Transient Synovitis vs Septic Arthritis of the Hip

By |Categories: Orthopedic, Pediatrics, Radiology|

Limping is a common reason for parents to bring their children to emergency departments. It is known that 77% of acute, atraumatic limp is dealt with in the ED, and 20% do not even complain of pain.1 Our job as physicians is to complete appropriate assessments to not miss any serious pathology. Specifically, differentiating between transient synovitis (TS) and septic arthritis (SA) of the hip can be difficult and frustrating for everyone. What is your approach? […]

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The SCRAP Rule: Indications for chest CT in blunt trauma

By |Categories: Radiology, Trauma|

At my institution, trauma patients frequently receive the “Pan Scan,” to rule out acute injury. Recently, Payrastre et al published the SCRAP Rule article in CJEM 2012 1 looking to derive and internally validate a clinical decision rule that would identify blunt trauma patients at very low risk for major thoracic injury with 100% sensitivity, thereby eliminating need for a chest CT. Currently, the decision on whether to perform a chest CT is made mostly by clinical judgment. […]

Trick of the Trade: Making the NG and NP procedures less painful

By |Categories: Tricks of the Trade|Tags: |

When doing nasogastric (NG) tubes and fiberoptic nasopharyngoscopy (NP) procedures, there many approaches in how patients can be locally anesthetized. Getting things pushed up your nose is so profoundly irritating that most patients only give you 1 or 2 changes to get it right. One option is to use nebulized lidocaine, although it takes a while to prepare and anecdotally tends to numb mainly the hypopharynx, placing the patient at risk for aspiration later on. Another option is to use viscous lidocaine to coat the NG or NP tubing, but this is fairly messy and only mildly helpful. Commercial intranasal [...]

Management of Syncope

By |Categories: Cardiovascular|

“Done Fell Out”, or DFO, is a common saying in the South to describe syncope. Although the saying is funny the diagnosis is not. Syncope accounts for about 3–5% of ED visits and 1–6% of hospital admissions. In patients >65, syncope is the 6th most common cause of hospitalization. How do you approach the management of patients with syncope? […]

Trick of the Trade: Rapid Oral Phenytoin Loading in the ED

By |Categories: Neurology, Tox & Medications, Tricks of the Trade|

A 57 y/o, 75 kg male presents to the ED after a witnessed seizure. He describes a history of seizure disorder and is prescribed phenytoin, but recently ran out. A level is sent and, not surprisingly, results as < 3 mcg/mL (negative). After a complete ED workup, the decision is made to ‘load’ him with phenytoin 1 gm and discharge him with a prescription to resume phenytoin. An IV was not placed. Can you rapidly load him orally? […]

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Chest Pain: Coronary CT Angiography in the ED

By |Categories: Cardiovascular, Radiology|

It is well known that taking a good history and physical, getting a non-ischemic EKG, and serial cardiac biomarkers, results in a risk of death/AMI of <5% in 30 days. Patients, in whom you still suspect have CAD, should undergo provocative testing within the next 72 hours based on the AHA/ACC guidelines. Their guidelines deem provocative testing as including: Exercise treadmill stress test, Myocardial perfusion scan, Stress echocardiography, and/or Coronary CT angiography (CCTA). […]