Question

Patient with liver disease presents with dyspnea, fever, and the following ultrasound? What's the diagnosis? (Hint: there are two)?

Show Answer

Show References

The flexor tendons of the finger may become thickened and narrowed from chronic inflammation and irritation.

 - Causes limitation in range of motion and snapping or locking during flexion

 - Can involve any digit but usually the ring and the long finger

CC: pain, "catching" May awake to finger being "locked" with spontaneous resolution during the day

Stenosis occurs at the MCP level

PE: Distal flexor crease tender to palpation and may have a painful nodule 

Full finger flexion is sometimes not possible

Tx: NSAIDs and steroid injection in tendon sheath. If this fails - surgical release.

Clinically important traumatic brain injuries are rare in children.  The PECARN study provides decision rules for when to avoid unnecessarily obtaining a CT for children who have suffered head trauma.

For children < 2 years old: <0.02% risk of clinically important TBI

• Normal mental status
• No scalp hematoma, except frontal
• Loss of consciousness < 5 seconds
• No palpalble skull fracture
• Normal behavior
• Nonsevere mechanism (fall < 3ft, pedestrian struck, rollover MVC)

For children > 2 years old: <0.05% risk of clinically important TBI

• Normal mental status
• No signs of basilar skull fracture
• No loss of consciousness
• No vomiting
• No severe headache
• Nonsever mechanism (fall < 5ft, pedestrian struck, rollover MVC)

Show References

Naloxone can be administered via pretty much any route. One that has gained popularity in the past several years is nebulized naloxone. Although anecdotal reports tout the benefits of nebulized naloxone, what does the literature say?

• Case report of 46 y/o f with initial oxygen saturation of 61%. Naloxone was administered by nebulizer and within 5 min oxygen saturation was 100% and mental status was normal. [1]
• Retrospective analysis of prehospital adminstration in 105 patients. 22% had "complete response" and 59% had "partial response." Problem is the initial respiratory rate was 14 bpm with GCS of 12. [2]
• Prospective analysis of 26 patients in an inner-city, academic ED. Pre-naloxone respiratory rate was 13 with GCS of 11. Post-naloxone respiratory rate was 16 with GCS of 13. Three patients (12%) experienced moderate-to-severe agitation and 2 (8%) were diaphoretic. [3]

Bottom Line: Many of the studied patients may not have needed naloxone in the first place (initial respiratory rate 13-14), with a few developing withdrawal symptoms. Nebulized naloxone may have a role in the not-too-sick opioid overdose in whom you want to prove your diagnosis and wake the patient up enough to obtain a history. It is not a therapy for the apneic opioid overdose.

Show References

General Information:

    ·You must know the diagnosis to deliver effective and high quality care to patients; likewise for health systems to be effective, it is necessary to understand what the global burden of disease is.

    ·In 1991, the World Bank and World Health Organization launched the Global Burden of Disease Study which as of 2010 evaluates 291 disease and injuries as well as 1160 sequelae of these causes.

    ·In order to compare the burden of one disease with that of another, you must consider death and life expectancy of persons affected by the disease as well as disability imposed by the condition.

    ·The combined composite summary metric is termed disability adjusted life years (DALYs).

    ·There have been three major worldwide studies to date (1990, 2005, 2010) attempting to quantify the burden of disease yet no study to date has ever attempted to quantify the burden of disease requiring emergent intervention.

Bottom Line:

DALYs are a useful tool for quantifying the burden of disease and provides essential input into health policy dialogues to identifies conditions and risk factors that may be relatively neglected and others for which progress is not what was expected. To date, there has been no rigorous scientific effort to quantify the burden of disease worldwide that requires emergent intervention to avoid death and disability.

University of Maryland Section of Global Emergency Health

Author: Emilie J. B. Calvello, MD, MPH

Show References

Bad brain, good lungs.... Right?

A recent retrospective study reviewed the incidence of acute respiratory distress syndrome (ARDS) in patients presenting with spontaneous intracerebral hemorrhage over a 10-year period.  After reviewing 1,665 patients, the authors found that:

• The development of ARDS occurred in approximately 27% of patients with spontaneous ICH (similiar to previous literature).
• The incidence ARDS after spontaneous ICH was similiar to other "high-risk" conditions such as sepsis, trauma, & aspiration.
• Modifiable risk factors include: high tidal volume ventilation, higher total fluid balance, & transfusion of PRBCs/FFP.
   

It's of particular importance to note that high tidal volume ventilation (>8cc/kg) was the single greatest modifiable factor for the development of ARDS.

Bottom line:  Try and use lung-protective ventilation strategies (6-8cc/kg ideal body weight) and avoid excessive volume resuscitation in your critically-ill patients whenever possible.  Even in cases of isolated intracerebral hemorrhage - where the patient's lungs may appear to be completely normal - traditional tidal volume settings may be harmful.

Show References

Question

45 year-old man presents after he cannot close his left eye. In the photo below, he is trying to simultaneously raise his forehead and smile. Of note, he was also started on doxycycline recently for Lyme disease. What two medications should he receive?

Show Answer

Show References

• Classically MVP is considered a benign diagnosis associated w/palpitations, atypical chest pain, dyspnea, and carries a low risk of complications 
• A recent study investigated MVP and its association w/ventricular arrhythmias in a cohort of unexplained out-of-hospital cardiac arrest (OHCA)
• A small subset of patients w/MVP experienced life threatening arrhythmias coined "malignant" MVP
• Malignant MVP was most often associated w/female sex, bileaflet valve, and frequent complex ventricular ectopic activity

Show References

A recent review identified 5 key points to consider when prescribing fluids.

1. Fluids should be prescribed as drugs, recognizing that any fluid can be harmful if dosed incorrectly.
2. The differences in efficacy between administering a 'crystalloid versus colloid' are modest; however, the cumulative differences in safety appear more significant.
3. The qualitative toxicity associated with hydroxyethyl starch (HES) and isotonic saline remains a concern.
4. The differences in chloride load and strong ion difference between cystalloid solutions, such as isotonic saline compared with physiologically more balanced solutions, appear to have clinical relevance.
5. The 'default' resuscitation fluid for acutely ill patients should likely be physiologically balanced crystalloid solutions (eg, PlasmaLyte or Ringer's lactate ).

Show References

Definition: An episode that is characterized by some combination of apnea, color change, change in muscle tone, choking, gagging, or a fear in the observer that the infant has died.

DDx: VAST!

- GERD is by far the most common underlying etiology

- Do NOT forget about child abuse

Workup: Dependent on your Hx/PE (Take into account the child’s age (<30 days or h/o prematurity), existence of prior ALTE episodes, general appearance, etc.)

One study showed the concordance of initial working to discharge diagnosis of GERD was 96%, and non-concordant diagnoses evolved within 24 hours

Dispo: The easy part! ADMIT!

Even well-appearing children with a “benign” diagnosis like GERD have been shown to benefit from admission. And there is a high likelihood that ALTE’s from a serious cause are likely to recur within 24hours.

A recent study looked at 176 infants who presented to the ED with an ALTE over a 5 year period. Essentially all were admitted.

• Blood cultures were obtained in 63% and CSF cultures were obtained in 37% and no pathogens were identified in either
• CXRs were obtained in 115 (65%) patients and 12 had infiltrates
• RSV nasal washing were obtained in 32% and positive in 9 patients
• At the time of follow up, 2 patients had died, both after hospital discharge and within 2 weeks of ED visit and both of pneumonia. Both had a negative diagnostic evaluation in the ED.

Conclusion: The risk of subsequent mortality in infants presenting ALTE is substantial, and we should consider routine admission for all of these patients.

Show References

A recent article was published in the Journal of Medical Toxicology reviewing the use of sodium acetate for treatment of overdoses and poisonings.

Acetate is metabolized to bicarbonate, causing a net increase in cations; this increased strong anion difference leads to alkalemia.

It has been used to treat acidosis in uremia, diarrhea, and in trauma patients.

Although no studies have been conducted using sodium acetate as an antidote, if bicarbonate is unavailable this is a viable option for management of salicylate overdose, and for qrs widening or arrhythmias due to overdoses.

Sodium acetate, if given rapidly (in animals and hemodialysis patients), causes myocardial depression, hypotension, and hypopnea.

The bolus dose should be given as 1-2 mEq/L given over 15-20 minutes. For the maintenance infusion, dilute 150 mEq diluted to 1 L in dextrose 5%, infuse at 2X the maintenance rate.

It must be diluted in dextrose 5% and NOT normal saline.

Show References

General Information:

As of July 30^th, 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

Show References

Question

Elderly patient who originally presented for severe pancreatitis now intubated for worsening hypoxemia. CXR is shown below, what's the diagnosis?  

Show Answer

Show References

Question

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?

Show Answer

Show References

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%

Show References

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

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.

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

Show References

HIV, ART, and the ICU

• Though survival has dramatically improved for patients with HIV, there has been no decrease in the quantity of ICU admissions for this select patient population.
• One of the most common reasons for ICU admission is now adverse effects of antiretroviral therapy (ART).
• When managing a critically ill HIV patient in the ED or ICU, consider the following effects of ART as an etiology:
  • Lactic acidosis
    • Seen with nucleoside reverse transcriptase inhibitors (NRTIs): greatest risk with didanosine, stavudine, and zidovudine
    • Presentation: fatigue, malaise, vomiting, abdominal pain, hepatomegaly
    • Lactate often > 10 mmol/L
  • Abacavir hypersensitivity
    • Usually within first 6 weeks of drug initiation
    • Presentation: rash, fever, shortness of breath, vomiting, abdominal pain
    • Can rapidly progress to cardiovascular collapse

Show References

Question

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)

Show Answer

Show References