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EM@3AM: Inflammatory Bowel Disease - emDocs
A 24-year-old male with no past medical history presents with several days of oral ulcers and throat pain. He also notes multiple months of diarrhea and hematochezia. He has lost roughly 30 lbs over the preceding 6 months. He has normal vital signs but appears malnourished, with a weight of 48 kg. He has dry oral mucous membranes, abdomen is diffusely tender, and he has ulcers on the uvula and soft palate. Labs reveal anemia, leukocytosis, electrolyte abnormalities, and elevated inflammatory markers. What is the diagnosis?
EM@3AM: Systematic Approach to Massive Hemorrhage and Nuances in Special Patient Populations - emDocs
A 32-year-old female presents with chief complaint of “abdominal pain”. Her pain started 8 hours ago and became severe within the last 30 minutes. Initial vitals demonstrate a blood pressure of 88/48 mm Hg, HR 122 bpm, Temp 36.4 C, and 20 respirations/min. On your physical exam she has tenderness to palpation in the left lower pelvic region with rebound tenderness. You note her hypotension and perform RUSH exam. During your exam you note free fluid in the rectouterine pouch. As you finish your exam, she is now pale, clammy, and minimally responsive to pain with repeat blood pressure 64/33 mm Hg. What is the systematic approach to a patient with signs of massive hemorrhage?
The Pediatric EMS Podcast: Prehospital Pediatric Traumatic Cardiac Arrest - Priorities for Care - emDocs
On this episode of the Pediatric EMS Podcast focuses on the case of a pediatric out-of-hospital traumatic cardiac arrest. Dr. Finney and Dr. Romeo Ignacio discuss the unique management priorities for traumatic arrest and how it differs compared to medical cardiac arrest.
emDOCs Podcast - Episode 118: Lisfranc Injury - emDocs
Today on the emDOCs cast with Brit Long (@long_brit), we cover the Lisfranc injury. emDOCs.net Emergency Medicine (EM) Podcast Episode 118: Lisfranc Injury Share on Facebook Share on Twitter Share on LinkedIn Subscribe with Apple Podcasts Subscribe with RSS Download this episode April 14, 2025 emDOCs.net EM Crew Episode 118: Lisfranc Injury What is it? The Lisfranc joint complex is a tarso-metatarsal articulation named for Jacques Lisfranc (1790-1847), one of Napoleon’s battlefield surgeons. A Lisfranc injury is any injury/disruption to this joint complex. Exist along a spectrum: minor subluxation to fracture and dislocation. Account for approximately 0.2% of all fractures with an annual incidence of 1 per 55,000 persons. A study published in 2020 found an incidence of 14 per 100,000 person-years; the incidence of unstable injuries was 6 per 100,000 person-years. Most common in male patients in their 20s. Easy to miss: uncommon, x-ray findings often subtle or absent; 20-50% of cases are misdiagnosed during the initial evaluation. Delay in diagnosis and treatment of Lisfranc injuries can cause post-traumatic pain and arthritis -> decrease in quality of life. What is the tarsometarsal joint complex? TMT joint complex involves the articulation of the three cuneiform bones and cuboid bone with the bases of the five metatarsals along with ligaments. These join the midfoot and forefoot. The bases of the first, second, and third metatarsals and cuneiform bones form a transverse arch. The second metatarsal is the key part of that arch. The Lisfranc ligament connects the medial cuneiform and the second metatarsal. This anchors the entire complex and prevents displacement. It consists of the dorsal, interosseous, and plantar ligaments and Strongest = interosseous ligament; weakest = dorsal ligament. Injury usually associated with dorsal displacement of the metatarsal bases because the dorsal ligament is weakest. No ligament connects the 1st and 2nd metatarsals – greater susceptibility to injury. Injuries range from sprain to fracture-dislocation; divided into low energy and high energy. History: Consider Lisfranc injury in any patient presenting with midfoot pain after an injury (low or high energy). Low-energy mechanisms are more common and occur when a rotational or axial force is transmitted to a stationary plantarflexed foot. Most common mechanism is plantar flexion and external rotation of the ankle. Classic description is a person riding a horse and falls with their foot caught in the stirrup or windsurfing because the forefoot is held in a fixed position as the rest of the body is falling or rotating Other sports-related injuries (football, gymnastics), falls, or missteps (stepping off a curb or down into a hole, missing a step, stepping on a heel of another person when plantar flexed). In kids it’s known as a “bunk bed fracture” where a child jumps and then land on their toes. High-energy mechanisms: motor vehicle or motorcycle accidents, industrial accidents, crush injuries. Consideration: Patients with neuropathy may not remember the exact onset or mechanism. Exam: Classic presentation is midfoot pain, swelling, medial plantar ecchymoses, inability to bear weight. Subtle injuries: patients may only have pain with activity or movement of the foot. Suggestive findings: Pain with palpation of the midfoot and compression across the TMT joint complex; plantar ecchymosis. Other exam maneuvers: “Piano key test” can isolate the area injured; hold the midfoot form and move each head of each metatarsal. Pronation-abduction test (stress test): use one hand to abduct and pronate the forefoot while using the other hand to stabilize the heel. Can also stress the Lisfranc complex by having the patient plantar flex the foot while adducting the first digit. Single limb heel raise: patient stands on the affected leg and then on tiptoes. Pain along midfoot with these tests -> suggestive of Lisfranc injury. Neurovascular exam necessary; Lisfranc injury can cause neurovascular compromise from DP artery transection or compartment syndrome. Assess dorsalis pedis pulse, capillary refill, and deep peroneal nerve (sensation in the first dorsal webspace and extension of the first digit). Consider compartment syndrome in patients presenting after a high-energy trauma, pain out of proportion, NV changes, paresthesias, requiring multiple doses of analgesics without relief. Pallor, temperature changes, pulselessness, paralysis are later findings in compartment syndrome. Imaging: 1st line imaging: X-ray of the foot with AP, lateral, 30-degree oblique views. Big picture: look for bony widening, misalignment and fracture or avulsion. X-ray findings: Widening: > 2 mm widening between the bases of the first and second (most common finding on x-ray) or the second and third metatarsals on AP or oblique x-rays. Misalignment: AP x-ray: Misalignment of the medial edge of the second metatarsal base with the medial edge of the middle cuneiform. Oblique x-ray: Misalignment of the third metatarsal base with the lateral cuneiform and fourth metatarsal base with the cuboid. Lateral x-ray: Misalignment of the dorsal and plantar borders of the metatarsals with the articulating cuboid and cuneiforms; dorsal displacement of the proximal 1st or 2nd metatarsal base. Fracture/avulsion: “Fleck sign” – small bony avulsion fragment from the second metatarsal or medial cuneiform; pathognomonic fracture of the base of the first, second, or third metatarsals. X-ray sensitivity over 80%, specificity over 90%. 20-24% of Lisfranc injuries are missed on plain x-ray, mainly because it could be a sprain and not a fracture, or we are not looking for the injury. Three ways to improve diagnostic accuracy: 1) Compare radiographs of the affected and unaffected foot (look for asymmetric widening > 1-2 mm between the medial cuneiform and the base of the second metatarsal and/or between the bases of first and second metatarsals. 2) Obtain weight bearing films and compare (of note, weight bearing is painful, and patients may require PO/IV analgesia, local anesthetic, or an ankle nerve block prior to obtaining these views). A 2023 case report discusses injecting 10 mL of 1% lidocaine into the second and third tarsometatarsal joint spaces for analgesia. Ankle nerve block involves blocking the five peripheral nerves that innervate the foot and ankle but can be challenging to perform in the ED setting. 3) Obtain other imaging:
EM@3AM: Pediatric Aural Foreign Bodies - emDocs
A 6-year-old boy with past medical history of ADHD is brought in by his parents with left sided ear pain and irritability for 12 hours. He was at his normal state of health prior to this and has been afebrile. Parents deny any history of frequent ear infections or tympanostomy tubes, and he is up to date on his vaccinations. Otoscopic exam shows a smooth round green object in the right auditory canal. The tympanic membrane is not visualized.
US Probe: Suprapatellar Recess Injection for Chronic Knee Pain in the Emergency Department - An Effective Approach for Relief - emDocs
For chronic knee pain in the emergency department, ultrasound-guided suprapatellar knee injections provide an effective, minimally-invasive treatment option. By leveraging real-time imaging, emergency physicians can accurately deliver medications like corticosteroids or anesthetics to provide significant pain relief and improve function. Whether treating osteoarthritis, meniscal tears, or inflammatory arthritis, this technique is a valuable tool in managing chronic knee pain in the ED setting.
Image Test Post - emDocs
Introduction Mumps is a contagious viral infection characterized by the swelling of the parotid glands, located near the ears. This infection can lead to complications such as meningitis, encephalitis, and orchitis. Vaccination is the most effective way to prevent mumps and its associated complications. The Mumps Virus Mumps is caused by the mumps virus, which is transmitted through respiratory droplets. Symptoms typically appear 16-18 days after exposure and include fever, headache, muscle aches, tiredness, and loss of appetite, followed by the characteristic swelling of the parotid glands1. Image – Add Media button – large size Classic Editor Vaccination: The MMR Vaccine The MMR vaccine, which protects against measles, mumps, and rubella, is the primary method of preventing mumps. The vaccine is administered in two doses, with the first dose given at 12-15 months of age and the second dose at 4-6 years2. The MMR vaccine is highly effective, with studies showing that two doses are about 88% effective at preventing mumps3. Image medium size and scaled larger Classic Editor Vaccine Efficacy and Outbreaks Despite the high efficacy of the MMR vaccine, outbreaks can still occur, particularly in settings with close contact, such as schools and colleges. Factors contributing to outbreaks include waning immunity over time and the intensity of exposure. In recent years, there have been reports of mumps outbreaks among vaccinated individuals, prompting discussions about the potential need for a third dose of the MMR vaccine. Medium image posted in Elementor medium size – scaled up using the text editor Public Health Measures In addition to vaccination, public health measures are crucial in controlling mumps outbreaks. These measures include isolating infected individuals, timely contact tracing, and effective communication and education for the public and healthcare providers. Maintaining high vaccination coverage is essential to reduce the incidence of mumps and prevent complications. Medium image posted in Elementor text editor – edited in editor and size reset to large. Conclusion Mumps is a preventable disease, and vaccination remains the cornerstone of prevention. The MMR vaccine has proven to be highly effective, but ongoing vigilance and public health measures are necessary to manage outbreaks and protect public health. Ensuring compliance with vaccination recommendations and considering additional doses in outbreak situations can help mitigate the risk of future mumps outbreaks.
EM@3AM: Pediatric Osteomyelitis - emDocs
A 2-year-old female with a past medical history of failure to thrive presents for evaluation of right arm pain. The mother states that the patient was recently started on mupirocin for a spot on her right forearm the day prior. Since then, the mother states she has noticed a “hard spot” on the patient’s right clavicle. Mother denies any recent trauma or falls and also reports a temperature at home of 37.8° C. Per chart review, the patient was recently discharged a week prior after a 6-day admission for failure to thrive. Vital signs include temperature 37.0° C, HR 136 bpm, RR 32 breaths/minute, and blood pressure of 99/57 mmHg. The head is atraumatic and normocephalic. Auscultation of the heart reveals a regular rate and rhythm, and lungs are clear to auscultation bilaterally. Physical exam is notable for guarding of the right upper extremity with induration overlying the proximal right clavicle with minimal surrounding erythema. There are no step-offs or bruising throughout the bilateral upper extremities. The patient has 2+ bilateral radial pulses. There is decreased active range of motion of the right shoulder which appears to be secondary to pain. She has full range of motion of all other joints.