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Treatment Pathway for the Management of a Genitourinary Laceration in a Pediatric Girl October 19, 2018

Posted by Andy Jagoda, MD in : Feature Update , add a comment
The presentation of genital injuries and emergencies in pediatric girls can sometimes be misleading. A traumatic injury with excessive bleeding may be a straddle injury that requires only conservative management, while a penetrating injury may have no recognizable signs or symptoms but require extensive surgery.
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This clinical pathway will help you improve care in the management of a genitourinary laceration in a pediatric girl. Download now.
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Treatment Pathway for Initial Management of Patients with Sepsis October 17, 2018

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far
Sepsis is a common and life-threatening condition that requires early recognition and swift initial management. Diagnosis and treatment of sepsis and septic shock are fundamental for emergency clinicians, and include knowledge of clinical and laboratory indicators of subtle and overt organ dysfunction, infection source control, and protocols for prompt identification of the early signs of septic shock.
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This clinical pathway will help you improve care in the initial management of patients with sepsis. Download now.
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Severe Pelvic Pain with Dysuria — Managing Genital Emergencies in Pediatric Girls Conclusion October 14, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far
Case Recap:
A 15-year-old adolescent girl is brought into the ED by her mother for severe abdominal and pelvic pain with dysuria. The patient is otherwise healthy, with no significant past medical history. She is not sexually active and denies any trauma. Upon questioning, the patient states that she has had cyclical abdominal pain over the past year and a half, which typically lasts 2 to 3 days, and then self resolves. She has not yet started her menses. This is the first time that the pain has been 10/10 in severity, and she has new urinary urgency, with inability to fully empty her bladder. On physical examination, she is Tanner stage V for breast and pubic hair development, her abdomen is soft with no palpable mass, and she has no costovertebral angle tenderness. On visual inspection of her perineum, she is noted to have a large, bulging purplish mass in her vaginal area with a small leak of blood. 
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Are there any laboratory tests that you should order? What imaging—if any—would be the best choice for confirming the diagnosis? Should you try to release the pressure and evacuate the blood?
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Case Conclusion:
You obtained a urine sample from the 15-year-old girl to evaluate for pregnancy and a urinary tract infection simultaneously; the results of both were negative. You also ordered an abdominal ultrasound to assess the mass. The ultrasound showed a semisolid pelvic mass measuring about 15 x 10 x 10 cm, suggestive of hematocolpos, with a normal uterus and ovaries. Gynecology was consulted, and the patient was admitted for a hymenotomy.
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Congratulations to Kimia Kashkooli, Eva Soos-Kapusy, Kenneth Dowler, Dane O’Donnell, and Christopher Cruz — this month’s winners of the Pediatric Emergency Medicine Practice Audio Series Vol IV
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To Discharge Or Not — Sepsis In The ED Conclusion October 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far
Case Recap: 
A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/ min; blood pressure, 130/90 mm Hg; SpO2, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 103/mm3, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you…
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Case Conclusion:
The 45-year-old man with the urinary tract infection had a SOFA score of 2 and met the Sepsis-3 definition of sepsis, due to pyelonephritis. The patient was convinced to stay in the hospital, had 2 sets of blood cultures drawn, 30 mL/kg of IV fluids administered, and a dose of ceftriaxone 2 grams IV administered. His vital signs remained stable, and the patient was admitted to a monitored hospital bed. He was discharged 2 days later to continue oral antibiotics.
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Congratulations to Rachael Kinuthia, Micelle Jo Haydel, Annie Nunley PA-C, Dennis Allin, and Walter L Novey — this month’s winners of the Emergency Medicine Practice Audio Series Vol IV
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Severe Pelvic Pain with Dysuria — Managing Genital Emergencies in Pediatric Girls October 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 24comments
A 15-year-old adolescent girl is brought into the ED by her mother for severe abdominal and pelvic pain with dysuria. The patient is otherwise healthy, with no significant past medical history. She is not sexually active and denies any trauma. Upon questioning, the patient states that she has had cyclical abdominal pain over the past year and a half, which typically lasts 2 to 3 days, and then self resolves. She has not yet started her menses. This is the first time that the pain has been 10/10 in severity, and she has new urinary urgency, with inability to fully empty her bladder. On physical examination, she is Tanner stage V for breast and pubic hair development, her abdomen is soft with no palpable mass, and she has no costovertebral angle tenderness. On visual inspection of her perineum, she is noted to have a large, bulging purplish mass in her vaginal area with a small leak of blood. 
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Are there any laboratory tests that you should order? What imaging—if any—would be the best choice for confirming the diagnosis? Should you try to release the pressure and evacuate the blood?
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Enter to win a free copy of Pediatric Emergency Medicine Practice Audio Vol IV, the latest in our audio series collection, by submitting your answer to the question above. To do so, simply enter your response in the comments box. A valid email address is required to enter. The deadline to enter is October 11, 2018.
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Sign up for our email list below and come back on October 13th to see if you got it right and if you won!
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To Discharge Or Not — Sepsis In The ED October 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 30comments
A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/ min; blood pressure, 130/90 mm Hg; SpO2, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 103/mm3, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you…
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What do you do next?
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Enter to win a free copy of Emergency Medicine Practice Audio Vol IV, the latest in our audio series collection, by submitting your answer to the question above. To do so, simply enter your response in the comments box. A valid email address is required to enter. The deadline to enter is October 11, 2018.
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Sign up for our email list below and come back on October 12th to see if you got it right and if you won!
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Case Conclusion — Retching Patient With Diabetes June 15, 2014

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

Case Recap: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.

Conclusion: You ordered the appropriate tests for the first patient, the 26-year-old woman who was vomiting and sleepy, and discovered that her serum beta-hydroxybutyrate was 4 times normal. You asked the nurse to start the normal saline IV, and the patient received several liters prior to the lab tests returning. The tests showed that she had a serum potassium of 5.8 mEq/L, so you initiated the insulin drip at 0.14 units/kg/h and decided to forgo the insulin bolus, based on your recent reading about insulin in DKA. Since the patient’s bicarb was 9 mEq/L, you decided to admit her to the ICU. Unfortunately, there were no ICU beds, so for the next 8 hours you managed the patient in the ED. When her serum glucose approached 200 mg/dL, you changed to D5 half-normal saline for the fluid infusion, and decreased the insulin infusion to 0.04 units/kg/h. By the time she went up to the ICU, her gap had decreased from 29 to 19 mEq/L and her bicarbonate had increased to 18 mEq/L. She had an unremarkable course in the ICU, was eventually transferred to the floor, and by her fourth day in the hospital, was able to be safely discharged.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about new strategies for managing patients with diabetes?

Retching Patient With Diabetes June 12, 2014

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , add a comment

June’s Case: You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.

Share your diagnosis in the comments box below — The case conclusion will be revealed on June 16!

Case Conclusions — Mosquito-Borne Illness May 11, 2014

Posted by Andy Jagoda, MD in : Infectious Disease , add a comment

Recap of Case 1: A 50-year-old man presents with fever for 3 days. He is an immigrant from Nigeria, but has resided in the United States for a decade. Ten days ago, he visited his family in a rural part of his homeland. He complains of fever, chills, and vomiting. His only medication was chloroquine, which was prescribed by his primary care physician prior to his trip. You recall reading something about increased resistance to one of the antimalarial medications in certain countries, but you can’t remember the specifics. A nurse brings you an ominous-looking ECG from EMS, just as you’re attempting to recall where to look up that information…

Recap of Case 2: A 35-year-old woman presents with fever and malaise for 1 day. While taking her blood pressure, she is noted to have petechiae on the ipsilateral arm. She says she recently returned from a trip to Puerto Rico. You have heard that there is a current outbreak of dengue on the island, but you have never seen the disease before, so you need to quickly assess whether your patient has dengue and how to manage her disease…

Case Conclusions: For your 50-year-old patient from Nigeria, you checked the CDC malaria website and called the CDC malaria hotline ([855] 856-4713), and they were able to assist you in navigating the case. The patient was well appearing and did not meet any criteria for complicated malaria. In your discussions with the patient, he felt safe going home with a prescription for atovaquone/proguanil, pending the results of the thick and thin smears.

You examined the 35-year-old female patient with petechiae who recently visited Puerto Rico, and after evaluation of the WHO Clinical Criteria for suspected dengue, you were comfortable that she did not have any warning signs for dengue. You sent off the appropriate tests (dengue virus PCR and dengue IgM antibody testing). You asked her to either return to the ED or be seen by her primary care doctor in 48 hours once her fever resolved. You carefully explained why reevaluation was so crucial, given the natural history of dengue. You made sure she understood the return precautions prior to discharging her from the ED.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about treating mosquito-borne illness in the ED? Simply click the links below:

Mosquito-Borne Illness May 6, 2014

Posted by Andy Jagoda, MD in : Infectious Disease , add a comment

Read the following cases and let us know how you would care for these two patients in the comments box below.

Case 1: A 50-year-old man presents with fever for 3 days. He is an immigrant from Nigeria, but has resided in the United States for a decade. Ten days ago, he visited his family in a rural part of his homeland. He complains of fever, chills, and vomiting. His only medication was chloroquine, which was prescribed by his primary care physician prior to his trip. You recall reading something about increased resistance to one of the antimalarial medications in certain countries, but you can’t remember the specifics. A nurse brings you an ominous-looking ECG from EMS, just as you’re attempting to recall where to look up that information…

Case 2: A 35-year-old woman presents with fever and malaise for 1 day. While taking her blood pressure, she is noted to have petechiae on the ipsilateral arm. She says she recently returned from a trip to Puerto Rico. You have heard that there is a current outbreak of dengue on the island, but you have never seen the disease before, so you need to quickly assess whether your patient has dengue and how to manage her disease…

Our answers will be posted on May 12. Thanks in advance for participating!

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