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Just in case people are not familiar with the free PV review cards as posted by ALiEM (more than 150), I have linked to a particularly good one dealing with algorithms for rash management: paucis-verbis. These were also highlighted as very useful in the ACEP Now, Nov 2016; and back in 2013 they were brought up by Buckingham on Room9ER. I have attached photos of the rash algorithms below, might be a potentially very applicable Norton Children’s reference.
There are many different types of challenging patients that we all dread seeing when they pop up on the board. Whether the patient’s chief complaint is headache, back pain, or pregnant female with abdominal pain. Another very challenging patient presentation is the crying infant. The differential when evaluating a crying infant is broad. In this post I will include a list of differential diagnosis to consider based on organ system and then a patient I had that presented in this way.
CNS- Meningitis, epidural hematoma, subdural hematoma, hydrocephalus
HEENT- Skull fracture (accidental or non- accidental trauma), ocular foreign body, corneal abrasion, otitis media, nasal foreign body.
Cardiovascular- SVT, myocarditis, congestive heart failure
Pulmonary- foreign body in airway, bronchiolitis, pneumonia
GI- Malrotation/volvulus, pyloric stenosis, appendicitis, gastro-esophageal reflux, intussusceptions, anal fissure
GU- Testicular torsion, UTI, incarcerated inguinal hernia, soap vaginitis, phimosis, paraphimosis
Musculoskeletal- Fracture, septic arthritis, dislocation, hair tourniquet
My patient presented as a 1 month old male with his Spanish speaking Hispanic parents. Mom stated that he has been crying consistently for the past 4 days. She does not remember a specific time when the crying started but she states it has not improved.
Mom is breastfeeding the baby and denies any dietary changes. The baby was full term and mom had no complications with the pregnancy. Patient up to date on all vaccinations. Baby has been afebrile and per mom has not been lethargic. Baby is still feeding well and gaining weight appropriately and mom denies any projectile vomiting after feeds, denies any change in stooling, and notes good urine output. Baby lives at home with mom and dad and I have no red flags to suspect non-accidental trauma.
On exam he is overall well-appearing and does not appear to be in any type of distress: crying but consolable. He appeared to be healthy. He was interactive, tracking me with his eye movements, and did not appear to be meningitic or lethargic. Heart and lungs were unremarkable and abdomen was soft, nontender and non distended. GU exam (make sure you do this) was unremarkable. Baby was moving all extremities while lying on the oversized adult bed in the middle of the hallway and on inital exam did not appear to have any outward bruising or signs of trauma.
Upon removing the patient’s socks I noticed something odd on his second toe of his right foot. Just distal to his PIP joint he had a circumferential red line. As soon as I started to examine that toe his crying increased substantially. On further examination he had a hair tourniquet that had eroded its way all the way down to the bone of the middle phalanx of the second toe.
At this point the baby was still in the hallway and we took him to Room 9 to attempt to try any remove it. I am sure you can imagine how awesome this was on a crying kicking 1 month old. We attempted to unwind the hair but ultimately were unable to do so as it was just to deep into the tissue. I called Kosair and the patient was transferred and I do not yet follow up on the final outcome.
This just re-enforces the importance of a good head to ahem, toe physical exam on patient’s that are not straight forward. Mom had been with the infant 24/7 for the past 4 days and had not noticed this; not to mention who knows when the hair tourniquet actually started. Just something to keep in mind and hopefully this helps next time you all have to examine a crying baby.
All,
I know this came up during conference today so thought I’d send the article I think was cited. At least this is the one I found from EMRAP, below is their summary of this article. Long and short of it, complication rates are really low, when done in sterile fashion in a controlled environment.
This was done in the ICU, not in the emergency department.
Overall they didn’t say that one site was absolutely the best.
nejm-2015-central-line-site-complications
Take Home Points
No central line site is superior.
Femoral lines are fastest and most successful. Subclavian lines have a lower infection risk but higher rate of pneumothorax.
Parienti, JJ et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015 Sep 24;373(13):1220-9. PMID: 26398070
Bottom line: no line was superior. Femoral lines were the fastest to place and had the highest success rates. Subclavian lines had the lowest infection risk but had a higher rate of pneumothorax.
A patient needs central line access. Which should we choose? Which is best? There are multiple complications; infection, mechanical complications like artery puncture or pneumothorax and thrombotic complications.
The authors of this study conducted a randomized, controlled trial in 10 French ICUs. They enrolled adult patients with at least two accessible sites. Patients with all three sites accessible were randomized in a 1:1:1 fashion while those with only two sites were randomized in a 1:1 fashion. The doctors had all performed at least fifty central lines. However, they were all aware of the study and probably tried harder to reduce complications.
They looked for symptomatic clots and/or infection from the time of insertion up to 48 hours after removal. This was a large study; 3471 catheters were placed in 3027 patients. Catheters were assigned to a randomly assigned site and side; placement was successful approximately 91% of the time. 85% of subclavian lines were successfully placed, 91% of the jugular lines were placed and 95% of the femoral lines were placed. Femoral lines were most successful and subclavian lines were least likely successful.
Placement of femoral lines was also more rapid, by about a minute.
The primary outcome was a composite of infection, symptomatic clot and mechanical complications such as pneumothorax and bladder puncture. The jugular line performed the worst followed by the femoral line, then subclavian line. However, it is important to look at the individual components.
For mechanical complications, the subclavian line performed the worse. 2% had a complication versus 1.5% of jugular lines and less than 1% of femoral lines.
All lines were fairly low for symptomatic clots; 0.5% for subclavian, 1% for jugular and 1.4% for the femoral group.
In terms of infection, the subclavian group was the lowest (0.5%). The highest? Surprisingly, jugular lines had a 1.4% rate of infection versus 1.2% in the femoral line group.
Overall, there were fairly low rates of complications. These were performed in very sterile conditions in the ICU. These were not placements in crashing or coding ED patients.
Placement of central lines, including femoral lines, when done carefully under sterile conditions has a low rate of complications. This article does not identify one superior line placement.
This came up recently during Peds Sim and my group struggled to remember how to make all of this work. This is a good review of supplies needed and steps for needle cric and jet insufflation.
I’ve recently had several of the interns asking me about studying. I think all of us should be studying one of the core texts: Rosen’s, Tintinalli’s, or Harwood-Nuss. My own preference is for Tintinalli’s for a number of reasons. It is the most direct, in terms of what do I need to know to take care of a patient with this condition. It is also slightly more comprehensive than Rosen’s. I also love that it has three versions: Emergency Medicine: A Comprehensive Study Guide; Emergency Medicine Manual (with a new version coming out soon); and Emergency Medicine: Just the Facts. For those that don’t know, the manual is a shortened version of the big book, still in paragraph form. Just the Facts is an outline version. I use the big book as my primary resource, the manual when I just can’t make myself read the renal chapter, and Just the Facts as a quick review.
Rosen’s is a wonderful book, extremely well written, and something I plan to read after residency. Hawood-Nuss is too simplistic, leaves out too much of what a good ER doctor needs to know, and in my opinion is only suitable for NPs and PAs.
If you are trying to decide which book works for you, pick a couple of chapters of each book, read the chapters and see what works better. Notice that I say a couple chapters, because each chapter is written by different authors. You don’t won’t to stick with less than ideal book, just because one chapter was written beautifully.
A resource I recently discovered and have been enjoying is CrackCast. It is written by a Canadian group and they publish a new lecture each week going over a single chapter of Rosen’s, in order. Now even though I am a Tintinalli’s man and the material is slightly different, core content is core content. The lectures are wonderful.
Something else wonderful about this group is their belief in spaced repetition. The group publishes flashcards for every lecture that they do.
For our interns, here are a couple previous blog posts about learning and spaced repetition:
As mentioned on R and R in the Fast Lane. This article by Friedman is a welcomed update to evidence-based migraine management. Some people love treating migraine patients, some hate it. But we all have our cocktails we believe in.
I am a fioricet/neurontin/IM compazine, escalating to IV compazine/benadryl/decadron/toradol OR if they want to drive home IV MAG/decadron/toradol … kind of guy.
This article starts with criteria for delineating migraine from other headache forms. Then provides a succinct algorithm for treatment, starting with reglan or compazine +/- benadryl, then another dose plus toradol, then dihydroergotamine, then occipital nerve blocks (very fun), then as a last resort, opioids. I would encourage you to attempt a few other methods before the blocks and especially before the opioids.
Many other medications can be used (keppra, depakote, propofol, etc). But this is a solid overview of the EM approach. Also of note, see the Oct 2016 EM-RAP paper chase of the reglan +/- IV fluids in migraine article which showed no real benefit to the addition of IVF.