Big thanks to Dr Schiebler who came to conference to drop radiologic-knowledge bombs on us. This lecture was loaded with tons of information; here are some of the big take-aways!
This week’s 5-minute Journal Article discussion covered
“Validation of a Clinical Prediction Rule for the Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children” by Kocher et al.
Why is it important to differentiate between septic arthritis and transient synovitis in pediatric patients? Because both diseases can present similarly with acute onset of pain, fever, limp or inability to bear weight and patients holding their hip in the flexed, abducted, externally rotated (FABER) position. The difference is transient synovitis is exactly that, transient, while septic arthritis can lead to permanent joint damage and disability if not treated aggressively with surgical intervention and IV antibiotics.
I have to say that scuba injuries are not my strong suit. However, in doing this blog post, I have to say it’s not the worst thing to read about. For instance, you get a lot of random information like for some reason depth is measured in fathoms (which is just 2 yards, and seems completely unnecessary to have this). Also since a lot of these disorders were discovered in the 1800s, they have awesome nicknames like the bends, rapture of the deep, the chokes, and all the squeezes including face squeeze and ear squeeze.
For this blog post, I wanted to keep it simple and have it be a quick rundown of the things we need to know when looking at diving injuries as well as when our friends inevitably ask about if it’s okay for them to go diving. And as always, end on some fun history.
Last week’s 5-minute EKG discussion was lead by our APD, Dr. Scott Heinrich.
You get handed this EKG from a patient in triage with chest pain. Should you activate the cath lab?
Goal of This Blog
Pacemakers are becoming increasingly common as our population ages, and are seen more and more in the emergency department. The goal of this post is to summarize common pacemaker settings, the 5-letter nomenclature of pacemakers, indications for pacemaker placement, pacemaker components, common pacemaker complications (majority of blog), and lastly the management of pacemakers in the ED (including applying a magnet). …And as always, the blog ends with some medical history
Part of our new conference schedule is doing a quick 5 minute summary on a journal article of interest, EKG from the past week, and Xray. The idea being that by the end of the year, we will have roughly covered 40 journals, EKGs, and Xray Topics.
We can all recall learning about the NYHA classification, and being taught to ask about our CHF ” greatest hits”: orthopnea, dyspnea on exertion, number of pillows (my favorite question), worsening edema, etc., but how does this stack up in the literature?
Here are some resources for hyperglycemia based on our session today. First here are RMC’s DKA protocols for adults and pediatric patients.
Then some videos (old and new) about DKA and HHS.
2013 DKA and HHS
These video review diabetic ketoacidosis and hyperglycemic hyperosmolar states. The second one has some formulas that you should know exist.
The management of DKA in children has some important differences, namely worrying about cerebral edema.
Of note, the PECARN network released an article in NEJM June 14, 2018 comparing fast and slow IV administration of 0.45% and 0.9% NS to determine who gets neurologic deficits. There were no differences between the groups.
1: Kuppermann N, Ghetti S, Schunk JE, Stoner MJ, Rewers A, McManemy JK, Myers SR, Nigrovic LE, Garro A, Brown KM, Quayle KS, Trainor JL, Tzimenatos L, Bennett JE, DePiero AD, Kwok MY, Perry CS 3rd, Olsen CS, Casper TC, Dean JM, Glaser NS; PECARN DKA FLUID Study Group. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018 Jun 14;378(24):2275-2287. doi: 10.1056/NEJMoa1716816. PubMed PMID: 29897851.
I hope I never ever have to do this, but these people at the Essentials of EM conference make it look easy. I think this is worth watching.
Some points I took away from the video:
- This is a resuscitative delivery. It is meant to save the mother. The fetus and uterus are diverting a lot of blood away from mom.
- Chest compressions are going on the entire time.
- The immediate next stop if you get ROSC is the OR, so call OB right away.
- Don’t forget to deliver the placenta and massage the uterus. Get that thing out and the uterus smaller. Both divert blood away from mom.
Whenever the Neurology team comes down and starts asking for special MRI scans with T2-this and gadolinium that, my eyes usually glaze over. So here’s a very brief guide to MRI’s. Very brief.
The MRI works by applying a magnetic field to the body. This magnetic field aligns the protons in water nuclei. Next, external radio frequency energy is applied which displaces the protons from that alignment. When this RF energy is removed, the energy emitted is measured.
There are two different ways to apply this RF energy, each with different time constants. Each differ based on how often the pulses are applied (TR) or the time between the RF pulse and reading the emitted energy (TE).
- T1: longitudinal, short TE and TR times, and
- T2: transverse, longer TE and TR times.
- T1 can be used using gadolinium (a non-toxic paramagnetic contrast agent) which changes the signal intensities in T1. This makes vascular structures very bright and is good for looking at the breakdown of the blood-brain barrier (tumors, abscesses, MS, among others).
- FLAIR is a kind of T2 that uses longer times. T2 FLAIR is good for differentiating between CSF and other abnormalities.
- Diffusion weighted imaging (DWI) detects the random movement of water protons in the space it has available to it. Normally, extra cellular water is able to move around freely. In ischemic tissue, diffusion becomes limited as the NA/K pump shuts down and water gets trapped in the smaller intracellular space.
||Which tissue appears brighter
|T1: T1-weighted MRI
||Tissue with short T1 relaxation time appears brighter (hyperintense). Grey matter is bright, CSF is dark.
This is good for looking at anatomy.
|T2: T2-weighted MRI
||Tissue with long T2 relaxation time appears brighter (hyperintense). Edema lights up. Air will be black.
|T1C: T1-weighted MRI after administration of contrast media
||Many tumors show signal enhancement after administration of contrast agent.
So contrast is good for looking at any structural abnormality.
|FLAIR: fluid-attenuated inversion-recovery MRI
||Bright signal of the CSF (cerebrospinal fluid) is suppressed which allows a better detection of small hyperintense lesions.
This is good for looking at pathology in the white matter.
|DWI: Diffusion weighted imaging
||Bright signal in ischemic tissue, good for looking for acute stroke.
And there you have it. I’ll find some good open source pictures to include, as well.