Pediatrics: Refusal to use arm

Clinical Scenario:

A 5 week old infant presented to the Emergency Department (ED) with refusal to move right arm for the past 3 days. No significant past medical history; the pregnancy was uncomplicated, and born via Cesarian-section due to failure to descend at full term at 40 weeks.  The patient has otherwise been feeding well and moving all of his other extremities. No history of trauma or fever. The arm and shoulder have no erythema, no swelling, however the patient screams in pain whenever you move the arm. 

X-rays of the right shoulder and entire right arm were unremarkable. Laboratory tests demonstrated a slightly elevated white blood cell count (WBC), however the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were both elevated.  You admit the patient for further work up.  The following day (actually a few hours later since was a late admission) the patient underwent a sedated MRI, which revealed humeral osteomyelitis with associated septic arthritis.

Clinical Question:

What are common causes of osteomyelitis/septic arthritis in a newborn?  What is the best tests/imaging to diagnose it?

Literature review:

Osteomyelitis can cause significant morbidity and mortality in a neonate/infant and can be difficult to diagnose.  In one small study, Wong and colleagues found that only 10 of the 30 babies studied demonstrated any systemic signs of infection, such as fever.  This study also found that more than half of the infants affected were born pre-term, and 70% of the patients with osteomyelitis had extended contact with the healthcare system (eg prolonged stay in the hospital).

A review by Montgomery and colleagues found that Staphylococcus aureus (S. aureus), to be the most common cause of osteomyelitis, with cases of Methicillin resistant S. aureus rising nationally.  In infants and children specifically, other common bacteria causing osteomyelitis are Group B Streptococcus, Ecsherichia coli, Kingella kingae usually spread hematogenously.

In a review of septic arthritis with concomitant adjacent osteomyelitis, such as this particular case, it was found that the shoulder was the most likely of all the joints (elbows, hips, knees, ankle) to be infected, as it was in this patient.  S. aureus again was the most common organism to cause a simultaneous osteomyelitis with associated septic arthritis.

In osteomyelitis, the WBC is often not a sensitive marker. One study in the journal of Pediatrics found that only 35% of children with osteomyelitis had an elevated WBC.  In contrast, ESR and CRP elevations were more sensitive, at 92% and 98% respectively.  Combined together, ESR and CRP offered the greatest sensitivity in detecting osteomyelitis.  After initiation of treatment, the ESR usually normalized within 24 days and the CRP in 10 days.

The recommended imaging modality for acute osteoarticular infections is magnetic resonance imaging (MRI) with contrast given the superior imaging it provides of bone as well as the soft tissues when compared to other imaging modalities.  In follow up after treatment, positron emission tomography (PET) or commuted tomography appears to be better imaging modalities. 

Take home points:

-Osteomyelitis/septic arthritis needs a high degree of suspicion for diagnosis given paucity of other symptoms such as fever.

-WBC can be normal, ESR and CRP together are more sensitive.

-Patients can have no other symptoms besides from joint pain.

-Preferred imaging is MRI with contrast.

References: 

1. Montgomery NI, Rosenfeld S. Pediatric Osteoarticular Infection Update. J. Pediatr Orthop. 2014.

2. Unkila-Kallio L, Kallio MJ, Eskola J, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics. 1994;93(1):59

3. Wong M, Isaacs D, Howman-Giles R, Uren R. Clinical and diagnostic features of osteomyelitis occurring in the first three months of life. Pediatr Infect Dis J. 1995;14(12):1047-53

Submitted by Steven Hung (@DocHungER), PGY-2

Faculty reviewed by Joan Noelker

Pediatrics: There's blood in the stool!

Clinical Scenario:

A 2 week old child presented to the emergency department with blood in the stool.  The child was otherwise well, tolerating feeds, no apparent abdominal pain, no abdominal distension, no fever.  Other than the dark red blood, the stool appeared about the same.  Child was born via vaginal delivery following an uncomplicated 40 week pregnancy.  Had stool within minutes of birth and has had normal stooling since.

Clinical Question:

What should be considered in a neonate/infant presenting with bloody stool?

Differential Diagnosis (DDx) of bloody stool in neonate:

-Swallowed maternal blood

-Anorectal fissure

-Necrotizing enterocolitis (NEC)

-Malrotation with midgut volvulus

-Hirschsprung disease

-Food protein-induced proctitis/colitis (not to be confused with similar food protein-induced enterocolitis syndrome [FPIES] where child is usually sicker and involves vomiting)

Other Differentials in later infancy:

-Intussusception (more common between 6-36 months of age, 60% before 1 year, 80% before 2 years)

-Infectious colitis – rare during neonate period given reduced exposure

-Meckel’s direrticulum – rare cause of bleeding in neonatal period

Several of the DDxs listed above could be excluded after review of the history and physical exam. Physical exam in this patient excluded anorectal fissure.  The child was 2 weeks old, making persistent swallowed maternal blood highly improbable.  As the patient was a well appearing neonate NEC and malrotation were also unlikely.  Normal stooling made Hirschsprung less likely.  Her age made intussusception, infectious colitis, and Meckel’s less likely.  This left food protein allergy, most commonly due to cow’s milk.  But there was a problem: I remembered asking the mother about the child’s diet, and she had reported that the infant was exclusively breastfed.  How could cow’s milk be a causal factor in a breast fed infant?

Literature review: 

As it turns out, many of the proteins consumed by mothers are passed onto their infants and can cause food protein-induced proctitis/colitis in which the only symptom in infants under 2 months of age is blood in the stool.  A small study of 95 breastfed infants presenting with only bloody stool found that elimination of specific proteins in the maternal diet or through use of extensively hydrolyzed casein-based formula resolved the bleeding within 72 to 96 hours.  65% of the infants were found to be sensitive to cow’s milk, 19% to egg, 6% to corn, and 3% to soy.  This proctitis/colitis, as the name implies, only induces an inflammatory response in the rectum and distal sigmoid colon.  At least half of the infants manifesting this condition are breast fed.  The symptoms will usually resolve by one year of age with the elimination of the offending protein, and most of these children can go on an unrestricted diet with no further problems.  Interestingly, this reaction does not appear to be IgE-mediated, so routine food allergy testing is not recommended.

Take home points:

-With blood in stool, must have wide differential

-If child otherwise well, with other dangerous conditions ruled out, can send stool culture and discharge home with trial of elimination of most common offending agents

-Most common agent is cow's milk, even if the only source is through the mother's breast milk

References:

1. Lake AM. Food-induced eosinophilic proctocolitis. J Pediatr Gastroenterol Nutr 2000;30 Suppl:S58

2. Odze RD, Wershil BR, Leichtner AM, Antonioli DA. Allergic colitis in infants. Journal of Pediatrics 1995;126(2):163-170.

Submitted by Steven Hung (@DocHungER), PGY-2

Faculty reviewed by Joan Noelker

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.

EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  

#FOAMed Digest No. 6: Ain't Nobody Got Time For That

Welcome back, FOAMheads! My apologies for the delay this week. I ended up being a bit busier than I expected, which not coincidentally brings me to the theme for today's entry.

Sometimes you have a lot on your plate and may not be able to set aside a large chunk of time to watch/listen to a 30-minute-plus podcast. But that doesn't mean you don't have time to get your learn on! This time around, we'll highlight some of the best FOAMed sources of short-and-sweet educational pearls. Easily digestible for the highly-distractible mind of the EM trainee.

There is no moment like the present -- let's get started!

A Happy Ending?

Your patient is a young adult male with no significant past medical history presenting with a chief complaint of testicular pain and heaviness. He reports that the pain occurred 2 hours prior to presentation. It was gradual in onset, progressively worsened, and is now plateaued. The pain is constant, dull, and achy. It is not localized to a single side. The patient feels like his scrotum is heavy, like someone is weighing it down. It is worse with movement, better when still. The patient could not recall any inciting trauma. 

Prior to onset of symptoms, the patient reports “getting my swerve on” with a new female partner, which he insisted did not consist of penetrating vaginal or anal intercourse would not further elaborate. He denies ejaculation prior to pain onset. He denies a history of penetrating intercourse altogether, but does endorses receptive oral sex activity. He denies a history of STI. Further ROS is negative. 

The physical exam is notable for bilaterally descended testes, and normal-appearing Tanner stage 4 genitalia. There is generalized bilateral testicle tenderness to palpation, without scrotal discoloration, testicular deformation, or penile discharge. There is no transverse lie, nor change in symptoms with elevation. The cremasteric reflex is intact.

You’re pretty sure you are least colloquially familiar with this patient’s current affliction, but have no idea if there’s any evidence-based interventions to lessen his discomfort.

Clinical Question:

What are suggested treatments for male pelvic congestion?

The Literature:

There is a paucity of academic information regarding this phenomenon:  scrotal pain following sustained sexual arousal unrelieved due to lack of orgasm and ejaculation. In the limited literature available, it is known as male pelvic congestion or epididymal hypertension. In lay terms, it has been referred to as “blue balls,” “lover’s nuts,” or “deadly sperm build-up” (DSB). Most of the available information is from anecdotal reports – “common knowledge and experience,” as one (unreferenced) article from a human sexuality journal described in 1989. Prior to the publication of a case report, with responding letters to the editor/author, published in Pediatrics in 2000, there was no information on the subject to be found in textbooks or online searchable databases (as concluded by medical librarians in three different institutions queried by the authors of this case report).

The included signs and symptoms are similar to the patient’s presentation above. In most cases the tenderness appears to be localized to the epididymis. The remainder of the GU exam and urinalysis should be normal. The pain usually resolves spontaneously within three hours of onset.

Proposed pathophysiology involves sexual arousal that produces increased blood flow to the penis and testes leading to pelvic venous dilatation. If this persists over time, testicular venous drainage slows, pressure builds, and this causes pain. 

Anecdotal treatments include sexual release via ejaculation, Valsalva maneuver, or lifting a heavy object. The case report included an anecdote about a physician in Los Angeles in the 1940s who, while teaching a course on human sexuality, gave a lecture on “lover’s nuts” in which he advised that masturbation was an appropriate medical treatment. This view is shared by most sexual health "experts" in the lay press.

Take home:

Male pelvic congestion is a real phenomenon, but is rarely discussed in medical literature.

It is a self-limiting and non-morbid process, but anecdotal evidence suggests that Valsalva, weight-lifting, or ejaculation via masturbation may expedite relief of discomfort.  

References:

1) Pediatrics. 2000;106;843-843.

2) Pediatrics 2001;108;1233

Contributed by Daniel Kolinsky, PGY-2.

#FOAMed Digest No.5: But This One Goes to 11

Time once again for your mid-week blast of FOAMy goodness from around the interwebs. There’s no particular subject today; instead we’re going to highlight some of the better podcasts/vodcasts that updated this week. Podcasts are great. They break up the monotony of reading (and the monotony of mundane things like laundry, grocery shopping, training for this damn marathon…). For the more distractible among us, they usually come in easily-digestible 20-30 minute morsels. They expose you to different presentation styles, and allow you to match a face and a voice with the big names in FOAMed. Most of them also feature written show notes with references as well, which allows you both to reinforce the things you learned while listening, and also to dig deeper into topics you’re interested in.

Fun for the whole family!

Three Stars:

1. I think FOAMcast, authored by residents and EM social media savants Jeremy Faust and Lauren Westafer, might be the first example of “metaFOAM.” They peruse the FOAM world for interesting recent posts, then integrate that information with relevant material from the most popular EM textbooks (i.e., “Rosenalli”), other relevant blogs/podcasts, primary literature, and even Rosh Review questions. This week they use a post from ALiEM on calcium channel blockers vs beta blockers for A-Fib as a jumping-off point for a discussion on ED management of A-Fib and A-Flutter. There’s links to vodcasts from Scott Weingart and Amal Mattu on narrow-complex tachydysrhythmias, and plenty of cited references from the primary literature (including one from our own Brian Cohn!). It’s good stuff.

2. Speaking of the Godfather of ED EKG, Dr. Mattu has two quick cases for you to ponder. Remember: T-wave inversion does not always mean cardiac ischemia!

Remember: Gotta think tox in a seemingly unprovoked wide complex tachycardia!

3. Steve Carroll at EM Basic provides an excellent analysis of the ED management of asymptomatic hypertension, including references to the relevant ACEP Clinical Policy document and other FOAMed resources.

Oldie But Goodie:

Chris Nickson, creator and administrator of Life in the Fast Lane, gave an excellent talk at the original SMACC conference in March 2013 with the confidence-inspiring title, “All Doctors are Jackasses.” Why are we jackasses? Because we don’t do enough to understand how we think and how we make decisions, and this leads us to make errors. Watch Nickson’s lecture and begin to understand how to remedy this situation.

(EXTRA CREDIT: Links in the show notes to the other SMACC talks in the “Mind of the Resuscitationist” plenary by Weingart, Cliff Reid, and Simon Carley.)

F(FN)OAMed:

By this point you guys all know how awesome EM:RAP is, but this week is particularly relevant because Herbert & Co. just released an “EM:RAP Mini” segment about the newly-published “Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis” trial in the New England Journal. For those of you that aren’t familiar, this was a study in which we participated, and our own Drs. Aubin and Griffey are authors on the paper! An excellent summary of this paper is found on the Emergency Medicine Ireland blog, with a link to download the EM:RAP Mini segment in the show notes.

The Gunner Files:

1. Time to synthesize the knowledge you gained about non-surgical management of pediatric appendicitis at Journal Club last month. Dr. Cohn is back with another excellent EMJClub podcast along with Drs. Trehan and Horst, summarizing the primary literature.

2. EMin5 is back at it with a review of the four types of shock, in a little over four minutes.

3. From the Maryland Critical Care Project, an excellent lecture from Neuro Critical Care and ED intensivist Dr. Wendy Chang describing the ED management of status epilepticus. She covers the gamut from first-line benzos to second-line AEDs and third-line agents for initiation of therapeutic coma.

4. The good people at the All NYC EM blog posted a lecture given during their conference day by the FOAMed superstar Dr. Haney Mallemat. He covers all the basics of ultrasound evaluation of pericardial effusion and tamponade, even ultrasound-guided pericardiocentesis.

5. In case you’re not familiar, US Air Force Pararescuemen, a.k.a. “PJs,” are the ultimate badasses. Just look at it this way: think becoming a SEAL is tough? PJ training has an even higher failure rate. But I digress.

Former PJ and critical care flight retrieval medic Mike Lauria is now in medical school, and is making a bit of a splash in the FOAMed community as an expert on training, thinking, and operating in high-stress environments. Scott Weingart recently interviewed him on EMCrit about the concept of “mental toughness,” how that translates from the combat realm to the ED, and how to incorporate it into physician training. Really interesting stuff.

That Others May Live,

Sam Smith, PGY-3

#FOAMed Digest No. 4: Butter My Biscuit, Baby

Welcome back, to the brand new edition of the WUEMR FOAMed Digest. Get out your Tintinalli’s and strap in, because we’re going back to basics today. It’s all about the bread and butter. The things any PGY-2 setting off to an overnight Saturday shift in the Deuce should have down cold…yet us seniors still screw up on the daily.

FOAMed…ENGAGE!

Three Stars:

1. If my last shift at Children’s is any indication, the season is upon us – pharyngitis in every exam room. Casey Parker over at Broome Docs (a blog authored by EPs & GPs practicing in rural Australia), presents a magnificent summary of the data surrounding rapid strep swabs, antibiotic use for symptom relief, and antibiotic use for preventing secondary complications of strep. As always, be sure to check out the original literature for yourself. And don’t miss Minh Le Cong’s excellent counterpoint in the comments, which is also well-referenced.

2. What’s your record for most C-collars cleared in one shift? (When you hit double-digits, then we can talk.) The best tools in our arsenal for clearing C-spine in low-risk patients remain the Canadian C-spine and NEXUS instruments. But which one should you use? Do you even remember which criteria belong in each rule, or do you find yourself trying to apply the “Canadi-EXUS” criteria, like I do? Luckily for us, Alayna Hawling at BoringEM authored an excellent rundown and comparison – with a pretty flowchart!

3. As much as you want to start the fist-pumping and beer-chugging as soon as you drop that tube past the cords, your work with the intubated patient is not done, my friend! We’ve already touched on our persistently poor rates of achieving adequate analgesia & sedation in the intubated patient. Another part of quality post-intubation care is knowing what to do if your ventilated patient acutely decompensates. Check out Chris Cresswell’s summary of the DOTTS mnemonic over at EM Tutorials.

(EXTRA CREDIT: He also included a link to Scott Weingart’s notes regarding care of the crashing ventilated patient, which are well worth a look.)

Oldie But Goodie:

There’s been some e-mail discussion lately among our attendings regarding the best way to clean lacs prior to closure. Back in February, Ken Milne at the Skeptic’s Guide (along with Eve Purdy, a rockstar med student and creator of the excellent Manu et Corde blog) published a piece dedicated to breaking down the dogma of management of simple lacerations. Tap water vs sterile water, sterile gloves vs clean gloves, to sew or not to sew…it’s all covered here. Plus there’s links to other excellent FOAMed resources regarding wound care dogma.

F(FN)OAMed:

The good folks over at EB Medicine recently published a stem-to-stern guide to UTI diagnosis and management in the ED, all based on best available evidence. A bit lengthier than your average blog post, but incredibly high-yield and well worth your time. It’s a bit difficult for me to place a direct link here, but you can find it simply by logging into your account at EBMedicine, following the link to browse issues of Emergency Medicine Practice, and opening the July 2014 issue on UTI.
(As always, contact your friendly neighborhood Social Media Committee member if you need help obtaining access to EB Medicine resources.)

The Gunner Files:

1. Hard to get through a Deuce shift without breaking out the prochlorperazine at least once. We’ve all seen patients get jittery, agitated, or downright whacky following its use. Does Benadryl help? A PharmD expert at ALiEM has a good lit review of the topic.

2. Short and sweet: some diabetic medications are more likely to cause harmful hypoglycemia after overdose than others. Quick table-based rundown over at ALiEM.

3. It is asthma season, and you may find yourself in the worst-case-asthma-scenario of impending need for intubation. Check out this post from The Kings of County regarding care for the sick asthmatic, including intubation and mechanical ventilation issues.

4. FOAMed is taking the world by storm! Does the UK College of Emergency Medicine launching a dedicated FOAMed site mean it’s officially gone mainstream? Don’t worry – we were all into FOAMed before it was cool. But seriously, check out this vodcast on diagnostics in EM, and not feel quite so much increase in sphincter tone when Carpenter or Cohn pimp you on likelihood ratios or Bayesian analysis.

5. Another classic from the Skeptic’s Guide, this time addressing another oh-so-common ED complaint: renal colic. Fluids? Flomax? Any good evidence for either? In news that will surprise no one, Ken Milne is skeptical.

Never stop learning,

Sam Smith, PGY-3

#FOAMed Digest No. 3: You Need Me On That Wall

Emergency Medicine physicians practice in a unique environment. We must synthesize plans for  diagnosis, management, and disposition while utilizing input from almost every subspecialty, and the ED is the ultimate proving ground for diagnostic tests and treatment modalities of every sort. Unsurprisingly, a fair deal of controversy and debate exists regarding the optimum management of patients. (For reference, see any Trauma Case Conference featuring Drs. Schuerer and Aubin.) The “best evidence” is often poor evidence. We in Emergency Medicine retain the rebellious spirit of our founders, and are always looking for new and innovative techniques. Some physicians are too quick to jump on the bandwagon, and others lag behind the curve when it comes to adopting new practices.

The selections this time around are not meant to tell you the best way to do things. The algorithms and practice patterns suggested are not universally adopted, written in textbooks, or taught as part of any standard curriculum. They are meant to promote thought, to prompt you to read the primary literature for yourself, to encourage you to seek the opinions of other experts on the subject, and to form your own conclusions. Hopefully they will inspire you to suggest new ideas to your seniors and attendings during your next shift – or even question ideas you think are unsound. Maybe, just maybe, they will even inspire a new research or QI project. FOAMed is by design perfectly adapted to assist you in this quest.

Ramblers, let’s get ramblin’.

Three Stars:

1. Ken Milne at the Skeptic’s Guide to Emergency Medicine pretty much sets the bar when it comes to FOAMed of the latest EBM topics. He asks his clinical questions in the PICO format, he applies a rigorous quality checklist when analyzing the available literature, and includes in his discussion other FOAMed experts (including on occasion our very own Chris R. Carpenter, a.k.a. “Captain Cranium”). This episode he turns his skeptical eye to a topic sure to generate heated discussions for years to come: tPA for stroke.

2. If there’s anyone that looms larger in the ED Critical Care world than Weingart, it’s Resuscitationist Extraordinaire Cliff Reid. His lecture from the SMACC Gold conference hit resuscitation dogma like an A-bomb, leaving irradiated bits of unfounded practice patterns strewn about the Outback countryside.

(EXTRA CREDIT: Reid’s talk from the original SMACC conference, “Making Things Happen,” should be required viewing for anyone wanting to be a Trauma Senior someday.)

3. If pediatric surgeons have come to accept ultrasound as a stand-alone diagnostic method for appendicitis, maybe there’s hope that someday ultrasound can also be used as a radiation-sparing technique for diagnosis of small bowel obstruction. Academic Life in EM has an excellent run-down of the technique and comparative research studies.
(EXTRA CREDIT: The book Evidence-Based Emergency Care, authored in part by our own Captain Cranium Chris R. Carpenter, has a chapter dedicated to the inferiority of plain films for SBO diagnosis. You can read it for free online via Becker Library.)

Oldie But Goodie:

I think here in a few more years this will reach “accepted standard practice” level, and maybe even “textbook” level, but it’s not there yet. It should be: there’s good evidence to show kayexelate doesn’t work, and may even cause harm. Let Weingart and the PaperChase fellows from EM:RAP give you the ammunition you need to stand up to any pesky floor seniors.

F(FN)OAMed:

In a very enlightening segment from this month’s EM:RAP, Rob Orman interviews a community ED practitioner, Dr. Cameron Berg, regarding his hospital’s new Accelerated Diagnostic Protocol for low-risk chest pain. While his exact algorithm hasn’t been externally validated and probably isn’t ready for prime-time at our shop, the evidence-based and pragmatic approach is certainly worth considering. And he provides links to almost all of his references in the show notes!

The Gunner Files:

1. The “Research & Reviews” segment on Life in the Fast Lane is worth checking out every week. A group of some of the brightest minds in the FOAMed world get together and spoon-feed us summaries some of the most relevant, practice-changing, or downright strangest papers in the EM literature.

2. Josh Farkas over at PulmCrit wrote an excellent piece laying out his argument for super-high-flow NC (think 30-45L!) as an acceptable method of preoxygenation before RSI. It’s also got a good rundown of apneic oxygenation using NC (which we all should be doing every time), and an enlightening counterpoint from the grand maester of ED Critical Care, Scott Weingart.

3. Pediatric EM expert Sean Fox provides an excellent summary of the neonatal ALTE on his blog Pediatric EM Morsels.

4. Two EM airway heavyweights, Rich Levitan and Reuben Strayer, slug it out in the ultimate Direct Laryngoscopy vs Video Laryngoscopy debate, posted to the Prehospital and Retrieval Medicine podcast hosted by Minh Le Cong.

5. All of us will be the bearer of the -07 phone at some point, and that means you better have your act together when discussing decision-making capacity. Bill Johnston, EMT-P and author of the excellent blog Prehospital Wisdom, shares his fundamentally sound and no-bullshit method for determining capacity in the field.

In the words of Ken Milne: “Meet ‘em, greet ‘em, treat ‘em, and street ‘em!”

Sam Smith, PGY-3

#FOAMed Digest No. 2: Breathless Love

Welcome back! Fresh new FOAMy goodness for you, this time with an emphasis on airway and pulmonary care. Let’s do it!

Three Stars:

1. No way around it: “Delayed Sequence Intubation” is the new hotness. If you want to be one of the cool kids, you better get on board. I’ll let the more graphically-minded folks at EMCurious lay it all out for you with a prototypical case. Don’t miss the links – more excellent FOAMed resources on DSI.

(And Weingart’s seminal paper on the subject is required reading at this point.)

(And, oh yeah, ketamine does NOT increase ICP. Let’s use these two systematic reviews 1 & 2 to stop the foolishness already.)

2. Someday you will need to perform a cricothyrotomy. Accept it as reality, and do everything you can to prepare for it. Start here, with Weingart’s lecture on the surgical airway delivered at the SMACC Gold conference last fall. This page from the EMCrit blog has compiled all sorts of great surgical airway resources from around the FOAMed world all in one spot, including can’t-miss stuff about the scalpel-finger-bougie technique and Weingart’s pre-intubation checklist. You should probably add it to your favorites list now.

3. Wouldn’t be a FOAMed Digest without getting a little off-topic, and Rick Body’s recent contributions over at St. Elmyn’s regarding ACS & “low-risk” chest pain in the ED are too good to pass up. Great post analyzing his recent paper, which concluded ED physicians simply aren’t capable of ruling out ACS in chest pain patients with an acceptable accuracy using only the clinical exam. Dr. Body also gives you a run-down of how to properly utilize high-sensitivity troponin in his talk from SMACC Gold.

(Link to Body's paper here.)

Oldie But Goodie:

By the end of our Ultrasound rotation, we can all diagnose pneumothorax with ultrasound at the bedside. It’s time to take it next-level. A-lines, B-lines, pneumonia vs edema…the experts at the Ultrasound Podcast help you figure it all out in a two-part 1 & 2 podcast.

F(FN)OAMed:

Sanjay Arora and Mike Menchine, hosts of the PaperChase segment on EM:RAP, summarize the current literature about how terrible we are at adequately sedating patients after RSI. Roc lasts longer than Sux – the patients won’t be able to tell us they need sedation!

(Links to relevant papers in the show notes.)

The Gunner Files:

1. Brett Sweeny at EMDocs provides an exhaustive review of FOAMed resources regarding permissive hypotension in trauma. Great lectures and podcasts from some of the brightest minds in EM & trauma surgery.

2. We’re seeing it already – asthma cases are starting to pile up over on the SLCH side. Luckiliy for you, Pediatric EM rockstar Andy Sloas just published an excellent podcast on the evaluation and management of asthma in the Peds ED.

3. Next time you’re consulting Ortho or Plastics for a hand injury, sound like you know what you’re talking about. The folks over at EMin5 hit you with the quick rundown on the neuro exam of the hand.

4. Last week, St. Elmyn’s helped the rooks get up to speed when it came to dealing with the dyspneic patient in the ED (and I bet the seniors learned a thing or two as well). This time, get your mind right when faced with a syncopal patient.

5. Who doesn’t love infographics? And if they actually help us learn something about managing septic patients, that’s just a bonus! Very well done by EMCurious, with embedded links to the relevant studies!

6. New podcast from R.E.B.E.L.EM, summarizing the results of a meta-analysis just published this month in Annals which concluded prehospital application of NIPPV in patients with severe respiratory distress regardless of cause reduced need for intubation (NNT 8) and in-hospital mortality (NNT 18). 

w00t prehospital medicine!
(Original pub here.)

That’s all, folks! Go get your learn on!

Sam Smith, PGY-3

#FOAMed Digest No. 1: Total Eclipse of the Heart

Welcome to the very first edition of the WUEMR FOAMed Digest! The Social Media Committee hopes with this segment to parse out from the overwhelming FOAMed universe a few of the most high-yield pieces of highest relevance to the general EM trainee. We hope to deliver this in an easily digestible format that you can realistically work through over a week – even if you’re stuck in an ICU.

Each post will contain several sections:

1. Three Stars: Three of the best-of-the-best from the FOAMed world published in the past week or so.

2. Oldie But Goodie: The FOAMed universe has been around long enough that there’s already a good number of very well-done and highly informative blog posts and podcasts.

3. Free (For Now) Open Access Med Ed: F(FN)OAMed for short. There are some great resources out there that are not free to the vast majority of EM practitioners but, due to your EMRA membership being graciously covered via the residency and MoCEP, you have access to them. Most notably, your EMRA membership allows you subscription to the EM:RAP podcast and the EB Medicine resources – EM Practice, EM Critical Care, etc. You should take advantage of this opportunity while you can, and this section will help you do so. (Contact your friendly local Social Media Committee member if you need help setting up your access.)

4. The Gunner Files: The Social Media Committee recognizes that, with this being Wash U and all, some of you will always be overachieving. So we’ll include a few extra selections for those of you that have a more insatiable FOAMed appetite.

Without further ado, let’s kick the tires and light the fires.

This week, “Total Eclipse of the Heart,” will focus on care of various cardiac conditions.

Three Stars:

1. Ever heard of Wellens’ Syndrome? If you have any hope of passing your boards one day, you should. Not mention that whole “you shouldn’t miss a critical EKG finding that portends certain doom” thing. Never fear, Salim Reazie, author of the excellent R.E.B.E.L.-EM blog, has you covered. 

(Don’t miss the links list at the bottom that highlights posts from other top-notch FOAMed resources!)

2. Syncope is one of those presenting complaints that really must be approached in a systematic manner. The grandmaster of EM EKG interpretation, Amal Mattu, reviews the differential while highlighting the characteristic EKG findings of a can’t-miss diagnosis.

3. Okay, so DKA isn’t exactly a “cardiac” condition – but the worst-case-scenario is still hemodynamic collapse, right? It counts. The EBM gurus over at Anand Swaminathan’s blog EMLyceum give you the latest & greatest when it comes to evidence-based care of DKA.

Oldie But Goodie:

So you’ve achieved the nigh-impossible – achieved sustained ROSC in an OHCA patient. Now what? The reigning American Idol of EM Critical Care, Scott Weingart, tells you what in an excellent two-part interview with one of the lead authors of the TTM trial, Stephen Bernard.

F(FN)OAM:

Worst-case scenario #137: Running ACLS on a patient brought in with PEA arrest. As CPR continues, the staff looks to you. “Uhhhhhh…more Epi?” Like all things resus, you need a systematic approach. The smart dudes over at EM:RAP, along with EM cardiology expert Amal Mattu, review a newly published paper that will help you do just that in the August 2014 edition.

PubMed link to the paper itself here.

(Once again, contact the Social Media Committee if you need helping subscribing to EM:RAP.)

The Gunner Files:

1. Excellent review article from the journal Emergency Medicine Australasia covering that bane of the overnight Deuce shift. No, not vaginal discharge – dental pain.

2. EMLyceum deals in pearls once again when addressing ocular emergencies.

3. Ryan Radecki over at EMLitofNote looks at a very interesting paper just published in JAMA regarding the use of pulse oximetry and dispo of bronchiolitis patients. 

(And as always, be sure to read the original paper for yourself!)

4. My FOAMed man-crush, Rory Spiegel of EMNerd, tackles the C-spine injury algorithm debate.

5. The Aussies over at St. Elmyn’s get you straightened out when dealing with the breathless patient in the ED. Incredibly high-yield for new ‘terns, but useful for docs of all ages.

Now get to FOAMing! 

As always, comments/concerns/criticisms are appreciated!

C. Sam Smith, PGY-3

A suspected case of Eczema Herpeticum

Your patient is a 2 y/o with a history of eczema who was brought in by his mother for a new rash x 1 day, associated with fever. The rash is pustular-appearing and in other places vesicular. It covers the arms, legs (including palms and soles), and trunk with relative sparing of the face. There are no oral lesions were noted. In the emergency department, the patient is febrile and tachycardic, but otherwise non-toxic appearing.

You are worried that he might have eczema herpeticum or a staph superinfection. You collect viral and bacterial swabs, and admit him to the pediatrics service. 

Question:

Should you start acyclovir right away, or is it okay to wait until the swab results come back?

Literature: 

Fortunately, an article in Pediatrics aimed at answering this very question. The study was a large, retrospective cohort study conducted between 2001-2010. This study included 1331 children age 2 mo to 17 yrs treated at 42 different centers for eczema herpeticum (identified by their primary discharge diagnosis). The primary objective of the study was to determine whether delayed acyclovir therapy was associated with increased LOS. Secondarily, the study examined the mortality rate (0%), the rate of ICU admission (3.8% ), co-existing bacterial infection (30.3%) and Staph bacteremia (~3.9%). Using multivariable linear regression models, the authors found that a delay in initiation of acyclovir was associated with an increased length of stay. Adjusted increase in LOS was 11% (95 % CI 3-20), 41% (95 % CI 19 - 67), and 98% (95% CI 60-145) for a delay in initiation by 1, 2, and 3-6 days respectively. These results were statistically significant (p <.001). The authors found no significant difference between the administration of acyclovir in IV vs. oral form. Given the above results, the authors concluded that “Patients clinically suspected of having eczema herpeticum should receive empiric therapy with acyclovir because there is a statistically significant time-dependent increase in LOS with every day of delaying in initiating acyclovir therapy". Adverse events from acyclovir therapy were not addressed.


Take Home:

1) If you are admitting a child because you are worried about eczema herpeticum, start acyclovir. Oral form is fine if kid can take it.

2) Send blood cultures and start antibiotics for co-existing Staph infection, especially if the kid is febrile because ~ 30% have co-existing Staph infection and ~4% are bacteremic.


Reference:

Aronson et. al. “Delayed Acyclovir and Outcomes of Children Hospitalized with Eczema Herpeticum.” Pediatrics 2011; 128; 1161.