Kohler’s disease

Osteonecrosis of the tarsal navicular bone

Affects children ages 4 to 7

               4x more likely in males

Can be painless or present with arch/midfoot pain and a limp (usually activity related)

               Usually unilateral but can be bilateral (in up to 25%)

PE: Tenderness to palpation over the length of the arch esp the medial navicular

Swelling, warmth, redness

               -Can be misdiagnosed as an infection

X-ray: Sclerosis, collapse/flattening or fragmentation of navicular

Treatment: Walking boot or short leg cast

http://www.texasfootdoctor.org/images/kohlers%20xray.jpg

Is that a fracture or a growth plate?

Pediatric elbow x-rays are complicated to interpret due to the large number of ossification centers.

Elbow trauma is common in pediatrics.

Ossification centers of the elbow appear in a reliable chronologic pattern which aids in distinguising fractures from growth plates.

Note the age ranges are an estimate with great variability. For example, girls can develop these up to 2 years earlier than boys.

The numbers 1/3/5/7/9/11 correspond to the average age of development of each ossification center

Years of fusion shown below in ()

Capitellum (12-14yo)

Radial head (14-16yo)

Medial epicondyle (16-18yo)

Trochlea (12-14yo)

Olecranon (15-17yo)

Lateral epicondyle (12-14yo)

Pneumonic: "Can't Resist My Team Of Lawyers"

Consider ordering films of both elbows to compare if in doubt.

How is this useful? If the trochlear center is present, but there is no medial epicondyle then you are most likely looking at a fx where the ossification center has been avulsed and displaced. 

During rapid sequence intubation (RSI) we endeavor to avoid positive pressure ventilation, prior to securing a definitive airway. As such, an adequate buffer of oxygen is necessary to ensure a safe apneic period. This process involves replacing the residual nitrogen in the lung with oxygen. It has been demonstrated that a standard nonrebreather (NRB) mask alone does not provide a high enough fractional concentration of oxygen (FiO2) to optimally denitrogenate the lungs (1). Even when a nasal cannula at 15L/min is utilized in addition to the NRB, the resulting FiO2 is not ideal. A bag-valve mask (BVM) with a one-way valve or PEEP valve has been demonstrated to provide oxygen concentrations close to that of an anesthesia circuit. But its effectiveness is drastically reduced if a proper mask seal is not maintained during the entire pre-oxygenation period (1). This is not always logistically possible in the chaos of an Emergency Department intubation.

A standard NRB with the addition of flush-rate oxygen appears to be a viable alternative. Recently published in Annals of Emergency Medicine, Driver et al demonstrated that a NRB with wall oxygen flow rates increased to maximum levels, rather than the standard 15L/min, provided end-tidal O2 (ET-O2) levels similar to an anesthesia circuit (2).

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During rapid sequence intubation (RSI) we endeavor to avoid positive pressure ventilation, prior to securing a definitive airway. As such, an adequate buffer of oxygen is necessary to ensure a safe apneic period. This process involves replacing the residual nitrogen in the lung with oxygen. It has been demonstrated that a standard nonrebreather (NRB) mask alone does not provide a high enough fractional concentration of oxygen (FiO2) to optimally denitrogenate the lungs (1). Even when a nasal cannula at 15L/min is utilized in addition to the NRB, the resulting FiO2 is not ideal. A bag-valve mask (BVM) with a one-way-valve or PEEP valve has been demonstrated to provide oxygen concentrations close to that of an anesthesia circuit. But its effectiveness is drastically reduced if a proper mask seal is not maintained during the entire pre-oxygenation period (1). This is not always logistically possible in the chaos of an Emergency Department intubation.

A standard NRB with the addition of flush-rate oxygen appears to be a viable alternative. Recently published in Annals of Emergency Medicine, Driver et al demonstrated that a NRB with wall oxygen flow rates increased to maximum levels, rather than the standard 15L/min, provided end-tidal O2 (ET-O2) levels similar to an anesthesia circuit (2). 

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Steroids and Back Pain:

This pearl, https://umem.org/educational_pearls/2805/, by Dr. Corwell reported on the trail published in JAMA that showed that Steroid use does NOT help in the treatment of acute sciatica. But what about just general back pain. Do steroids help with that?

An article published in January in the Journal of Emergency Medicine, http://dx.doi.org/10.1016/j.jemermed.2014.02.010, reported on a randomized controlled trial of prednisone 50mg daily for 5 days versus placebo for the treatment of Emergency Department patients with Low Back Pain.

The study showed that at follow-up there was no difference between the groups in respect to pain, resuming normal activities, returning to work, or days lost from work. More patients in the prednisone group then the placebo group sought additional medical treatment (40% vs 18%).

CONCLUSION: The authors detected no benefit from oral corticosteroids in ED patients with musculoskeletal back pain, and it might actually increase their chance of returning for additional medical care. Just say NO to steroids in back pain.

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There is no effective pharmacologic treatment known to hasten recovery from concussion. In future pearls we will examine possible interventions that may help.

The importance of educating our patients was demonstrated in two studies looking at concussion education. Patients were separated into 2 groups. The intervention group received a booklet of information discussing common symptoms of concussion, suggested coping strategies and the likely time course of recovery. At a 3 month follow-up evaluation, the intervention group reported fewer symptoms. This was repeated in pediatric patients with similar results.

Take Home: Consider taking the time to put such an information sheet together for concussed patients seen in the ED.

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• occurs during neonatal period
• sterile pustules which then change to hyperpigmented macules, often with a rim of scale
• may persist up to 3 months
• histology is characterized by leukocytes
• benign condition with no sequelae
• requires no treatment

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NMS is most often seen with the typical high potency neuroleptic agents (e.g haldol, fluphenazine)

All classes of antipsychotics can cause NMS, including low potency and newer atypical agents; antiemetics can cause this as well.

Symptoms usually occur after the first 2 weeks of therapy, but may occur after years of use

Signs and symptoms include:

mental status changes

muscular rigidity (“lead pipe”)

hyperthermia (>38 - 40 degrees).

Autonomic instability (tachycardia, tachycardia and diaphoresis)

Treatment includes discontinuation of the offending agent and providing supportive care.

While no clinical trials have ever been undertaken, dantrolene (muscle relaxant) is commonly used.

Bromocriptine (dopamine agonist) may also be used, and amantadine (dopaminergic and anticholinergic agent) is used as an alternative to bromocriptone

Recently, several case reports have documented the successful use of diazepam as a sole pharmacologic agent. This may be an alternative or a supplement to the above agents

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.

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Diffuse Idiopathic Skeletal Hyperostosis

aka 1) ankylosing hyperostosis, 2) Vertebral osteophytosis

Large amount of osteophyte formation in the spine, confluent, spanning 3 or more disks

Most commonly seen in the thoracic and thoracolumbar spine.

Osteophytes follow the course of the anterior longitudinal ligaments.

2:1 male to female ratio. Most patients >60yo.

Sx's: Longstanding morning and evening spine stiffness.

PE: Spinal stiffness with flexion and extension.

Dx: plain films

Tx: NSAIDs and physical therapy

http://www.learningradiology.com/caseofweek/caseoftheweekpix2013%20538-/cow542-1arr.jpg

40 yo previously healthy male in China who presents with prolonged “seizure” after receiving a cut on his foot while fishing 5 days ago.

Dx: Tetanus

Clinical features:

·      Incubation period 4-14 days

·      3 clinical forms:

1.     Local spasm

2.     Cephalic (rare) -  cranial nerve involvement

3.     Generalized (most common) - Descending spasm: facial sneer (risus sardonicus),   “locked jaw” trismus, neck stiffness, laryngeal spasm, abdominal muscle spasm.

·      Spasms continue to 3-4 weeks and can take months to fully recover

Complications: apnea, rhabodymyolysis, fracture/dislocations

Treatment: supportive, benzodiazepines, RSI, Tetanus IG (3000-5000 units IM), wound debridement

University of Maryland Section for Global Emergency Health

Author: Veronica Pei, MD

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Pericarditis is based on clinical diagnosis; typically two of four criteria are found (pleuritic chest pain, pericardial rub, diffuse ST-segment elevation, and pericardial effusion).

Treatment of pericarditis should be targeted at the cause.

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Chronic exertional compartment syndrome (CECS)

An overuse injury common in young endurance athletes

In athletes with lower leg pain, CECS was found to be the cause in 13.9% - 33%.

*This is likely under diagnosed as most recreation athletes will discontinue or modify their activity level at early symptom onset

Common in runners and most often involves the anterior compartment

Occurs due to increased pressure within the fascial compartments, primarily in the lower leg

Symptoms are bilateral 85 - 95% of the time

Exercise increases blood flow to leg muscles which expand against tight surrounding noncompliant fascia. This, in turn, increases compartment pressures and eventually reduces blood flow which leads to ischemic pain. Pain usually begins within minutes of starting exercise and experienced athletes can often pinpoint the time/distance required for symptom onset.

Symptoms are primarily pain (tightness, cramping, squeezing) but may also include paresthesias and numbness. Symptoms gradually abate with cessation of activity.

Diagnosis:  Although some physicians’ make a clinical diagnosis based on Hx and exam, definitive diagnosis requires measurement of compartment pressures both at rest and post exercise.

Nonsurgical treatment: activity modification and rest

Surgical treatment: >80% success with anterior and lateral compartments vs. 50% with deep posterior compartment.

Amiodarone is a class III anti-arrhythmic for tachyarrhythmias

Although most patients remain euthyroid on amiodarone, 4-18% develop thyroid disease months to years after exposure.

Amiodarone-induced thyroid disease occurs because amiodarone is structurally similar to triiodothyronine and thyroxine and each 200mg tablet contains 75 mg of iodine.

Two types of amiodarone-induced thyroid disease:

• Amiodarone-induced hypothyroidism (AIH)
• Amiodarone-induced thyrotoxicosis (AIT)

Amiodarone-induced hypothyroidism (AIH)

• Presents with subtle to overt hypothyroidism 
• Treat by discontinuing amiodarone; thyroid recovers within 3 months
• If amiodarone cannot be discontinued, start levothyroxine

Amiodarone-induced thyrotoxicosis (AIT)

• Sudden symptom onset months to years following exposure; mean 2-47 months post-exposure
• Can be a life-threatening presentation (similar to thyroid storm) with severe cardiac manifestations and hemodynamic instability
• Treatment (treat like thyroid storm, if severe)
  • Discontinue drug, if possible
  • Thionamides (inhibit enzyme producing thyroid hormones)
  • Methimazole or propylthiouracil
  • Beta-blockers
  • Steroids
  • Airway and hemodynamic support

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Ever see that patient who shows up in the ED with blue painful toes? You look at the foot (or feet) and quickly determine that clot has embolized into the foot.

What is the differential diagnosis to consider in patients with evidence of embolic phenomenon in the feet (i.e. blue, painful toes)?

• AAA-many times asymptomatic. Most AAAs have mural thrombi associated with them, and tiny clots can flip off and distally embolize. Common cause of the "blue toe" syndrome.
• Atherosclerotic disease in the aorta, iliacs, femoral arteries. Plaques in these vessels are often chronic and don't always lead to acute occlusion.
• Cardiac sources-atrial fibrillation, mural thrombi in patients with recent MI or in patients with dilated cardiomyopathy.

Things to consider:

• Obviously, a vascular surgery consult
• CT abdomen to r/o a AAA
• Arterial doppler studies to assess for stenosis and arterial disease
• ABIs

Clearly we can't do the complete workup of embolic foot lesions, and many if not most of these patients will need to be admitted to complete their workup.

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Great resource for teaching in the emergency department....

Here is a great new app that you can use when teaching residents and students in the ED. It's the NEJM app. Great pics, videos, audio, procedures, and articles. And, it's FREE.

Just go to the App store and search "NEJM"

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• in the US, the right of an adolescent (<18yrs) to seek and receive treatment without parental consent varies from state to state.
• usually, the right to self-consent for treatment is specified through public health statutes when there is clinical suspicion of a STD
• many states allow minors to seek help for pregnancy, contraception, substance abuse, and mental health issues without parental consent

some absolutes or almost always cases include the following:

1. emancipated minors: moved outside of the home and support themselves financially, married, in the military, or has a child
2. emergencies: patient is unconscious or unable to give consent
3. mature-minor: possess the ability to comprehend the risks and benefits of treatment/therapy

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Some considerations in the patient with a penetrating vascular injury (gunshot, stab):

• Obtain ankle-brachial index on all patients and document
• An ABI <0.9 indicates the need to perform an arterial study
• Traditional approach to penetrating extremity injury has been to perform angiography
• Recent (good) studies have shown that CTA of the involved extremity is just as good if not better than angiography, and a lot of centers have moved to CTA
• Obtain vascular surgery consultation if there is any concern for an arterial injury. Never hurts to err on the side of caution. 

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Uveitis and Iritis Treatment:

• Once the diagnosis is suspected or made ensure that the patient has ophthamology followup.
• Antibiotics are not needed as this is not an infectious process.
• Pain control is the painstay of therapy (no not narcoletics) but cycloplegics like:
  • Cyclopentolate 0.5-2% 1 gtt TID
  • Homatropine 2-5% 1 gtt TID
  • This will relieve pain and photophobia symptoms
• Topical steroid can be initiated to decrease inflammation but should be done in consultation with the ophthamologist
  • Prednisolone 1% 1 gtt every 1-6 hours.