Necrotizing Fasciitis (quick-hits)

10 Oct

submitted by Amit Kumar, M.D.


1) Physical exam

-pain out of proportion of external appearance of skin, crepitus, dish-water foul-smelling fluid; rapidly progressive


2) Criteria: LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score

  • CRP >/= 150: 4 points
  • WBC 15-25: 1 point; >25: 2 points
  • Hgb 11-13.5: 1 point; <11: 2 points
  • Na <135: 2 points
  • Creatinine >1.6: 2 points
  • Glucose >180: 1 point

General rule of thumb:

-Score <6: Low risk but not “no risk” (use history, PE, and clinical gestalt)

-Score >6: +NF (PPV of 92% and NPV of 96%)


3) Imaging

-CT without contrast (best at assessing for gas within fascial planes)




  1. Early and aggressive surgical exploration and debridement
    • debridement of all necrotic tissue until healthy, viable tissue is reached
    • reevaluate in OR ~24 hours later, redebride as needed
  2. Broad-spectrum empiric antibiotics
    • Acceptable regimen: carbapenem/b-lactam and b-lactamase + clindamycin + anti-MRSA (example: meropenem/zosyn or unasyn + clindamycin + vanc/linezolid/daptomycin)
  3. Hemodynamic support
  4. +/- hyperbaric oxygen, IVIG?

-UpToDate (

-MDCalc (

-Picture of CT scan of abdominal wall abscess (

Captain Morgan hip reduction

4 Aug

quick review of this technique, which works great, and takes much less effort than standing on the bed breaking a sweat (my personal recent N of 3 in recent months has been a 3 for 3 success rate)


Provider’s leg up on the stretcher, a-la Captain Morgan’s pose.

Patients leg bent over provider’s thigh

Provider pushes up with their foot, pulls down (lever-action) on patient’s lower leg

Pop’s back into place.

VIDEO ASSIST: (start at the 0:45 mark if you’re short on time)


ORIGINAL ARTICLE (Hendey & Avila):

12/13 successful reduction; only failure had an intra-articular fragment that needed the OR


There you go. Add it to the toolbox.


References: video, picture, article


Calcaneal Fracture

15 Jul

submitted by Christina Brown, M.D.


Definition – Fracture of the calcaneus secondary to fall from significant height. calcaneal_fracture Attributed to shear stress adjoined with compressive forces combined with a rotary direction.  The calcaneus, also known as the heel bone, is the largest of the tarsal bones and articulates with the cuboid bone anteriorly and the talus bone superiorly.


Signs and Symptoms

Most common symptoms = pain upon plantar flexion and palpation of heel.  

Other symptoms include: Inability to bear weight, limited mobility. 

“Mondor sign” = Hematoma extending to sole of foot; pathognomonic for calcaneal fracture [3].   

Associations – Vertebral compression fractures occur in approximately 10% of these patients [1].  A trauma-focused clinical approach should be implemented to evaluate for tibial, knee, femur, hip tenderness.


Diagnostic Imaging:

Xray’s – Recommended views = Axial, AP, Oblique [1].

CT – Best for visualization of subtalar joint


Intraarticular vs Extra articular:

Intraarticular fractures = more common and tends to involve the posterior talar articular facet of the calcaneus. 

  1. Type I – Non-displaced fractures (displacement < 2 mm).
  2. Type II – Single intraarticular fracture that divides the calcaneus into 2 pieces.
  3. Type III – Two intraarticular fractures that divide the calcaneus into 3 articular pieces.
  4. Type IV – More than three intraarticular fractures.



Non-surgical treatment is indicated for intraarticular fractures and Sanders Type I intraarticular fractures. Recommendations include no weight-bearing for a few weeks followed by range-of-motion exercises and progressive weight bearing for a period of 2–3 months.

Displaced intra-articular fractures require surgical intervention within 3 weeks of fracture, before bone consolidation has occurred. 


Complications:   Skin blisters may become infected if medical attention is delayed, which can lead to necrotizing fasciitis or osteomyelitis, causing irreparable muscle/bone damage [4].



  1. Stoller, D. W.; Tirman, P. F. J.; Bredella, M. (2004). “Ankle and foot, osseous fractures, calcaneal fractures”. Diagnostic imaging: orthopaedics. Salt Lake City: Amirsys. pp. 70–4.
  2. Calcaneus Fractures at eMedicine
  3. Richman, JD; Barre, PS (1986). “The plantar ecchymosis sign in fractures of the calcaneus”. Clinical Orthopaedics and Related Research (207): 122–5.
  4. Heier, Keith A.; Infante, Anthony F.; Walling, Arthur K.; Sanders, Roy W. (2003). “Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome”. The Journal of Bone and Joint Surgery. American Volume 85–A (12): 2276–82.
  5. picture


27 Jun

submitted by Christina Brown, M.D.

Definition – Blood entering intimal tear in aortic wall.  Blood subsequently dissects through the media under aortic systolic pressure.

Risk Factors – HTN, Tobacco abuse, pregnancy, congenital heart disease (bicuspid AV, Coarctation), Marfan’s, Ehler’s Danlos, Inflammation (Lupus, syphilis, endocarditis, GCA)



Proximal – Occur at the aortic root, coronary ostia and/or pericardium.  

Distal – Dissect distally to involve any or all branches of the aorta ie -carotid and subclavian arteries.

Stanford classification:

  • Type A: Ascending aorta
  • Type B: Distal to ascending aorta

Peak Age for Occurrence

  • Proximal dissection: 50–55 yr
  • Distal dissection: 60–70 yr


  • Occlusion of the coronary ostia, aortic valve incompetence, or cardiac tamponade.


Signs & Symptoms

Chest Pain:

  • May be absent in as many as 15% of patients
  • Acute onset, sharp
  • Substernal -> type A dissection
  • Intrascapular -> descending thoracic dissection
  • Lumbar -> abdominal aorta involvement

Back pain:

  • Commonly interscapular or lumbar. May present as combination of chest, back, and abdominal pain.

Neurologic complaints: Stroke symptoms, Vision changes


Physical Exam

Hypertension: 35–40% may be normotensive.

Pulse deficits: Discrepancies in BP in upper extremities

Neurologic/spinal cord deficits

New murmur of aortic regurgitation: Occurs in up to 31% of patients



EKG – Dissection may involve coronary ostia and cause MI:

  • Inferior MI (RCA territory) is more common than LCA territory.
  • A normal EKG + severe, acute-onset chest/back pain/shortness of breath – high suspicion for aortic dissection.


  • CBC, BMP, UA – Evaluate renal function, hematuria
  • Amylase – May be elevated d/t bowel ischemia
  • Troponin – May be elevated d/t myocardial ischemia



Unstable Patient:

CXR – Widened mediastinum or abnormal aortic contour.

Echocardiogram – Transthoracic vs Transoesophageal (if intubated) – Tamponade, valvular incompetence for evaluation. 

Stable Patient:  CT, Aortography


ED Treatment

BP Control = Reduce shear force on aortic wall and slow down the dissection process.

  • Esmolol (IV) or labetalol (IV): Start before Nitroprusside therapy to prevent reflex tachycardia. 
    • Contraindications:Bradycardia,  COPD, hypotension
  • Nitroprusside


Emergent surgery:

  • Treatment of choice for type A dissection
  • Treatment for type B dissections in those who have failed medical therapy

Medical management:

  • Treatment of choice for stable type B dissections



ADMIT – All patients with an evolving aortic dissection should be admitted to the ICU.  C/S  cardiothoracic surgery for type A dissection.



1] Jeffrey I. Schneider and Jonathan S. Olshaker.  Aortic Dissection, Thoracic. Rosen & Barkin’s 5-minute Emergency Medicine Consult.
2] Erbel R, Alfonso F, and Boileau C et al.: Diagnosis and management of aortic dissection. Eur Heart J. 2001; 22(18):1642–1681. [PMID: 11511117]
[3] Hagan P G, Nienaber C A, and Isselbacher E M et al.: The international registry of acute aortic dissection: New insights into an old disease. JAMA. 2000; 283(7):897–903. [PMID:10685714]
[4] Khan I A and Nair C K.: Clinical, diagnostic, and management perspectives of aortic dissection. Chest. 2002; 122(1):311–328. [PMID: 12114376]
[5] Klompas M.: Does this patient have an acute thoracic aortic dissection? JAMA. 2002; 287:2262–2272. [PMID: 11980527]
[6] Mészáros I, Mόrocz J, and Szlávi J et al.: Epidemiology and clinicopathology of aortic dissection. Chest. 2000; 117(5):1271–1278. [PMID: 10807810]
[7] Moore A G, Eagel K A, and Bruckman D et al.: Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International registry of acute aortic dissection. Am J Cardiol. 2002; 89:1235–1238. [PMID:12008187]


tox bradycardias: fingerstick for clues

7 Jun

often taught, often forgotten clue to help differentiate beta-blocker vs. calcium channel blocker overdoses:


Calcium Channel Blockers can present with hyperglycemia (CCBs prevent insulin release)

Beta Blockers can present with hypoglycemia (BBs  inhibits both glycogenolysis and gluconeogenesis)



The above difference has been difficult to remember for me, and I frequently look it up as a reminder, so here’s an attempt to associate/remember which is which:



visual association:








Appreciate any other tips/mnemonics y’all have on remembering the difference.  


References: emdocs post, beta blocker, ODs, picture 1, 2, 3



tendon repair – Kessler stitch

2 Jun

via a nice quick review of tendon lac repair concepts in last December’s ACEP Now:

modified Kessler stitch for tendon repair:

basic idea: stronger stitch, tension distributed across multiple points (e.g. with mattress sutures)

the stitch:


concept walkthrough (tune in from 2:00-4:00 if tight on time):

live action video (start at 0:30 if tight on time)

There you go. Add one more technique to the toolbox.


References: ACEP Now article (& picture); concept video; live video

insulin memory aid: Can I tell from the name if its short or longer acting?

30 May

nice memory tool pulled from an April emdocs post:



rapid acting: LOGs (e.g. NovoLog, HumaLog)

short to intermediate acting: LINs

  • Lin R – Short acting (NovoLin R, HumuLin R)
  • Lin N – Intermediate acting (NovoLin N, HumuLin N)

long acting: other stuff (e.g. Lantus, Levemir)


There you go. Check out the original post, which has a nice chart on the pharmacokinetics, as well as this handy visual aid, too.