The classic teaching is that bite wounds should not be closed due to concern for infection; however, several studies have challenged this dogma, particularly in low-risk wounds and patients. We discuss the evidence this week on the blog.
Do It Yourself: Dental Emergencies
A simple, do-it-yourself, graphical approach to management of common dental emergencies.
Pulmonary Embolism: Don't Throw Out That EKG!
The EKG is easy to obtain and is certainly useful to potentially exclude or uncover other etiologies of chest pain. Furthermore, an EKG can aid in diagnosis or at least increase suspicion or PE as well as provide prognostic data on an already diagnosed PE. This week we dive into the data regarding EKG analysis in PE.
Infestations
Skin infestations are frequently encountered in the ED, particularly among the homeless population, though data on the number of visits are lacking. While patients with infestations may seem like pests in the middle of a busy shift, these conditions can be a public health menace, and may be markers of serious underlying pathology.
Pneumothorax Part II: Management In The ED
While spontaneous pneumothorax is a common problem encountered by emergency physicians, there remains regular controversy regarding its appropriate management. Read this weeks post to learn more.
What you didn't know about the Holiday Season. A Brief on Holiday Morbidity and Mortality
Author: Matt Klein, MD
Citation: [Peer-Reviewed, Web Publication] Klein M (2016, December 22).What You Didn't Know About The Holiday Season: A Brief On Holiday Morbidity & Mortality [NUEM Blog]. Retrieved from http://www.nuemblog.com/blog/holidazed
Santa Claus and his elves aren’t the only ones preparing for a busy holiday season. Emergency departments across the country are bracing for an influx of casualties as the most wonderful, and possibly the most dangerous, time of the year is underway.
According to an analysis of US death certificates from 1979 to 2004, more deaths occur in, or on arrival to, the ER on Christmas and New Years than on any other day. Beyond mortality, a review of the literature reveals a not-so-heavenly host of hazards threatening to maim Yuletide revelers.
Deck the Halls
National Lampoon’s Christmas Vacation features family man Clark W. Griswold hanging from his gutter while trimming hearth and home, and he’s not alone in holiday mishaps.
The US Consumer Product Safety Commission reports that holiday decorations send an estimated 15,000 injured people – roughly 240 a day during the peak – to local hospitals during the Christmas season.
In a series of patients with holiday-related fractures, one third were injured while putting up decorations, and twice as many fell while attempting to reach an attic.
Among patients presenting to a Level I trauma center with injuries sustained while installing Christmas lights, 30 percent required surgery and more than 10 percent were transferred to a rehab or long-term care facility.
O Christmas Tree
Charlie Brown’s Christmas tree may just need a little love, but it might also require a wide berth.
The National Electronic Injury Surveillance System – a treasure trove of data on what consumer products send their users to the ER – contains records on hundreds of victims of Christmas trees and their decorations.
A 12-year-old sustained second-degree burns after a power socket exploded while plugging in a string of lights, for example, while a three year-old required medical care to remove a piece of a Christmas light bulb shoved up his nose. Surgical case reports describe pediatric tracheostomy and right lower lobectomy following ingestions of decorations.
You’ll Shoot Your Eye Out
Everyone from the school teacher to a department store Santa warns A Christmas Story’s Ralphie that his coveted Red Ryder BB gun will lead him to shooting his eye out, and with good reason.
Holiday ocular trauma, including scratched corneas from gift tags and eyes poked by Christmas tree branches, is commonly reported by ophthalmologists. According to a study from the American Academy of Pediatrics, the face is the most commonly injured body part in children visiting the ER on Christmas.
Assault-related facial trauma, including broken bones and soft tissue injuries, are significantly higher at Christmas than an average non-holiday week of the year. Not surprisingly, the authors of this UK study noted that alcohol played a role in many of the cases.
Blue Christmas
Clarence the angel may never have received his wings in It’s a Wonderful Life without George Bailey’s drunken suicide attempt, but what role does an excess of holiday spirits play in self-destructive behavior?
Australian hospitals see a significant spike in intoxicated patients on the last working day before Christmas, while Finland experiences a peak in fatal alcohol poisonings around the holiday.
In the United States, a review of the National Poison Database System found that suspected intentional exposures were significantly less common on Christmas day, and multiple other studies show a decrease in suicide on December 25th.
The Holly and the Ivy
In 2010, poison centers fielded 750 calls related to poinsettia exposures, but danger of the decorative plant is grossly overstated. The urban myth stems from the unconfirmed death of a two year-old child nearly a century ago. In a review of nearly 23,000 poinsettia exposures published in 1996, zero fatalities were reported.
If you’re intent on finding a sinister Christmas plant, ingestion of holly berries and mistletoe can lead to gastrointestinal symptoms, but they’re rarely dangerous.
Reindeer Games
There are no reported cases of reindeer-induced trauma, let alone grandmothers getting run over by Santa’s favorite mode of transportation. However it may be a good idea to skip the holiday petting zoo. Myiasis, or infection with fly larva, has been described in children as the result of coming in contact with reindeer; two of whom developed ophthalmomyiasis, with one child losing vision in the affected eye.
How can you keep Christmas a time of peace and goodwill? Be careful decorating for the holiday. Keep ornaments out of the reach (and mouths) of children. Drink alcohol in moderation.
Here’s hoping your stockings are hung by the chimney with care, and without a call to 911.
References
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- Phillips DP, Barker GE, Brewer KM. Christmas and New Year as risk factors for death. Social Science and Medicine. 2010;71:1463-1471.
- Islam S, Uwadiae N, Hayter J. Assault-related facial injuries during the season of goodwill. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;121(6):e139-42.
- D’Ippolito A, Collins C, Comstock RD. Epidemiology of pediatric holiday-related injuries presenting to US emergency departments. Pediatrics. 2015;125:931-937.
- Tsatsos M, Tsemetzoglou E, Triandaffilidis C et al. Christmas-related eye injuries: a prospective study. Clin Experiment Ophthalmol. 2010;38(1):85-86.
- Gordon R, Dhokia R, Eames N. Christmas related fractures admitted to the fracture department, Northern Ireland. Ulster Med J. 2013;82(3):192-196.
- Norberg HP, Reyes HM. Complications of ornamental Christmas bulb ingestion. Arch Surg. 1975;110:1494-97.
- Philip J, Bresnihan M, Chambers N. A Christmas tree in the larynx. Paediatr Anaesth. 2004;14(12):1016-20.
- Lloyd B, Matthew S, Livingston M, et al. Alcohol intoxication in the context of major public holidays, sporting and social events: a time-series analysis in Melbourne, Australia, 2000-2009. Addiction. 2013;108(4):701-9.
- Poikolainen K, Leppanen K, Vuori E. Alcohol sales and fatal alcohol poisonings: a time-series analysis. Addiction. 2002;97:1037-40.
- Bergen H, Hawton K. Variation in deliberate self-harm around Christmas and New Year. Soc Sci Med. 2007;65(5):855-67.
- Beauchamp GA, Ho ML, Yin S. Variation in suicide occurrence by day and during major American holidays. J Emerg Med. 2014;46(6):776-81.
- Carley S, Hamilton M. Best evidence topic report. Suicide at Christmas. Emerg Med J. 2004;21(6):716-7
- Evens ZN, Stellpflug SJ. Holiday plants with toxic misconceptions. West J Emerg Med. 2012;13(6):538-42.
- Krenzelok EP, Jacobsen TD, Aronis JM. Poinsettia exposures have good outcomes…just as we thought. Am J Emerg Med. 1996;14(7):671-4.
- Krenzelok EP, Jacobsen TD, Aronis JM. American mistletoe exposures. Am J Emerg Med. 1997;15(5):516-20.
- Kan B, Otranto D, Fossen K et al. Dermal swellings and ocular injury after exposure to reindeer. N Engl J Med. 2012;367(25):2456-7.
Cerebral Venous Sinus Thrombosis: The Forgotten Headache
Cerebral venous sinus thrombosis (CVT) is becoming recognized as a more common and treatable disorder in young patients. Unfortunately, headaches are overwhelmingly common complaints in the emergency department (ED), so CVT can be easy to miss since it has confusing clinical and imaging findings. This week we discuss this clinical entity, when to suspect it and what to order.
The PESIT Trial: Not all first time syncope needs testing for PE
We do not doubt that PE can be a factor in syncope, but we have concerns over possible over testing for PE among undifferentiated syncope patients secondary to the PESIT study conclusions.
TXA In Epistaxis
Sixty percent of the general population experiences a nosebleed at least once in their lifetime, making this a common emergency department (ED) presentation. This week we discuss a novel use of TXA and its potential as an effective adjunct to management of epistaxis.
Managing Alcohol Withdrawal In The ED
Over 16.3 million adults have an alcohol use disorder as defined by the NIH. Though the emergency department (ED) sees its fair share of intoxicated patients, many patients also present to the ED with withdrawal symptoms. This week we cover a few tips on management.
Methadone Induced Torsades
Torsades de Pointes (Tdp) is a term that is often used synonymously with polymorphic ventricular tachycardia (PVT) but it is important to understand the differences. This week we take a deep dive into an interesting case of Tdp with expert commentary by Amal Mattu!
Ask The Expert: Acute Right Ventricular Failure in the ED
This post will introduce key concepts regarding the pathophysiology of RV failure and provide you with answers to high yield questions in management of these difficult patients.
Understanding Inhalation Injury
Smoke inhalation injuries are one of the leading causes of morbidity and mortality in the United States. In emergency medicine, we must be aware of harbingers of impending airway issues that come along with this deadly injury. We discuss pathophysiology, diagnosis and management in this week's post.
Blood Cultures In Community Acquired Pneumonia
The reflex of obtaining blood cultures before the initiation of antibiotics has pervaded the practice of medicine; however, this practice may not necessarily be evidence-based. Learn more in this week's post.
Modern Headache Management: Best Practices Update
Headache is one of the most common chief complaints for patients in the emergency department (ED). In this week's post we discuss the evidence behind our common management strategies.
Physician Burnout
Over the past decade, medical practice has become increasingly difficult due to worsening stressors in the workplace, leading to a rising prevalence of physician burnout. Learn the scope of the problem and what we can do as individuals to prevent burnout from happening to us.
Understanding An Enigma: Lumbar Puncture After A Negative CT in SAH
Acute headache is a common emergency department complaint, and in the right clinical setting, subarachnoid hemorrhage can often be high on the differential. We review an article that delves into the data on whether patients with a negative head CT still need an LP. The jury may still be out.
Nursing Communication 101
Good communication with nursing staff is not rocket science but it does take deliberate practice and effort on the part of the physician. Here are a few tips to help new physicians become an effective communicator and team leader.
Influenza Like Illness Mimics
Before labeling a patient as an “influenza like illness” what other potentially life-threatening flu mimics should be considered? Specific clinical questioning will help you to narrow your differential diagnosis.
Infantile Colic
Most infants cry more during the first three months of life than at any other time. As an emergency medicine physician, it’s crucial to rule out other etiologies of fussiness before discharging with pediatrician follow up. You can find some tips and tricks here to help you with this difficult diagnosis in the emergency department.