Ur g e n t C a r e RAP Ma r ch 2017 W r itte n S u mma r y · Look for a hemothorax or pericardial effusion ... Ph o n e ca lls h e lp e n su r e th a t th e p a tie n t is a dh e

Urgent Care RAP March 2017 Written Summary Editor-in-Chief: Mike Weinstock MD Executive Editor: Mizuho Spangler, DO Associate Editor: Megan Johnson, MD Clavicle Fractures Mizuho Spangler DO & Mike Weinstock MD

Pearls: ❏ The most concerning thing about a clavicle fracture is the risk of damage to important

underlying structures. ❏ The more proximal the fracture, the more risk there is to underlying structures. ❏ Most clavicle fractures heal well with conservative treatment (a sling), but there are

some patients who should be referred to Orthopedics CASE: A 22 yo man presents to the Urgent Care with his parents with a distal clavicle fracture after a fall while playing basketball. The case was straightforward and Mike planned to discharge him in a sling to follow up with his primary care doctor. Then the patient and his parents started asking questions. Not all of which he knew the answer to. So he did some research and shared it with us.

● Clavicle fractures are classi�ed by location. ○ Group 1: Middle clavicle - the most common location of clavicle fracture ○ Group 2: Distal clavicle ○ Group 3: Proximal clavicle - an uncommon fracture

● The most concerning thing about a clavicle fracture is the possibility of damage to underlying structures.

○ Pneumothorax

Urgent Care Care RAP March 2017 Written Summary | hippoed.com/uc

http://www.hippoed.com/urgentcare/rap/



○ Vascular injury - remember that the subclavian vessels run underneath the clavicles (the more proximal the fracture, the more likely there is to be a vascular injury). Look for a hemothorax or pericardial effusion/tamponade

○ Nervous injury - including the brachial plexus. ● Physical exam: Look for and document

○ Skin tenting ○ Ecchymosis ○ Crepitus ○ Pulses and perfusion ○ Neuro exam including brachial plexus palsies ○ Shoulder ROM for dislocation or fracture

● Imaging: ○ XR clavicle ○ CXR ○ XR shoulder, if indicated

● Treatment: ○ Arm sling - even for signi�cantly displaced fractures

■ Figure-of-eight slings were previously recommended. Now we know that there are no higher rates of healing, but there is a higher rate of patient dissatisfaction. The �gure-of-eight retracts the clavicle and allows the bones to rub against each other.

○ Surgery - there is a higher rate of nonunion without surgery, however most physicians agree that initial management should be conservative. Operative repair can be done later if there is poor union and there are risks to operative repair.

■ There are higher rates of nonunion in patients of advanced age, females, displaced fractures or comminuted fractures.

■ Indications for referral to ED: ● Open fractures ● Concern for other injuries including pneumothorax ● Unstable vital signs ● Proximal clavicle fracture indicates a signi�cant mechanism and

these patients may require advanced imaging to evaluate for additional injuries

■ Indications for referral to Ortho: ● High performing athlete - even if the care remains nonoperative,

these patients need close monitoring for healing and guidance about when and how to return to sports

■ One study found that over 90% of non-displaced fractures heal well without surgery and about 85% of displaced fractures heal well without surgery

Urgent Care RAP March 2017 Written Summary | hippoed.com/uc 2


The Art of Callbacks Mizuho Spangler DO, Mike Weinstock MD and Alan Sielaff MD

Pearls: ❏ Patients are looking for clinicians who care more than just writing a prescription and

sending them out the door. A follow up phone call can go a long way to make sure the patients know the physician cares about them.

❏ Phone calls help ensure that the patient is adhering to the treatment plan. ❏ Physicians learn from the feedback about how their patients do on their treatment plan.

● We are not just about providing standard of care, but really want to provide excellence of

care. Callbacks are one way to provide excellent care and an excellent patient experience. ● Urgent Care medicine is not a �eld in which we experience much continuity of care.

Callbacks give us an opportunity to make sure patients are getting the follow up care they need, are responding to the therapy we prescribed and are overall doing well. These calls also give the provider the opportunity to get some feedback about their diagnosis and care plan and an opportunity to intervene if the patient is not doing well.

Alan’s Approach: The 4 Ws:

● Why do you call? ○ Patients love it ○ It is an opportunity to further educate the patient ○ Feedback for the provider about their diagnosis and care plan ○ An opportunity to intervene if the patient is not doing well, you can bring them

back in or recommend that they go to the Emergency Department ○ Generates job satisfaction

● Who do you call? ○ Not everyone ○ Higher risk patients, or those with some diagnostic uncertainty ○ Patients you considered transferring and then decided not to ○ Anyone who may have had a bad encounter (long wait, expectations not met, felt

mistreated by a staff member) ○ Pediatric patients ○ Alan usually calls 5-10 patients from the previous shift

● When do you call? ○ Alan gets to his shifts 15-20 minutes early. He uses this time to sign charts, �nish

his coffee and make a few calls. Each call typically only lasts a few minutes. ○ If he leaves a message, he either gives the patient the direct line to his desk to call

back. If he doesn’t have one, he tells the clerk that the patient may call back and he would like to speak to them.



■ Some places are able to temporarily forward calls to the physician’s cell phone.

○ If Alan identi�es a patient during the encounter that he intends to call, he tells them that and gives them a time frame.

● HoW do you call patients effectively? ○ Discuss the plan and ask if they’ve been able to follow it (i.e. �ll a script, arrange

follow up, etc) ○ Documents the call in the EHR, including if the patient is doing better, and if not,

what the new plan is. Guss DA, et al. The impact of patient telephone call after discharge on likelihood to recommend in an academic emergency department. J Emerg Med. 2014 Apr;46(4):560-6. [PMID: 24484625 ]

● Concluded that patients who receive callbacks are much more likely to have a favorable impression of the overall visit.

● The callbacks in this study were not even made by the physicians.

UTIs Mizuho Spangler DO, Mike Weinstock MD & Bryan Hayes PharmD

Pearls: ❏ Cipro�oxacin used to be the mainstay of treatment for simple, uncomplicated UTIs, but

now it has a black box warning. ❏ Nitrofurantoin has become the �rst-line treatment recommendation. ❏ Cephalosporins can be used for uncomplicated UTIs, but they require a longer duration

of therapy. ❏ It was previously recommended that Nitrofurantoin not be used in the elderly, but newer

studies demonstrate it is likely safe in all patients with creatinine clearance above 40.

● Recommendations for the treatment of uncomplicated urinary tract infections (UTIs) are frequently changing as resistance patterns change and we learn more about the frequency of side effects of the different therapies.

● What is an uncomplicated UTI? ○ Dysuria, urgency and/or frequency (aka cystitis) in a woman without signi�cant

comorbid medical conditions. No fever, hypotension, nausea/vomiting or back pain indicative of pyelonephritis.

● What are the most common organisms? ○ The most common bacteria causing UTI is E. coli, but can also see proteus,

klebsiella and other gram negative organisms. ○ In healthy patients, these bugs are generally sensitive to our �rst-line therapies.


https://www.ncbi.nlm.nih.gov/pubmed/24484625


● Treatment guidelines. The most recent guidelines for the treatment of uncomplicated UTIs came out in 2011.

○ First line: ■ Nitrofurantoin (Macrobid) 100mg PO BID x 5 days, or ■ Trimethoprim-sulfamethoxazole DS PO BID x 3 days (only if your local

resistance is < 20%), or ■ Fosfomycin 3 g PO x 1 (covers E. coli and VRE (vancomycin resistant

enterococcus), but is rather expensive at $35/dose) ○ Second-line:

■ Fluoroquinolones x 3 days (these are now second line due to drug interactions and the FDA’s black box warning), or

■ Beta-lactams including cephalosporins can be used, but require a longer duration of therapy, typically 7 days.

● Cephalexin (Ke�ex) is problematic because it is typically dosed 4 times a day. You can use 1g cephalexin PO BID to increase compliance.

● 2nd and 3rd generation cephalosporins have better action against e. Coli.

○ Cefuroxime is a 2nd generation and can only be dosed IM or IV

○ Cefpodoxime 100mg PO BID x 5-7 days is a 3rd generation cephalosporin given orally that has the same coverage as ceftriaxone (Rocephin). This makes it a nice drug to transition to if you have already given a dose of ceftriaxone IV in the Urgent Care and now want a similar PO medication for the patient to continue at home.

■ The problem is that not all pharmacies carry cefpodoxime and, although it is generic, not all insurances cover it.

● Who requires a different treatment regimen?

○ Patients with a history of resistant infections need therapies tailored to their histories.

○ Complicated UTIs and pyelonephritis require longer duration of therapies with medications that will penetrate the kidneys (nitrofurantoin will not).

● When to send a urine culture? ○ Patients with uncomplicated cystitis do not need to have cultures sent. ○ Cultures are important when the patient presents with

■ Treatment failure ■ Immunosuppression with diabetes, AIDS, chronic steroids ■ Indwelling foley catheters or nephrostomy tubes



■ History of recurrent or resistant infections ● Is nitrofurantoin safe to use in elderly women?

○ The Beers Criteria is a list of medications that should be used in extreme caution in the elderly. Nitrofurantoin is on this list. Why?

○ Prior to the 2015 Beers Criteria, the use of nitrofurantoin in the elderly was recommended against. The 2015 version is the �rst one to say that you can use it in the elderly, but you need to use caution.

○ When the drug was originally approved in 1988, the package insert recommended that nitrofurantoin not be used in patients with creatinine clearance < 40 from pre-existing or new renal dysfunction.

○ In 2003, the creatinine clearance recommendation was changed from 40 to 60. Many elderly people have normal creatinine levels, but borderline creatinine clearance around 60.

○ If nitrofurantoin is in the body at supratherapeutic levels because it is not being cleared appropriately by the kidneys, there is a risk of pulmonary toxicity, hepatotoxicity and hemolytic anemia.

○ Bains A, et al. A retrospective review assessing the ef�cacy and safety of nitrofurantoin in renal impairment . Can Pharm J 2009; 142 :248–52. [ Free open access link ]

■ A retrospective chart review looking at ef�cacy and safety in over 400 patients with renal impairment.

■ Found that the cure rates for UTIs and adverse events were similar in those with and without renal impairment.

■ This study is likely why the Beers Criteria now allows nitrofurantoin to be used in the elderly.

○ Geerts AF, et al. Ineffectiveness and adverse events of nitrofurantoin in women with urinary tract infection and renal impairment in primary care. Eur J Clin Pharmacol. 2013 Sep;69(9):1701-7. [PMID: 23660771 ]

■ 21,000 women who used nitrofurantoin were studied. ■ Looked at patients with moderate renal impairment with creatinine

clearance of 30-50. ■ Did not �nd any association in 21,000 of this level of renal impairment

with adverse pulmonary events leading to hospitalization. ○ Based on these studies, if you have an elderly patient with a creatinine clearance

of 40 or above, it is safe to use nitrofurantoin for 5 days to treat an uncomplicated UTI.


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4467927/



What Should I Do Next? | Left Upper Quadrant Pain Mike Weinstock MD, Jessica Brown PA & Nate Finnerty MD

Pearls: ❏ We can make the diagnosis of mononucleosis clinically ❏ We need to give patients instructions to prevent traumatic splenic rupture and return

precautions for the rare case that develops a spontaneous splenic rupture ❏ Remember Kehr’s sign: left shoulder pain indicative of a splenic rupture

CASE: A 27 yo man presents to the Urgent Care with left upper abdominal pain, on and off for the last 3 days that radiates to the left shoulder. He has no other complaints including no fever, or nausea/vomiting. His abdomen is soft with minimal tenderness to palpation. On repeat abdominal exam his left upper quadrant becomes somewhat more tender. What do we do next with left upper quadrant pain? Differential Diagnosis:

● This is a young patient, so it is not likely mesenteric ischemia, AAA or MI ● This is a male, so it is not ovarian torsion, TOA or PID ● A review of anatomy gets you on the right track to diagnose this patient:

○ Stomach: gastritis or peptic ulcer disease ○ Spleen: injury or pathology ○ Colon: the transition between the transverse colon and the descending colon, the

splenic �exure, is a watershed area and at risk for ischemia in the right patient ○ Tail of the pancreas: pancreatitis

● Zoster ● DKA ● Black widow spider bites contain a neuro toxin that causes myalgias and abdominal pain

CASE CONTINUES: CT AP showed a splenic hemorrhage with hematoma. On further history, the patient reports a bad cold 2 weeks ago, that has since resolved. The patient tests positive for mononucleosis. Final diagnosis: atraumatic splenic rupture from mononucleosis

● In retrospect, the left shoulder pain is a key historical �nding that would lead you right to the diagnosis. Kehr’s sign is left shoulder pain referred from a splenic hemorrhage.



● Remember the value of time and re-examination. It was on Jess’s second abdominal exam, where she noticed the pain had worsened, that lead her to order the CT that made the diagnosis. Give the disease time to manifest itself. Sometimes the opposite happens. The pain improves and allows you to roll back your work up and often avoid a transfer to the emergency department.

INFECTIOUS MONONUCLEOSIS

● Infectious mononucleosis is a clinical syndrome associated the the Epstein-Barr Virus. 95% of adults are infected with EBV.

● EBV is commonly diagnosed in the acute phase of the illness, between the ages of 5-25 years old. Highest peak is between 16-20 years old.

● Classic presentation: ○ Fever ○ Sore throat ○ Adenopathy ○ Malaise/fatigue

● How can we differentiate a viral pharyngitis from the more serious mononucleosis? There are some signs that are more associated with mono than other illnesses:

○ Palatal petechiae ○ Posterior cervical lymphadenopathy ○ ANY lymphadenopathy other than the anterior cervical chain

■ Signi�cant lymphadenopathy is also associated with: ● Acute anti-retroviral syndrome ● Malignancy

○ Splenomegaly - present in 25-50% of mono patients ○ Signi�cant fatigue ○ Prolonged duration of symptoms

● Diagnosis: ○ The diagnosis is a clinical diagnosis. The CDC states that EBV antibody tests are

not usually needed to diagnose infectious mononucleosis. This is partly because we test for the heterophile antibody, which is not present in the acute phase of the illness. The false negative rate in the �rst week is between 20-30%. This number improves as the disease progresses.

○ For most patients, a con�rmed diagnosis is not critical, because we have no effective therapies.

○ The exception is very active, very competitive athletes. These patients face signi�cant consequences when we recommend no activity given the risk of splenic rupture.

■ For these patients, consider sending a viral capsule antigen. This test is not typically readily available, but is more speci�c.


https://www.cdc.gov/epstein-barr/laboratory-testing.html


■ You can also send a peripheral blood smear. The presence of atypical lymphocytes (>10%) or a lymphocyte predominance (50%) has a better correlation with mononucleosis than the heterophile antibody test in the acute phase of illness. If the atypical lymphocytes are > 40%, the LR of mononucleosis is 50. This is very high.

● Splenic rupture: ○ Atraumatic rupture is very rare: 5 in 8,000 patients in 1 study. However, give

patients with mono return precautions for the development of left upper quadrant pain.

Traumatic rupture is most common in the �rst 2-4 weeks of the illness. There are no published guidelines, but most recommendations suggest 4 weeks of abstinence from contact sports from the time of symptom onset.

Preeclampsia Mizuho Spangler DO & Sam Ashoo MD

Pearls: ❏ Remember that preeclampsia can occur up to 6 weeks postpartum ❏ Risk factors include many conditions our patients have: hypertension, diabetes and

obesity. ❏ Know when to consider the disease and look for the secondary criteria. The spectrum is

vast and asymptomatic or mildly symptomatic patients can rapidly decompensate CASE: Sam’s wife gave birth to their 3rd child and mom and baby are discharged home seemingly well. 6 days postpartum, mom begins to experience epigastric pain. They initially attribute it to gastritis from NSAIDs, but the pain becomes increasingly worse and they go to a free-standing ED near their home. The patient’s blood pressure in triage is 185/110. They initially attribute it to pain, but her blood pressure remains high despite pain control. She has no headache or blurry vision. She receives a dose of hydralazine and while waiting for her labs to come back, she turns to Sam and asks why the lights are �ashing (they are not) and then develops a severe headache. The labs come back with mildly elevated transaminases. The ED physician speaks with the on call OB-Gyn and they decide to transfer the patient to the Labor & Delivery �oor for BP control and continued monitoring. Over the next few hours the patient’s headache becomes increasingly severe and she is rocking back and forth in pain despite multiple doses of IV dilaudid. She is started on a magnesium drip.



Her headache persists for 24 hours and she undergoes CT angiography of the head which is negative. Over the next several days, the patient’s headache and blood pressure gradually resolve and she goes back to her normal, healthy life. PREECLAMPSIA EPIDEMIOLOGY

● Occurs after 20 weeks gestation and up to 6 weeks postpartum (very rare exception: a molar pregnancy can cause preeclampsia earlier than 20 weeks)

● Affects 3-4% of pregnancies in the U.S. and 4-5% of pregnancies worldwide ● There is 1 death in every 100,000 births in the U.S. from eclampsia and there are 6.5

deaths in every 10,000 cases of preeclampsia ● Preeclampsia is 1 of the 4 major causes of obstetric death in the U.S. (other 3 are

hemorrhage, cardiovascular conditions like cardiomyopathies and thromboembolism) RISK FACTORS

● Prior history of preeclampsia (7x more likely to have it again, and it is more likely to be severe)

● First pregnancy ● Family history in �rst degree relatives ● History of diabetes ● Pre-gestational hypertension ● Anti-phospholipid antibodies ● Obesity (BMI > 26) ● Baseline chronic kidney disease ● Twin pregnancy ● Age 40 or older

PATHOPHYSIOLOGY

● Not well understood. The leading theory is that there is reduced placental circulation that causes hypoxia or ischemia within the placenta leading to the release of in�ammatory markers resulting in endothelial dysfunction/vasoconstriction/coagulation pathway activation and multisystem organ damage.

● Associated pathology: increased risk of placental abruption, renal failure and intracranial hemorrhage

PRESENTATION

● Hypertension ● Headache or visual changes



● Upper abdominal or epigastric pain ● Nausea or vomiting ● Shortness of breath or chest pain ● Altered mental status

DIAGNOSIS

● Primary criteria: ○ BP>140/90 (2 readings 4 hours apart), or ○ BP>160/110 (2 readings a few minutes apart)

● Secondary criteria: ○ Proteinuria (1+ or higher on a urine dipstick) ○ Platelets < 100,000 ○ Creatinine > 1.1 ○ Doubling of transaminases ○ Pulmonary edema ○ Blurred vision, �ashing lights or scotomas ○ Cerebral pathology including severe persistent headache that does not respond to

typical analgesics, altered mental status or signs/symptoms of a stroke

● The spectrum of this illness is vast and can range from mildly elevated blood pressures with proteinuria to full blown seizures with central nervous system collapse, increased intracranial pressure, pulmonary edema, liver failure, DIC and stroke.

● HELLP syndrome involves similar pathology, though there is debate in the OB literature whether HELLP syndrome is related to preeclampsia or an entirely different entity.

○ H emolysis ○ E levated L iver enzymes ○ L ow P latelets

DISPO

● Severe cases require emergent transfer to the Emergency Department ● More mild cases like asymptomatic hypertension with mild proteinuria: call the patient’s

OB/Gyn for close follow up and possible initiation of antihypertensive medication (usually labetalol or hydralazine)



Sutures vs Butter�y Closures vs Glue Brian Lin MD & Jonathan Kantor MD

Pearls: ❏ Consider wound, host, and social factors in wound repair decision-making ❏ Consider butter�y closures or tissue adhesive glue to repair wounds that are acute,

linear and under low tension

● Three factors to consider when determining how to close a wound: ○ Wound-related factors:

■ What does the wound look like (linear, macerated, stellate)? ■ Is the wound under signi�cant tension? ■ Is there copious bleeding? ■ Are there underlying anatomic structures like tendons or vascular

channels? ■ Is it located over an extensor surface that will expose the wound to dynamic

tension? ○ Host-related factors:

■ Is the patient likely to reinjure the area before it has fully healed? ■ Does the patient have underlying medical conditions that will make wound

healing dif�cult? ■ Is the patient’s skin too thin to tolerate sutures?

○ Social-related factors: ■ Is the patient able to clean and care for the wound? ■ Is the patient able to return for suture or staple removal? ■ Does the patient require sedation for the repair and would therefore

require the same for removal? ■ Will the patient leave steri-strips or glue alone, or will they pick at it until it

comes off? ● When to consider butter�y closures or tissue adhesive? Wounds with no fat visible, that

are under minimal tension and are in less cosmetically critical areas. ○ Farion KJ, et al. Tissue adhesives for traumatic lacerations: a systematic review of

randomized controlled trials. Acad Emerg Med. 2003 Feb;10(2):110-8. Review. [ Free open access link ]

■ Compared the use of tissue adhesive glue to other types of wound closure including sutures, staples and adhesive strips for lacerations that were repaired in the emergency department or primary care setting and were

● Acute ● Linear ● Low tension


http://onlinelibrary.wiley.com/doi/10.1197/aemj.10.2.110/epdf

http://onlinelibrary.wiley.com/doi/10.1197/aemj.10.2.110/epdf


■ Included 8 studies. In all 8 studies, no signi�cant difference was found in cosmesis at any time point examined.

■ There was a small but statistically signi�cant risk of dehiscence using tissue adhesive glue compared to standard wound closure .

○ Simon HK, et al. Lacerations against Langer's lines: to glue or suture? J Emerg Med. 1998 Mar-Apr;16(2):185-9. [PMID 9543399 ]

■ Looked at facial lacerations that were either parallel with Langer’s lines of tension or were greater than 20 degrees deviated from Langer’s lines.

■ Compared cosmetic outcomes between conventional sutures to tissue adhesive glue.

■ As would be expected, they found that sutured wounds had a poorer cosmetic outcome if they ran against Langer’s lines. However, they also found that wounds that were closed with tissue adhesive had the same outcomes whether they ran with or against Langer’s lines.

■ Concluded that wound orientation has a greater impact on cosmesis than the decision to suture or glue.

Hemorrhoids Casey Parker MD Pearls:

❏ Hemorrhoids are both internal (above the dentate line) and external (below the dentate line).

❏ Grading system: ❏ 1. Non-prolapsing ❏ 2. Prolapse but reduce spontaneously ❏ 3. Prolapse but need manual reduction ❏ 4. Non-reducible, at risk of becoming acutely thrombosed.

❏ Treatment consists of lifestyle modi�cation (�ber, �uid, exercise), medications (laxatives, �avonoids) and procedures (banding, excision, stapling, ligation, sclerotherapy).

❏ Exercise caution in the following special populations: pregnancy, anticoagulation, cirrhosis and immunocompromise

● Hemorrhoids generally aren’t painful, present with rectal bleeding, a palpable lump when

passing stool and/or rectal fullness. However, it is important to take a look down under and not to miss a colorectal cancer.

● Classi�cation system: ○ Internal hemorrhoids originate above the dentate line, columnar epithelium of anal

mucosa




○ External hemorrhoids originate below the dentate line, squamous epithelium or skin of the anus

○ Grading: ■ 1. Non-prolapsing , very common (ie: will often see in women who have had

children), don’t usually cause problems beyond some itching and fullness. ■ 2. Prolapse (come out when people strain) and then reduce spontaneously ■ 3. Prolapse but need manual reduction ■ 4. Non-reducible, at risk of becoming acutely thrombosed

● Treatment: ○ Lifestyle

■ First and foremost → FIBER and increased �uid intake to decrease the amount of straining in the rectum. Good randomized control trial evidence showing adding daily dietary �ber supplements provides consistent symptom relief from bleeding/pruritus 50% of the time.

● The ADA recommends 25-35g of daily �ber; however, the research is mixed on if �ber actually improves constipation.

■ Exercise. Be careful to avoid weightlifting or maneuvers that require Valsalva because that can exacerbate the problem.

○ Medications: ■ Occasional laxative but remember that diarrhea and loose stools can

actually exacerbate hemorrhoids, too. ■ Flavonoids - may work on the arachidonic acid pathway to reduce

in�ammation. Cochrane Review from 2012 showed they had a signi�cant bene�t on patient symptoms such as bleeding, pruritus, discharge and overall symptoms improvement.

● They are in many things: parsley, blueberries, black tea, citrus, wine, cocoa, peanuts, red onion, thyme.

● The FDA has not currently approved them for this use ○ Procedures:

■ Rubber band ligation (putting a band around base of hemorrhoid thereby strangling its blood supply) - generally pretty well tolerated without much pain. Can be done during a colonoscopy, too. Low recurrence and complication rate. Need to be careful in groups that are anticoagulated.

■ Excision hemorrhoidectomy - mainstay for high grade hemorrhoids where the surgeon excises ellipses of skin and closes the defect with sutures. Very low recurrence rate, small risk of incontinence (if muscularis layer is hit) or anal stenosis/strictures.

■ Staple hemorrhoidopexy - stapling device inserted into the rectum above the hemorrhoid line. The hemorrhoid is removed as the mucosa above the hemorrhoid is pulled over that area, effectively shortening the mucosa. Trial



showed it was non-inferior to traditional hemorrhoidectomy, less painful and quicker recovery. However, recurrence is higher.

■ Doppler-guided hemorrhoidal artery ligation (DGHAL) - uses ultrasound or Doppler to try and identify the blood vessels feeding the tissue and then ligates those vessels. Low pain but very high recurrence rates (up to 60% of high grade hemorrhoids recurred)

● Hemorrhoids in special populations: ○ Pregnancy : generally self-resolve but important to examine and be on top of early

in pregnancy. Advise laxatives, �ber, avoid straining and lying on side so as not squash the vena cava and cause additional engorgement.

○ Immunocompromised : need to be careful with the risk of infection so commonly conservative measures are employed. If using sclerotherapy, important to cover with antibiotics before and after the intervention.

○ Cirrhosis/portal hypertension : important to distinguish hemorrhoids from anorectal varices (ie: treat the portal hypertension and do not attempt surgery). Patients are also at increased risk of bleeding, so sclerotherapy is a safer option.

○ Anticoagulation : exercise caution and consider the reason they’re on anticoagulation. You will need to weigh the risks and bene�ts with your patients of

stopping the medication to remove the hemorrhoids.

Bad Newborn Rashes Sol Behar MD and Danielle Fisher MD

Pearls:

❏ Most newborn rashes are benign, however, there are some infectious and noninfectious rashes in newborns that can be life threatening

❏ The following neonatal infections can cause similar appearing rashes: Toxoplasmosis, Syphilis, Varicella, Rubella, CMV, HSV and HIV. To differentiate between theses rashes you must look at the other symptoms present. These babies will typically appear quite ill.

❏ Ichthyosis and Epidermolysis bullosa are two serious noninfectious newborn rashes that likely require the collaboration of many specialty teams including ICU, neonatology, and infectious disease.

● How common is congenital herpes simplex virus(HSV)? HSV occurs in only 1:2,000 live

births with slightly more than 60% being caused by HSV-1 and just over 30% being HSV-2. This is a change from past epidemiology that showed neonatal HSV being primarily caused by HSV-2.



● What is the typical appearance of the rash in congenital HSV? The appearance of the lesions will depend on what point in time you are looking at the rash, as they progress over the course of several days.

○ They typically will start out as 2 - 8 mm macules or papules and progress to a single vesicle or group of vesicles. The vesicles will then break open and leave a sore that will crust and turn a pink to red color.

○ If you are seeing the rash in the very early stages, it may look fairly benign, so you really need to be thorough and follow up if there is any suspicion for HSV.

● When does the rash appear? A lot of babies are asymptomatic and doing well for the �rst week of life and then start to decompensate. Babies can have systemic signs, including poor feeding, lethargy, fever, and seizures.

○ A localized infection will show up around day 10 of life. There may not be evidence of a CNS infection until 16 or 17 days of life.

○ These are not necessarily kids that will present with symptoms in the nursery at the hospital. General pediatricians need to keep their eyes out for these symptoms and any concerns that parents have about their child’s skin should be taken very seriously.

● If a rash looks suspicious for congenital HSV, what components of the maternal history are important to focus on? A history of HSV in a pregnant mother should be elicited by the OB, however due to a lack of recent symptoms or lack of knowledge about the disease, some mothers may not know that they have been infected.

○ Exposure to HSV occurs when the baby is going through the birth canal. The concern is much higher if the baby was a vaginal delivery versus a Cesarean delivery. In a Cesarean delivery, the odds of having an HSV infection drop a lot.

○ It is important to remember that 20% of congenital HSV infections are caused by HSV type one. A mother with an active cold sore should probably not be kissing her baby and both the baby and the mom should have close medical follow up.

● Does HSV one act the same way as HSV two on a neonate? Yes it does. ○ There are many different ways to detect HSV and to determine what type of

infection is present. The Tzanck smear of the vesicular lesions will reveal multinucleated giant cells, the hallmark of HSV infection. HSV can also be detected through culture, PCR for HSV DNA, and direct immuno�uorescence with the monoclonal antibody.

● If you are suspicious of a congenital HSV infection in an outpatient setting, what are the next steps? The infant needs to be admitted to the hospital for work-up and Acyclovir needs to be started.

○ Even if the baby is afebrile and appears well, if there is a suspicious lesion present, the baby needs a full workup which includes a blood, urine and CSF.

○ The infant should be worked up as if he has a CNS infection in addition to a disseminated infection.

○ It is imperative to start Acyclovir right away, because it could be life saving.



● What causes the blueberry muf�n rash? A “blueberry muf�n” rash can be seen due to congenital infection with toxoplasmosis, varicella, rubella, CMV, HSV or HIV.

○ The appearance of the rash itself is usually a blueish red to purple, circular or oval shaped lesion that is about 2-8 mm in diameter. They are purpuric macules or papules present on the face, the neck, the trunk, and the extremities. These lesions actually represent centers of extramedullary hematopoiesis.

● How do we differentiate between infections that cause a “Blueberry Muf�n” rash? You have to look at the other symptoms that are present to help guide your diagnosis.

○ In toxoplasmosis, you can also see lymphadenopathy, hepatosplenomegaly, hydrocephalus, microcephaly, cataracts, pneumonitis, chorioretinitis, and seizures. We diagnose toxoplasmosis using either a Wright or Giemsa stain on the CSF or using a sample from a lymph node. A baby who has congenital toxoplasmosis will have diffuse, comma shaped intracranial calci�cations on a skull X-ray.

○ In a congenital CMV infection, you can see jaundice, hepatosplenomegaly, anemia, thrombocytopenia, respiratory distress, seizures, and chorioretinitis. These babies can also have sensory neural hearing loss. CMV diagnosis is made by culture of the urine, CSF, gastric washings, the pharynx, or the liver. It will show characteristic large cells with intranuclear and cytoplasmic inclusions.

○ Babies who have a congenital rubella infection may have cataracts, deafness, growth retardation, hepatosplenomegaly, cardiac de�cits, and meningoencephalitis. The diagnosis is made by culture from the nasopharynx, the urine, the CSF, the skin, the eye or the stool. The baby will have an increased anti-rubella IgM. There is no treatment for congenital rubella. The treatment is supportive care.

○ These infections have a lot of symptom overlap (blueberry rash, eye problems, hearing loss and some abnormality of their growth or the size of their head). If you see any of these symptoms, think about the TORCH infections and consider consulting a neonatologist and/or an infectious diseases specialist.

● How and when does congenital syphilis appear? Early congenital syphilis appears in children less than 2 years of age and skin lesions are only present in about a third to a half of infected infants. A baby with congenital syphilis may never have any skin �ndings.

● If the baby does have skin �ndings from congenital syphilis what do they look like? The lesions can start out as either maculopapular or papular-squamous lesions on the body. There can be patches on the mucus membranes or raised varicose plaques on the anogenital or oral membranes. These patches look pinkish red, and then fade to a copper color. Sometimes there is desquamation of the skin over the entire body.

● How do we separate the desquamation that can happen from congenital syphilis versus normal amount of peeling skin in a newborn? Peeling skin in a newborn usually covers small areas. The peeling skin appears white and the baby is not necessarily going to have any other speci�c lesions. In the case of congenital syphilis, these babies may have these



pinkish red lesions that turn a copper brown color. If they have the desquamation, it can be over the entire body surface.

● What is ichthyosis? Ichthyosis affects the stratum corneum of the epidermis and causes a sheet like peeling of thick white layers of skin. The �ndings are not subtle. These babies are very prone to infection, they have temperature regulation problems, and a whole host of other problems.

● What is epidermolysis bullosa? Epidermolysis bullosa is an extremely rare condition affecting the gap junction of the epidermis.

○ The skin is covered in giant �uid �lled vesicles called bullae. ○ These babies are at high risk for dehydration due to insensible losses. They need to

have a good amount of �uid intravenously, which can be incredibly challenging to place.

○ The babies often need to be sedated to avoid movement and at times need to be intubated.

○ They will require very acute care with the collaboration of many specialty teams including ICU, neonatology, infectious disease, dermatology and ENT.

Paper Chase #1: Hyperpronation is more effective that supination-�exion for Nursemaid’s Elbow reduction Mike Weinstock MD & Nate Finnerty MD Bexkens R, et al. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. Am J Emerg Med. 2017 Jan;35(1):159-163. [PMID: 27836316 ] BOTTOM LINE: HP was more effective than SF for treatment of nursemaid's elbow. Background: Nursemaids elbow is probably the most gratifying pediatric presentation out there. It typically occurs between 2-3 years of age following axial traction to the forearm., resulting in radial head subluxation and entrapment of the annular ligament. This usually occurs when an adult abruptly pulls a child by the hand or wrist, typically lifting the child, catching them before they fall, or spinning with them. And the poor parents think they broke their child, they wont use there arm! They just hold it to their side. And we get to swoop in with an easy �x and be the hero. But which is the best approach? Hyperpronation or supination-�exion. Study design/methods: These authors performed a systematic review and meta-analysis of randomized and quasi randomized controlled trials comparing HP with SF. The primary outcome was failure rate at �rst




attempt. 7 trials were included with a total of 701 patients, 350 were treated with HP and 351 with SF. Results/Conclusions: HP was more effective than SF for treatment of nursemaid's elbow. Pooled failure rate with hyperpronation was 9.1% and 27.3% with supination/�exion., an absolute risk difference of about 26%, , giving a NNT of 4, meaning for every 4 children treated with HP, you prevent 1 failure. Pain scores also favored HP. Limitations: The quality of evidence was low in all of the studies due blinding and outcome assessment. Application: HP is the way to go!

Paper Chase #2: Pediatrician follow up after an UC visit Mike Weinstock MD & Nate Finnerty MD Chen J, et al. Primary Care Follow-up After Emergency Department Visits for Routine Complaints: What Primary Care Physicians Prefer and What Emergency Department Physicians Currently Recommend. Pediatr Emerg Care. 2016 Jun;32(6):371-6. [PMID: 25695845 ] BOTTOM LINE: Some kids need time-speci�c follow up with their primary care doctors. For those that don’t, it is okay to leave it up to the primary care physician to decide how soon they would like to see the patient for follow up. Background: Parents bring their kids to the UC for a variety of reasons, but ultimately, the vast majority are discharged home after their visit. When I send kids home, I always try to give the parents an idea of what to expect and when to follow up with their pediatrician. But we know it can be hard to get an appointment, which is one of the reasons they came to see us in the �rst place. If the go in to early, there may be nothing to do, requiring a second return visit, and just makes it more dif�cult for another child to be seen, so they come to the UC, and then we send them back to soon, ha ha, it’s a vicious cycle. So we have an idea of when we would like the child to follow up, but how does that compare to what their PCP wants? Study design/methods: This is not the typical study we cover on PPC. This was a survey of community pediatricians, asking their preference for follow up after their patients were seen in the ED for 12 routine complaints.




Responders were asked to assume these were otherwise healthy children who improved with time after their visits. Seven options for follow-up were included, but they really focused on 1-5 day follow up recommendations. A similar survey was created for pediatric emergency physicians employed by the hospital regarding their current recommendations for PCP follow-up after these same complaints. Results/Conclusions: 53.8% of community pediatricians and 100% of emergency physicians responded to the survey. So, statistically we all agree that asthma should be seen in the of�ce within 5 days of presentation. And the majority of providers agreed that pneumonia should be seen within 5 days as well. For the remainder of the complaints listed (ankle sprain, OM, strp, UTI, gastroenteritis, croup, uri, viral exanthema, urticarial, and constipation) emergency physicians tend to recommend follow-up closer than desired by pediatricians after ED visits for simple complaints. For example, for patients with streptococcal pharyngitis, URI, and viral exanthema, most pediatricians did not feel any follow-up was necessary and a fair number of pediatricians felt phone follow up rather than in of�ce was a reasonable option for patients with gastroenteritis, croup, and urticaria. Limitations: Response rate was low and the study was limited to a single community and results may not apply to your community. Application: For pediatric patients that do not follow the typical presentation for routine complaints, I will continue to make speci�c recommendations for follow up on a case-by-case basis. However, for otherwise healthy kids with routine complaints, I will often tell the parents to call their pediatricians of�ce in the morning and ask when they would like to see them in of�ce.

Paper Chase #3: Clinically Signi�cant cervical Spine Injury is Very Rare After a Ground-Level Fall Mike Weinstock MD & Nate Finnerty MD Benayoun MD, et al. Utility of computed tomographic imaging of the cervical spine in trauma evaluation of ground-level fall. J Trauma Acute Care Surg. 2016 Aug;81(2):339-44. [PMID: 27454805 ] BOTTOM LINE: In this study, the incidence of C-spine fracture was <1% and the application of either the NEXUS criteria or Canadian C spine Rule would reduce the imaging utilization by approximately 20%.




Background: Falls are big business and one of the leading causes of injury in the acute care setting. Our job is to determine what was injured, how severe, and who needs imaging. Regardless of mechanism or age, I always ask “did you hit your head” and “did you injury your neck.” The primary outcome of interest was the presence of C-spine fracture Secondary outcomes of interest included appropriateness of radiologic imaging based on the NEXUS and CCR CDRs as well as estimated radiation dose exposure and �nancial cost associated with C-spine imaging studies. Imaging appropriateness was de�ned as meeting at least one CDR indication for imaging. The goal of this study was to investigate the incidence of C-spine fractures in patients with GLFs presenting to the ED of a Level I trauma center. Secondary goals were to determine whether the fractures were stable or unstable, to calculate the negative predictive value of NEXUS and CCR CDRs in excluding C-spine imaging cost-resource use and radiation dose exposure in patients presenting after GLF. Study design/methods: This was a chart review of patients with a documented GLF (de�ned as </= 3 ft or </= 5 stairs) who underwent a C spine CT scan. Excluded for axial load injury and age <16 y/o. Results/Conclusions: 760 patients were included and 7 C spine fractures were identi�ed (0.92%). Six fractures were stable, and one fracture was unstable. Two patients with C-spine fracture had concurrent traumatic SCI, as seen on MRI performed later. All seven patients with C-spine fractures met imaging criteria by the NEXUS and CCR CDRs. The C-spine fracture rate following GLF in patients older than 65 years was 5 in 208 (2.4% ± 2.1%). Inappropriate imaging, de�ned as imaging in patients not meeting CDR criteria for imaging studies, occurred in 22.0% of NEXUS. Inappropriate imaging by CCR was performed in 20.7% Both CDRs were 100% sensitive for identifying patients with fractures Inappropriate imaging occurred in 31.3% ± 6.3% (n = 65) of patients within this age group by NEXUS criteria. Since all patients 65 years and older would require imaging by CCR and �ve of seven fractures occurred in patients of this age, a subset analysis was performed on this subgroup with respect to imaging criteria by NEXUS.



Limitations: Retrospective, a large percentage of patients were considered indeterminate due to lack of documentation in the EMR. Application: This is not ground breaking information, but a nice reminder. NEXUS and CCR work and by reviewing them for your patients you may prevent unnecessary transfer, imaging, radiation exposure, and costs.

Paper Chase #4: IVF Offers No Short or Long Term Bene�t to Migraine Patients Mike Weinstock MD & Nate Finnerty MD Balbin JE, et al. Intravenous �uids for migraine: a post hoc analysis of clinical trial data. Am J Emerg Med. 2016 Apr;34(4):713-6. [PMID: 26825817 ] BOTTOM LINE: In this post hoc analysis, there was no evidence of short-term or sustained improvement among migraine patients administered IVFs. Background: Headaches have the potential to be very scary and even life threatening, however, most of the time these patients do not have an underlying bleed or clot, and so our primary goal is symptom control, which we often refer to as the migraine cocktail. Mike what are you mixing into your cocktail? Metoclopramide, Prochlorperazine, +/1 diphenhydramine, maybe some ketorolac? What about �uids? That is the question these authors addressed. Study design/methods: They performed a post hoc analysis of data collected from previous migraine trials where the primary intervention was IV metoclopramide. They focused on the subset that received IVFs which was not standardized, but left to the discretion of the treating physician. The short-term outcome was improvement in 0 to 10 pain score between baseline and 1 hour later. The sustained outcome was sustained headache freedom, de�ned as achieving a pain level of “none” in the ED and maintaining the level of “none” for at least 24 hours post discharge. Results/Conclusions: 570 patients were included and about 20% received IVFs. Nausea was more common in the IVF arm, but otherwise characteristics were similar. Patients who received IVFs improved by 4.5




points on a 10 point scale, whereas those that did not improved by 5.1 points and 14% of those receiving IVFs achieved sustained relief compared with 18%. Limitations: This was a post hoc analysis of previous trials, all patients received metoclopramide and we don’t know if IVFs are bene�cial with alternative therapies, the administration and volume administered was not randomized which could bias the results. Application: This study suggests that the addition of IVFs to the migraine cocktail does not add any bene�t to short term or sustained pain scores. Paper Chase #5: IV Is Not Better Than PO for First-Dose abx for Patients Admitted for CAP Mike Weinstock MD & Nate Finnerty MD Belforti RK, et al. Association Between Initial Route of Fluoroquinolone Administration and Outcomes in Patients Hospitalized for Community-acquired Pneumonia. Clin Infect Dis. 2016 Jul 1;63(1):1-9. [PMID: 27048748 ] BOTTOM LINE: Among hospitalized patients who received �uoroquinolones for CAP, there was no association between initial route of administration and outcomes. Background: Current guidelines written by the Infectious Diseases Society of America and American Thoracic Society on the management of community-acquired pneumonia in adults recommend treatment with either a �uoroquinolone or Beta lactam plus macrolide, but these can be given orally or IV based on patient risk factors for developing severe pneumonia. Given that the bioavailability of many antibiotics, including �uoroquinoloes, is the same whether given orally or IV, is there a bene�t to IV administration? Study design/methods: These authors performed a retrospective analysis of patients hospitalized for community-acquired pneumonia treated with a �uoroquinolone (Levo�oxacin or Moxi�oxacin). The Primary outcome was in-hospital mortality, secondary outcomes included transfer to ICU, need for vasopressors, intubation, antibiotic escalation, LOS and cost. Results/Conclusions:




Of the 36,000 patients included, 94% received IV abx and 6% received oral abx. After propensity matching for demographics, co morbidities, and initial medicaitons and treatments, there were no signi�cant differences in mortality, hospital LOS, hospital costs, or escalation to ICU, intubation, or vasopressor use. Limitations: Retrospective, observational. Application: The authors conclude that more patients admitted for CAP may be treated with PO abx without worsening outcomes. My take home from this is to really scrutinize who needs transfer and admission from the UC. Im looking for signs of sepsis, hypoxia, inability ot tolerate PO, CURB65, etc. If not, these patients likely don’t need admission and certainly not just for IV abx.

