Anand Swaminathan discusses recognition and management of adrenal crisis; Maria Ivankovic shares indications for antibiotics in strep throat. Jesse McLaren talks about recognizing posterior MI from ECG Cases. Justin Yan & Hans Rosenberg present facts of DKA approach. Brit Long debunks ovarian torsion imaging myths. Walter Himmel explains how to properly use the HINTS exam. Ian Stiell discusses proper use of Canadian CT head rules.
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Quick takeaways
Prompt diagnosis and treatment of adrenal crisis with hydrocortisone replacement is crucial in preventing serious complications.
Children with strep throat should still be tested and treated to prevent complications like rheumatic fever and PANDAS.
Recognition of specific ECG patterns, such as tall anterior R-waves and horizontal ST depression, is essential for diagnosing posterior myocardial infarction.
Deep dives
Adrenal crisis: Recognizing the Signs and Symptoms
Adrenal crisis is a life-threatening emergency due to acute deficiency of adrenal cortical hormones, specifically cortisol and aldosterone. Patients with adrenal insufficiency can present with nonspecific complaints like weakness, confusion, fever, nausea, vomiting, and abdominal pain. It is important to consider adrenal insufficiency in patients with unexplained hypotension, especially in those with known primary adrenal insufficiency, pituitary disease, or prolonged steroid therapy. Prompt diagnosis and treatment with hydrocortisone replacement is crucial in preventing serious complications.
Antibiotic Treatment for Strep Throat in Children
While antibiotics are no longer routinely recommended for adults with strep throat, the approach differs for children. The Canadian Pediatric Society still encourages testing and treating children with strep throat due to the higher risk of rheumatic fever compared to adults. Children, especially those within the age range of 5 to 15, are at higher risk for rheumatic fever and can serve as a reservoir for group A strep infections. Treating strep throat in children can prevent complications like pediatric autoimmune neuropsychiatric disorders associated with strep (PANDAS). Therefore, the current recommendation is to test and treat children to prevent the spread of infections and potential long-term effects.
Recognizing and Managing Posterior Myocardial Infarction
Diagnosing a posterior myocardial infarction (MI) can be challenging as it does not produce typical ST elevation on a 12-lead electrocardiogram (ECG). However, there are specific patterns and indicators to consider. Posterior MI can manifest as tall anterior R-waves, horizontal ST depression in the precordial leads, and upright T-waves. These findings help differentiate posterior MI from sub-endocardial ischemia, which presents with ST depression in lateral leads and T-wave inversions. Several factors can cause posterior MI to be overlooked, such as outdated dichotomized MI classifications and the reliance on ST segment elevation criteria. Clinicians should be vigilant in recognizing the unique ECG patterns and considering posterior leads to ensure prompt and appropriate management.
Proper Utilization of the HINTS Examination for Vertigo
The HINTS (Head Impulse, Nystagmus, Test of Skew) examination is a valuable tool for diagnosing and managing patients with continuous, relentless vertigo. However, it is important to apply the HINTS examination only in cases of continuous vertigo and nystagmus. The head impulse test should be performed in patients who are alert and cooperative, and it involves analyzing eye movements when the head is rapidly turned. Patients with peripheral vestibular neuronitis will exhibit eye movement where the eyes move with the head and then make a corrective saccade back towards the nose. Conversely, patients with central nystagmus will show a normal head impulse test, with their eyes remaining focused on the examiner's nose. It is crucial to understand the indications and interpretation of the HINTS examination to ensure accurate diagnosis and appropriate management.
Understanding the Canadian CT Head Rule
The Canadian CT Head Rule is a validated clinical decision tool for evaluating patients with minor head injuries. It consists of seven criteria, including five high-risk criteria, such as a Glasgow Coma Scale score less than 15, suspected open or depressed skull fracture, and age 65 years or older. The medium-risk criteria include prolonged amnesia and overtly dangerous mechanism of injury. It is important to apply the rule correctly and not to make assumptions about its application. For example, patients who have a minimal head injury with no neurological insult, or those who are alert and have a GCS score of 15, do not require a CT head. Additionally, the Canadian CT Head Rule does not automatically include a CT cervical spine scan for patients undergoing a CT head unless there are specific indications for cervical spine imaging. Proper understanding and adherence to the Canadian CT Head Rule ensure appropriate utilization of resources and accurate clinical decision-making.
Anand Swaminathan on recognition and ED management of adrenal crisis, Maria Ivankovic on indications for antibiotics in strep throat from EM Cases Course 2020, Jesse McLaren on recognition of posterior MI from ECG Cases, Justin Yan & Hans Rosenberg on just the facts of approach to DKA, Brit Long on ovarian torsion imaging myths, Walter Himmel on how to use the HINTS exam properly, and Ian Stiell on how to use Canadian CT head rules properly...
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