jump to navigation

68-year-old woman presents with severe abdominal pain May 31, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
As you begin your shift, a 68-year-old woman presents with severe abdominal pain. She requires 4 mg of morphine before you can even talk to her. Surprisingly, her abdomen is soft, and not particularly tender. She is tachycardic to the 120s, and her pulse feels irregular. Her blood pressure is 100/50 mm Hg. It seems strange that her pain is so incongruent with her exam, and you wonder: What is the best imaging study to help clarify things?

Case Conclusion:
You recognized that she needed pain control and fluids along with a full sepsis workup, including lactate, ECG, CT abdominal angiography, and an almost-certain surgical consult. Her ECG showed atrial fibrillation, and the CT angio confirmed the diagnosis. She was emergently taken to the OR, where a dead bowel segment was resected and she had a surprisingly good recovery, thanks to your rapid mobilization of specialty care.

Did you get it right?

Brush up on most recent best practices in evaluating patients with abdominal pain in the ED with our 20th anniversary Emergency Medicine Practice issue, Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

Sign up for our email list below to get updates on future blog posts!

A 3-year-old girl with a known peanut allergy May 31, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:
A 3-year-old girl with a known peanut allergy arrives to your ED via EMS. The girl was given a cookie by a classmate and immediately developed a generalized urticarial rash. EMS personnel gave her 12.5 mg of oral diphenhydramine and transported her to the ED. On examination, the patient has a heart rate of 160 beats/min with normal oxygenation and perfusion. She has bilateral periorbital swelling, without respiratory distress, wheezing, vomiting, or diarrhea. The accompanying daycare teacher tells you that the girl has previously been admitted to the intensive care unit for anaphylaxis.

You call the girl’s parents for more information and wonder what to do in the meantime. Is diphenhydramine sufficient treatment for this patient? Are corticosteroids indicated? Is this just an allergic reaction or could it be an anaphylactic reaction? What are the criteria for diagnosis of anaphylaxis? What are the indications for administering epinephrine in patients with anaphylaxis?

Case Conclusion:
The parents of the 3-year-old girl stated that the girl’s previous anaphylactic reaction began with urticaria and facial swelling that progressed, resulting in a critical care admission for airway compromise due to angioedema. You administered epinephrine 0.01 mg/kg IM for suspected anaphylaxis and observed the patient in the ED for 4 hours. The girl had complete resolution of the facial swelling and urticarial rash. You reviewed the signs and symptoms of anaphylaxis with the parents, discussed allergen avoidance, and demonstrated appropriate use of an epinephrine autoinjector. You discharged the patient with a prescription for 2 epinephrine autoinjectors and an anaphylaxis action plan.

Did you get it right?

Brush up on most recent best practices in evaluating and treating pediatric patients with anaphylaxis in the ED with the latest issue of Pediatric Emergency Medicine Practice issue, Anaphylaxis in Pediatric Patients: Early Recognition and Treatment Are Critical for Best Outcomes.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

Sign up for our email list below to get updates on future blog posts!

EB Medicine Celebrates 20 Years Of Evidence-Based Emergency Medicine Publishing May 31, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

June 7, 2019 – Atlanta, GA – EB Medicine, the premier provider of cutting-edge, evidence-based emergency medicine content, is celebrating their 20th anniversary this year. The company is using the opportunity to celebrate client contributions over the years with an anniversary sale and special offers for current subscribers.
EB Medicine is known for their evidence-based clinical content, including the Emergency Medicine Practice and Pediatric Emergency Medicine Practice journals.

The History of EB Medicine

EB Medicine was founded in 1999 by Dr. Stephen Colucciello, an emergency physician at Carolinas Medical Center, who saw a need for a high-quality, evidence-based journal that would analyze and summarize all of the available evidence on a given topic and present the best recommendations based on the evidence.

Before EB Medicine, doctors found it challenging to stay up to date on the latest information. With thousands of new studies being published every year, how could one doctor comb through all of this information to make sure he is at the cutting edge of his practice? Unlike today when there are dozens of websites, blogs, podcasts, and newsletters that discuss recent findings or spur point-counter point internet debates, there were almost no resources to help emergency physicians stay current with new treatments and protocols 20 years ago. The resources that were available were not evidence-based, but more like textbooks whose dogma proclaimed a standard of care that due to years-long publication cycle was out of date by release date.

Perhaps, even more importantly, the resources that were available focused on the treatment, and assumed that the diagnosis had already been made. Dr. Colucciello recognized this information gap. He focused on importance of presenting the information from a chief-complaint perspective rather than from a diagnosis. We rarely get ED patients who tells us: “I’m having a myocardial infarction.” Most likely, it’s a chest pain complaint.
Dr. Colucciello, an emergency physician with 18 years of experience, and Robert Williford, a medical publisher with more than 25 years of experience, aimed to address these challenges by creating Emergency Medicine Practice and published the first issue in June 1999.

The inaugural issue on assessing abdominal pain is still used by physician educators around the country to train emergency medicine residents on the proper way to work-up and manage patients with abdominal pain.
Over the next few years, based on industry needs and at the request of customers, EB Medicine expanded to pediatric-focused content. As is often said in the ED: Kids aren’t just little adults; they require different tests, different treatment, and different care. In 2004, EB Medicine launched Pediatric Emergency Medicine Practice to address this need.

Read the full story here.

 

EB Medicine Celebrates 20 Years Of Evidence-Based Emergency Medicine Publishing May 31, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

June 7, 2019 – Atlanta, GA – EB Medicine, the premier provider of cutting-edge, evidence-based emergency medicine content, is celebrating their 20th anniversary this year. The company is using the opportunity to celebrate client contributions over the years with an anniversary sale and special offers for current subscribers.

EB Medicine is known for their evidence-based clinical content, including the Emergency Medicine Practice and Pediatric Emergency Medicine Practice journals.

EB Medicine Today

Today, EB Medicine has 11 full-time employees, over 50 physician editorial board members, and more than 2,000 physician authors and reviewers. Board members, authors, and reviewers are carefully selected by physician Editors-in-Chief Andy Jagoda, MD, FACEP; Ilene Claudius, MD; and Tim Horeczko, MD based on their experience and expertise in a given topic area; EB Medicine contributors are recognized leaders in their field and have frequently published original research and review articles, presented at national conferences, and educated other physicians. They are committed to providing the very best educational content and truly believe in the value and importance of what EB Medicine does every day.

What started out as one print journal, Emergency Medicine Practice, has evolved into a multimedia resource that goes beyond its flagship print publication; it now includes a podcast, an online digest/summary, a supplement that reviews and links to relevant calculators and risk scores that can be used in real time, and more. Last year, EB Medicine launched an all-new mobile responsive website that makes it easier for clients to access the information they need even while they’re on shift.

“Over the years, we’ve continued to develop resources to meet the needs of our customers. Our goal is to help them improve decision making and patient care, and we will continue to create products to fulfill that goal,” said EB Medicine CEO Stephanie Williford.

EB Medicine continuously partners with other forward-looking organization and associations to make sure they continue to evolve and stay relevant to the customers they serve. They have also created an Emerging Leaders Council, which is made up of 12 young leaders in the field of emergency medicine who have joined EB Medicine to make sure they stay up to date with various industry needs and deliver relevant education to emergency clinicians at all levels of their careers.

Click here to read the full story.

 

May is Trauma Awareness Month! May 16, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

Spinal injuries from blunt trauma are uncommon in pediatric patients, representing only about 1.5% of all blunt trauma patients. However, the potentially fatal consequences of spinal injuries make them of great concern to emergency clinicians.

Clinical goals in the emergency department are to identify all injuries using selective imaging and to minimize further harm from spinal cord injury. Achieving these goals requires an understanding of the age-related physiologic differences that affect patterns of injury and radiologic interpretation in children, as well as an appreciation of high-risk clinical clues and mechanisms.

Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury

This clinical pathway will help you improve care in the management of pediatric patients with suspected cervical Spinal cord injury. Click here to download yours today. 

It is Stroke Awareness Month! May 16, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

10 Risk Management Pitfalls For Cervical Artery Dissections

Cervical artery dissections involve the carotid or vertebral arteries. Although the overall incidence is low, they remain a common cause of stroke in children, young adults, and trauma patients. Symptoms such as headache, neck pain, and dizziness are commonly seen in the emergency department, but may not be apparent in the obtunded trauma patient. A missed diagnosis of cervical artery dissection can result in devastating neurological sequelae, so emergency clinicians must act quickly to recognize this event and begin treatment as soon as possible while neurological consultation is obtained.

Use these risk management pitfalls to avoid unwanted outcomes when performing cervical artery dissections. Download now.

1. “This patient has a left temporal headache that radiates into his left ear. His examination is benign, except his pupil is smaller on that side. I did a noncontrast CT head and it’s negative. The headache is probably just due to a hard game of basketball yesterday. I’m going to give him some IV ketorolac and send him out.”

Dissections can occur spontaneously or as a result of minor trauma, even from a basketball game. Failure to consider the diagnosis will result in a missed diagnosis. Headaches in carotid artery dissections can be nonspecific, but are mostly located in the frontal or temporal regions; the radiation to the ear is also characteristic. His examination is also concerning for a partial Horner syndrome. Both of those are suspicious for carotid artery dissection and warrant further vascular imaging.

2. “She has a history of migraines, and she says that this one is different from what she usually feels, but it definitely sounds like a migraine because it is unilateral, pulsatile, and she had a visual aura. I’m going to give her the usual migraine cocktail and see how she does.”

Not suspecting cervical arterial dissection in the beginning of the evaluation results in a significant delay to diagnosis. It can be many hours by the time she has a couple of migraine cocktails before you realize her headache isn’t better and you need to rethink your plan. Due to the risk of early stroke in these patients, a delay in diagnosis could lead to long-term neurological sequelae. Headaches in carotid dissections can be unilateral, pulsatile, and with an aura. Any time a patient with a history of migraines states that the symptoms are not typical, take note.

3. “A 35-year-old woman was attacked by her boyfriend. He hit her on the right side of the neck near her jaw, causing her head to snap around to the left. Her neurological examination is completely normal. She is in a great deal of pain, but it seems to be related to the soft-tissue injury from the hit, because her noncontrast CT head and c-spine are negative. I’m going to treat her pain and see how she feels.”

Pain due to the trauma could mask specific signs or symptoms of dissection. In these patients, relying on the history to identify high-risk factors is important. Due to the location of the blow, it may have caused a hyperextension and rotation of her head in addition to direct trauma, which could have caused a dissection. Patients with risk factors should have advanced vascular imaging (CTA or MRA).

4. “I couldn’t do a neurological examination because she was in too much pain. I’ll treat her headache and then try again later.”

Although it seems kind to give patients a little time to obtain comfort before performing an examination, a prompt neurological examination is absolutely necessary in order to determine any findings that need to be addressed immediately, such as an acute stroke.

5. “A 12-year-old boy fell off of his bike after running into a parked car, and then he had a seizure. The noncontrast CT head and c-spine were normal. He is still in some pain, but I don’t see anything abnormal on his neuro examination, so I’m going to clear his c-spine.”

Pediatric patients with dissection have different symptoms from adults; seizure has been shown to be a presenting symptom in 12.5% of cases. The seizure, along with the mechanism, should prompt vascular imaging to assess for a cervical artery dissection before the cervical collar is removed.

6. “I really thought that patient with the headache, anterolateral neck pain, and partial Horner syndrome had a carotid dissection, but the CTA was read as negative, so I guess I was wrong. I’ll just treat her pain and send her home.”

CTA is an excellent screening tool, but it is not 100% sensitive and can miss small intimal flaps, intramural hematomas, or a slight fusiform dilatation of the vessel. In patients for whom there is a high suspicion of dissection and a negative or equivocal CTA or MRA, further imaging with MRI or digital subtraction angiography is indicated.

7. “The CTA showed a dissection, so I gave him an aspirin and called neurology. However, he now says he doesn’t want to wait and wants to go home. His neuro examination is normal, so I was thinking of sending him out on aspirin.”

Sending the patient home in the acute setting without consultation is not a good idea. Due to high risk of stroke in the first 24 hours and the high incidence of progression of lower-grade dissections, these patients warrant close monitoring and early follow-up imaging to determine the need for escalation of care.

8. “The intubated trauma patient had his noncontrast CT head and c-spine and the radiologist just called and said there is a temporal bone fracture through the carotid canal. I’m going to pass it along and let the trauma service finish the workup after he gets to the intensive care unit.”

This will lead to a significant delay in diagnosis, which could be devastating for the patient. Due to its sensitivity and availability in the ED, a CTA should be performed prior to the patient being transported upstairs, so treatment can be started immediately.

9. “The CTA showed a vertebral artery dissection on that patient from the roller coaster ride, so I consulted the neurology service for admission. Her neuro examination is normal, so I’m going to wait to treat her and see what they recommend.”

An antithrombotic agent for stroke prevention needs to be started on this patient and can be started in the ED to avoid treatment delays. Studies in this population have not shown superiority of one over the other, so the choice of aspirin or heparin depends on patient factors. For uncomplicated dissections, antiplatelet agents are sufficient, and heparin is preferred in patients with an acute thrombus or high risk for thromboembolic events if no contraindications exist.

10. “The patient is a 42-year-old man presenting with an acute onset of right-sided hemiplegia and global aphasia that started 1 hour ago while at the grocery store. His CT head was negative for hemorrhage, but the CTA showed a dissection in his left carotid artery with about 50% vessel occlusion. Unfortunately, that excludes him from treatment with rtPA due to the risk of hemorrhage or intramural hematoma expansion.”

Data have shown rtPA to be as safe in patients with cervical dissections as with patients with strokes due to other causes. Therefore, this patient should be treated with rtPA as soon as possible if there are no contraindications. Endovascular treatment should also be considered if there are contraindications to IV rtPA or if he does not improve after treatment.

Need more information or Stroke CME?
Click here to review the issue and take the CME test, but hurry, CME expires August 1, 2019!

It is Trauma Awareness Month! Can you solve the trauma case below? May 10, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Do you need to do anything regarding the missing fragment? — ED Management of Dental Trauma in Pediatric Patients

Case Recap:
You are then asked to see a 15-year-old adolescent boy who has come in with a tooth avulsion. He was at basketball practice when another player accidentally elbowed him in the mouth. He did not lose consciousness and has pain only in his mouth. He was immediately brought to your ED, which is about 15 minutes away from where the accident happened. His coach arrives with the boy’s tooth in a container of milk. On physical examination, the patient has lost his right lateral incisor and a clot remains where his tooth had been. How much time do you have to replace the tooth to have the best success of replantation? What do you need to consider while handling, storing, and cleaning the tooth?

Case Conclusion:
For the 15-year-old boy, you decided to replace the tooth as soon as possible. The patient had no other medical problems. You used Yankauer suction and light irrigation to remove the clot from the socket. You held the tooth by the crown, briefly rinsed it off, and used firm, gentle pressure to reinsert the tooth without any difficulty. You had Coe PakTM paste available at your facility, and you created a temporary splint to secure the tooth. You instructed the mother to follow up with the dentist tomorrow and to provide only a soft diet until then. You told the coach and the boy’s mom that, in the future, they should attempt to reimplant the tooth at the time of the accident and instructed them on the steps involved.

Did you get it right?

Click here to review the issue, Emergency Department Management of Dental Trauma: Recommendations for Improved Outcomes in Pediatric Patients (Trauma CME and Pharmacology CME).

Sign up for our email list below to get updates on future blog posts!

It is Stroke Awareness Month! Can you solve the stroke case below? May 10, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

Was it a “mini stroke”? — ED Management of Transient Ischemic Attack

Case Recap:
A 59-year-old obese woman presents to your community hospital ED after experiencing a distinct episode in which her left hand felt “clumsy,” along with a left facial droop and left-sided numbness. She denies experiencing frank weakness and states that the symptoms resolved in less than 10 minutes. She mentions that she experienced a similar episode 2 weeks prior, and is concerned because both her parents and an older sibling experienced disabling ischemic strokes. Her vital signs and point-of-care glucose were normal, and her ECG showed sinus rhythm. Her physical examination, including a detailed neurologic examination, was largely unrevealing, with no facial asymmetry, unilateral weakness, sensory loss, or dysmetria appreciated. A noncontrast cranial CT scan of the brain was remarkable only for nonspecific subcortical and periventricular white matter changes without evidence of acute or old infarction, mass, or hemorrhage. Although she is relieved to learn that she has not had a stroke, she is concerned that this may be a precursor of a more serious event. She does not have a primary care physician and states that she has not seen a physician in several years. She asks whether this was a “mini stroke” and, if yes, what the chances are that she will have a stroke in the future?

Case Conclusion:
The 59-year-old obese patient’s detailed description of abrupt, negative symptoms appropriately raised your concern for a right anterior circulation TIA. You calculated her ABCD2 score as a 2, correctly counting her reported facial droop and unilateral weakness. Knowing recent risk stratification data, you counseled her that her 7-day stroke risk was very low; however, you also remembered that the periventricular white matter hypointensities on CT may be indicative of underlying small-vessel cerebrovascular disease, and her report of multiple recent episodes raised your concern. Since your observation unit was at capacity, you insisted on hospital admission. As an inpatient, she underwent MRI/MRA, revealing extensive small-vessel disease and multiple lacunar infarctions of varying ages. She was seen by a neurologist, started on antiplatelet therapy, and counseled on diet and exercise strategies. She remained stroke-free at a 3-month follow-up appointment.

Did you get it right?

Brush up on most recent stroke care best practices and earn 8 stroke CME with this great online resource, Emergency Stroke Care: Advances And Controversies, Volume II.

Sign up for our email list below to get updates on future blog posts!

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 08-17-2019
© EB Medicine