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Prostate Pro Tips Oct 17, 2020

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD

When someone comes in with prostate related symptoms and infection, it’s hard to know if we’re working with prostatitis vs prostate abscess. How can we improve our prostate game? Tarlan Hedayati, MD schools Matthieu DeClerck, MD, and Neda Frayha, MD with her prostate pro-tips.

Pearls:

Think about acute bacterial prostatitis when someone presents with symptoms of acute prostatitis AND has the following characteristics: immunocompromised, symptoms > 36 hours, progressive urinary retention, recent antibiotics for prostatitis.
Avoid prostate exams in people with neutropenia given theoretical risk of seeding bacteria.

Distinguishing between acute bacterial prostatitis and prostate abscess can be difficult because patients will look sick (fever, tachycardia, abdominal pain) in both cases
- Suprapubic pain
- Abdominal pain
- Urinary retention
- History of having had prostatitis in the past
- Pain with defecation or with prolonged sitting
- Immunocompromised patient
- Protracted symptoms > 36 hours
- Progressive urinary retention
- Patients who have received antibiotics for prostatitis but are getting worse
- Overlap symptom:
- Physical exam and CT scan ultimately will help rule out deadly abscess or other
- Things to make you think more about abscess:
- Pearl: do not send a PSA during acute prostatitis. Leads to unnecessary worry and future monitoring of PSA levels.
Prostate exam tips:
- Start with palpation of the anal-rectal junction to get a sense if discomfort is coming from the exam itself versus the prostate and examine if there a rectal abscess
- Palpate the prostate last to feel for bogginess, tenderness
- Prostate massage is supposed to increase the sensitivity of urine culture by squeezing bacteria out of the prostate into the urethra. However given the discomfort, probably not needed in the emergency or even primary care setting → it should be a quick exam
- Pearl: avoid prostate exam in people with neutropenia given theoretical risk of seeding bacteria
Categories of prostatitis:
- A urinalysis, gram stain and culture should not have any bacteria
- Patients have been dealing with for a longer time and are non-toxic appearing
- Chronically have WBC’s in the urine with no symptoms
- Diagnosed by biopsy
- Acute bacterial prostatitis
- Chronic bacterial prostatitis
- Chronic prostatitis or chronic pelvic pain (90% of prostatitis)
- Asymptomatic inflammatory prostatitis
Treatment:
- E-coli is the bacteria you’re treating against → check your local antibiogram for resistance patterns
Prostate abscess
- 5th or 6th decade of life
- Immunosuppression
- End stage renal disease
- Indwelling catheter
- Any recent instrumentation of the prostate
- Potential complication of inflammatory prostatitis
- At most 2.5% of patients
- Risk factors:

REFERENCE:

Carroll DE, Marr I, Huang GKL, Holt DC, Tong SYC, Boutlis CS. Staphylococcus aureus Prostatic abscess: a clinical case report and a review of the literature. BMC Infect Dis. 2017 Jul 21;17(1):509.
Datillo WR, Shiber J. Prostatitis or prostatic abscess. J of Emerg Med. 2013; 44(1):e121-e122
Hsieh MJ, Yen ZS. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 1: Is there a role for serum prostate-specific antigen level in the diagnosis of acute prostatitis? Emerg Med J. 2008 Aug;25(8):522-3.
Khan FU, Ihsan AU, Khan HU, Jana R, Wazir J, Khongorzul P, Waqar M, Zhou X. Comprehensive overview of prostatitis. Biomed Pharmacother. 2017 Oct;94:1064-1076.

What Do I Do Next? | Pancreatitis Oct 17, 2020

Matthieu DeClerck, MD, Mike Weinstock, MD, and Cameron Berg, MD sit down to discuss the diagnostic criteria for acute pancreatitis. They discuss workup: the role of imaging to rule out gallstone pancreatitis. They go into risk stratification of acute pancreatitis as well as Initial management: pain control, IV fluids, nutrition. And ultimate disposition – when to go home? When to admit to a higher level of care?

Pearls:

Confirmatory CT scanning is rarely needed to confirm pancreatitis
Amylase level is neither as sensitive or specific as lipase.
Early feeding, has been shown to improve outcomes in patients with pancreatitis.

DIAGNOSING PANCREATITIS

Must meet 2 of the following 3 criteria:
- Clinical presentation that is consistent with pancreatitis - epigastric or upper abdominal pain, frequently radiating to the back often with associated with nausea and vomiting,
- A lipase level that is three times the upper lab limit of normal for a given assay.
- - Do not order an amylase as it not as sensitive or specific for pancreatitis as lipase.
  - The initial lipase level cannot predict outcomes of patients with pancreatitis and there's no utility in trending lipase levels
- A CT scan demonstrating pancreatic inflammation consistent with pancreatitis.
- - Note: A CT is rarely needed to confirm pancreatitis but it is the gold standard when there is diagnostic uncertainty.
Perform a RUQ ultrasound to rule out gallstone pancreatitis as the most common cause of pancreatitis in the United States is biliary.
- Patients with biliary tract obstruction will need an ERCP or MRCP urgently that many facilities cannot get 24/7.
Obtain a triglyceride level as hypertriglyceridemia is the third most common cause of pancreatitis after alcohol and gallstones.

MANAGEMENT

Not all patients with acute pancreatitis require hospital stay.
Consider the following factors before deciding on admission:
- Patient vital signs
- Clinical appearance
- Ability to perform ADLs
- Presences or absence of markers of end organ stability
Patients with pancreatitis who are admitted should receive adequate fluid resuscitation in the form of 2-3L of IV crystalloid.
Feed the patient orally as soon as possible as early enteral nutrition, rather than bowel rest, has been shown to greatly increase recovery.
Patients with gallstone pancreatitis and pancreatitis secondary to hypertriglyceridemia require a higher level of care and should be referred appropriately.

REFERENCES:

Uhl, W. et al. 2003. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology.
Tenner, S. 2013. American College of Gastroenterology Guidelines: Management of Pancreatitis. The American Journal of Gastroenterology.

Knee X-rays Oct 16, 2020

Arun Sayal, MD runs through a thoughtful approach to the knee exam with Neda Frayha, MD, Matthieu DeClerck, MD. One that includes the Mnemonic “SLR-CDEF” as a reminder of what diagnosis we should think about with every knee injury. The mnemonic stands for Septic knee, Locked knee, Referred pain, Compartment syndrome, Dislocation (spontaneously reduced), Extensor mechanism disruption (Over 40, look over the patella – i.e., a quadriceps tear. Under 40 look under the patella – i.e., a patellar tendon rupture), Fracture (radiographically occult …

Pearls:

History of injury and patient age often will narrow the differential for post-traumatic knee pain to a short list of possible diagnoses.
Knee dislocations can occur in obese patients with very minor trauma and often spontaneously reduce resulting in ‘normal’ x-rays.
Adding oblique x-ray views improves the sensitivity in the diagnosis of tibial plateau fracture.
Radiologists ability to read films in a helpful way is highly influenced by the completeness of the history and the differential diagnoses of concern provided to them.

History will often reveal the source of knee pain after trauma, as a full and careful exam is not generally possible due to pain, swelling, and spasm.
- For example, patients with an ACL tear will describe four classic historical features:
- - Deceleration mechanism
  - Swelling within 1 hour
  - Sensation of a “pop” or shift at the knee joint
  - Inability to return to play
- Patients with a meniscal tear will describe a twisting mechanism.
- - The force of twisting required to tear the meniscus decreases with age.
  - - Elderly patients can simply tear their meniscus by standing up.
- Valgus (ie: knee bending inward) stress tends to cause different injuries depending on the age of the patient.
- - Salter-Harris Femur and/or Proximal fibula in adolescents
  - MCL injury in younger patients (ie: 20-30 years old)
  - Lateral tibial plateau fractures in older patients (ie: >50 years)
Examining patients before reviewing their x-rays will help to determine what to suspect clinically and look for radiographically.
- Other advantages of performing a history and physical prior to ordering x-rays include recognizing that additional views may be helpful and providing a more complete history for the radiologist interpreting the films.
A mnemonic for x-ray ‘negative’ injuries of the knee that can prove useful is SLR-CDEF.
- S - Septic joint
- L - Locked knee (ie: when the knee cannot be fully extended) from meniscal injury
- R - Referred pain (e.g. hip pathology) due to Obturator nerve irritation
- - Knee pain which is not reproduced when ranging the knee is suggestive of a referred source of pain.
- C - Compartment syndrome
- - This can easily excluded by palpating the compartments and, when in doubt, comparing the firmness to the contralateral, uninjured side.
- D - Dislocation (ie: at least 3 of 4 collateral ligaments have been disrupted)
- - Instability is the key finding indicating that a knee dislocation has likely occurred.
  - Knee dislocations commonly will spontaneously reduce, however, even if reduced, patients are at high risk of popliteal artery injury and subsequent ischemia/amputation.
  - In very obese patients, knee dislocation can occur with minimal force (e.g. stepping off a curb).
- E - Extensor Disruption (e.g. Patellar fracture, Patellar tendon rupture, and/or Quadriceps tendon rupture)
- - Patient will be unable to extend their knee/lower leg fully against gravity.
  - Patellar tendon rupture generally occurs in younger patients with high mechanism injury.
  - Quadriceps tendon rupture is more often spontaneous or low mechanism in older patients.
- F - Fracture (occult)
- - The most common occult fracture of the knee is a lateral tibial plateau fracture.
  - - Oblique knee films can allow for better examination for tibial plateau fractures.
  - Segond fractures involve the tibial spine.
  - Osteochondral fragments from the patella can be seen radiographically after certain injuries in adolescent athletes, commonly gymnasts, and should be suspected if when there’s significant knee swelling.
  - Osteochondritis desicans is caused by a twisting mechanism (similar to medial meniscal injury) in adolescents.

Pediatric Burns and the Cup-O-Noodles Oct 16, 2020

Ilene Claudius, MD, Matthieu DeClerck, MD, Lisa Patel, MD, and Mizuho Morrison, DO walk us through the classification of burns in pediatric patients and how this affects management. Criteria and referral to a burn center is discussed as well as the treatment of burns for outpatient vs. inpatient management.

Pearls:

When calculating the total body surface area burned, only include areas of partial or full thickness injury.
A good burn area estimation tool is that a child’s hand is ~1% of their total BSA.
Any partial and/or full thickness burn involving >15% of the total BSA requires immediate burn center referral.
Topical antibiotic ointment is now preferred over silver sulfadiazine for superficial partial thickness burns.
All full thickness burns and partial thickness burns to the hands, face, genitals, or over joints should be seen within several days by a pediatric burn specialist.
When considering burns in children, it is useful to classify them into 3 categories: life threatening, common, and negligible burns.
- Superficial burns (ie: those with erythema only) are of no clinical consequence.
When using a burn formula to calculate the total body surface area (BSA) involved, only the areas of partial and full thickness areas of burn count (ie: with blistering and/or loss of skin).
- Partial thickness burns involve the papillary (superficial partial) or reticular (deep partial) layers of the dermis.
- - These are generally very painful.
- Full thickness burns involve any tissue below the dermis (e.g. fat, muscle, bone etc).
- - These are commonly less painful because the nerves have been destroyed.
- Overestimation of burned surface area is common, especially in children.
- - Most pediatric burns have a small area of partial thickness surrounded by extensive superficial burn.
  - A common pitfall is to count the entire area of injury in the estimate of the percent of total BSA burned.
When estimating the percent of total BSA affected in children, the “rule of 9’s” (commonly used in adults) does not work because the proportional anatomy of children is different.
- The Lund Browder Chart (see references) is useful for estimating total BSA burned in children.
- 1% of a child’s BSA is also roughly the size of the palm and fingers on one of their hands.
Serious burns may require immediate burn center referral or outpatient follow-up depending on anatomic areas affected and the percent of total BSA burned.
- Burns involving >15% of the total BSA require immediate burn center referral because of the risk of significant fluid losses.
- - Lactated Ringer’s is preferred over Normal Saline because of the risk of acidosis.
  - - In an ED/ICU setting, fluid management is guided by monitoring urine output.
  - If possible, it is reasonable to begin IV fluids from UC while arranging an emergent burn center referral.
- Heat loss and risk of hypothermia can be significant for children with large burns and covering children with a warm, dry sheet can help mitigate this while arranging transfer.
- - Burns are very painful, so the liberal use of topical and oral analgesia for severe burns is critical.
- Smaller areas partial thickness burns involving the hands, face, genitals, or extending over a joint or complete circumference of an extremity can cause serious cosmetic and functional impairment and are best managed with close burn center follow-up.
- All full thickness burns will require non-urgent burn center follow-up (ie: within several days) because skin grafting will usually be required to allow for healing.
Recommended topical wound/burn care depends on the depth of the burn.
- Superficial burns require no wound care but aloe products or Vaseline™ can soothe discomfort.
- Superficial partial thickness burns with intact blisters seem to become infected less often and heal faster if the blister is drained and debrided, but this remains controversial.
- - It is appropriate to NOT debride blisters that are thick walled or

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