We are in San Diego for the American College of Emergency Physicians (ACEP) Scientific Assembly and are bringing you daily pearls from the lectures.
Nazerian P, Mueller C, Dematosoeiro A, et al. Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study. Circulation. 2018 Jan 16;137(3):250-258
Check out this post from Highland on regional anesthesia for rib fractures
We review the American Urological Association guidelines on penile fracture and priapism. We supplement this with core content from Tintinalli and Rosen’s.
Rosh Review Emergency Board Review Questions
A 16-year-old boy with sickle cell disease presents to the emergency department having intermittent but frequent short and painful erections. He denies current pain but reports having had four unwanted painful erections beginning this morning, each becoming progressively longer with the most recent lasting one hour. On exam he is well appearing and in no distress with a flaccid non-tender penis on genitourinary exam. Which of the following is the most appropriate next step?
A. Corporal aspiration
B. Oxygen
C. Pseudoephedrine
D. Warm penile compress
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C. Priapism is a painful erection unrelated to sexual stimulation. It is most common in sickle cell patients and is usually an ischemic, low–flow process resulting in venous stasis and sickling of cells. Irreversible tissue damage begins at six hours, so patients with a painful erection are taught to seek medical attention with erections lasting more than four hours. Optimal management is not well defined and local expert opinion may vary. Brief episodes can often be managed at home with oral analgesics, brief exercise, warm/cold compresses, or showering. Recurrent episodes of priapism such as seen in our patient are referred to as stuttering priapism which may herald a longer event. The first-line treatment for stuttering priapism is with an oral alpha-adrenergic agent such as pseudoephedrine. Patients with priapism lasting more than four hours are treated with a combination of intravenous fluids, intravenous analgesia, and emergent urology consult for corporal aspiration. Conscious sedation may be indicated depending on patient age and anxiety. Once low-flow priapism is confirmed, intracavernosal injection of an alpha-adrenergic receptor agent such as phenylephrine can help to achieve detumescence. If multiple attempts at corporal aspiration fail, a surgical shunt may be indicated.
Corporal aspiration (A) is not recommended in patients with current detumescence as in our patient. Oxygen (B) is recommended if hypoxic but has not been shown to assist in achieving detumescence. Warm penile compresses (D) are a recommended home therapy to achieve detumescence early in a painful erection but will not help between recurrent stuttering priapism.
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A 21-year-old man presents to the Emergency Department with sudden onset penile pain that occurred while having intercourse with his wife. Physical examination reveals an angulated circumcised penis with fusiform swelling and ecchymosis. Which of the following is the next best step in management?
A. Analgesic therapy and outpatient urology follow up
B. Foley catheter placement
C. Intracavernosal phenylephrine injection
D. Urologic consultation for surgical repair
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D. A urologic consultation for surgical repair is required to optimize functional outcome in the case of penile fracture. Penile fractures occur during direct penile trauma and involves rupture of Buck’s fascia, tunica albuginea, or corpora cavernosa. Symptoms include acute pain and swelling, angulation of the penis, and loss of erection. The penis may take on a characteristic “eggplant deformity” due to swelling and ecchymosis from extravasated blood that collects within Buck’s fascia. Complications include deep dorsal vein injury and partial or complete urethral rupture. Sexual intercourse is the most common cause, but other causes include animal bites, ballistic injuries, stab wounds, and vigorous masterbation. Management involves early surgical repair of the tunica albuginea (within 24-36 hours after the injury) to improve functionality.
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The Infectious Disease Society of America (IDSA)/SHEA released new clostridium difficile (c diff) guidelines in 2017.
Rosh Review Emergency Board Review Questions
An 85-year-old woman who was recently treated with ciprofloxacin for a urinary tract infection presents to the emergency department with diarrhea and lightheadedness. Her vital signs are heart rate 95 bpm, blood pressure 84/50 mm Hg, and temperature 38.9°C. Laboratory studies are notable for a white blood cell count of 19,000 and creatinine of 2.8 mg/dL. On abdominal X-ray, the transverse width of the patient’s colon is 7 cm. Chest X-ray and urinalysis are unremarkable. In addition to fluid resuscitation, what is the most appropriate treatment for this patient?
A. Intravenous and rectal vancomycin
B. Intravenous vancomycin and oral ciprofloxacin
C. Oral metronidazole and surgical consultation
D. Oral vancomycin and surgical consultation
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D. This patient presents with severe, life-threatening Clostridium difficile colitis. This is evidenced by a history of severe diarrhea preceded by recent antibiotic use. When the normal microbial flora of the colon is disrupted by exposure to antibiotics, Clostridium difficile can opportunistically dominate. It produces several toxins, which cause inflammation of the colon (colitis). Clinically, these patients present with watery diarrhea and crampy abdominal pain. Fever is often present, particularly in severe cases. This is a severe case of colitis due to the white blood cell count greater than 15,000, impaired renal function and presence of severe sepsis. This patient should receive empiric treatment with oral vancomycin. Given the dilated colon on abdominal X-ray, this patient likely has toxic megacolon and requires early surgical consultation to evaluate for surgical colectomy (if condition is unresponsive to medical management). Clostridium difficile is a species of gram-positive spore-forming bacteria that can exist in the human colon. A novel macrocyclic antibiotic called fidaxomicin was recently approved for the treatment of Clostridium difficile colitis. However, there is a lack of evidence to support its use in life-threatening illness.
The use of oral metronidazole (C) is appropriate for mild infections, but its use in severe disease is strongly discouraged. Intravenous vancomycin (A and B) is not a recommended treatment for Clostridium difficile colitis, as bactericidal concentrations are not achieved in the colon. Moreover, ciprofloxacin is a cause of Clostridium difficile colitis not a treatment. Rectal vancomycin can be considered as an adjunct to oral vancomycin when ileus is present.
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We cover Free Open Access Medical Education (FOAM) on mass casualty incidents, an unfortunate reality in the current United States climate (and elsewhere). There is a must read (truly, emergency providers really should read this) in EP Monthly by Dr.Kevin Menes, “How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History”. He details his process in running the Emergency Department that evening. Some of our favorite pearls
We cover pearls from other great resources include a post on the St. Emlyn’s blog, “Mass Casualty Incidents: Lessons from the AAST” and a free EBMedicine article on ballistic injuries. We recommend this article by Dr. Kellerman on the reasons for the lack of firearm research in the United States.
We cover core content on triage and ED treatment pearls using Rosen’s Emergency Medicine Chapter 192 and Tintinalli Chapter 5 as guides
Rosh Review Emergency Board Review Questions
A massive explosion occurred at a nearby automotive plant injuring hundreds of employees. You are called to help as part of the disaster team. You are assigned to work on scene triaging patients according to the Simple Triage and Rapid Treatment (START) protocol. Your first victim is found unconscious with significant head and facial trauma. The patient has no spontaneous respirations. What is the most appropriate next step?
A, Assign the patient a black tag
B. Intubate the patient with an endotracheal tube
C. Oxygenate the patient with a bag-valve mask
D. Reposition the patient’s airway
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You should reposition the patient’s airway. In mass casualty situations, emergency personnel often use the Simple Triage and Rapid Treatment (START) technique that allows for rapid assessment of patient’s respirations, perfusion and mental status (RPM). Anyone that is able to walk is asked to move away from the incident site and is assigned a green tag (walking wounded). At this point emergency personnel then quickly assesses the remaining patient’s respirations, pulse and mental status, in order to assign red (immediate), yellow (delayed) or black (deceased) tags. The first step is to assess the patient’s respirations. If they have no spontaneous respirations, you make one attempt to reposition the airway. If there is no improvement, they are assigned a black tag. If they are breathing greater then 30 breaths/minute, they are assigned a red tag. If respirations are less than 30 breaths/minute, then you assess the patient’s perfusion. If their radial pulse is absent or their capillary refill is over 2 seconds, they are given a red tag. If the have a radial pulse or capillary refill less than 2 seconds, you assess their mental status. If they are able to follow commands they are assigned a yellow tag. If they cannot follow commands, they are assigned a red tag.
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We bring you pearl from the American College of Emergency Physicians (ACEP) 2017 Scientific Assembly.
Pearls on H. Pylori from: It’s Alimentary – Poo-Pourri of Conditions From the Mouth to Rectum – Dr. Adebayo, Dr. Batra, Dr. Bavokek
References :
Emerging Infections: Zika and Its Friends – Dr. Joan Noelker
High Yield Toxicology – Dr Erickson, Dr Traub, Dr. Perrone
We bring you pearl from the American College of Emergency Physicians (ACEP) 2017 Scientific Assembly.
Pediatric Pitfalls – Dr. Tim Horeczko
Critical Care Literature Updates – Dr. Michael Winters
In this episode, we summarize recent literature we feel is high yield, important, or frequently discussed in emergency medicine. As always, we encourage you to read the papers and not FOAM it alone.
Antibiotics and abscesses – Daum et al
FAST in hemodynamically stable patients – Holmes et al
Haloperidol in gastroparesis – Roldan et al and Ramirez et al
Ignoring PERC – Buchanan et al
Steroids in non-asthma/COPD lower respiratory tract infections – Hay et al
ENDAO – Caputo et al
Gender pay gap persists in academic EM (and it’s not due to hours, rank, or roles) – Madsen et al
We are in Berlin for #dasSMACC and have lots of pearls to share from the speakers at this amazing conference. Talks will be released for free on the SMACC podcast over the next year, but this podcast holds some pearls that we thought couldn’t wait.
Overall trope of the conference….
for more on the Dunning-Kruger effect check out this post
Drs. Jacob Avila and Ben Smith on Airway Ultrasound
Check out this 7-minute video on ETT placement confirmation using ultrasound
Dr. James Rippey on Point of Care Ultrasound Incidental Findings
Dr. Jack Iwashyna on Persistent Critical Care
We interrupt our normal core content to cover an important topic highlighted in JAMA’s recent article, “Medical Texting and Protected Health Information. What is permitted?“
Other pearls:
Reference:
Department of Health and Human Services. “Guidance Regarding Methods for De-identification of Protected Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.” November 16, 2015
