Tag Archives: stone

pertussis: quick hits

17 Feb

(Should’ve been posted earlier, but didn’t make it up somehow.  Here it is now, though, for your learning pleasure).

Pertussis is bad and increasing – it kills ~300,000/yr in non-vaccinated places & can cause serious systemic issues like vert dissection, etc.

– B. pertussis starts like a viral URI (cough, rhinorrhea, malaise)

incubation period is about a week or so, and it is very contagious by air particles (use precautions!)

– more common in older adults who have waning immunity.

– The danger is for passing it to infants who have not immunity.

– In older adults, it is persistent cough lasting ~3-4 weeks and getting worse from week 1 to 2. Often paroxysmal.

– In infants, it is flu-like symptoms followed by paroxysmal cough with whooping inspiration against a closed glottis.

– Protect against pertussis with DTaP or Tdap.

– Test for pertussis with PCR (earlier) or culture (later)

– Treat pertussis early if possible, use Azithromycin

– Treat in those with high suspicion, those exposed, and those with suspicion with infants at home.


Submitted by J. Stone.


Sources: uptodate.com;  EMRap podcast discussion; picture


TTP: quick review

27 Oct

TTP is thrombotic thrombocytopenic purpura, characterized by a pentad (FATRN)

  • Fever,
  • Anemia (microangiopathic hemolytic),
  • Thrombocytopenia,
  • Renal dysfunction,
  • Neurologic dysfunction (that may be transient)

All of these are present only 1/3 of the time.


TTP occurs usually in adults and rarely in children, while HUS is more common from age 6 mos to 5 years.

TTP is a hematologic emergency with 100% mortality if untreated, and 10-20% if treated- bad stuff.


– If TTP is suspected, steroids should be started, give FFP, and consult hematology for plasma exchange therapy.


Why FFP?

As in treatment of hereditary angioedema which lacks C1 esterase, in TTP the protease ADAMTS13 (aka vWF-cleaving protease) is qualitatively or quantitatively absent, but this is found in FFP.


Avoid platelet transfusion unless there is bleeding that will kill the patient before TTP does, as platelet replacement may exacerbate the thrombus formation.


– All of the pentad are cause by the effects of large, uncleaved vWF monomers clumping with platelets, causing unstable thrombi that transiently cause vessel occlusions, leading to renal and neurologic dysfunction, the shearing of RBCs in the small vessels, and low platelets.


– So what causes TTP anyway?

It is associated with HIV, flu vaccination, acute pancreatitis, and often medication use including Plavix, flouroquinolones, resperdol, valacyclovir, and infliximab, among others.


References: Koyfman A. Thrombotic Thrombocytopenic Purpura.[Review] Pediatric Emergency Care. 27(11):1085-1088, November 2011.; uptodate.com; picture

ultrasound for AAA

4 Sep


Bedside ultrasound is the initial imaging modality of choice for identifying the size of the abdominal aorta.


It does not show leak, although if significant blood is present in the abdomen, that may be seen (e.g. positive FAST)


Ultrasound by a trained operator is 90-100% sensitive.


may identify a dissection flap.



abdominal aorta > 3cm define AAA.  Measurement is from outside wall to outside wall. 


Ultrasound may be more difficult in some due to obesity, bowel gas, or tenderness.

Common pitfall: ID-ing the IVC instead of the aorta


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine, Chapter 63 – Symptomatic Abdominal Aortic Aneurysms; Emergency ultrasound imaging criteria compendium. Annals of Emergency Medicine 48: 487, 2006.; http://www.sonoguide.com); picture; picture 2

tracheostomy complications

2 Sep

There are generally three categories of tracheostomy complications

Immediate after placement, early, and late.

  • Immediate and early happen within 48 hours of placement.
  • Late happens after


the most concerning late complication is tracheoinnominate fistula

  • this is severe with high mortality.
  • may be heralded by small amounts of bleeding in the days prior to a large hemorrhage.
  • Usually it takes about 5 days for a tracheostomy tract to mature.
  • Tracheoinnominate fistula usually occurs in the first three weeks after placement, peaking in the 1st to 2nd week.

Treatment for hemorrhage is pressure

Usually by first hyperinflating the trach tube cuff in attempt to tamponade the bleeding.

If this is unsuccessful, then next is placing a finger in the tracheostomy and applying direct digital pressure by pressing the artery against the manubrium.

Surgical consultation should be immediate.  And tamponade of the artery should be maintained to the operating room.


Other complications may be recurring tracheitis or bronchitis related to tracheostomy tube site infection.

Gauze soaked with 0.25% acetic acid can treat local wound infections.


Submitted by J. Stone.


References: Tintinalli’s Emergency Medicine Chapter 242 Compications of Airway Devices; picture

transexamic acid for epistaxis?

29 Aug

recent article on use of transexamic acid (which binds plasminogen and prevents it turning into plasmin):


Randomized trial for anterior bleeding:

using soaked cotton pledgets with TXA in one group vs. cotton pledget with epinephrine + lidocaine for ten minutes and packing with several cotton pledgets covered with tetracycline.  Nasal packing was removed after 3 days.


  • significantly higher rate of bleeding arrest in TXA group (71% to 31%)
  • significantly higher discharge with TXA at 2 hours or less (95% vs 6.4%),
  • non-significant rates of rebleeding at 24 hours (4.7% TXA vs 11% ANP).
  • higher patient satisfaction in the TXA group. 


However, it should be noted that this is not compared to rapid rhino or other commercially available products, simply to anterior nasal packing with cotton pledgets in place for ten minutes. No mention of holding pressure was noted.



Submitted by J. Stone. 


References: Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. PMID: 23911102.; picture

septic arthritis: quick hits

26 Aug


Your next patient is a 54 y.o. male who presents to with complaints of swelling in the right elbow while he was at a party a few days prior.  

He also feels feverish since the onset of swelling, though he denies any pain in the elbow or any recent injury.  

Do you want to tap the joint?  What are you looking for?



the most common organisms involved in septic arthritis:

  • The most common overall cause of septic arthritis is Staphylococcus aureus 
  • Neisseria gonorrhea is the most common organism in young sexually active adults. 
  • Special populations and their common organisms include:
    • History of leukemia – Aeromonas spp.
    • IV drug users – Serratia spp (especially sternoclavicular and SI joints).
    • Sickle cell — higher Salmonella spp osteoarthritis 

Common characteristics of septic arthritis include

  • fever,
  • limited range of motion of the joint,
  • erythema
  • tenderness of the joint,
  • warmth over the joint.

Joint aspiration should usually show greater than 50K WBCs but sensitivity is only 64%.

ESR has sensitivity of 96% but is non specific.

Culture is definitive but is often negative in gonococcal septic arthritis.

Treatment is with vancomycin and and 3rd generation cephalosporin most commonly.


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine, Ch 281 – Acute disorders of the joints and bursae); picture

bleach ingestion

11 Aug


Liquid bleach is dilute 3%-6% sodium hypochlorite with a pH of around 11 – and is minimally corrosive at household bleach levels. 

Small ingestions of household bleach usually results in no damage and patients are asymptomatic. 

It is most helpful if the family can bring the bottle or take a picture of the bottle to confirm that the material was solely household bleach. 


Industrial strength bleach on the other hand has much higher concentration of sodium hypochlorite and may result in gastric and esophageal necrosis. 

Emesis may lead to aspiration or chemical pneumonitis.

Industrial bleach may need admission, observation, and possible endoscopy. 


Household bleach patients without symptoms may be discharged with early follow up.


Submitted by J. Stone.


References: (Tintinalli’s Emergency Medicine 7th ed. Ch. 194 Caustics); picture