PEM Source

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All posts with tag: "gi"

Tips and Tricks

Hyperemesis due to cannabis use is on the rise, particularly in areas with marijuana legalization. While classically it is seen in chronic, daily users, affected patients sometimes have been using cannabis for less than a year, and may be using it as infrequently as once a week. Patients present with bouts of severe nausea, vomiting, and abdominal pain. A classic symptom is relief with hot showers (due to activation of the TRPV1 receptors). Symptom relief in the ED involves fluid rehydration and ondansetron (although this often no longer works for the patient after multiple bouts). There are also many reports of successful resolution of acute symptoms with benzodiazepines, haloperidol, and topical capsaicin. Curative treatment involves convincing the patient to stop cannabis use. Therein lies the tip, which I just learned from a colleague – a good way to help the patient understand is to tell them they suffer from an “allergy” to marijuana– while some people may be able to use marijuana chronically, they cannot, as it will cause these symptoms. Cessation of cannabis use can result in symptom relief as soon as 12-24 hours but sometimes not for as long as 3 weeks. So let them know how long that “allergic reaction” can continue!
Your local hospital cafeteria can be a useful resource in managing your PED patients:
  1. Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts
  2. A mayonnaise packet provides useful lubricant for removing a tight ring
  3. Tannins from a tea bag (particularly black tea) can help clotting with post dental extraction bleeding (place a moistened tea bag in the socket and have the patient apply pressure by biting down)
  4. A packet of sugar + 10 mL sterile water = make your own sucrose solution for treatment of pain associated with procedures in infants
Know of any more? Comment below!
What can you do if your patient is maxed out on ondansetron but still feels nauseated? A recent study in Annals EM found a positive treatment effect of deeply inhaling from a standard isopropyl alcohol pad held 2.5 cm from the patient's nose. Patients inhaled for 60 seconds at 0, 2, and 4 minutes (stopping if nausea resolved), and nausea was rated up to time 10 minutes. (Caveat: this study enrolled only adults). A 2012 Cochrane review also found isopropyl alcohol inhalation beneficial, although less so than standard antiemetic medications. Also, anecdotally, for dehydrated patients, rehydration and resolution of ketosis is thought to improve nausea and vomiting. For the grammar police out there, clarification of nauseated vs nauseous can be found here

PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!) 14yo boy presents with LLQ abdominal pain and left hip pain for 5 days. He has not had any fever. He is an active baseball player and skinned his right knee the week before. On exam, he prefers to keep his left hip flexed at 90 degrees, walks with a limp and lordosis, and is most comfortable laying on his right side with his hips flexed. He has LLQ abdominal tenderness and has maximal pain with any attempt to extend or internally rotate his left hip. Genitourinary exam is normal. [yop_poll id="61"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 month old comes in with diarrhea x 3 days, 5 times per day initially now 3 times per day, non-bloody, no fever, no vomiting. The patient was seen in the ED the day before, and had stool culture sent which was negative, C. difficile toxin which was positive, and stool WBC negative. [yop_poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old girl was sitting with lap belt only in the back seat of a minivan involved in a motor vehicle accident where her car was rear-ended. She has a “seat belt sign,” or ecchymosis over her lower abdomen. Her CT abdomen with contrast is normal, but she continues to have tenderness to palpation. However, she states she is hungry. [yop_poll id="48"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 10 month old infant with history of constipation comes in with a 1cm dark red (but not dusky) painless mass extruding from the anus. The patient is afebrile, well appearing and playful, and the remainder of the exam is unremarkable. Rectal_Prolapse_Toddler_1 Wikimedia Commons, user BellaVuk [yop_poll id="42"]
(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]
A family obtained tuna from the local farmer’s market and prepared it for dinner. The children thought the fish tasted weird, peppery or metallic, but the parents did not, and told the children to stop complaining and eat dinner. Within 20 minutes of consumption, the children complain of headache, dizziness, pruritis, abdominal cramping, and nausea. They appear somewhat flushed in the face, neck, and chest. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="12"]
A 19yo man presents with his 3rd bout of unremitting nausea and vomiting. He has been admitted twice before and treated with ondansetron and IV fluids. He was noted to take frequent long showers while admitted. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="8"]
All of the following preclude expectant outpatient management in the case of an ingested button battery found by imaging to be in the stomach except: A. Co-ingestion of a magnet B. Child complains of abdominal pain C. Child has history of constipation D. Battery is > 15mm diameter and has been present > 4 days in a child < 6 years old E. N/A; ingested batteries should always be endoscopically removed
A 6yo boy is in the ED with his third episode of intussusception over the past year. Previous episodes presented with colicky abdominal pain and stool guaiac positive, and were successfully managed using barium enemas. He has been completely well between episodes. What imaging study is indicated to assess for the most common cause of a pathologic lead point? A. Complete ultrasound of the abdomen B. Computed tomography of the abdomen with oral and IV contrast C. Upper gastrointestinal study with small bowel follow-through D. Technetium-99m-pertechnetate scintigraphy E. Magnetic resonance imaging of the abdomen

Conundrums

What do you include in your GI cocktail for adolescents? [poll id="15"]
You are seeing a 5 year old with intermittent LLQ abdominal pain for a month. She is well appearing and has a benign abdominal exam. She is eating normally, not vomiting, and has no fever or diarrhea. The parents deny constipation or hard stools, but you suspect constipation is the diagnosis. [poll id="13"]
You are seeing a 6 week old ex-full term infant who is breastfeeding exclusively, having 6 wet diapers per day, 4 or more soft seedy stools per day, growing well, and no fever. Baby has been jaundiced since 1st week of life, and while it is not worse, parents come in because it is prolonged. Jaundice is to the level of the chest, and transcutaneous bili is 10. [poll id="12"]

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