Authors: Kenneth Akapo, OSU MS4 // Dr. Michael Barrie, OSU EM Attending
A 24 year old female with history of sickle cell disease presents with a 6 hours history of widespread pain. The pain is in her lower back but also present within the lower and upper extremities. She also endorses mild shortness of breath although she attributes this to her pain episode. She mentions being seen a week ago due to a similar episode during which she also had new onset headaches associated with blurry vision. During that episode, CT scan was unremarkable. During the current encounter, there was low concern for ischemic stroke. The headaches have persisted until now, however, she no longer endorses changes in vision. She also denies any other focal neurologic symptoms.
Upon initial examination, the patient appeared to be in mild distress. She was mentating well and exhibited no focal neurologic symptoms. She was diffusely tender to palpation although she seemed to exhibit more pain when palpating the lower extremities and back. Breath sounds were clear to auscultation bilaterally, and cardiovascular exam was normal.
Before presenting the case to the senior resident, you consider your differential diagnosis – sickle cell pain crisis, acute chest syndrome (ACS), ischemic stroke, acute coronary syndrome (the other ACS), and heart failure among others.
But what findings would help support or refute a diagnosis of acute chest syndrome? And what is the plan to manage the initial diagnosis and treatment of possible acute chest syndrome?
By Josh Faucher, MD, JD // Edited by Michael Barrie, MD
A 24 year-old male presents to your rural ED’s fast-track area with purulent penile discharge and dysuria. These have been present for the past week, and he recently began intercourse with a new female sexual partner. They have not used barrier contraception. He denies hematuria, fevers, genital lesions, or other associated symptoms; his physical exam is within normal limits other than purulent penile discharge. Rapid urine testing is positive for Neisseria gonorrhea infection; the patient is treated empirically in the ED with one-time doses of ceftriaxone and azithromycin. He denies any other recent sexual partners. The patient’s sexual partner works full time but is uninsured, and in your rural area there are no local STD clinics that are easily accessible for partner follow-up. Your patient asks if he can have a prescription to conveniently treat possible infection in his female partner at home, saving the time and cost of an additional ED visit or delayed outpatient follow-up. Can you provide the sexual partner any treatment without seeing her directly as a patient?
By Michael Barrie, OSU EM Assistant Professor
A great emergency medicine study in this month’s JAMA: Friedman et. al “Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: A randomized clinical trial.” This was a randomized, double-blind controlled trial to see if adding narcotics or cyclobenzaprine to naprosyn helps improve symptoms in patients with lumbar back pain compared to those that received naprosyn plus placebo. They showed there was NO benefit.
Conclusions and Relevance Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1-week follow-up. These findings do not support use of these additional medications in this setting.
Written by Michael Barrie @MikeBarrieMD, OSU EM Assistant Professor
It’s clear that when a patient presents with sudden onset of a rash, wheezing, vomiting and hypotension every emergency physician knows that epinephrine is life saving. But evidence is mounting against the routine administration of steroids in our patients with anaphylaxis.
Should we abandon corticosteroid administration in anaphlaxis? This month’s issue of Annals of Emergency starts that discussion with Grunau et al “Emergency Department Corticosteroid Use for Allergy or Anaphylaxis is Not Associated with Decreased Relapses.”