A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. “It feels different than my RA flare.”
“Distracting injury” is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of “distracting injury”. Although both are studies at different sites, both conclude the same:
So let’s say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a “long bone fracture”), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might consider this patient to have a “distracting injury” because of the long bone fracture. Instead, the literature now supports your clinically clearing the cervical spine without imaging.
Wait, let’s rethink this. Does this mean that you should get cervical spine imaging for ALL blunt trauma patients with ANY chest wall tenderness?! NO. That’s just crazy. You should still factor in the mechanism of injury, severity of pain, and your clinical gestalt.
So for me, these “distracting injury” studies are helpful such that:
Go to ALiEM (PV) Cards for more resources.
With all of the advances in technology and social media, the “old school” world of traditional academia doesn’t know what to do with medical professionals who incorporate technologies into their educational practices. To justify these past 2 years of blogging during my free time, I wanted to collect data on who my readers are and the impact of my blog (if any).
I could sure use a few minutes of your time and input to help with my promotions process. Let’s push traditional academia to change with the times. Thanks a bunch.
You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.
Is your first-line treatment meclizine or benzodiazepines?
You diagnose a 35 years old woman with uncomplicated cystitis. She is not diabetic and not pregnant. Which antibiotics should you give? What if she had pyelonephritis?
Answer: It depends on your local antibiogram.
Today, go find out about your hospital’s local resistance rates for uropathogens to various antibiotics. For San Francisco General Hospital, I found our antibiogram publicly posted online. Urine isolates of E. coli demonstrate relatively high resistance rates to trimethoprim-sulfamethoxazole and ciprofloxacin:
So based on the new 2010 practice guidelines by the ID Society of America and the European Society for Microbiology and Infectious Diseases,1 I should give:
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV).
I find 2 things challenging in this maneuver.
The key is to maintain about 20-30 degrees of neck extension to align the posterior semicircular canals with the direction of gravity. Placing several blankets under the patients’ shoulders can accomplish this same position without having to scoot the patient close to the gurney edge. I’m sure the patient would appreciate keeping their head movement to a minimum.
Contact dermatitis from poison oak
We see a variety of rashes in the Emergency Department. The first step is to accurately describe the rash. Is this a macule or nodule? Is this a vesicle or bulla? The next step is to quickly “profile” it to see if it fits any classic pattern by patient age, lesion distribution, or presence of hypotension. And finally, if you are still stumped, use an algorithm based on the rash type.
These figures are from March 2010’s Emergency Medicine Magazine. It’s not meant to be a comprehensive article on rashes but it sure does take the guesswork out of 90% of the rashes you see.
Go to ALiEM (PV) Cards for more resources.
Thanks to Dr. Hemal Kanzaria for including this idea as a PV card.