The Dying Gut: Identifying Patients with Intestinal Ischemia

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Author: Ashley Grigsby, DO PGY-1M
Indiana University
Originally Published: Modern Resident, February/March 2015

Intestinal ischemia is a serious illness with severe and life threatening complications. The likelihood of developing complications improves with earlier diagnosis. However, early diagnosis can be difficult, especially in the setting of no known risk factors.

Acute mesenteric ischemia is any process that causes hypoperfusion to the small intestine. The large intestine can also become ischemic from hypoperfusion, usually referred to as ischemic colitis.[1] Intestinal hypoperfusion can be due to arterial or venous obstruction from acute embolism, thrombosis or low-flow states.

We all learned in medical school, “abdominal pain out-of-proportion to physical exam” means acute mesenteric ischemia. However, in real-life situations, many emergency department patients presenting with abdominal pain would fit into this category. The question becomes, who gets a workup and who does not? First, a careful history should be performed; about one third of patients with acute intestinal ischemia will have a previous history of embolic event.[1] Patients with peripheral vascular disease, cardiac disease, atrial fibrillation, hypercoaguable states and hypovolemic states are all at increased risk of developing intestinal ischemia.[1]

Shiitake Mushroom Dermatitis: A Case Report

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Author:
Megan Litzau, MD
Emergency Medicine Resident
Indiana University
AAEM/RSA Social Media Committee


Overview:
A 31-year-old African American male presented with an erythematous rash of 8 days duration. The patient had been seen in the emergency department one week prior for the rash. At that time, he was given Eucerin cream, prednisone taper, and diphenhydramine. The patient returned one week later as the rash had not improved. Upon examination, the patient had a violaceous, linear rash across his torso and all of his extremities. The linear lesions appeared as though the patient had been scratching. However, he adamantly denied scratching and was unable to reach several of the lesions on examination. Upon further questioning, the only recent change in the patient’s habits was consuming a large amount of uncooked shiitake mushrooms 9 days prior. Approximately 12 hours after consuming the mushrooms, the rash appeared. Since that time, the rash had persisted. The rash was initially erythematous and had faded to a violaceous color during the course of the rash. The patient noted the rash to be constantly pruritic, which prompted his return visit to the emergency department. The patient also noticed that the rash and itching got worse when he was working outdoors. 

When Back Pain is More Than Musculoskeletal: The Red Flags of Spinal Epidural Abscesses

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Author: Kaitlin M. Fries, OMSIV
Ohio University Heritage College of Osteopathic Medicine

Originally Published: Modern Resident April/May 2015

As an emergency medicine physician it is important to always think about the worst-case scenario. What is the worst thing that could explain this patient’s symptoms? What could potentially kill this patient if not quickly identified and appropriately managed? For common complaints such as back pain, this mindset can easily be over looked. No matter how simple and straightforward a case of back pain may seem, it is still important to ensure there are no red flags. One of the most concerning worst-case scenarios of low back pain is that of a spinal epidural abscess.

Recent studies have shown that the number of cases of spinal epidural abscesses is rising due to an increase in IV drug abuse and spinal surgeries.[2,3] If overlooked, this infection can cause a rapid decline and lead to sepsis, meningitis and permanent paralysis.[3] With a mortality rate as high as 20%, it is vital to catch this infection on the patient’s first presentation.[2,3] Diagnostic delays are far too common in these patients. In 2003, a retrospective study looked at 63 cases of spinal epidural abscesses. It was found that 75% of these cases had multiple ED visits or were admitted without a clear diagnosis.[1]

More Than Meets the Eye: The Subtle Presentation of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) in the Emergency Setting

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Authors: Taraneh Matin, OMS-IV MA; Victoria Comeau, DO; Daniel F. Leiva, DO, MS
Nova Southeastern University

Rashes in the emergency department can often be overlooked as benign skin conditions. Being able to differentiate between life-threatening and non-life-threatening rashes is vital for the emergency physician. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) comprise a spectrum of the same subset of vesiculobullous diseases with an incidence that ranges from 0.4 to 7 per million per year, with a mortality that ranges from 1-5% for SJS and 25-40% for TEN.[1,2] The majority of cases are caused by medications while a lesser extent are caused by infections.[1] Typical causative agents include allopurinol, antibiotics, nonsteroidal anti-inflammatory drugs, and anticonvulsants.

Although it is a fatal condition with serious systemic complications, SJS presents with very subtle and often times overlooked or misdiagnosed prodromal symptoms including fever, painful eyes, or pain with swallowing. These are often mistaken for a benign viral illness. When evaluating a patient with these findings, obtaining a thorough history is important due to the high correlation of these symptoms with the onset of a new medication. The cutaneous manifestations present within days of the initial symptoms as ill-defined, erythematous macules or purpura beginning on the trunk and spreading outward. The oral, genital, and/or ocular mucosa are involved in 90% of cases as well as frequent involvement of the palms and soles.[3] With progression, vesicles and bullae form and the skin begins to slough leading to a positive Nikolsky sign on examination.[5-7] Ocular involvement can present as erythema, conjunctivitis, keratitis, and endophthalmitis and has been seen in 50-80% of cases. One-third of these cases can lead to vision impairing ocular sequelae.[8] Other organ systems including the gastrointestinal or pulmonary systems may be involved. It is important when evaluating these patients to note the body surface area (BSA) involved. SJS has a BSA involvement of <10% while TEN has a BSA involvement of >30%. Risk factors include co-morbid HIV infection or an immunocompromised state.[6]

Drug Choice for Procedural Sedation: Propofol vs. Ketamine

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Author: Randy Kring, MSIV
Tufts University School of Medicine

Procedural sedation is frequently performed in the emergency department, whether it is for electrical cardioversion, closed joint reduction or abscess incision and drainage. Although the focus in these cases is often on the procedure, smart preparation for procedural sedation and an understanding of the different strategies that can be used is vitally important.

The goal of procedural sedation is to provide moderate sedation and analgesia while preserving the patient’s protective airway reflexes, adequate ventilation and cardiovascular function. Relative contraindications for procedural sedation may include advanced age, significant medical comorbidities such as CHF or COPD or signs of a difficult airway.[1] Recent food intake is not a contraindication for procedural sedation, but aspiration risk should be assessed and minimized whenever possible.[2] Many drugs can be used for procedural sedation, including midazolam, etomidate, propofol and ketamine. Which drug is “the best?”

Propofol, a sedative and amnestic, has onset in about 40 seconds and duration of action of about six minutes. Common side effects include pain at the injection site, hypotension and respiratory depression.[3] Ketamine, a dissociative anesthetic that provides sedation, amnesia and analgesia, has onset in about 30 seconds and duration of action of about 10 to 20 minutes. Common side effects include agitation on emergence, nausea and (rarely) tachycardia and hypertension.[4]

Clinical Pearl: Procalcitonin and Lower Respiratory Tract Infections

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Author: Jordan Kaylor, MD PGY4
Northwestern/McGaw Medical Center

Procalcitonin (PCT) is a serum biomarker that, when paired with clinical judgment, may help guide management of lower respiratory tract infections (LRTIs) in the emergency department (ED). Procalcitonin levels can help clinicians distinguish between bacterial and viral infections and might subsequently guide decisions to initiate or discontinue antibiotics. Procalcitonin is a prohormone of calcitonin. It is an acute-phase reactant synthesized in many tissues and released in response to cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-α.1 Normal serum concentrations are <0.05ng/mL, but in bacterial infections, PCT increases to detectable levels within three to four hours (earlier than ESR or CRP).[1] Elevations are not seen in noninfectious inflammatory conditions or viral infections, but are possible in Addisonian crises, malaria, severe fungal infections and medullary thyroid carcinoma.[1] In viral infections, interferon (INF)-ɣ probably decreases PCT release, leading to lower or undetectable serum levels.[2]

Exploring an interest in Wilderness Medicine

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Author: Josh Symes, MD
EM PGY-1
University of Mississippi Medical Center

Wilderness Medicine affords the opportunity to combine passion for the outdoors with passion for medicine. Many people pursue wilderness medicine to be better equipped to use their medical training and expertise in medical situations they may encounter outside the hospital such as fishing, backpacking, mountain biking, etc. Others apply the training in lower resource settings on medical service trips abroad. Some make it a significant part of their career in medicine. It also provides an excellent teaching platform (ex. making the physiology of altitude more interesting). WM can provide opportunities for team building exercise through scenario-based training in medical school or residency. Some medical schools and residency programs have wilderness medicine built into the curriculum, but many do not. This blog entry aims to provide a primer of ways to explore an interest in wilderness medicine.

Summer and Acute Otitis Externa

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Author: Christine Au
Medical Student- OMS-II
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific
AAEM/RSA Social Media Committee




As summer is nearing an end, the days of pool parties and water sports has brought many cases of the much dreaded ear infection to emergency departments around the country. Otitis externa is known among most as “Swimmer’s Ear.” Acute otitis externa (AOE) is an inflammation of the external ear canal and is further explained as a cellulitis of the skin inside the external ear canal. In North America, 98% of the causes of AOE are bacterial, but viral and fungal sources have also been documented.[1] The most likely bacterial causes of AOE are Pseudomonas aeruginosa and Staph aureus.[1] According to Rosenfeld, the diagnosis is based on the rapid onset of disease; in most cases, the pain occurs within 48 hours from the time of exposure.[2] In addition, most patients experience itching, severe pain (otalgia), and in some cases, may complain of a feeling of “fullness” in the affected ear.[2] Some patients may also have pain upon jaw movement or even hearing loss.[2-3]

It’s a Privilege, Not a Burden

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Author: Jacob Stelter, MS4
Loyola University Chicago
Stritch School of Medicine
Originally Published: Common Sense November/December 2014

After years of battling things like prematurely adopted EMRs, government bureaucrats, clueless hospital administrators, greedy insurance companies, malignant tort lawyers, CMG profiteers, and "emergency" patients who don't need to see any doctor at all — much less an emergency physician — it is easy to become jaded and lose sight of our real value. That's why I chose to publish this editorial from a medical student. I hope it reminds you of the true worth of what you do, and how important you are. Stay strong! — Andy Walker, MD FAAEM, Editor Common Sense

I recently read an article in the Chicago Tribune entitled, “Expert’s New Career Prescription: Forget About Becoming a Doctor.”[1] In it author Dawn Turner Trice interviews the executive director of the Chicago Area Health and Medical Careers Program, Regnal Jones, who advises students not to pursue a career as a physician. He cites the cost of tuition, the many years of training, the long hours, and more medical graduates than residency spots — among other things — as reasons not to become a physician. I respect his opinion and have no doubt that some of his points are legitimate, especially regarding the cost of tuition and the fact that there are insufficient residency spots for graduating medical students. However, I respectfully disagree with much of what he says. At the end of her article Trice says, “You've heard Jones' position. Now tell me what you think.” Well, I did just that — sending her an email rebutting most of Jones' arguments. Now I want to explain to you why Jones is largely wrong, and present some of the positive aspects of being a physician.