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Which empiric antibiotics to use? — Pediatric Bacterial Meningitis Conclusion November 14, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far
Case Recap:
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
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Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
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Case Conclusion:
The 4-month-old boy with a history of cough, pallor, fever, and decreased feeding was placed in a warmer on a cardiorespiratory monitor with continuous pulse oximetry. His heart rate and respiratory rate rose and his degree of responsiveness declined. You decided the patient needed a lumbar puncture, knowing that vital sign abnormalities and subtle neurologic changes can be the first signs of bacterial meningitis in this age group. After obtaining consent from the mother, CSF was obtained on the first attempt, and was visibly purulent. The CSF WBC count was 2257 with 85% polys. The CBC showed a peripheral WBC of 9.9, Hb of 9, and platelets of 329,000. A CSF Gram stain revealed gram-positive cocci in pairs and occasional chains. You immediately suspected pneumococcal meningitis and initiated IV dexamethasone 0.15 mg/kg and IV cefotaxime 100 mg/kg and admitted the patient to the PICU. The CSF grew S pneumoniae that was sensitive to cefotaxime. Over the next 24 hours, the patient developed respiratory failure and progressive cerebral edema, the complication that you feared most. Over the next several days, his cerebral edema was unresponsive to therapy and the child died on the seventh day of hospitalization due to this complication.
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How would you prioritize the workup? — Electrical Injuries in the ED Conclusion November 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment
Case Recap: 
As you start work, you wonder where your end-of shift colleague is. The question is answered when the curtain for bay 2 is pulled back and you see her intubating a young man. She tells you he arrived by ambulance for “burn care.” He fell 12 feet to the ground after his mop pole touched a power line above the semi-trailer he was cleaning. There are minor burns to his hands and chest wall, but more worrisome is the pink fluid draining from his ears and nose. As you assess the patient, you wonder how best to prioritize the patient’s workup…
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Case Conclusion:
The pink fluid draining from the nose and ears of your patient who fell off the semi-trailer was caused by the patient having sustained a basilar skull fracture from the fall. The burns on his hand and chest most likely represented the entrance and exit of the electrical discharge and the fall possibly due to a transient dysrhythmia. Fortunately, his vital signs were stable and there was no evidence of myocardial damage. Instead, the leaking cerebrospinal fluid was the biggest concern, and you were reminded of the importance of a careful secondary survey in patients with electrical injuries. The patient was admitted to the neurosurgical ICU, remained stable, and had an uneventful recovery.
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Which empiric antibiotics to use? — Pediatric Bacterial Meningitis November 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 8comments
A 4-month-old boy presents with a history of cough, pallor, fever to 38.9°C (102°F), and decreased feeding on the morning of presentation. The infant drank 6 ounces about 4 hours before arrival, but would not feed at presentation. The boy’s parents state he did not vomit or have diarrhea. His past medical history is notable for cesarean delivery at 36 weeks’ gestation. There was prolonged rupture of membranes and he was hospitalized for 3 days after delivery. The boy’s parents report no prior illnesses, and his immunizations are up-to-date. On physical examination, the boy’s vital signs are: temperature, 38.9°C (99.6°F); heart rate, 158 beats/min; respiratory rate, 50 breaths/min; and oxygen saturation, 98% on room air. The boy is arousable but sleepy and does not fix and follow. His fontanel is flat. His HEENT examination is notable for nasal congestion with mucus secretions. The boy’s cardiopulmonary and abdominal examinations are unremarkable. The boy’s capillary refill is < 2 seconds, but his muscle tone is decreased. He is fussy during the examination. 
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Is this merely an upper respiratory infection or should meningitis be considered? What are common clinical features of meningitis in this age group? What further management is indicated? Which empiric antibiotics—if any—are indicated at this time?
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How would you prioritize the workup? — Electrical Injuries in the ED November 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 5comments
As you start work, you wonder where your end-of shift colleague is. The question is answered when the curtain for bay 2 is pulled back and you see her intubating a young man. She tells you he arrived by ambulance for “burn care.” He fell 12 feet to the ground after his mop pole touched a power line above the semi-trailer he was cleaning. There are minor burns to his hands and chest wall, but more worrisome is the pink fluid draining from his ears and nose. As you assess the patient, you wonder how best to prioritize the patient’s workup…
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Where would you begin?
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Straddle Injuries with a laceration — Brain Teaser. Do you know the answer? October 26, 2018

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Did you get it right? Click here to find out!

The correct answer: D.

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Fever, chills, and abdominal pain — Brain Teaser. Do you know the answer? October 24, 2018

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

find bike trails

Did you get it right? Click here to find out!

The correct answer: C.

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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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