septic arthritis vs. transient synovitis in kids

HOW CAN WE TELL THE DIFFERENCE?
--lots of overlap in signs/symptoms
--one article came up with a decent decision rule


J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.
--looked at 282 cases, excluded 114 atypical patients (e.g. immunocompromised), leaving 168
--38 had "true" septic arthritis
--septic arthritis defined by positive culture or joint WBC >= 50,000 cells/mm3

--four things they decided on that might differentiate:

• history of fever
• non-weight-bearing
• erythrocyte sedimentation rate (ESR) >= 40 mm/hr
• serum WBC > 12,000 cells/mm3

--predicted probability of septic arthritis using these four predictors:

• < 0.2 percent for zero predictors
• 3.0 percent for one predictor
• 40.0 percent for two predictors
• 93.1 percent for three predictors
• 99.6 percent for four predictors

BOTTOM LINE:
--septic arthritis is bad, transient synovitis not so bad
--hard to tell sometimes, signs/symptoms are often similar
--useful: history of fever, non-weight bearing, ESR>40, WBC>12k
--if none of the above: unlikely septic arthritis
--more of the above: worry a bit more


Submitted by S. Lee.


Reference(s): kocher article, picture

chest pain with recent negative stress test

EP MONTHLY EXCERPT:
--nice overview on stress tests from March 2011(see reference link)


DOES THE RECENT NEGATIVE STRESS MEAN THIS PATIENT CAN'T HAVE ACS?
--No.
--stress tests are good, not great


SOME ROUGH EXAMPLES:
--Sensitivity for single vessel CAD:

• exercise ECG stress test ~68%
• exercise nuclear stress test (thallium) 60-82%
• exercise nuclear stress test (sestamibi) 82-97%
• adenosine/dipyridamole nuclear stress 77-92%
• dobutamine nuclear stress 80-100%

BOTTOM LINE:
--stress sensitivity is not perfect
--negative stress test does NOT rule out ACS


Reference(s): ep monthly article, picture

blood gas vs. serum electrolytes

HOW CLOSE ARE THEY?
--not a lot of data
--pubmed biopsy produced only 2 articles


ARTICLE 1:
--"Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the emergency department"
--looked at 46 DKA patients, compared serum and VBG electrolytes

• sensitivity of VBG electrolytes for diagnosing DKA: 97.8%
• specificity of VBG electrolytes for diagnosing DKA: 100%
• Correlation coefficients between VBG and serum chemistry
• sodium 0.90
• chloride 0.73
• bicarbonate 0.94
• anion gap 0.81

ARTICLE 2:
--"Comparison of the point-of-care blood gas analyzer versus the laboratory auto-analyzer for the measurement of electrolytes"
--looked at 200 ICU patients, compared ABG and serum lab Na+ and K+

• mean ABG sodium value was 131.28 (SD 7.33)
• mean lab sodium value was 136.45 (SD 6.50) (p < 0.001).
• mean ABG potassium value was 3.74 (SD 1.92)
• mean lab potassium value was 3.896 (SD 1.848) (p = 0.2679).

--conclusions: no significant difference between the potassium values; however, the difference between the measured sodium was found to be significant
--decisions can be made by trusting the K+ values obtained from ABG (less so with the sodium)


BOTTOM LINE:
--how close are blood gas electrolytes to the lab serum electrolytes?
--not much data, seems close enough for acidosis, potassium
--not as good for sodium



Submitted by S. Lee.


Reference(s): article 1, article 2, picture

should you give prophylactic antibiotics for intraoral wounds?

GOOD QUESTION:

--(anecdotally) many intraoral lacerations seem to be people biting themselves or somehow teeth-related
--do we need to treat these like other bite wounds? (e.g. with antibiotics)


THE DATA (sort of):
--limited studies with small numbers

--no statistically significant differences in the incidence of infection with systemic oral antibiotics vs placebo.

--trends indicate a decrease in the rate of infection if patients comply with antibiotic regimens

--a report showing no infection in 28 children who did not receive antibiotics

--suggestions include prescribing antibiotics for dirtier wounds, through & through lacs, and bite-related wounds


BOTTOM LINE:
--data is inconclusive (awesome)
--use your clinical judgment (wasn't this helpful?)
--deeper, dirtier, delayed presentation, etc---common themes for recommending antibiotics
--augmentin or clindamycin are decent choices, if antibiosing


Submitted by S. Lee.


Reference(s): annals review; trauma review; uptodate.com: evaluation and repair of tongue lacerations; picture

should we pack an abscess after I&D?

ABSCESS PACKING DATA:

--very limited, based on Pubmed biopsy


REVIEW ARTICLE:
--referenced one small article, and that was it


ONE SMALL ARTICLE:
--"determine whether the routine packing of simple cutaneous abscesses after incision and drainage (I&D) confers any benefit over I&D alone"
--prospective, randomized, single-blinded trial, N =48

• no significant difference in need for a second intervention at the 48-hour follow-up between the packed (4 of 23 subjects) and nonpacked (5 of 25 subjects) groups (p = 0.72; relative risk = 1.3, 95% confidence interval [CI] = 0.4 to 4.2)
• higher pain scores immediately postprocedure in packed group and at 48 hours postprocedure
• greater use of ibuprofen and oxycodone/acetaminophen in packed group 

ABOUT PERIANAL ABSCESSES:
--"designed to show that perianal abscess may be safely treated by incision and drainage alone" vs. I&D + packing
--50 patients were recruited (7 lost to follow-up); 20 in the packing and 23 in the nonpacking arm

• Mean healing times were similar ( P = 0.214).
• The rate of abscess recurrence was similar ( P = 0.61).
• Postoperative fistula rates were similar ( P = 0.38).
• Pain scores at the first dressing change were similar ( P = 0.296).
• Although pain scores appeared much reduced in the nonpacking arm, this did not attain statistical significance

BOTTOM LINE:
--limited data out there on packing abscesses
--packing doesn't seem to improve healing or reduce recurrence
--packing might hurt more
--probably ok to NOT pack abscess after I&D


Submitted by S. Lee.


Reference(s): review article, one small article, perianal abscess article, picture

management of diabetic ketoacidosis (DKA) in adults

DKA Basics
-Definition:  Blood glucose >250 (e.g. diabetic), moderate ketonemia, anion gap >10, Bicarbonate <15, and pH <7.3 (acidosis)

-Metabolic acidosis, hyperglycemia, hyperosmolality, potassium depletion, and hypovolemia

-Infection is often a precipitating event

Initial Labwork:

-Serum electrolytes

-Calculate Anion gap
-CBC
-UA
-Plasma osmolality
-ABG
-EKG
-Blood cultures, urinalysis, CXR to determine possible infectious cause

Hyperglycemia and Serum Sodium:

-Corrected Serum Na = Measured Na + 0.024 * (Serum glucose - 100)

-boils down to this: add 1.2 to the sodium for every 50 mg/dL over 100

Management:
Order of priorities is volume first, correction of potassium deficits, and then insulin administration
1.      ABCs
2.      get labwork and investigate source of DKA/HHS (infectious causes)
3.      Fluid resuscitation with isotonic saline (Increases insulin responsiveness by lowering plasma osmolality)
4.      Insulin therapy (after confirmation of potassium greater than 3.3) --bolus of Regular Insulin IV followed by an insulin drip

5.      KCl is generally added to the replacement fluid once the serum K+ falls below 5.3
6.      When the serum glucose reaches 200 in DKA or 250-300 in HHS, saline is switched to dextrose containing solution
NOTE:  Use of supplemental bicarbonate in the DKA is not recommended

Submitted by J. Grover.

Reference(s): Tintinalli’s 7^th edition, uptodate.com, picture

the TASER-ed patient

PHYSIOLOGY OF TASERS:
--nice article in Emergency Medicine News from Feb '12 (link below)


HIGHLIGHTS:
--TASERs deliver electrical current to cause diffuse muscular contraction, thus incapacitating

--people who need to be TASERed may be drugged up, overexherted, or sustain trauma, so there are other things to think about

--in studies with healthy subjects, there were minimal (returning to baseline in 10 minutes) or no changes in pulse, 02 saturation, bicarb, lactate, electrolytes, troponin, EKGs, acidosis


EVERYTHING'S RELATIVE:
--TASER joule output: 0.36-1.76 joules


RANDOM FACT:
--TASER stands for "Thomas A. Swift's electric rifle", after the developer's childhood hero


BOTTOM LINE:
--asymptomatic, awake post-TASERed patient, unlikely to need routine labs/monitoring


Submitted by S. Lee.


Reference(s): EMN article, review article, taser joules, picture

lumbar puncture (sitting) procedure video

TEST VIDEO 2:
--lumbar puncture (sitting upright, does not cover opening pressure measurement)


LUMBAR PUNCTURE (sitting):

rapid chest tube (procedure video)

TEST VIDEO:
--planning a series of short, just-in-time procedure videos, goal being to keep them 1-3 minutes (as short as possible), and keep it to the bare-bones key points that you'd need to know if you need a quick refresher.
--here's one:

RAPID CHEST TUBE (TUBE THORACOSTOMY):

How likely is this septic patient to die?

Submitted by E. Hawkins.

needle thoracostomy: optimal site?

TRADITIONAL SITE:
--2nd intercostal space, mid-clavicular line


ALTERNATIVE SITE:
--4th/5th intercostal space, mid-axillary line (chest tube site)


CADAVER STUDY:
--2nd intercostal, mid-clavic: needle thoracostomy successfully placed in 58% (23/40)
--5th intercostal, mid-ax: needle thoracostomy successfully placed in 100% (40/40)


CT MEASUREMENT:
--distance from skin to pleura at:

• anterior 2nd intercostal space averaged 46.3 mm on the right and 45.2 mm on the left
• midaxillary line, 4th intercostal space was 63.7 mm on the right and 62.1 mm on the left
• midaxillary line, 5th intercostal space was 53.8 mm on the right and 52.9 mm on the left

KINKING STUDY:
--significant pressure difference required to achieve free flow through the in situ angiocatheter

• 2nd intercostal space midclavicular line (7.9 ± 1.8 mm Hg)
• 5th intercostal space midaxillary line (13.1 ± 3.6 mm Hg )

BOTTOM LINE:
--2nd intercostal space, mid-clavicular line (classic site): tougher to find, but less tissue in between, less kinking
--5th intercostal space, mid-axillary line: easier to aim, but more distance (especially with rising obesity) to the pleura, risk of kinking


Submitted by S. Lee.


Reference(s): cadaver study; CT study; kinking study; picture

Predictors of Pneumonia in Peds ED

•Prospective cohort study in urban peds ED with 2574 patients < 21 years old (most < 5 years old)

•Looked at history and physical exam findings that correlated with radiographic (i.e. CXR) pneumonia (PNA)

•16% of patients had radiographic PNA

•Significant predictors of PNA

• chest pain
• focal rales
• fever > 72 hours
• O2 sat < 92%

•Limits of study: not blinded, did not study all patient with cough or fever, do not know reliability of physical exam findings, did not include children who had suspected PNA but did not get a CXR

•Take home: There is not a great clinical prediction rule for whether to get CXR on kids with respiratory complaints and fever.

•Best of a bad situation: Single best predictor of radiographic PNA in kids < 5 = O2 sat < 92%

Submitted by F. DiFranco.

Reference(s): Neuman M.I., Monuteaux M.C., ScullyK.J., Bachur R.G. Prediction of pneumonia in a pediatric emergency department. Pediatrics.128(2):246-253, 2011; picture

migraine headache treatment

Submitted by E. Hawkins.

asthma and nebulizer treatments

Submitted by E. Hawkins.

Simple Partial Status Epilepticus

Submitted by E. Hawkins.

Serotonin syndrome (quick review)

BASICS:
-Caused by excessive stimulation of 5-HT1A and 5-HT2A receptors
-Combination of autonomic instability, mental status change, and increased neuromuscular tone


CLINICAL FINDINGS:
-Acute hyperthermia, hypertension, tachycardia, dilated pupils, agitation with delirium, muscle rigidity, diaphoresis (e.g. sympathomimetic picture)

-slow continuous horizontal nystagmus (ocular clonus), hyperreflexia, tremor, and ankle clonus.
-Muscle rigidity is especially prominent in the lower extremities when present.
-If left untreated: rhabdomyolysis, metabolic acidosis, renal failure, seizures, shock

MECHANISM OF SSRIs:

-Inhibit the reuptake of Serotonin selectively in CNS neurons as well as peripherally, increasing the stimulation of the serotonin receptors.

Disparity between SSRI and SNRI toxicity
-SNRIs are associated with greater risk of mortality in overdose; extended release medications require longer observation and are associated with higher morbidity/mortality
-Only 10-14 percent of SSRI overdose lead to serotonin syndrome, but most of these are mild presentations.


MANAGEMENT:
-Supportive Care is the primary treatment
-Watch for QTc prolongation (greater than 560 msec)- monitor with serial EKGs
-Seizures are more common with SNRI than SSRI
-Severe cases (muscular rigidity and core temperature >41) require paralysis, intubation, and external cooling
-Benzodiazepines are non-specific serotonin antagonists, promote muscle relaxation, and are effective at preventing seizures
-Cyproheptadine is an effective anti-serotoninergic agent. It is given orally, with initial dose of 4 to 12 milligrams PO. It can be repeated in 2 hours.
-Dantrolene can be used for malignant hyperthermia

10-SECOND RECAP:

-serotonin syndrome is not cool
-looks a bit sympathomimetic, + hyperreflexia, clonus, horizontal nystagmus
-tx: supportive care, benzos, cyproheptadine, maybe dantrolene

Submitted by J. Grover.

Reference(s): Tintinalli’s Emergency Medicine and Uptodate article entitled “SSRI Poisoning”, picture

pulmonary embolism and the pregnant patient

Submitted by E. Hawkins.

Do steroids prevent post-herpetic neuralgia in shingles?

Submitted by E. Hawkins.

indications for inpatient operative management of an ankle fracture

Submitted by E. Hawkins.


Reference(s): quick read, worth the trip--Management of ankle fractures. Mordecai S, Al-Hadithy N. BMJ. 2011 Oct 28;343:d5204. doi: 10.1136/bmj.d5204. http://www.ncbi.nlm.nih.gov/pubmed/22039272

autoimmune diseases and pulmonary embolism

RAGING HYPOTHETICAL:
--you have a patient with an autoimmune disease & symptoms of a PE. d-dimer might be elevated anyways. how worried should you be about a PE?


SURPRISING NUMBERS:
--In a January Lancet article, a cohort of patients with autoimmune diseases were found to have a higher chance of having a pulmonary embolism. 
--for example: The Odds Ratio (OR) for a patient having polymyalgia rheumatica is 7.86.
--check out this table from the article:

Submitted by T. Boyd.


Reference(s): Risk of pulmonary embolism in patients with autoimmune disorders. Lancet 2012;379:244-49.

succinylcholine and hyperkalemia

Submitted by K. Sullivan.


Reference(s): Rosen's. as if you don't know which one.