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EM@3AM: Scleroderma and Severe Sequelae

A 45-year old African American woman presents with progressive fatigue over the past week and has experienced intermittent episodes of severe hand pain that typically self-resolve. She has also noted a worsening headache over the last day. Her blood pressure is 197/105 mm Hg and heart rate is 90 bpm. The physical exam is notable for smooth and taut skin on the patient’s face and hands. Laboratory values show a creatinine of 3.1 mg/dL. What is the likely diagnosis?

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    Articles

    • practice updates, TOXCards

    Lipid Emulsion Therapy

    • 2 Comments
    "The lack of high-quality controlled human studies precludes ILE as a first-line agent for indications other than local anesthetic systemic toxicity"
    Thanks to James Cao, MD for this excellent review of the literature on the use of ILE therapy in various toxicologic emergencies.
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    Mystery Bleed (M&M)

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    We're grateful to Mathew Miskimon, MD PhD for providing this morbidity and mortality (and improvement!) case from Janus General. Includes a nice discussion at the end on the systemic factors contributing to the outcome.
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    Airway Subtleties in Critically Ill Patients

    • 16 Comments
    DKA: "Trying to intubate [...] using standard approaches can cause a period of apnea, which can kill your patient"
    Cynthia Santos, MD with recs for your patients with salicylate toxicity, sepsis-induced ARDS, and DKA (ie, the ones who will likely require some modification to your usual airway algorithm). Crucial info
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    "Rule out SBO"

    • 2 Comments
    A diagnostic dilemma from the case files of Janus General. The presentation of this clinical zebra is provided by one of our esteemed editors, Adaira Landry, MD (@AllAroundDoc).
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    Massive Vaginal Bleeding

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    "Packing may be the most effective hemostatic temporizing measure that can be performed in the ED"
    Jessica Lopez, MD discusses the management of the non-pregnant patient with severe vaginal bleeding, including tamponade techniques and the utility of tranexamic acid.
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    Shoulder Ultrasound: Intra-Articular Injection and Reduction

    • One Comment
    "One systematic review found intra-articular injections to be as safe and effective as procedural sedation for bedside shoulder reductions"
    Last month Tyler Dschaak, MD told us about using ultrasound to diagnose a septic hip. Today's post is on the utility of ultrasound in the diagnosis and management of shoulder dislocations.
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    Acute heart failure exacerbation disposition

    Not all patients require admission

     

    Consider patient hemodynamics, respiratory status, ECG, labs (Cr, troponin, sodium/electrolytes), ability to ambulate, follow up

     

    Elevated troponin and serum Cr associated with worse outcomes

     

    Don’t use risk tools alone for DC, but Ottawa Heart Failure Risk Scale may assist in admission (ACEP Level B)

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