Septic arthritis of the hip
-Most common hematongenous spread
- Up to 20% of patients with non-gonococcal septic arthritis will have 2 or more joints involved –> always do a full musculoskeletal exam!
- 50% will have positive blood cultures –> always obtain cultures.
- Risk factors: Extremes of age, hardware/recent instrumentation, skin infection, underlying arthritis, IV drug use
- You cannot rule out septic arthritis with inflammatory markers or any physical exam findings, so err on the side of obtaining joint fluid.
Pediatric septic arthritis vs. transient synovitis
- Kocher criteria can help differentiate: Temperature >38.5, WBC >12K, ESR >40, unable to bear weight.
1. Osteomyelitis can be difficult to detect in the ED so always maintain a high suspicion for it in children with refusal to bear weight or persistent pain in a long bone.
2. Bloodwork rarely helps diagnose osteomyelitis, but can be reassuring if normal and you have low suspicion.
3. X-rays help rule-out other causes of pain such as fracture but more definitive imaging (i.e. MRI vs bone scan) are usually needed to diagnose.
Consider Ketamine for:
Consider administering zofran concomitantly (NNT=7), but do not prophylactically treat with benzos
-Immediately isolate any patient that you believe may have TB, and document that you have done so!
-Upper lobe pneumonia should always prompt further consideration of tuberculosis, screen with risk factors
-Patients with TB often have multiple ED visits with active disease, risk factors are often overlooked in triage
-Remember, PPD and IFN blood testing is for latent TB only and will not help you diagnose active TB
-Involve infectious disease, ensure that the health department is involved in the patient's case
Elderly Falls - Missed Femoral Neck Fracture
-95% due to falls, more than 300k admissions per year
-One year mortality in those over 65: 12-37%
-High risk of malunion, poor healing, and avascular necrosis if missed
-Surgical repair is performed as soon as medically stable for procedure
-Range all joints, low threshold to image
-Before discharge, consider home/social factors
-For a full reassessment, ambulate the patient personally or with the nurse to prevent missed injuries and assess feasibility of discharge
High Pressure Injuries
-Surgical emergency despite benign exam
-Paint/grease guns, pressure washers
-Material rapidly spreads to tissue spaces and can cause compartment syndrome
-Time Sensitive: Amputation rate 38% within 6 hours, 58% after that
-EMS transportation if transferring for ortho evaluation from OSH/Urgent Care
Field treatment: don’t make things worse, get to the nearest hospital
In the hospital:
2. Wound assessment and pain control
3. Labs to assess for coagulopathy and rhabdomyolysis
4. Call poison control – should always talk to toxicologist
5. CroFAB vs observation only
- Mild/dry bite: no CroFAB, just observation
- Moderate/severe: one or more doses as needed based on wound progression
CroFAB is only curative treatment currently but VERY expensive; Currently evaluating anti-TNFa agents
TNFa pilot study: active now, enrolling nonpregnant healthy adults
Abnormal Presentations of ACS
-Always think of this on your differential
-Frequently re-evaluate patients
-Interpret ECGs in a systematic fashion - and do this every time!
RBBB and STEMI
- No criteria for STEMI as there are in LBBB
- Any ST elevation is abnormal
- Read your EKG’s carefully and compare to old
- It is never a bad idea to get serial EKG’s if the presentation is unclear ("One ECG Begets Another")
De Winter’s Sign
- This is an Anterior STEMI Equivalent!
- Seen in 2% of acute LAD occlusions
-Tall prominent symmetric T waves in the precordial leads
-Upsloping ST segment depression > 1mm at the J point
-No ST elevation in the precordial leads
-ST elevation in aVR
-Widespread horizontal ST depression, most prominent in I, II, V4-V6
-ST elevation in aVR >1mm
-ST elevation in aVR >V1
- Defined as blood in the anterior chamber
- Complete a full visual examination
- Must evaluate for ruptured globe
- Ruptured Globe = Tetanus, antibiotics and emergency consultation
- Evaluates for aqueous humor leak secondary to violation of the anterior chamber
- Apply topical anesthesia
- Paint eye with fluorescein dye
- Test is positive if there is a stream of dye emanating from the wound site
High Pressure Injuries
- Surgical issue - Don't send them home!
- Leave the finger alone
- No Ice (decreases perfusion further)!
- High risk for amputation
Spontaneous Bladder Rupture
- Extremely rare diagnosis
- Expand your differential, use your diagnostic pause
- Consider in pts with chronic GU issues
- Add creatinine to abdominal fluid studies
- Temp >40 with AMS
- Patients die from multisystem organ failure
- Cooling and supportive care
- Call Pearson for therapeutic hypothermia
Nec Fasciitis and Ultrasound
- Take time to ultrasound your patients
- Look for air (hyperechoic areas with shadowing), fascial thickening, deep fluid
- Cannot rule out nec fasc with US
1) SCD pain is complex and real (despite lack of objective findings).
- 1/2 have no objective findings.
- Those with higher baseline Hgb have higher risk of pain crisis.
- Adult patients increased pain frequency have higher mortality.
2) Evaluate for potentially critical masqueraders.
3) Give pain medications fast; strongly encourage intranasal fentanyl as first-line opioid.
- don't act like normal organs
- won't hurt and are in weird locales
RAID - Potential Complications to Consider
- Hyperacute - w/in minutes - we won't see
- Vascular - stenosis, aneurysm, thrombosis
- Nonvascular - leak, scar formation, dislodged stint, stone formation
- First 28 days - nosocomial
- 1-6 months - viral infections - CMV, hepatitis, EBV, HH6; oppurtunisitcs - PCP, listeria, fungal
- > 6 months - Healthy - UTI, PNA, cold, Chronic viral infection - EBV, zoster, HSV
- Transplant immunosuppressants - cyclosprine, tacrolimus > can hurt the kidneys;
- Imuran, cellcept - hematologic effects
- Lots of Drug- Drug interactions