Test Your Knowledge: Failure to Thrive March 24, 2020


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Emergency Medicine Practice Blog Brain Teaser

Failure to thrive (FTT) is a relatively common presentation in the emergency department. Up to 90% of cases of FTT have no identifiable cause and are categorized as nonorganic. Before deciding that FTT is nonorganic, it is imperative to consider and rule out organic causes. Identifying the underlying issues surrounding FTT is essential, as it will likely impact the treatment the patient receives.

Test Your Knowledge


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The correct answer: A.

Need a refresher on the subject? Review the summary below: 

Points from the Emergency Department Management of Patients With Failure to Thrive:

  • The following criteria can be used to identify patients with failure to thrive (FTT): weight deceleration crossing more than 2 percentile lines, weight for chronological age below the fifth percentile, and length for chronological age below the fifth percentile.
  • Organic causes of FTT should be ruled out before deciding the cause is nonorganic. Examples of organic causes of FTT include congenital heart disease, gastrointestinal etiologies (eg, chronic malnutrition, pyloric stenosis, reflux, food insensitivities, celiac disease, cystic fibrosis, cow’s milk protein intolerance), hyperthyroidism, congenital nephrogenic diabetes insipidus, renal tubular acidosis, asthma, choanal atresia, malignancy, and anatomic/genetic abnormalities (eg, cleft lip/palate, trisomy 21).
  • Clinicians must have a high index of suspicion for nonaccidental trauma and/or neglect, as they can also result in FTT.
  • Inquire about difficulty with feeding, types of feeds, frequency of feeds, and feeding technique.
  • Improper formula mixing can lead to diluted formula, hyponatremia, and poor growth.

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Test Your Knowledge: Synthetic Drug Intoxication in Children February 21, 2020


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Pediatric Emergency Medicine Practice Blog Brain Teaser

The continually changing chemical formulations of synthetic drugs makes recognition and diagnosis of intoxication from these substances challenging. When children and adolescents present to the emergency department with agitation or mental status changes, intoxication from synthetic drug use should be in the differential diagnosis. Identifying the responsible compound(s) may be difficult, so asking the patient broad questions and utilizing appropriate diagnostic studies, when indicated, will aid in making the diagnosis and help identify more-serious complications.

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The correct answer: D.

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Points from the Synthetic Drug Intoxication in Children: Recognition and Management in the Emergency Department (Pharmacology CME):

  • For older children and adolescents, use a conventional screening tool such as HEADSS (Home; Education/Employment; Activities; Drugs; Sexuality; and Suicide/depression) to elicit key historical information, as those who use synthetic cannabinoids are more likely to engage in risky behaviors involving substance use and sexual activity when compared peers who use conventional marijuana only.
  • Assess patients for suicidality and common co-ingestions, as polysubstance abuse is common. In particular, acetaminophen overdose is concerning given the brief window of opportunity for intervention.
  • Conventional urine and serum laboratory studies cannot reliably detect the presence of all synthetic drugs and their metabolites. However, a urine toxicology screen that is positive for conventional marijuana should raise suspicion for synthetic marijuana use.
  • Provide supportive care for mild cases of synthetic cannabinoid intoxication.
  • Avoid nonsteroidal anti-inflammatory drugs and acetaminophen in patients with hyperthermia due to synthetic cannabinoid use, as hyperthermia in these cases is not due to hypothalamic regulatory set points.
  • Do not use beta-blockers as first- or second-line treatment for synthetic-drug induced hypertension, since beta-blockade precipitating unopposed alpha-agonism is a well-documented concern with other drug overdoses.

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Test Your Knowledge: Evaluation and Management of Life-Threatening Headaches in the ED February 6, 2020


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

Emergency Medicine Practice Blog Brain Teaser

Though patients often present to the ED seeking relief from headaches that cause significant pain and suffering, 90% of them can be considered “benign.” It is essential to identify the 10% of headache patients who are in danger of having a life-threatening disorder presenting with a sudden and severe headache to ensure that they are treated quickly and effectively.

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The correct answer: C.

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Points from the Evaluation and Management of Life-Threatening Headaches in the Emergency Department (Stroke CME and Pharmacology CME):

  • The most common life-threatening causes of headaches are subarachnoid hemorrhage (SAH), cervical artery dissection (CAD), cerebral venous thrombosis (CVT), idiopathic intracranial hypertension (IIH), giant cell arteritis (GCA), and posterior reversible encephalopathy syndrome (PRES), and pre-eclampsia.
  • SAH is commonly caused by aneurysm rupture; 75% present with abrupt onset. Administer nimodipine in aneurysmal SAH to improve outcomes. The use of prophylactic antiepileptic drugs is controversial.
  • CAD is commonly associated with trauma and connective tissue disorders. Treat extracranial dissections with IV heparin followed by warfarin or a direct oral anticoagulant. Treat intracranial dissections with aspirin or clopidogrel.
  • CVT presents as a gradual-onset headache that is often the result of thrombotic disease and spreading facial infections. Treat with low-molecular weight heparin or heparin bridge to warfarin. Consider broad-spectrum antibiotics if an infectious etiology is suspected.
  • IIH is associated with obese women of childbearing age as well as hypervitaminosis A. Lumbar puncture (LP) is both diagnostic and therapeutic for IIH. Open-ing pressures will be = 25 mm H2O. Acetazolamide is a first-line pharmacotherapy.
  • ESR and CRP are poor screening tests for GCA. Biopsy should be obtained in those with high suspicion for GCA after treatment has already been begun.
  • Consider a D-dimer to exclude CVT in low-risk patients.

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Test Your Knowledge: Rash and Fever in the Pediatric Patient January 21, 2020


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

Rash and fever are some of the most common chief complaints presenting in emergency medicine. The evaluation of skin rashes in the febrile pediatric patient includes a broad differential diagnosis and utilizing the signs and symptoms to identify red flags, such as hemodynamic instability, erythroderma, desquamation, petechiae/purpura, mucous membrane involvement, and severe pain, in the history and physical examination that require a high index of suspicion for worrisome disease.

Test your knowledge of characteristics of common rashes in a pediatric patients!


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The correct answer: B.

Review this Pediatric Emergency Medicine Practice issue to get up-to-date on common and life-threatening skin rashes with fever in children, guidance for differentiating the types of infections based on signs and symptoms, indications for diagnostic studies, and recommendations for treatment of pediatric skin rash with fever in the emergency department.

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Test Your Knowledge: Managing Dislocations of the Hip, Knee, and Ankle in the ED January 9, 2020


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Dislocation of the major joints of the lower extremities–hip, knee, and ankle–can occur due to motor-vehicle crashes, falls, and sports injuries. These are painful presentations in the trauma ED that must be managed quickly to avoid morbidity, disability, and even possible amputation.

Test Your Knowledge


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The correct answer: B.

Need a refresher on the subject? Review the summary below:

Points from Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department (Trauma CME):

  • 90% of hip dislocations are posterior; 10% percent are anterior.
  • Typically, an AP pelvic radiograph is adequate to diagnose a hip dislocation. Judet views are help­ful in diagnosing associated fractures.
  • Traumatic dislocations of the native hip should be reduced within 6 hours to reduce the risk of avascular necrosis and posttraumatic arthritis.
  • The Allis, Bigelow, Captain Morgan, Rocket Launcher, and East Baltimore Lift techniques can all be used to reduce a hip dislocation. None have proven to be superior to the others; the choice can be made according to provider capability and preference.
  • All hip reduction methods can be used on both native and prosthetic hips.
  • Consider an ultrasound-guided fascia iliaca com­partment block to augment and reduce proce­dural sedation and analgesia.
  • All hip fracture dislocations should be deferred to orthopedic surgery.
  • After reduction of a native hip dislocations, a CT scan should be obtained. The patient will need to be admitted to the hospital.
  • Many knee dislocations spontaneously reduce. Maintain a low threshold of suspicion for this injury, as missing a knee dislocation could have catastrophic consequences.
  • In any knee dislocation with a pulse deficit, perform immediate reduction without imaging. Delays longer than 8 hours have a higher inci­dence of amputation.
  • After reduction of the dislocated knee, patients should be admitted for serial vascular examina­tions or vascular imaging should be obtained. Compartment syndrome is a delayed complica­tion of knee dislocations.
  • Ankle dislocations require immediate recognition and prompt reduction, as they can be associated with significant neurovascular, skin, and soft-tissue complications.
  • Subtalar dislocations are rare, but appear similar to ankle dislocations. Attempting to reduce a subtalar dislocation before imaging may lead to worsening of the dislocation.
  • Emergent orthopedic consultation and post-reduction CT are necessary after reduction of a dislocated ankle.

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Test Your Knowledge: Pediatric Septic Arthritis and Osteomyelitis Management in the ED December 18, 2019


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Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae.

Patients with SA or OM classically present with fever, ill appearance, malaise, pain, and swelling of the involved joint. Given the large differential diagnosis for a limping child, obtaining a thorough history and physical examination is paramount to narrowing the differential diagnosis and to obtain the appropriate testing and treatments.

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The correct answer: A.


Review this Pediatric Emergency Medicine Practice issue to get up-to-date evidence-based recommendations for the diagnosis and management of pediatric patients with septic arthritis and/or osteomyelitis and offers guidance for appropriate antibiotic treatment.

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Christmas Is The Busiest Air Travel Season. Would You Be Ready In An Emergency Happened Mid-Flight? December 10, 2019


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A Common Occurrence

More than 4 billion passengers are expected to fly in 2019, and more than 60,000 medical emergencies are expected to occur during commercial flights.1 Emergency clinicians who work with acutely ill patients may have had the experience of boarding an aircraft and wondering what they would do if a medical emergency occurred.

“Should I respond?”

“What kinds of medications and equipment are aboard?”

“Would I be legally protected if something went wrong?”

These questions can be paralyzing and prevent otherwise highly trained medical personnel from delivering life-saving care.

Lifelong Learning, Applied

Megan Carman, NP, encountered one of those 60,000+ inflight medical emergencies just last month. She used the Emergency Medicine Practice issue, “Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls” to familiarize herself with the roles, equipment, and protections available if called upon to respond to an in-flight medical emergency. Little did she know, Carman would be putting that knowledge to use shortly thereafter.

“How helpful that inflight emergency module was! Right after I read it, I was on a flight and a passenger started seizing. I knew to ask for the drugs and which ones they would have and to ask for IV supplies, and when people got upset about why we weren’t going to land, I told them it was a pilot decision and the average cost of landing. Also, when an anesthesiologist, who was also on the plane, was hesitant to help, I was able to tell him there are specific protections for medical providers who assist on planes as long as you are not grossly negligent or acting out of scope… Thank you for all this great info!” -Megan Carman, NP

Carman and many other Emergency Medicine Practice subscribers have specifically noted that they would be more likely to volunteer to assist with an inflight medical emergency after reading this issue.

Review This Issue

To review the issue that helped Carman and other Emergency Medicine Practice subscribers have increased confidence when faced with an inflight medical emergency, click here.

Test your knowledge


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The correct answer: B.

1. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013;368(22):2075-2083. (Retrospective review; 11,920 in-flight medical emergencies)

Test Your Knowledge: Pediatric Stroke: Diagnosis and Management in the ED November 21, 2019


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Stroke is a leading cause of morbidity and mortality in children. The etiologies, risk factors, and presentation of stroke differ from those of adults, and the diagnosis of stroke is often delayed in children. The management of pediatric stroke can be challenging because there are few data to support the efficacy of interventions.

Test your knowledge and see if you’d spot stroke in a pediatric patient!


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The correct answer: B.


Review this Pediatric Emergency Medicine Practice issue to get up-to-date on the most common causes of pediatric stroke, provides guidance for distinguishing stroke from stroke mimics, discusses the indications for diagnostic studies, and offers evidence-based recommendations for treatment in the emergency department.

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Test Your Knowledge: Assisting With Air Travel Medical Emergencies November 21, 2019


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

As an emergency clinician, you have special expertise in dealing with acute medical conditions, but when an emergency occurs onboard a commercial aircraft and you raise your hand to help, what are the resources and risks in volunteering? Qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal reprisal.

Test your understanding with a question below.


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The correct answer: B.

Check out the issue on Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls (Ethics CME) to brush up on the subject. Plus earn CME for this topic by purchasing this issue

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5 Tips to Improve Clinical Efficiency November 7, 2019


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We’ve all heard the saying, “time is money!”

As your day of delivering emergency care gets more complex, it’s critical to operate with clinical efficiency. While there is a myriad of ways to improve clinical efficiency, our team at EB Medicine has selected their five favorite tips and compiled them into a helpful infographic you can feel free to share with your team.

EB Medicine helps practices just like yours save time, improve patient care, and stay confidently up to date. We’d love to hear about your unique needs and share how we feel EB Medicine can meet them. So do not hesitate to reach out to Dana (contact info included below) with any questions.

5 Tips to Improve Clinical Efficiency

Dana Stenzel
Account Executive, EB Medicine
Email: Danas@ebmedicine.net
Direct: 678-336-8466 x 120
www.linkedin.com/in/dana-stenzel