Author: Sue Chilton, MD Educational Pearls: Triad of fat emboli syndrome is a petechial rash, AMS, and respiratory distress. Petechiae usually start in the axilla. 90% of patients with long bone fractures will shed fat. May see ground-glass opacities on imaging, but perfusion defects will not be seen on CTA or V/Q scan Patients with a PFO can have cerebral involvement. References Newbigin K, Souza CA, Torres C, Marchiori E, Gupta A, Inacio J, Armstrong M, Peña E. Fat embolism syndrome: State-of-...
Jul 04, 2018•3 min
Author: Don Stader, MD Educational Pearls: Steakhouse syndrome is an impacted esophageal food bolus. Occurs because they have an esophageal stricture (schatzki ring, scarring, esophagitis). Classic treatments have consisted of effervescents, glucagon, and/or sublingual nitroglycerin (NTG). Recent case series has shown oral 400mcg tablet of NTG dissolved in 10cc tap water was 100% successful. Complications of NTG are hypotension and headache. References Kirchner GI, Zuber-Jerger I, Endlicher E, e...
Jul 02, 2018•4 min
Author: Sam Killian, MD Educational Pearls: Recent study examining fasting and adverse events during procedural sedation found no association between fasting duration and any type of adverse event. Of the 6,183 children in the study, about 6 vomited during the procedure, and about 300 vomited recently after the procedure, and there were no episodes of aspiration. References Bhatt, M, et al. (2018). Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children. J...
Jun 29, 2018•3 min
Author: Chris Holmes, MD Educational Pearls: There is a risk of cerebral edema in pediatrics with DKA if over resuscitated. Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion. Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS). References Glaser, N. S., Ghetti, S., Casper, T. C., Dean, J. M., & Kuppermann, N. (2013). Pediatric Diabetic Ketoacidosi...
Jun 27, 2018•4 min
Author: Sue Chilton, MD Educational Pearls: IV drug use and spinal procedures are major risk factors. Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline. MRSA is most common organism, but GNR and MSSA are also possible. References Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aur...
Jun 25, 2018•5 min
Author: Aaron Lessen, MD. Educational Pearls: When foley is stuck, balloon may not have deflated. Make sure balloon is not in the urethra, which can block drainage. Cut off the port as it may be obstructed. If still not draining, pass guide wire through port to unclog catheter. Other techniques have been described using mineral oil to dissolve, rupturing the balloon through over-inflation, and transcutaneous guided drainage. Crystallization can be a cause of catheter obstruction - sterile water ...
Jun 22, 2018•3 min
Educational Pearls: Snake bites commonly occur between April and October. Rattlesnake bites are the most common. Venom contains proteins/enzymes that cause local inflammation, coagulopathy, and systemic effects (hypotension, angioedema, renal failure, etc.) along with neurotoxins may cause fasciculations, ptosis, drooling, or hyporeflexia. Management: Mark site for swelling. Monitor progression. Elevate and immobilize injured limb and treat pain. Check basic labs including coagulation studies, a...
Jun 20, 2018•6 min
Author: Jared Scott, MD Educational Pearls: Scombroid is a type of food poisoning associated with dark fish (i.e. tuna, salmon, mackerel) that mimics anaphylaxis. Occurs through conversion of histidine to histamine by bacteria in the fish. Symptoms include flushing, lips swelling, nausea, diarrhea in setting of recent fish consumption. Treat with antihistamines. References Ridolo E, Martignago I, Senna G, Ricci G. Scombroid syndrome: it seems to be fish allergy but... it isn't. Curr Opin Allergy...
Jun 18, 2018•5 min
Author: Rachel Beham, PharmD Educational Pearls: Tenecteplase is more specific for fibrin and has a longer half-life than alteplase. In setting of ischemic stroke, tenecteplase before thrombectomy was associated with a statistically higher incidence of reperfusion and better functional outcome than alteplase. References Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. New England Journal of Medicine. 378:1573-1582...
Jun 13, 2018•3 min
Author: Chris Holmes, MD Educational Pearls: Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian. Freshwater and ocean water may have more bacteria than pool water. Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema. Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival. Workup includes CXR and ABG; consider C-spine immobilization/imaging when ...
Jun 11, 2018•5 min
Author: Jared Scott, MD Educational Pearls: Data is mixed, but some studies show 1-2% of pregnancies are ectopic. Risk factors for ectopic pregnancies include: pelvic inflammatory disease, prior ectopic pregnancy, prior abdominal surgery, prior abortion, advanced maternal age, IUD, tubal blockage, and smoking (including spouse). Greatest risk factor is a prior ectopic pregnancy, which carries a 17x higher risk. Patients with histories of PID and cigarette smoking present educational opportunitie...
Jun 08, 2018•5 min
Author: Chris Holmes, MD Educational Pearls: Symptoms commonly seen with mononucleosis are palatal petechiae, posterior cervical lymphadenopathy, inguinal/axillary lymphadenopathy, splenomegaly, and/or atypical lymphocytes > 10% on CBC. Among these, posterior cervical lymphadenopathy and atypical lymphocytes > 10% were the most sensitive (sensitivities of 0.64 and 0.66 respectively). References Welch, JL et al. What Elements Suggest Infectious Mononucleosis? Annals of Emergency Medicine. 2018. 7...
Jun 06, 2018•3 min
Author: John Winkler, MD Educational Pearls: Singed nasal hairs, soot around mouth, hoarse voice, drooling, and burns to head/face are signs suggestive of inhalation injury. Early intubation is critical for these patients as the airway changes rapidly. With inhalation injuries, the upper airway is burned while the lower airway is damaged by inhaled chemicals in the soot and can cause ARDS. Carbon monoxide (CO) and cyanide (CN) poisoning can occur with inhalation injuries. Treatment for CO poison...
Jun 04, 2018•7 min
Author: Dylan Luyten, MD Educational Pearls: Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth? Oral repletion is faster, cheaper, and more effective than IV repletion. Give IV potassium when patients have K Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation. Checking a level is unnecessary. References Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium diso...
May 31, 2018•4 min
Author: Peter Bakes, M.D. Educational Pearls: Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance. Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration. References Bullock, M. R. et. al. . Surgical management of acute subdural hematomas. 2006. Neurosurgery , 58 (SUPPL. 3). DOI: 10.1227/01.NEU.0000210364...
May 29, 2018•8 min
Author: Dylan Luyten, MD Educational Pearls: Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control. Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes. Do not perform resuscitative thoracotomies on patients who have no signs of life on scene, asystole as their presenting rhythm, or...
May 25, 2018•8 min
Author: Michael Hunt, MD Educational Pearls: Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3. Alternative scoring system is the GCS-P score which is GCS score - number of non-reactive pupils. GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months. GCS-P score is a better prognostic indicator than GCS score. References: Han J, et al (2014). External valid...
May 23, 2018•3 min
Author: Nick Hatch, MD Educational Pearls: Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002). Flaw in study is that there were significant baseline differences between groups. References: Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794...
May 21, 2018•3 min
Author: Nick Hatch, MD Educational Pearls: The sodium-glucose cotransporter in the gut is essential for rehydration. Oral rehydration therapies require an equimolar concentration of glucose and sodium to be effective. ORT has saved millions of lives globally. Consider using ORT in patients with dehydration. Especially useful in resource limited settings. References: Victora CG, Bryce J, Fontaine O, Monasch R. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Orga...
May 19, 2018•4 min
Author: Nick Hatch, MD Educational Pearls: Behcet Disease is an autoimmune disease that can affect any organ system. Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes. Patients with Behcet disease with hypotension should have low threshold for giving steroids. References: Arlt W, Allolio B. Adrenal insufficiency. Lancet, 2003; 361:1881. Sakane T, Takeno M, Suzuki N, Inaba G. Behçet's disease. New England Jou...
May 17, 2018•4 min
Author: Dylan Luyten , MD Educational Pearls: Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness. Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures. Supplemental potassium can rapidly reverse symptoms. Important to rule out thyrotoxicosis (get a TSH!). Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can hel...
May 15, 2018•4 min
Author: Sam Killian, MD Educational Pearls: Insufficient sleep and disrupted circadian rhythms are a major health problem today Millions of dollars, thousands of deaths, and millions of injuries are related to sleep deprivation every year 56 billion dollars - 24,000 deaths - 2.5 million disabiling injuries related to a sleep-type deprivation Exxon valdez, challanger, chyrnobel linked to sleep deprivation- at least partially Data has shown that in the Spring (when people lose an hour of sleep) th...
May 11, 2018•6 min
Author: Don Stader, MD Educational Pearls: The use of fecal occult blood tests is falling out of favor in emergency departments These tests have strong evidence suggesting their efficacy in colon cancer screening but clinical significance in ED is limited They have relatively high false positive and false negative rates Small/microscopic bleeding are often not clinically significant in the ED but can lead to increased costs from over-testing and other harms from fecal occult blood testing Refere...
May 09, 2018•3 min
Author: Michael Hunt, MD Educational Pearls: Valley fever is a fungal infection known as Coccidiomycosis that can present with vague symptoms like cough, fever, myalgias. A thorough history is critical to the diagnosis. Disease is localized to the Southwestern US (California, New Mexico, Arizona, Nevada, Utah) and parts of Central/South America. Disease is caused by inhaling fungal spores which damage the lung. Rarely, the disease can disseminate and cause infections that require systemic anti f...
May 07, 2018•3 min
Author: Sam Killian, MD Educational Pearls: Being exposed to E-cigarette vapor may increase risk of pneumonia. Recent study has shown e-cigarette vapor increases quantities of Platelet-activating-receptor factor in epithelial cells, which may aid pneumococcal bacteria in entering pneumocytes. References: Miyashita L, et al. (2018). E-cigarette vapour enhances pneumococcal adherence to airway epithelial cells. The European Respiratory Journal. 7;51(2)....
May 04, 2018•3 min
Author: Rachel Beham, PharmD Educational Pearls: Some synthetic cannabinoids have been contaminated with Brodifacoum. Brodifacoum is a Vitamin K antagonist and can present with a severe coagulopathy. Brodifacoum is commonly known as “superwarfarin” and has a very long half life of 120+ days. Check PT/INR in patients with a bleeding diathesis in setting of synthetic cannabinoid use. Treatment is activated charcoal and large doses of Vitamin K (10mg Q6H for months). References: Lipton R.A.; Klass ...
May 02, 2018•4 min
Author: Jared Scott, M.D. Educational Pearls: Cardiac myocytes and vascular smooth muscle are dependent on an intracellular calcium influx for contraction. Pancreatic beta cells rely on calcium to release insulin. Calcium channel blockers will decrease cardiac contractility and heart rate, but will also cause vascular smooth muscle relaxation with a subsequent decrease in systemic vascular resistance. Resultant cardiac depression and hypotension. Pancreatic beta cells also use calcium to release...
Apr 30, 2018•7 min
Author: Nick Hatch, M.D. Educational Pearls: Methemoglobinemia is when the iron in hemoglobin is in the Fe3+ (ferric) state rather than the normal Fe2+ (ferrous) state. Methemoglobin cannot release oxygen at the tissues. Symptoms include cyanosis, headache, tachycardia, dyspnea, and lethargy. Suspect in setting of hypoxia that does not improve with oxygenation, and clinical cyanosis with a normal PaO2 on ABG. Treatment is methylene blue which reduces the iron back to the ferrous state. Causes ca...
Apr 27, 2018•5 min
Author: Jared Scott, M.D. Educational Pearls: Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED. Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid. Compazine + Benadryl is a superior migraine treatment than Dilaudid. References: Friedman BW, et. al. (2017). Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology . 89(...
Apr 25, 2018•3 min
Author: Don Stader, M.D. Educational Pearls: Pulmonary embolism is one of the leading causes of maternal mortality. There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester. A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT. Keep in mind, both a V/Q scan and CT scan have a significant amount of r...
Apr 23, 2018•4 min
