Author: Susan Ryan, DO Educational Pearls: General orthopedic principles: Examine above and below the injury Document neurovascular status X-ray imaging typically requires three different views Fracture description should include name the bone, location of fracture, degree of displacement, and if it is closed or open Osgood-Schlatter (tibia) and Sever's (calcaneus) disease are apophyseal injuries caused by ligaments that are "stronger" than the bones they attach to When looking for scaphoid inju...
Aug 19, 2019•13 min
Author: Dylan Luyten, MD Educational Pearls: While certain aspects of the history, exam, and EKG may increase likelihood of ACS, there is no one element that performs well on its own Elements of the history have been found to have different likelihood ratios, which can increase or decrease the probability of a patient having ACS Likelihood ratios greater than one increase the chance of the patient having the disease. Ratios less than one decrease it Bilateral arm radiation is one of very few his...
Aug 15, 2019•15 min
Author: David Holland, MD Educational Pearls: Hallucinogenics have been used for a variety of cultural and religious reasons for thousands of years In the 1960's a Harvard professor began experimenting with psilocybin mushrooms. There was resulting public outcry, eventually leading to all hallucinogens being listed as schedule I drugs Common hallucinogens include: LSD (acid), Mescaline (peyote), DMT (ayahuasca), Psilocybin (mushrooms), MDMA (ecstacy) Effects vary by specific drug but may include...
Aug 12, 2019•7 min
Author: Rachel Brady, MD Educational Pearls: Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs. Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds Be sure to ask...
Aug 06, 2019•7 min
Contributor: JP Brewer, MD Educational Pearls: Obtaining collateral is often vital to determine the potential drugs accessible to the patient - this may include After this, use ancillary sources such as EMS, family/friends, and police to determine the patient's last normal, PMH and medications To help separate toxidromes , pupillary exam and skin exam are helpful Important physical exam clues in toxicology include the pupils and the skin Adjunct laboratory evaluation may include liver function t...
Aug 02, 2019•7 min
Contributor: JP Brewer, MD Educational Pearls: Because of their smaller size, there are a variety of adult-dose pills that are potentially toxic to children. The most common categories of medications that may be toxic include cardiac, diabetic, pain, psychiatric, anti-malarial, and herbals/caustics Oral hypoglycemics such as sulfonylureas can be particularly dangerous in children. Opiates and benzodiazepines have the potential for respiratory arrest Anti-malarial medications are arrhythmogenic t...
Jul 31, 2019•6 min
Contributor: Don Stader, MD Educational Pearls: Buprenorphine is a partial Mu-agonist and binds with higher affinity than most opioids Pain management with opioids therefore can be difficult in patients taking buprenorphine Ketamine is a good option for pain control in these patients You can also consider using additional buprenorphine Intravenous buprenorphine is dosed differently than oral formulations Consider receptor availability - patients on high doses of buprenorphine (32mg) will have fe...
Jul 26, 2019•4 min
Educational Pearls: Buprenorphine is a semi-synthetic derivative of the opium poppy FDA approved for the treatment of opiate use disorder and chronic pain Benefit in emergency department use is the ceiling effect - producing less euphoria as well as respiratory depression with higher doses It has an onset of 30-60 minutes, peak effect at 1-4 hours Duration of action depends is dose dependent, typically 6-12 hours, but can be as long as 24-72 hours in doses over 16 mg Use buprenorphine in those i...
Jul 24, 2019•5 min
Contributor: Don Stader, MD Educational Pearls: Syncope is usually benign but can be caused by serious etiologies which include: PE, certain cardiac arrhythmias, AAA, intracranial bleed/stroke The Canadian Syncope Rule appears to identify those patients with syncope and low risk of serious outcomes The score is based on vital signs, EKG and history Negative scores preclude a very low risk of adverse events A calculated score greater than 1 are considered medium risk Scores greater than 4 are hig...
Jul 22, 2019•5 min
Contributor: Jared Scott, MD Educational Pearls: The CDC recommends rabies prophylaxis if there was a direct encounter with a possibly rabid animal except... Bats are treated differently since their bites may be very superficial and not seen/felt. All people with possible close encounters with a bat should receive rabies prophylaxis From 1990-2007 there were 34 rabies cases associated with bats: 6 of these had a reported bat bite 15 there was a reported exposure but no reported bite 11 had no re...
Jul 18, 2019•4 min
Contributor: Nick Hatch, MD Educational Pearls: Dalbavancin (Dalvance®) is an antibiotic that can be used for skin and soft tissue infections, providing MRSA coverage It cannot be used in other infections or sepsis Dalbavancin may be appealing as a single dose lasts about 2 weeks Expense is currently a large barrier to use Patients with a vancomycin allergy will likely be allergic to Dalbavancin as the two are related References Patel M, Smalley S, Dubrovskaya Y, Siegfried J, Caspers C, Pham V, ...
Jul 15, 2019•4 min
Contributor: Michael Hunt, MD Educational Pearls: Due to the efficacy of vaccination, epiglottitis is now more common in adults than children Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor Diagnosis can include x-ray to look for the "thumbprint sign," nasofiberoptics, and/or CT Antibiotics are mainstay of treatment but severe cases ...
Jul 10, 2019•4 min
Contributor: Nick Hatch, MD Educational Pearls: True morel mushrooms are commonly foraged The false morel mushroom ( Gyromitra esculenta ) looks similar to the true morel, but is toxic False morel mushroom toxicity can cause gastrointestinal symptoms as well as liver failure, rhabdomyolysis, and seizures Seizures can be refractory to benzodiazepine therapy and may require use of vitamin B6 and propofol References Horowitz KM, Horowitz BZ. Gyromitra Mushroom Toxicity. [Updated 2019 May 12]. In: S...
Jul 08, 2019•4 min
Contributor: Jared Scott, MD Educational Pearls: Cerebellar strokes make up a disproportionate number of missed or delayed diagnosis for stroke likely due to the subtle nature of the presentation Cerebellar strokes can present with vomiting, dizziness, and ataxia. Unlike anterior circulation stroke, exam findings in a cerebellar stroke are ipsilateral to the lesion On neuro exam, findings may include: Dysmetria: lack of coordination with overshooting/undershooting intended position of limb Dysdi...
Jul 06, 2019•5 min
Contributor: Charleen Gnisci, PharmD Educational Pearls: Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma. While definite treatment is to remove the offending cause, there are emergency medicine Non-pharmacologic methods include elevating head of bed and removing noxious stimuli Pharmacologic options include mannitol and hypertonic saline Hypertonic saline is best delivered through a central line but not required Both these agents benefit from...
Jul 04, 2019•7 min
Contributor: Don Stader, MD Educational Pearls: Antiplatelets include aspirin and clopidogrel, and are generally used for arterial clotting (MI, stroke) Anticoagulants such as coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE) Growing data suggests that dual antiplatelet therapy (aspirin+clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA References: Kheiri B, Osman M, Abdalla A, Haykal T, Swaid B, Ahmed S, Chahine A, Hassan M, Bachuwa G, A...
Jun 28, 2019•3 min
Contributor: Michael Hunt, MD Educational Pearls: Tetracycline antibiotics such as minocycline can cause greyish hyperpigmentation This hyperpigmentation can sometimes be reversible but not always Minocycline has been used for its effects in autoimmune and neurological diseases, where it is often taken chronically, which can lead to increased pigmentation References La Placa M, Infusino SD, Balestri R, Vincenzi C. Minocycline-Induced Blue-Gray Discoloration. Skin Appendage Disord. 2017 Aug;3(3):...
Jun 26, 2019•4 min
Contributor: Peter Bakes, MD Educational Pearls: While there are many different types of medical error, one of the most common errors in emergency medicine is failure to diagnose Systematic error in thinking that negatively affects judgement Medical errors are often driven by cognitive biases, which include anchoring, attribution, and availability Anchoring bias occurs when early information leads to premature closure on a single diagnosis. There is subsequent failure to consider alternative dia...
Jun 21, 2019•6 min
Author: Sam Killian, MD Educational Pearls: Abuse occurs by breathing in volatile substances such as solvents, glues, paints, butane, and propane Inhalants are generally depressants Estimated that 100-125 people die every year in the US from acute inhalant abuse. Short-term effects include memory impairment, slurred speech, diplopia, seizures, and cardiac arrhythmias Long term effects include renal dysfunction, neuropathy, blindness and cognitive blunting Evaluation includes a detailed lung exam...
Jun 19, 2019•4 min
Author: Nick Hatch, MD Educational Pearls: Pregnancy is a hypercoagulable state, which predisposes women to venous thromboembolism, but also elevates levels of circulating d-dimer A recent study evaluated the YEARS protocol in combination of adjusted d-dimer cutoffs in pregnant women to evaluate for DVT and PE Using this protocol, only 1 DVT was missed. No PE's were missed. This protocol has growing evidence as an option in pregnant women in whom you must rule out a DVT/PE but more validating st...
Jun 17, 2019•4 min
Author: Chris Holmes, MD Educational Pearls: Hallucinogenic drugs have been in use since ancient times for both medical and recreational purposes Ayahausca is an ancient psychedelic with origins in Bolivia that causes intense vomiting followed by a psychedelic experience This and other hallucinogens are gaining gaining interest for their use in depression with some startling positive initial results References https://www.nationalgeographic.com/culture/2019/05/ancient-hallucinogens-oldest-ayahua...
Jun 14, 2019•3 min
Author: Nick Hatch, MD Educational Pearls: Postpolypectomy electrocoagulation syndrome (PES) is a rare complication of polypectomy and electrocautery during colonoscopy Occurs when cautery causes transmural thickening from a contact burn Patients can present as if they have peritonitis, with guarding, leukocytosis, fever, etc. CT is the imaging of choice mainly to evaluate for bowel perforation as PES may not be seen on imaging Treatment is often with antibiotics and supportive care - in severe ...
Jun 12, 2019•4 min
Author: Dylan Luyten, MD Educational Pearls: Actual wait times are weakly correlated to patient satisfaction but the difference between perceived/expected wait times and actual wait times is strongly correlated Having others in the room or with the patient while they wait also has a positive effect Under-promising and over-delivering can result in better patient experience Managing up others and services provided also is demonstrated to improve satisfaction Perceived time with health care member...
Jun 05, 2019•4 min
Author: Michael Hunt, MD Educational Pearls: A recent study evaluated the relationship between abnormal orthostatic vital signs and serious outcomes within 30 days in patients over 60 presenting to the ED with syncope Of the roughly 2000 patients enrolled, about ⅓ had abnormal orthostatic vital signs There was no statistically significance between orthostatic vital signs and serious outcomes in 30 days Editor's note: study used a composite end-point of multiple serious outcomes References White ...
Jun 02, 2019•3 min
Author: Peter Bakes, MD Educational Pearls: The differential diagnosis for pedal edema includes issues in the heart, kidney, and liver Obesity hypoventilation syndrome (OHS) is an important and common cause of right heart failure. Nighttime hypoventilation leads to pulmonary hypertension, causing right heart strain followed by right heart failure OHS criteria includes obesity, sleep disordered breathing, and alveolar hypoventilation (PaCO2 > 45 mmHg) The causes of OHS are multifactorial, and ...
May 29, 2019•9 min
Author: Sam Killian, MD Educational Pearls: A recent study in Pediatrics compared the rates of antibiotic prescriptions for acute respiratory infections (ARIs) between direct to consumer (DTC) telemedicine, urgent care, and primary care providers Among the nearly 530,000 visits studied, the rate of antibiotic prescription was 52%, 42% and 31% for telemedicine, urgent care, and primary care providers, respectively Nearly 4/10 antibiotic prescriptions from telemedicine visits were not indicated ba...
May 24, 2019•3 min
Author: Gretchen Hinson, MD Educational Pearls: In most healthcare settings, normal saline (NS) has become ubiquitous as an intravenous fluid despite some potential drawbacks Compared to normal saline, a balanced crystalloid (either lactated Ringer's or Plasma-Lyte) was associated with a lower composite endpoint of mortality, renal replacement therapy, and renal injury in SMART (Isotonic Solutions and Major Adverse Renal Events Trial) Balanced crystalloids such as lactate Ringer's may be prefera...
May 23, 2019•6 min
Author: Don Stader, MD Educational Pearls: Cyclic vomiting syndrome (CVS) is different than cannabis hyperemesis syndrome (CHS). It is important to differentiate the two. CHS is thought to be caused by activation of THC receptors in the gut CVS is associated with migraines and therefore responds to similar medications Olanzapine (Zyprexa) is an alternative to haloperidol (Haldol) Amitriptyline, as well as anti-epileptics can be used to prevent CVS Opioids worsen CVS References Lapoint J, Meyer S...
May 21, 2019•4 min
Author: Jared Scott, MD Educational Pearls: Ondansetron (Zofran) is one of the latest drugs that has had concerns raised about side effects, particularly in pregnancy 2018 study probed two birth defect databases to assess increases in 51 major birth defects with increased exposure to ondansetron Only two of the 51 had even a modest increase, which is unclear in causation (cleft palate and renal agenesis) When administering ondansetron (or any drug) to pregnant women, be able to discuss any poten...
May 17, 2019•4 min
Author: Dave Rosenberg, MD Educational Pearls: Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not References Alyssa Cheng-Cheng Zhu , Aalok Agarwala , Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after ...
May 16, 2019•4 min
