Evaluation of an Ankle Injury in the Emergency Department

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Authors: Sachin Allahabadi, MSIV
Jorge Louis Aceves, MSIV
Joseph Nathaniel Chorley, MD
Veronica Tucci, MD JD
Baylor College of Medicine; Houston, TX

This post was peer reviewed.
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An 18-year-old male presents to the emergency department after a fall and painful, twisting right ankle injury during a soccer game. The patient is unable to bear weight, and denies numbness and tingling. Initial exam reveals generalized ankle swelling and ecchymosis, with intact and equal sensation to light touch in bilateral lower extremities, brisk capillary refill, and a 2+ dorsalis pedis pulse. The patient is non-tender to palpation of bilateral malleoli, but has exquisite bony tenderness over his distal fibula. The proximal fibula is non-tender to palpation. There is also tenderness over the medial joint line. Ankle range of motion is limited due to pain, but the patient is able to wiggle his toes.

Reflections on Mentorship

Author: Mary Haas, MD
AAEM/RSA President '16-'17
Originally Published: Common Sense September/October 2016



Mentorship has played a crucial role in my brief EM career. Perhaps, more importantly, it has also contributed to my personal and professional wellness. Realizing this, I asked myself a few questions. Why does mentorship matter? What makes a good mentor?

The term mentor originated from Homer’s Odyssey, as the name of the man entrusted by Odysseus, the king of Ithaca, to care for his son and household while he fought in the Trojan War. Following that example, a mentor is one who guides a junior colleague. Specifically a mentor should teach, advise, and share wisdom with their colleague. A mentor may provide personal advice, professional advice, or both. One useful definition of mentorship is “a process for the informal transmission of knowledge, social capital, and psychosocial support perceived by the recipient as relevant to career or personal development.”[1]

The Poor Porphyrias Don’t Get Enough Respect in the Emergency Department

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Authors: Kristen Pena, DO; Nicholas Mota, DO; Terrance McGovern, DO MPH
Emergency Medicine Resident Physicians
St. Joseph’s Regional Medical Center, Paterson, NJ

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Introduction
All emergency physicians have had patients that arrive at the emergency department with 10/10 abdominal pain, coming in like a screaming banshee from the waiting room. We pursue and rule out the dangerous diagnoses that we don’t want to miss: abdominal aortic aneurysm, pneumoperitoneum, appendicitis, ischemic bowel, etc., but what happens when all the labs and imaging you ordered are normal? Perhaps it is a not so uncommon case of hypodilaudidemia, but is there something else more sinister that we should have in the back of our minds with these patients?

The eight-step process that is required for the biosynthesis of heme is something we rarely think of in emergency medicine, but can be the source of great concern for patients that suffer from one of the many porphyrias. There is a wide range of clinical entities that can manifest by a defect or absence of the multiple enzymes within this pathway; luckily, there are only four inherited and one acquired subtype that present acutely.

Etiology
Acute intermittent porphyria (AIP) is the most common of these acute porphyrias occurring in 1-2/10,000 people, and most commonly in those of northern European descent.[1] Variegate porphyria (VP), hereditary coproporphyria (HCP), and aminolevulinic acid dehydratase deficient porphyria (ALAD-P) constitute the remaining inherited acute porphyrias; whereas, Plumboporphyria (also known as lead poisoning) is the only acquired form and acts at the same catalytic step as the ALAD-P porphyria.[1] The biochemical differences between the different acute porphyrias are not essential to know as they are not distinguishable in their clinical presentations, and the treatment is uniform for all of them.

Maybe Grandma Was Right: Dilute Apple Juice for Pediatric Oral Rehydration

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Author: Ashley Grigsby, DO PGY-3
Indiana University
Emergency Medicine/Pediatrics Residency

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Acute gastroenteritis is a common diagnosis for pediatric patients in emergency departments across the country. Although the cause is usually viral, successful treatment consists of adequate fluid hydration and supportive care through the course of the child’s illness.[1] The ability to keep a child hydrated through the illness is a major contributor to the successful outpatient management of these patients. There are oral rehydration solutions (ORS) available that have been recommended due to their ideal electrolyte concentrations, however, some children refuse to drink them because of the taste.[1] High sugar drinks, such as sports drinks, have also been thought to induce osmotic diarrhea and therefore have not been previously recommended for gastroenteritis.[1] Throughout my short career, I’ve had many parents tell me they give watered-down juice because “that’s what Grandma told me to do.” A recent study published in JAMA attempted to determine if half-dilute apple juice would be an acceptable oral rehydration option, and perhaps prove that grandmas sometimes do know best.

Tox Talk: Calcium Channel Blocker Overdose

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Author: Erica Schramm, MS4
Cooper Medical School of Rowan University
Originally Published: Modern Resident April/May 2016

Calcium channel blockers (CCBs) are used to treat a variety of common conditions such as hypertension, cardiac dysrhythmias and headaches. But use of CCBs is not without risk, particularly in cases of toxicity and overdose. CCBs are the ninth most widely prescribed class of drugs in the United States, accounting for an estimated 92 million prescriptions filled per year. The American Association of Poison Control Centers’ 2008 data noted over 10,000 human exposures to CCBs and 60 deaths associated with CCB overdose.[1]

What are the signs of CCB overdose?
The most common signs of CCB overdose are hypotension, sinus bradycardia, and shock. Other associated signs of overdose are hyperglycemia, pulmonary edema, myoclonus, dizziness, syncope, seizures, nausea, vomiting and acute kidney injury. Sustained release formulations can cause initial signs of overdose up to 12 hours post-ingestion. Diagnosis is clinical and thorough history taking is key to identifying CCB overdose. Patients taking CCBs who present with signs of toxicity should be questioned about intentional or unintentional overdose. Physicians should also inquire about details of how and when the patients take their medication to identify potential overdose.[1]