Archive | July, 2014

quick review of erythema multiforme

31 Jul

Rash that usually occurs in adults

appears within 72 hours of the offending agent or pathogen.

hypersensitivity that occurs as a result of exposure to several things including medications and infections most commonly but also malignancy and vascular disorders.

Hands and forearms are most commonly affected but it can involve all areas.

usually characterized by variously sized target lesions. Plus or minus enanthem (mucosal rash).

The most common causes are HSV, then mycoplasma infections.

Other common offenders are sulfonamides, penicillins, phenytoin, lupus, barbiturates, hepatitis, and lupus.

The pneumonic SOAPS may be used

  • Sulfonadmines,
  • Oral hypoglycemics,
  • Anticonvulsants/antibiotics,
  • Penicillin/phenytoin,
  • nSAIDS.

EM is on the spectrum with Stevens-Johnson and TEN, and has the least amount of epidermal detachment – none, versus SJS which has less than 10% and TEN having greater than 30% epidermal detacthment.

Patients may complain of burning or itching, fever, myalgias, arthralgias or malaise.

Treatment of localized disease involves short steroid burst and analgesics and antihistamines, while more advanced disease may benefit from inpatient admission to a burn unit.


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine, Ch 245 Serious Generalized Skin Disorders.); picture

common dental diagnoses

29 Jul


inflammation of the operculum (overlying tissues over an erupting tooth) when food gets stuck under it and inflammation gets bad.


Dental Caries

breakdown of the enamel to expose the dentin which can cause pain



two kinds – reversible and irreversible.

Occurs when the enamel and dentin are breached.

Usually heat or cold, or sweet sensitivity like with caries.

If pain is spontaneous, it usually means irreversible pulpitis with pulpal death or necrosis.

Penicillin VK or Clindamycin are treatment with dental referral for definitive root canal therapy or dental extraction.


Periapical abscess or periradicular periodontitis

The disease extends beyond the pulp to the root and apex of the tooth and surrounding tissues

may have formed a track for infection to drain (periapical abscess with sinus/fistula) or not (periapical abscess without sinus/fistula).

pain with percussion of the tooth is characteristic.


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine Chapter 240); picture

dental anatomy: quick review

28 Jul

QUICK Anatomy:

there is the dentin, which is most of the tooth, which surrounds the pulp.

The pulp is the neurovascular supply of the tooth in the core of the tooth.

The Crown is the visible portion of the tooth consists of a thick layer of enamel overlying the dentin.

The Root extends into the alveolar bone and is covered by a thin layer called Cementum.

Beyond the cementum wrapping the tooth is the periodontal ligament, which abuts the bone.

At the apex of the tooth is a feeding neurovascular bundle that gives to the pulp.






Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine Chapter 240); picture 1, picture 2.

Proximal 5th Metatarsal Fractures

24 Jul


meta1 meta2 meta3 meta4



Submitted by Joran Sequeira.



• Ramponi et al. Proximal fifth metatarsal fractures. Adv Emerg Nurs J. 2013. 35 (4): 287-92

• Strayer et al. Fractures of the Fifth Metatarsal. 1999. Am Fam Physician. 59 (9): 2516-2522



22 Jul


22 month old male presents to the ED with a CC of right forearm wound after being bitten by an unknown dog the previous day.

On physical exam the puncture wounds are non-draining and non-erythematous with no obvious bony deformity.

In addition to antibiotic and tetanus prophylaxis, should we vaccinate him against rabies?



CDC epidemiological survey published in 2010

92.1% of all rabid animals were wild animals

                Raccoons, skunks, bats, foxes, and other mammals

7.9% of all rabid animals were domestic

                Cats > dogs


Map of rabid dogs and cats reported in 2010


All wild animals listed above are considered rabid unless they test negative in laboratory.

                Give RIG and vaccine and if negative discontinue


Domestic animals

Animal captured

-> normal behavior for 10 days -> no prophylaxis

->abnormal behavior when captured or after -> animal brain testing

Animal escaped

-> epidemiological absence of rabies in species -> no prophylaxis

-> epidemiological existence of rabies in species or data lacking -> prophylaxis


Submitted by Matthew Kongkatong. 


References: Blanton, J. D., Palmer, D., Dyer, J., & Rupprecht, C. E. Rabies surveillance in the United States during 2010. Journal of the American Veterinary Medical Association, 773-783.; Tintinalli, J. E. (2012). 152. Rabies. Tintinalli’s emergency medicine manual (7th ed., ). New York: McGraw-Hill Medical.; picture


occipital neuralgia (quick pearls)

18 Jul

can be caused by cervical spondylosis and stenosis – a very common thing we usually call osteoarthritis of the cervical spine and degenerative disk disease.

Spurs, facet narrowing, disk space narrowing, ostephytes, etc, most commonly at C5-C7 are blamed.

Others have blamed inflammation around the C2-3 nerve roots.


Limited cervical range of motion or neck muscle spasms may occur.

Occipital neuralgia occurs as pain in the distribution of the greater or lesser occipital nerves.


Treatment with lidocaine can work to stop syptoms, but carbamazepine and gabapentin may also be helpful.

Injection of local steroids, local heat, and anti-inflammatory medication may also be useful.


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine Chapter 276 – Cervial Spondylosis and stenosis), (Adam’s and Victor’s Principles of Neurology – Ch.10 Occipital Neuralgia), (UpToDate – Ivan Garza- Occipital neuralgia); picture

Carbon monoxide poisoning (quick pearls)

15 Jul


usually worse in the morning

improves as you leave the environment.

Often worse in winter

  • using heating elements such as natural gas, wood, or other fuels,
  • people spend more time inside with less ventilation.

Flu-like symptoms like headache, nausea, vomiting, and general malaise are often early symptoms.

Often many people in the household will have similar symptoms, which can mimic a viral syndrome again.


CO binds hemoglobin stronger than does oxygen,

shifting the oxyhemoglobin dissociation curve to the left so the blood hangs on to more oxygen and does not off-load it to the tissues

decreased oxygen delivery and thus tissue hypoxia.


  • carboxyhemoglobin level — venous VBG sampling is equal to arterial
  • Levels up to 10% can be seen at baseline, especially in smokers.
  • Correleation of symptoms with levels is not great
  • Pulse oxymetry is not reliable because carboxyhemoglobin and oxyhemoglobin share the same range of wavelengths picked up by standard pulse oximetry



oxygen, which decreases the half-life of COHb.

Hyperbaric oxygenation is still controversial with regard to ultimate benefit, but an option to consider.


Submitted by J. Stone.


References: (Maloney, G., Tintinalli’s Emergency Medicine, Chapter 217 Carbon Monoxide); picture