 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.
Contrast Extravasation
Spontaneous Pneumomediastnum
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 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  Tuberculosis
-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  · Erections lasting more than 4 hours are a medical emergency.
· Secondary to impaired contraction of corporal smooth muscle. · Immediate aspiration/irrigation and/or injection of phenylephrine are the mainstay of treatment. · Don’t be afraid to use a big needle. 
Field treatment: don’t make things worse, get to the nearest hospital In the hospital: 1. ABCs 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 - Criteria -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 aVR Sign -Widespread horizontal ST depression, most prominent in I, II, V4-V6 -ST elevation in aVR >1mm -ST elevation in aVR >V1 Hyphen
- Defined as blood in the anterior chamber - Complete a full visual examination - Must evaluate for ruptured globe - Ruptured Globe = Tetanus, antibiotics and emergency consultation Siedel’s Sign - 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 Heat Stroke- 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.  Transplanted organs
- don't act like normal organs - won't hurt and are in weird locales RAID - Potential Complications to Consider Rejection - Hyperacute - w/in minutes - we won't see - Acute - Chronic Anatomy - Vascular - stenosis, aneurysm, thrombosis - Nonvascular - leak, scar formation, dislodged stint, stone formation Infection - 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 Drug Toxicity - Transplant immunosuppressants - cyclosprine, tacrolimus > can hurt the kidneys; - Imuran, cellcept - hematologic effects - Lots of Drug- Drug interactions |
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