emDocs.net is another great emergency and acute care medicine resource. The posts are relevant to primary care office and urgent care practitioners as well as to emergency phyisicians.
There is a site map for emdocs which lists all the topics covered so far on one page.
The five posts I reviewed:
- BELL’S PALSY: PEARLS AND PITFALLS IN EVALUATION AND MANAGEMENT FEBRUARY 24, 2016 DREW A. LONG “Perhaps the most worrisome mimic of BP is stroke. “The possibility of stroke in a patient presenting with what looks like BP must be considered and ruled out immediately. Ischemic stroke is the second leading cause of unilateral facial paralysis, behind BP. ” If there are any other cranial nerve involvement or any other abnormality on the neurologic examination immediate CNS imaging is indicated.
- HEMOPTYSIS: AN EM PRIMER FEBRUARY 18, 2016 ALEX KOYFMAN Acute bronchitis is the most common cause but there are many potentially fatal causes of hemoptysis.-Most episodes are mild and resolve on their own-Disruption of blood vessels w/in airways (bronchial circulation is high-pressure system)–Don’t hesitate to ask for help from consultants, as even small amounts can cause asphyxiation–Definitions variable: Minor = small volumes in stable patient with no comorbid lung disease; Massive: 100 to >1,000mL / 24 hrs-Massive–Airway management: intubate with large-diameter (8-0) ETT, cric set-up; affected lung down; consider intubating good lung or tamponading bleeding lung with Fogarty catheter–Resuscitate with IVF + blood products PRN // reverse coagulopathy-Emergent IR consult: bronchial artery embolization-Emergent Cardiothoracic surgery consult; who needs surgery => TI fistula, aortic aneurysm, thoracic trauma, iatrogenic pulmonary artery injury–CT chest: if HD stable, consider obtaining to guider further treatment–Bronchoscopy: assess for bleeding vessel and treat–ICU admission
- APPENDICITIS: PEARLS AND PITFALLS IN ADULT AND PEDIATRIC POPULATIONS FEBRUARY 11, 2016 CRISTINA M. ZERETZKE-BIEN ” The lifetime risk of appendicitis is 7-8% for all patients. Close to 70% of all cases of appendicitis occur in patients less than 30 years of age with incidence peaks of 10-14 yo males and 15-19 yo females. (Cole MA, 2011) (Bhangu A, 2015) In pregnant females, appendicitis is the most common abdominal emergency not related to pregnancy and it is most commonly seen in the 2nd trimester.” “There is no individual sign or symptom that can reliably exclude appendicitis in any patient. (Vissers RJ, 2010). . . . Of note, the classic presentation of a young adult with mid-epigastric pain that migrates to the RLQ over 12-24 hrs is present in as few as 6% of patients with acute appendicitis. The incidence of correctly diagnosing appendicitis in men is between 78-92% of the time and in women only 58-92% of the time. (Cole MA, 2011). In adolescent females, it has often been said that the only test needed is a urine pregnancy test (serum or urine B-human chorionic gonadotropin), as appendicitis is a clinical diagnosis. WBC count and C reactive protein (CRP) have limited utility in the workup of appendicitis, although CRP has been shown to be helpful in detecting perforation or abscess formation. WBC count and CRP are also both components of some common scoring algorithms. (Rothrock SG G. S., 1992)”
- INFLUENZA MIMICS: PEARLS & PITFALLS FEBRUARY 9, 2016 BRIT LONG ” Differential Diagnosis: Typical influenza symptoms include fever, headache, myalgias, malaise, cough, and rhinorrhea. Patients may also have GI symptoms such as abdominal pain and vomiting. You should have a broad differential diagnosis that can be narrowed by the patient’s specific symptoms. Organize your differential into infectious diseases vs. non-infectious diseases and stable vs. unstable. Unstable vital signs may indicate severe illness and helps identify those in need of resuscitation. Keep in mind the critical diagnoses in every patient. You won’t find it if you don’t think about it.” The post has an excellent discussion of the differential diagnosis which should be considered in every case of routine influenza. “Treatment of Influenza: Treatment of influenza is largely supportive care. The CDC recommends empiric treatment with neuraminidase inhibitors within 48 hours of symptom onset or up to 5 days from symptom onset in severe cases; although even the CDC admits their efficacy is questionable. A summary of the evidence supporting antivirals for influenza is available on the CDC website.[vii] It is not required to test for influenza prior to treatment. Tamiflu (oseltamivir) is available orally. Relenza (zanamivir) is inhaled and contraindicated in those with respiratory comorbidities. Rapivab (peramivir) is intravenous. Rimantadine and amantadine are discouraged due to high resistance in influenza A and inactivity against influenza B. Consider admission for any patient suspected of having influenza with unstable vital signs after treatment, an oxygen requirement, poor follow up, extremes of age, significant comorbidities, or if unable to exclude other serious diagnoses.” “Patients may suffer from influenza pneumonia or a secondary bacterial pneumonia. Risk factors for severe influenza and influenza pneumonia include age >65 or <2 years, pregnancy, obesity, chronic pulmonary disease such as asthma and COPD, chronic cardiovascular / renal / hepatic / hematologic disease including sickle cell disease, neuromuscular disorders, and immunosuppressed patients such as those as with diabetes, cancer, or HIV.[i] Female sex and influenza vaccination are protective against severe illness.[ii],[iii],[iv] While this information may not be available to us, the virus subtype also contributes to severity. The predominant virus circulating this flu season is influenza A (H1N1)pdm09[v] which is the strain responsible for the 2009/2010 pandemic and is associated with higher mortality among the young (age <65) and pregnant. Also keep in mind post-influenza staph pneumonia classically affects the young and healthy and can have high mortality.[ii] It is important to instruct all patients to return to the ED with worsening disease. Procalcitonin level may be considered to help exclude bacterial coinfection,[vi] but results are not always readily available in the ED.”
- CENTRAL RETINAL ARTERY OCCLUSION FEBRUARY 4, 2016 JUSTIN BRIGHT
The post has an excellent discussion of this entity and of the usual treatments for this visual catastrophe. None of the treatments make any difference. However, there is a new treatment that might help that all doctors should know about: “Recently, the undersea and hyperbaric medicine society made a recommendation for the consideration of hyperbaric oxygen therapy (HBOT) in patients with a CRAO.14 While experiencing a CRAO, the inner retinal layers become ischemic due to poor perfusion / oxygenation. Animal models have shown that under hyperbaric conditions, the collateral circulation from the choroid is capable of supplying 100% of the retina’s oxygen needs.15,16 Additionally, as mentioned before, approximately 20% of the population has cilioretinal artery, which supplies blood to the area around the macula. This ability to hyperoxygenate and meet the retina’s oxygen demands while the central retinal artery re-cannulates is part of the rationale behind the use of hyperbaric oxygen.” “There are a number of clinical trials looking at the effect of hyperbaric oxygen on patients affected by a CRAO. In a literature summary of 476 patients treated with hyperbaric oxygen, 306 (65%) experienced vision improvement after their treatment.18Overall, the American Heart Association classification of evidence was considered IIB with fair to good evidence with retrospective control case series, but no prospective randomized controlled trials.18 Additionally noteworthy is that therapy with hyperbaric oxygen is generally considered to be benign and safe with proper patient selection and medical control.” “To add to the existing evidence, Hennepin County Medical Center has one of the largest single cohorts of CRAO patients treated with hyperbaric oxygen therapy. Patients found to have a CRAO are being treated with hyperbaric oxygen and seeing significant results. In patients who are treated in <6 hours from time of onset, 83% are seeing improvement in their vision, averaging 6 lines of improvement on a Snellen eye chart. Overall, patients had 4.6 lines of improvement when treated with HBOT.19 Though this is a small and promising study, further investigation is needed. As with all strokes, it appears that time is crucial.” In reviewing hyperbaric oxygen treatment centers I came across another interesting suggested use: the treatment of sudden idiopathic sensorineural hearing loss