Drs Blake Baker, Sam Lee, and Chris Spruell kicked off our academic year at journal club! Highlights of their presentations included an analgesic limit to Toradol for pain in the ED, evaluating clinical decision rules for SAH, and tailoring our workups for first time seizures in the ED. Thanks to Dr. Max Hockstein for making our first journal club a success!
Diabetic foot infections
1) Diabetic foot cellulitis - it comes from ulcers, if there is/was no ulcer, it's likely not cellulitis.
2) Limb-threatening diabetic foot infections - cellulitis extending >2cm from ulcer, probes to bone
3) Charcot foot - occurs in stages, no systemic symptoms, labs will likely be normal. 45% mortality in 4 years.
Orthopedic pearls/orthopedic lab
1) Shoulder dislocations - anterior dislocations are the most common, and most of those are subcoracoid dislocations. Least common dislocation is an inferior dislocation - aka luxatio erecta - the arm will be locked in abduction.
2) Nursemaid's elbow - reduce by supinating the child's forearm with the elbow flexed and apply pressure over the radial head. You should hear a 'click' as the annular ligament is liberated from the joint.
1) Withdrawal seizures - you should not need a lot of benzodiazepines to control alcohol withdrawal seizures. If the patient requires escalating doses of benzodiazepines to control seizures, consider additional seizure etiologies.
2) CIWA score - it is not diagnostic of alcohol withdrawal, just a severity score. Diagnose withdrawal based on signs and symptoms in the right context. The patient must be able to participate in questioning as 4 out of the 6 categories necessitate answers from the patient.
Dissociated ramblings - attachment from ASA (short read, funny)
1) Achilles ultrasound - sensitivities and specificities vary from paper to paper, however, you can use it to diagnose Achilles' tendon rupture. One difficulty with tendon ultrasound is a sonographic artifact called anisotropy. This occurs when the probe is not perpendicular to your higher-than-average refractive structure (ex: tendon) and will cause the structure to appear hypoechoic.
2) Local anesthetic toxicity (LAST) - the more lipophilic, the more potent the local anesthetic (the uncharged drug must penetrate nerve membrane as well as bind to a hydrophobic site on the sodium channel). If systemic toxicity occurs, you can consider giving lipid emulsion as a reversal agent. Lipid rescue is a big area of research in toxicology.
Wellness - attachment from Journal of Graduate Medical Education
1) Do not forget to complete your wellness survey!
2) Employee Assistance Program (EAP). This program is designed to confidentially assist employees who may be dealing with personal problems that affect their relationships at home and work.
3) Committee on Practitioner Peer Review and Assistance at Parkland (COPPRA) serves to identify and manage, through the peer review process, matters of individual health for licensed independent practitioners to protect patients, its medical staff members, and other persons presents in the hospital from harm.
Atraumaticlow back pain
1) Red-flag age range: 70<age<20.
2) 20% of patients with epidural abscesses have no predisposing factors (!).
3) Urinary retention in Cauda Equina Syndrome is >90% sensitive. Post-void residual > 300mL is abnormal.
1) Succinylcholine and hyperkalemia. We get it. But who actually gets it? A sentient review of the literature reveals that patients with renal failure are not the only ones who get hyperkalemia from succs. Patients who have upregulated immatureACh receptors - specifically, those that have evidence of
denervation (functional or anatomic), immobilization, infection, or burn injuries (after 2-5 days) - are at also risk of hyperkalemia from succs.
2) High-sensitivity troponin assay - this has been discussed in European literature for years and has created a considerable amount of grief in the EM and cardiology communities. In January, the FDA approved an assay for HsT and it's coming to Parkland. More information to come, but, the attached AHA paper is a good primer.
3) Demotivators - this is a"glass half-empty" website.
Likely the antithesis of wellness, however, it's funny.
- Academic Chief Max Hockstein, MD (lightly edited for internet compatability)
Team Based Learning and Flipped Classrooms are the learning way of the future at our program. A few times monthly, interns lead discussions on bread and butter cases, beefed up with EMB from their senior residents and experience from their attendings. Check in here for summaries of the discussions.