Hypokalemic Periodic Paralysis in the ED

Hypokalemic Periodic Paralysis in the ED

Case Presentation

A middle-aged man with a two days history of weakness in his legs. The patient works as a construction worker and is used to conducting heavy physical activity.

After a thorough history and examination, the weakness was reported in the lower extremities with a power of 2/5, whereas the power in upper extremities was 4.5/5, Achilles tendon reflex was reduced, plantar response and other reflexes were intact, with normal sensation. Rest of the examination is unremarkable.

The vitals are within normal ranges, Blood investigations include – Urea and electrolytes, liver and renal function, full blood count, thyroid function tests, creatine kinase, urine myoglobin, vitamin B12 and folic acid levels.

Potassium level was 1.7 mEq/L (normal 3.5-5.5), and all other parameters were within normal ranges.

The ECG showed inverted T waves and the presence of U waves. An Example of an ECG:

Hypokalemic periodic paralysis is a rare disorder that may be hereditary as the primary cause, or secondary due to thyroid disease, strenuous physical activity, a carbohydrate-rich meal and toxins. The patients are mostly of Asian origin.

The most common presentation is of symmetrical weakness in lower limbs, with a low potassium level and ECG changes of hypokalemia. The patients may have a history of similar weaknesses which may be several years old. An attack may be triggered by infections, stress, exercise and other stress-related factors.

The word ‘weakness’, can lead to physicians thinking about stroke, neurological deficits and other life-threatening illnesses such as spinal cord injuries associated with high morbidity and mortality which need to be ruled out in the ED.

In this case, history and examination are vital. Weakness in other parts of the body, a thorough neurological examination are important aspects.

Patients are monitored and treated with potassium supplements (oral/Intravenous) until the levels normalize. ECG monitoring is essential, as cardiac function may be affected. 

The patient should be examined to assess the strength and should be referred for further evaluation and to confirm the diagnosis.

The differential diagnosis for weakness in lower limb include :

  1. Spinal cord disease (https://iem-student.org/spine-injuries/)
  2. Guillain barre syndrome
  3. Toxic myositis
  4. Trauma
  5. Neuropathy
  6. Spinal cord tumour

References

Cite this article as: Sumaiya Hafiz, UAE, "Hypokalemic Periodic Paralysis in the ED," in International Emergency Medicine Education Project, September 7, 2020, https://iem-student.org/2020/09/07/hypokalemic-periodic-paralysis-in-the-ed/, date accessed: October 23, 2020

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: October 23, 2020

A place for covoptimism?

Whether you are an optimist, a pessimist, or a strict realist is likely to impact how you would project potential effects of COVID on the post-COVID world.

I would argue that from the medical-practical perspective, the three attitudes above are not mutually exclusive. As we often conclude when reading pro- and con- arguments for a new legislature, unrefined reality allows for enough mixed data and scattered observations upon which to base and justify either stance.

My approach here is more of realistic anticipation: what changes to our global emergency care practice environment may result from what we are experiencing today? Undoubtedly, such changes will affect trainees a lot more than seasoned EM providers.

Telemedicine

While by no means a new thing, Telemedicine has advanced exponentially over the last few months and has come to the forefront of medical care in terms of its scope, breadth, and practical applications.

I am what my spouse would call “technologically challenged” (if she were to put it kindly). Yet even a tech-doofus (me) has had to dabble in Telehealth over the last few weeks – both inside my ED and to reach patients thousands of miles away.

Local Resource Preparedness

Everyone now realizes that you need to have tucked away but keep readily available roughly two N-95 masks per healthcare worker per day for three hundred and sixty-five days, amen.

Which changes in how entire healthcare systems are financed are necessary is a huge comprehensive topic. But point-preparedness, as in being ready at the actual place where you and I live and work locally, is a much easier thing to wrap our heads around and become directly involved in.

Provider Cross-Training

I do not know if golf practice makes you better at playing basketball or swimming at karate. But I do know that we have become so specialized, it is almost like there are hand specialists nowadays who will only deal with the left index finger.

COVID has shown all of us that it is not helpful to only possess knowledge and skills within the comfort zone of your specialty or sub-specialty.

As an EM doc, I have been okay with my ventilator and ARDS management skills. But the last few weeks have been extraordinary in reading up on anything from the forgotten basics of epidemiology and virology to palliative care. And that’s a good habit of keeping up for the future.

Sorting Out The Trash In Medical Literature

It is one thing to be able to verbally shred a New England or a Lancet paper at a leisurely journal club; it is quite another to be able to apply new (or old) reported research to clinical practice without harming anyone.

In the times of YouTube anxieties and misinformation, the latter task becomes even more crucial yet difficult. COVID controversies ranging from antimalarials to early intubation are a prime example.

But the good news with COVID is that I think we have just been handed the requirement for a free refresher course on how to appraise medical literature critically. We have to do this under pressure, without much time, and, arguably, fighting with our own natural inclination that “to do something is better than doing nothing.”

Patient Privacy and Empty EDs - As They Were Intended?

These points are controversial. But with medical information privacy requirements being loosened in many locations and with fewer non-COVID patients going to EDs, it is a valid question to ask: is right now how things should have always been?

Whether certain patients do not belong to an ED is a complex topic. Finding the golden middle between protecting confidential patient information and enabling providers to reach and treat patients most efficiently is likewise easier said than done.

For now, I am just inviting you to think about it.

Viruses In Focus

After decades and billions poured into research, we finally have stuff against HIV. Hepatitis and the herpes families are the two runners up, plus we developed a few effective vaccines like the MMR – but that’s about it really.

So much time and focus have gone into killing bacteria, we have somewhat neglected the other big guy. Until now.

The Cure For The Common Burnout

Emotional exhaustion may indeed be the key factor in professional burnout for emergency care providers. But other factors contribute as well – including feeling unappreciated or not needed, and work seems routine and mundane.

We now have COVID, which has reignited the fire for many EM providers, no matter how deep are those post-N95 facial marks. Otherwise, why would one fly to New York or elsewhere right now “to help”?

Frontline medicine certainly takes its toll on you. But hardly anyone in our specialty should feel not needed or unappreciated anymore.

The few changes I have listed come from a very long list. Whether they will prove to be overwhelmingly positive remains to be seen. Of course, future benefits do not negate the tremendous harm and suffering the pandemic has already brought and will continue to bring in the months to come.

But one thing is for sure: COVID is not the last time we are dealing with something like this. What your attitude and knowledge will be then, is up to you.

Cite this article as: Anthony Rodigin, USA, "A place for covoptimism?," in International Emergency Medicine Education Project, May 8, 2020, https://iem-student.org/2020/05/08/a-place-for-covoptimism/, date accessed: October 23, 2020

Epistaxis on a Flight

Epistaxis On A Flight

A couple of days ago, a friend told me about an incident that had occurred on a plane where a middle-aged man was found to have epistaxis (bleeding from the nose) midway between a 4-hour flight. Although epistaxis has various degrees of severity and only a small percent are life-threatening, the sight of blood, no matter the amount, is a cause of panic and anxiety for everyone. Hence, the cabin crew was called and helped in managing the patient until the flight landed.

Some of the causes of epistaxis on a flight are dryness in the nose due to changes in cabin pressure and air conditioning. Other causes depend on patients’ previous health problems, which may include medications such as warfarin, bleeding disorders, nose-picking.

As important as it is to learn the emergency management of epistaxis in a hospital setting, often you come across a scenario such as this, in your daily life and its essential to know how to manage it, out of the hospital setting or even in the emergency department, while taking history or waiting to be seen.

The following are a few steps you can take for initial conservative management of epistaxis:

If the following measures fail, further medical management may be advised.

Overview

Epistaxis is acute hemorrhage from the nose, nostrils, nasopharynx, and can be either anterior or posterior, depending on the source of bleeding. It is one of the most common Otolaryngological Emergencies.

Anterior bleeds are the most common, and a large proportion is self-limited. The most common site is ‘Little’s area’ also known as Kiesselbach’s plexus (Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery).

Posterior bleeds are less common and occur from posterolateral branches of the sphenopalatine artery and can result in significant hemorrhage.

Causes of epistaxis

Nose picking, dryness, allergic or viral rhinitis, foreign body, trauma, medications (anticoagulants), platelet disorders, nasal neoplasms, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), aspirin.

Assessment and Management

References and Further Reading

Alter Harrison. Approach to the adult epistaxis. [December 24th, 2019] from:  https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis

Cite this article as: Sumaiya Hafiz, UAE, "Epistaxis on a Flight," in International Emergency Medicine Education Project, December 27, 2019, https://iem-student.org/2019/12/27/epistaxis-on-a-flight/, date accessed: October 23, 2020

How to make the most of your EM Clerkship

How to make the most of your EM Clerkship

Emergency Medicine has something for everyone!

Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.

Prepare a list of common conditions

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.

As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.

Brush up on your history taking and examination skills

Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.

Read about common ED procedures

ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”

Watch videos on examination, interpreting X-rays, & procedural skills

Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.

Interpretation of ECG & X-rays

Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.

Books

Before the rotation

Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.

iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)

If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.

During the rotation

During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.

These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.

Cite this article as: Sumaiya Hafiz, UAE, "How to make the most of your EM Clerkship," in International Emergency Medicine Education Project, October 4, 2019, https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/, date accessed: October 23, 2020

A becoming specialty – EM in Tanzania

We all pass through milestones of growth and every stage is a hurdle to the next, how we choose to view it is our own choosing. Imagine seeing it from a child’s perspective; a five-month-old wobbly reaching for a shiny new toy that seems just a grasp away, falls flat on his face cries then realises; ooh wait there is that shiny new toy again. Picks up from where he left off and with every advance sitting transforms to crawling.

Joshua Yonazi 2014
Currently doing her Paediatric Cardiology Fellowship

As a medical student, I had no exposure to Emergency Medicine as a specialty. We had an OPD that was functional 24 hours. Paediatrics was what I set my mind to do, and Dr. Stella Mongella, who remains a role model to date influenced a lot of what I am today in my timeliness and responsibilities. It was a see admire and try to become not her but myself in the best way I could. 

After completing my medical school, which is a five-year program, the next step was to go for my one-year internship training. I moved from a mostly public health facility to a private health facility. It was until 2014 when I was employed as a Resident Medical Officer at the Accidents and Emergency Department of the Aga Khan Hospital Dar es Salaam when I met Dr. Yash Dubal, an Emergency Physician who had just joined the hospital that same year. He had graduated from Muhimbili University of Health and Allied Sciences (MUHAS) and working with him is what made me realise what a becoming speciality Emergency Medicine is and in less than a year I decided to join the same residency program he had graduated from.

This three-year residency program is a core competency-based training in research, trauma, paediatric care, leadership skills, bedside ultrasound, recognition and treatment of toxicological, obstetric and medical emergencies. Offers elective exchange opportunities for residents to go abroad for observership as well as those from abroad coming to Tanzania. Muhimbili National Hospital first and the only hospital to date to have an Emergency Medicine Residency Program in Tanzania and first to have initiated an Undergraduate Emergency Medicine Rotation in 2014. Since the presence of this fully capacitated Emergency Medicine department, there has been great change in the delivery of services and outcome within the hospital and its graduates are part of regionalisation of emergency care in Tanzania.

To date there are nine health facilities with fully functional 24 hours emergency departments with Emergency Physicians available at; Muhimbili National Hospital, Bugando Medical Center, Kilimanjaro Christian Medical Center, Arusha Lutheran Medical Center, Mount Meru Hospital, Mbeya Zonal Referral Hospital, Bombo Hospital, Benjamin Mkapa Hospital and The Aga Khan Hospital. Development of EMS is in progress with basic ambulance providers, attendants and dispatch training complete.

Muhimbili National Hospital
Mbeya Zonal Referral Hospital
Benjamin Mkapa Hospital
Kilimanjaro Christian Medical Center
Emergency Medical Services
The Aga Khan Hospital Dar es salaam

Emergency Medicine is a Becoming Specialty with core values to safely deliver those critically ill and injured from the community to the acute care units for resuscitation, stabilization and transfer to specific units for definitive care.

Cite this article as: Kilalo Mjema, "A becoming specialty – EM in Tanzania," in International Emergency Medicine Education Project, June 24, 2019, https://iem-student.org/2019/06/24/a-becoming-specialty-em-in-tanzania/, date accessed: October 23, 2020

ICON360: Tracy Sanson – Full Interview – Audio

iEM team proudly presents the ICON360 project. In this pleasantly educational series, world-renowned experts will share their habits, give advice on life, wellness and the profession.

In this episode, we shared the full interview of Dr. Tracy Sanson. 

Who is Dr. Sanson?

Dr. Sanson is a practicing Emergency Physician. She is a consultant and educator on Leadership development and Medical education and Co-Chief Editor of the Journal of Emergencies, Trauma and Shock; an Emergency Medicine international journal. A frequent speaker for Emergency Medicine programs, Dr. Sanson also serves as a core faculty member for the American College of Emergency Physicians. Dr. Sanson has consulted and lectured nationally and internationally on administrative and management issues, leadership, professionalism, communication, patient safety, brand development, personal development, womenäó»s issues and emergency medical clinical topics for a wide range of health care organizations. Dr. Sanson’s experience spans 20 + years in Emergency Medicine Education and ED management and leadership development. She has held director positions in the US Air Force, University of South Florida and TeamHealth for the past 15 + years. Dr. Sanson trained at the University of Illinois at Chicago for medical school and her emergency medicine residency. She is well versed in leadership, patient safety and medical management issues having served on TeamHealth’s Medical Advisory Board, Patient Safety Office Division Director and faculty in their Leadership Courses. (resource: https://feminem.org/author/tracy-sanson-md/)

iEM team proudly presents the ICON360 project. In this pleasantly educational series, world-renowned experts will share their habits, give advice on life, wellness and the profession.

The interview was recorded and produced by

Arif Alper Cevik

Elif Dilek Cakal

Murat Cetin

What every Med Student/Intern should know about EM

james-holliman

Rob Rogers

Joe Lex

C. James Holliman

Learn the secrets of Emergency Medicine from the fabulous four chapters prepared by three worldwide experts. Listen or read, but know these stuff as early as possible in your medicine/emergency medicine career.

Choosing the Emergency Medicine As A Career

by C. James Holliman The specialty of Emergency Medicine (EM) is a great career choice for medical students and interns.  In August 2013, I celebrated

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Emergency Medicine: A Unique Specialty

by Will Sanderson, Danny Cuevas, Rob Rogers Imagine walking into the hospital to start your day – ambulances are blaring, the waiting room is clamoring, babies

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The Importance of The Emergency Medicine Clerkship

by Linda Katirji, Farhad Aziz, Rob Rogers Introduction The Emergency Medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some

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Thinking Like an Emergency Physician

by Joe Lex Emergency Medicine is the most interesting 15 minutes of every other specialty. – Dan Sandberg, BEEM Conference, 2014 Why are we different?

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iEM Weekly Feed 3

iEM world

Welcome to iEM Weekly Feed!

With this feed, you do not miss anything. You will find all published blog posts during this week. Click the “title” or “read more” to open each page you interested in.

Pulmonary Embolism

by Elif Dilek Cakal Case Presentation A 45-year-old female with no prior medical history presented to the emergency department (ED) with three days of constant shortness

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Three days of constant shortness of breath

Do you recognize these findings in the US and CT scan? https://youtu.be/Dh-Q23xdqeEhttps://youtu.be/lhops90o6_g Pulmonary Embolism by Elif Dilek Cakal from Turkey. Read Listen

Read More »

Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

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My Leg Is Swollen!

A New Chapter Is Just Uploaded To The Website! An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and

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A Little White Coat and A Stethoscope

Ibrahim Sarbay Turkey I will never forget the time that I acted as a “medical doctor” at the 1st year-end show of the elementary school.

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Fall From Bicycle!

In case you didn’t encounter a child fallen from a bicycle today! Read “Multiple Trauma” Chapter Listen “Multiple Trauma” Chapter iEM Education Project Team uploads

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Core EM Clerkship Topics

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your

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Left Flank Pain

In case you didn’t encounter flank pain today! iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images

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iEM Image and Video Albums

Uploading Image and Video Archive More than 350 images and videos are uploaded into iEM Flickr channel. Thousands to come… Uploading Image and Video Archive

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Is Troponin Enough?

You are the emergency doc working in a rural ED. It is the Saturday night at 23:25 and you have three patients with chest pain.

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A 13-year-old with testicular pain

In case you didn’t encounter a patient with testicular pain today! iEM Education Project Team uploads many clinical picture and videos to the Flickr and

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Listen chapters on the go!

Uploading Audio Chapters 68% 28 chapters are ready to listen and download, 100 to go…

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Acute Heart Failure (AHF)

by Walid Hammad – USA Case Presentation An ambulance crew rushes into your emergency department (ED) with a 56-year-old man. He is severely short of

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I…can’t…breathe!

A New Chapter Is Just Uploaded To The Website! An ambulance crew rushes into your emergency department with a 56-year-old man. He is severely short

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A kid with wrist pain!

In case you didn’t encounter a kid with wrist pain today! Pediatric fractures affecting growth plate are classified with Salter-Harris classification. It is from I

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Managing Psychosis In The ED

Case 1.  It is a quiet Wednesday night in the emergency department when you suddenly hear someone coming down the hall continuously spouting out a string of profanities.  You leave the comfort of your chair to see what the commotion is all about only to find a 37-year-old female brought in by police for altered mental status.  She is acutely agitated on presentation, spouting obscenities non-stop, refusing to answer questions and uncooperative with a physical exam.

Case 2.  As you are pondering your next step, you see the paramedics wheeled an older gentleman past you and into the next room.  You step into the next room to get a report.  The family is at the bedside and states the patient is an 82-year-old male with a history of hypertension and BPH who has been increasingly confused and aggressive over the past two days.  You note that he is mildly tachycardic when you hear the PA system announce, “Security is needed in the critical care hallway.”

Case 3.  A nurse pops her head into the room and requests your immediate assistance.  You follow him down the hall and see your charge nurse along with three security officers trying to hold down a male patient.  The patient, who appears to be in his late twenties, is actively kicking and trying to bite and spit at the medical staff.  He appears flushed and diaphoretic.

by Michelle Chan, Nidal Moukaddam, and Veronica Tucci from USA.

A Kid With Wrist Pain!

In case you didn’t encounter a wrist pain today!

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Happy week with tons of education!