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Sore throat accounts for a whopping 7.3 million outpatient pediatric visits. Group A Streptococcus (GAS) accounts for 20-30% of pharyngitis cases with the rest being primarily viral in etiology. However, clinically differentiating viral versus bacterial causes of pharyngitis is difficult and we, as providers, often don’t get it right. In addition, antimicrobial resistance is increasing.. So who do we test and when do we treat for strep throat? The 2012 Infectious Diseases Society of America (IDSA) guideline on GAS pharyngitis helps answer these questions.

Bacterial or viral pharyngitis?

Group A streptococcus (GAS) is the most common bacterial cause of pharyngitis in both children and adults. It is important to diagnosis and treat GAS pharyngitis to prevent the non-suppurative complication of acute rheumatic fever and suppurative complications such as peritonsillar abscess, retropharyngeal abscess, mastoiditis, and lymphadenitis.​1​ Additionally, it is important to rule out GAS pharyngitis so as to avoid unnecessary antibiotic use in a time of increasing antibiotic resistance patterns. 

Strep pharyngitis most commonly occurs in children ages 5-15 years old, and symptoms include sore throat, pain with swallowing, and fever. In children, headache, nausea, abdominal pain, and vomiting are also commonly present. Physical exam findings include tonsillopharyngeal erythema and exudates, cervical lymphadenopathy, uvula swelling, palatal petechiae, and a scarlatiniform rash. Viral pharyngitis may present similarly to GAS pharyngitis; however, a lack of fever and the presence of rhinorrhea, cough, conjunctivitis, stomatitis, oral ulcers, and viral exanthem suggest a more viral etiology. 

While there exist several prediction tools designed to aid in the clinical diagnosis of GAS pharyngitis, such as the Centor and McIsaac Criteria, none perform well in children.​2,3​ In some cases these scoring systems can help to identify children at low risk for GAS and therefore reduce the need for further testing; however, as many as 65% of patients who present with all of the clinical criteria in a particular tool will test negative for GAS on throat culture, indicating a viral etiology.​1​

Table 1: Classic symptoms and findings for a viral and bacterial pharyngitis
SymptomViralBacterial
Sore throat + +
Scarlatiniform rash +
Fever +/- +
Pain with swallowing + +
Headache +/- +
Nausea/vomiting/abdominal pain +
Rhinorrhea +
Cough +
Conjunctivitis +
Stomatitis/oral ulcers +
Viral exanthem +
How to test: Rapid Antigen Detection Tests and the strep culture

In patients with suspected GAS pharyngitis a Rapid Antigen Detection Test (RADT) should be used for diagnosis. RADTs allow providers to quickly test for GAS instead of relying on inadequate clinical tools or waiting for a strep culture to result. They are highly specific with a low false positive rate. Thus if positive, the patient should be treated with antibiotics and a confirmatory strep culture is not necessary. Of note, rapid strep testing will remain positive on average for 4 days after initial diagnosis, but can remain positive for up to 2 weeks depending on the individual and antibiotic compliance. Repeat testing with RADT after a course of antibiotics for GAS pharyngitis should be reserved for patients only with the recurrence of classic symptoms of strep throat.​4​

What if the rapid strep test is negative?

RADTs have a sensitivity of 70-90%, leading to some false negative results.​5,6​ Thus if the  RADT result is negative, a strep culture should be sent with a follow-up plan, should the culture become positive. Antibiotics can be initially withheld, unless the patient is at high risk (immunosuppressed, medically complex) or has high-risk contacts.

Who to test: Children younger than 3 years old don’t need to be tested

GAS pharyngitis is rare (0-14%) in children <3 years of age.​7​ Furthermore, the incidence of rheumatic fever is rare.​8​ The 2012 IDSA guidelines recommended that routine testing for GAS pharyngitis in patients <3 years of age is NOT indicated. Only in situations of a household contact with known GAS infection would it be reasonable to consider testing.​1​

How to treat GAS pharyngitis

Fortunately GAS is a relatively easy bug to kill. It is susceptible to penicillins and its sister beta-lactams, amoxicillin, and ampicillin. While penicillin is cheaper and as efficacious as amoxicillin, pediatrician tend to choose a 10-day course of amoxicillin due to its better taste and therefore higher compliance rate. 

For penicillin-allergic patients, first generation cephalosporins such as cephalexin are recommended in those without anaphylaxis to penicillins. For those with anaphylaxis to penicillins, a 10-day course of clindamycin or a 5-day course of azithromycin is recommended.​1​

Table 2: Antibiotic recommendations for Group A Streptococcal pharyngitis per 2012 IDSA guidelines, if the patient is NOT allergic to penicillin
AntibioticDosingDuration
Penicillin V *Children: 250 mg po BID/TID
*Adolescent/Adults: 250 mg po QID or 500 mg po BID
10 days
Amoxicillin * 50 mg/kg (max 1,000 mg) po daily, or 
* 25 mg/kg (max 500 mg) po BID 
10 days
Benzathine penicillin G * Weight <27 kg: 600,000 units IM
* Weight ≥27 kg: 1.2 million units IM
1 time dose
Table 3: Antibiotic recommendations for Group A Streptococcal pharyngitis per 2012 IDSA guidelines, if the patient IS allergic to penicillin (*avoid if anaphylactic to penicillin)
Antibiotic Dosing Duration
Cephalexin* 20 mg/kg/dose (max 500 mg) po BID  10 days
Cefadroxil* 30 mg/kg (max 1,000 mg) po daily  10 days
Clindamycin 7 mg/kg/dose (max 300 mg) po TID 10 days
Azithromycin 12 mg/kg (max 500 mg) po daily  5 days
Clarithromycin 7.5 mg/kg/dose (max 250 mg) po BID  10 days
What about GAS carriers? 

GAS carriers are patients with persistent GAS positive throat cultures despite treatment and without any further symptoms of GAS pharyngitis. These patients have GAS present in the pharynx but no signs of immunologic response, meaning that their antistreptolysin O (ASO) titers are negative.​9​

RADTs and strep cultures do not distinguish between active infection and carriers. Carriers do not require treatment and have a low risk of spreading infection to those in close contact. They are also at low risk for developing suppurative and non-suppurative complications.

Can we do better? 

Despite the fact that RADTs have the potential to drastically reduce the number of antibiotic prescriptions for viral pharyngitis, prescribing rates remain high. Studies cite that antibiotics are prescribed in as many as 53% of all patients with pharyngitis symptoms, which is, well above the known prevalence of GAS at 20-30%.​8​ So why are we still giving antibiotics for viral pharyngitis? The answer is probably multifactorial, including providers empirically treating sore throat without testing, testing in inappropriate cases, such as young children, and the increasing prevalence of carrier states. 

Take Away Points
  • Do not rely on the clinical diagnosis for GAS pharyngitis in children. Instead use a Rapid Antigen Detection Test (RADT) and, if negative, a throat culture for diagnosis.
  • There is no indication to test children <3 years of age for GAS pharyngitis with the RADT or strep culture unless there is a known household contact with GAS.
  • Treat with a 10 day course of amoxicillin or cephalexin in non-anaphylactic, penicillin-allergic patients. Clindamycin or azithromycin are appropriate antibiotics in anaphylactic, penicillin-allergic patients. 

References
  1. 1.
    Shulman S, Bisno A, Clegg H, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):1279-1282. https://www.ncbi.nlm.nih.gov/pubmed/23091044.
  2. 2.
    Shaikh N, Swaminathan N, Hooper E. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr. 2012;160(3):487-493.e3. https://www.ncbi.nlm.nih.gov/pubmed/22048053.
  3. 3.
    Fine A, Nizet V, Mandl K. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-852. https://www.ncbi.nlm.nih.gov/pubmed/22566485.
  4. 4.
    Homme J, Greenwood C, Cronk L, et al. Duration of Group A Streptococcus PCR positivity following antibiotic treatment of pharyngitis. Diagn Microbiol Infect Dis. 2018;90(2):105-108. https://www.ncbi.nlm.nih.gov/pubmed/29150372.
  5. 5.
    Tanz R, Gerber M, Kabat W, Rippe J, Seshadri R, Shulman S. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics. 2009;123(2):437-444. https://www.ncbi.nlm.nih.gov/pubmed/19171607.
  6. 6.
    Gerber M, Shulman S. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. 2004;17(3):571-580, table of contents. https://www.ncbi.nlm.nih.gov/pubmed/15258094.
  7. 7.
    Nussinovitch M, Finkelstein Y, Amir J, Varsano I. Group A beta-hemolytic streptococcal pharyngitis in preschool children aged 3 months to 5 years. Clin Pediatr (Phila). 1999;38(6):357-360. https://www.ncbi.nlm.nih.gov/pubmed/10378093.
  8. 8.
    Tani L, Veasy L, Minich L, Shaddy R. Rheumatic fever in children younger than 5 years: is the presentation different? Pediatrics. 2003;112(5):1065-1068. https://www.ncbi.nlm.nih.gov/pubmed/14595047.
  9. 9.
    Johnson D, Kurlan R, Leckman J, Kaplan E. The human immune response to streptococcal extracellular antigens: clinical, diagnostic, and potential pathogenetic implications. Clin Infect Dis. 2010;50(4):481-490. https://www.ncbi.nlm.nih.gov/pubmed/20067422.
Author information
Shannon Flood, MD

Pediatric Emergency Medicine Fellow
Children's Hospital Colorado

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The post Strep Pharyngitis in Children: Review of the 2012 IDSA Guidelines appeared first on ALiEM.

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The Problem

Emergency physicians (EPs) experience professional burnout more than 3 times that of the average physician.​1​ In a recent study, the prevalence of burnout among emergency medicine residents was found to be an astounding 76.1%, suggesting that burnout begins as early as residency training.​2​ The emotional impact of witnessing suffering and death and the high-stakes, stressful environment of the ED likely contribute to burnout among trainees.

One potential protective factor against burnout is the strategic use of debriefing to mitigate work-related stress. Debriefing involves taking the opportunity to discuss and reflect upon a recent experience with a group of peers who share an understanding of the experience’s context. Debriefing can create a space for peers to provide mentorship, support and feedback to each other, thereby reducing work-related stress.​3,4​

The Innovation

Saving Society is a podcast series that provides residents with a medium for self-reflection and an opportunity to debrief impactful experiences with each other. Thus far, 3 podcast episodes have been recorded and explore complex topics such as gun violence, death and dying, and diversity in medicine.

Target Learners

This innovation was targeted toward resident learners of all levels.

Group Size

Ideally, the group size is chosen to allow everyone the opportunity to both speak and listen. We aimed at 6-8 residents over the course of a 1.5 hour recording window.

Materials Needed

There are many free, online resources that describe the materials needed to record a podcast in depth. Below are the resources utilized by this innovation.

Sample Materials Cost
Microphone $70
Headphones $20
Pop Filter $10
Portable Recorders $90
Storage $5
Sound Editing Software Free
  Description of the Innovation

Saving Society is a podcast series that consists of 1.5 hour long podcasts. In preparation for developing the podcast, the team watched Youtube tutorials to learn how to record and edit podcasts.

In order to record the podcasts, the team reserved a comfortable space that minimized ambient noise and provided those sharing their experiences with uninterrupted time to reflect. The team identified sensitive topics that are often difficult to discuss in large groups but have significant emotional impact on individuals, including gun violence, death and dying, and diversity in medicine. Residents were invited to participate in reflection on these topics.

Participants were notified in advance that the discussion would be recorded and released to the public. While residents spoke freely during the recording sessions, any information traceable back to a particular patient or institution was later edited out. After the final edits were made using sound editing software, the podcast episodes were shared with the involved residents to provide an opportunity for them to request removal of any clips thought to be inappropriate for public release.

When the final version was complete, the team uploaded the podcasts to a SoundCloud account. Subsequently, a Twitter account entitled @_Saving Society_ was created to disperse the audio files with commentary. Finally, the team created a Hootsuite account to schedule the podcast releases via Tweets over a 2-week window in July 2019.

Theory Behind the Innovation

Reflective Practice: Based on the work by Kolb and Fry in the 1970s, Saving Society incorporates reflective practice as its main educational learning tool.​5​ Reflective practice is similar to learning from past experiences. The predetermined questions for each interview prompted participants to consider their thought process and decision-making during some of their most emotionally-challenging experiences. A flexible outline, inspired by Graham Gibbs, an expert in the space of debriefing, was created to facilitate the conversation. The structure of each podcast episode was framed around Gibbs’ recommended stages: description, feelings, evaluation, analysis, conclusions and action plan.​6​

Lessons Learned

Despite the intense stress and frequency of emotionally challenging scenarios in the emergency department, there is a paucity of time and space to debrief in real-time. The opportunity for residents to unpack their thoughts on some of the more commonly shared difficult experiences faced such as violence in our communities, death and dying, and the ongoing fight to celebrate team diversity is critical to an emotionally-sustainable career.

From conversations with resident participants, we identified that they appreciated the podcast as an outlet for unloading their emotional cargo on to a wider audience. They found the process therapeutic and cathartic, and found value in using reflective practice techniques to support the conversation.

Challenges identified included learning the logistics of facilitating, recording, and editing podcasts. Recording clean audio was difficult in a large group with multiple voices present. Designating an individual to monitor audio in real-time to ensure speakers are at an appropriate distance from the microphone and ambient noise is minimized could improve the quality of the audio captured. Although strategies for cleaning up audio during the editing phase were identified, recording higher quality audio upfront and recording in a very quiet room makes this process significantly easier. After recording the episodes, the opportunity to rent space at a podcasting studio that can also perform podcast editing was identified and will be utilized for future recordings.

Read more about the IDEA Series.

References
  1. Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. October 2012:1377. doi:10.1001/archinternmed.2012.3199
  2. Lin M, Battaglioli N, Melamed M, Mott S, Chung A, Robinson D. High Prevalence of Burnout Among US Emergency Medicine Residents: Results From the 2017 National Emergency Medicine Wellness Survey. Ann Emerg Med. March 2019. https://www.ncbi.nlm.nih.gov/pubmed/30879701.
  3. Gunasingam N, Burns K, Edwards J, Dinh M, Walton M. Reducing stress and burnout in junior doctors: the impact of debriefing sessions. Postgrad Med J. 2015;91(1074):182-187. https://www.ncbi.nlm.nih.gov/pubmed/25755266.
  4. Michie S, Williams S. Reducing work related psychological ill health and sickness absence: a systematic literature review. Occup Environ Med. 2003;60(1):3-9. https://www.ncbi.nlm.nih.gov/pubmed/12499449.
  5. Kolb D, Fry R. Towards an applied theory of experiential learning. In: Theories of Group Processes. London: John Wiley & Sons; 1975:33-58.
  6. Gibbs G. Learning by Doing: A Guide to Teaching and Learning Methods. London: Further Education Unit; 1988.
Author information
Nicole Duggan, MD

Emergency Medicine resident
Harvard Affiliated Emergency Medicine Residency

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Welcome to Leg Day #4 of the SplintER Series! Ankle dislocations are an emergent condition in the Emergency Department (ED) that requires expert-level examination and management. We review the pertinent and subtle sports medicine examination and management techniques that will help you feel in control from time of presentation to disposition. 

Bottom Line
  • Closed ankle dislocations without any other fracture are rare. 
  • Posterior ankle dislocations are the most common type of ankle dislocation.
  • If patients have signs of neurovascular compromise or skin tenting from a posterior dislocation, they should be reduced immediately without waiting for radiographs. With an assistant, bend the knee, plantar-flex the ankle, and apply traction with an anterior force to the heel.
  • If high energy / complex fracture-dislocation, consider a post-reduction CT to ensure there are no additional injuries.
  • Place patients in a short posterior leg splint ± stirrup after reduction.
  • Bosworth fracture-dislocations, which will require an open reduction internal fixation, may be missed on plain film with CT imaging providing better visualization. 
  • Emergent orthopedics consultation should be obtained for an ankle dislocation if it is irreducible, associated with a fracture, demonstrates neurovascular compromise, or is open.
Ankle Dislocation: An Overview

Closed ankle dislocations without fractures are rare. Compared to uncomplicated fractures, the complication rate in ankle fracture-dislocations is tripled.1 Dislocations are classified based on the position of the talus relative to the tibia. Most commonly, ankle dislocations are posterior or lateral and require a high-energy mechanism.2,3 Lateral dislocations are more likely to be associated with an open fracture.

Skin tenting and neurovascular compromise are indications for immediate reduction without waiting for radiographs.4  After reducing the injury, neurovascular status should be re-confirmed, a splint should be applied, and imaging should be obtained to confirm alignment. The patient will need to be immobilized for approximately 6-9 weeks followed by physical therapy. Once rehabilitated appropriately, patients are usually able to return to their normal activities as before.5  

Anatomy Figure 1: Lateral View of the Ankle (Wikimedia Commons Public Domain by Jak)

The ankle is a stable joint due to the support given by the medial ligaments (deep and superficial deltoid) and lateral ligaments (anterior talofibular, calcaneofibular, posterior talofibular; Figure 1). The talus position in the mortise adds additional support. The anterior and posterior stability of the ankle is not as robust, considering that the joint capsule and surrounding musculature are supportive. In posterior ankle dislocations, for instance, when the ankle is plantar flexed it reciprocally causes the talus to be less stable in the mortise. The combination of axial, eversion, and/or inversion forces can then easily lead to the dislocation of the talus from the tibiotalar joint. 5,6

Physical Examination Findings

Document any obvious deformities, swelling, and presence of distal pulses (dorsalis pedis and posterior tibial). Compared to the lower leg, the foot will appear more posterior for posterior dislocations. Look for any breaks to the skin, which could indicate an open injury. Assess sensation at all surfaces of the foot (dorsum, plantar, lateral, medial).

Imaging Figure 2.Lateral (left image) and AP (right image) radiograph of a posterior ankle dislocation (image courtesy of Dr. Henry Knipe from the Radiopaedia case on Ankle Fracture-Dislocation)

For uncomplicated ankle dislocations, there should be no additional fractures and the tibiofibular syndesmosis should not be pathologically widened. With regards to posterior dislocations, the talus is located posteriorly to the tibia and may be better visualized on lateral views (Figure 2). While plain films should be the initial imaging study, CT imaging should be considered to evaluate for concomitant injury or osteochondral fragments trapped within the joint space.5

Bosworth Fracture-Dislocation
Figure 3: Plain films of a Bosworth fracture-dislocation of the ankle (image from The Orthopod 2014 case report)

The Bosworth fracture-dislocation is a rare entity, which is a posterior talar dislocation and displacement of the distal fibula posterior to the distal tibia, best noticed on the lateral xray. On plain film, it may initially appear as a posterior dislocation with a uni/bimalleolar fracture.7 However, it is extremely difficult to reduce as the proximal part of a fibular fracture becomes entrapped behind the lateral tibial tubercle. Reduction of the tibio-talar joint may be achieved in some circumstances; however, the fibular fragment will remain entrapped posteriorly. Given patient discomfort, positioning of lateral radiographs may not reveal the displacement. With a high degree of suspicion, CT imaging is recommended.7 Open reduction and internal fixation is necessary to achieve appropriate alignment.

Reduction Technique

Ensure the patient has received sedation and/or pain medications for comfort and to increase reduction success. Usually an assistant is needed to help with patient positioning and providing traction during the reduction procedure. When reducing any joint, the initial step is to recreate the mechanism. Knee flexion can help to remove tension on the Achilles tendon at the heel.5 

  • Lateral fracture-dislocations
    • Bend the knee 90°
    • Plantar-flex the ankle
    • Apply axial traction on the foot
    • Apply lateral traction proximal to and medial pressure distal to the injury
  • Posterior ankle dislocation2
    • Bend the knee 90°
    • Plantar-flex the ankle
    • Apply axial traction on the foot
    • Apply posterior traction proximal to and anterior pressure distal to the injury

Similar approaches are taken for medial and anterior ankle dislocations.

Splint

Patients should have a short leg posterior splint placed after reduction. A stirrup can provide additional stability.

Return Precautions & Post-Discharge Care

Similar to other lower extremity injuries, patients should be advised to keep their extremity elevated to reduce swelling. They should be given crutches and advised to be non-weight-bearing until re-evaluated by an orthopedist. They should be instructed regarding proper splint care and to monitor for new numbness, tingling, weakness, discoloration, or worsening pain for potential compartment syndrome. Decisions regarding DVT prophylaxis and anticoagulation should be made in conjunction with the orthopedist involved with the patient’s care. 

When to Consult an Orthopedist in the Emergency Department

Depending on the extent of injuries and institutional culture, initial orthopedic consultation and follow up scheduling can vary. Patients with signs of neurovascular compromise or skin tenting from an ankle dislocation should be reduced immediately without waiting for radiographs or an orthopedics consultation. Below is a general list of when to involve orthopedics:

  1. Persisting neurovascular compromise despite reduction
  2. Open fracture-dislocation
  3. Concurrent fractures
  4. Failed reduction attempts
Expert Evaluation and Pearls: Dr. Anna Waterbrook

Associate Professor of EM, University of Arizona Associate Program Director, Sports Medicine Fellowship Team Physician for the University of Arizona

  1. Neurovascular exam: Ankle dislocations typically occur due to a high mechanism force. They frequently have associated fractures and neurovascular (NV) injuries – it is imperative to perform a quick but thorough NV exam upon initial presentation and monitor that status throughout the ED course. Do not delay reduction for radiographs if there is compromise.  
  2. Soft tissue injury: Isolated dislocations can lead to significant instability due to ligamentous or cartilage injuries – there is a risk for chronic ankle instability.
  3. Unable to reduce: If unable to reduce the dislocation in the ED, consider a Bosworth fracture, underlying cartilage disruption, or osteochondral injury. CT imaging is recommended.
  4. Mimicker: Differentiate a true ankle (talar) dislocation from a subtalar dislocation, as the methods for reduction are different. Subtalar dislocations can be more difficult to reduce in the ED. 
  5. Post-reduction care: All patients with ankle dislocations being discharged require complete instructions including splint care, monitoring for complications, and close outpatient orthopedic follow-up. Ligaments are torn in dislocations and can sometimes result in chronic ankle stability.
References
  1. Carragee EJ, Csongradi JJ, Bleck EE. Early complications in the operative treatment of ankle fractures. Influence of delay before operation. J Bone Joint Surg Br 1991;73(1):79–82. PMID 1991782
  2. Handel DA, Gaines SA. Ankle Injuries. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill Education; 2016.
  3. Davenport M. Ankle [Internet]. In: Sherman SC, editor. Simon’s Emergency Orthopedics. New York, NY: McGraw-Hill Education; 2014.
  4. Schwartz DT. Chapter IV-1. Ankle Fractures. In: Emergency Radiology: Case Studies. New York, NY: The McGraw-Hill Companies; 2008.
  5. Mubark I, Anwar S, Hayward K. Closed posterior ankle dislocation without associated fractures: a case report. J Surg Case Rep 2017 [cited 2019 Apr 13];2017(8). PMID 28928920
  6. Agrawal AC, Raza H, Haq R. Closed posterior dislocation of the ankle without fracture. Indian J Orthop 2008;42(3):360–2. PMID 19753168
  7. Silverio A, Rebich E, Basso-Williams M, Vardiabasis N, Robinson M. Bosworth Ankle Fracture-Dislocation [Internet]. The Orthopod. [cited 2019 Apr 10]; Webpage available from: https://www2.aoao.org/members/news/2014winter/casereport2.html
Author information
Summer Chavez, DO MPH

Medstar Health, Health Policy Fellow
Georgetown University

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[Click for larger view]

Chief Complaint: Right lower extremity injury while spear fishing

History of Present Illness: A 33-year-old male went river fishing with a homemade spear and diving mask in Papua New Guinea. He felt sudden pain and tugging to the right lower extremity. He was near shore and grabbed a tree root. He held on for dear life as he was being pulled back into the water. It felt as if his foot had been torn off. He did not let go of the tree root and eventually the pulling force ceased. He got out of the water and walked 2 miles unassisted before finding help and hospital transport.

Extremity exam: The foot is well perfused, with sensation intact distally. Minimal movement of toes, no other foot movement.

X-ray: Reveals no fracture

Crocodile bite

The photo with the foot being held up shows the width of the crocodile mouth.

Crocodiles kill their prey by drowning. If this man would have let go of the root he would have died.

This wound was managed with a thorough washout under anesthesia, IV antibiotics, and splinting. The wounds was left open and transport was arranged to a surgical facility.

Do not swim alone in water inhabited by crocodiles.

Crocodile, Alligator, and Caiman Range by Country

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved.

Author information
Michael Parsa, MD

Associate Professor and Clerkship Director
Department of Emergency Medicine
Texas Tech University Health Sciences Center El Paso

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A 46 year-old male presents with wrist pain after sustaining a mechanical fall and catching himself on his outstretched hand. An anteroposterior (left) and lateral (right) plain films of the wrist are obtained (photo credit).

What is the diagnosis (hint – there are 2 findings), injury classification system, associated findings, and the recommended management plan?

Lunate dislocation with associated ulnar styloid fracture1

Mayfield Classification: A mechanism of forced wrist extension with ulnar deviation produces a classic pattern of injuries that progressively worsen in severity:1-4

  • Stage I: Scapholunate dissociation (Figure 2A)
  • Stage II: Perilunate dislocation (Figure 2B)
  • Stage III: Perilunate dislocation with dislocation of triquetrum
  • Stage IV: Lunate dislocation (Figure 2C)

Figure. A. Scapholunate dissociation evidenced by widening between scaphoid and lunate (Terry Thomas sign). B. Perilunate dislocation (note that lunate articulates appropriately with radius). C. Lunate dislocation (tipped teacup with normal alignment of radius and capitate). Images courtesy of Radiopaedia on scapholunate dislocation (Radswiki), lunate dislocation (Dr. Andrew Dixon), and trans-scaphoid perilunate dislocation (Dr. Andrew Dixon). These injuries are important to identify as misdiagnosis and mistreatment may result in chronic instability, arthritis, or scapholunate advanced collapse (SLAC) with significant functional impairment. 1, 3, 4

Pearls to assess for an occult scapholunate dissociation
  • Perform a Watson’s scaphoid shift test. Production of a clunk or pop during radial deviation or after releasing scaphoid pressure indicates possible scapholunate instability.4 The movement is the scaphoid subluxing or relocating, respectively.

Watson Test / Scaphoid Shift Test | Scapholunate Instability - YouTube
  • If you suspect this injury, obtain a clenched fist view or a PA view with the wrist in ulnar deviation to accentuate scapholunate dissociation.3
Due to proximity, a median nerve injury is common in lunate dislocation injuries.3,4

A lunate dislocation will likely require an orthopaedics or hand surgery consultation in the ED unless appropriately reduced and immobilized.

Overview on Lunate Injuries
  1. Scapholunate dissociation
  • Cock-up or volar wrist splint
  • Outpatient follow-up with an orthopedist or hand specialist within 1 week
  1. Perilunate or lunate dislocation
  • Consult an orthopedist or hand surgeon. Closed reductions are often unsuccessful.
  • If a specialist is not available, attempt closed reduction by applying traction, extending and ulnar-deviating the wrist to recreate the injury. Then perform carpal pronation, radial deviation, and wrist flexion.1
  • Indications for emergent surgery include:
    • Open dislocation
    • Median nerve involvement
    • Unsuccessful closed reduction
  References
  1. Kennedy SA, Allan CH. In brief: Mayfield et al. classification: Carpal dislocations and progressive perilunar instability. Clin Orthop Relat Res. 2012;470(4):1243-1245. PMID 22322787
  2. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5:226–241. PMID 7400560
  3. Williams D, Kim H. Wrist and forearm. In: Marx J, ed. Rosen’s Emergency Medicine Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier, Saunders; 2014: 570-595.e2
  4. Tsyrulnik A. Emergency department evaluation and treatment of wrist injuries. Emerg Med Clin N Am. 2015;33(2): 283-296. PMID 25892722

For more cases like these, you can subscribe to the Ortho EM Pearls email series hosted by Drs. Will Denq, Tabitha Ford, and Megan French, who have kindly shared some of their content with ALiEM.Click edit button to change this text.

Author information
Tabitha Ford, MD

Chief Resident
Department of Emergency Medicine
University of Utah

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Chief Complaint: Abdominal distention

History of Present Illness: A 36-year-old male with a history of cerebral palsy, gastrointestinal dysmotility, epilepsy, hypertension, gastroesophageal reflux disease, and insomnia presents to the ED after referral by his family physician for a 3-day history of abdominal distention. Due to the patient’s neurological disorder, he is unable to communicate but is accompanied by his mother who provides his medical history. The patient’s mother states that he had a loose bowel movement this morning, which is normal for him. He has had a history of bowel problems since the age of 14. Two months previously the patient was admitted for abdominal distention and had a rectal tube placed which relieved his symptoms. The patient has not experienced nausea, vomiting, or changes in bowel movements.

Vitals:

  • BP 145/104
  • Pulse 82
  • Respiration Rate 18
  • Temp 97.7C

General: Patient is lying in bed in no acute distress

Abdominal: Abdomen is grossly distended, tympanic to percussion, and bowel sounds are present in all 4 quadrants and not high-pitched

Neurologic: Patient is nonverbal but able to follow mother’s commands; unable to assess cranial nerves

Rectal: Tense rectal tone

A BMP and CBC were both within normal limits.

Ogilvie Syndrome

Neostigmine can be given IV to cause rapid colonic decompression.

Ogilvie syndrome is a rare condition characterized by non-obstructive colonic distension due to loss of proper peristalsis. The condition is most common in patients with underlying medical conditions and those that are hospitalized, institutionalized, or have recently undergone surgery.

Patients typically present with abdominal distension and pain, nausea, and vomiting. Complications include ischemic bowel and perforation, and therefore rapid treatment is imperative. Diagnosis is based upon the patient’s history, presentation, plain abdominal films, and computed tomography. Acquiring a clear history, physical examination, and imaging is necessary to rule out other forms of colonic distension.

Treatment depends on the severity of the patient’s presentation but includes observational, medical, and surgical options. Medical therapy includes treatment of underlying conditions that may have precipitated colonic dysmotility, discontinuation of any anticholinergic and opioid medications, and the use of neostigmine for rapid decompression. Decompression can also be achieved through placement of a rectal tube. Patients may additionally benefit from a nasogastric tube to reduce the amount of air entering the bowels. Surgical intervention is reserved for those that fail conservative management and includes cecostomy and colectomy depending on the severity of the condition and presence of complications such as bowel ischemia and perforation.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved.

Author information
Benjamin Gibson

Medical Student
University of South Alabama College of Medicine

|

The post SAEM Clinical Image Series: Distended Bowels appeared first on ALiEM.

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Chief Complaint: Possible seizure, Left arm rash

History of Present Illness: A 29-year-old with a history of migraine headaches, thalassemia of unknown phenotype, and no history of hypertension or epilepsy arrived to the emergency department via ambulance after possible seizure. The patient had nausea and vomiting the morning after a night of heavy drinking. After several rounds of vomiting, she felt shaky, lightheaded and experienced paresthesia in both of her hands and feet. There was no loss of consciousness, confusion or incontinence. EMS reported hypertension and tremors with upper extremity spasms. The patient developed a left upper extremity rash distal to the blood pressure cuff after paramedics did the first blood pressure measurement.

General: 162/103, otherwise normal vital signs

HENT: Oropharynx clear, no sign of tongue biting

Skin: Petechial rash that covered the distal left upper extremity to the proximal arm, with a sharp line of demarcation where the blood pressure cuff was located.

Neurologic: GCS 15, unremarkable.

BMP: Hypokalemia

CBC: Hemoglobin 12.2 g/dL with MCV of 65.5 FL. Platelet count 258,000 platelets/µL.

Coagulation studies: Within normal limits

Creatine kinase: 914 U/L

Urine dip: Positive for hematuria with scant red blood cells

The Rumpel-Leede phenomenon is a rare condition in which the small dermal capillaries rupture in response to compression of the extremity, leading to the development of a petechial rash distal to the site of compression. This phenomenon commonly presents in the setting of thrombocytopenia or microvascular fragility that is due to hypertension (hypothesized to be due to elevated venous pressures) or diabetes (due to microvascular injury).

Also seen in patients with:

  • Ehlers-Danlos
  • Platelet dysfunction
  • Intravenous drug use
  • Chronic steroid use
  • Mechanical trauma
  • Infections (e.g. Dengue fever)

The high red blood cell turnover in thalassemia causes an overall increase in bodily absorption of iron. Increased amounts of iron can lead to the creation of reactive oxygen species, such as via the Fenton Reaction. These reactive oxygen species are believed to be involved in various vascular disorders, possibly predisposing the patient to this phenomenon.

The patient’s vessel injury due to thalassemia, her hypertensive state, and the blood pressure cuff inflation together could have led to the occurrence of the Rumpel-Leede phenomenon.

There are no known consequences of the Rumpel-Leede phenomenon. The patient’s petechiae resolved in just over one week, consistent with the typical spontaneous resolution of the rash within 6 to 14 days.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved.

Author information
Mallory Hawksworth

University of Illinois at Chicago College of Medicine

|

The post SAEM Clinical Image Series: Rash with Blood Pressure Cuff Inflation appeared first on ALiEM.

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Our ALiEMU learning management system, which currently houses the AIR series, Capsules series, and In-Training Exam Prep courses, is ready to slowly open the doors to welcome external authors with high quality content. We are thrilled to welcome a UCSF-sponsored pediatric emergency medicine (EM) point of care ultrasonography (POCUS) series, led by Dr. Margaret Lin. The first course is on the intussusception scan, filled with multiple ultrasound scans showing normal variants and two different types of intussusception.

Why learn the intussusception POCUS scan?  

Although few studies have looked at POCUS for intussusception, the existing studies have shown excellent test characteristics and a decreased length of stay with this technique.

Two studies assessed the test characteristics of the intussusception POCUS.

PublicationStudy MethodologySensitivitySpecificity
Riera et al. (2012)​1​ This journal publication was a prospective study of 82 patients who underwent POCUS by pediatric emergency medicine (PEM) providers. The gold standard was a comprehensive radiology ultrasound.85%97%
Trigylidas et al. (2017)​2​ This abstract reported a retrospective study of 105 intussusception POCUS scans by PEM providers. The gold standard was either a direct radiology over-read of the POCUS scans or a radiology department ultrasound.96.2%92.6%

UCSF Sponsorship

Congratulations and thanks to the UCSF Division of Pediatric Emergency Medicine for hosting and sponsoring this series on ALiEMU, where we hope to continue host core educational content for EM residents and other lifelong learners.

If you are interested in authoring and hosting peer reviewed, online educational content on ALiEMU, please contact us for more information.

Image credit: By Olek Remesz (Wikimedia, CC-BY-SA-3.0)

References
  1. 1.
    Riera A, Hsiao A, Langhan M, Goodman T, Chen L. Diagnosis of intussusception by physician novice sonographers in the emergency department. Ann Emerg Med. 2012;60(3):264-268. https://www.ncbi.nlm.nih.gov/pubmed/22424652.
  2. 2.
    Trigylidas TE, Kelly JC, Hegenbarth MA, Kennedy C, Patel L, O’Rourke K. 395 Pediatric Emergency Medicine-Performed Point-of-Care Ultrasound (POCUS) for the Diagnosis of Intussusception. Annals of Emergency Medicine. October 2017:S155. doi:10.1016/j.annemergmed.2017.07.365
Author information

ALiEM Editor-in-Chief
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

The post Pediatric Point of Care Ultrasonography ALiEMU Course on Intussusception appeared first on ALiEM.

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This abnormal ECG would be typical following an overdose on which of the following medications?

  1. Amitriptyline
  2. Buspirone
  3. Citalopram
  4. Haloperidol

Answer: 1
Amitriptyline

TCA Poisoning & ECGs

The above shows classic ECG findings seen with tricyclic antidepressant (TCA) poisoning. Cardiac toxicity from TCA is secondary to cardiac sodium (Na+) channel blockade, cardiac potassium (K+) efflux blockade, and direct alpha-1 antagonism [1,2]. Cardiac Na+ channel blockade leads to a widening of the QRS interval, cardiac K+ efflux blockade causes widening of the QTc interval, and alpha-1 antagonism causes hypotension [2]. TCA toxicity produces characteristic ECG findings including QRS interval widening >100 msec and terminal R wave in aVR (defined as ≥3 mm in aVR) [3]. QRS widening ≥160 msec increases the risk for ventricular dysrhythmias and >100 msec increases the risk of seizures [3,4].

Presentation

TCAs such as amitriptyline are used for depression, neuralgic pain, migraines, enuresis, and ADHD. Their therapeutic mechanism is inhibition of norepinephrine and/or serotonin reuptake; however, they also have anticholinergic, antihistamine, and anti-alpha-1 adrenergic effects [1].

Following overdose, patients will initially have an anticholinergic toxidrome. This may include altered mental status, dry mucosal membranes, urinary retention, mydriasis, tachycardia, and anhidrosis [2]. Seizures often occur in TCA overdose and are likely related to the increased amounts of norepinephrine, anticholinergic tone, Na+ channel blockade, and GABA inhibition [1,5]. Cardiac conduction disturbances may degenerate into malignant ventricular dysrhythmias and cardiac arrest [1-5].

Treatment

The first line agent for the treatment of cardiac Na+ channel blockade is sodium bicarbonate. Sodium will increase the electrochemical gradient of the Na+ channels assisting in the generation of action potentials in the Purkinje fibers [6]. The bicarbonate will alkalize the serum decreasing the free and ionized fraction of the TCA that is available to bind to the Na+ channel [6]. Initial bolus dose is 1-2 mEq/kg, repeated every 5 minutes until narrowing of the QRS interval has occurred or limited by hypernatremia or alkalosis [1,2]. These numerical value limitations are frequently set at 155 mmol/L for serum sodium and 7.55 for serum pH [2,7].

Seizure management with benzodiazepines and barbiturates is recommended, as seizures cause acidosis which can worsen cardiotoxicity [1,2]. Extracorporeal membrane oxygenation (ECMO) has also been used in severe cases [1,2].

Take Home Bedside Pearls
  • TCA toxicity causes cardiac Na+ channel blockade, leading to an abnormal ECG with widened QRS interval and arrhythmia.
  • Sodium bicarbonate is the preferred treatment for TCA induced QRS prolongation.
  • Aggressive seizure management with benzodiazepines is important as acidosis can precipitate worsening cardiotoxicity.

This post was expert peer-reviewed by Dr. Michelle Burns, Dr. Bryan Judge, & Dr. Louise Kao.

The American College of Medical Toxicology hosts this Toxicology Visual Pearls series.

References
    1. Liebelt E. Cyclic Antidepressants. In: Goldfrank’s Toxicologic Emergencies. 10e Eds. Robert S. Hoffman et al. New York, NY. McGraw-Hill. 2015.
    2. Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a review. Emerg Med J 2001;18(4): 236-241.
    3. Liebelt E et al. ECG lead AVR versus QRS interval in predicting seizures and arrhythmias in acute tricyclic antidepressant toxicity. Ann Emerg Med. Aug 1995; 26(2):195–201.
    4. Boehnert M. Value of the QRS Duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. NEJM. Aug 22 1985; 13(8):474-479.
    5. Citak A et al. Seizures associated with poisoning in children: Tricyclic antidepressant intoxication. Pediatr Int. 2006; 48(6): 582–85.
    6. Bruccoleri RE & Burns M. A Literature review of the use of sodium bicarbonate for the treatment of QRS widening. J Med Toxicol 2016; 12(1):121–29.
    7. Seger DL, Hantsch C, Zavoral T, Wrenn K. Variability of recommendations for serum alkalinization in tricyclic antidepressant overdose: a survey of U.S. Poison Center medical directors. J Toxicol Clin Toxicol 2003; 41(4):331–338.
Author information
Colin O'Neill, MD

Emergency Medicine Resident
Carolinas Medical Center, Charlotte, NC

|

The post ACMT Toxicology Visual Pearls: Abnormal ECG appeared first on ALiEM.

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In January of 2019, ALiEM was able to continue leveraging the power of social media by delivering high quality educational content to Instagram. We love your enthusiasm for our weekly #TrickoftheTradeTuesday posts and hope you check out our content if you haven’t visited yet. It has been inspiring to follow the many residency programs who have a presence on Instagram, and so we’ve come up with a way to try and help you disseminate all of your hard work. Read on to learn more about the ALiEM “Gram” Rounds!

The Idea

Your conference didactics, gamification, and wellness initiatives have blown us away and got us thinking: what if we could help residency programs disseminate the amazing teaching points, educational innovations, and on shift learning to a broader audience? 

Contest Details

ALiEM is proud to introduce the ALiEM ‘Gram’ Rounds Contest. We are looking to crown one residency program as the world’s most educationally innovative and engaging program. Follow these steps in order to participate:

  1. Follow @aliemteam on Instagram. Encourage all residents, medical students, faculty, and official residency profiles from your program to follow so they can participate. The more engagement, the better chance of winning!
  2. From July 1st to July 12th, if you have an awesome teaching point or wellness activity related to your residency, snap a photo or video and add it to your Instagram Story. 
  3. Tag @aliemteam in the post and use the hashtag #ALiEMGramRounds
  4. Be sure to denote which residency you are part of so your program can receive credit!

The residency with the combination of most tags and most creative content will be the winner of ALiEM Gram Rounds. Winners will be exclusively featured on the ALiEM Instagram Account with a spotlight video highlighting your residency, educators, and content! The contest will take place July 1st-12th and any emergency medicine training program can compete (including PAs and NPs). Happy Gramming!

Author information
Gabe Sudario, MD

ALiEM Instagram Director
Multimedia Design Education Technology Fellow
Clinical Instructor of Emergency Medicine
University of California, Irvine
2015 ALiEM Essentials of EM Fellow

| Twitter |

The post ALiEM “Gram” Rounds | Contest Announcement! appeared first on ALiEM.

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