EMERGENCY MEDICINE UPDATE

AUGUST 2013 1) So you have a patient who is overweight

And you go to intubate him. This article looked at the Glidescope versus the Fastrach. Just to refresh your memory here is a Glidescope

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And here is a Fastrach

And here is a dinosaur In this study- both did well (ACTA Anaest Scand 56(6)755) While it is true there was no significant difference between the two, but the Glidescope did perform better than the Fastrach. And of course this study was done by airway experts; if you aren't so good, your results may be worse, but most big people in the
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field believe that the these newer devices are superior than the dinosaur I showed above. We have a Glidescope in my shop- I love the visualization but the insertion technique is different and takes some getting used to. TAKE HOME MESSAGE: Glidescope and Fastrach are good ways of intubating the morbidly obese. 2) A little early for the clinical quiz but that is just the way the reading went. And it is by one of my favorite authors- who I have never met- but I love his articles- Burke Cunha from Winthrop on Long Island. Here we have a 45 year old man with watery diarrhea, a maculopapular rash and fever. The rash started on his face and soon covered his whole body other than his soles and palms. Of note, the liver functions tests were slightly elevated. He had gotten all the childhood vaccinations. He had not been out of the USA recently. While this looked to the authors to be either C difficle or a drug eruption- investigations revealed none of this. This is not a weird syndrome like last month. The rash looks like this:

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Want to take a guess? (J Clin Micro 50(6)1835) 3) Oh, otitis externa isn't interesting at all. Well, you bet you're sweet bippy it is (OK, old guys- who said that?) Otitis externa has a few dangers to think about. Remember that painless ear discharge can be a Cholesteatoma which can be dangerous if not taken care of. Another look alike with hearing loss, cranial nerve palsy, and fever- can all be signs of necrotizing OEwhich is actually an osteomyelitis. Be careful especially in diabetics- this is the one case where you need real antibiotics and not just the drops. Do not forget foreign bodies as causes of OE. If there is pain behind the ear- consider mastoiditis. None of the above? Just give them the drops. (BMJ 344:E3623) TAKE HOME MESSAGE: Otitis externa can be dangerous in rare cases- watch it in diabetics. Consider all foreign body and Cholesteatoma Our quotes of the month- you think you got a tough life? Listen to these sad folks- you ain't got it as half as
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bad as Rodney Dangerfield and Phyliis Diller. Rodney first: My wife and I were happy for twenty years. Then we met I had plenty of pimples as a kid. One day I fell asleep in the library. When I woke up, a blind man was reading my face. 4) Low voltage on EKGscan be the machine and can be a pericardial effusion- but you are not going to miss those things. Think about some others, however. Here is the listischemic cardiomyopathy, amyloid, scleroderma, hemachromatosis, mxyedema, neonatal hyperbilirubinemia, hypothermia, obesity, COPD, pneumothorax, pleural effusion, anasarca, and massive MI with poor LV function. Got it? Well, will use this opportunity to give a shout to Dr. Goh- our only subscriber from this country- and yes please invite me for a guest lecture- I will cover three dollars of the ticket! ( Singapore Med J 53(5)299) TAKE HOME MESSAGE: Lots of stuff can cause low EKG voltage- see the list. What a kid I got, I told him about the birds and the bees and he told me about the butcher and my wife. I told my wife the truth. I told her I was seeing a psychiatrist. Then she told me the truth: that she was seeing a psychiatrist, two plumbers, and a bartender. 5) Bob Centor weighs in on his Centor criteria- which, as we reported in the past- have been under a little fire recently. Recall his four point scoring system consisted of fever, no other reason for a sore throat (sneezing, coughing etc) exudates on the tonsils and anterior lymphadenopathy. He points out that his works well for pre adolescents- those whom RHD is most commonly seen. However as kids become young
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adults the beast- that is group A strep seems to change or maybe it is the host. Firstly, older kids and adults respond well to PCN- with a two day reduction of symptoms- this reduction is not seen in kids. Non group A occurs more often in older people- and antibiotics reduce the symptoms about one day. Thirdly everyone can get EBV but only young adults get the full blown mono syndrome. Fusobacterium infection the cause of Lemiere's syndrome- an internal jugular thrombophlebitis- is more of a disease of young adults than kids. Now in the original scoring we treated four points empirically and tested three and two but often we just treated three and two as well. What about with older kids and adults with two and three points? Well, if you just throw on the antibiotics it will reduce the symptoms (my comment- a day is not worth the dangers), although this may not be true with Fusobacterium infections where symptoms may persist. Treatment will reduce the spread of the disease to others (my comment: the IDSA guidelines we quoted last month disputed this) it will reduce the suppurative complications (my comment: RHD is much less likely in adults and nothing prevents glomerulonephritis). He claims that the failure of his score when it occurs is due to non group B and fusobacterium which is nearly impossible to test for- so he says with a three of a four- just throw on the antibiotics. I am just an ant compared to Dr. Centor, but I do not agree with the use of antibiotics with out good reason. However, this should give you the tools to discuss this with your patients and do shared
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decision making ( Arch Intern Med 172(11)852) TAKE HOMEMESSAGE: Should you treat sore throats that have Centor scores three in older kids and young adults? Yes. Or no. Or maybe. A girl phoned me the other day and said, 'Come on over. There's nobody home.' I went over. Nobody was home. When I was born I was so ugly the doctor slapped my mother. 6) This meta analysis found that old blood results in more mortality. What is old blood? Well, all blood is thrown out after 42 days. Here they arbitrarily decided on 21 days as being old and there was an increase in mortality in using blood older than 21 days. (Transfusion 52(6) 1184) This is all cause mortality, but it is unclear if the two arms- those receiving old blood and those getting newer blood were equal. Furthermore old blood being more than 21 days old needs to be refined- perhaps the mortality will get to zero if the blood is 5 days. Or 10 days. They also did not take into account multiple transfusions to the same patient. But in any case if you can control it- try getting the freshest blood you can- or auto transfuse. Here is what Life in the Fast Lane (Chris Nickson) has to say about this: The ANZICS Clinical Trials Group currently has a RCT underway that will definitively answer this question: the TRANSFUSE study. TAKE HOME MESSAGE: Old blood- greater than 21 days may increase mortality. Look out for number one and try not to step in number two.
One year they asked me to be poster boy - for birth control.

7) Not many articles on the subject- but this just shows how little we

know. These olecranon bursitis patients did well if they had

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aspirations (sometimes repeated) and antibiotics. Of course sicker ones needed surgical procedures and IV antibiotics (J Hand Surg AM 37a(6) 1252) The real question is if they needed the antibiotics. These are orthopedists so we may never know. TAKE HOME MESSAGE: Olecranon bursitits- does well with aspiration. Ab? We sleep in separate rooms, we have dinner
apart, we take separate vacations - we're doing everything we can to keep our marriage together.

I went to see my doctor. Doctor, every morning when I get up and I look in the mirror, I feel like throwing up; What's wrong with me? He said, I don't know but your eyesight is perfect. 8) This is a shut case. When you inject fingers with epinephrine. They fall off. All of them. And they get icky and necrotic and then just fall on the floor. Truth be told all of these fingers falling off occurred before 1950. Since then in at least this series- they have done over a thousand with no problem (ibid p1254) TAKE HOME MESSAGE: Inject those fingers with epi and enjoy a bloodless field and longer anesthesia- the finger will not fall off. More from Chris: David Newmans article on this is well worth reading. Truth, and epinephrine, at our fingertips: unveiling the pseudoaxioms
http://www.ncbi.nlm.nih.gov/pubmed/17719691

Its been a rough day. I got up this morning, put a shirt on and a button fell off. I picked up my briefcase, and the handle came off. I'm afraid to go to the bathroom. My wife is such a bad cook, if we leave dental floss in the kitchen the roaches hang themselves.
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9) OK time to be a real man

The patient: an anticoagulated PAF patient with minor head trauma. The CT- normal. What do you do next? Well, these kinds of bleeds are slow, and 1 in 25 patients taking anticoagulants will have serious delayed bleeds. So if you are an European, your guidelines say do another CT in 24 hours. . But not everyone can do that outside. So admit them and do it through admission. But this is expensive and we all know that neuro checks in the hospital are worthless. So what should you do? Just call your patient or invite them back to see how they are. (Ann Emerg Med 59(6)457). TAKE HOME MESSAGE: Minor head injury in the anitcoagulated patient- is

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a slow bleed- be careful OK, so time now to be a real woman

10) Are you a sputum lover? You can confide in me- I'll never

squeal Does the color of sputum really make a difference? Well, at least in COPD patients the sensitivity of green or yellow sputum was actually pretty good but specificity was terrible that means you can not consider yellow or green sputum as being bacterial. (Eur Resp J 39(6)1354) What to do with this information is another matter- in COPDers who are constantly colonized- there is
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much you can say by this. TAKE HOME MESSAGE: Sputum color is a useless parameter. And please don't consume that stuff. One day as I came home early from work, I saw a guy jogging naked. I said to the
guy, Hey buddy, why are you doing that? He said, Because you came home early.

I got myself good this morning too. I did my pushups in the nude; I didn't see the mouse trap. 11) This has nothing- absolutely nothing to do with EM- but I do want you to be healthy. This meta analysis from China says the more fish you eat- the less chance of colon cancer. (AJM 125(6)551) Now this is all fish- I am sure there are fish that are better for you and some that aren't which is probably why the reduction was only 12%. In addition the decrease was significant for rectal cancer but much less for colonic cancer. And besides you end up smelling like fish. TAKE HOME MESSAGE: Fish reduces rectal cancer rates and to a certain respect also colon cancer. Sputum does not have the same

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effect. This blond beauty was once married to Lee Majors and was one of the original Charlie's Angels. She died of rectal cancer in 2009. Who was she? My psychiatrist told me I was crazy and I said I want a second opinion. He said okay, you're ugly too I'm taking Viagra and drinking prune juice - I don't know if I'm coming or going. 12) Lidocaine works well for local pain. Inhalations may help asthma and hiccups- the evidence isn't that convincing. It is used to attenuate ICP elevations in intubation. And it is a wonderful anti arrhythmic. But giving it IV to deal with procedure pain or burn pain- didn't help. OK, it was only one
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studybut (Cochrane 6:5622 2012) (Cochrane 6:5622 2012) This morning when I put on my underwear I could hear the fruit-of-the-loom guys laughing at me actually- that isn't only Rodney that has this problem- My Playtex Living Bra died of starvation Phyllis Diller 13) I am going to be honest- I would have blown this. Lady who takes Topiramate comes in with a worse than usual migraine headache complaining of blurry vision. What do you do now? CT? It was normal. Swing and a miss. LP? It was also normalanother strike. Neuro consult? Strike three you're out. How about acute angle closure glaucoma secondary to Topiramate? (AJEM 30(5) e3) Blurry vision in headache is just so common and we usually dismiss it. TAKE HOME MESSAGE: Blurry vision and headache can be glaucoma and can be from meds. "What a dog I got. When he realized we looked alikehe killed himself." "I went to this great massage parlor- it was self service." 14) We have spoken about this before but it is good to review the PERC rule consists of eight criteria- age below 50, pulse below 100, oxygen sat above 94% , no unilateral leg swelling, no hemoptysis no surgery or trauma in the last four weeks, no oral hormone use, no DVT/PE history. This rule is good to rule out PE, but being positive on any one or more criteria tells you- nothing. However, with a normal PERC score you do not need a D Dimer (Ann Emerg Med 59(6)517) Of course if you ask me, you never need a D dimer. TAKE HOME MESSAGE: Use PERC for PE ruling out instead of a D dimer. I also use
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Wells with it. My wife- she is just so fat. I once hit her with a car and she asked why I didn't go around her. I answered "I was afraid I didn't have enough gas." 15) We think we know that not everyone with PAF needs anticoagulation. And there are definitely dangers with it. They developed the CHADS-2 instrument to help with this but now this has been supplanted with the CHA2DS2-VASc score. CHADS2 is one point for CHF, hypertension, age greater than 75 and stroke, with greater than 2 warranting consideration for anticoagulation. The latter includes 1 point for CHF, HTN, DM vascular diseases, age above 65, and being female. Two points are given for age above 75 or a history of stroke. Here too greater than two points warrants giving anticoagulation. (Indeed the second score will result in more people in the high risk group-see the last abstract #29) (AJM 125(6)603) but it seems to me that if they keep changing this, than it may not be that good of a tool after all. I am sorry, I still remember a young person that I did not give Coumadin to who stroked out. I may not give it to older folks who don't qualify, but I do to the younger folks. TAKE HOME MESSAGE: CHAsDs2-Vasc is somewhat more inclusive, whether it is better is questionable. "My wife has a face like a saint- a Saint Bernard." "Some kid I got. He scotch tapes the worms to the sidewalk and watches the birds get a hernia" 16) Kiddies with chest pain are just like little adults stress testing is very low yield. However, so were the echos. EKG is the big test but even here, picking up long QT and WPW in
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their series was rare. However, pulmonary function testing was much higher yield a lot of these folks just had reactive airway disease. Now there was referral bias here and it was retrospective. Nevertheless, I think an EKG will suffice in most cases. Syncope is more worrisome, especially after exercise. (Clin Ped 51(7)659) TAKE HOME MESSAGE: Echo and stress tests are low yields in kids. Some kid I got. He put Krazy Glue in my Preparation H." "My wife just had her driving test. She got 8 out of 10. The other two jumped clear. " 17) This was good shtick, but I do not know how useful it wasmaybe my trauma pals from last month can tell me. This is a case report of a stable abdominal stab wound patient who had is wound irrigated with povidone iodine and some air mixed in. He then worsened and in the CT scanner- the air and iodine form the irrigation outlined the injury. (AJEM 30(5)835) . TAKE HOME MESSAGE: Is there one? Time for Phyllis Diller's brand of depression.(BTW Burt Reynolds was a hunk from the eighties) Burt Reynolds once asked me out. I was in his room. 18) Let me make something clear there is a fine line between heretic and lunatic. I think with regards to the house of medicine I have been both. This opinion piece challenges the fluid bolus we give people in shock. He points out- rightly so- that we spend more time studying which fluids (crystalloid versus colloid versus sputum) and what the physiologic effects are then whether it improves patient outcomes. Maybe, just maybe hypotension in shock is good for you. Maybe, just maybe, pouring lots of cytokine rich poisonous
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blood around the body is not a healthy thing. Folks who get fluid loaded get more ARDS. He then presents an article of 3000 kids who had greater mortality if they got saline or albumin. However, many of the kids were questionably shocky. There are studies now in progress, but until then, give fluids judiciously and consider pressors earlier. (although I haven't seen any survival benefit to pressors either) (Crit Care 16:302) Now this may not be true for all types of shock ,although we now know that in trauma it is best to leave them somewhat hypotensive. TAKE HOME MESSAGE: Fluid bolus therapy in shock may not be a good idea

19) Ischemic colitis is common in the elderly and shouldn't bother

you. It should bother you if the patient is young and a cocaine user. They have abdominal pain and bleeding make sure
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you image them. This has a high mortality (GI Endoscopy 75(6)1226) TAKE HOME MESSGE: Careful with ischemic colitis symptoms in the young adult. It could be Cocaine Ischemic Colitis "My husband can't stand to see trash and garbage lying around the house. He can't stand the competition " " I should have suspected my husband was lazy. On our wedding day, his mother told me: "I'm not losing a son; I'm gaining a couch." 20) This subject is hot I mean really hot. If you are not an American- you have to know what is going on. In the USAthey have a rule that if there is an iatrogenic infection such as from a catheter- the hospital eats the charges- the insurance doesn't have to pay. This article carries this a little further. In South Africa- and this could be in other places as well- - a hospital can be labile for damages if they fail to implement infection control policies or even if the staff fails to comply with them (So Afr Med J 102:353). This last premise seems a little sticky what can a hospital do if the staff does not comply? What you must take home here is that hospitals are and you are going to are going to be eating a lot of money for your infections. I have I think one So Afr subscriber- what can you say on this? TAKE HOME MESSAGE: Infections are becoming unforgiving and will affect (and infect) your wallet.

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It would seem that something which means poverty, disorder and violence every single day should be avoided entirely, but the desire to beget children is a natural urge. 21) I am looking for solutions for longer term pain control that lidocaine can not give. I used to use bupicvicaine but I have been disappointed- it lasts about four hours. However, if you liposomal it- that is liposomal bupivicaine- you get great pain control. This stuff lasts 96 hours and can be instilled during the painful procedure directly into the affected area. (Pharmcother 32(9 suppl) 19s). While our procedures do not tend to be that painful or extended- it is an option for those post op pains (extractions, buionectomies etc) that we see in the ED. TAKE HOME MESSAGE: Liposomal bupivicaine gives an option for long term pain control. "It's a good thing that
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beauty is only skin deep, or I'd be rotten to the core" "My photographs don't do me justice - they just look like me." "You know you're old when your blood type has been discontinued". 22) Another non clinical article, but I doubt that anyone other than Ken Iserson is still reading at this point, and he likes this stuff. Although this is an older article I missed it last time around. Standardized tests are great- they are reliable, they are fair and they are objective. But they are probably not a good idea for medicine where we should be emphasizing more important capabilities such as creativity, thinking process, critical thinking, fund of knowledge and collaboration (J Am Coll Rad 8(4)271). I think that the department chairman or clinical instructor is the best way to decide who should go further in their, as well as clinical presentations/oral exams. Anyone can be good at taking standardized test (remember, never give three "all of the above answers in a row") TAKE HOME MESSAGE: Standardized tests may not be the best way to rate a physician. Women want men, careers, money, children, friends, luxury, comfort, independence, freedom, respect, love, and a three-dollar pantyhose that won't run . 23) You give Ketamine- you will see vomiting. Doesn't bother us much but it does bother patients and their parents. Older kids seem more likely to vomit (actually, though, I never see it in adults) and they postulate that higher BMI kids do as well. (PEC 28(11)1203) I wish I could believe this, but this was a retrospective study with no reasons given for giving
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ondensetron- could be it was prophylactic. Furthermore, no physiology is presented to explain this TAKE HOME MESSAGE: Ketamine causes more post sedation vomiting in older kids and possibly fat ones. "You know you're getting old when your back starts going out more than you do". If you are old enough, you'll get this one: "They just elected me Miss Phonograph Record of 1966. They discovered my measurements were 33 1/2, 45, 78!" 24) This so doesn't interest me, but they do this at my shop. NAC to prevent contrast injury has never been proven to work. You want to see both sides of the issue- the article. I'll just go back to sleep (Cleve Clinic 79(11)746)

"The reason women don't play football is because eleven of them would never wear the same outfit in public"
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25) I have gone over this over and over again, but here is the list

so you can remember it. Troponin concentrations can be elevated in sepsis, amyloidosis, intracranial hemorrhage, hemo dialysis; chemotherapy induced left ventricular dysfunction, fragility, hip fracture, CHF, COPD, and defibrillator discharge. Normal troponin is a bad sign in CHF with myocarditis. (AJM 125(6)527 ). Troponin can also be elevated in aortic dissection. TAKE HOME MESSAGE: Troponins are specific for the heart- NOT!!!! "I hate smart sales clerks. I said to one, "What do you have in lingerie?" She says, "More than youll ever have!"
26) If you are an Israeli- I would appreciate you reading this article. If you are a lawyer (yes they read EMU) - please read

this. Guidelines- are not law. They are not rules. They aren't even good suggestions. Doctors often roll their eyes about guidelines when they know they are harmful but even so they abide by the same ones they see as harmful. They are based on expert opinion in most cases of whom 71% have significant industry ties. (BMJ 346: f3830 ). I have other problems with guidelines. They can be old. It takes a long time to produce them and the information could have been changed. They are not usually based on enough evidence and the guideline is not constructed to take this into account. They are used by lawyers as law and not suggestion. They are often written by doctors with no ties to EM or who do not understand what goes on in smaller hospitals or hospitals with different patient populations. And they blunt the creative diagnostic process
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we all need as physicians. TAKE HOME MESSAGE: Guidelines are to guide they by definition cannot account for all issuesand they are so biased

. "Its hard to find a negligee in my size. I wear a Junior Mister"

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"Im the only woman who can walk in Central Park at night... And reduce the crime rate 28) Well, I guess some one had to write this article it is all you need to know about feeding tubes. This is a really dry subject (well, actually, not really it is quite fluid) but if you work in a nursing home or if you live in one you gotta know a few things. First of all feeding tubes do not improve outcomes of pneumonia, pressure ulcers, or nutritional status nor do they lessen mortality in dementia. They claim that decreased oral intake does not cause hunger or discomfort in the terminally ill- I find hay hard to believe, epically as I write this during the period that for Jews is Tisha Bava fast day and Muslims is Ramadan a month of fasting. In any case, in most instances the feeding tube will be in the stomach; indications for small bowel placement include severe pancreatitis, GERD, gastric outlet obstruction or altered gastric anatomy- like perhaps the sleeve operation. Small bowel feedings may cause less reflux, aspiration pneumonia and ventilator associated pneumonia, but the studies are equivocal. Leakage is common, irritation of skin wall as well, but frank infection is unusual. The rest of the article describes troubleshooting, but this depends on the type of tube they put in and its makeup. (Nutr Clic Practice 2012 27:238) All I can tell you is do not force things. A tube that is in the duodenum is smaller in diameter than gastric feeding tubes and forcing them in can cause tears. TAKE HOME MESSAGE: Feeding tubes- all you ever wanted to know- And yes, father Greg41 23

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you can give a 2008 Chardonnay Bleu form Ernest Gallo and sons via the feeding tube. Most people get an appointment at a beauty parlor... I was committed! I'm eighteen years behind in my ironing. There's no use doing it now, it doesn't fit anybody I know. 29) This is real important; I have no idea why I hid it in the back. People do have real angina and do make real MIs and do have real ACS and still have normal coronaries. How does this happen? Actually before I answer you the numbers are pretty impressive. In a study by Patel et al, where they did angiograms on chest pain patients- 400000 of them- only 37.6% had 70% occlusions of major vessels or 50% of the LAD which by all measures is borderline. All the rest had minimal occlusions. 105 of patients with troponin elevation have a normal PTCA. And here is the kicker- they have a worse prognosis. So what are the causes? One is hypertension it causes microvascular dysfunction and reduced coronary vessel reserve. You can best diagnosis this problem with a stress echo. Go for ACE or Calcium channel blockers as treatment. Microvascular disease is another problem but you aren't going to find it without really hard tests to get (what? you don't have a pocket PET scanner in your lab coat? It is usually found next to the Gallo Bros Chardonnay) Just know this could be the cause in people with traditional risk factors and normal coronaries- reduction of risk factors may help control the disease. Cardiomyopathies
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and those with coronary artery disease can also have this. Nitrates do not wok well here; calcium channel blockers may. Syndrome X- they have ST depressions, angina symptoms, and no risk factors. This is also a form of microvascular disease; they treat with ranolazine. Lastly there is Prinzmetals; these people can even have ST elevation- this is "tonus" at the site of a plaque. They should get calcium channel blockers, nitrates, and statins even if their cholesterol is fine. And do not forget one other causemyocarditis. (Heart 98:1020) Notice something? Beta blockers were not mentioned as being of any benefit here. That is a surprise? No. TAKE HOME MESSAGE: Normal coronaries do not mean a normal heart. I've been asked to say a couple of words about my husband, Fang. How about short and cheap " 30) Let me tell you something about your self- you have an undiagnosed psychiatric disorder that causes you to dream about baobab trees and have a cancer that will kill you when you reach age 152. Your answer will be-who cares? And you are right so why- as technology improves-are we chasing and screening and incidental- omas that have no relevance? In addition by changing definitions we have suddenly made more people sick- like everyone has ADHD now Many cases of osteoporosis and cholesterol up to 80% according to them now have these diseases and has no relevance. And of course, we won't mention those ubiquitous and annoying subsegmental PEs. What is the solution? They are having conferences about this but you can learn more by going up on
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www.preventingoverdiagnosis.net (BMJ 344.e3502) TAKE HOME MESSAGE: We over diagnose. Period. Let's leave healthy people alone. Never go to bed mad. Stay up and fight. 31) Hey the mail bag has been active. Here is first of all a correction. I know Brian Mac Murray well and he is a very intelligent doctor-so I should have realized that when he wrote about Azithromycin being a great antiviral he didn't make a mistake, rather he meant: it is being used as an antiviral that is for bronchitis and sinusitis which are viral diseases- we treating with azithro. OK, Brian- got it- and I apologize. Ken Iserson checked in and so did Knox Todd- here is what they had to say: Ken: Good issue, as usual (July).

Once again, you cited (and praised) some folks for doing the same work I had already cited in Improvised Medicine (I wish theyd simply read the book!) about using bacteriostatic saline as a good local anesthetic. I also discuss using injected sterile water (aquapuncture), antihistamines, antidepressants, narcotics, and using various cold and pressure techniques. Heres the section on bacteriostatic saline from page 179 of Improvised Medicine:

Bacteriostatic Normal Saline Benzyl alcohol, the preservative in bacteriostatic NS, is an ideal alternative local anesthetic. Inexpensive and readily available, bacteriostatic NS is frequently used to flush IV catheters and to dilute or reconstitute medications for parenteral use.
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Benzyl alcohol (0.9%) can be mixed to a solution with 1:100,000 epinephrine. This formulation is less painful, but slightly less effective, than 0.9% buffered lidocaine. In children, the pain on injection is about the same as that with lidocaine.(24) Without epinephrine, the anesthetic effect of benzyl alcohol lasts only a few minutes.(25) With epinephrine, the anesthetic effect begins to diminish about 20 minutes after injection. Prepare a benzyl alcohol-epinephrine solution by adding 0.2 mL epinephrine 1:1000 to a 20-mL vial of multi-dose NS solution containing benzyl alcohol 0.9%.(12) And here is

Knox: Regarding EM/palliative care, our good friend Gil Shlamovitz recently authored a case study
bringing two of my favorite topics ketamine and palliative care together (see attached). For emergency physicians looking for more, the IPAL-EM website has a number of tools to offer. Check them out at http://www.capc.org/ipal/ipal-em

True Knox, but take some credit too- you were an author of this paper too- It was in JEM in 2012 and was very interesting. I BTW have had a lot of success with ketamine in RSD and fibromyalgia Thanks to both of you for writing 32) The answer in number two above was Measles. I could give

you a quick review of this, but you should know about it- it is spread by the airborne route and antibody titers after vaccination may not be enough to imply protection. Diarrhea is rare. Coryza and the rash were typical. Koplik's spots are of course very helpful. Want to know more- press on the link ( J

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Clin Micro 50(6)2184) And in number three- Dick Martin would say that to Dan Rowan

(these two folks on the TV show called Laugh In back in the late 1960s . This show launched the careers of Lily Tomlin, Goldie Hawn, Richard Dawson, and Ruth Buzzi. And in 11- that was Farrah Fawcett. She was only 60 when she died.

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Correct. We are going to discuss two disease complexes that involve the joints. I don't know about you, but I am really weak in rheumatology. Now two of these articles have to do with pediatric rheum- BUT DO NOT SKIP THEM- alot of the entities in pediatric rheum are similar to adult ones. The sources for the peds rheum are Ped Clin Am 59(2)407, and ibid 59:285,, the second essay is from Int Med J 42:1445 RHEUM 1) Almost all of these start out the same way-that is non specific. Fever, malaise, and elevated acute phase reactants such as CRP or ESR. Yeh, rashes and glomerulonephritis help, but that is much later on. Other general principles are take blood pressure even though it is a child. Takayasu characteristically causes differential HTN so check in all four extremities. Bruits are often common. Livideo Reticularis is also common. And do a good neuro exam- you'll see more on this later. 2) Most common rheum disease in kiddies is one we all have seen and in adults too. Henoch Sholein Prupura or HSP is fairly common and it is a vasculitis of the small vessels. Your typical patient is white, male and between the ages of 4 and six. Viruses, bacteria and FMF (Familial Mediterranean Fever) may all be risk factors. These present with lower
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3) extremity purpura, abdominal pain and renal disease. The rash can become bullae or even necrotic. It can affect the joints especially the knees and ankles but it is non destructive and self limited. GI manifestations include bleeding and pain; this can lead to intusseception. Renal disease is usually microscopic hematuria. Renal failure is rare. HSP can look like TTP, hemorrhagic edema of infancy, ITP, DIC, HUS post strep GN and hypersensitivity. Treatment for HSP is supportive: fluids and NSAIDS. Steroids seem to help for GI complications in severe cases, mild cases- controversial. It probably doesn't help in preventing nephritis. Severe cases may need cyclophosphamide or plasmaphroresis. Kawasaki disease- we discussed this only a half a year ago. Conjunctivitis is the most common finding as is prolonged fever; the cervical adenopathy is the least often seen. What is interesting is that there are some symptoms that are not part of the diagnostic criteria including diarrhea, vomiting, and abdominal pain. Also scrotal pain and swelling (found usually in males only) dysuria. Knees ankles and hips can have arthritic symptoms. KD can look like viral exanthams, JIA (formerly JRA) polyarteritis nodosa, and Stevens Johnson. The treamtnet is aspirin, IVIG steroids are questionable. Polyarteritis nodosa: This is also associated with FMF. In adults it is associated with Hep B. In general, adults do worse with this disease than kids. This disease can affect the vascular supply to any organespecially the skin, kidneys and GI tract. Lung involvement is rare. The presentation- not surprisingly is fever, malaise, weight loss, myalgias and arthalgia. Here are some signs that must make you think of this
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disease in anyone but especially kids: HTN, IHD, testicular pain( also found more often in males) abdominal pain, hematuria, proteinuria, mononeuritis multiplex., Here you may also see digital gangrene and levedio retiuclaris and purpura. Treatment includes steroids, stronger immunosuprression and biologicals 7) Takayasu's is a vasculitis that likes big arteries- it goes after the aorta, renal, subclavian and carotid arteries. In the initial presentation-as usual- not much that is specific- headache, dizziness, visual loss, claudication, fever and abdominal pain. HTN is present in almost every kid. Because if involvement of the aortic arch there can be CNS manifestations and cardiac manifestations including seizures and stroke. The best way to diagnose this is with CT or MRI. The treatment is the same as the others, but less successful, for example, steroids help only in 60% of cases. 8) OK, adult docs- you can skip this one- you will not see this in your practice. PACNS is childhood primary central nervous system vasculitis. These are kids who fairly suddenly develop terrible neuro and psych changes. It comes in two flavors- big vessel and small vessel. There can be focal signs but the CSF and inflammatory markers are negative. This can be devastating but if caught early it can be reversible. Treatment is steroids and immunosuprresive agents, and anticoagulation., Sometimes, only a brain biopsy can confirm the diagnosis 9) Almost done the vascultides- ANCA vasculitis. Not familiar to you? Well it is now considered a group of vasulitides that you may recognize-Wegener's Granulomatosis, Microscopic Polyangitis (MPA) and Churg Strauss syndrome. These entities may cause rapidly
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progressive glomerulonephritis, pulmonary hemorrhage, and respiratory and renal failure. The mortality is 100%- that is if you do not treat it. Relapses are common. As usual, this starts as fever and malaise. Weight loss as well. 80% then develop pulmonary manifestations which can include respiratory failure. Renal failure and bleeding in the upper respiratory tract occur in about 3/4 of the cases. Cyclophosphamide is tried but infections commonly occur as do relapses. Biologicals and plasmapharesis seem to work better. Mild cases can respond to steroids. 10) The rest of rheumatologic emergencies are kind of rare and come from the second article. To make your life easier, if you are an adult doctor, what is in italics are things you will need to know. The rest will be for Peds guys and EPs. 11) OK so you have a neonate with CHB. You know this because you were monitoring the birth and you saw bradycardia. They may also be in CHF and have a pericardial effusion. Do some blood tests and you may find elevated liver enzymes and low platelets. And you will occasionally find a rash. Yes even at this age you can see immune mediated damage to the AV node and this is probably neonatal SLE. Females present with this more, and they may have oral lesions (usually a hard palate ulceration this is not an apthous ulcer) and generalized lymphadenopathy. In older folks- kids and adults- you can see arthritis and edema, with vasculitis changes, pericarditis, pleural effusions, chorea, psychosis and headache. Urinalysis shows protein and blood. Hemolytic anemia, low platelets and WBC will also be present. Look also for hepatosplenomagaly. Mom should be given fluorinated steroids if the this is diagnosed in utero, and beta
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sympathomimetic agents can be given to the neonate as a temporizing measure, These little ones may need a pacer 12) Febrile kid with pancytopenia can be macrpophage activation syndrome. Yes, of course you also need to think about leukemia, but do not forget this. It can be triggered by SLE, Kawasaki and JIA all of which can be seen in adolescents and adults so keep this in mind in unexplained fever and neutropenia. Look also for splenomegaly Ferritin may be very high; there may high triglycerides, hepatic enzyme elevation and coagulopathy. SLE can also cause fever and cytopeniabut not this bad. JIA has an especially high ferriten and salmon colored plaques. Give these people antibiotics and high dose steroids. There may be a need for immunosuppressive therapy 13) Respiratory distress and renal failure: think SLE here too, but also consider Goodpasture syndrome and ANCA vasculitis. We discussed SLE and ANCA already. Good pasture is primarily a glomerulonephritis, and the presentation with a falling blood count, full alveoli on chest film and protein in the urine are quite impressive., The diagnosis is by anti GBM antibodies in the blood and IGG deposition in the glomeruli with crestent changes on biopsy . Treatrnent is again steroids, but palasmapharesis works well for ANCA and Good pasture. 14) I guess you could see this in adults, I have never heard about it, multiple organ dysfunction, (Hell, that can be due to anything). But if you can find thrombosis and systemic inflammatory response- think CAPS-Catastrophic APLA syndrome. Infection is a trigger as is malignancy and SLE. Since this is primarily small vessel occlusions, they go into ARDS, have PEs, CVAs. seizures, and encephalopathy. Cerebral venous thombosis may occur. Renal failure, abdominal pain41 33

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then progression to DIC. You need to recognize this fast, but don't look at me I will for sure blow this one. Dialyze, ventilate, treat infections, and give steroids. IVIG, plasmaphoresis anticoagulate. Got it? Forget it chief- if I see this, I give up and will go to be a plumber. 15) Lastly pericardial tamponade in kids- think again SLE and JIA although viral infection should be high on the list as well

Our Second essay has got to be one our favorites- an old disease that almost disappeared but now it's back and it is pissed. If you have had this disease, please share your experiences with us- but not your diseases. 1) What else could we be talking about? Syphilis of course. Interestingly enough- the old tests are the still the best ones. The VDRL test and the RPR give you info about the stage of infection and treatment responsebut they are less sensitive for screening. If the patient is asymptomaticand one of these tests is positive- do a second as false positives are common. FTA tests and TPPA will be positive in all cases where there is some history of the disease. PCR is great. Dark ground microscopy: no one knows how to do this anymore. 2) Well, we all know there are three stages of this wonderful disease. It begins with a painless chancre at the inoculation point. If it is on the

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penis (most often in men) it is easy, but go find one on a cervix. There may be lymphadenopathy nearbywhich helps but this is painless and likely to be missed as well. 3) Secondary syphilis is more systemic. Headache, sore throat, malaise, fever, and a scaly rash, Condylomata lata; patchy alopecia, oral erosisons, and hepatosplenomegaly occur next. Lata are papules that develop in moist areas. Here is a latte

Here is a Lata.

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I would rather have the former. Neurological symptoms at this point can include lymphocytic meningitis and a transient eight nerve deficit. There may be CSF abnormalities but only in one quarter of the patients. Here RPR and VDRL are always positive- if they are negative- it ain't syphilis. 4) Now to the most fun you can possibly have latent syphilis. This is probably not infectious but can cause some bad stuff- specifically neuro syphilis and cardiovascular syphilis. Up to 12 years after the initial exposure you can see seizures, and a stroke like syndrome due to endarteritis of the cerebral vessels. Syphilis that involves the parenchyma can cause all the good stuff- depression, confusion, paranoia, and delusions of grandeur. Physical signs include facial tremor, expressionless facies, hyperrelfexia. They progress fairly rapidly to dementia and death over a few months to years. Here is one for memory lane that I am sure Father Greg remembers- Tabes
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Dorsalis. This can be 20 years after the initial infection. The syndrome includes DTRs that are reduced, abnormalities of proprioception and parasteias, Charcot's joints and Argyll Robertson pupils. Chris reminds us of how to remember what these pu[pils are- they are like bordello workers- they accommodate but do not react! There is bladder and bowel dysfunction. Diagnosis in neuro syphilis is aided by CSF with elevated lymphocytes and CSF VRDL that is positive. Most people with tertiary syphilis become successful politicians Here are some more blasts from the past. CV syphilis. Which is mainly a proximal aortic aneurysm and AR. This can be even after 1530 after exposure. These aneurysms do not generally dissect. Here is another of our favorites: Gummas. These are graulomas. But need not be cutaneous. They can ulcerate. Usually they take five years to develop. Ah yes, may yes, what should we treat this disease with? PCN was always a great treatment, and Doxy works well. Azithro worked well, but resistance is growing. Cefrtiaxone probably works well too; there is less data on its success. Following titers is important up to 12 months later. One last remembrance for the sentimental among us- Jarish Herxheimer Reaction- this is basically you kill these worms- you are going to pay. It is a cytokine mediated reaction to lysis of these buggers and resolves within 24 hours with NSAIDS, HIV causes all sorts of problems and often these go together. They can have more usual presentations, such as multiple chancres (yum!) Seroconversion may be erratic and syphilis may cause the CD 4 count to fall and viral load to rise. So here is a real Blast from the past the Partridge family sit com from the seventies about a musical family
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that was "groovy". The redhead boy- Danny Bonaduce was busted for drugs many times and fell out of the public light. Shirley Jones the mother- died. Susan Dey had a long career including starring in the show "LA law" she still appears in some shows. She is the brunette at the back. David Cassidy was the heartthrob singer- but did little after

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leaving the show. Love the style

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9) Here is Susan Dey today

But then again here is a picture of Greg Henry- at least that is what Google

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says: You handsome beast!

Ah Father Greg-

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