July 2014 archive

Epi-Pen to the finger!

Presentation:  48 to M accidentally injected Epipen into finger Physical Exam:  Pale painful finger with decreased sensation. Management:  Nitroglycerin ointment to finger and 1.5mg Phentolamine mixed with 1cc 2% lidocaine and inject into the finger. Outcome:  Patient was discharged with close hand followup.


Case:  5 yo F with sudden onset of R sided neck pain, no PMHx Presentation:  VS NL, no report of trauma, well appearing child crying, head twisted with chin pointing toward L shoulder Diagnosis:  Torticollis.  Spasm of the sternocleidmastoid common in children.  On the differential is retropharyngeal abscess in patients with sore throat and fever …

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Thyroid Storm

Presentation:  50 yo F patient presents with altered mental status.  Her husband reports a history of anxiety, agitation, shortness of breath, vomiting and diarrhea. She has severe tachycardia and hyperthermia. She is delirious and has proptosis and an enlarged thyroid on exam. What’s the diagnosis? Thyroid storm is a rare endocrinologic emergency that carries a …

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Radiation Risk

Radiation Risk: Average US background radiation in one year:  3 mSv CxR:  0.02 mSv  Pelvis XR: 0.7 mSv  CT Head: 2mSv CT Chest:  8mSv CT A/P: 10mSv  Cardiac PET: 14mSv So what is the risk for cancer?  It varies by study type, age, and sex.  So for example, if a 20 yo F gets a …

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Ear Lacerations

Ear Lacerations: Pt. with a laceration through the helix of the ear with exposed cartilage 2 Point Ear Block:  Am Fam Physician. 2004 Feb 1;69(3):585-590. Goal:  Approximate cartilage with absorbable 5-0 monocryl.  It’s ok to trim away small amount of jagged or devitalized skin or cartilage to ensure proper approximation.  Close the skin over the cartilage with 5 …

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Anal Fissures!

Exciting topic:  Anal Fissures! Definition:  Tear in the anorectal dermal tissue, usually at the posterior “6 o’clock” position where the anorectal muscle come together Hx:  Patient presents with sudden onset rectal pain with small amount of bleeding PE:  Usually posterior tears, but if tear occurs at any other position consider comorbid conditions such as IBD …

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Hypertension and Pregnancy

Got a hypertensive pregnant patient?  Preelampsia:  Hypertension >140/90 with proteinuria >300mg/24hours Eclampsia:  Addition of SZ activitity, signs of end organ involvement (i.e. visual complaints and headache, creatinine elevation) Watch out for HELLP!  Hemolysis, elevated liver enzyme, low platelets Treatment:  Expectant management, delivery if possible, treat seizures with Magnesium Dose:  6g loading followed by 2g/hour Learning point …

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Insulin in the ED

Insulin in the ED: Adjusting home insulin dosing is uncommon for ED providers however it may be encountered due to patient lack of access to primary care. Types:  There are several different types of insulin, rapid acting (Humalog, Apidra), regular insulin, long acting (NPH, Lantus, Levemir), and insulin combinations (70/30). Regular, NPH, 70/30, and Humalog …

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52 in 52: Preoxygenation

Today we read and discussed a landmark article on preoxygenation: Weingart SD, Levitan RM. 2012. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 59(3):165-75.e1. Take home points: Preoxygenation increases length of time for “safe apnea” (SpO2 >88-90%) Positioning is important- use 20-degree head-up or reverse Trendelenberg during preoxygenation; position patient’s head …

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