Webucation 5/9/18

This episode of webucation gives us insights into old diseases and new. From cardio to dermatology and from myth to righteousness. Credit as always to the original content providers.

• Resuscitation communication - why its as important as any other treatment
• 4th Universal definition of MI - if you deal with heart attacks, you probably want to know this
• Simplifying mechanical ventialtion - great guide on the basics
• Myths of heart failure - still believing in some of these? 
• Moral injury - are you at risk of this or is it something we just live with?
• The migraine cocktail - catch up with the latest admixture for this pesky pathology

• Severe cutaneous reactions - a great run through one of my blindspots - dermatology. It sets out the differences and nuances of treatment of SJS / TENS etc

Don't over-complicate it

Good reminder (for some this may be new!) on overuse of an important test. Thanks to Journalwatch for this read.

Blood Cultures (Still) Not Indicated for Uncomplicated Skin Infections Daniel J. Pallin, MD, MPH Reviewing Torres J et al., Am J Emerg Med 2017 May 26; Even with selection bias and inclusion of injection drug users, this single-center study found that only 7% of blood cultures in admitted patients were positive.

Blood cultures are positive in about 4% of all comers with cellulitis. In a prospective, observational, single-center study, researchers assessed the rate of positive blood cultures in admitted patients with skin and soft tissue infections, and in the subsets with injection drug use or fever. Importantly, the investigators did not determine who would undergo blood cultures. Of 246 admitted patients with skin infection, 86 (35%) had blood cultures, and 7.0% of cultures were positive. Among the 29 blood-cultured patients who were febrile, 3.5% had positive blood cultures. Of 101 admitted patients who were injection drug users, 46% had blood cultures, and of these, 8.7% were positive. Comment This study is difficult to interpret because the investigators did not determine who underwent blood cultures, and it is likely that sicker patients were the ones who did; moreover, inclusion of only admitted patients enriched the sample for sicker patients. Therefore, the results represent upper limits for blood culture positivity. Blood cultures should never be done for patients with uncomplicated cellulitis, whether admitted or not, and fever is not an indication. For admitted patients with cellulitis and injection drug use, blood cultures may be a reasonable option. Don't forget that cellulitis complicating lymphedema often results in bacteremia, and cultures are indicated in this group. Of course, blood cultures are indicated for septic patients and those with suspected necrotizing soft-tissue infection.

Webucation 29/9/13

Web musings this week come from the worlds of critical care, paediatrics, orthopaedics and even the dermatologists! A lot of the below has risk management and error reduction pearls included. So visit and support the content creators as always. 

• Pneumonia detection - difficult x-rays in children, but not impossible
• Splinting upper/lower - EM in 5 gives a great rundown about casting limbs
• Is it Nec Fasc? - ALiEM relate a fascinating case, with a bit of risk management thrown in
• Variability of different BVMs - this article was a surprise to me. Click to be surprised as well.
• Is this distracting? - Ryan Radecki breaks down another myth. This  time about c-spine clearance.
• What is a wide mediastinum? - The trauma pro answers this much asked question
• Vent settings in asthma - what to do AFTER the intubation

The last link is a good reminder to trainees and professionals alike on the subtler aspects of holistic critical care. Additionally we would like to remind our readers of an old adage: 

                            "If you are intubating an asthmatic, you have failed him/her medically"

It's not a judgement but rather to remind you that there are tons of things that you can do prior to mechanically ventilating an asthmatic (most of the time). So make sure you have thought of the following prior to attempting this very high risk procedure:

• Broncho-dilator maximisation 
• Continuous nebs
• Ipratropium
• IV infusions of beta agonists 
• Theophylline (old school I admit)
• Adrenaline 
• Magnesium
• Non invasive ventilation and nebs via that route (anecdotally works great in our XP)
• Steroids

Emcit has the best crashing asthmatic talk over here.

The Case of the Mysterious Rash

A 58 year old Chinese Missionary without any chronic co-morbidity or drug allergies, presented to our ED with an intensely itchy rash to his feet and body after recent travel to Tanzania a week ago.

His vital signs were stable and there was no fever or constitutional upset.

Morphology of the rash on his foot, as per photograph shown below -

Q1. What is the diagnosis?

Q2. What is the causative agent?

Q3. What is the commonest presentation?

Q4. What is the management ?

Q5. How can it be prevented?

Know your rashes!

Good stuff from experienced ACEM examiners.

Rash