January 20, 2020

Definition: Acute infection of the ascitic fluid in a patient with liver disease without another source of infection

Epidemiology: (Runyon 1988, Runyon 1988, Borzio 2001)

  • Incidence
    • 10-25% risk of at least one episode per year
    • 20% risk in those with ascites admitted to the hospital
  • Historically, mortality ~ 50%

Pathophysiology:

  • Not completely understood
  • Increased portal systemic hypertension
    • Causes mucosal edema of the bowel wall
    • Increases transmural migration of enteric organisms into the ascitic fluid
  • Impaired phagocytic function in the liver
  • Impaired immunologic activity in ascitic fluid

January 15, 2020

Take Home Points 
  • Osteomyelitis is an infection in any part of a bone. It has a varied presentation including acute and chronic forms. Patients can present septic, or rather well appearing.
  • Patients may present with fever, chills, musculoskeletal pain, erythema, swelling or drainage from an ulcer.
  • Lab evaluation includes WBC, ESR and CRP, which we expect to be elevated in acute osteo, but less so in chronic.
  • MRI is the best imaging modality, but XR and CT may have some findings that suggest osteo.
  • Unstable patients should be started on broad spectrum antibiotics, usually vancomycin and cefepime, right away. Stable patients can be started on antibiotics in conjunction with your orthopedic consults.

December 19, 2019

Background: E-cigarettes or “vapes” are now the most popular tobacco product among US teens and are used by 20% of all high-schoolers2. Vapes are used to heat and vaporize a liquid (e-juice or vape juice) that may contain nicotine, tetrahydrocannabinol (THC), cannabidiol (CBD), or ultraconcentrated THC resin (hash oil, wax, or dabs.)3. Since their introduction, vaping devices have been studied for the numerous potentially harmful chemicals they can introduce into users, including: heavy metals (cadmium, nickel, lead), plastic-related toxic gases (like cyanide and phosgene), volatile organic compounds, ultrafine particles, and diacetyl flavoring (linked to a chronic pulmonary syndrome known as ‘popcorn lung,’ which is not as appealing as it sounds)4. More recently, a spectrum of lung illnesses related to vaping have become the focus of a national public health investigation. These cases have been described in almost every US state since early summer 2019; as of November 2019, there have been over 2000 cases of ‘Vaping-Associated Lung Injury’ (VALI) reported to the CDC, with 42 associated deaths. The article discussed below is a large case series from the Midwest depicting the clinical characteristics and outcomes of patients with VALI from April to August 2019.  Since then, several more epidemiological and analytical investigations have been published, and studies are ongoing to clarify the causes and best treatments for this disorder. We chose this article for REBEL EM because it represents a well-done early investigation of an emerging epidemic which contributed valuable clinical insights for emergency medicine practice.

December 18, 2019

Take Home Points

  • Important as front line providers to know research and data behind stroke care
  • Patients eligible for endovascular care are those with large vessel occlusion in the anterior circulation - anterior cerebral artery, middle cerebral artery, distal intracranial carotid artery and they have to have perfusion mismatch (small infarcted core with a large penumbra).