A New Home for The EM Res Podcast and Blog!
I started the EM Res Podcast and Blog about one year ago, and things have taken off in that time. To accommodate the growth of the podcast and the blog, I am excited to announce that I have a new website: www.emrespodcast.org.
The new site offers a number of exciting advantages. First, it offers a better aesthetic and navigation across all platforms, including smartphones and tablets. It is overall much cleaner and easier to use. It is also everything EM Res in one location. You get the blog, the podcast, and the show notes all in one place. The podcast is still on iTunes, but is also hosted here for streaming from any device. The new format allows for easier commenting and interactivity between myself and readers/listeners. The search functionality is much easier, allowing you to search blog posts and podcast episodes all at the same time. I can also make more dynamic, involved posts with more capabilities than I had before. Finally, you get one click connectivity to all my social media outlets, including Facebook, Twitter, Google, Vimeo, and Tumblr.
For those of you who are die hard Tumblr fans and following that, the Tumblr site is not going away. You can still follow along there, as all future blog posts and podcasts will be pushed to Tumblr as well.
Thank you all for reading, listening, and making this such a fun and rewarding experience for me. Hopefully you get as much out of it as I do. I’m looking forward to what the next year has to bring, and please bookmark/head on over to emrespodcast.org!
Peritonsillar Abscess
About a month ago, I posted a video with the following history and questions. Let’s take a look at the answers:
A 23 year old male presents to the ED with 4 days of sore throat, getting much worse over the last 24 hours. You note that he has a muffled sounding voice. On exam, he has trismus, uvular deviation, L sided tonsillar asymmetry, and could seriously use a breath mint. Your attending decides to perform an intraoral ultrasound to evaluate the patient, and you see the above image.
1. What do you see?
As correctly pointed out by a few, what you were looking at was a peritonsillar abscess, noted as the anechoic circular area adjacent to the tonsillar tissue. This is the most common deep space infection of the head and neck.
2. What is the next step in management?
First, you want to make your patient comfortable. Start with some pain medicine. Steroids have been shown in some studies to potentially decrease hospitalization time, and perhaps help with symptom relief, but there is question as to the risk-benefit profile. Use your clinical discretion. Perform intramural US to confirm the presence of a PTA and distinguish from cellulitis. Once comfortable, you may proceed with needle aspiration (no significant evidence that aspiration or ID are different in terms of outcomes). I prefer ultrasound guidance. More on that in the podcast.
3. Should you start antibiotics or not?
Antibiotics are indicated, with Penicillin and Flagyl being 98-99% effective in the below referenced review. Nontoxic patient can be treated as an outpatient, while those who fail aspiration or I/D or are toxic may require surgical consultation.
Want more in depth info? Check out the podcast!
The latest episode of the EM Res Podcast talks about where new residents should start if they are looking to get into the FOAMed world. It can be daunting to start out, but once you get into it you’ll find it a great way to learn anytime, anywhere.
This is by no means an exhaustive list, and if your blog or website was left off it is by no means a slight. There are many great resources out there. Go to www.lifeinthefastlane.com to see their full listing of EM/CC Podcasts and blogs. Remember, start with basic core content, and branch out from there. If you are a more seasoned EM resident or attending, go big from the start.
Also, check out the actual responses to my Twitter poll on the top 3 FOAMed resources for the new EM Resident here.
A Case of a Sore Throat
A 23 year old male presents to the ED with 4 days of sore throat, getting much worse over the last 24 hours. You note that he has a muffled sounding voice. On exam, he has trismus, uvular deviation, L sided tonsillar asymmetry, and could seriously use a breath mint. Your attending decides to perform an intraoral ultrasound to evaluate the patient, and you see the above image.
1. What do you see above?
2. What is the next step in management?
3. Should you start antibiotics or not?
The Answer to Dr. Shafer’s Neuro Dilemma
From the last post:
A 57 y/o male presents to the ED with a chief complaint of sudden loss of memory. His wife reports that when he awoke this morning he was his normal self, had coffee and ate breakfast but while his wife was showering he suddenly told her that he felt “weird”. His wife realized that he had forgotten everything that had happened not only this morning but also the night prior and was very tearful and frightened which is unlike his normal personality. Last night he drank four beers which he usually does every weekend. His wife denies any trauma, or LOC, slurred speech or weakness. His only medical problem is hypertension. He has no significant family history, does not smoke and denies any illicit drug use. On physical examination, initially on arrival to the department he was only oriented to self but after an hour on he began to remember events from the night prior and became oriented to time and place. He was noted to persistently have trouble making new memories as he scored 0/3 when asked to recall three objects and was also noted to occasionally ask the same questions multiple times. He can easily remember past events such as his first car and his birthday. Cranial nerves are intact, he has normal sensory and muscle strength in all four extremities bilaterally, normal finger to nose testing and also has a normal gait. The rest of the physical exam is unremarkable
1) At this time, what testing should be performed?
Answer: No further testing is needed.
2) What is your diagnosis?
Answer: Transient Global Amnesia
3) What is the prognosis for this diagnosis?
Excellent prognosis. The attack typically resolves in 24 hours
Transient global amnesia(TGA) is a rare condition where there is a sudden, temporary episode of memory loss that cannot be attributed to a neurologic condition such as epilepsy or stroke. Patients do not have any focal neurologic findings before or after the attack and there is no history of recent head injury; however, 1/3 of patients have an identifiable precipitating event. Females are more likely to have an emotional precipitating event while in men the precipitating event is likely to involve physical exertion. The deficit is in short-term memory and ability to make new memories resulting in speech perseverance. Long-term memory remains intact as demonstrated in our clinical case where our patient was able to recall things such as his birthday and his first car. During the event the patient is aware of their amnesia because their consciousness is not effect often leading to anxiety. In one study, 11% of patients exhibited “emotionalism” (as our case patient experienced) and 14% “fear dying”. The average duration lasts between 2-8 hours and per diagnostic criteria resolves within 24 hours making this a rather benign disorder. The cause of TGA remains unknown at this time and about 6% of patients experience a relapse of TGA per year. These patient’s are not at an increased risk for stroke and management of these patients is simply reassurance and time.
Resources:
1) Miller, J. W.; Petersen, R; Metter, E; Millikan, C; Yanagihara, T (1987).”Transient global amnesia: Clinical characteristics and prognosis”. Neurology 37 (5): 733–7.
2) Quinette, P.; Guillery-Girard, B; Dayan, J; De La Sayette, V; Marquis, S; Viader, F; Desgranges, B; Eustache, F (2006). “What does transient global amnesia really mean? Review of the literature and thorough study of 142 cases”. Brain 129 (Pt 7): 1640–58.
3) Pantoni; Bertini, E; Lamassa, M; Pracucci, G; Inzitari, D (2005). “Clinical features, risk factors, and prognosis in transient global amnesia: a follow-up study”. European Journal of Neurology 12 (5): 350–6
A Neuro Dilemma from Dr. Shafer
Welcome back Dr. Krystle Shafer, who has the following conundrum for us:
A 57 y/o male presents to the ED with a chief complaint of sudden loss of memory. His wife reports that when he awoke this morning he was his normal self, had coffee and ate breakfast but while his wife was showering he suddenly told her that he felt “weird”. His wife realized that he had forgotten everything that had happened not only this morning but also the night prior and was very tearful and frightened which is unlike his normal personality. Last night he drank four beers which he usually does every weekend. His wife denies any trauma, or LOC, slurred speech or weakness. His only medical problem is hypertension. He has no significant family history, does not smoke and denies any illicit drug use. On physical examination, initially on arrival to the department he was only oriented to self but after an hour on he began to remember events from the night prior and became oriented to time and place. He was noted to persistently have trouble making new memories as he scored 0/3 when asked to recall three objects and was also noted to occasionally ask the same questions multiple times. He can easily remember past events such as his first car and his birthday. Cranial nerves are intact, he has normal sensory and muscle strength in all four extremities bilaterally, normal finger to nose testing and also has a normal gait. The rest of the physical exam is unremarkable
1) At this time, what testing should be performed?
2) What is your diagnosis?
3) What is the prognosis for this diagnosis?
The Importance of A Good History in Tox Patients
From our last post: “EMS brings in a 22 year old male who has presented multiple times previously with suicidal gestures. Tonight, they state he took an unknown quantity of acetaminophen about 4 hours prior to arrival. You draw a 4 hour acetaminophen level, and it is 105 micrograms/mL. Feeling good that he is below the treatment threshold of 150 micrograms/mL, you are just about to call the psychiatrist when the patient tells you he actually ingested “Tylenol PM.” Does this matter? Is the patient medically clear?”
Pimpsmanship 101: if an attending asks you a question like that, the answer is not going to be “yes, the situation you presented me is the right answer with no change. Medically clear.” Unless your attending is doing some 5th level Jedi-type pimping.
Tylenol PM is a combination of acetaminophen and dihenhydramine. Diphenhydramine overdose is concerning in and of itself as it can cause the anticholinergic toxidrome. In this case, however, the diphenhydramine is cause for a different concern.
Diphenhydramine can cause delayed GI motility, potentially causing delayed acetaminophen toxicity. In fact, any agent that causes delay in GI motility (think opioids) can cause this problem. Because of this, your 4 hour level is not going to be reliable. If you are concerned that a patient may have delayed motility or gives you a history of co-ingestion of any drug that causes slowed GI motility, you should check an 8 hour level, and treat if toxic based on the Rumack Nomogram. The same goes for extended-release acetaminophen preparations (see references below)
This case and topic highlights the importance of the history in patients presenting to the emergency department with potential toxic ingestions. In particular, remember these 3 tremendously important points:
1. When did they ingest, what did they ingest, and how much? This obviously gives you the basics. It also is helpful in calculating toxic doses (do you know the toxic dose of acetaminophen in mg/kg?)
2. Were there any co-ingestants? Obviously this makes a huge difference in this case. In all cases, you want to know the full spectrum of what you may be facing, and what toxidromes you need to look for.
3. To what medications did they have access? This is a crucial historical point, and this is one of those cases where not showing up with your cynical hat can prove foolish. Remember, patients who have ingested medications often have done so with the intent to harm themselves. Now they are talking to a doctor who is trying to save them. They may not be straightforward with you. Knowing what medications were available to them may give you a hint about what they really took.
Talk to family, those who live with them, and definitely talk to your prehospital providers. This is also a big pearl for your oral boards: If anyone is available to provide extra history, they are there for a reason. Ask the question: is there anyone else who can provide me with additional history? This extra history can prove to be vital. In this case, it is the difference between treating your patient appropriately or sending them to psych to crump.
Want to learn about Point of Care Ultrasound?
Do you want to learn about Point of Care Ultrasound (POCUS)? Have you ever wanted to learn about point of care echocardiography from Haney Mallemat (@CriticalCareNow)? Have you ever wondered what I am like in non-blog, podcast or Twitter form?
You can accomplish all of these things by attending the Wellspan York Hospital Point of Care Ultrasound Conference, June 13-14, 2013. This is a two day course that covers both basic and advanced POCUS. Didactic sessions will be mixed with hands on scanning with live models and phantoms. Two day attendees will earn 16 hours of Category 1 CME.
The course itself is located in York, Pennsylvania. We are about 45 minutes north of Baltimore, and 2 hours west of Philadelphia. For more information, including the schedule and fees, check out: http://www.yorkhospital.edu/default.aspx?program=2&type=text&content=165
If you have any further questions, please contact me here, on Twitter (@BobStuntz), or email me (bobstuntzmd@gmail.com). We hope to see you there!
What kind of Tylenol was it?
EMS brings in a 22 year old male who has presented multiple times previously with suicidal gestures. Tonight, they state he took an unknown quantity of acetaminophen about 4 hours prior to arrival. You draw a 4 hour acetaminophen level, and it is 105. Feeling good that he is below the treatment threshold, you are just about to call the psychiatrist when the patient tells you he actually ingested “Tylenol PM.” Does this matter? Is the patient medically clear?
The answer later this week, unless you come up with it first!
Altered Mental Status: The Forgotten Four
Altered mental status is an all too familiar complaint to emergency physicians. The differential is broad, and includes multiple life threatening diagnoses. We of course think the worst: does the patient have a head bleed or a stroke? Are they septic? Have they ingested some life threatening drug or toxin?
All too often, we get caught up in the rush to get the patient to CT without thinking about a few common, easily diagnosed, and relatively easily fixed problems that require no radiation. It is something we all do from time to time. I have noted four diagnoses that I and my residents occasionally forget to look for, and wind up kicking ourselves over later. Think about these early, and look for them routinely.
1. Glucose: In my experience this is far and away the most commonly forgotten cause of AMS. Glucose is the syphillis of AMS. It can cause seizures, mimic strokes, and make a patient look like they are having an MI. I have seen patients sent to CT for stroke and even intubated, only to later discover they have a low serum glucose. Ask EMS for a fingerstick reading on all AMS patients. If they did not check, you should. Consider D for Dextrose along with disability in your ABC’s (and remember to ask for a chem stick on your oral boards!). Treatment options range from oral glucose in the awake, to IV dextrose in those with contraindications to oral repletion (1-2 mg glucagon IM is an option if IV access is not immediately available). What you give depends on age:
Adults: 1 mL/kg D50
Kids: 2 mL/kg of D 25
Infant/newborn: 5 mL/kg D10
2. Hypoxia: You would think this is a simple one, but it does get missed. A patient is not themselves at home, and a family member brings them in. In the heat of the moment, no one tells the triage nurse they are oxygen dependent and ran out of their home O2 the day before. This one is as simple as sticking a pulse ox on and administering supplemental O2.
3. Hypercarbia: Seen frequently in COPD, and thus usually in an older, sicker population, we often forget to look for hypercarbia as we look for other causes of AMS. This is as simple as getting a screening VBG or iSTAT (an iSTAT gets you your glucose as well). As I described in a previous post, a venous pCO2 < 45 mmHg is nearly 100% sensitive in the evaluation of hypercarbia. Remember, however, that it does not correlate well to an absolute number. The interpretation: Normal pH and pCO2 < 45 mmHg on your VBG, and you are clear. If the patient is acidotic or has an elevated pCO2, get an ABG to get a true evaluation and ventilate them (invasively or non invasively as indicated).
4. Hepatic encephalopathy: You would think this would be easy: Your patient is yellow, or has a history of liver disease. But again, patients prone to hepatic encephalopathy tend to be overall sickly, and I see extensive workups to rule out ICH, sepsis, or other causes of AMS, but lack a simple ammonia. Do not forget to check that ammonia if the patient has any risk factors for hepatic encephalopathy. Treatment involves initiation of lactulose and further investigation as to the root cause.
Three of these can be checked and treatment initiated within 5 minutes of arrival (apply a pulse ox and get an iSTAT to check a sugar and screen for hypercarbia). While you always want to fully work up your patients with AMS, do not miss these oft forgotten, easily identified and fixed causes of AMS.
