You remembered from your evidence-based review of the literature that there is no serum blood test that can adequately rule out septic arthritis, so the patient’s history and exam warranted arthrocentesis. After laying the patient flat and partially flexing the knee with a pillow, you guided the needle medially under the patella and you aspirated watery, but cloudy, material. A point-of-care sLactate came back quickly at 15 mmol/L, and removed any ambiguity — this was a septic joint. While synovial culture and Gram stain (and blood cultures) were sent, along with sWBC and pre-op labs, you initiated IV antibiotics — vancomycin and ceftriaxone. Then you called up the orthopedist and asked him to prepare the OR.

Congratulations to  Dr. Lalitha, Dr. Averick, Dr. Karagöz, Dr. Piebalga, and Dr. Dube— this month’s winners of the exclusive discount coupon for Emergency Medicine Practice For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Monoarticular Arthritis, purchase this issue.

What do you do next?

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A subdural or epidural hematoma would have to be extensive to cause hemiparesis, hemisensory loss, and neglect. A Todd paralysis after seizure was possible, but was considered only after ischemic causes were ruled out. Since the initial noncontrast head CT showed a small subdural hematoma, ischemic stroke was the next most-worrisome possibility. Concern for dissection should be raised when ischemic stroke is considered in the setting of trauma. A CTA was obtained that showed near occlusion of the right internal carotid artery. IV tPA was not administered for this traumatic dissection for concern of worsening or creating hemorrhagic complications. Interventional neuroradiology was consulted immediately, and the patient was placed on a heparin infusion as a bridge to the procedure. Stenting of the vessel was performed, and though it was not successful in reversing her neurological deficits, it may have prevented further ischemic damage.

Congratulations to  Dr. Cohen, Dr. Orecchioni, Dr. Brown, Dr. Averick, and Dr. Kerr— this month’s winners of the exclusive discount coupon for Emergency Medicine Practice For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Carotid And Verebral Arterial Dissections, purchase this issue.

Is there anything you should be doing?

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The patient had clearly developed pneumonia, which was unsuccessfully treated from the previous hospitalization, and nowhttp://www.ebmedicine.net/empblog/wp-admin/post.php?post=40&action=edit&message=1 presented with severe sepsis. You treated her with broad-spectrum antibiotics, taking into account her risk for gram-negative bacteria, and started crystalloid infusion to support her hemodynamically. You found that the she had developed rhabdomyolysis from sepsis and had already developed acute renal failure, with a BUN:Cr ratio concerning for myoglobinuria-induced renal failure. You checked the urine pH, which was 4.6, and switched her normal saline to 0.45% saline with 2 ampules sodium bicarbonate per liter to alkalinize the urine to a pH > 6.5. You continued early goal-directed therapy, performed endotracheal intubation to decrease her work of breathing, and consulted your intensive care unit for admission.

Congratulations to  Dr. Hugo, Dr. Anda, Dr. Achacoso, Dr. Cohen, and Dr. Peschanski— this week’s winners of Emergency Medicine Practice’s “Rhabdomyolysis: Advances In Diagnosis And Treatment!” For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Rhabdomyolysis, read this issue.

This case reminds you that rhabdomyolysis has many causes, but the treatment in all cases is based on an aggressive hydration strategy. You recall that sodium bicarbonate infusion may be indicated and wonder: when, and how should it be initiated? You also wonder, “Is there anything else I can do for this patient that would mitigate against complications from renal failure?”

What’s Your Next Step?

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The local Poison Control Center was promptly contacted and the controversies, risks, and benefits of HBO treatment were discussed. The local HBO center was contacted and because of its close proximity and because the patient had evidence of end-organ damage, the decision was made to transfer the patient for treatment. She received an aspirin for her ECG changes and was transferred with ongoing NBO therapy. The HBO treatment was provided without complication. The patient was admitted to the medical service, after which she underwent 2 additional “dives” during her hospitalization. Her 6-hour troponin I level peaked at 2.1 mg/L, and an ECG obtained at that time had returned to her baseline. Subsequent cardiac biomarkers were obtained 12 hours after presentation and were normal. She remained hemodynamically stable and free of symptoms during her hospitalization. After undergoing stress echocardiography testing on hospital day 2, which did not reveal evidence of reversible myocardial ischemia, she was discharged on hospital day 3. At a 6-week clinic follow-up appointment, she denied any symptoms and had a normal examination. However, she said she had sold her apartment and moved in with her son’s family.

Congratulations to Dr. Aziz, Dr. Garcia, Dr. Koury, Dr. Luvetz, and Dr. Stanley — this week’s winners of Emergency Medicine Practice’s “Advances In Diagnosis And Management Of Hypokalemic And Hyperkalemic Emergencies!” For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for detecting hypokalemia and hyperkalemia, read this issue.

What’s Your Next Step?

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The 35-year-old female was young and healthy, and therefore a decision was made for outpatient management that included coverage for atypical organisms. In the ED, 500 mg of azithromycin was administered and a prescription for 4 additional days at 250-mg-per-day dosing was provided. She was given strict instructions to return if she felt more shortness of breath or worse in any way. She followed up with her primary care doctor in 3 days, feeling much better.

The 70-year old female was presumed to have a mild delirium induced by her UTI. She was given IV ciprofloxacin, and her mental status returned to normal on hospital day 2. Her urine culture grew E coli sensitive to fluoroquinolones, and she was discharged on oral ciprofloxacin on hospital day 4.

The 23-year-old with the infected forearm had the abscess incised and drained in the ED. Because there was also a surrounding cellulitis, he was given oral trimethoprim-sulfamethoxazole and instructed to return for a wound check. His arm was markedly improved by a day 3 wound check, and his wound culture was positive for CA-MRSA.

The 85-year-old from the nursing home had a CT of the abdomen and pelvis that revealed diverticulitis with no evidence of abscess or perforation. Treatment with cefepime and metronidazole was initiated, and he was admitted. The hospital discharge summary indicated that he defervesced after 4 days and was sent back to the nursing home on day 8.

Congratulations to Dr. Barone, Dr. Brown, Dr. Cohen, Dr. Nabhani, and Dr. Tampi— this week’s winners of Emergency Medicine Practice’s “Evidence-Based Guidelines For Evaluation And Antimicrobial Therapy For Common Emergency Department Infections!” For a discussion of common infectious diseases presenting to the ED and a review of the current literature and guidelines, read this issue.

The second patient on your tracking board is a 70-year-old female with fever, nausea, and back pain for 3 days. She is accompanied by her daughter, who states her mother hasn’t been herself today and that she had a similar presentation when she had a UTI 2 years ago. She is febrile to 38.3°C (101°F), oriented x2, with left costovertebral angle tenderness. Her urine dipstick is positive for leukocyte esterase and nitrites.

In the next bed, you are evaluating a 23-year-old male who has had a painful, swollen right forearm for 2 days. He reports a subjective fever earlier in the evening, but no other systemic symptoms. He denies any past medical history and has no IV drug abuse and no history of diabetes. He is afebrile with normal vital signs. A 6-cm area of erythema, induration, and tenderness is noted on his proximal forearm with a 2-cm central fluctuant, raised area. He has full range of motion at the elbow.

Just as you sit down for a cup of coffee, the triage nurse notifies you that she just received an 85-year-old male from a nursing home that was sent in for evaluation for fever. He has a history of insulin-dependent diabetes mellitus, hypertension, and dementia. On physical examination, he is febrile, with otherwise normal vital signs. His abdomen is slightly distended, soft, but diffusely tender to palpation.

Four infectious disease cases in a row — it feels like an epidemic. In the age of emerging pathogens — and when the right antibiotic choice may be the difference between a good or bad outcome — which antibiotic(s) do you use?

(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is January 6th.)