Strep pharyngitis, commonly known as “strep throat” is a bacterial infection of the oropharynx caused by group A beta hemolytic streptococci (GAS), specifically S. pyogenes. This infection affects more than 500,000,000 people annually worldwide per year, ultimately resulting in a significant number of doctor’s visits, including to the ED (1). The classic clinical presentation of GAS pharyngitis includes sudden onset of sore throat, fever, and odynophagia. If untreated, complications of GAS pharyngitis include scarlet fever, rheumatic heart disease, post-streptococcal glomerulonephritis and peri-tonsillar abscess. In this post, we explore the diagnostic evaluation of pharyngitis with special attention to the use of the Centor criteria and rapid antigen testing.Read More
This week we were led through the evaluation and management of the difficult pediatric airway with Dr. Carleton in our quarterly airway grand rounds, and discussed cranial nerve abnormalities with Dr. Neel in our recurring EM-neuro combined conference. Dr. Jarrell presented an interesting case of a child with a cough and weight loss, and Dr. Jensen walked us through the clinical utility of BNP. Finally, Dr. Miller presented an interesting case of a patient with multisystem organ failure and cecum perforation.Read More
Dr. Ventura discusses the value of head CT and risk factors of CNS complications in HIV. Dr. Goel discussing the cognitive biases that drive decision making in EM. Dr. Stettler taught us that framing feedback can be as important as giving it and finally our CCHMC colleagues run through some difficult tox and airway cases. Plenty of learning to go around this week!Read More
This week in Grand Rounds: lessons learned in mass casualty from our recent experience with a mass shooting, a case of abdominal pain in a patient with a TIPS, understanding the UA, the importance of diagnosing HIV in the emergency department, dental emergencies, point of care ultrasound in pediatrics, and a deep dive into the literature about management of low risk PE.Read More
This week in UCEM Grand Rounds: the harrowing story of the desaturating trauma patient with a metal pole impaled through his mouth and neck. Also: making the diagnosis of HIV in the ED. Managing hemorrhagic shock on Air Care. How much did that ED visit or hospitalization cost your patient? Managing tachy-arrhythmias in the setting of cardiac arrest with a pacemaker.Read More
Not every runny nose is a viral URI. This case presents a relatively immunocompetent HIV+ male presenting with left sided rinorrhea and a fungal sinusitis diagnosed by CT. We also discuss diagnostic and therapeutic strategies for this rare diagnosisRead More
This week we got an operations update with some new markers of quality and new guidelines on HIV testing. We were reminded about patient literacy and the advantages of keeping it simple. Dr. Hill also taught that every shift our biases and decision making do affect patient care, it is our duty to recognize and use them to our patients' advantage.Read More
M&M with Dr. LaFollette
Case 1: Troponin Use in ESRD
- Evaluating cardiac ischemia in ESRD patients can be difficult due to baseline troponin elevations. However, all is not lost...
- Troponins can be used as a reliable marker of ischemia, even despite its collection in proximity to dialysis, if you take some things into account:
- Studies vary widely on troponin levels during dialysis, consensus being that troponin levels do not vary significantly vary with dialysis.
- Although the baseline may be abnormally elevated, ESRD patients nonetheless have a new baseline. Changes above this baseline and especially up trending troponins should trigger alarms that the patient may be having active ischemia.
- Troponin elevation in ESRD patients, even if at their baseline, is an independent risk factor for short term mortality
You are an EM resident from the US working in a rural South African hospital as part of a global health elective. The political climate is such that a prolonged government strike is leading to severe staffing and resource shortage. There are no disposable gloves and many procedures are performed barehanded. One day during rounds in the Labor Ward, the Chair of the department asks you to draw blood from an HIV-positive woman in labor as the team is presenting the patient in her room. The only remaining gloves in the hospital are a few pairs of sterile gloves reserved for emergency cesarean deliveries. There are high rates of HIV-exposure and many staff members are currently on post-exposure prophylaxis.Read More