EM Reflections – September 2015

Thanks to Joanna Middleton for her M&Ms presentation today.

Here are the ‘top tips’ from today’s M and M Rounds.

1)  Review of plain film C-spine x-rays.  Low threshold for CT if any finding noted on x-ray (ex – straightening of cervical lordosis). Here is a great online course for C-Spine X-Ray Evaluation.

2)  Epiglottitis in adults – pretty rare!  Think of it in patients who are complaining of severe pain with swallowing, hoarse voice, and pain to palpation over the hyoid area.  Lateral x-ray may show a “thumb print” sign (epiglottis of >8mm in adults).  Airway compromise is less frequent in adults, but these patients still need aggressive monitoring in an ICU setting.  Unlike children, the causative organism does not tend to be Hib.  See this article in the NEJM


3)  Isolated, severe neutropenia (ANC of 0) in a non-immunosuppressed patient is often medication-induced and there is a long list of drugs that can do it.  Treat the patient the same as a chemotherapy-induced neutropenic patient.  G-CSF is often very helpful.  A reminder that if the differential count for a CBC is delayed in i3, it usually means there is a abnormality and that they are running the test manually.  Consider calling the lab or holding the patient until all the results are back.

4)  Confusion in psychiatric patients…always consider organic causes and have a low threshold for CT if there is any history of trauma.  Great article in BMJ Best practice

5)  Discussion was had regarding senior residents in the department – how to allow resident autonomy without compromising patient safety.

6)  Appendicitis is the great mimicker and patients can present with RUQ pain.

7)  Head injury + warfarin/novel anti-coagulants – need to have a very good reason NOT to do a CT…      See the SJRHEM Minor Head Injury Guideline here

Thanks for all those that attended, please keep sending myself or Natasha any PPRN’s you may have (with a brief explanation note).  

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