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septic arthritis vs. transient synovitis in kids

3 Nov

repost of an old entry, but came up again recently, worth a review:

HOW CAN WE TELL THE DIFFERENCE?
–lots of overlap in signs/symptoms
–one article came up with a decent decision rule

J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.
–looked at 282 cases, excluded 114 atypical patients (e.g. immunocompromised), leaving 168
–38 had “true” septic arthritis
septic arthritis defined by positive culture or joint WBC >= 50,000 cells/mm3

–four things they decided on that might differentiate:

  • history of fever
  • non-weight-bearing
  • erythrocyte sedimentation rate (ESR) >= 40 mm/hr
  • serum WBC > 12,000 cells/mm3

–predicted probability of septic arthritis using these four predictors:

  • < 0.2 percent for zero predictors
  • 3.0 percent for one predictor
  • 40.0 percent for two predictors
  • 93.1 percent for three predictors
  • 99.6 percent for four predictors

BOTTOM LINE:
–septic arthritis is bad, transient synovitis not so bad
–hard to tell sometimes, signs/symptoms are often similar
–useful: history of fever, non-weight bearing, ESR>40, WBC>12k
–if none of the above: unlikely septic arthritis
–more of the above: worry a bit more

Reference(s): kocher article, picture

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blood pressure targets (strokes, bleeds, and tears)

15 Sep

 

Adapted from an old post, but a good refresher that came up again recently, with a new little table from a recent emed journal article that includes some recommendations for BP targets in stroke (ischemic or otherwise):

neuroBP

 

(and from a previous post):

IS SOMETHING BLEEDING (OR ABOUT TO)?  MINIMIZE THE DAMAGE:

ICH:

–lowering to SBP 140-160 probably safe

–theory: less/slower hematoma growth

–options: nicardipine (less cerebral vasospasm)

 

AORTIC DISSECTION:

SBP 100-120, HR <60

–theory: reduce shear forces

–options: beta blocker (labetolol push, esmolol drip), nitroprusside

 

RUPTURED AAA:

–goal SBP 80-100

–theory: permissive hypotension; bleed slower, less likely to blow out the few clots they’re making

Reference(s): emed-journal articleuptodate.com: Ruptured abdominal aortic aneurysm, management of aortic dissection, Spontaneous intracerebral hemorrhage: Prognosis and treatment, Kodama K, et al. Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection, picture

Kanavel signs for flexor tenosynovitis

12 Mar

(some via an old post, but came up recently, and was the most basic evidence found on a pubmed biopsy.  if anyone knows of any larger data/studies, please share in the comments section)

CLASSIC TEACHING:
Kanavel signs for flexor tenosynovitis

  • pain on passive extension (early finding)
  • finger held in flexion
  • uniform swelling of finger
  • tenderness to percussion along flexor tendon sheath (late finding)



HOW GOOD IS OUR H&P?
incidence of H&P findings in 75 patients with flexor tenosynovitis

  • fusiform swelling (97%)
  • pain on passive extension (72%)
  • semiflexed posture (69%)
  • subcutaneous purulence (68%)
  • tenderness along flexor sheath (64%)
  • elevated WBC (59%)
  • diabetes mellitus (35%)
  • skin necrosis (23%)
  • fever (17%)

 

overall, the 4 signs aren’t perfect, but are there individually in at least 2/3rds of patients

one study of 41 patients with flexor tenosynovitis:

  • all patients had tenderness along the flexor tendon sheath and pain with passive extension.
  • only 22/41 patients (54%) had all four Kanavel signs

TREATMENT TOOLBOX:

IV antibiotics: staph and strep coverage, think pasturella for bite-associated infections

–surgery: consult your hand surgeon ASAP

Kanavel signs for flexor tenosynovitis (REVISITED)

  • pain on passive extension (early finding)
  • finger held in flexion
  • uniform swelling of finger
  • tenderness to percussion along flexor tendon sheath (late finding)
 

Reference(s): uptodate.com: infectious tenosynovitis; study; picture.; article

valproic acid toxicity and ammonia

12 Sep

(repost, but came up again recently, so worth a review)

RAGING HYPOTHETICAL:

–wacky/altered patient, happens to be on valproate, what could be going on?

psych?

seizure?

or maybe….

VALPROIC ACID TOXICITY
–if you’re worried about this, your differential for secondary problems/causes can include:

  • cerebral edema,
  • electrolyte abnormalities,
  • hepatotoxicity,
  • hyperammonemia/encephalopathy

HYPERAMMONEMIA w/VALPROIC ACID:

can occur after acute toxicity or chronic use

not always associated with elevated liver function tests

happens ’cause a metabolite of valproic acid inhibits an enzyme needed for ammonia elimination by the urea cycle (you can look up the names if you really want to)

valproate may also mess with carnitine, elevate ammonia that way too


BOTTOM LINE
:

wacky patient with valproate on their med list, consider sending an ammonia level and/or checking for asterixis

 

Reference(s): uptodate.com: valproic acid poisoning, picture

Nebulized Lidocaine

23 Jan

(repost, but came up again lately, worth a re-visit)

KEY POINTS:
–not a ton of evidence for use, but sounds cool, probably safe (in the appropriate non-toxic dose)
–reminder: max dose of lidocaine (without epinephrine) = 4.5mg/kg

ASTHMA/COPD:
–some benefit in daily long-term therapy for asthma, but doesn’t apply to us in the ED
lidocaine can cause bronchospasm in asthmatics, so one study pretreated with albuterol
–one study’s sample dose: 1ml of 1% lido in 4 ml NS
–may be useful for cough suppression

NG TUBE PLACEMENT (in kids):
–apparently, not much proof that it helps or makes it less painful

NG tubes are one of the most painful procedures with limited utility, anyways

Reference(s): asthma long-term, cough suppression, more cough suppression, ng tube, more ng tube

orthostatic vital signs in the ED

6 Nov

revisiting an old topic, but useful (in that it tells us a test is not that useful)

THEORY:

normally, standing leads to 

  • a small fall in systolic BP (5 to 10 mmHg),
  • an increase in diastolic BP (5 to 10 mmHg)
  • a compensatory increase in pulse rate (10 to 25 beats per minute)

 

traditional criteria for orthostatic hypotension

  • > 20 mmHg decreased SBP
  • > 10 mmHg decreased DBP
  • Symptoms of cerebral hypoperfusion
  • >20 increased HR

 

WHAT HAPPENS WHEN YOU TEST REGULAR PEOPLE?

study of 132 random, presumed euvolemic ED patients, took lying & standing vitals

  • HR range was from -5.0 to +39.4 beats per minute
  • SBP range was -20 to +25.7 mm Hg
  • DBP range was -6.4 to +24.9 mm Hg

43% had “positive” orthostatic vital signs according to currently accepted values

 

BOTTOM LINE:

43% non-hypovolemic patients had “positive” orthostatic vital signs

orthostatic vital signs: probably not a useful test

  

Reference(s): uptodate.com: Mechanisms, causes, and evaluation of orthostatic and postprandial hypotension; study from 1991, picture

abscess packing after I & D?

28 Oct

2013 Peds Surg article:

N = 85, (43 packing, 42 non-packing)

excluded: diabetic/immunosuppressed, perianal or pilonidal, post-op abscess

everyone got I&D, 7 days oral abx (puts a damper on this data, a bit) warm soaks

two groups were not statistically different with respect to

  • recurrent abscesses (one in each group),
  • MRSA incidence (81.4% PG/85.7% NPG)

 

FROM AN OLD POST:

–prospective, randomized, single-blinded trial, N =48

  • no significant difference in need for a second intervention at the 48-hour follow-up
    • packed (4 of 23 subjects)
    • nonpacked (5 of 25 subjects)
    • (p = 0.72 (NOT SO GOOD))
  • higher pain scores immediately postprocedure in packed group and at 48 hours postprocedure
  • greater use of ibuprofen and oxycodone/acetaminophen in packed group 

 

PERIANAL ABSCESSES:
–“designed to show that perianal abscess may be safely treated by incision and drainage alone” vs. I&D + packing
–50 patients were recruited (7 lost to follow-up); 20 in the packing and 23 in the nonpacking arm

  • Mean healing times were similar ( P = 0.214).
  • The rate of abscess recurrence was similar ( P = 0.61).
  • Postoperative fistula rates were similar ( P = 0.38).
  • Pain scores at the first dressing change were similar ( P = 0.296).
  • Although pain scores appeared much reduced in the nonpacking arm, this did not attain statistical significance

 

BOTTOM LINE:

limited data out there on packing abscesses
–packing doesn’t seem to improve healing or reduce recurrence in limited studies, some with Abx
–packing might hurt more
might be ok NOT to pack abscess after I&D, but limited size studies limit the statistical significance.  small data is suggestive, though.

 

Reference(s): peds surg article;   ; previous post on abscess packing; picture