Small Bowel Obstruction

• Although it takes about 11 minutes to diagnose SBO on ultrasound, newer studies have shown a decrease in sensitivity and specificity of SBO with 11 false negatives and 57 fall positives. So PLEASE BE CAREFUL when looking for SBO with ultrasound.
• Let’s give a shout out to one of our medical students, Alexa Van Besien, who recently took some great images of a patient with a known SBO.

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Aortic Dissection 

• Ultrasound has a great specificity for aortic dissection. Remember to take a look at your aorta on all cardiac views.

• Let’s give a shout out to Nikki Cali for diagnosing aortic dissection in a patient with a recent PE. Can you find the dissection flap in this image?

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Peritonsillar Abscess 

• Ultrasound can differentiate abscess vs cellulitis and has been shown to increase EP success of drainage as well as lower CT use. If you are concerned about complicated PTA with extension, use your clinical judgment.
• Let’s give a shout out to Kelsey Johnson and Karl Dachroeden who successfully identified and drained a PTA at bedside as well as Taylor Miller who had a difficult case of phlegmon vs early abscess.

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Pulmonary Embolism 

• In patients with high pretest probability and abnormal vital signs think about cardiac evaluation for pulmonary embolism. McConnell’s sign is most specific but can also be found in acute RCA infarct. TAPSE < 1.8 cm is also a good identifier of RV strain. Remember that patients with COPD or Pulm Htn may have RV dilation at baseline. You may also want to risk stratify patients with PE with labs as well as lower extremity dvt studies. 
• Let’s give a shout out to Ashley Pickering who recently took some awesome echo images of a patient with a known saddle embolism. 

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Bottom Line: In a recent meta-analysis the risk factors for patellofemoral syndrome are weak hip abduction strength, quadricep weakness in military recruits, and increased hip strength in adolescence.

PatelloFemoral Syndrome: Patellofemoral pain is not clearly understood and is believed to be multi-factorial.  Numerous factors have been proposed including muscle weakness, damage to cartilage, patella maltracking, as well as others.  Patient often complain of anterior knee that is aggravated by walking up and down stairs or squatting. Patellofemoral pain is extremely common. In the general population the annual prevalence for patellofemoral pain is approximately 22.7%, and in adolescents it is 28.9%.

Though commonly taught, the following have no evidence to support that they are a risk factor for patellofemoral syndrome: Age, Height, Weight, BMI, Body Fat or Q Angle of patella

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• Didanosine: pancreatitis
• Indinavir: nephrolithiasis
• Isoniazid: hepatitis
• Trimethoprim-sulfamethoxazole: hyperkalemia, Stevens-Johnson Syndrome
• Ritonavir: paresthesias, metabolic syndrome
• Pentamidine: hyperglycemia or hypoglycemia
• Efavirenz: psychosis
• Dapsone: hepatitis
• Nevirapine: hepatic failure
• AZT: bone marrow suppression and macrocytic anemia

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1. Decreased hepatic function
2. Decreased renal function
3. Multiple comorbidities and polypharmacy that can affect pharmokinetics of pain medications.

Therefore, pain medications must be dosed carefully, which runs the risk of underdosing.  Pain medications can also contribute to delerium, and decreased functional status.

Recommendations:

1. Start with non-opioid medications in most cases. Consider combination acetaminophen and ibuprofen/naproxen.
2. Consider regional nerve blocks where applicable due to the decreased risk of systemic side effects and excellent analgesic properties.
3. If using opioids, start low and reassess and use the lowest dose possible. Remember half-lifes are often prolonged so patient may not need the standard dosing interview.

Remember to evaluate for any rotational deformity when evaluating patients with a phalanx fracture.

The easiest way to do this is to have the patient flex all their fingers. They should all point to the scaphoid. If a finger deviates or overlaps another finger there is a rotational deformity.  One should also make sure that all the nailbeds align.

This video shows how to evaluate for rotation https://www.youtube.com/watch?v=Dhp25UVn7RQ

Even if the finger is reduced otherwise, persistent rotational deformities should be referred to a hand surgeon for consideration of corrective surgery.

When caring for a patient with a laceration we often do lcoal infiltration prior to suturing but remember the benefits of regional nerve blocks

Benefits of Regional Nerve Blocks

• Less Painful
• Prevents distortion of the wound which can help with cosmetic closure
• Allows for a greater area to be anesthesized with less anesthetic use (prevents toxic levels)
• Can allow for longer anesthetic time

Quick reminder of properities of common anesthetic

Final reminder:  There is no evidence that epinephrine causes necrosis and it can be used safely in digital blocks. Duration of action is max 90 minutes. Even individuals that have injected themselves with EpiPens into their hands have not had any long term sequelue or necrosis seen. Vast majority required no treatment at all.

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• High-quality CT is adequate for clearing c-collar in obtunded patients.
• A follow-up exam before discharging the patient strengthens your decision making and documentation.
• MRI can be reserved for high-risk patients, patients who are being admitted to surgical critical care units, and those who have residual findings once alert.

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Question

33 y/o M with PMH of ETOH induced pancreatitis presents with epigastic/RUQ pain & N/V after drinking last night, per patient his usual “pancreas pain”. The nurse shows you his blood tubes because they look “milky”. Lipase 1200, Ca 6.8.

What lab test would you add?

 

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Bottom Line:

1. The most often cited meta-analysis regarding route of PPI use in bleeding peptic ulcer disease evaluates rebleeding AFTER endoscopic treatment and only ulcers with high-risk features.  There is no good data on optimal pre-endoscopy dosing.
2. These studies appear to show non-inferiority of intermittent dosing with a trend towards superiority when compared with continuous dosing.
3. The proper dosing, frequency, and route of intermittent PPI use is widely variable without good data on an optimal regimen.
4. ED decision of intermittent vs continuous PPI should consider other patient factors including severity of illness, compatibility of IV lines (pantoprazole is often incompatible), and patient disposition.

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Bottom Line:

Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.

In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.

Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571

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Question

75 y/o M is brought in by EMS after he fell off the light rail and hit his head. In the ED he is A&Ox3, and is asking for a urinal. Two minutes later the tech comes running to show you the following:

What is the cause of this patients Jolly Rancher Green Apple looking urine sample? 

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A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen.  The study looked at adults with fractures and sprains and randomized them to one of four groups.

• 400mg Ibuprofen and 1000mg acetaminophen
• 5mg Oxycodone and 325mg acetaminophen 
• 5mg Hydrocodone and 300mg acetaminophen
• 30mg Codeine and 300mg acetaminophen

Pain relief was similar in all groups.

With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.

https://jamanetwork.com/journals/jama/article-abstract/2661581

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Infectious Diarrhea:

Have your wondered what you should do with patients that you suspect have infectious diarrhea. Well the IDSA has updated their 2001 guidelines for the management of infectious diarrhea. The TAKE HOME Points are:

• Most patients with diarrhea do not need to be tested for an infectious cause. Stop ordering those cultures.
• Testing IS recommended in the folllowing populations:
  • Patients younger than 5 years
  • Elderly
  • Patients that are immunocompromised
  • Patients with bloody diarrhea
  • Patients with severe abdominal pain or tenderness, or have signs of sepsis.
  • Testing may be considered for C. difficile in people >2 years of age who have a history of diarrhea following antimicrobial use and in people with healthcare-associated diarrhea
• Some additional recommendations that are noteworthy:
  • Fecal leukocyte examination and stool lactoferrin detection should NOT be used to establish the cause of acute infectious diarrhea
  • A peripheral white blood cell count and differential and serologic assays should NOT be performed to establish an etiology of diarrhea
  • Reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy of mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause

You can find all the recommendations at https://academic.oup.com/cid/article/doi/10.1093/cid/cix669/4557073/2017-Infectious-Diseases-Society-of-America

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