Emergency Medicine Jeopardy Dr Kelly Kasteel Whats in

Emergency Medicine Jeopardy Dr. Kelly Kasteel

What’s in Hodgea Name Podge Handy Tips Rashes Bones $100 $100 $200 $200 $300 $300 $400 $400 $500 $500 Finish

Rashes Bones What’s in a Name $100 $100 $200 $200 $300 $300 $400 $400 $500 $500 Hodge. Podge Handy Tips

Rashes $100 • A 24 year old male presents with an itchy rash to his arms

Rashes $100 • Questions?

Rashes $100 • Allergic contact dermatitis • Toxicodendron species (poison ivy)

Poison Ivy • Susceptible individuals • Type IV allergic reaction • Urushiol containing compounds (also mango skin, unroasted cashew nutshells)

Poison Ivy • Treatment? – Decontamination – Symptomatic – Steroids?

Rashes $200 • A 34 year old female presents with lesions to her legs

Rashes $200 • Questions?

Rashes $200 • Erythema nodosum • Painful nodules most commonly to shins • Prodromal “flu-like” symptoms +/arthralgias

Causes of Erythema Nodosum? • Infectious – – Strep Staph TB Fungal (coccidiomycosis) • Drugs – OCP – Sulfonamides • • • Pregnancy Hodgkin’s, NHL Sarcoid IBD Behcet’s

Treatment? • • Symptomatic NSAIDS Colchicine Potassium iodide (mechanism unknown) • Underlying cause

Rashes $300 • What can cause the following skin changes?

Rashes $300

Rashes $300 • • Nikolsky’s sign Causes? Erythema multiforme major (SJS) Staph scalded skin syndrome (SSSS) Toxic Epidermal Necrolysis (TEN) Toxic Shock Syndrome Bullous pemphigus Burns

Rashes $300 • • Treatment? Burn unit Fluid resuscitation Infection potential

Rash $400 • A 28 year old male presents with a nonpruritic rash to his torso that over time spreads to his extremities:

Rash $400 • Questions?

Kaposi’s Sarcoma • • Cause: HHV-8 Initial presentation: cutaneous Tumour cells --> spindle cells Can spread to mucous membranes, internal organs • AIDS defining illness

Rashes $500 • A 48 year old gentleman presents with a painful red face

Rashes $500 • Questions?

How to differentiate cellulitis from erysipelas? • Cellulitis • More indiscreet margins • Erysipelas • Sharply demarcated borders • Fiery red, indurated • Lymphatic involvement • “St. Anthony’s Fire”

Cause of erysipelas? • Group A Strep

Bones $100 • A 17 year old female involved in an MVC complains of neck pain

Bones $100

Bones $100 • Clay shoveler’s fracture • Mechanism? – Forced hyperflexion • Stable or unstable? – Stable • Treatment? – Symptomatic

Bones $200 • Two patients injured their thumbs:

Patient 1

Patient 2

Thumb fractures • Rolando: • Bennett: • Comminuted fracture • Intrarticular fracture / dislocation base of 1 st MCP • Most common of all • Usually three main thumb fractures fragments: “Y” shaped • Less common; poorer prognosis

Bones $300 • A 40 year old female tripped and fell when she stepped into a gopher hole while running and now has pain to her foot:

Bones $300

Bones $300 • Lisfranc injury • Normal alignment: • PA view: – Medial edge of 2 nd metarsal should align with 2 nd cuneiform • Oblique view: – Medial edge of 3 rd metatarsal should align with 3 rd cuneiform

Bones $400 • A 12 year old boy injured his leg after sliding into base during a ball game:

Bones $400

Bones $400 • Tillaux fracture • Salter-Harris Type III; adolescents • Mechanism: • External rotation injury of the foot in a • Anterior tibiofibular ligament intact: avulsion of epiphysis

Bones $500 • A 25 year old female fell onto her knee:

Bones $500

Bones $500

Bones $500 • Patellar fracture • Treatment?

Patellar Fracture • Non-surgical – – Undisplaced Vertical Peripheral No step-off • Surgical – Displaced – Horizontal

What’s in a Name $100 • Hearing Loss • Tinnitus • Vertigo

What’s in a Name $100 • Meniere’s disease

Meniere • Prosper Meniere (1799 -1862) • French otologist

What’s in a Name $200 • Bobbing of head in time with arterial pulse, seen in aortic insufficiency

What’s in a Name $200 • Musset’s sign

Musset • Described by author Paul de Musset • His brother Alfred suffered from “aorta failure” -->Musset noted that when he put his finger on his brother’s carotid his head stopped bobbing

Bonus Question $200 • Capillary pulsation of nailbed seen in aortic insufficiency • Quincke’s capillary pulse

What’s in a Name $300 • Fever, RUQ pain, jaundice

What’s in a Name $300 • Charcot’s triad • Ascending cholangitis • Combined with CNS changes and hypotension --> Reynaud’s pentad

Charcot’s Triad • Jean Martin Charcot, french neurologist (1825 -1893)

Bonus Question $300 • Charcot is credited with two separate “triads” of clinical signs relating to two different diseases • Charcot triad II = ascending cholangitis • What is Charcot Triad I ?

Charcot Triad I • Nystagmus, intention tremor, staccato speech • Suggestive of multiple sclerosis

What’s in a Name $400 • Clenched fist by patient to describe chest pain

What’s in a Name $400 • Levine’s sign

Levine • Dr. Sam Levine • Pioneering American cardiologist • Served in WWI at British Military Heart Hospital with William Osler

Bonus Question $400 • Name another cardiac related syndrome which Levine is associated with • Lown-Ganong-Levine • Class of pre-excitation syndromes associated with a short PR

What’s in a Name $500 • Dullness to percussion over scapula caused by pericardial effusion

What’s in a Name $500 • Ewart’s sign

Ewart • William Ewart (1849 -1929) • English physician trained in England France • Worked in a field hospital during Franco -Prussian War

Hodgepodge $100 • A child steps on a nail in sneakered feet • Concerns?

Hodgepodge $100 • Sneakers = pseudomonas

Hodgepodge $100 • Pitfalls: – Exploration of wound – Prophylactic antibiotics

Hodgepodge $200 • A 23 year old female complains of pleuritic chest pain

Hodgepodge $200

Hodgepodge $200 • Hampton’s hump LLL • Pulmonary infarct --> pulmonary embolism • Usually wedge shaped in lung peripherally

Hodgepodge $300 • Give a differential diagnosis for a DECREASED anion gap

Hodgepodge $300 • • • Hyponatremia Low serum albumin Ocult neoplasm --> multiple myeloma Hyperchloremic acidosis Lithium toxicity (sodium effect) Kidney disease (unmeasured cations)

Hodgepodge $400 • What’s wrong with the following X-ray?

Hodgepodge $400 • Gastric bubble deviated medially • Enlarged spleen (in trauma, splenic hematoma)

Hodgepodge $500 • A gentleman presents with the following: • Questions? • Differential Diagnosis?

Genital Ulcers • • • Chancroid Herpes Syphilis Behcet’s Other: – – Lymphogranuloma venereum (LGV) Granuloma inguinale (GI) Drug eruption Systemic/dermatologic

Chancroid • Pathogen: – Hemophilus ducreyi • Treatment: – Azithromycin, ceftriaxone, ciprofloxacin

Handy Tips $100 • A 22 year old male complains of a very sore throat for the last three days

Peritonsillar Abscess • Tips for draining?

Handy Tips $200 • While minding his own business, this patient broke a tooth which is now very painful:

Fractured Tooth • Ellis I: enamel • Ellis II: dentin • Ellis III: pulp

Treatment • • Dentist Analgesia Antibiotics Protective barrier: Chewing gum?

Handy Tips $300 • How would you repair this laceration?

Skin Glue • • Advantages glue vs sutures Contraindications How not to get stuck to the patient How not to glue the kid’s eye shut

Handy tips $400 • A RN accidentally injected herself with epinephrine in her thumb • The thumb is cool and pale • How would you treat it?

Phentolamine • Alpha antagonist • Management of adrenaline induced digital ischemia in children after accidental injection from an Epipen Emerg Med J 2004; 21: 387 -388

How to use phentolamine • Dilute 1. 5 mg of phentolamine mesilate (vials contain 10 mg/cc) = 0. 15 cc in 1 cc of 2% lidocaine • Inject subcutaneously into the site and stop when skin becomes pink

Handy tips $500 • A 50 year old man has very painful burning sensation to hands after working with a rust remover:

Hydrofluoric Acid Burns • Treatment? • Calcium Gluconate • How to administer? • 1 amp= 10% Ca gluconate= 10 cc • Reference: E-medicine

Calcium Gluconate • Gel: Mix one amp with one ounce of surgical gel (10 packets of muco) • Nebules: Mix one amp with 30 cc NS to form a 2. 5% solution • IV Calcium: one amp + 5000 units heparin diluted in 40 cc D 5 W; use a Bier block • Intra-arterial calcium: Mix one amp with 40 cc D 5 W; infuse over a 4 hour period

Questions?

Online Resources • • ECGs: medstat. med. utah. edu/kw/ecg/image_index X-rays: www. rad. washington. edu/teachingfiles. html Eye cases: icarus. med. utoronto. ca Trauma pics: trauma. org/imagebank Derm pics: dermis. net Medical pictures: www. mic. ki. se/MEDIMAGES. html Eponyms: www. whonamedit. com Online teaching: www. mdchoice. com