1. Transient Tenosynovitis
2. Guillain-Bare Syndrome
3. Muscular Dystrophy
4. Benign Acute Childhood Myositis

Who does Benign Acute Childhood Myositis (BACM) tend to affect?

BACM usually affects school-aged children, typically around 6-8 years old and usually more in BOYS, though it can occur in both genders.

How does it present? How is it diagnosed?

• BACM is usually a clinical diagnoses and is based on the clinical presentation of
  • History of recent viral infection – Fever, sore throat
  • Symmetric bilateral leg / calf pain,
    • Often a “stiff legged gait” or hesitant to walk
    • Pain is WORSE after rest
  • Normal or slightly elevated temperature

Are there any tests that are useful in making this diagnosis?

• Creatinine Kinase (CK) is very useful because it is usually elevated in BACM
• Typical tests to order:
  • CBC, Cr, CK, CRP, Urea, Urine analysis
    • Note: WBC and platelet counts are typical normal or decreased
  • Pro Tip: Check Cr and Urine to make sure the rhabdomyolysis (a complication of BACM) is not also present
    • Cr – would be elevated
    • Urine – would show signs of myoglobinuria (tea coloured)

Hey Doc, Transient Synovitis also causes a limp after a febrile illness. What are the main differences between transient synovitis and Benign Acute Childhood Myositis?

• Transient Synovitis is
  • UNILATERAL, and
  • NO CK involvement

Are there any complications of BACM?

• Complications are quite RARE.
• The most common complication, if there is one, is rhabdomyolysis, and rarely acute kidney injury if the rhabdomyolysis is severe

What is the prognosis or outcomes for BACM?

• Prognosis for BACM is Excellent,
•  Most children have a full recovery with fluids and pain control
• No long-term effects and recurrence is extremely rare

Take Home Points

• Benign Acute Childhood Myositis (BACM) also known as Viral Myositis is COMMON
• It typically follows a viral infection and tends to occur in BOYS 6 – 8 yrs
• It is SELF RESOLVING majority of the time and just needs Fluids and Pain control
• CK tends to be elevated,
• Complications such as rhabdomyolysis is RARE
• Hospitalization is rarely required and most children are back to normal in a couple of days

References

Brisca, G., Mariani, M., Pirlo, D. et al. Management and outcome of benign acute childhood myositis in pediatric emergency department. Ital J Pediatr 47, 57 (2021).

Magee H, Goldman RD. Viral myositis in children. Can Fam Physician. 2017 May;63(5):365-368.

Skrzypczyk P, Przychodzień J, Pańczyk-Tomaszewska M. Benign acute childhood myositis complicating influenza B infection in a boy with idiopathic nephrotic syndrome. Cent Eur J Immunol. 2016;41(3):328-331.

Terlizzi V, Improta F, Raia V. Simple diagnosis of benign acute childhood myositis: Lessons from a case report. J Pediatr Neurosci.

Hey Doc, Are you recommending us to use L.E.T in ADULTS?? I thought it is only for children?

While historically LET has mainly been used in children, there is no reason why we cannot use it in adults. There is a decrease in pain experienced, decrease in distortion caused by local anesthesia AND doesn’t necessarily increase the amount of time of the procedure.

Recall: LET is a topical anesthetic made up of: lidocaine-epinephrine-tetracaine and CAN be used on open wounds

Will LET provide enough anesthesia for me to actually do my procedure?

YES!! If LET is applied PROPERLY and for the proper DURATION you may NOT need to supplement with injectable lidocaine.

Research has shown that LET on its own provides adequate analgesia in the majority of patients, if properly selected.

Note- even if you DO need lidocaine, the pain with injection is LESS

You are suggesting to use LET for ABSCESS And Paronychia management? I haven’t done that before!

 YES! Remember LET anesthetises the skin, and the main reason we give local lidocaine in abscess management is to decrease pain with incision. BUT injecting lidocaine is one of the most PAINFUL aspects of I&D management. SO why not try and decrease pain, topically anesthetize the skin and make the I&D procedure LESS painful!

Note- for paronychias LET needs to be applied longer to ensure adequate penetration.

Yes I have done this, YES it works

Pro-tip: In pediatric patients studies have shown that LET even sometimes helps to spontaneously drain the abscess

What are situations where I cannot use LET?

L.E.T has been extensively studied in children and has been considered safe up to 3mL of LET gel without any reported serious adverse effects. [70].

Contraindications:

• Lacerations of Mucous membranes – Ex Lips, or Vulva regions
• LARGE lacerations (> 5 cm)
• Patients with Allergy to amide or ester topical anesthetics
• Grossly contaminated wounds
• Use in caution in infants less than 1 month of age:
  • Higher potential for systemic absorption in neonates and the theoretical risk of methemoglobinemia posed by the tetracaine component

• Note that the amount of systemically absorbed lidocaine and tetracaine is actually LESS than calculated amount because of the presence of epinephrine, and if 3mL or less is used, risk for lidocaine toxicity is minimal

Hey Doc- you are Using LET on Finger tips and Nose?? What about the epinephrine

 YES, LET CAN be used. Remember we DEBUNKED the myth that Epinephrine cant be used on fingertips, nose ears etc. As long as the vascular supply is fine, (ie no history of significant peripheral vascular disease etc) go ahead, Use LET!

Can LET be implemented at TRIAGE?

YES!!

In fact, many hospitals are starting to have standing orders or triage protocols for LET application

An example of a standing order can be:

Eligible patients

• Age >3 months and weight >5 kg
• Simple lacerations <5 cm in length
• Simple Abscess

Contraindications

• Lacerations of mucous membranes (eg, lip, vulva)
• Large lacerations (> 5 cm)
• Patient known to be a significant smoker or history of peripheral vascular disease
• Grossly contaminated wounds
• Patients with allergy to amide or ester local anesthetics
• Age < 3 month

Procedure

• Clean the area
• Apply LET Gel GENEROUSLY (max of 3mL)
• Cover with adhesive dressing (Ex Tegaderm/ Opsite), or elastic wrap for 20 – 30 minutes
• Document time of placement in patient’s chart/ Medical records

References/ Further Reading

1. Adler, Adam J., et al. “Does the use of topical lidocaine, epinephrine, and tetracaine solution provide sufficient anesthesia for laceration repair?” Academic Emergency Medicine, vol. 5, no. 2, Feb. 1998, pp. 108–112, https://doi.org/10.1111/j.1553-2712.1998.tb02593.x.
2. C Hsu, Deborah. “Clinical Use of Topical Anesthetics in Children.” UpToDate,. Accessed 15 June 2024.
3. Otterness, Karalynn, and Adam J Singer. “Updates in emergency department laceration management.” Clinical and Experimental Emergency Medicine, vol. 6, no. 2, 8 Apr. 2019, pp. 97–105, https://doi.org/10.15441/ceem.18.018.
4. Poulton, Theodore, et al. “Anaesthetic management of subcutaneous abscesses: Current status.” British Journal of Anaesthesia, vol. 125, no. 2, Aug. 2020, https://doi.org/10.1016/j.bja.2020.03.018.
5. Singer, Adam J, and Mary Jo Stark. “Pretreatment of Lacerations with lidocaine, epinephrine, and tetracaine at triage: A randomized double‐blind trial.” Academic Emergency Medicine, vol. 7, no. 7, July 2000, pp. 751–756, https://doi.org/10.1111/j.1553-2712.2000.tb02262.x.
6. Stella Yiu, MD. “Trick of the Trade: Topical Anesthetic Cream for Cutaneous Abscess Drainage in Children.” ALiEM, 11 July 2019

OK doc, So I have asked these questions, but What are some key things on physical exam that I should be paying attention to?

• Typically low voltage exposure have very minimal injuries
• On ALL patients evaluate the following:

Ok, I’ve taken the History and Done the Physical, is there any TEST that I should do?

• An ECG! This should be done on EVERYONE!
  • There are reports of myocardial infarction, arrhythmia, and other ECG abnormalities after both low- and high-voltage exposure.

What am I MOST LIKELY to see on ECG?

• Usually NOTHING or Sinus Tachycardia
• May see (Though uncommon if <120V)
  • 1^st and 2^nd degree AV blocks
  • Atrial fibrillation
  • Premature ventricular complexes, (PVCs)
  • Note- the above are typically seen within the first couple of hours and tend to self-resolve

Any SERIOUS ECG Findings

Yes, but they are MUCH Less Common but important to know

• Ventricular fibrillation – Most common fatal dysrhythmia
  • Typically Occurs RIGHT AWAY
  • Treat as normal ACS- Shock!
• Asystole – for High voltage currents
  • Rare, immediate
• Myocardial infarction – RARE

Wait Doc, what about the TROPONIN?

• A troponin is NOT useful if the patient has a:
  • LOW voltage exposure (<600V),
  • ASYMPTOMATIC – ie NO chest pain, no burns,
  • NO shortness of breath etc and
  • NORMAL ECG-
• A troponin is only helpful if we are suspecting an MI or cardiac contusion – both of which are quite rare

What about a CK? Blood work ETC?

• In low voltage injuries the incidence of rhabdomyolysis and compartment syndrome are rare. Discharge instructions should be given so that patients return if there are signs of it, though they are uncommon

Ok doc, What now? Who do we discharge? Who do we ADMIT?

See below for the algorithm:

You can Discharge the patient if:

• Low voltage (<600V)
• Asymptomatic- no chest pain, no current symptoms
• No reported loss of consciousness
• Normal physical exam
• Normal ECG
• NOTE: NO Cardiac Monitoring, NO Bloodwork/ Troponin Needed

Observation in ED with Cardiac Monitoring if

• Low Voltage Exposure (<600V) BUT Higher Risk
  • Skin wet during injury
  • May have had tetany/ significant muscle contractions
  • Symptomatic- Ex chest pain
  • High risk for cardiac complications- significant cardiovascular history etc
  • Loss of consciousness
  • Mild cutaneous burns
  • Minor Abnormalities on ECG
• Note- Can discharge these patients after 4-6 hours of cardiac monitoring if:
  • No more symptoms
  • Normal ECG
    • (Or has normalized after monitoring)
  • Normal blood work- troponins, CK, Urine myoglobin
  • Normal cardiac monitoring

Admit the patient if

• High Voltage
  • See Next blog post for full management!!
• Deep Skin and Local Soft tissue burn
  • RARE – but happens if patient was unable to “let go” of current
    • May have deeper burns than seen externally
  • TRANSFER to BURN center for evaluation – may need more extensive repair
• Major ECG abnormalities
• Failed above discharge criteria
• Consider Transfer to Burn Unit

Any Discharge instructions?

• YES! Discharge instructions are VERY IMPORTANT!
• Advise patients that
  • Delayed neurologic symptoms may occur, even psychological- difficulty concentrating etc
  • They should return if signs of chest pain, palpitations, syncope, and compartment syndrome – increased pain/ swelling in a particular limb.

Any Special Populations we should be paying attention to?

• Yes!
• Pediatrics patients and Pregnant women
  • But stay tuned to the next blog for management of these patients!

 So Back to the Case:

The patient was working with a toaster- ie Low volatage, no symptoms, normal physical exam, and normal EKG,

 So DISCHARGE would be best in this scenario

Summary

• Electrical injuries have a full spectrum of presentation
• Important questions to ask are:
  • What was the voltage of the device – < 600V or >600V? , was there a Prolonged Exposure or not, what was the Degree of “wetness”, what was the current, Any Symptoms currently, Any Burns
• Important to do a full physical exam
• An ECG is required on EVERYONE
• Can safely discharge the patient with NO bloodwork or ECG if:
  • Low voltage (<600V)
  • Asymptomatic- no chest pain, no current symptoms
  • No reported loss of consciousness
  • Normal physical exam
  • Normal ECG
• For management of High Voltage patients or Special populations see: The NEXT BLOG!

 

References/ Further Reading

1. Goffeng, L. O., et al. (2022). Low-voltage electrical accidents, immediate reactions and acute health care associated with self-reported general health 4 years later. Burns. Elsevier.

2. Electrical injuries and lightning strikes- Evaluation and management. (n.d.). UpToDate.

3. Electrical injuries in the emergency department: An evidence-based review – Trauma CME: EB Medicine. (n.d.). Electrical Injuries: Electric Shock, Burns, and Lightning Strikes.

4. Helman, A. (2022). Electrical injuries. Emergency Medicine Cases.

5. Zemaitis, M. R. (2023). Electrical injuries. In StatPearls. U.S. National Library of Medicine.

 
]]> https://pintopearls.com/its-so-electric/feed/ 1 https://pintopearls.com/iv-nitro-to-the-rescue/ https://pintopearls.com/iv-nitro-to-the-rescue/#comments Sun, 04 Feb 2024 23:34:00 +0000 https://pintopearls.com/?p=7135 Case: A 75 yo F with a history of hypertension, diabetes and congestive heart failure comes in with acute shortness of breath which started in the past hour. On exam she is saturating 80% on room air and 88% on a non-rebreather. Her blood pressure is 180/100 and she is really working to breathe with significant indrawing and tachypnea. Her history is consistent with acute heart failure (aka flash pulmonary edema) and so you have called the respiratory therapist to initiate non invasive ventilation (NIV aka BiPAP/CPAP). While you are waiting, what is the first medication you should give?  
1. Furosemide (Lasix) 
2. Nitroglycerin Patch 
3. IV Nitroglycerin
4. None of the above 

Answer: 

IV Nitroglycerin 

IV Nitroglycerin should be the FIRST LINE medication in patients in acute heart failure (aka flash pulmonary edema) as long as they are not in shock (IE BP < 100).  

 

Why?

These patients are usually in SCAPE – Sympathetic Crashing Acute Pulmonary Edema where there is a large sympathetic surge resulting in systemic vasoconstriction, pathologically elevated afterload and hypertension causing pulmonary congestion and dyspnea .  

       Ie- the sympathetic system is in overdrive causing the veins and arteries to constrict, forcing fluid into the lungs so the patient cannot breathe.  

How does IV Nitroglycerin Help?

The high blood pressure causes the afterload to increase, causing fluid to build up in the lungs. So one of the top priorities, is to reduce the blood pressure/ afterload. Nitroglycerin reduces afterload and preload and redistributes fluid from the pulmonary system. It has actually been shown to decrease the need for intubation, ICU admission and faster resolution of symptoms. 

But Doc, what about the Nitro Patch? 

The nitro patch is USELESS in acute situations. Throw the patch out! The patch takes about 2 hours for full absorption and  1 patch is equivalent to max 13mcg/min 

Ok, Got it. We give IV Nitro. That means we start at 10mcg/minute and titrate up right? 

WRONG– You want to reduce the afterload and preload FAST. The faster you reduce it, the faster the patient improves.  

If the blood pressure is greater than 140, then ideally you want to give about a 400-800ucg Bolus, and start a drip at around 150 ucg/min and titrate according to the blood pressure and symptom severity. It is better to start HIGH and titrate down.  If blood pressure is still high, you can titrate upwards (Up to 300mcg/min, Some studies have shown patients receiving up to 800mcg/min for short durations). If the blood pressure is improving, you can titrate down 

Note- If it is taking a while for the nurses to draw up or prepare the IV Nitroglycerin drip, then give 2 – 3 sprays of Nitroglycerin SL while waiting. 1 spray = 400 ucg  

Whoa Doc. These doses are REALLY HIGH! Wont the patient become HYPOtensive? 

Higher doses of Nitroglycerin are needed to achieve arterial vasodilation, compared to the doses given in angina, where the goal is veno-dilation. Also, these patients are profoundly vasoconstricted, so it takes a lot of afterload reduction for the BP to drop. In addition, IV nitroglycerin has a short half-life. Therefore, if the patient becomes hypotensive, you can either stop the IV nitro, or decrease it rapidly, and the patient’s blood pressure will improve in minutes. 

IV Titration

Make sure that you are at bedside if IV Nitroglycerin drip concentration is above 150mcg. Just as quickly as SCAPE develops, it can resolve rapidly, so you want to decrease the infusion levels rapidly as well 

But Doc, we heard that Lasix/ Furosemide is the best medication, and should be started RIGHT AWAY? 

WRONG 

Furosemide takes 1 hours to START working and max effect is within 1 – 2 hours. Therefore, it is NOT going to help in the ACUTE situation. Save your nursing resources! Start the IV nitro drip FIRST, THEN start furosemide.  

Summary 

1. In the acute heart failure patient with HIGH blood pressure, first line medication is IV Nitroglycerin 
2. Start HIGH- Give a Bolus of 400mcg – 800mcg (up to 1200mcg) (Or 3 Nitroglycerin sprays SL) and start IV infusion at 150mcg 
3. Be at BEDSIDE if starting at high doses (> 150mcg) and titrate as per blood pressure 
4. Throw away the Nitro patch in acute situations 
5. Furosemide should be started AFTER the nitroglycerin. You have time 

References/ Further Reading

1. Hayes, B. D. (2021). High-dose nitroglycerin for sympathetic crashing acute pulmonary edema. ALiEM
2. Farkas, J. (2022). Sympathetic crashing acute pulmonary edema (SCAPE). EMCrit Project
3. Helman, A. (2022). Acute heart failure ED management. Emergency Medicine Cases
4. McDonald, M., et al. (2021). CCS/CHFS heart failure guidelines update: Defining a new pharmacologic standard of care for heart failure with reduced ejection fraction. Canadian Journal of Cardiology, 37(4). Elsevier
]]> https://pintopearls.com/iv-nitro-to-the-rescue/feed/ 1 https://pintopearls.com/traumatic-cardiac-arrest-cpr-or-no-cpr-that-is-the-question/ https://pintopearls.com/traumatic-cardiac-arrest-cpr-or-no-cpr-that-is-the-question/#respond Tue, 28 Nov 2023 23:43:00 +0000 https://pintopearls.com/?p=7139 Case: A 25 yo F brought to your community emergency department after a motor vehicle crash where she was found ejected from the car. She initially had vital signs but lost them on route. EMS brings the patient to your community emergency department instead of the trauma hospital because it is the closest one. They are doing CPR on arrival.

What would you do?

a)      Continue CPR as per ACLS protocol only pausing every 2 minutes for rhythm check

b)      Continue CPR but pause for however long it takes to do any necessary procedures

Answer

B: Pause CPR for however long it takes to do the necessary life saving interventions.

Hey Doc, you are saying to PAUSE CPR when a person has NO PULSE? Isn’t that the OPPOSITE of what ACLS tells us to do?

YES, in blunt or penetrating trauma the rate of survival after cardiac arrest is quite poor. The mortality rate has been found to be as high as 96- 98%

CPR has NOT been shown to increase survival.

The causes of cardiac arrest in trauma are DIFFERENT than in a non-trauma case. In NON-traumatic cases, the most common cause of medical cardiac arrest is a CARDIAC cause. IE the heart CANNOT beat.

In cases of trauma, the causes of cardiac arrest are different – ie hypoxia, inadequate preload- hypovolemia, hemorrhage, obstructive shock- pericardial tamponade, hemo/pneumothorax, etc. So the heart CAN beat, but there is NO VOLUME or something is BLOCKING it. So doing CPR is futile because there is NOTHING to PUMP.

Ok, but can CPR be BAD?

In Trauma what actually HELPS is focusing on the reversible causes and actually treating them- Ie finger thoracostomy, intubation. Ie FIX the REVERISBLE Causes!

In a community hospital resources are often limited. There are often not enough nurses and physicians to run the code, and focusing primarily on CPR can distract from actual LIFESAVING interventions. IE if personnel are too focused on doing proper CPR, drawing up the epinephrine, etc, there may not be someone available to get the chest tube tray, intubation equipment, setting up MTP/ Rapid transfuser etc. Priority needs to be given to these lifesaving actions.

Also doing CPR while doing these procedures can increase risk of injury to the providers and decrease chance of success.

As per the European Resuscitation Council, “chest compressions take a lower priority than addressing the reversible causes. Chest compressions must not delay immediate treatment of reversible causes”

So if doing CPR makes you more comfortable, fine. Though do NOT delay other interventions because of CPR, and actually PAUSE CPR when you do the procedures (ie intubation, chest tubes etc), for faster/ greater success.

It is safe to PAUSE CPR for 3-5 minutes while addressing these other priorities.

What about epinephrine?

Once again interventions that are useful for medical cardiac arrest may NOT be useful during trauma. Epinephrine causes peripheral vasoconstriction, which can cause end organ damage and dysfunction. In certain studies they found that those who received epinephrine had higher rates of mortality and other studies found no improvement in survival rate.

Conclusion: Epinephrine has minimal benefit and could distract from useful solutions. Focus should be on the Lifesaving interventions

Ok Doc, So CPR is not useful, Epinephrine is NOT useful; so what DO we do in traumatic Cardiac Arrests?

Great question! You should treat the REVERSIBLE Causes! These interventions should ideally be done SIMULTANEOUSLY. However, in resource limited environments they may need to be done sequentially. The main reversible causes are:

• Hypovolemia/ Hemorrhage
• Hypoxia,
• Tension pneumothorax/ Hemothorax,
• Tamponade

Also see the flow diagram at the end

Cardiac Arrest Causes	Interventions
Hypovolemia  / Hemorrhage	Control Hemorrhage/ Bleeding & Replace – STOP the blood from pouring out – Ie Pressure dressing, Tourniquet, Pelvic Binders, splint fractures etc. -Replace the Blood -> Blood Products, MTP o  Central line ABOVE the Diaphragm!
Hypoxia	– BVM until you can Secure the Airway – Supraglottic Airway (LMA)/ Intubation
Tension Hemo/Pneumothorax	Decompress the Chest – Bilateral Finger Thoracostomies o  IE you do NOT need to put a chest tube in. o  Just decompress the area first w/ scalpel and Kelley. It is faster and more effective! o  Come back later once the patient is stable to put in the chest tube
Tamponade	– Ultrasound to check for pericardial tamponade – Ultrasound guided pericardiocentesiso  (+/- Thorocotomy -> ONLY if you have a trauma surgeon available)

Note:

Please note that some trauma cases can be a mixed trauma/ medical cases– Ie an 80 year old in an isolated MVC with Cardiac arrest- Did the trauma/MVC cause the cardiac arrest, or did a medical cause (MI/ Bleed etc) cause the MVC. So it is important to consider medical causes even in trauma cases. If it is likely to be a primary medical cause you would treat as per ACLS protocol (Ie CPR, and Epi), though the interventions listed above will still be helpful.



The algorithm suggested above is referring to primarily TRAUMA Victims- ex the young pt with MVC, The pedestrian vs MVC, gunshot, stabbings etc.

Summary

• Make sure  to consider/ rule out  MEDICAL causes of cardiac arrest
• If the patient has a primary TRAUMATIC cause of cardiac arrest, then CPR and epinephrine are not likely to be helpful
• Focus should be on trying to address: Hypovolemia/ Hemorrhage, Hypoxia, Tension Hemo/pneumothorax, Tamponade
• Interventions include: Controlling the bleed, replacing the blood, BVM/ Intubation, Bilateral finger thoracostomies, pericardiocentesis
  • MAYBE thoracotomy- though unlikely in a community hospital
• STOP CPR when doing the procedures.
• Remember – survival rate is generally poor for traumatic cardiac arrests, so despite your best attempts, the patient may not survive

References/ Further Reading

1. Bledsoe, B. E., & Salomone, J. P. (2023). Traumatic cardiac arrest (TCA): Maybe we could do better? Journal of Emergency Medical Services
2. Costain, N., & Suttie, R. (2018). Management controversies in traumatic cardiac arrest. EMOttawa Blog
3. Crewdson, K., & Lockey, D. (n.d.). Mortality in traumatic cardiac arrest. Resuscitation. Retrieved November 25, 2023
4. Truhlář, A., Deakin, C. D., Soar, J., et al. (2021). European resuscitation council guidelines for resuscitation 2021: Section 4. Cardiac arrest in special circumstances. European Resuscitation Council Guidelines
5. The Royal Children’s Hospital. (n.d.). RCH trauma guideline – Management of traumatic pneumothorax and haemothorax
6. Vianen, N. J., et al. (2022). Prehospital traumatic cardiac arrest: A systematic review and meta-analysis. European Journal of Trauma and Emergency Surgery: Official Publication of the European Trauma Society. U.S. National Library of Medicine
7. Konesky, K. L., & Guo, W. A. (n.d.). Revisiting traumatic cardiac arrest: Should CPR be initiated? European Journal of Trauma and Emergency Surgery: Official Publication of the European Trauma Society. U.S. National Library of Medicine
]]> https://pintopearls.com/traumatic-cardiac-arrest-cpr-or-no-cpr-that-is-the-question/feed/ 0 https://pintopearls.com/all-about-that-discharge/ https://pintopearls.com/all-about-that-discharge/#respond Wed, 13 Sep 2023 23:20:00 +0000 https://pintopearls.com/?p=7084 Case: 68 yr old female comes in with worsening dysuria, frequency, discharge and subjective fever.  

What is high on your differential? 

a)      Urinary Tract infection 

b)      Pyelonephritis 

c)       Sexually Transmitted Infections- ie chlamydia, gonorrhea, syphilis   

d)      All over the Above 

 Answer: 

e)      All of the above 

Wait Doc, she is 68 and STIs are HIGH on your differential?? 

YES! 

Did you know that the cases of chlamydia, gonorrhea and syphilis are rising and are actually rising FASTEST in the elderly population!  

While absolute rates are HIGHEST in the 15 – 29 yr olds, numbers are rising in the elderly.  

Between 2009 and 2019 There was a 114% relative increase of chlamydia in those 40 – 49 yo and 90.2% increase in those above 60 years old. 

But don’t ignore the other end of the spectrum! 

The young adolescents (15 – 19 yr olds) have the second highest absolute rates of STIs.  

So doc, what are you saying?  

STIs are on the rise in EVERYONE! So Test liberally! 

Especially, don’t discount those who are young (< 20 yo) and those older (>60 yo) , they are ALL sexually active!  

Ok, I understand gonorrhea and chlamydia, but Syphilis? Why are we worried about that? 

Syphilis has never gone away and its rates are also dramatically rising!  

Syphilis however is much more common in males (72%), and especially in the men who have sex with men (MSM) population, but rates are increasing in women. So look at the patient’s risk factors and presentation and do not hesitate to test.  

Ok Doc, if we are worried about STIs in women, can we just do Urine testing or do we need to do swabs? 

Urine testing is great for minimally symptomatic individuals and for asymptomatic patients.  

However, a recent study showed that vaginal swabs were more accurate than urine tests when detecting Chlamydia and gonorrhea

Also, you cannot test for bacterial vaginosis, candidiasis, and trichomonas* with urine testing.  

So for patients with any vaginal discharge, odour, vaginal pain etc, a swab would likely be more useful. 

*Note- at some institutions you can test for trichomonas in the urine 

So does that mean we HAVE to do a PELVIC / genital exam?  

If the patient is symptomatic or STI is suspected a physical exam is essential! 

There is a lot of useful information which can be gained by doing a pelvic exam.  

You can check for pain, other masses, lesions, ulcers (herpes), vaginal/ penile discharge etc which may increase your suspicion for empiric treatment for an STI in the equivocal patients or point to other diagnoses.  

Also, as previously mentioned, vaginal swabs are  the most accurate way to test for major STIs and also the only way to test for bacterial vaginosis, trichomonas (at SHN), candidiasis.  

So don’t ditch the pelvic exam! It is an essential part of our physical. 

Ok, so we suspect patient may have gonorrhoea or chlamydia. How do we treat? 

Chlamydia trachomatis (CT)	Neisseria gonorrhoeae (NG)
Doxycycline 100 mg PO bid for 7 days	Ceftriaxone 500 mg IM/IV in a single dose

You treat empirically for BOTH gonorrhoea AND Chlamydia, so give BOTH medications.  

Note- Ceftriaxone CAN be given IV (intravenous), so if patient ALREADY has an IV, don’t torture them with an IM! 

NOTE- in the US if gonorrhoea solely is identified, monotherapy with ceftriaxone 500mg IM for gonorrhoea is now recommended. However in Canada DUAL therapy (ceftriaxone AND doxycycline)  (to cover Chlamydia) is STILL recommended to increase efficacy and prevent resistance ^[iv]  

Practice Changes! 

Important updates:  

• Ceftriaxone- Increased from 250mg to 500mg  
  •  WHY? – Increased multi drug resistance 
• Azithromycin is NO longer First Line for chlamydia treatment! Doxycycline is 
  • WHY?
    • According to the CDC azithromycin had higher treatment failures in men and did not have good coverage for rectal infections.  Note- women can be asymptomatic carriers of rectal chlamydia.  
    • Doxycycline, on the other hand, appears effective for infections in urogenital, rectal, and oropharyngeal sites 
    • HOWEVER Azithromycin is STILL quite effective for urogenital infections in women and should be used in patients with high risk of non-compliance  and  pregnant  patients 

If the patient comes back POSITIVE for one of the tests, what do I do? 

1. Treat for the positive result – as indicated above 
2. Treat for OTHER STIs!! 

Patients with one STI are at HIGH risk for having OTHER STIs. So if a patient has tested positive for gonorrhoea or chlamydia, Make sure to test them for:  

• Either Gonorrhoea or chlamydia (if BOTH weren’t originally tested for) 
• Syphilis and  
• HIV,  
  • As per the recommendations in the HIV Screening and Testing Guide 
  • Infection with chlamydia can increase the risk of acquiring  and transmitting  HIV 

If the patient is being treated for an STI what discharge instructions do you want to give? 

• Abstain from any sexual activity until:
  • A) Treatment of the person is complete and ALL symptoms have resolved.
    • Ie at LEAST
      • 7 days for those on Doxycline and  
      • 7 days AFTER single dose of azithromycine/ Ceftriaxone. 
  • B) Treatment of ALL current partners is complete and all symptoms resolved 
    • Ask patient to inform ALL partners in the prior 60 days to get tested 

Future testing 

• Advise patient that they MAY need to be retested in 4 weeks if:
  • Symptoms or signs persist post-therapy 
  • Compliance to the prescribed treatment is suboptimal 
  • Preferred treatment regimen is not used 
  • The person is prepubertal 
  • The person is pregnant 
• ALL patients should be re-tested in 3 months
  • At 3 months if patient has symptoms it is NOT because of treatment failure, but actually because of re-infection
    • Ie failure of sex partners to receive treatment or initiation of sexual activity with a new infected partner 

Note: For those with EMRs, attached below is a discharge instruction template. Feel Free to copy/use/ adapt it for your practice 

But Doc, I never see these patients once they leave the ED. Doesn’t public health or their family doctor follow up? 

• While public health usually follows up, many patients are LOST to follow up, OR do not KNOW that they need to follow up 
• As their first line of contact it is useful to at least let them KNOW that they need follow up, so at the very least can seek it out themselves. 

Summary: 

• STI rates are INCREASING – especially those young and old 
• Rates are highest in those 15 – 29  
• Don’t forget about the above 60 population.  
• Syphilis is NOT gone, and is actually rising.
  • Prevalence is higher in MALES and MSM population, so test liberally. 
• Urine test for gonorrhea and chlamydia is great for asymptomatic individuals 
• Swabs are preferred for symptomatic females 
• Physical exam/ Pelvic exam on all high risk patients 
• Treatment is:
  • Doxycycline 100mg PO BID x 7 days 
  • Ceftriaxone 500mg IM/ IV x 1 
• If patient is positive for ONE STI, make sure to test for HIV and Syphilis! 
• Good discharge and follow up instructions are necessary 

Random tip: To increase the accuracy of urine tests: 

  1) The patient should not urinate for at least one hour prior to collecting the specimen. 

  2) Collect the first 15 – 20 ml of void­ed urine (ie FIRST void not midstream)  

References/ Further Reading

1. Aaron, K. J., et al. (2023). Vaginal swab vs urine for detection of chlamydia trachomatis, neisseria gonorrhoea, and trichomonas vaginalis: a meta-analysis. The Annals of Family Medicine, 21(2), 172–179.
2. Chlamydia and LGV guide: Key information and resources. (n.d.). The Government of Canada. Retrieved September 13, 2023
3. Chlamydial infections – STI treatment guidelines 2021. (n.d.). Centers for Disease Control and Prevention. Retrieved September 13, 2023
4. Gonococcal infections among adolescents and adults – STI treatment guidelines 2021. (n.d.). Centers for Disease Control and Prevention. Retrieved September 13, 2023
5. Gonorrhea guide: Key information and resources. (n.d.). Government of Canada. Retrieved September 13, 2023
6. Helman, A., & Jalali, H. (2023). STIs: Cervicitis, vulvovaginitis and urethritis. Emergency Medicine Cases
7. Report on sexually transmitted infection surveillance in Canada, 2019. (n.d.). Government of Canada. Retrieved September 13, 2023
]]> https://pintopearls.com/all-about-that-discharge/feed/ 0 https://pintopearls.com/all-about-the-pressure/ https://pintopearls.com/all-about-the-pressure/#respond Sat, 01 Jul 2023 05:19:00 +0000 https://pintopearls.com/?p=7146 Hey Doc, His Blood Pressure is 190/ 110. Now what do we do?  

Case: 

Case 1– Patient comes to the ED sent by the GP with a BP of 200/110 and a history of hypertension. No symptoms. What do you do? 

Case 2- Patient is coming in with headaches/ migraines and a history of headaches & Migraines. Blood Pressure is 180/105. What do you do? 

Case 3- Patient is coming in a laceration to his hand. Blood pressure is 200/100. No known history of hypertension, but no symptoms. What do you do? 

Case 4- Patient is coming in with new onset headache, blood pressure is 180/105. No known history of hypertension. What do you do? 

Case 5- Patient is brought in by husband because she is acting confused, no history of confusion. No fevers, or any other symptoms. Blood pressure is 185/90. No known history of hypertension. What do you do? 

Hypertension is a common presenting complaint in the emergency and depending on the physician and nurse assessing can have a wide range in workup from nothing, to everything. When does a high blood pressure need to be treated? When can it be left alone? 

Important questions to answer: 

1. Are they pregnant? 

Pregnant patients are excluded from this management approach, since pre-eclampsia is a risk and should be managed differently 

• Is there evidence of END ORGAN DAMAGE:  

Need to assess the 3 areas that could be affected 

1. The Brain 
2. Sudden onset of severe headache -> Subarachnoid Hemorrhage 
3. Signs of stroke or neurologic conditions 
4. Focal Neurologic Deficit 
5. Vision loss 
6. Altered mental status/ Confusion 
7. Seizure          
• The Heart / Lungs 
• Chest Pain/ Epigastric pain- concerning for acute myocardial ischemia or acute aortic dissection 
• Respiratory distress, hypoxia, volume overload, pitting edema -> Signs of Heart Failure 

3) The Kidneys 

• Oliguria, NOT making urine, pitting edema, 
• Physical Exam should include:
  • Full Neurologic Exam, Full cardiovascular Exam, Full Respiratory Exam.  

NOTE: Patients with asymptomatic hypertension may have mild symptoms such as mild headache or lightheadedness, but this does not necessarily indicate need to search for end-organ damage 



If NO evidence of end organ damage, this is NOT a Hypertensive Emergency. 

It could be considered a“Hypertensive Urgency”(this classification/term is no longer used) – ie severe BP elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction. (ACC 2017)

If NO hypertensive emergency, do NOT aggressively lower blood pressure 

“There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients.” 

• American Heart Association and American College of Cardiology Guidelines 

The patient does NOT need acute blood pressure lowering in the ED, and does NOT need IV Medications 

American College of Emergency Physicians 2013 Guidelines 

EVEN if BP > 200, patient does NOT need IV medications OR Resus / Acute bed, UNLESS signs of End organ damage 

Just start on PO meds- ex Captopril (if you need  ACUTE lowering of meds) 

Note- Rapidly lowering blood pressure could theoretically CAUSE a stroke due to hypo-perfusion of the brain, especially in patients with chronically high blood pressure 

So- MAX drop of 20% in blood 

But Doc, What about Blood work? 

ACEP 2013 Guidelines  

Routine screening for acute target organ injury (e.g. creatinine, UA, ECG) is NOT required 

In select patient populations, screening of creatinine may identify injury that affects disposition 

IF Diastolic < 120  -> No ED Work up needed 

If Systolic > 210 BPM OR Diastolic > 120 – 130 

Consider: CBC, Chemistry (Creatinine) 

IF Normal, Outpatient treatment sufficient 

“No other diagnostic screening tests (e.g. UA, ECG) appear to be useful”

So then what do we do? Anything? 

If prior history of high blood pressure -> restart/ adjust  medications 

If NO history of high blood pressure, can consider starting on an ORAL antihypertensive 

Do NOT need to see significant drop in blood pressure before discharging home 

** Arrange CLOSE Follow up! **

SEE FLOW DIAGRAM Below ( Attached)

Commonly used Oral Antihypertensive Medications in ACUTE setting

Agent	Class	Onset of Action	Duration of Action	Dosing	Adverse Effects
Captopril ** (preferred)	ACE-I	5 – 15 minutes	2 – 6 hr	25mg PO/SL  Range: 6.25 – 50mg PO (max)	ACE-I side effects: Hyperkalemia, angioedema, etc
Labetalol	a1- selective, B-Blocker	2 hrs	4 hr	200mg PO, followed by 200mg PO Q1-2hrs until desired effect	Hypotension, dizziness, headache, nausea
Amlodipine	Calcium channel blocker	4-6 hrs	24 – 72 hrs	5 – 10 mg PO	peripheral edema, dizziness, palpitations, and flushing

Often adjusting or initiating LONGER term antihypertensive is preferred to ACUTELY lowering BP 

Note- Amlodipine takes LONG to work, so may not see effect until ~ 4hrs later 

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