Archive | August, 2012

How extensive should an ALTE workup be in the ED?

31 Aug
ALTE = Acute Life-Threatening Event

•Workup is very dependent on history and physical

If event did not seem to be life-threatening (eg, transient laryngospasm after an episode of reflux), then a full history and physical may be sufficient

•If event seems truly life-threatening with no alternative explanation,
  • check CBC, BMP, UA and culture, CXR, and EKG.
  • Consider a tox screen, blood cultures, or CSF studies in certain patients

Admit just about every ALTE, even if they look perfect in the ED. They may have a witnessed event in house, or another symptom or sign that provokes further evaluation (EEG, head CT, Holter, echo, metabolic studies)

Risk factors for clinically significant recurrences of apneic episodes on infants with idiopathic ALTE’s include:
  • History of prematurity
  • Postconceptional age under 43 weeks
  • History of multiple ALTEs preceding presentation to the hospital
  • Viral URI

Submitted by M. Smith.

References: Corwin MJ. Apparent life-threatening event in infants., 2011.; picture

Malaria: quick review

30 Aug


-1500 Malaria cases reported in the US each year with around 13 deaths, almost all from Plasmodium Falciparum

Incubation period varies, with most patients being symptomatic within 1 month

-consider Malaria with recent travel to an endemic area with influenza-like symptoms



Inluenza-like symptoms including fever, headaches, diaphoresis

-Symptoms often wax and wane

-“Cerebral malaria”- more common in pediatric patients- headache/vomiting/Altered mental status/seizures.

-Pulmonary complications ranging from cough to ARDS

Renal dysfunction



Thick and thin blood smear examination is gold standard

Thrombocytopenia is the most common labwork finding (60%), followed by hyperbilirubinemia (40%) and anemia (30%).  Elevated liver enzymes and LDH levels are also common.

-In combination, thrombocyoptenia and hyperbilirubinemia has high positive predictive value of malaria




Dengue Fever should also be in differential

-Shorter incubation period (4-7 days)

-sudden high fever, headaches, nausea/vomiting, MYALGIAS (“Break Bone Fever”), and a morbilliform rash on the trunk and spreads to the extremities and face

-Does NOT usually have lymphadenopathy like West Nile Fever

-Labwork Findings: Leukopenia, thrombocytopenia

-Acute Schistosomiasis

-Shorter incubation period (median 11 days)

-Check Eosinophil count

African tick bite fever


Severe Malaria

-Generally caused by Plasmodium Falciparum

-Greater than 10% parasitemia

-Associated with renal failure and acute respiratory failure in adults and severe anemia, seizures, increased intracranial pressure in children.

-Management is mostly supportive care in combination with antimalarial agents

-Some debate regarding the use of exchange transfusion


Submitted by J. Grover.


References: D’Acremont V, Landry P, Mueller I et al.  “Clinical and Laboratory Predictors of Imported Malaria in an Outpatient Setting:  An Aid to Medical Decision Making in Returning Travelers with Fever.  Am J Trop Med Hyg 2002;66:481-486.; Newman RD, Parise ME et al.  “Malaria-Related deaths among U.S. Travelers 1963-2001.  Ann Intern Med 2004;141:547-555.; Sarkar PK, Ahluwalia MD, et al.  “Critical Care Aspects of Malaria.”  Journal of Intensive Care Medicine.  2010.  25(2) 93-103.; Sandhu G, Ranade A, et al.  “Influenza-Like Illness as an Atypical Presentation of Falciparum Malaria in a Traveler from Africa.”  Journal of Emergency Medicine 2011.  (41)1: 35-38.; Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.; picture

Cough Treatment in Children with Common Cold

29 Aug

Up to Date recommends NOT using:
  • Codeine for cough (Grade 2B recommendation)
  • Honey for cough (Grade 2B)
  • Vicks vapo-rub or other topical aromatic with menthol, camphor, or eucalyptus (Grade 2B)
  • OTC cough medication for children under age 6 (grade 1A recommendation), and suggests not using it for children age 6-12 yrs (Grade 2A recommendation)

Up to Date recommends using:
  • Cough drops,
  • lozenges,
  • hard candy,
  • oral hydration,
  • warm fluids like tea or soup (Grade 2C)

Submitted by M. Smith.

References: Pappas DE, Hendley JO. The Common Cold in Children: Treatment and Prevention. 2012.; picture

What is the Difference between Mania and Psychosis?

28 Aug
“The term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance. The narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. A slightly less restrictive definition would also include prominent hallucinations that the individual realizes are hallucinatory experiences.

Broader still is a definition that also includes other positive symptoms of Schizophrenia (i.e., disorganized speech, grossly disorganized or catatonic behavior). Unlike these definitions based on symptoms, the definition used in earlier classifications (e.g., DSM-II and ICD-9) was probably far too inclusive and focused on the severity of functional impairment. In that context, a mental disorder was termed “psychotic” if it resulted in “impairment that grossly interferes with the capacity to meet ordinary demands of life.” The term has also previously been defined as a “loss of ego boundaries” or a “gross impairment in reality testing.”

“In this manual (the DSM-IV), the term psychotic refers to the presence of certain symptoms. However, the specific constellation of symptoms to which the term refers varies to some extent across the diagnostic categories. In Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, and Brief Psychotic Disorder, the term psychotic refers to delusions, any prominent hallucinations, disorganized speech, or disorganized or catatonic behavior. In Psychotic Disorder Due to a General Medical Condition and in Substance-Induced Psychotic Disorder, psychotic refers to delusions or only those hallucinations that are not accompanied by insight. Finally, in Delusional Disorder and Shared Psychotic Disorder, psychotic is equivalent to delusional.”

A manic episode is defined as a period of time when there is abnormally and persistently elevated, expansive, or irritable mood.

Mania and psychosis can coincide. A manic patient is often (but not always) psychotic, but a psychotic patient may be so due to schizophrenia, substance use, or another underlying disorder

Submitted by M. Smith.

References: DSM-IV-TR. Diagnostic and Statistical Manual  of Mental Disorders, Fourth Edition, Text Revision. APA, 2000.; picture

Diagnosing Complete Achilles Tendon Rupture

27 Aug
Calf-squeeze method (Thompson and Doherty Test):
With patient laying prone, squeeze the calf.

Lack of passive plantar flexion of the foot when calf is squeezed indicates rupture of the Achilles tendon

Needle Test (O’Brien):

Insert a 25-g needle at a right angle through the skin of the calf just medial to the midline, 10cm proximal to the superior border of the calcaneus.

Passively plantar and dorsi-flex the foot.

If the tendon is intact, the tip of the needle should move inferiorly with the tendon when foot is dorsi-flexed, and the hub should move superiorly. Opposite with plantar-flexion.

Lack of expected needle movement when foot is passively plantar and dorsi-flexed indicates complete Achilles tendon rupture.


Submitted by M. Smith.

References: O’Brien T. The Needle Test for Complete Rupture of the Achilles Tendon. J Bone and Joint Surgery, 66-a (7), 1984. 

The Cunningham Technique for Shoulder Reduction

24 Aug
The patient is seated against a hard-back chair. The operator kneels on the floor in front of the patient, with one hand on the patient’s wrist. The patient’s hand is on the operator’s shoulder.

The patient’s humerus is gently moved into full adduction. The patient is asked to shrug the shoulders superiorly and posteriorly. The operator massages the biceps at the mid-humeral level.

The shoulder reduces without traction after a few minutes.

The data are limited to a preliminary report of five cases of successful reduction. Otherwise anecdotal reports predominate.

Submitted by M. Smith

References: Cunningham, NJ. Techniques for reduction of anteroinferior shoulder dislocation Emergency Medicine Australasia. Volume 17, Issue 5-6, October 2005, Pages: 463–471.; Cunningham NJ. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):521-4.; Academic Life in Emergency Medicine.; video

Leukostasis-Related Pulmonary Distress Syndrome and Leukemic Infiltrates

23 Aug


Hyperleukocytosis is commonly found in newly diagnosed AML, with up to 10-20% of cases

-In contrast, leukemic infiltrates are seen in less than 7% of leukemia patients


-Concern for leukostasis/leukemic infiltrates is generally reserved for only the highest WBC counts (100×109 L-1)

Leukemic Infiltrates

-Relatively non-specific radiographic findings including bilateral interstitial and airspace opacities

-Often have other complications such as pneumonia, hemorrhage, or pulmonary edema as well which make findings less specific

-The most common radiographic intrathoracic finding in any myeloid leukemia is simply mediastinal lymphadenopathy

Leukostasis on Imaging

May appear similar to a PE on CTPA!

CXR can be normal or show bilateral airspace consolidation


Treatment for these conditions is generally based most on treatment of the malignancy- do not start anticoagulation on these patients!

Leukopharesis in combination with chemotherapy is the standard of care

-For patients with either of these conditions, also be concerned for Tumor Lysis Syndrome given the high cell turnover and high WBC count needed to generate this condition so close monitoring will be necessary.


Submitted by J. Grover.


References: Koh TT, Colby TV, Muller NL.  “Myeloid Leukemias and Lung Involvement”.  Seminars in Respiratory and Critical Care Medicine.  2005 Oct;26(5):514-9.  Piro, E, Carillio G et al.  “Reversal of Leukostasis-Related Pulmonary Distress Syndrome After Leukopharesis and Low-Dose Chemotherapy in Acute Myeloid Leukemia.”  Journal of Clinical Oncology.  Vol 29, No. 26 (September) 2011: 725-726.; picture