By Schon Roberts MD PGY-3

61yo M with h/o of metastatic adenocarcinoma p/w numbness, tingling, and weakness in B/L UE and LE X 3 weeks. This has worsened in the past 3 days. He is now unable to walk or feed himself. He denies bowel/bladder incontinence, HA, fevers, chills, N/V/D, abdominal pain.  He denies any IVD. He was 3 weeks ago able to work full time as an electrician. He complains also of chronic neck and back pain.
Vital Signs are unremarkable.  Back is normal appearance. Pt has 4/5 strength in B/L UE and LE. He has rigidity of R arm with spasm. Decreased sensation B/L UE and LE R>L.  What is the best treatment option for this pt?

A. Discharge home. This is chronic back pain.
B. Refer patient to both pain management and a spinal surgeon to evaluate for disc herniation
C. Obtain consults from nuclear medicine, spinal surgery, and admit pt. Give steroids
D. Place pt in a TLSO brace and admit to the hospital
E. Start broad spectrum antibiotics: pt has an epidural abscess  

By Schon Roberts MD PGY-3

14 mo F, seen 3 days ago in ED with fever and possible UTI p/w new onset rash. She was placed on Omnicef and followed up with her regular doctor today. He sent her for evaluation. Parents state that she has had swelling of her hands and feet. Mother states that she has had a fever for 5 days. Fever was TMax 103 F. She has had adequate PO intake with good urine output and stooling. Parents deny URI Symptoms, N/V/D, or recent travel. Vital Signs show a pulse of 179, RR of 28, Temperature of 102.1 F, and patient has a spO2 of 99% on RA. Physical exam is remarkable for injected sclera, swelling of her hands and the dorsum of her feet. She has an erythematous rash on her trunk and extremities that blanches. It spares the palms and soles. Lungs are CTABL and cardiac exam is unremarkable. What is the best treatment option for this child?
 
A. Broaden antibiotic coverage for meningitis to include listeria coverage, LP, and admit to the hospital
B. Discharge home; Pt has a URI
C. PO Tylenol, wait for defervescence, and D/C if improved
D. Obtain an echocardiogram, start on high dose ASA, IVIG, and admit
E. Start on steroids and admit with nephrology consult

​

By Emerson Posadas MD PGY-1
 
Aaron Heckleman, MD
The Crashing Heart
Heart Failure

• if nitroglycerine helps, be aggressive with it, but maintain blood pressure MAP >=65
• start the nitroglycerine drip at 100 mcg/min, go up by 50 q5min
• critical aortic stenosis is preload dependent

 
Adenosine

• Safe for everyone except Afib with WPW (Wide, irregular)
• If giving through central line cut the initial dose in half to 3 mg

 
Ross Berkeley, MD
Advanced Documentation

• don’t forget to document patient reassessments, interventions performed, discussion with patient/family, chaperone in the room, informed consent, conversations with consultants, review of EMS/nursing notes
• document due diligence, that you reassessed

 
 
Kelly Morgan, MD
Traumatic Brain Injury

• Mild Traumatic Brain Injury – GCS 13-15 with no structural change
• Second Impact Syndrome – rare condition caused by rapid brain swelling/herniation after a second concussion in close succession to a prior MTBI
• Explain expected course and possibility of post-concussive symptoms to patients

 
 

Dr. Tony Zitek offers his evidence-based approach to pregnant and non-pregnant vaginal bleeding in this lecture. This lecture is a nice evidence-based complement to the most recent EMRAP C3 project on this topic.

​Certainly, a more in depth review will reveal a more complete understanding of the methodology, however, here are a few takeaways: First, a thorough history and physical is necessary in these cases. If my patient meets the definition of BRUE, they are in the low risk category and I find no worrisome characteristics on physical and history and can have follow up the next day, then I plan to discharge them. I would consider keeping the patient hooked up to a cardiorespiratory and pulse ox monitor during my evaluation and would consider getting an EKG, as there is a 4% incidence of cardiac disease found in ALTE patients in one study. Beyond those things, I would not do any more for my low risk BRUE patients.  With this guideline in place, the hope is more specific research and studies can be done to further guide practitioners in dealing with BRUE patients.
 
References
1.     Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016 May;137(5).
2.     McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. 2004;89(11):1043–1048pmid:15499062
3.     Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr. 2013;163(1):94–99, e91–e96
4.     Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005;115(4):885–893pmid:15805360
5.     Green M. Vulnerable child syndrome and its variants. Pediatr Rev. 1986;8(3):75–80pmid:3332339
6.     Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics. 2007;119(4):679–683pmid:17403838
7.     Bonkowsky JL, Guenther E, Filloux FM, Srivastava R. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event. Pediatrics. 2008;122(1):125–131pmid:18595995
8.     Al-Kindy HA, Gelinas JF, Hatzakis G, Cote A. Risk factors for extreme events in infants hospitalized for apparent life-threatening events. J Pediatr. 2009;154(3):332–337, 337.e1–337.e2
9.     Ramanathan R, Corwin MJ, Hunt CE, et al; Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Cardiorespiratory events recorded on home monitors: comparison of healthy infants with those at increased risk for SIDS. JAMA. 2001;285(17):2199–2207pmid:11325321
10.  Mittal MK, Sun G,, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care. 2012;28(7):599–605pmid:22743742
11.  Hoki R, onkowsky JL, Minich LL, Srivastava R, Pinto NM. Cardiac testing and outcome in infants after an apparent life-threatening event. Arch Dis Child. 2012;97(12):1034-1038pArchmid:23012307

Travis Marshall MD PGY-1
 
A 14 year-old female walks into your ED with her parents. She has a wobbling gait with chorea-like movement of her extremities and her head, and her jaw protrudes to the left in a fixed position. You enter the room and after introductions, ask the patient what brought her in today. She is lying stiffly on the exam bed with her head still rigidly to left and you are able to discern a mumbled “I can’t move my jaw.” You turn to her parents and ask why they bought her in. They respond, “An hour ago, she became stiff and had difficulty talking so we came here.” When asked what medical problems she has, they report “she was diagnosed with a mood disorder three months ago and has been on these medications.” Mom pulls three medications out of her purse and hands them to you: Sertraline, Buspirone, and Aripiprazole. She notes that she just started the aripiprazole a few days ago. You ask the nurse to place an IV and give 50 mg of Benadryl.
 
While she is doing this, you complete a quick neurologic exam having already assessed her gait as she walked in. She responds appropriately to your questions but it is difficult to understand her. The patient is unable to move her jaw and neck but her cranial nerves are otherwise intact. Her eyes track but revert to the left upper quadrant when relaxed. Her jaw is stuck in a mid-open position. She has full range of motion of her extremities, but they appear stiff and slow in their movement.  Her reflexes are 2/4 bilaterally in the upper and lower extremities. Sensation with 2-point discrimination is intact.
 
At this point, the nurse has placed an IV and given the Benadryl. Over the course of 45 seconds while you watch the clock, you see the patient’s jaw relax and head and eyes turn to midline. When asked how she is feeling, she clearly states “I feel amazing.” She then promptly falls asleep. Well done, doctor. Over the course of four minutes, you’ve correctly identified, diagnosed, and treated this patient’s Dystonic Reaction. After a period of observation, she was discharged with Benadryl 25mg Q6h for 48 hours and told to stop the aripiprazole after speaking to her psychiatrist.
 
Quick Review for Dystonic Reactions:

• Classically caused by antipsychotics
• 50% of reactions occur within 48 hours and 90% with 5 days of starting a D-2 antagonist.
• Beware of laryngeal dysfunction (rarely, can be an airway emergency)
• Physical Exam Findings May Include:
  • Trismus
  • Eye deviation in all directions
  • Forced jaw opening
  • Torticollis
  • Difficulty speaking
  • Facial grimace
  • Tortipelvic crisis: tensing of hip, pelvis, and abdominal wall muscles that cause difficult ambulation
• Treat acutely with Benadryl 25-50mg or Benztropine 1-2mg, weight-based for children.
• Recommend continuing treatment for 48-72 hours to ensure resolution of reaction.

• Symptoms may recur for up to 72 hours but no long term effects are expected.

 
References:
Barach E, Dublin LM, Tomlonavich LC, Kottamasu S. Dystonia presenting as upper airway obstruction. J Emerg Med. 1989 May-Jun. 7(3):237-40
Hawthorne JM, Caley CF. Extrapyramidal reactions associated with seritonergic antidepressants. Ann Pharmacother.  2015 Oct. 49(10)1136:-52.
Hockberger RS, Richards JR: Thought Disorders; in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2014, (Ch) 110: p 1460-1466.
Juurlink DN. Antipsychotics. Nelson NS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE. Goldfrank’s Toxicologic Emergencies. 9. New York, McGraw-Hill; 2011. 1007-8.

By Zachary David Skaggs MD PGY-2

Presenting to your ED is a 2 year old male here for abdominal recheck. He has had 16 hours of fever, vomiting, and RLQ pain. Found to be fecal occult blood positive and to have elevated CRP on your labwork today. You perform a bedside ultrasound and see no definite evidence of intussusception. You pull the trigger on a CT A/P + IV contrast scan with consideration for appendicitis.