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Here you will find information regarding rotation schedules, academic resources, wellness and facts about our program and residents. Check out our bios and photos. Please also visit the Emergency Department's official residency website. This site is intended for Mount Sinai EM residency purposes only, and no information on these pages is intended or should be construed as medical advice. Read more.

Flexor Tenosynovitis

Tenosynovitis = inflammation of a tendon and its sheath.  Most acute cases of flexor tenosynovitis (FT) are infectious but may also be secondary to inflammation from noninfectious cause (e.g. diabetes, overuse, arthritis)

Infectious tenosynovitis

May be result of trauma with direct inoculation (eg, laceration, puncture or bite), contiguous spread from infected adjacent soft tissues, or hematogenous spread. The most common pathogens in the setting of trauma are skin flora (eg, Staphylococcus aureus and streptococci). Pathogens associated with hematogenous spread include N. gonorrhoeae and mycobacteria.

Physical examination reveals Kanavel signs of flexor tendon sheath infection:

  • Finger held in slight flexion
  • Fusiform swelling
  • Tenderness along the flexor tendon sheath
  • Pain with passive extension of the digit

Clinical features of gonococcal tenosynovitis include:

  • Erythema, tenderness to palpation, and painful range of motion (ROM) of the involved tendon(s)
  • Fever – A common sign
  • Dermatitis – Also a common sign; it occurs in approximately two thirds of disseminated gonococcal infections; it is characterized by hemorrhagic macules or papules on the distal extremities or trunk

Inflammatory flexor tenosynovitis

  • Usually the result of an underlying disease process
  • Presentation is indolent but progressive if therapy is not initiated
  • Similar findings to those found in infectious FT eventually present
  • Swelling is the most common initial finding
  • Hallmark is a difference in active, versus passive, flexion
  • As the tissue expands and impingement occurs, pain and restricted motion ensue

Diagnosis

Diagnosis of tenosynovitis is confirmed by microbiological and histopathological evaluation: culture of the suppurative synovial fluid, diagnostic arthrocentesis is indicated if joint effusion is present (may have septic arthritis also, especially with gonococcal infection).

Management

Surgical intervention and antibiotic therapy.  Generally, early infection should be managed with tendon sheath irrigation and drainage, with or without debridement. Advanced infection should be managed with debridement of the tendon sheaths and surrounding necrotic tissue.

In certain circumstances, an acute presentation within the first 24 hours of infection development may initially be medically managed.  Prompt improvement of symptoms and physical findings must follow within 12 hours; otherwise, surgical intervention is necessary.

 

Tick-borne Illness – Not All Lyme

27M h/o sickle cell anemia presents with high fevers, sweats, HA, muscle aches, N/V.  Recent camping trip in New England.  Blood smear shows the following:

 

Diagnosis?

What complications would you worry about?   Continue reading “Tick-borne Illness – Not All Lyme” »

Interesting Studies About Learners in the Emergency Department

The following study results about learners in the ED are department specific for each study, though they offer a sense of general perspective on the issues at hand.

-  Medical students do not affect attending or resident productivity

- One resident with one attending will see more patients than the attending alone

- mid-level providers consistently see more patients in high and low acuity settings than residents

- In high acuity settings mid-level providers have lower RVUs than residents

- In low acuity settings, mid-level providers have higher RVUs per hour but lower RVUs per patient than residents

- EM interns increase the number of patients seen per shift over the course of the year. Other department interns or EM second years do not.

- EM residents see more patients and bill at higher acuity levels as they progress through residency

Feel free to leave any others in the comments.

Mid-2014 Updates in Emergency Medicine

Some 2014 updates so far…

- age adjusted d-dimer
- ultrasound assisted, catheter directed thrombolysis
- thrombolysis for RV dysfunction (intermediate risk PE)

- sepsis treatment: early recognition, early antibiotics, and attentive care
- restrictive transfusion (Hgb 7-8)

- Good Outcome For Attempted Resuscitation (GO-FAR) score for predicted neuro outcome of in-hospital arrests
- palliative care review on dying with dignity

Do you have any others? Please leave in comments.

Management of Traumatic Subarachnoid Hemorrhage

Prioritization of following steps is based on individual patient needs:

1. Assess stability
- stabilize
- neuroprotective intubation as needed

2. Determine secondary damage
- neuro exam, including GCS
- CT scan

3. Treat (may begin simultaneously with 1 and 2)
- reverse anticoagulation as necessary
- prevent potential seizures
- minimize cerebral edema
- normocapnic, normothermic, normotensive, normovolemic, normal oxygenation
- minimize sympathetic surge
- may need ICP (CPP) monitoring (remember CPP = MAP – ICP)

Some pointers:
Hypertonic saline is preferred to mannitol
Hyperventilation is no longer a mainstay therapy unless the patient is hypercapnic or herniating
Elevate the head of the bed to 1/2 the length of the head of the bed (or 30 degrees)
Consider high dose barbiturates or fentanyl/propofol for inducing a medical coma, intubating where necessary

Haddad and Arabi. Critical care management of severe traumatic brain injury in adults. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:12
Peds Neuroprotective Strategies

 


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