Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis

N Engl J Med 2014; 371:1100-1110
September 18, 2014
DOI: 10.1056/NEJMoa1404446
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1404446 [PDF]


Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations.


Journal Club Articles, Posted 9/10/2014

Time to cardioversion for acute atrial fibrillation and thromboembolic complications.
Nuotio I, Hartikainen JE, Grönberg T, Biancari F, Airaksinen KE.
JAMA. 2014 Aug 13;312(6):647-9. doi: 10.1001/jama.2014.3824.
[Full Text]

Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials.
Cavender MA, Sabatine MS.
Lancet. 2014 Aug 16;384(9943):599-606. doi: 10.1016/S0140-6736(14)61216-2.
[Full Text]

Program Director Rounds (Articles)

Reforming the Financing and Governance of GME
Gail R. Wilensky, Ph.D., and Donald M. Berwick, M.D., M.P.P.
N Engl J Med 2014; 371:792-793August 28, 2014DOI: 10.1056/NEJMp1406174
[Full Text]

Long-Term Effect of Hospital Pay for Performance on Mortality in England
Søren Rud Kristensen, Ph.D., Rachel Meacock, M.Sc., Alex J. Turner, M.Sc., Ruth Boaden, Ph.D., Ruth McDonald, Ph.D., Martin Roland, D.M., and Matthew Sutton, Ph.D.
N Engl J Med 2014; 371:540-548August 7, 2014DOI: 10.1056/NEJMoa1400962
[Full Text]

Effect of Oximetry on Hospitalization in Bronchiolitis: A Randomized Clinical Trial
Suzanne Schuh, MD, FRCPC1,2; Stephen Freedman, MD, FRCPC3; Allan Coates, MD2; Upton Allen, MD, FRCPC1,2; Patricia C. Parkin, MD, FRCPC1,2; Derek Stephens, MSc2; Wendy Ungar, PhD2; Zelia DaSilva, RT1; Andrew R. Willan, PhD2
JAMA. 2014;312(7):712-718. doi:10.1001/jama.2014.8637
[Full Text]

Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis.
Al Deeb M1, Barbic S, Featherstone R, Dankoff J, Barbic D.
Acad Emerg Med. 2014 Aug;21(8):843-852. doi: 10.1111/acem.12435.
[Full Text]

Troponin Elevations Only Detected With a High-sensitivity Assay: Clinical Correlations and Prognostic Significance.
Korley FK, Schulman SP, Sokoll LJ, DeFilippis AP, Stolbach AI, Bayram JD, Saheed MO, Omron R, Fernandez C, Lwin A, Cai SS, Post WS, Jaffe AS.
Acad Emerg Med. 2014 Jul;21(7):727-735. doi: 10.1111/acem.12417. Epub 2014 Aug 11.
[Full Text]

The Opportunity Cost of Futile Treatment in the ICU*.
Huynh TN1, Kleerup EC, Raj PP, Wenger NS.
Crit Care Med. 2014 Sep;42(9):1977-82. doi: 10.1097/CCM.0000000000000402.
[Full Text]

Effect of early metoprolol on infarct size in ST-segment-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: the Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction (METOCARD-CNIC) trial.
Ibanez B1, Macaya C, Sánchez-Brunete V, Pizarro G, Fernández-Friera L, Mateos A, Fernández-Ortiz A, García-Ruiz JM, García-Álvarez A, Iñiguez A, Jiménez-Borreguero J, López-Romero P, Fernández-Jiménez R, Goicolea J, Ruiz-Mateos B, Bastante T, Arias M, Iglesias-Vázquez JA, Rodriguez MD, Escalera N, Acebal C, Cabrera JA, Valenciano J, Pérez de Prado A, Fernández-Campos MJ, Casado I, García-Rubira JC, García-Prieto J, Sanz-Rosa D, Cuellas C, Hernández-Antolín R, Albarrán A, Fernández-Vázquez F, de la Torre-Hernández JM, Pocock S, Sanz G, Fuster V.
Circulation. 2013 Oct 1;128(14):1495-503. doi: 10.1161/CIRCULATIONAHA.113.003653. Epub 2013 Sep 3.
[Full Text]

Wednesday Lecture Notes, 9/3/2014 (Irritable Child) [EDITED 9/9/2014]

EDITED 9/9/2014 with additional note on NMS vs. Seratonin Syndrome

1230 – Jr/Sr Session (Cantor)

Rabies manifestation ascending paralysis (anterior horn neuron)

Botulism dt honey, home canning, motor paralysis.  Adult gut flora suppresses toxin dt normal flora & pH.

Erythroderma ~Staph or Strep dt erythrogenic toxin relase & slough c streptokinase…

Ornithine transcarbamylase deficiency ~ hyperammonemia (urea cycle) & lethargy

“sleepy kids get sugars”

HSV encephalitis will have temporal & liver involvements, CSF blood & whites… should CT first.

Myasthenia Gravis ~ edrophonium chloride (acetylcholinesterase inhibitor sp autoimmune synapse degradation) …like physostigmine for anticholinergic  tox.

JONES criteria for Rheumatic Fever (Joints, Heart, Erythroderma, Sydenham)

Dialyzable drugs…

Radioopaque ingestions include Fe. Pneumonic (“COINS” ~ chloral hydrate & cocaine, opiate packets, Iron & metals, Neuroleptic agents, Sustained Release capsules/Salicylates)

Toxic alcohols Methanol, Ethylene Glycol, Isopropyl

NMS Red Hot & Rigid (antipsychotics) v Serotonin Red Hot & Flaccid (SSRI), benzos!

[EDIT: NMS is classic lead pipe rigidity; Serotonin toxicity is classically described as lower extremity hyperreflexia/clonus which can have rigidity. The main helpful differentiators is: the causative agent; the onset and duration of effects]

“caine” anesthetics ~ Methemoglobinemia

Theophylline ~ hypokalemia (Aldosterone causes Na up, K down) ~ Albuterol or black licorice

Clarithromycin & Aminoglycosides affect Tegretol (carbamazepine) metabolism!

Windshield washer fluid… Fomepizole.

6yo Leg Calve Perthes avascular necrosis “dead head” from medial circumflex femoral aa.

Afebrile irritability in 3wk old babies, think: corneal abrasion, hair tourniquet, torsion, uti, rib frx.

…fluorescein & tetracaine!

Apt test is for infant hematemesis to determine fetal v maternal blood.

Sepsis in neonate from UTI/ecoli most common.

3wks old in heart failure… VSD.  PDA dependent… (NSAIDs close, PrOstaglandins Open)

Aberrant L coronary (ALCAPA) ~ infant STEMI (L coronary off Pulm aa rather than Ao)

5Ts Truncus, Transposition, Tricuspid Atresia, Tetralogy, Total Anomolous Venous return

130p – Congenital Metabolic (Cantor), Tox (Cantor)

3yo Sz febrile… simple? can be… but pupils dilated, hypertense, SWEATY.

OTIS CAMPBELL mnemonic for Sz. <http://www.fpnotebook.com/er/toxin/TxnIndcdNrlgcChngs.htm&gt;

Caladryl can cause benadryl toxicity.

Cholinomimetics can cause severe toxicity (~bug bombs, organophosphates) ~SLUDGE mnemonic. …atropine & pralidoxime.

MUDPILES for anion gap…<http://netscut.templaro.com/acid_base/mudpiles.html&gt;

toxic alcohols CAN be tested in house.


230 – Limp (Barus)

Keep an open mind… pain in lower extremity often refers.

Dicrocoeliumdendriticum … ANT ZOMBIES <http://www.cdc.gov/dpdx/dicrocoeliasis/index.html&gt;, <http://en.m.wikipedia.org/wiki/Ophiocordyceps_unilateralis&gt;.  ~Rabies…

Gradual exam, make the kid try to move!

Ask mom where the pain is. “Mom knows best” [when she cares to].

FABER test (flex, abduct, & external rotation) ~ SI joint pathology.

Septic Hip Rules (Kocher 1999, 2004 commonly cited).

Galeazzi test for dislocation, Ortellani/Barlow test at birth…

Trendelenburg gait… fast side is the good side, gluteus medius weakness.

Antalgic (foot drag) gait represents offloading…

“Stooped” Gait, Hip flexor or abdominal pathology.

Hip circumduction ~ antalgic.

Ataxic Gait (vestibular, ~drunk…)

Foot Drop  “marching” or “foot slap” gait, “steppage”.

Toddler’s fracture, won’t walk, “toe pain”.

SCFE ~Klein’s Lines.

JRA can cause severe disability & deformity.

Radial Head reduction ~ supination & flexion, feel for click, squeeze radial head.

Osteosarcoma osteoclastic c cortical elevation.

Maisonneuve Frx c ankles, check the calf!

Osteomyelitis c periosteal elevation.

Child femur frx ~ almost always call CPS!

Calcaneal Frx ~ Bohler’s Angle (20* to 40*) associated c lumbar burst frx!

Candy works for attention! (…even on adults.)


3p – SIDS v SUDI… (Thabet) & Congenital Metabolic Disorders…

<1yr of age, 2200 cases in 2005.  Leading cause of death 1 to 12 months.

Most common @ 2 to 4 months (highest risk), starting to develop head movements.

Males > Female.  Sleep positioning important.   Unaccustomed prone positioning worse.

supervised “tummy time” is ok only with active parental observation, but otherwise “back to sleep”!  Cosleeping with siblings or parents

Pacifier use found to be protective?

Minimize blankets & stuffed animals!

…*Congenital Metabolic: Sugars? Fats? Proteins? …go down the line…

Ketosis? Lactic Acidosis? Fatty Acid Problems…

Ammonia? Blood Sugar! Check Lactate & Pyruvate, LFTs, Uric Acid, UA!

Galactosemia cannot break down milk sugars…

Glycogen Storage: vonGierke, Pompe, Cori, Anderson, McArdle…

Newborn screen for PTU, proprionic acid, melonic acid… takes 1 to 2 weeks for newborn screen to process.

Can present c ALTE or SIDS!

MCAD deficiency do poorly c fasting…

Resp Alkalosis, consider Ammonia.

Met Acidosis broader DDx, usually high anion gap. (Consider Lactate/Pyruvate ratio…)

AliEM AIR Series 2 HEENT

AIR Series: Head, Ear, Eye, Nose and Throat (HEENT)

“Welcome to the second ALiEM Approved Instructional Resources (AIR) Module! In an effort to reward our readers for the reading and learning they are already doing online, we have created an Individual Interactive Instruction (III) opportunity utilizing FOAM resources for US Emergency Medicine residents. For each module, the board curates and scores a list of blogs and podcasts. A quiz is available to complete after each module to obtain residency conference credit. Once completed, your name and institution will be logged into our private Google Drive database, which participating residency program directors can access to provide proof of completion.”

See Also: ALiEM Approved Instructional Resources (AIR)

Tony’s Take Home Memo

From Wednesday lectures, 8/3/2014

Week 9 (Block 3 Wk1) Derm [+NYS Fair Week!]

10a – Dermatitis (Kloss)

Eczema ~ Atopic Dermatitis, scaling, crusting, oozing…

Dermatitis ~ “inflammation” of “skin”

Seborrheic, Contact, Irritant, Nummular…

Poison Ivy is common allergic contact dermatitis, Urushiol allergic oil component. Sensitization ~age8. Toxicodendron ~ class IV hypersensitivity rxn, can cause urticaria or E. Multiforme.

4 to 96 hours onset.  “Leaves of 3, let it be”.  Course often lasts 2 to 3 weeks, steroid taper…

Nickel dermatitis is common on neck, arms, infraumbilical dt jewelery & clothing.

“Formication” ~ “coke bugs” (dt cocaine or amphetamines)

Acne ~ DCX c MRSA coverage!

Contact dermatitis can be allergic or irritant.

Benadryl is good drug if any allergic component.

Steroids can be oral or topical depending on severity.

“If it’s dry, make it wet; wet, make it dry.”

Always consider Herpes for vesicular lesions.

Dyshydrotic Eczema may be confused c herpetic whitlow, pruritic vesicular dematitis off palms & soles.

Empiric treatment for tinea appearing rash ~ ketoconazole c steroids for possible nummular eczema. Pruritic dermatitis common on trunk & lower extremities, can be numerous lesions.

1030 – Cellulitis (Wang)

Acute spreading of skin infection c pain, warmth, swelling, & erythema.

Often after wounds or exposure to other ppl c cellulitis ~ MRSA.

Immune compromise, DM2, stasis predispose.  Staph most common.

Crepitance, Streaking, sloughing are bad signs.

Extent, location, systemic Sx, complicating factors are important to consider in Dispo…

Failure of appropriate outpatient treatment? Consider admission strongly.

Paolo says no wound cultures for superficial abscess!

Keflex, Augmentin, Clinda, Bactrim, DCX…

Necrotizing Fasciitis is rare but ~50% Mortality (DM2 biggest risk factor), usually precipitated by minor trauma.  May not have significant overlying cellulitis!  May need surgery & HBO therapy, Strep one of the most common bacterial causes, but among Abx, ALWAYS USE CLINDA! (for alpha toxin suppression in case of Clostridia http://www.ncbi.nlm.nih.gov/pubmed/288273).

11a – Small Groups (Sarsfield)

Name that rash!

1 ~ Measles Rubeola

2 ~ Scarlet Strep

3 ~ Rubella (German Measles)

4 ~ Dukes Dsx? Staph

5 ~ Parvovirus B19 Erythema Infectiosum

6 ~ Roseola (HSV6&7)

Herald Patch, Pityriasis Rosacea ~ Xmas Tree…(self limited)

Erythema Migrans ~ Bulls Eye

Erythema Multiforme (central clearing), SJS, TEN

Nikolvsky’s Sign ~ slough.

Scabies… RMSF… Varicella… Impetigo…

Smallpox… Coxsackie… Nickel Dermatits… HSP v meningococcemia…

1130 Small Groups (ERod)

Salmon Colored Plaques and Papules… Psoriasis.

Scabies in the webs spaces, intensely pruritic. Permethrin creme.

Painless genital lesion. Syphilis Chancre Primary. Pen VK IM.

Secondary Syphilis Palms & Soles lesion… coxsackie, EMult…

*Infxn, Drugs, Autoimmune, CA?

Disseminated Gonococcus needs continuous IV Ceftriaxone…

Toxic Shock Syndrome ~ erythroderma, fever, hypotension, desquam, mult organ involvement.

Erysipelas ~ older pt c sharply demarcated lesions.  Admit for facial lesions c IV Abx (for Strep!)

Staph ~ suppurative.

1230 – Jr/Sr (Cantor)

Autonomic Dysfunction ~ Spinal Shock

Lap Belt sign only ~ consider lumbar spine & small bowel injury (Chance frx)

To decrease ICP, Hyperventilation effective, intubation allows for good access.

Central Cord Syndrome ~ Motor deficits in Upper extremities, but not lower…

Pulmonary Contusion can progress to PTX, so should be observed

Passive & Active Immunizations for Rabies & Tetanus if never previously immunized.

Erythema Multiforme plus mouth lesions, think SJS/TEN…

ASA in young child causes Reye Syndrome. Serum Ammonia & LFTs elevated. ICP increase, hyperventilate!

ITP, Rhogam?! Need Blood Type!



Nonbloody diarrhea ~ Norwalk (calicivirus) is quick on, quick off (v Adeno & Rotavirus)

Blood in stool c diarrhea is dysentery. Canoeing is water… Typhoid Mary & rotten eggs…

Bacterial GastroEnteritis ~ Bloody Diarrhea.

Infantile HIV often has parotid involvement c immune compromise.

130 – Maculopapular Rash (Kolb)

Acute Retroviral Syndrome HIV rash, Dermatomyositis, 2* Syphilis, SLE, Porphyria Cutanea Tarda, Dengue v Dengue Hemorrhagic Fever…

STIs cause many maculopapular rashes, sexual hx?!…

Photosensitive? DCX/TCX side effects…

2p – Vesicular/Bullous Rash (GJ)

Starting IVs!?! ONLY for sick people & infants! Venipuncture does not necessitate IV!

PGY2 should not waste too much time on venipuncture since needed for other critical patients.

Stable for floor requires IV? Probably not…

Peds ED may be moving to hospital 4th floor?!?!

*Rashes… Fever & Vesicles consider: TEN, TSS, SSSS, disseminated HSV/varicella, Pemphygus, Bacteremia…

SJS goes to Burn Unit.

Varicella 2wks incubation period.  Vaccine since 1998.

Hutchinson’s v Ramsey Hunt … beware ophtho keratitis

Nikolvsky’s sign c blisters… TEN, pemphygus, pemphygoid, SSSS…

230 – Peds Exanthems (Thabet)

Erythema Multiforme common for viral infxn treated c Abx.

Tinea ~ oral griseofulvin (no LFTs needed if otherwise baseline)

Coxsackie may be 2 to 3 weeks, may get worse before better.  Coxsackie A is HFM typically, but can be Coxsackie B which is associated c rare myocarditis.  Anterior involvement ~HSV.

Candida in infant should be treated Nystatin for groin, feeding nipples…

Strep can be complicated by Scarlet Fever, Rheumatic Fever, PSGN…

Lyme Dsx is endemic in this area.

Lichen Sclerosis is NOT STI finding!

HSP (hematuria, abd pain, purpura) think kidneys & intussusception…

5th Dsx, Erythema Infectiosum, Reticulated “Cutis Marmorata”

NYS Fair!!!