 by Feras Khan, MD
(Updated: 11/27/2024)
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Risk of infection from Blood transfusions
JAMA Meta-Analysis
What they found
Bottom Line
Rohde J, et al. Health Care Associated Infection after Red Blood Cell Transfusion. A systematic Review adn Meta-Analysis. JAMA 2014; 311(13): 1317-1326.
Category: Visual Diagnosis
Posted: 6/30/2014 by Haney Mallemat, MD
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49 year-old female on trimethoprim/sulfamethoxazole presents with a rash & lesions on her oral mucus membranes. What's the diagnosis?
Answer: Steven-Johnson Syndrome (SJS)
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Category: Cardiology
Keywords: IVUS, CAD, vulnerable plaques (PubMed Search)
Posted: 6/29/2014 by Semhar Tewelde, MD
(Updated: 11/27/2024)
Click here to contact Semhar Tewelde, MD
IVUS Plaque Correlation to Cardiovascular Death
Several non-invasive studies are currently utilized for the identification of coronary artery disease (i.e. coronary CTA, intravascular ultrasound- IVUS, etc.)
Few studies have quantified which of those with CAD (i.e. coronary plaques) are considered high-risk or unstable plaques
A recent study utilizing IVUS looked at autopsies over a 2 year-period comparing near-infrared detection of high-risk plaques and cardiovascular related deaths
IVUS findings associated with CAD are classified into 3 categories: echo-attenuation, echolucent zone, and spotty calcification
Echo-attenuated plaques, especially superficial echo-attenuation, was found to be a significant and reliable finding suggestive of vulnerable plaques and future cardiovascular death
Pu J, Mintz G, et al. Insights into echo-attenuated plaques, echolucent plaques, and plaques with spotty calcification. JACC Vol 63, No 2, 2014.
Category: Toxicology
Keywords: Colchicine, Poisoning, Arrhythmia (PubMed Search)
Posted: 6/29/2014 by Kishan Kapadia, DO
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Colchicine tablets and injectable solution is frequently used for the treatment of gout and familial Mediterranean fever. An overdose is extremely serious, with considerable mortality that is often delayed. It is considered a cellular poison due to its inhibition of cellular mitosis of dividing cells.
After an acute overdose, symptoms typically are delayed for 2-12 hours and include nausea, vomiting, abdominal pain, and severe bloody diarrhea.
Chronic poisoning presens with a more insidious onset.
Late complications include bone marrow suppression, particularly leukopenia and thrombocytopenia (4-5 days) and alopecia (2-3 weeks).
Treatment includes aggressive supportive care, monitoring and treatment of fluid and electrolyte disturbances.
The usual cause of death from acute poisoning is due to hemodynamic collapse and cardiac arrhythmias (typically 24-36 hours after ingestion or could be sudden) or from infectious or hemorrhagic complications.
1) Finkelstein Y et al. Colchicine poisoning: the dark side of an ancient drug. 2010 Clin Tox 48(5):404-414.
2) Olson KR, ed. Poisoning & Drug Overdose. 5th ed. New York: McGraw Hill; 2007.
Category: Orthopedics
Keywords: Elbow extension test (PubMed Search)
Posted: 5/27/2014 by Brian Corwell, MD
(Updated: 6/28/2014)
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Jie KE et al. Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma. Ann Emerg Med 2014
Category: International EM
Keywords: tetanus, global, international, infectious disease (PubMed Search)
Posted: 6/25/2014 by Andrea Tenner, MD
(Updated: 11/27/2024)
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General Information: Tetanus is caused by the toxin of Clostridium tetani--a gram-positive bacillus found in soil and animal excrement. It is a life-threatening but preventable disease. Cases have declined by > 95% in the past 65 years, but dozens of cases still occur annually in the US and it is still frequently seen in developing countries.
Clinical Presentation:
Diagnosis:
Clinical Case Definition: In the absence of a more likely diagnosis, an acute illness with muscle spasms or hypertonia. There is no diagnostic laboratory test for tetanus.
Treatment:
Bottom Line:
Tetanus is not as rare as we would like to think. Acute diagnostic acumen and assertive clinical management can help save the life of someone with this potentially deadly disease
University of Maryland Section for Global Emergency Health
Author: Jon Mark Hirshon, MD, MPH, PhD
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6012a1.htm
http://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.html
http://emedicine.medscape.com/article/229594-treatment
Category: Critical Care
Posted: 6/24/2014 by Mike Winters, MBA, MD
(Updated: 11/27/2024)
Click here to contact Mike Winters, MBA, MD
Prophylactic FFP for Procedures?
Category: Visual Diagnosis
Posted: 6/22/2014 by Haney Mallemat, MD
(Updated: 6/23/2014)
Click here to contact Haney Mallemat, MD
35 year-old female presents with nausea and vomiting 1 week post-op for an abdominal surgery. Abdominal ultrasound is below; what's the diagnosis?
Small bowel obstruction (SBO)
Ultrasound for Small bowel obstruction (SBO)
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Category: Orthopedics
Keywords: knee, injury, dislocation (PubMed Search)
Posted: 6/21/2014 by Michael Bond, MD
(Updated: 11/27/2024)
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Some quick facts about Knee Injuries:
Category: Pediatrics
Keywords: Ultrasound, pediatrics, appendicitis (PubMed Search)
Posted: 6/20/2014 by Jenny Guyther, MD
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Category: Toxicology
Keywords: NAC, acetaminophen (PubMed Search)
Posted: 6/19/2014 by Hong Kim, MD
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NAC is an effective antidote against acetaminophen (APAP) toxicity in preventing acute hepatotoxicity. It provides cysteine that is essential for glutathione synthesis and its availability is rate limiting.
Currently, PO and IV formulation is available in the U.S. Regardless of the route, NAC is equally effective in preventing APAP induced acute hepatotoxicity when administered within 8 hours after single acute ingestion. 1
Adverse effects of NAC
1. Anaphylactoid reaction
a. More frequently reported with IV administration and during the first regimen of NAC (150 mg/kg over 60 min) administration. (dose and rate dependent)
b. Higher risk of anaphylactoid reaction in patients with negative APAP vs. patients with elevated APAP level.2
c. Management: Benadryl as needed and slow infusion rate.
2. Hyponatremia in children if inappropriate volume of diluent (D5W) used. Dose calculator: http://acetadote.com/dosecalc.php
3. Laboratory: increase Prothrombin time (PT).3
4. Fatality from iatrogenic NAC overdose has been reported.
Advantage of IV NAC
1. Convenience
2. 100% bioavailability
3. Shorter hospital length of stay
4. Minimum GI symptoms (nausea & vomiting) compared to PO route
Indication of IV NAC
1. Severe hepatotoxicity or fulminant liver failure
2. APAP poisoning during pregnancy
3. Unable to tolerate PO intake (nausea, vomiting, altered mental status)
However many clinicians administer IV NAC for their advantages over PO NAC.
Take home message:
1. PO and IV NAC are equally effective when administered within 8 hours after single acute ingestion.
2. Anaphylactoid reaction is frequently encountered AE during the infusion of 1st NAC regimen and patients with negative/low APAP level may be at higher risk.
3. No emergent need to start NAC in presumed acetaminophen overdose patients prior to obtaining APAP level.