Core EM - Emergency Medicine Podcast

Episode 0.0: Intro to the Core EM Podcast. Every Monday we'll release a podcast featuring pearls, pitfalls and critical take home messages from our weekly resident conference.

We dissect one of the most common injuries we see in the ER -- ankle sprains

Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD

Show Notes

Background

• Among most common injuries evaluated in ED
• A sprain is an injury to 1 or more ligaments about the ankle joint
• Highest rate among teenagers and young adults
  • Higher incidence among women than men
• Almost a half are sustained during sports
• Greatest risk factor is a history of prior ankle sprain

Anatomy

• Bone: Distal tibia and fibula over the talus → constitutes the ankle mortise
• Aside from malleoli, ligament complexes hold joint together
  • Medial deltoid ligament
  • Lateral ligament complex
    • Anterior talofibular ligament
      • Most commonly injured
      • Weakest
      • 85% of all ankle sprains
    • Posterior talofibular ligament
    • Calcaneofibular ligament
  • Syndesmosis

Mechanism of Injury

• Lateral ankle sprains
  • Most common among athletes
  • ATFL most commonly injured
    • Combined with CFL in 20% of injuries
  • 2/2 inversion injuries
• Medial ankle sprains
  • Less common than lateral because ligaments stronger and mechanism less frequent
    • More likely to suffer avulsion fracture of medial malleolus than injure medial ligament
  • 2/2 eversion +/- forced external rotation
  • Typically landing on pronated foot -> external rotation
• High Ankle sprains
  • Syndesmotic injury
  • More common in collision sports (football, soccer, etc)
• Grade I
  • Mild
  • Stretch without “macroscopic” tearing
  • Minimal swelling / tenderness
  • No instability
  • No disability associated with injury
• Grade II
  • Moderate
  • Partial tear of ligament
  • Moderate swelling / tenderness
  • Some instability and loss of ROM
  • Difficulty ambulating / bearing weight
• Grade III
  • Severe
  • Complete rupture of ligaments
  • Extensive swelling / ecchymosis / tenderness
  • Mechanical instability on exam
  • Inability to bear weight

Examination

• Beyond visual inspection for swelling, ecchymoses, abrasions, or lacerations
  • Palpation
  • Pain when palpating ligament is poorly specific but may indicate injury to structure
  • Check sites for Ottawa ankle rules to evaluate if there may be an associated fracture with injury
    • Posterior edge or tip of lateral malleolus (6 cm)
    • Posterior edger or tip of medial malleolus (6 cm)
    • Base of fifth metatarsal
    • Navicular bone
  • Acute ATFL rupture / Grade III Sprain
    • 90% chance of this injury if hematoma and localized tenderness with palpation present on exam over this ligament
    • Anterior drawer test
      • Assess for anterior subluxation of talus from the tibia
        • Ankle in relaxed position, distal extremity is stabilized with one hand while the other cups the heel to apply anterior force
      • Compare to contralateral side
      • Difficult to determine if there is an acute rupture at this point and may be more easily diagnosed in subacute phase (4-5 days after injury)
      • Ability to perform exam adequately limited by pain, swelling and potential muscle spasm
    • Talar tilt test
      • If applying inversion force to ankle and there is excessive mobility → calcaneofibular ligament
    • Thompson test
      • Can be performed if there is concern for concomitant Achilles tendon injury
  • Do not miss a Maisonneuve fracture by palpating proximally about the fibular ahead as forces may be transmitted through the syndesmosis
    • Squeeze test – pressure just proximal to ankle
      • If elicits pain → concern for syndesmotic injury

Diagnostics

• X-rays indicated if unable to rule out usi...

This week we dive into a recent article highlighting a major update in the treatment of community acquired pneumonia (CAP)

Show Notes

Read More

REBEL EM: Update in Community Acquired Pneumonia (CAP) Treatment – Macrolide Resistance

Moran GJ, Talan, DA; Pneumonia, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 76: p 978-89.

Haran JP et al. Macrolide resistance in cases of community-acquired bacterial pneumonia in the emergency department. J Emerg Med 2018. PMID: 29789175

Mandell LA et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S27–72. PMID: 17278083

Arnold FW et al. A worldwide perspective of atypical pathogens in community-acquired pneumonia. AmJ Respir Crit Care Med 2007;175:1086–93. PMID: 17332485

In this episode, we discuss the recent measles outbreak and how ED providers can best prepare to treat this almost vanquished foe.

Show Notes

Episode Produced by Audrey Bree Tse, MD

References:

CDC Measles for Health Care Providers. https://www.cdc.gov/measles/hcp/index.html#lab.

Gladwin M, Trattler B. Orthomyxo and Paramyxoviridae. In: Clinical Microbiology Made Ridiculously Simple. 4th ed. Miami, FL: MedMaster, Inc; 2009: 240-243.

Hussey G, Klein M. A Randomized, Controlled Trial of Vitamin A in Children with Severe Measles. N Engl J Med. 1990; 323: 160-164.doi: 10.1056/NEJM199007193230304.

Nir, Sarah Mailin and Gold, Michael. “An Outbreak Spreads Fear: Of Measles, of Ultra-Orthodox Jews, of Anti-Semitism.” New York Times [New York City] 03/29/2019. https://www.nytimes.com/2019/03/29/nyregion/measles-jewish-community.html

A massive thanks to:

Shweta Iyer, MD: NYU Langone 3rd year Pediatric Emergency Medicine Fellow.

Jennifer Lighter, MD: Assistant Professor of Pediatric Infectious Diseases, NYU School of Medicine.

Michael Mojica, MD: Associate Professor of Pediatric Emergency Medicine, NYU Langone Medical Center.

Michael Phillips, MD: Chief Hospital Epidemiologist, NYU Langone Medical Center.

In this episode, we discuss acute decompensated heart failure and how to best manage these dyspneic patients in the ED.

Show Notes

• Features that increase the probability of heart failure. (Wang 2005)
• B-lines seen in pulmonary edema.
• Positioning of ultrasound probe in BLUE protocol. (Lichtenstein 2008)