Emergency Medicine

A new study finds that patients who go into in-hospital cardiac arrest (IHCA) during the weekend have a lower chance of survival compared to those who are admitted to the hospital during a weekday.

A 30-year-old male presents with a one-year history of worsening lower back pain and alternating buttock pain. He mentions his symptoms are typically worse first thing in the morning, but seem to remit later in the day with NSAIDs and exercise. Physical examination reveals swelling of the proximal interphalangeal joints of several digits, restricted lumbar movement, and tenderness of the sacroiliac joint. An X-ray demonstrates the findings seen here. Which of the following extra-articular clinical manifestations is most commonly associated with this patient’s condition?

A) Blurred vision
B) Right lower quadrant pain
C) Plaques with silver scale
D) Shortness of breath

Click here for answers to this clinical conundrum. 

Visit Figure 1 for more medical images and information.

A 31-year-old female presents to the emergency department with deep puncture wounds on her forearm after being attacked by a pack of stray dogs. On examination, she has a loss of sensation throughout her right medial palm and fingers and she is unable to extend her fourth and fifth digits. After her wounds are irrigated, she is administered tetanus, rabies, and antibiotic prophylaxis. Based on this patient’s detected nerve damage, what other hand functions might also be impaired?

A. Finger abduction
B. Extension of wrist
C. Pinching
D. Extension of thumb

Click here for answers to this clinical conundrum. 

Visit Figure 1 for more medical images and information.

• Deaths due to traffic collisions rose in 2015 by 7.7%—the largest increase in 1966.
• Opioid-related overdose deaths are at epidemic levels.
• Cannabis use is legal in 25 states.
• The cost of these collisions and deaths is estimated at nearly $38 billion.

• Are these phenomena related?

• The primary cause of death during self-photography was falling.
• Wikipedia reports nearly 60 self-photography-related deaths since 2014.
• Physicians can remind patients how profoundly distracting and dangerous smartphones can be.
• Remind patients to first take full view of their surroundings, then stop and pay full attention to the phone, and then put it away; They are much safer doing just one thing at a time.

• Fibromyalgia etiology is complex and multifaceted.
• Syndrome affects millions of patients worldwide.
• Fibromyalgia has significant negative personal, interpersonal, professional, and socioeconomic repercussions.
• While fibromyalgia is frequently recalcitrant, pregabalin has been found to be an anchor therapy for the syndrome.
• The syndrome afflicts between 6.5 million and more than 13 million Americans.
• Pharmacoeconomic studies have revealed that pregabalin is cost-effective.

• Dabigatran anti-coagulation can now be reversed.
• FDA approves idarucizumab for reversal of dabigatran anti-coagulation.
• Normal coagulation is established “in minutes.”
• Preliminary data show idarucizumab to be safe and effective for reversal of dabigatran anti-coagulation.
• Both efficacy and safety trials are sponsored by the manufacturer and published in top-tier journals.

• Dealers are manufacturing fentanyl in order to mix it with heroin.
• Widespread combining and selling of illicit fentanyl with street heroin.
• Combination produces profound euphoria and powerful addiction.
• Combination is significantly more lethal than either drug alone.

• At around $70 per kit, this may be the most cost-effective life-saving intervention available to physicians.
• The opioid epidemic is arguably the most significant current public health emergency in the U.S.
• Depending on geography, the cost of an overdose survival is ~$10,000.
• The average cost of an overdose-related death at the MetroHealth System in Cleveland, Ohio, is approximately $3000.
• Naloxone kit distribution programs can be run at a cost of <$1000/life saved.

• About 25% to 30% of ischemic strokes occur during sleep.
• Tissue-plasminogen activator is the only specific stroke treatment proven effective in large randomized trials.
• Without knowledge of exact time of symptom onset, this large group of patients is excluded from treatment with tissue-plasminogen activator.
• Clinical and imaging studies suggest that many wake-up strokes occur close to awakening and these patients might be within the approved time-window for thrombolysis upon arrival at the emergency department.

• About 25% to 30% of ischemic strokes occur during sleep.
• Tissue-plasminogen activator is the only specific stroke treatment proven effective in large randomized trials.
• Without knowledge of exact time of symptom onset, this large group of patients is excluded from treatment with tissue-plasminogen activator.
• Clinical and imaging studies suggest that many wake-up strokes occur close to awakening and these patients might be within the approved time-window for thrombolysis upon arrival at the ED.