US for Shoulder Dislocation and Reduction

Complications of the Foot by Dr. Ford

• Osteomyelitis
  • High risk groups: Substance abusers, Diabetics, open fractures
  • Bone biopsy is gold standard for diagnosis
  • Get a deep culture (with a piece of tissue or bone) before initiating abx
  • Bone mineral loss of 30% is required for changes to be visible on X-ray
• Charcot neuroarthropathy
  • Progressive noninfectious condition
  • 2 etiologies: neurovascular and neurotraumatic (microfractures)
    • Neurovascular: massive amounts of blood flow “water log” the bones. Caused by autonomic dysfunction
  • Initial phases can look like cellulitis but erythema is DEPENDENT (resolves with 10min of elevation)
  • Consolidation (chronic) phase = rocker bottom foot. Mid foot bony deformity
  • DISCHARGE if no WBC or open wound. Normal to have elevated ESR, CRP, temperature.
  • ADMIT if open wound present to r/o infection with biopsy
  • Treatment is offloading with total-contact cast
• Gout
  • Gouty arthritis can break down bone and mimic osteo. Differentiate with history.
  • Uric acid level will be elevated

Lightning Lectures

Gout

• Monosodium urate crystal deposition
• Elevated uric acid levels
• Monoarthritis often involving first MTP or knee joint
• US can demonstrate “double contour sign”
• Treatment options: NSAIDs, Prednisone, Colchicine

Septic Arthritis

• <35yo: N gonorrhea; >35yo: S. aureus
• Pain with ROM
• Arthrocentesis with synovial fluid analysis is diagnostic

Pharmacology in Open Fractures and Reductions

• In antibiotic selection in open fractures consider Gustilo Classification and environmental exposures.
• Grade I & II fractures: gram positive coverage w/ Cefazolin
• Grade III fracture: gram positive and negative coverage w/ cefazoline and gentamicin

I have recently seen many patients sent to the ED from urgent care centers and PCP offices for evaluation of hypertension. While true hypertensive emergency often leads to straight forward disposition, this condition is rare and much more commonly patients present with severe asymptomatic hypertension (sometimes referred to as hypertensive urgency). I will discuss an approach to management of these conditions below.

Image source: https://epmonthly.com/article/dont-let-hypertension-stress/

Common causes of hypertension:

• Medication noncompliance
• Pain
• High-salt diet
• Amphetamine or stimulant use
• Alcohol withdrawal or drug withdrawal

Less common causes of hypertension:

• Pheochromocytoma
• Thyroid Storm
• Intracranial hemorrhage
• Preeclampsia/Eclampsia

Special considerations in hypertension:

• Ischemic/hemorrhagic stroke
• Aortic Dissection

Hypertensive Emergency: Severe hypertension, commonly defined as BP > 180/120, with signs of end-organ damage.

End-organ damage:

• Neurological: intractable headache, vision changes, ischemic or hemorrhagic stroke, hypertensive encephalopathy or PRES
• Cardiac: chest pain, EKG changes or elevated cardiac biomarkers indicative of cardiac stress
• Pulmonary: dyspnea, pulmonary edema
• GI: abdominal pain, nausea/vomiting, transaminitis
• Renal: AKI, proteinuria, electrolyte abnormalities

Image Source: https://em3.org.uk/foamed/8/6/2016/hypertensive-crisis

Work-up:

• CBC
• CMP
• EKG
• Troponin
• Chest X-ray
• Urinalysis
• β-hCG in females
• Consider Head CT if neurological symptoms

Management:

Treatment with IV anti-hypertensives and admission to appropriate service, usually medicine or cardiology.

Common IV anti-hypertensives:

• labetalol IV push (5-20 mg)
• hydralazine IV push (10-20 mg)
• nicardipine drip (start at 5 mg/hr and titrate to goal BP)
• nitroglycerin drip – specifically for acute pulmonary edema (see SCAPE management for dosing)

BP Goal: reduction in MAP by 10-20% in the first hour followed by gradual reduction in MAP by ~25% over the first 24 hours.  Commonly a goal BP of ~160/100 achieves goal of 10-20% reduction.

*There is increased risk of cerebral and cardiac ischemia if lowering BP too rapidly

Exceptions:

• Hemorrhagic CVA and aortic dissection have specific guidelines for BP goals and rapid lowering
• Ischemic CVA allow for permissive hypertension

*Beta-blocker contraindicated in amphetamine intoxication and pheochromocytoma

• amphetamine intoxication – use benzodiazepine
• pheochromocytoma – use alpha-blockers (phentolamine)

Severe asymptomatic hypertension (hypertensive urgency): Severe hypertension, commonly defined as BP > 180/120, with no signs of end-organ damage.

*Some physicians strongly dislike the term “hypertensive urgency” and ACEP utilizes the term “asymptomatic severely elevated blood pressure”.

This is a diagnosis of exclusion. As an ED physician it is your job to first rule out hypertensive emergency.

Management of severe asymptomatic hypertension:

* The first 3 steps below should apply to any patient presenting for hypertension.

1. Place patient in a quiet and relaxing environment (when possible)
2. Administer patient’s home PO anti-hypertensives if not taken today
3. Control patient’s pain and treat any underlying causes
4. Consider additional PO or IV anti-hypertensives
   1. PO anti-hypertensives
      1. Captopril (6.25-50 mg)
      1. Enalapril (2.5-20 mg)
      1. Clonidine (0.1-0.2 mg) *Would avoid due to variable response
   1. IV anti-hypertensives
      1. labetalol IV push (5-20 mg)
      1. hydralazine IV push (10-20 mg)
5. BP reassessment following administration

Goal BP prior to discharge:

• Ideally BP ~160/100
• In a completely asymptomatic patient, BP ~180/110 or even higher may be acceptable with appropriate follow-up
• No definitive recommendation exists for a blood pressure cut-off for which an asymptomatic patient must be acutely treated
• Many physicians have personal practice patterns and different comfort levels with this

Discharge Medications:

• If initiating home PO anti-hypertensives common medications include:
  • Amlodipine (5-10 mg)
  • Hydrochlorothiazide (HCTZ 12.5-25 mg)
• May considering increasing current home anti-hypertensive dose but would avoid this in most circumstances
• Once again, many physicians have personal practice patterns and different comfort levels with initiating or increasing doses of antihypertensives from the ED

Image source: https://epmonthly.com/article/dont-let-hypertension-stress/

Follow-up:

• All patients should be provided resources for appropriate outpatient management
• Recommend repeat BP check within several days
• Recommend repeat renal function testing within 1 week if initiating anti-hypertensive therapy or increasing ACE or ARB

References:

1. UpToDate: Evaluation and treatment of hypertensive emergencies in adults
2. UpToDate: Management of severe asymptomatic hypertension (hypertensive urgencies) in adults
3. TamingTheSRU: Clinical Practice Guidelines: Hypertension
4. https://epmonthly.com/article/dont-let-hypertension-stress/
5. https://em3.org.uk/foamed/8/6/2016/hypertensive-crisis

Upper and Lower Extremity Nerve Palsies

Pediatric Ortho

• Always consider non-accidental trauma in children
• Occult fractures are more common in peds
• If in doubt, splint and follow-up with ortho
• Presence of fat pads can indicate underlying fracture
  • Posterior is always pathologic.
  • A thin anterior fat pad is normal, but a “sail sign” is pathologic
• Management of common fractures
  • Monteggia fracture – urgent ortho consult for ORIF
  • Seymour fracture – physeal fracture of distal phalanx with associated nailbed injury. High risk for soft tissue entrapment. Requires Hand consult for likely ORIF
  • Tufts fracture w/ nailbed injury – antibiotics not required. Follow-up in 7-10 days with Hand
  • Common avulsion fractures (e.g. ASIS, lesser troch, iliac crest apophysis avulsion) should be NWB on affected extremity and f/u with ortho.
  • Torus fracture – splint with short arm cock-up splint
  • Greenstick fracture – unstable, requires splinting
  • Bowing deformity – treat it like a fracture and splint it
  • Mid and proximal humerus fracture – sling and swathe OR coaptation splint, sling, ortho f/u

Drug Rashes

• Common drug-induced rashes
  • Exanthematous drug eruption (EDE) – maculopapular
  • Urticaria w/o anaphylaxis
  • Vancomycin flushing syndrome (“Red man”)
• Uncommon and severe drug-induced rashes
  • Fixed drug eruptions
  • angioedema
  • acute generalized exanthematous pustulosis
  • DRESS
  • SJS and TEN
• DRESS can occur up to 8 weeks from drug exposure
• EDE (T-cell related) vs Urticaria (histamine) – draw an image on patient’s skin. If it appears red and/or raised after 10 min, it is urticaria
• Antihistamines: First gen (sedating): diphenhydramine, hydroxyzine; Second gen (less sedating): cetirizine, loratadine
• Topical corticosteroids – medium to high potency preferred for short course

ABEM

• ABEM exists to verify the abilities of physicians and to promote quality, trust, and responsibility.
• They aim to make our board certification more valuable by advocating for our value in hospitals
• See ABEM website for details about board certification and the exam
• Study for your exam!

Small Group: Nail bed Infections

• Flexor tenosynovitis
  • Hand emergency. Pt will often require OR washout with Hand surgery.
• Paronychia
  • Manage with warm compress and/or I&D
• Subungual hematoma
  • Ensure there is no underlying fracture
  • Trephination is generally reserved for symptomatic treatment within the first 24hrs

HIPAA: common scenarios and what is appropriate

• Family member: provider may disclose “directory info” (patient location and general health status) if caller identifies the patient by name.
  • The provider must first provide the patient with opportunity to agree or object
• Personal physician
  • Disclosures of PHI from one provider to another for treatment purposes are permissible without the patient’s authorization. Disclosing provider must use professional judgement to determine whether the requested PHI relates to the patient’s treatment by the requesting physician
• Press
  • Location and general health status can be disclosed if requestor identifies the patient by name, unless the patient has objected to such disclosures
  • Can’t just ask about the status of a GSW
• Test results
  • Provider must use their judgement to infer from the situation that a patient does or does not object
• Law Enforcement
  • Limited situations – PHI about a patient who is suspected to be a crime victim and the patient cannot agree to disclosure; the provider may disclose the PHI if (1) she/he determines that disclosures is in the patient’s best interest and the law enforcement officials represent that the PHI needed to determine whether another person violated the law. (2) The PHI is not intended to be used against the patient. (3) An immediate law enforcement activity depends on disclosure.