What’s Your Diagnosis? 11-year-old boy with acute abdominal pain August 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 5 comments

But before we begin, check out if you got last month’s case right, about the 8-year-old boy presenting to the ED after falling at a local playground. Click here to check out the answer!

Case Presentation: an 11-year-old boy with acute abdominal pain

An 11-year-old previously healthy boy presents to the ED on a busy Saturday evening. He has acute abdominal pain that started 18 hours ago as diffuse periumbilical abdominal pain. Within the last 3 hours or so, the pain migrated to the right lower quadrant and worsened in severity. The child says the bumps on the car ride to the hospital were painful, and hopping up and down makes the pain worse. He says it seems to be a bit better when he lies still and does not move. Oral ibuprofen has not really helped the pain. The patient has not eaten a meal all day and has vomited 3 times today. On presentation, he has a temperature of 38.3°C (101°F). He is fully immunized and does not have any upper respiratory symptoms. He has never had similar pain in the past and has no history of previous
abdominal surgeries. He has a normal genitourinary examination. He has obvious discomfort with palpation of his abdomen with maximum tenderness in the right lower quadrant. He exhibits guarding and rebound tenderness.

His mother asks you whether this could be appendicitis, and whether he will need surgery. You begin to think…

Is this appendicitis? What else could it be? How will you definitively determine the diagnosis? What laboratory evaluation and imaging tests should you order? It is now 2:00 AM. If the patient definitely has appendicitis, does he need an emergent appendectomy or can it wait?

Case Conclusion

You sent a CBC and CRP for the 11-year-old boy with abdominal pain and vomiting. The WBC count and CRP were both elevated. An appendix ultrasound showed a dilated, noncompressible appendix with mesenteric fat stranding and appendiceal wall hyperemia, and you diagnosed the boy with appendicitis. The on-call pediatric surgeon was contacted and asked that you start antibiotics and admit the patient for appendectomy in the morning.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review Pediatric Emergency Medicine Practice

What’s Your Diagnosis? Assisting With Air Travel Medical Emergencies August 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

But before we begin, check out if you got last month’s case, on assess anticoagulation status, right. Click here to check out the answer!

Case Presentation: a 53-year-old female passenger in the economy section has become “unresponsive.”

You are flying from London Heathrow Airport to New York JFK on British Airways when a flight attendant makes a request over the intercom for medical personnel to respond to an ill passenger. Among the responders is a Basic Life Support-trained EMT, a nurse intensivist, a psychiatrist, and yourself, an emergency medicine physician. The flight attendant informs you that a 53-year-old female passenger in the economy section has become “unresponsive.” Her husband says that she has a history of diabetes, hypertension, and coronary artery disease; has 2 stents; and is currently taking insulin, aspirin, clopidogrel, and metoprolol. On physical exam, she is initially diaphoretic, pale, and lethargic, but quickly regains consciousness and is able to provide some history, and she reports feeling lightheaded prior to losing consciousness. She reports ongoing general weakness and presyncope. She is bradycardic at 35 beats/min but she is alert, with no increased work of breathing. Her neurological exam is nonfocal, and she has a soft abdomen and thready peripheral pulses.

Case Conclusion

For your diabetic patient with weakness and loss of consciousness, you were able to access the AED and could see that she was bradycardic with a ventricular escape rhythm. Her husband retrieved her glucometer from her carry-on luggage, and her glucose measured at 45 mg/dL. She was able to drink some juice, and her glucose improved to 100 mg/dL and her heart rate improved to 60 beats/min, with improved mental status and peripheral pulses. She reported improving symptoms. The flight attendant connected you to the medical control officer employed by the airline, and you were able to describe the situation to her. Given the patient’s improving condition and the current location over the Atlantic Ocean, she recommended continuing to your final destination. The patient did well for the remainder of the flight, and was transported to an ED by EMS upon landing.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

Brain Teaser: When should ketorolac be avoided? August 22, 2019


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

Test your knowledge and see how much you know about pediatric pain management in the emergency department.

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

The correct answer: C.


Review this Pediatric Emergency Medicine Practice issue to get up-to-date on guidance on assessing pain in pediatric patients and provides evidence-based recommendations for developing strategies to successfully manage pain in pediatric patients.

Test Your Knowledge Management of Patients With Complications of Bariatric Surgery August 22, 2019


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

As bariatric procedures have become more common, more of these patients present to the emergency department postoperatively. The most common complaints in these patients are abdominal pain, nausea, and vomiting.

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

The correct answer: A.


Check out the issue on Emergency Department Management of Patients With Complications of Bariatric Surgery to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

Ultrasound Assessment for Skull Fractures August 15, 2019


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

The use of ultrasound at the point of care by emergency clinicians, as well as by other specialists, has become increasingly common over the last 25 years. Emergency POCUS can be used as a diagnostic test and also to visualize anatomy for procedural guidance. It allows the emergency clinician to rapidly rule in or rule out disease processes and guide ongoing investigation and management of patients in the ED.

Pediatric emergency ultrasound has been slower to progress than adult emergency ultrasound. However, the use of emergency ultrasound for pediatric patients has recently begun to formalize.

The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

Ultrasound can be used in the evaluation of children with blunt head trauma to assess for skull fractures. (See Figure Below) The presence of a skull fracture increases the risk of traumatic intracranial hemorrhage 4- to 6-fold.

While the absence of a skull fracture does not rule out the presence of intracranial injury, assessment for skull fracture has been used to risk stratify.

Skull Fracture on Ultrasound

Patients with blunt head trauma. In a meta-analysis published in 2000, skull x-rays had a sensitivity of 38% and a specificity of 95% when interpreted by radiologists. Given this poor sensitivity, skull x-rays have been falling out of favor for assessment of skull fracture. However, there has been a renewed interest in skull ultrasound as perhaps a better tool to assess for skull fracture and to risk stratify patients with blunt head trauma.

Technique
Skull ultrasound is performed with a high-frequency linear array probe. The probe should be placed on the area of the skull with maximal tenderness, hematoma, or other sign of possible fracture. It should be scanned in 2 planes, looking for disruptions in the cortex. Sutures can be differentiated from fractures by following the cortical break to a fontanelle and by scanning the contralateral side for comparison. Additionally, the cortical break in a fracture will appear ragged, with sharp margins, while a suture will have a smooth appearance.

Several prospective studies have evaluated bedside ultrasound for skull fractures in children. Rabiner et al pooled data from previous trials along with their own data. They reported a sensitivity of 94% and specificity of 96% for ultrasound detection of skull fractures. Parri et al performed another study not captured in the Rabiner et al study, and showed a sensitivity of 100% and a specificity of 95%, with 1 false-positive result. A limitation of these studies was that the ultrasounds were performed on patients for whom a CT scan was planned. Therefore, the study population was already determined to be at higher risk for injury as compared to the entire spectrum of head trauma patients presenting to the ED. Nonetheless, it can be concluded that the diagnostic accuracy of skull ultrasound is superior to that of skull x-ray.

Future Applications
The current trend in the evaluation and risk stratification of pediatric head trauma is the incorporation of clinical decision rules, with the PECARN pediatric head injury prediction rule being the most sensitive and most commonly used in the United States.56 An area of future research is the incorporation of skull ultrasound in conjunction with a clinical decision rule to better risk stratify patients and possibly further decrease the number of CT scans being performed.

To read more about the PECARN Pediatric Head Injury Prediction Rule, go to: www.ebmedicine.net/PECARN-head-rule

Need more information?
Click here to review the issue!

Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications August 14, 2019


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

As bariatric procedures have become more common, more of these patients present to the emergency department postoperatively.

The most common complaints in these patients are abdominal pain, nausea, and vomiting, though each of the surgical procedures will present with specific complications, and management will vary according to the surgical procedure performed. Computed tomography is often the primary imaging modality, though it has it limits, and plain film imaging is appropriate in some cases.

This clinical pathway will help you improve care in the management of patients with bariatric surgery complications. Download now.

Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications

Get access to more pathways with an individual or group subscription. Visit www.ebmedicine.net/EMPinfo to find out more!

Need more information?
Click here to review the issue!