A patient presents to your Emergency Department with altered mental status and somnolence. You don’t smell alcohol on breath and you don’t see needle track marks. What clinical clue points you towards cocaine or methamphetamine ingestion?
Is your Emergency Department administering Tdap immunization boosters instead of dT boosters? Patients with wounds are getting updated not only for tetanus and diphtheria, but also now for pertussis.
Apparently there has been sharp rise in the national incidence of pertussis (Bordetella pertussis shown in image) in 2010. The infection has been documented in both infants (underimmunized less than 3 months old) and adolescents/adults (loss of immunity after 10 years). In fact, the CDC has issued an epidemic warning in California.
How do you diagnose pertussis ? What are the classic symptoms? Better yet, how do you rule-it out clinically?
You won’t like the answer. It often presents like the common cold and clinical symptoms are minimally helpful in making the diagnosis. So, according to the American Academy of Pediatrics, you should treat anyone under the age of 3 months in whom you suspect pertussis. Complications from pertussis in infants include apnea, seizures, secondary pneumonia, and death. That means any with an innocent cough should be treated with azithromycin!
The following is a meta-analysis article from JAMA on diagnosing pertussis in adolescents and adults.
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits.
How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach.
Def Leppard may have been right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. The prolapse often reduces spontaneously or with gentle manual pressure.
How do you risk-stratify undifferentiated chest pain patients in the Emergency Department? There are a multitude of causes for chest pain. We are always taught to think of the 5 big life-threats: ACS, PE, aortic dissection, tension pneumothorax, and pericardial tamponade.
So how do YOU risk-stratify your patients for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI)? STEMI’s are usually obvious. UA and NSTEMIs — not so much.
Fortunately a 2000 JAMA article and a followup Academic Emergency Medicine 2006 study have solidified the TIMI risk scoring system as a reasonable risk-stratification tool for all-comer ED patients with chest pain requiring an ECG.
Generally there is an upslope in risk at a TIMI score of 3 and greater.
Adapted from [1, 2]
Go to ALiEM (PV) Cards for more resources.
Anyone who teaches medicine asks students to list their differential diagnosis when discussing a new clinical case. It’s also part of several models for education including the One-Minute Preceptor and SNAPPS.
For the most part, students are good at coming up with answers to the differential, but what do you do when they strike out? Or what if the answer is always the same, i.e. chest pain = myocardial infarction?
The most common cause of stridor in pediatric patients is croup, or laryngotracheobronchitis. The distinct high-pitched, seal-like,”barky” cough can be heard from outside the patient’s room often.
Check out the YouTube clip above. Go to the 1:15 mark (near the end) to hear the barking cough. Poor but cute kid.
What is the current treatment regimen? Did you know that the traditional treatment with cool mist or humidified air have shown to be of no added benefit?
Go to ALiEM (PV) Cards for more resources.
I finally tried the Modified HAT (Hair Apposition Technique) trick for the closure of scalp lacerations. I have used the traditional HAT trick multiple times but not the modified technique.
Instead of using your fingers, the modified approach involves the use of two instrument clamps to help twist and pull the hair strands taut. It turns out that this makes a huge difference, especially for short hairs. The clamps allow you to grab the hair strands so much more securely, before instilling a tissue adhesive at the twisting points.
The nice added benefit was that my chubby fingers were now out of the procedural field. This allowed my assistant to more easily see and reach the hair twisting points with the Dermabond applicator.
Check out the finished product of this 2.5 cm laceration on the scalp vertex.
The simple addition of two instrument clamps provides significantly superior control, stronger tensile strength, and better exposure when twisting hair strands together. Try it.
