Core Emergency Medicine

Distal radius fractures are commonly encountered in the ED. We review the topic with a focus on management and appropriate reduction.

Blast crisis is a rare, life-threatening emergency requiring early recognition and aggressive resuscitation.

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This week we discuss three common complications of delivery: cord prolapse, nuchal cord and shoulder dystocia.

This week we look at TBI and discuss some of the pitfalls and pearls in early management of traumatic ICH.

Core Procedures See More →

A brief video on how to perform and incision and drainage of a cutaneous abscess.

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This video discusses how a magnet helps you in the management of pacemaker mediated tachycardia + inappropriate shocks

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Core Blog See More →

Feb172017

Teaching on a clinical shift can sometimes be difficult: it’s busy, everyone’s running around and it’s hard to capture a trainees attention. Recently, on twitter, Amal Mattu (@amalmattu) has been posting pictures of his white board teaching: discrete pearls written down and shared with anyone who walks by. The pearls are often prompted by patients presenting during that shift but they don’t have to be.
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Feb102017

Teaching on a clinical shift can sometimes be difficult: it’s busy, everyone’s running around and it’s hard to capture a trainees attention. Recently, on twitter, Amal Mattu (@amalmattu) has been posting pictures of his white board teaching: discrete pearls written down and shared with anyone who walks by. The pearls are often prompted by patients presenting during that shift but they don’t have to be.
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Feb032017

Teaching on a clinical shift can sometimes be difficult: it’s busy, everyone’s running around and it’s hard to capture a trainees attention. Recently, on twitter, Amal Mattu (@amalmattu) has been posting pictures of his white board teaching: discrete pearls written down and shared with anyone who walks by. The pearls are often prompted by patients presenting during that shift but they don’t have to be.
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Core Journal Club See More →

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Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial Ann Emerg Med, 2016

The ability to perform procedural sedation and analgesia (PSA) is essential to the practice of Emergency Medicine (EM). Which agent an Emergency Provider chooses to use depends on a variety of factors,
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False-negative Interpretations of Cranial Computed Tomography in Aneurysmal Subarachnoid Hemorrhage Acad Emerg Med, 2016

Patients presenting with severe, sudden onset headaches can present a challenge to Emergency Physicians. While most headaches are benign, a minority of them are  a symptom of aneurysmal subarachnoid headaches (aSAH);
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Core Case of the Month More Cases →

CC

Abnormal movements x1 week

HPI

7yF w/ no PMH brought in by her parents with progressively worsening involuntary movements x 1 week, slurred speech x 3 days. The movements improve but persist during sleep. No trouble eating/swallowing or handling her secretions. She has remained alert, coherent, interactive over this time course.

PMH / PSH

PMH / PSH: none

Physical Exam

Afebrile, HR 91, 112/77, RR 22, 98% RA
Gen: AO x 3, NAD, nontoxic
HEENT: Atraumatic, no signs of injury, EOMI, conj wnl, PERRL
Cardiovascular: s1s2, regular rhythm, 2/6 systolic murmur loudest over apex
Pulmonary: CTAB, no wheeze, no rhonchi, no crackles, chest wall WNL
Abdominal: Scaphoid, soft, no distention, no mass, no tenderness, no hernia
Skin: warm, dry
Neuro: + dysarthria. Persistent, involuntary, flailing movements of entire body, seemingly at random, limbs > trunk (see video)
SILT throughout, 5/5 strength throughout. Normal tone. Normal coordination, no pronator drift, no ataxia

Questions

  1. What tests would confirm your diagnosis?

    TTE, ASO titers, Throat Culture, ESR/CRP levels

    The diagnosis of Rheumatic Fever is predominantly clinical and made using the Jones Criteria. There must be evidence of preceding GAS infection AND the patient must exhibit 2 major manifestations OR 1 major + 2 minor manifestations.

  2. What is your therapy of choice?

    1. Eradicate GAS with either IM Penicillin G x 1 or Amoxicillin x 10 days
    2. Prophylaxis against future GAS with IM Penicillin G every 28 days or Oral Azithromycin every day
    3. Symptomatic relief: most cases of Sydenham Chorea self resolve within a few weeks but for distressing symptoms consider dopamine receptor blockade, carbamazepine, VPA, steroids. For severe chorea consider steroids, IVIG, plasmapharesis. Arthritis can be managed with aspirin + NSAIDs

  3. What is the expected prognosis?

    Most patients make a full recovery within a few weeks. However, our patient’s chorea continued to worsen despite a prescribed course of prednisone upon discharge home. She followed up with her neurologist at an outside hospital and was subsequently admitted for IVIG and plasmapheresis. She responded well to therapy and has recovered nearly back to baseline.

More Info

Our patient is suffering from Sydenham chorea, a manifestation of Acute Rheumatic Fever.

ARF is a nonsuppurative sequela of group A Streptococcus (GAS) pharyngitis. The mechanism is likely cross reacting antibodies against a person’s own tissues. Genetics and underlying serotypes (strongly influenced by hygiene – thus the lower rates of disease in developed countries… but that’s a discussion onto itself) play a strong role in who develops the disease.
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