What’s Your Diagnosis? A 1-year-old Boy With Rhinorrhea January 3, 2020


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Case Presentation: a 1-year-old boy with rhinorrhea, congestion, cough, and fever

You arrive to a busy afternoon shift in the ED. Your first patient is a 1-year-old boy with rhinorrhea, congestion, cough, and 3 days of fever up to 39.4°C (103°F), measured rectally. His parents state that he has been playful at home and continues to eat and drink normally. They have been giving him acetaminophen and ibuprofen sporadically, but today he developed a generalized rash, and they became concerned. His vital signs are as follows: temperature, 38.7°C (101.7°F); heart rate, 135 beats/min; and blood pressure, 85/55 mm Hg. On examination, the rash is macular, erythematous, and blanching, but his eyes and mouth appear normal.

Does he need laboratory workup, or can you safely offer supportive care? Should he be on isolation, either for his own safety or for the safety of others?

Case Conclusion

The 1-year-old boy received antipyretics and was smiling, playful, and eating a cookie. After reviewing the history and physical examination findings, you decided that he did not exhibit any red flags. He had been vaccinated appropriately for his age, had not traveled recently, had a blanching rash that spared the mucous membranes, and he otherwise looked very well. You explained this to his parents and discussed that this was most likely a benign viral exanthem related to his viral upper respiratory infection and that it should self-resolve. You recommended supportive care, as needed, until the rash resolved.

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What’s Your Diagnosis? 76-year-old With Chest Pain January 3, 2020


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 2 comments

But before we begin, check out if you got last month’s case, on the timing-and-triggers approach to the patient with acute dizziness, right. Click here to check out the answer!

Case Presentation: A 76-year-old woman presents to the ED with chest pain

A 76-year-old woman presents to the ED with chest pain.

She said that for the past month she has been getting short of breath more easily on her daily walks, with occasional discomfort in her chest, requiring her to stop and rest.

Two hours prior to ED arrival, she was doing yard work and developed chest pain that was much more severe. The pain is located in the center of her chest, and she describes it as a “pressure” sensation. Her only past medical history is hypertension.

In the ED, her vital signs are within normal limits and her exam is unremarkable. Her ECG shows nonspecific ST-segment flattening, and her initial troponin is 0.09 ng/mL (reference range, 0-0.04 ng/mL).

Your intern asks if she can go home since her troponin is low and she looks well…

Case Conclusion

You agreed with your intern that your first patient was a low-risk NSTE-ACS patient—but she’s not going home with a positive troponin! You treated her with 325 mg oral aspirin, 180 mg oral ticagrelor, and 1 mg/kg subcutaneous enoxaparin. She was given 3 doses of 0.4 mg sublingual nitroglycerin and is now pain-free. Because she had no high-risk features, you told your intern that you would trend her troponins and admit her for medical management of her ACS.

While she was waiting for an inpatient bed, however, her 3-hour troponin came back at 0.74 ng/mL. As her troponin was now above the 99th percentile and had risen 7-fold since arrival, you started to think that she might be a candidate for early catheterization. You consulted cardiology, and they agreed to add her to the schedule for coronary angiography tomorrow morning.

You patted your intern on the back and reminded him that positive troponins are diagnostic of ACS, and mandate further workup even when they’re not that impressive.

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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.


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Pitfalls To Avoid With Septic Arthritis And Osteomyelitis In Pediatric Patients December 11, 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.

Septic arthritis and osteomyelitis in pediatric patients represent true emergencies, and can quickly threaten life and limb. A high index of suspicion should be maintained, as these conditions often present with a subacute course of illness and vague signs and symptoms. Septic arthritis and osteomyelitis can occur concurrently, so suspicion for one should also prompt investigation for the other.

The diagnostic evaluation should include blood work as well as samples from the infected joint or bone for culture. Management with antibiotics is a standard approach, but the duration of antibiotic therapy is controversial.

These risk management pitfalls will help you avoid unwanted outcomes in pediatric patients with septic arthritis and osteomyelitis in your ED.

1. “The patient did not have a fever, so I attributed the pain to minor aches and pains.”
Not all patients with SA and OM will present with fever. Patients may present with a subacute presentation with some pain and refusal to bear weight. There may also be a history of preceding minor trauma.

2. “The patient presented with vague/nonspecific pain. I didn’t consider a bone or joint infection.”
Both pediatric SA and OM present in a similar fashion, and the initial symptoms may be vague and nonspecific, so it is important to maintain a high index of suspicion. A thorough musculoskeletal examination should be completed and imaging should be obtained in order to fully assess the joint/bone involved.

3. “The x-ray was normal, so I did not obtain further labs or imaging studies.”
X-rays are often normal in cases of both pediatric SA and OM, especially early in the disease course. Signs on plain radiography that are consistent with SA include distention of the joint capsule, increased opacity within the joint, displacement of muscle surrounding the joint by capsular distention, increased distance between the subchondral ends of bone, and, occasionally, subluxation of the joint. Findings on plain radiography that are consistent with OM are bone destruction and periostitis, which appears as soft-tissue swelling, periosteal elevation, and lytic sclerosis.

4. “The MRI was negative, so we did not pursue further investigation for SA and OM.”
MRI is not 100% diagnostic and can give a false-negative result. In such cases, CT imaging can be pursued.

5. “The ESR and WBC results were below the established Kocher criteria.”
The ESR may be normal early in the course of SA, and neonates may have low WBC counts due to leukopenia. CRP is a useful early marker of disease and can be trended to monitor the response to antibiotics. Even in the absence of an elevated ESR and WBC, a patient with fever and refusal to bear weight still has a 40% risk of having SA.

6. “The initial lab results were not consistent with SA, so I decided to forego obtaining the arthrocentesis.”
Synovial fluid analysis remains the gold standard for diagnosis of a septic joint. The joint fluid analysis can be completed via arthrotomy, arthrocentesis, or ultrasound-guided needle aspiration.

7. “I wanted to start the antibiotics promptly, so I did not obtain a blood culture.”
With an increase in antibiotic-resistant organisms, it is essential to obtain culture specimens from as many sites as possible, such as blood, joint fluid, and bone, so initial empiric antibiotics can be modified to treat the specific microbiologic pathogen.

8. “I wanted to tailor the antibiotics to the specific microbial pathogen, so I decided to wait for culture results prior to starting antibiotic therapy.”
Ideally, empiric antibiotic therapy should be started after obtaining a reliable culture sample, but the initiation of antibiotics should not be delayed while awaiting results of culture samples. The antibiotics are geared toward the organisms known to be the most likely cause of SA and OM.

9. “We were so busy in the ED that I decided to discharge some other patients first before obtaining the appropriate labs and imaging studies.”
Time is of the essence for both pediatric SA and OM. It is imperative that the appropriate workup be initiated as soon as either diagnosis is suspected so that antibiotics can be initiated in order to avoid danger to both life and limb.

10. “I instructed my patient to continue antibiotics at least until his symptoms improved.”
Incomplete antibiotic treatment duration and/or microbial coverage can attribute to antibiotic resistance and recurrence of symptoms. Both OM and SA require initial inpatient parenteral antibiotic therapy followed by oral antibiotic therapy lasting several weeks.

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Influenza Risk Management Pitfalls to Avoid in the Emergency Department December 11, 2019


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Patients presenting to the ED with “influenza-like illness” (cough, sore throat, fever) are typical in the fall and winter. How can you tell whether a patient might have influenza and infect others with a potentially dangerous strain?

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management.

Because influenza infections can present with a wide range of nonspecific clinical signs and symptoms and numerous possible complications, emergency clinicians must be keenly alert to this possible diagnosis. A knowledge of the local seasonal prevalence of influenza as well as the specific strains circulating within a particular region are crucial for appropriate diagnostic and treatment decisions and will help to limit unnecessary testing when empiric therapy would be more appropriate.

These risk management pitfalls will help you avoid unwanted outcomes when treating a patient with a flu-like symptoms in the ED.

1. “The fever was low-grade; I thought the baby just had a cold.”
The presenting signs and symptoms of influenza infection are nonspecific, and a diagnosis based on clinical presentation alone becomes less accurate in children aged < 3 years. Although many children will experience a mild disease course and can be managed with supportive therapy, patients aged < 2 years are at high risk for a more severe clinical course. Be vigilant and have a high index of suspicion for possible influenza infection in high-risk populations, especially when disease prevalence is high.

2. “The patient had an infiltrate on chest x-ray, so bacterial pneumonia appeared to be the clear diagnosis.”
Numerous secondary complications can stem from a primary influenza infection. When addressing and treating these complications, do not overlook the possibility of a primary influenza infection and the need for medical management. In certain clinical situations, treatment with antiviral medications as well as antibacterial medications may be indicated.

3. “I thought I would just let it run its course.”
Many previously healthy people can be treated with supportive therapy alone; however, you must be aware of the numerous risk factors that are likely to result in a more severe disease course. For patients deemed well enough to be safely discharged from the ED, utilize shared decision-making with the patient and ensure a follow-up strategy is in place.

4. “It is the summer. Influenza occurs in the fall and winter, so I do not need to be concerned about it at this time of the year.”
Although influenza certainly exhibits seasonal fluctuations and regional outbreaks, the disease can occur year-round. Testing and possible empiric treatment of patients with an influenza-like illness are influenced by the regional prevalence of the disease, so monitor medical agencies that track the prevalence of influenza on a regional and national level, such as the CDC.

5. “My patient is pregnant and has influenza. The side-effect profile of antiviral medications concerns me, so I feel better treating her with supportive care.”
Pregnancy is a risk factor for a more severe disease course during an influenza infection. Initial CDC epidemiologic data from the last 10 influenza seasons indicate that some of the highest rates of morbidity and mortality are among pregnant women, which confirms the necessity of antivirals in this population.

6. “Medical knowledge has advanced over the past few decades, and now we have great antiviral medications. I do not need to worry about a devastating influenza infection today.”
While it is true that medical science has advanced considerably since the pandemic of 1918, influenza remains a significant threat. The ability of the virus to undergo genetic reassortment allows for the rapid development of new influenza strains to which the population has little or no immunity. Resistance to antiviral medications has been known to develop quickly for certain influenza strains and appears to be a rapidly increasing concern over time.

7. “Flu is everywhere. I don’t have the time to consult the CDC website. I will just give oseltamivir to my patient and be done with it.”
Even in times of epidemic influenza infection, numerous strains can be circulating at a given time within a particular region. In past epidemics, there have been reports of influenza strains resistant to oseltamivir. Thus, without knowing the prevalence of local strains, one might mistakenly choose an antiviral agent that will prove less effective on those strains. Treatment with more than 1 agent may even be indicated in some regions until more formal strain-specific diagnostic testing can be undertaken. Since certain medications are effective against only influenza type A, the local prevalence of any type B influenza should be determined in order to select the appropriate drug therapy.

8. “I see so many patients in the ED every hour. I can’t possibly wear a mask and wash my hands for every patient. Plus, I must have been exposed to influenza 100 times already.”
Maintaining effective infection control is crucial to protecting not only other patients in the ED but also healthcare staff. Patients suspected of having influenza require appropriate isolation, and strict hand-washing as well as personal protective equipment (eg, masks) are necessary to protect healthcare staff who are in direct contact with patients. The Strategic Plan for Management of an Influenza Outbreak, published by the American College of Emergency Physicians, is a good resource to ensure the highest level of preparedness on the part of the ED staff as well as their ability to handle a surge in patient volume that can be expected during a disease pandemic.

9. “The WHO has declared a pandemic. I feel better giving all my suspected influenza patients antiviral therapy, since I don’t want anyone to have a poor outcome.”
Declaration of a pandemic does not necessarily mean that the particular infectious organism is more virulent. It merely recognizes that the disease is spreading worldwide. Pandemics can occur during both mild and more severe disease outbreaks.

10. “I performed a rapid influenza test and it was negative, so I am safe sending my patient home on supportive therapy alone.”
Numerous forms of testing are available to detect influenza infection. Rapid diagnostic tests help guide clinicians in their immediate management decisions, but the quality of the specimen and the skill of the technician performing the assay can influence results. Certain rapid assays are specific for influenza type A, so knowing which strains are circulating locally is important. In times of high disease prevalence, the chance that a given patient with an influenza-like illness actually has the disease is increased, as are the number of false-negative results obtained from rapid diagnostic testing. At such times, empiric therapy based on clinical presentation alone is advised for patients at high risk. In more severely ill patients, viral culture and PCR testing are indicated when the initial rapid test yields a negative result.

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


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

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.

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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.

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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)

What’s Your Diagnosis? A 4-year-old with fever, right leg pain, and difficulty walking November 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 right, about a 7-year-old boy after a generalized seizure lasting 2 minutes Click here to check out the answer!

Case Presentation: a 4-year-old with fever, right leg pain, and difficulty walking

A 4-year-old boy presents to the ED with intermittent fever, right leg pain, and difficulty walking the last 3 days. His parents report that the child has a history of sickle cell disease and takes folic acid and penicillin for infection prophylaxis. The patient has never had surgery. On physical examination, there is point tenderness over the right thigh and an area of overlying edema, and the boy’s vital signs are within the normal limits for his age. You order a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, blood cultures, bone culture, and plain radiography.

What special bacterial pathogen must be considered in this case? How does this affect antibiotic treatment?

Case Conclusion

The 4-year-old boy with intermittent fever, right leg pain, and difficulty walking over the last 3 days was diagnosed with OM of the right femur. Since Salmonella is the most common cause of OM in patients with sickle cell disease, empiric treatment covering Salmonella was started. The bone culture grew out Salmonella. The patient was treated with vancomycin and ciprofloxacin parenterally for 5 days; he was then transitioned to oral therapy with a third-generation cephalosporin to complete 4 weeks of antibiotic therapy.

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What’s Your Diagnosis? Patient With Acute Dizziness November 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 Pain Management: Beyond Opioids, right. Click here to check out the answer!

Case Presentation: A previously healthy man with dizziness

The day shift signs out to you a 44-year-old previously healthy man. He is currently at CT.

His dizziness started 6 hours previously and has been present ever since. He describes unsteadiness and “feeling like I am drunk,” and has vomited 3 times. He denies headache or neck pain, weakness, or numbness. His vital signs are normal. There is some left-beating horizontal nystagmus in primary gaze and in leftward gaze. The head impulse test is normal.

The sign-out is that if his CT scan is normal, he can go home with meclizine and follow-up with his PCP in 2 days.

That sounds reasonable, but you wonder if there is something else that needs to be considered…

Case Conclusion

You are NOT OK with the plan for discharge if the man’s CT is normal. His CT was normal, but sensitivity of noncontrast head CT in early posterior circulation stroke is very low and a negative CT should never reassure physicians that they have ruled out ischemic stroke. The absence of a report of “vertigo” is diagnostically meaningless. Although his nystagmus is consistent with a peripheral problem, it is also consistent with a central problem, so completing the bedside examination for a patient with an AVS is important. Calling the HIT “normal” is also problematic. “Normal” means the absence of a corrective saccade, which in the setting of the AVS is worrisome for stroke. Better terminology would be that HIT is “worrisome” or “reassuring,” and better yet, “absence or presence of a corrective saccade.” Since physical examination
is more sensitive than even early MRI for posterior circulation stroke presenting as isolated dizziness, this patient was admitted for a stroke workup.

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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


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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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