Volume 32 Number 5 May 2018

Bitter Pill
Geriatric patients can be particularly complex to manage,
as they often present with multiple comorbidities for which
they are taking a number of medications. More than 90%
of elderly patients take at least one prescription drug (the
average is four), and 75% take at least one over-the-counter
medication. Indiscriminate prescribing practices often
lead to treatment overlap in this vulnerable population,
a complication that can increase the risk of drug-drug
interactions and adverse drug events.

Out on a Limb
The differential diagnosis for a limping child is quite
broad, ranging from simple musculoskeletal etiologies
such as sprains and contusions to serious infections
and malignancies. There are several important
factors that must be considered when evaluating such
cases, including the age of the child and particular
developmental milestones. An appropriate application
of historical, physical, laboratory, and imaging findings
can help determine which children can be safely
discharged with appropriate follow-up care, and which
require hospital admission.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 9 n The Limping Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Physicians. Additional volumes are available.
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
EDITOR-IN-CHIEF
Lesson 10 n Adverse Drug Events in Geriatric Patients . . . . . . . . . . . . 19 Michael S. Beeson, MD, MBA, FACEP
Northeastern Ohio Universities,
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Rootstown, OH
CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
SECTION EDITORS
Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Andrew J. Eyre, MD
Brigham & Women’s Hospital/Harvard Medical School,
Boston, MA
Contributor Disclosures. In accordance with the ACCME Standards for Commercial
Support and policy of the American College of Emergency Physicians, all individuals with Joshua S. Broder, MD, FACEP
control over CME content (including but not limited to staff, planners, reviewers, and Duke University, Durham, NC
authors) must disclose whether or not they have any relevant financial relationship(s) to Frank LoVecchio, DO, MPH, FACEP
learners prior to the start of the activity. These individuals have indicated that they have Maricopa Medical Center/Banner Phoenix Poison
a relationship which, in the context of their involvement in the CME activity, could be and Drug Information Center, Phoenix, AZ
perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants,
Amal Mattu, MD, FACEP
honoraria, or consulting fees), but these individuals do not consider that it will influence
University of Maryland, Baltimore, MD
the CME activity. Joshua S. Broder, MD, FACEP; GlaxoSmithKline; his wife is employed by
GlaxoSmithKline as a research organic chemist. All remaining individuals with control over Lynn P. Roppolo, MD, FACEP
CME content have no significant financial interests or relationships to disclose. University of Texas Southwestern Medical Center,
Dallas, TX
This educational activity consists of two lessons, a post-test, and evaluation questions;
as designed, the activity should take approximately 5 hours to complete. The participant Christian A. Tomaszewski, MD, MS, MBA, FACEP
should, in order, review the learning objectives, read the lessons as published in the print University of California Health Sciences,
or online version, and complete the online post-test (a minimum score of 75% is required) San Diego, CA
and evaluation questions. Release date May 1, 2018. Expiration April 30, 2021. Steven J. Warrington, MD, MEd
Accreditation Statement. The American College of Emergency Physicians is accredited Orange Park Medical Center, Orange Park, FL
by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians. ASSOCIATE EDITORS
Wan-Tsu W. Chang, MD
The American College of Emergency Physicians designates this enduring material for a
University of Maryland, Baltimore, MD
maximum of 5 AMA PRA Category 1 Credits™. Physicians should claim only the credit
commensurate with the extent of their participation in the activity. Walter L. Green, MD, FACEP
University of Texas Southwestern Medical Center,
Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for 5 ACEP Dallas, TX
Category I credits. Approved by the AOA for 5 Category 2-B credits.
John C. Greenwood, MD
Commercial Support. There was no commercial support for this CME activity. University of Pennsylvania, Philadelphia, PA
Target Audience. This educational activity has been developed for emergency physicians. Danya Khoujah, MD
University of Maryland, Baltimore, MD
Critical Decisions in Emergency Medicine is a trademark owned and published monthly by the American Sharon E. Mace, MD, FACEP
College of Emergency Physicians, PO Box 619911, Dallas, TX 75261-9911. Send address changes and Cleveland Clinic Lerner College of Medicine
comments to Critical Decisions in Emergency Medicine, PO Box 619911, Dallas, TX 75261-9911, or to
/Case Western Reserve University, Cleveland, OH
cdem@acep.org; call toll-free 800-798-1822, or 972-550-0911.
Jennifer L. Martindale, MD, MSc
Copyright 2018 © by the American College of Emergency Physicians. All rights reserved. No part of this
publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical,
Mount Sinai St. Luke’s/Mount Sinai West,
including storage and retrieval systems, without permission in writing from the Publisher. Printed in the USA. New York, NY

The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its
George Sternbach, MD, FACEP
publications are knowledgeable subject matter experts. Readers are nevertheless advised that the statements Stanford University Medical Center, Stanford, CA
and opinions expressed in this publication are provided as the contributors’ recommendations at the time
of publication and should not be construed as official College policy. ACEP recognizes the complexity of RESIDENT EDITOR
emergency medicine and makes no representation that this publication serves as an authoritative resource
Nathaniel Mann, MD
for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis
for the definition of or standard of care that should be practiced by all health care providers at any particular
Massachusetts General Hospital, Boston, MA
time or place. Drugs are generally referred to by generic names. In some instances, brand names are added
for easier recognition. Device manufacturer information is provided according to style conventions of the EDITORIAL STAFF
American Medical Association. ACEP received no commercial support for this publication. Rachel Donihoo, Managing Editor
To the fullest extent permitted by law, and without rdonihoo@acep.org
limitation, ACEP expressly disclaims all liability for Suzannah Alexander, Publishing Assistant
errors or omissions contained within this publication,
and for damages of any kind or nature, arising out of Lexi Schwartz, Subscriptions Coordinator
use, reference to, reliance on, or performance of such Marta Foster, Director, Educational Products
information.
ISSN2325-0186(Print) ISSN2325-8365(Online)
 Out on a Limb
The Limping Child

LESSON 9

By Mike A. Gardiner, MD, FACEP, FAAP; Coburn H. Allen, MD,

FAAP, FACEP, FPIDS; Robert Vezzetti, MD, FAAP, FACEP;
and Gael Lonergan, MD
Dr. Gardiner is an assistant clinical professor at the University of California, San
Diego School of Medicine and Rady Children’s Hospital – San Diego. Dr. Allen is the
director of the Pediatric Emergency Medicine Fellowship Program and an associate
professor of pediatrics; Dr. Vezzetti is an assistant professor of pediatrics; and Dr.
Lonergan is an attending physician in the Departments of Pediatric Radiology and
Pediatric Emergency Medicine at the University of Texas Dell Medical School –
Austin, Dell Children’s Medical Center of Central Texas.

Reviewed by Sharon E. Mace, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Identify common causes of limping in pediatric
patients.
2. Evaluate appropriate imaging modalities and
laboratory tests for a limping child.
3. Describe the optimal treatment for a limping child.
4. Understand which pediatric patients can be safely
discharged from the emergency department and
which require admission.
FROM THE EM MODEL
1.0 Signs, Symptoms, and Presentations
1.3 General
CRITICAL DECISIONS
n What common etiologies should be considered when
evaluating an afebrile child with a limp, and how
should they be managed?
n What etiologies should be suspected in a febrile
child with a limp, and how should they be
addressed?
n How and when should imaging be used to assess a
limping child?
n What laboratory studies are most valuable in the
evaluation of a limping child?
n When does a pediatric limp warrant inpatient
admission?

The differential diagnosis for a limping child is quite broad, ranging from simple musculoskeletal etiologies
such as sprains and contusions to serious infections and malignancies. There are several important factors that
must be considered when evaluating this common presentation, including the age of the patient and particular
developmental milestones.1 An appropriate application of historical, physical, laboratory, and imaging findings
can help determine which children can be safely discharged with appropriate follow-up care, and which require
hospital admission.

May 2018 n Volume 32 Number 5 3

 CASE PRESENTATIONS
■ CASE ONE
A 15-month-old boy presents with
a limp. His mother states that he was
“jumping around” at a playground
earlier in the day, but began favoring
his right leg soon after they arrived
home. No trauma is noted, and the
patient has not had a fever or recent
illness. He is otherwise healthy and
fully immunized.
His vital signs are blood pressure
90/60, pulse rate 110, respiratory
rate 25, and temperature 36.8°C
(98.2°F). He is boisterous and
active, and his physical examination
reveals a full range of motion of the
lower extremities at the hip, knee,
and ankle joints, without evident
erythema, edema, crepitus, or
deformity. There is no ecchymosis,
and there are no lesions. He is
grossly neurovascularly intact. When
prompted to walk to his mother, the
child does so readily, but with a slight
limp to his right. When his right tibia
and fibula are palpated, he begins to
cry and withdraws the leg.
■ CASE TWO
A 12-month-old girl is brought
in for fever, fussiness, and a refusal
to walk. The mother explains that
the child is normally active, cruising
and beginning to take steps, but has
CRITICAL DECISION
What common etiologies should
be considered when evaluating
an afebrile child with a limp, and
how should they be managed?
The potential causes of limping in
an afebrile child are quite broad, with
diagnoses ranging from benign to life-
threatening (Table 1). The most common
culprits include traumatic, skeletal,
oncological, infectious, and inflammatory
etiologies. It is important to note,
however, that children with transient
synovitis, osteomyelitis, septic arthritis,
and other infectious or inflammatory
conditions may present without fever. It
is crucial to consider these causes when
4 Critical Decisions in Emergency Medicine
refused to do either for the past 3 days.
She denies trauma, cough, congestion,
vomiting, or any other symptoms, but
mentions decreased oral intake. The
patient was previously healthy and is
fully immunized. Her vital signs are
blood pressure 100/65, pulse rate 160,
respiratory rate 30, and temperature
39°C (102.2°F).
The patient is irritable and clings
to her mother. Her ears, nose, and
throat are normal. Her chest is clear,
and aside from mild tachycardia,
her heart appears normal and is
well perfused. The child’s abdomen
is soft and nontender. She is grossly
neurologically intact but prefers not
to be moved; while she is lying on the
examination bed, she screams and holds
both lower extremities flexed at the
hip. She screams even louder when her
legs are manipulated, but it is difficult
to tell which leg is causing her pain.
She holds both legs slightly abducted
and externally rotated, but the position
appears more pronounced on the right.
■ CASE THREE
A 16-year-old girl presents with left-
knee pain. She says her symptoms began
about 6 months ago, but can’t recall any
preceding trauma. She is in generally
good health, and denies any recent
illness or other symptoms, including
evaluating any limping child, with or
without a history of fever.
Traumatic Etiologies
A history of trauma primarily raises
concern for soft-tissue injury and
fractures. Several important skeletal
differences between adults and children
make pediatric trauma unique. The bones
of growing children have an open physis
(“growth plate”), which is the weakest
part of the bone (Figure 1). At certain
stages of bony development, the physeal
portions are weaker than the ligaments
supporting them, making fractures more
likely than sprains or strains.
Pediatric bones are also more porous
and elastic than adult bones, which
fever. She is an active soccer player
and explains that her trainer has been
“working on” her hip during physical
therapy sessions, but has now advised
her to see a physician. The patient
was seen several times by her primary
care provider, who obtained several
plain radiographs of the knee, all of
which were normal. Although she has
continued to remain active, the pain
has begun to interfere with her daily
activities and she is starting to feel
“depressed.”
Her vital signs are blood pressure
110/70, pulse rate 65, respiratory rate
16, and temperature 36.8°C (98.2°F).
She does not appear to be in distress,
until she is asked to ambulate. She
walks with a limp, complaining of
left-knee pain. She is somewhat obese
and tells you that she is in the 90th
percentile for weight, but is “not fat.”
Her pelvis is stable to compression.
There are no indications of trauma;
no lesions; and no erythema, edema,
crepitus, or warmth in the hip,
knees, or lower extremities. She has a
complete range of motion in the right
extremity, but complains of pain with
manipulation of the left femur at the
hip. Her knee shows no abnormalities,
and she is neurovascularly intact.
can lead to plastic bony deformities
and unique injuries, including Torus
fractures (buckling deformities due
to compressive load) and Greenstick
fractures (the fracture of one cortex with
plastic deformity of the other). Any child
with a traumatic mechanism of injury
and a limp should undergo a thorough
physical examination of both legs and
the spine to determine locations of
tenderness, swelling, deformity, warmth,
or erythema.
Toddler’s Fracture
Toddler’s fractures are spiral fractures
of the tibia that occur in ambulatory
children between the ages of 9 and 36
months, often following minimal or
unwitnessed trauma. Children with this through manipulation of the foot with
type of injury often present with an acute the knee held stable.2 Plain-film x-rays
limp and may not bear weight on the often show a nondisplaced or minimally
affected limb. The physical examination displaced spiral fracture through the mid
may be normal, or the patient may exhibit to distal tibial shaft. These fractures can
subtle signs of tenderness and/or minimal be quite subtle on frontal and/or lateral
swelling in the mid to distal tibia. views, and are best visualized using the
Pain may be elicited through direct internal oblique view.
palpation over the fracture site, by passive As many as 40% of children with
dorsiflexion of the ipsilateral foot, or toddler’s fractures have normal x-rays
by applying a twisting force to the tibia on initial evaluation; however, a fracture
may be presumed if the history and
TABLE 1. Differential Diagnoses physical examination are consistent
of Pediatric Limping with this diagnosis and the child is
afebrile. Due to the minimal trauma
Traumatic Etiologies
required to cause a toddler’s fracture,
Fracture
this diagnosis can also be made based on
Sprain or strain
characteristic radiographic findings, even
Nonaccidental trauma
Overuse injury
without a history of witnessed trauma.
Apophysitis The treatment for a toddler’s fracture
Soft-tissue injury or foreign body involves immobilization with a posterior
long-leg splint and orthopedic follow-up
Skeletal Etiologies
for casting. Repeated imaging after 7 to
Slipped capital femoral epiphysis
10 days may show periosteal formation
Legg-Calvé-Perthes disease
Osteochondroma in cases of occult fracture with initially
Osteochondritis dessicans normal x-rays.2,3
Developmental dysplasia of the hip Compartment Syndrome
Tarsal coalition Any limping child with a traumatic
Leg-length discrepancy
mechanism of injury should be evaluated
Blounts disease
for possible neurovascular compromise
Oncological Etiologies and compartment syndrome. The clinician
Osteoid osteoma should assess the severity of pain,
Bone cyst sensation, strength, and distal pulses.1
Ewing sarcoma The disease can be caused by traumatic
Osteosarcoma
injuries, but also may occur as a result
Metastatic bone tumor
of vascular insult, infection, malignancy,
Leukemia
or other atraumatic etiologies.4 The
Infections most common fractures leading to
Septic arthritis compartment syndrome in children are
Osteomyelitis tibial shaft, humeral shaft, and forearm
Discitis
fractures, with tibial shaft fractures
Myositis
accounting for more than 40% of cases.
Spinal epidural abscess
The classic “five Ps” of compartment
Intra-abdominal infection
syndrome (pain, paresthesia, paralysis,
Noninfectious Inflammatory Conditions
pallor, and pulselessness) are often seen
Transient synovitis late, and may be absent or not assessable
Juvenile idiopathic arthritis
in pediatric patients. Other signs and
Henoch-Schönlein purpura
symptoms that should increase suspicion
Spondyloarthropathy
for this diagnosis include pain out of
Systemic lupus erythematosus
Acute appendicitis proportion to the injury, pain with passive
stretch, or the “three As” (increasing
Other Etiologies
anxiety, agitation, and analgesic
Muscular dystrophy
requirement). If compartment syndrome is
Neuropathy
suspected, an orthopedic surgeon should
Spinal cord lesion or compression
be consulted emergently; measurement
Reflex sympathetic dystrophy
Conversion disorder of compartment pressures and/or a
fasciotomy may be considered.
Nonaccidental Trauma
When a fracture is encountered in
any pediatric patient, particularly infants
and developmentally delayed children,
it is crucial for emergency providers to
ask themselves whether the fracture may
be the result of nonaccidental trauma.
Child abuse is an under-recognized
cause of pediatric trauma, and missed or
delayed identification may lead to further
morbidity and mortality.5 Any fracture
in a nonambulatory child should raise
concern for inflicted injury. It is crucial
to obtain thorough details about the
purported mechanism of injury.
It is helpful to understand several
general gross motor milestones in normal
infant development when evaluating for
possible inflicted injury. For instance,
infants typically begin rolling over at 3 to
4 months of age; therefore, a 2-month-
old infant presenting with a fracture
after “rolling off the bed” should arouse
suspicion. When encountering injuries
in children who are developmentally
delayed, the proposed mechanism must be
taken into account in the context of the
patient’s developmental state.
Red flags that may indicate
nonaccidental trauma include a significant
delay in seeking care, other evidence
of injury such as bruising or patterned
injuries (eg, belt marks or cigarette burns),
and multiple fractures in varied stages
of healing. Several fracture types that
should raise suspicion for inflicted injury
include metaphyseal fractures such as
corner fractures, bucket-handle fractures
(Figure 2), sternal fractures, scapular
fractures, spinous process fractures, rib
fractures (particularly posterior ribs),
femur fractures in nonambulatory
children, bilateral long bone fractures,
vertebral body fractures, digital fractures,
and complex skull fractures.6 While none
of these abnormalities are pathognomonic
for nonaccidental trauma, metaphyseal,
sternal, scapular, posterior rib, and
spinous process fractures are highly
specific for abuse.
The American Association of
Pediatrics recommends a skeletal survey
for the evaluation of suspected abuse in
children younger than 2 years; the test is
indicated on a case-by-case basis in those
between the ages of 2 and 5 years.7 The
initial survey may be repeated 10 days
May 2018 n Volume 32 Number 5 5
 later to evaluate for occult fracture. Note
that skeletal surveys add little additional
diagnostic value in patients older than 5
years.
Other studies that are used to evaluate
cases of suspected abuse vary depending
on each clinical scenario and local
practice policy. Potential studies include
a noncontrast head CT, evaluation of
transaminase levels, urinalysis with
microscopic evaluation, coagulation
studies, toxicology studies, a calcium and
vitamin D panel, and an ophthalmological
evaluation for retinal hemorrhages.
A consultation with child abuse
pediatricians (where available) and/or the
involvement of Child Protective Service
agencies can help guide appropriate
management and follow-up care.
FIGURE 1. Normal Knee of a Pediatric Patient
MRI of a child’s normal knee (lateral view), showing the open growth plates at the end of
the femur (upper bone) and the upper part of the tibia (lower bone). The growth plates
(yellow bands) cross horizontally and add length to the long bones. The brown-orange
ends of the bones are epiphyses, and the blue portion is the diaphysis.
6 Critical Decisions in Emergency Medicine
Overuse Injuries
Overuse and apophyseal injuries
frequently happen in adolescents aged 8
to 15 years following periods of new or
intense activity. Although stress fractures
commonly occur in the distal tibia or
foot, they can be found anywhere along
the lower extremity; x-ray findings may
be subtle or delayed. Focal tenderness
with or without a palpable callus
formation can indicate an overuse injury,
particularly in patients with a compatible
history.
Apophyseal injuries are caused by
inflammation at the point where major
tendons are inserted into bone. Common
causes include Sever disease (calcaneal
apophysitis), Osgood-Schlatter disease
(tibial tuberosity apophysitis), and
Sindig-Larsen-Johansson disease (inferior
patellar apophysitis). These diagnoses
manifest with pain and tenderness
isolated to the tendon insertion site at the
heel, tibial tuberosity, and inferior pole of
the patella, respectively.
X-rays are often normal or show
only soft-tissue swelling; however, subtle
bony changes occasionally appear at the
site of tendon insertion. Overuse and
apophyseal injuries are initially managed
conservatively with rest, nonsteroidal
anti-inflammatory medications
(NSAIDs), and stretching of the affected
muscles. Cases that do not respond
to conservative therapy often can be
managed with periods of immobilization
through splinting and/or casting.
Orthopedic surgery or sports medicine
clinic follow-up also is important.
Skeletal Etiologies
Slipped Capital Femoral Epiphysis
Children and adolescents, particularly
those who are overweight or obese, may
suffer from a condition known as slipped
capital femoral epiphysis (SCFE). This is
a disorder in which the capital femoral
epiphysis becomes displaced from the
femoral neck through the physis. While
most children with SCFE present with
hip pain or a chronic limp, thigh or knee
pain is the presenting symptom in as
many as 15% of cases.8 Most patients
complain of a dull aching pain in the hip,
groin, thigh, or knee that is worsened by
activity and relieved with rest.
Although the symptoms generally
are chronic, some patients present
with acute complaints, or following
trauma. SCFE occurs most commonly
in patients between the ages of 10 and
16 years, with obesity, male gender,
and underlying endocrinopathies (eg,
hypothyroidism, growth hormone
restriction, or panhypopituitarism) as
significant risk factors.9,10 On physical
examination, patients with a unilateral
SCFE often demonstrate out-toeing of
the affected leg, an antalgic gait, variable
hip tenderness, and decreased internal
rotation, abduction, and flexion of the
hip with pain during these maneuvers.
Patients with suspected SCFE should
undergo radiographs of the hips and
pelvis. Because a single anteroposterior
(AP) view can miss subtle cases, a lateral
 FIGURE 2. Classic Metaphyseal Bucket-Handle Fracture
The left distal femur shows an acute transverse metaphyseal fracture in a 4-week-old infant.
Metaphyseal fractures are also seen in the left distal tibia. Note the periosteal reaction
along the shafts of the left tibia and fibula.
IMAGE COURTESY OF DR. THOMAS SANCHEZ/EMRES.COM
view of the hips should also be obtained,
including a frog-leg view. Typical
radiographic findings include superior
and anterolateral displacement of the
femoral metaphysis relative to the capital
epiphysis. In a normal hip radiograph,
a line drawn along the superior femoral
neck (Klein’s line) intersects the lateral
portion of the femoral head. In cases
of SCFE, Klein’s line does not intersect
the epiphysis, or is asymmetrical when
compared with the unaffected hip.
Other radiographic findings may
include widening, increased lucency,
and irregularity of the affected physis.
These additional findings may be the
only identifiable abnormalities in cases
of “preslip,” in which the displacement is
minimal or not yet apparent. If suspicion
for SCFE persists despite normal or
inconclusive x-rays, magnetic resonance
imaging (MRI) can be used to detect
radiographically occult fractures.
The treatment of SCFE requires
surgical pinning of the epiphysis in the
current location at the time of diagnosis
without reduction, as attempts at
reduction have been correlated with
worse outcomes. The decision to pin
the contralateral hip prophylactically
in patients with unilateral SCFE is
controversial, and practice patterns
are variable.10,11 Patients with acute
(symptoms <3 weeks) or unstable
(non-weightbearing or with complete
dissociation between the epiphysis and
metaphysis) require emergent pinning.
Such patients also should be designated
as strictly non-weightbearing and
denoted as “nothing by mouth” or nil per
os (NPO) in preparation for immediate
surgical intervention.
Patients with chronic but stable
SCFE should also be designated as non-
weightbearing to prevent further slip;
surgical fixation may be delayed at the
discretion of the orthopedic surgeon.
Children with SCFE need long-term
orthopedic follow-up, as they are at high
risk for osteonecrosis of the affected hip
and development of contralateral SCFE.
Legg-Calvé-Perthes
Another common skeletal cause of an
afebrile limp is idiopathic osteonecrosis
of the hip, also known as Legg-Calvé-
Perthes disease (LCP). LCP has a typical
onset of symptoms between 3 and 12
years of age (with the peak between 5
and 7 years of age). The disease is four
times more common in males than in
females, and 10% to 20% of cases are
bilateral at presentation.12 Children with
FIGURE 3. Legg-Calvé-Perthes
Disease
AP view of the left hip in a 4-year-old boy
with Legg-Calvé-Perthes disease. The left
femoral head is irregular, flattened, and
sclerotic.
LCP typically present with an insidious
onset of chronic hip pain or a limp that
is worsened by activity. In many cases,
limping is the more prominent symptom,
with minimal or no complaints of
discomfort.
Occasionally, pediatric patients
experience stress fractures of the hip
with routine or minimal trauma, which
may lead to the diagnosis of LCP. The
physical examination may reveal an
antalgic gait to the affected limb with
limited passive abduction and internal
rotation of the hip, with or without pain
or tenderness. Plain films early in the
disease course are often normal, with
disease progression showing a small,
dense, fragmented capital epiphysis and a
widened, irregular physis (Figure 3). MRI
may show bone marrow changes and can
aid in diagnosis if plain films are normal.
Patients with LCP should avoid
bearing weight and should be referred to
an orthopedic surgeon. Such cases can
often be managed nonsurgically with
splinting to maintain the femoral head
within the acetabulum. Younger patients
with mild disease do very well; when
treated conservatively, children younger
than 6 years often make a full recovery
without long-term deficits.13 Patients
May 2018 n Volume 32 Number 5 7
 who fail conservative therapies may
require surgical osteotomy to obtain
proper healing and alignment of the
femoral head.
Oncological Etiologies
A variety of tumors — both benign
and malignant — commonly present in
children as bone pain or a limp.
Osteoid Osteoma
Osteoid osteoma is most common in
teenagers (70% of cases are diagnosed in
those younger than 20 years). Symptoms
include focal nocturnal pain and aching
that responds well to NSAIDs. Although
these benign lesions often affect long
bones, they can erupt anywhere in
the skeleton.14 While the physical
examination is often normal, it may
reveal focal swelling, muscle atrophy or
contractures, or leg-length discrepancy.
Osteoid osteomas are often apparent
on plain-film radiographs as a bony
lucency with a dense central nidus;
however, MRI occasionally is required
to make a definitive diagnosis. Treatment
consists of supportive care and pain
management with NSAIDs, as lesions
often resolve spontaneously over
months to years. Patients with severe
pain or tumors that do not improve
spontaneously may require surgical
excision or radiofrequency ablation of
the nidus. These procedures may be
curative, but recurrence is a common
complication.14
Malignant Tumors
The two most common malignant
bone tumors in children are Ewing
sarcoma and osteosarcoma. These
tumors often occur in the distal femur
and proximal tibia, but may manifest
anywhere along the axial or appendicular
skeleton.15 They may be diagnosed
incidentally on x-rays following minor
trauma, or may trigger an acute visit
for chronic pain, limping, or other
musculoskeletal complaints.
Pain that occurs at night, at rest, or
in nonarticular areas, as well as systemic
symptoms, should raise suspicion for
malignancy. These tumors are often
diagnosed on x-rays and show poorly
defined tumor margins and characteristic
findings, including “onion skinning” in
cases of Ewing sarcoma and a “sunburst”
pattern in osteosarcoma (Figure 4).
8 Critical Decisions in Emergency Medicine
The staging and treatment of malignant
primary bone tumors is beyond the
scope of this article; however, further
discussion with a pediatric oncologist is
recommended.
Acute Leukemia
A recent meta-analysis of presenting
signs and symptoms in children with
leukemia showed that 43% experience
bone pain.16 Although patients with
leukemia commonly present with several
complaints, pain and/or a limp can be
the only presenting symptoms. Related
findings include pallor, petechiae,
ecchymosis, and hepatosplenomegaly; a
thorough physical examination is crucial
in cases of atraumatic bony pain or
limping.17
Radiographic findings in leukemia
are variable, but may include osteopenia,
metaphyseal bands, lytic lesions, sclerotic
changes, and bony destruction. Although
the management of acute leukemia
is beyond the scope of this article,
consultation with a pediatric oncologist is
crucial for further evaluation.
CRITICAL DECISION
What etiologies should be
suspected in a febrile child with
a limp, and how should they be
addressed?
Fever and extremity injury/pain are
the two most frequent, chief complaints
of children seen in the emergency
department, according to a survey of
more than 600 facilities in the United
States.18 Infection is usually to blame in
febrile children who present with a limp;
however, other serious inflammatory
etiologies include rheumatological and
oncological diseases. A thorough history,
physical examination, and testing, when
appropriate, allow the clinician to quickly
ascertain the most likely culprits.
Infections
A broad number of pathogens
(typically viral or bacterial) have the
propensity to cause extremity pain and
fever. Extremity pain and limping may
originate from infections that involve
different types of tissues, including skin,
bone, joint, muscle, and vertebral disc
tissues. Infections frequently occur in
more than one tissue type at the same
time (eg, staphylococcal osteomyelitis
with adjacent myositis and/or septic
arthritis). Pyogenic processes tend to
be confined and therefore create focal/
unilateral signs and symptoms, whereas
viral and noninfectious causes of fever
and limping often present with more
diffuse, symmetric/bilateral signs and
symptoms or difficult-to-localize pain.
Skin and soft-tissue infections,
including cellulitis, boils, adenitis, and
paronychia, are readily identified with a
thorough examination of an undressed
patient. Special attention should be paid
to the feet, looking closely at and between
the toes and the plantar surface for signs
of puncture wounds and foreign bodies.
Boils have a propensity to develop on the
buttocks and perineal skin of children,
and can easily be missed through
misguided attempts to respect the privacy
of patients.
Gram-positive bacteria (eg, Strepto­
coccus pyogenes and Staphylo­coccus
aureus) are almost always the cause of
skin and soft-tissue infections; however,
Gram-negative bacteria and anaerobes
should be considered in puncture
wounds, infected foreign bodies, and in
any case that includes perianal/perineal
involvement.
Children suffer from higher rates
of bone and joint infections, most
commonly of the leg, than adult
patients.19 The majority of osteoarticular
infections are acquired through the
bloodstream (hematogenous) but may be
the result of trauma or chronic decubitus
wounds (especially pelvic and ankle/
foot) with direct inoculation of the
bone or joint. Osteomyelitis is clinically
characterized by fever and focal bone
tenderness, usually over the metaphysis
in long bones.
Children with bony involvement
from the foot to the spine may report
pain, a limp, and an inability to bear
weight; infants may simply be fussy.
Similar features occur in joint infections;
however, the tenderness is focused
around a joint in such cases, and mobility
is restricted and extremely painful.
Although bone and joint infections may
manifest overriding warmth, redness, and
swelling, these symptoms tend to be less
definitive than in children with cellulitis,
adenitis, or boils. Likewise, pediatric bone
and joint infections rarely develop from
an overriding skin or soft-tissue infection.
Vertebral, pelvic, and hip infections
are subtler in presentation than those
involving the knee, ankle, and foot.
Osteomyelitis with concomitant adjacent
septic arthritis occurs mostly in young
infants, in whom the venous connections
between the metaphysis and epiphysis
allow the spread of bacteria toward the
joint. These “bridging vessels” cease to
exist by 18 to 24 months of age.
The predominant organism implicated
in osteoarticular infections for all ages
and bone types is Staphylococcus aureus.
However, Gram-negative bacteria such
as Kingella kingae (in preschoolers
with septic arthritis) and Salmonella
FIGURE 4. Osteosarcoma
X-ray of the left knee reveals osteosarcoma of the upper part
of the tibia, with a rupture of the cortical bone.
(hemoglobinopathies) are recovered at
increased rates in select populations.
Polymicrobial infections are expected
in patients with chronic wounds and
in cases of trauma. Lyme disease also
should be considered in any child with
arthritis and fever who has been exposed
to a Lyme-endemic area.20
Myositis (“pyomyositis” if focal
purulent collection) can be bacterial or
viral in origin. Viral myositis is fairly
common in children with influenza (but
many other viruses have been implicated
to a lesser degree) and has an interesting
predisposition for the calf muscles,
leading to a classic “Charlie Chaplin”
gait (toes pointed out, shuffling to avoid
stretching the gastrocnemius muscles) or
FIGURE 5. Osteomyelitis
X-ray reveals acute osteomyelitis in an 11-year-old child.
toe walking. Bacterial myositis is usually
focal; it commonly involves the upper leg
or deep pelvic muscles, or erupts adjacent
to an underlying osteomyelitis.
Careful examination of the involved
area may reveal asymmetric swelling,
warmth, and more diffuse tenderness
than osteoarticular infections. There
is typically minimal to no overriding
redness, and features are even more subtle
when deep pelvic muscles are involved.
As with other bacterial causes of pediatric
fever and limping, Gram-positive bacteria
predominate; antistaphylococcal coverage
is warranted.21
Vertebral disc infections, or “discitis,”
can lead to fever (often remote) and
limping (or not bearing weight) in young
May 2018 n Volume 32 Number 5 9
 children, and are particularly easy
to miss. Discitis has a more indolent
presentation than osteoarticular and
muscle infections. Special attention to
the lower spine, especially tenderness
with percussion of the lumbar area, may
be the only localizing finding. Infants
may also prefer to lie down instead of
to sit, and may roll over and move more
gingerly than usual. The etiology of
discitis is seldom discovered; however,
Staphylococcus aureus is the organism
most often recovered.22
Noninfectious Inflammatory
Conditions
Transient synovitis (toxic synovitis)
is a more common cause of limping
in children between the ages of 3 and
8 years than infection. This condition
often causes acute hip pain, limping, or
refusal to bear weight, with or without
a fever.1 Transient synovitis (TS) is a
postinfectious autoimmune inflammatory
condition that commonly occurs after
a viral or group A strep infection;
however, in many cases, no specific cause
is identified. TS is a self-limited disease
that often resolves without incident.
Supportive care with NSAIDs is generally
sufficient for pain control.
Laboratory work and imaging are
not necessary to diagnose the disease;
FIGURE 6. Slipped Epiphysis
X-ray reveals slipped capital femoral epiphysis in an 11-year-old girl.
10 Critical Decisions in Emergency Medicine
however, in a child with hip pain, fever,
and/or refusal to bear weight, these tests
may be necessary to differentiate TS
from septic arthritis. In such cases, plain
films generally are normal, ultrasound
may show a hip effusion, and MRI may
demonstrate a hip effusion with synovial
enhancement and the absence of marrow
signal enhancement.
Pediatric rheumatological and onco-­­
­­logical conditions that may present as
fever and limping include juvenile
idiopathic arthritis (JIA), dermatomy­
ositis, systemic lupus erythematosus
(SLE), rheumatic fever, and leukemia.
In a large surveillance study of children
with acute musculoskeletal complaints,
only 0.1% of cases were attributed to
noninfectious inflammatory arthritis,
whereas nearly 90% were due to
trauma.23
Generally, children with these
conditions have important historical
and examination findings that suggest
a chronic systemic illness, and most
complain of bilateral symmetrical or
multifocal pain that may be migratory
or wax and wane. Additionally, these
cases typically are accompanied by more
ominous features such as weight loss,
organ dysfunction, pallor, and abnormal
blood cell lines or counts.
CRITICAL DECISION
How and when should imaging
be used to assess a limping child?
It is important to limit radiation
exposure as much as possible when
assessing a pediatric patient, regardless
of which imaging modality is selected.
This goal can be achieved without
compromising study integrity or
usefulness. Improved clinical decision
rules, the use of ultrasound and MRI,
lower-dose CT protocols, and a general
awareness of the effects of ionizing
radiation have led to a promulgation
of the concept “as low as reasonably
achievable.”24,25 The American College
of Radiology appropriateness guidelines,
which are an excellent resource for
managing a limping child, compare
imaging modalities to specific clinical
scenarios to help the clinician make
informed decisions.
Plain Radiography
Plain radiographs are an appropriate
first-line imaging choice for assessing
a limping child, especially in cases of
trauma. X-rays provide low doses of
radiation, are readily available, and do not
typically require sedation. If a specific area
of concern is identified during the physical
examination, initial selected imaging can
be confined to that area.
Unfortunately, this may not always
be possible, particularly in infants and
younger children (ie, <5 years of age). In
such cases, it is not uncommon to obtain
full-extremity x-rays, which may be
defined as AP and lateral views of the tibia
and fibula, and dedicated AP and lateral
views of the femur. This may also include
views of the pelvis or foot.27 The increased
number of views is understandable given
that most young children are unable to
accurately articulate the origin of their
pain. However, studies indicate that
the tibia is, by far, the most common
bone injured in cases of lower-extremity
trauma, especially in young children
who are non-weightbearing and without
focality on their physical examination (ie,
no apparent edema or localizing pain).
This suggests that initial imaging can
be limited to the tibia of the involved side
in patients who present in this manner;
additional imaging can be dictated by

FIGURE 7. Toddler’s Fracture
Radiograph of the right tibia and fibula in
a 16-month-old girl shows a nondisplaced
oblique fracture through the mid-
diaphysis of the right tibia (yellow arrow).
historical or clinical findings.27 It is
important to note, however, that if initial
imaging fails to reveal a pathology,
follow-up imaging is recommended.
Periosteal reactions are part of the normal
fracture evolution process and can be
reliable indicators of injury.
Plain radiography can reveal
subperiosteal reactions (in the case of
osteomyelitis) or joint-space widening
(in the case of a septic joint), findings
that may prompt more definitive imaging
studies. X-rays are recommended for
the initial evaluation of suspected
osteomyelitis (Figure 5) or joint
infections, principally to rule out other
etiologies such as unreported trauma,
malignancies, or previously undetected
congenital abnormalities. However, an
appreciable length of time (≥2 weeks)
is required for such changes to appear;
radiographs alone should not be used to
eliminate this process, especially if the
index of suspicion for disease is high.28
Plain radiographs can also be useful
when assessing a limp of nontraumatic
origin. This is especially true of patients
with hip pain. Classic examples include
a slipped capital femoral epiphysis
(Figure 6) or Legg-Calvé-Perthes disease,
both of which can be detected by plain
radiography and are clinical entities that
should not be missed. A frog-leg view
should be obtained in such cases, as
SCFE — in particular — can be subtle
and may not be apparent on a single AP
view. Because SCFE and LCP can also
be bilateral, a complete pelvic view is
required (not just the portion of the hip
in question).29 Neoplasms, congenital
malformations, and other findings such as
bone cysts can also be revealed by plain
radiography.
It is important to employ proper
technique when imaging any patient. The
evaluation should include two complete
views (AP and lateral) of the extremity
in question. In most cases, comparison
views of the contralateral extremity
are unnecessary; however, they may
be helpful if questions exist about the
normalcy of a particular finding/variant.
Remember that not all fractures can be
seen on two-view imaging; a third view
may be required. A common example of
this is the toddler’s fracture (Figure 7),
which may not be apparent on AP or
lateral views but is readily seen on an
oblique view. A good rule of thumb is to
start with two views of the extremity, and
then add an oblique view if warranted
by clinical suspicion for an extremity
fracture.
When interpreting pediatric x-rays,
it is important to keep in mind that
mineralization and ossification vary
across the age spectrum. A consultation
with a radiologist can help the clinician
determine if a questionable finding
is pathological or a normal variant.
Additionally, it is extremely beneficial to
provide the reading radio­logist with as
many historical and physical examination
details as possible. It is important
to remember that pediatric injuries,
particularly epiphyseal and buckle
fractures, can be extremely subtle.
Ultrasonography
Ultrasonography has increased in
popularity in recent years as an imaging
modality with multiple applications in
the evaluation of a number of pediatric
conditions, including limping. Readily
available, rapid, painless, and free of
ionizing radiation, the modality has
been advocated in both atraumatic and
traumatic clinical scenarios. Ultrasound
is excellent for the evaluation of
joint disease (eg, developmental or
rheumatological conditions), and is also
extremely sensitive for the detection of
hip effusion and fractures.30
Ultrasound has several limitations that
should be considered, however, including
its inability to distinguish the underlying
cause of a hip effusion. If performed too
early or inadequately, the test can lead to
false negatives.31 This presents a clinical
conundrum: If the study is positive, is
the effusion the result of an infection or
another etiology? And can a negative
study be falsely reassuring, leading to a
missed pathology?
Magnetic Resonance Imaging
MRI lacks ionizing radiation and
provides superior resolution for the
evaluation of a number of clinical
conditions. However, there are several
disadvantages that should be considered,
including cost. Given the time and
technique required to complete a
proper MRI, some children may require
sedation. Since contrast material is often
used, intravenous access may also be
necessary.
Although the modality is sensitive
for traumatic soft-tissue and bone
injuries, it is not typically employed as
an initial test.32 If a trauma diagnosis
is in question or there is concern for
alternative conditions, MRI may be
appropriate. In children with hip pain,
suspected inflammatory conditions (eg,
osteomyelitis or myositis), or concern for
malignancy, MRI is a superior imaging
choice.
MRI is very good at detecting joint or
cartilage inflammation as well as erosion
or loss of joint space, so it can be useful
for the evaluation of malignancies and
rheumatological conditions.33 Moreover,
it is the preferred definitive imaging
modality in any suspected case of
osteomyelitis, abscess, or pyomyositis.
Interestingly, the use of contrast
when evaluating a possible osseous
infection does not appear to increase
sensitivity or specificity; however, it does
appear to heighten the confidence of the
May 2018 n Volume 32 Number 5 11
 interpreting radiologist, and has the
added benefit of identifying the extent
of infection or abscess.34 Consequently,
MRI (with and without intravenous
contrast) is usually performed when
evaluating for infection or inflammatory
processes.
Computed Tomography
In most instances, CT does not play
an immediate role in the evaluation of
a limping child. This modality has the
advantages of being widely available
and fairly rapid; however, ionizing
radiation remains a concern. Sedation
may be required to obtain optimal
images — a process that may necessitate
additional medications (possibly through
intravenous access) and observation
in the emergency department. CT may
be used, however, in cases where a
localization of bone abnormalities is
indicated (eg, when lesions or masses
are present), or if an intracranial
pathology is the suspected cause of a
gait disturbance.35
When plain radiographs are unclear
and clinical suspicion persists, CT can
delineate suspected fractures quite well.36
In such cases, a noncontrast study is the
initial technique of choice. A contrast-
enhanced CT scan can be performed if
immediate imaging is warranted and
MRI is unavailable or contraindicated
(eg, in cases of suspected infection or
neoplasm).
Bone Scan
Bone scans, a radionucleotide
imaging modality, have shown efficacy
in the evaluation of children with
nonspecific limps.37 The whole body can
be imaged using this technique, which is
particularly sensitive to bone and soft-
tissue abnormalities.26 These benefits
come into play particularly when the
physical examination is limited (eg,
when a child is nonverbal or the history
is unclear).
Disadvantages of the technique
include radiation exposure. In addition,
the test often necessitates admission
or transfer to another institution due
to its limited availability. Bone scans
also take time to complete; typically,
the test is not initiated for several
hours after the injection of contrast
material. Radionucleotide bone scans
12 Critical Decisions in Emergency Medicine
are not a first-line imaging choice in from other types of crisis (high count).
the evaluation of a limping child and PCR testing is helpful in determining
are rarely employed in the emergency infectious causes of culture-negative
department. osteoarticular infections; specimens
containing purulent material obtained in
CRITICAL DECISION the emergency department can be held
What laboratory studies are most in the laboratory for molecular testing if
valuable in the evaluation of a cultures remain negative after several days.
Children with suspected rheumatic
limping child?
fever should undergo throat swabbing
Most cases of pediatric limping do for rapid testing and culture, as well as
not warrant a laboratory evaluation; blood testing for streptococcal antibodies
however, children with fever (eg, ASO). Antinuclear antibodies and
(current or remote), prolonged or rheumatoid factor tests are neither
indolent presentations, comorbidities sensitive nor specific, and are not
(hemoglobinopathies), or ominous recommended for the routine screening of
features (ie, weight loss, pallor, and/ children with joint pain. Lyme serology
or toxic appearance) are more likely to testing should only be performed in
have a process that could be identified patients who present with an appropriate
with simple laboratory tests. In children exposure history.20
with suspected focal bacterial infection Studies indicate that four criteria (fever
with fever, a complete blood count >38.5°C [101.3°F], refusal to bear weight,
with differential, a blood culture, an a white blood cell count >12,000/mm3,
erythrocyte sedimentation rate (ESR) and an ESR >40 mm/hr) can be used
test, and a C-reactive protein (CRP) test to help differentiate transient synovitis
are recommended. from septic arthritis.38,39 In a validation
Many experts also recommend study, subjects had a prevalence of septic
ordering a complete metabolic profile arthritis ranging from 2% with zero
(ie, a Chem-20) for patients with positive criteria to 93% with four positive
suspected infections, comorbidities, or criteria. Further research indicates that
chronic or severe presentations; the test a CRP greater than 2.0 mg/dL may be a
can identify other organ involvement moderate predictor of septic arthritis with
and help grade disease severity. Children a positive likelihood ratio of 2.9.40 Given
with hemoglobinopathies (eg, sickle-cell the significant morbidity associated with
diseases) should undergo a reticulocyte a delayed diagnosis, children with an
count to differentiate aplastic (low count) elevated CRP or any of the above criteria
n It is important to consider both benign and life-threatening etiologies when
evaluating a pediatric patient with limping or extremity pain. The child’s
history and physical examination should guide the appropriate workup.
n Radiography is a reasonable first imaging technique for most cases of
pediatric limping. In younger children with a nonfocal examination, it may
be necessary to image the entire extremity.
n Toddler’s fractures may occur with minimal or unwitnessed trauma to the
lower extremity, and x-ray findings may be subtle or absent on the initial
visit. This diagnosis may be made clinically with normal plain films, or based
solely on x-ray findings without a known mechanism.
n While transient synovitis is a common cause of fever and limping, septic
arthritis and osteomyelitis may be subtle; providers should maintain a
high index of suspicion for these diagnoses. Laboratory studies are often
necessary to evaluate a febrile limping child.
should be considered for orthopedic permitted angulation and displacement of worsening pain, particularly if the child
surgery consultation and/or MRI. fractures varies by fracture type, location, is unable to bear weight on the affected
In addition, Kingella kingae leads to and institutional practice. Therefore, in limb at home. Patients with suspicious
less significant elevation of all the noted borderline or atypical fractures, local or borderline laboratory findings, those
laboratory studies and is an increasingly practice guidelines should be reviewed, who do not bear weight in the emergency
identified cause of osteomyelitis in young and/or the clinician should discuss the department, and those who do not
children. This pathogen adds to the case with a pediatric orthopedic surgeon. improve with analgesia should receive an
complexity of interpreting laboratory Any child in which there is concern for appropriate consultation.
studies in limping patients. Clinicians neurovascular injury or compartment Further workup and management
should consider higher level imaging syndrome necessitates an emergent depends on the specific clinical scenario,
when managing a child whose history or surgical consultation. examination findings, laboratory results,
examination is indicative of osteomyelitis, For a child presenting with isolated and radiographs. Such treatments may
regardless of laboratory results. extremity pain or a limp without include arthrocentesis, further imaging
a history of fever or trauma, the (often with MRI), admission for serial
CRITICAL DECISION disposition often depends on the patient’s examinations, or close outpatient follow-
When does a pediatric limp overall appearance and weightbearing up. In many cases, appropriate next
status. If radiographs of the affected steps are not clearly defined or evidence
warrant inpatient admission?
extremity are normal and the patient based; such decisions should be made
The workup and disposition of most is able to bear weight in the emergency collaboratively between the emergency
limping children seen in the acute setting department, primary care follow-up physician, consultants, and the patient
can be determined without consulting a may be appropriate. On the other and/or caregivers.
pediatric orthopedic surgeon. In cases of hand, if an afebrile patient is provided
traumatic injury, most sprains, strains, Summary
NSAID analgesia and remains unable to
buckle fractures, and fractures that are not Most limping has a benign and self-
bear weight, or if the patient’s general
significantly angulated or displaced can be limited etiology; however, emergency
appearance or physical examination is
immobilized with a splint, and the patient clinicians should be mindful of the
concerning, a specialist consultation is
can be sent home with a plan for clinic potentially life- and limb-threatening
necessary.
follow-up. Any affected limb with swelling pathologies that can affect pediatric
The febrile limping child with normal
or tenderness overlying an open physis and patients. Laboratory and radiographic
x-rays, a reassuring white blood cell
normal radiographs should be immobilized studies can be used to help delineate a
count, and normal inflammatory markers,
and treated as an occult (Salter-Harris type diagnosis. Clinicians should consider the
who is able to ambulate in the emergency
I) fracture with clinic follow-up. child’s developmental stage and stated
department following a dose of analgesia,
The patient’s need for follow-up with history, especially when a fracture is
often receives a presumptive diagnosis
a primary care physician or pediatric discovered; nonaccidental trauma may
of transient synovitis. These patients
be present.
orthopedic surgeon should be guided should be advised to continue NSAIDs
In many cases, the cause of a child’s
by the specific injury and local practice and supportive care at home, and should
symptoms may not be readily apparent.
patterns. Fractures that are significantly receive close follow-up care with their
A specialty consultation is warranted
angulated or displaced, as well as intra- primary care provider.
if any laboratory or radiographic
articular fractures, often require reduction Caregivers should be instructed
abnormalities are found. In most cases,
or surgical management. The degree of on appropriate return precautions for
plain radiographs are recommended
as the initial imaging modality.
MRI is an excellent way to evaluate
for osteomyelitis, a septic joint, or
malignancy, but often requires sedation.
Ultrasound can be useful for the detection
of joint effusion. It is not uncommon for
n Dismissing a fracture in a nonambulatory or developmentally delayed child. children to be admitted for observation or
Nonaccidental trauma is an under-recognized and life-threatening diagnosis; further testing. If the patient’s pain cannot
emergency providers should maintain a high index of suspicion when children be reasonably controlled, admission
sustain fractures that do not align with their developmental state or the should be strongly considered.
purported mechanism of injury.
n Assuming a limp is due to a lower-extremity pathology. The back and hip REFERENCES
should not be ignored as possible etiologies of limping. 1. Herman MJ, Martinek M. The limping child. Pediatr
Rev. 2015 May;36(5):184-195.
n Neglecting to order frog-leg views of the hips when assessing for SCFE or 2. Tenenbein M, Reed MH, Black GB. The toddler’s
other hip pathologies. Such findings can be missed on AP views. fracture revisited. Am J Emerg Med. 1990 May;8(3):
208-211.
n Failing to seriously consider more insidious etiologies of pain in a young child 3. Halsey MF, Finzel KC, Carrion WV, Haralabatos SS,
complaining of back pain. Mechanical back pain is very rare in young children. Gruber MA, Meinhard BP. Toddler’s fracture:
presumptive diagnosis and treatment. J Pediatr

May 2018 n Volume 32 Number 5 13

 CASE RESOLUTIONS
■ CASE ONE
The emergency physician ordered
plain radiographs of the injured
boy’s right tibia and fibula (AP,
lateral, and oblique views), which
revealed a clearly visible nondisplaced
spiral fracture of the distal tibia,
consistent with a toddler’s fracture.
Although the injury was consistent
with accidental trauma, the clinician
consulted a social worker, who
interviewed the child’s mother
and concurred with the accidental
diagnosis. He was placed in a
posterior long-leg splint and pediatric
orthopedic follow-up care was
arranged.
■ CASE TWO
The toddler’s fever, fussiness,
and limping behavior concerned the
emergency physician and augmented
his suspicion about a more serious
pathology. The child’s laboratory
Orthop. 2001 Mar-Apr;21(2):152-156.
4. Livingston KS, Glotzbecker MP, Shore BJ. Pediatric
acute compartment syndrome. J Am Acad Orthop
Surg. 2017 May;25(5):358-364.
5. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC.
Analysis of missed cases of abusive head trauma.
JAMA. 1999 Feb 17;281(7):621-626.
6. Dubowitz H, Bennett S. Physical abuse and neglect
of children. Lancet. 2007 Jun 2;369(9576):1891-1899.
7. Diagnostic imaging of child abuse. Pediatrics. 2000
Jun;105(6):1345-1348.
8. Matava MJ, Patton CM, Luhmann S, Gordon JE,
Schoenecker PL. Knee pain as the initial symptom
of slipped capital femoral epiphysis: an analysis
of initial presentation and treatment. J Pediatr
Orthop. 1999 Jul-Aug;19(4):455-460.
9. Murray AW, Wilson NI. Changing incidence of
slipped capital femoral epiphysis: a relationship
with obesity? J Bone Joint Surg Br. 2008
Jan;90(1):92-94.
10. Kelsey JL, Acheson RM, Keggi KJ. The body build
of patients with slipped capital femoral epiphysis.
Am J Dis Child. 1972 Aug;124(2):276-281.
11. Siegel DB, Kasser JR, Sponseller P, Gelberman RH.
Slipped capital femoral epiphysis. A quantitative
analysis of motion, gait, and femoral remodeling
after in situ fixation. J Bone Joint Surg Am. 1991
Jun;73(5):659-666.
12. Wenger DR, Ward WT, Herring JA. Legg-Calvé-
Perthes disease. J Bone Joint Surg Am. 1991
Jun;73(5):778-788.
13. Canavese F, Dimeglio A. Perthes’ disease:
prognosis in children under six years of age. J Bone
Joint Surg Br. 2008 Jul;90(7):940-945.
14. Lee EH, Shafi M, Hui JH. Osteoid osteoma: a
current review. J Pediatr Orthop. 2006 Sep-
Oct;26(5):695-700.
15. Gereige R, Kumar M. Bone lesions: benign and
malignant. Pediatr Rev. 2010 Sep;31(9):355-362.
16. Clarke RT, Van den Bruel A, Bankhead C, Mitchell
CD, Phillips B, Thompson MJ. Clinical presentation
of childhood leukaemia: a systematic review and
meta-analysis. Arch Dis Child. 2016 Oct;101(10):
894-901.
17. Jonsson OG, Sartain P, Ducore JM, Buchanan
GR. Bone pain as an initial symptom of childhood
acute lymphoblastic leukemia: association with
nearly normal hematologic indexes. J Pediatr. 1990
Aug;117(2 Pt 1):233-237.
14 Critical Decisions in Emergency Medicine
results included a white blood cell
count of 22,000, with 90% neutrophils
and 5% lymphocytes. There were no
blasts. The child’s ESR and CRP levels
were elevated (90 mm/hr and 7 mg/L,
respectively). Her x-rays were normal.
Concerned for a septic hip joint or
osteomyelitis, the clinician consulted
pediatric orthopedic surgery, which
recommended inpatient admission.
Because the child was not toxic and her
irritability resolved, antibiotics were
held. Since she was difficult to examine,
the orthopedic team suggested an MRI
of the pelvis with contrast to examine
the femur and joint spaces. The results
demonstrated enhancement of the
right femoral head consistent with
osteomyelitis.
Clindamycin and ceftriaxone were
initiated, and serial CRP tests were
obtained. After 3 days on intravenous
antibiotics, the child improved and
remained afebrile for the next
18. Gorelick MH, Alpern ER, Alessandrini EA. A system
for grouping presenting complaints: the pediatric
emergency reason for visit clusters. Acad Emerg Med.
2005 Aug;12(8):723-731.
19. Macias CG, Allen CH. Bone, joint and vertebral
infections. In: Baren JMMMFF, Rothrock SGMFF,
Brennan JAMFF, Brown LMMFF, eds. Pediatr Emerg
Med. 2008:705-715.
20. Kimberlin DW, Brady MT, Jackson MA, Long SS,
eds. Red Book®: 2015 Report of the Committee on
Infectious Diseases. 30th ed. Itasca, IL: American
Academy of Pediatrics; 2015.
21. Pannaraj PS, Hulten KG, Gonzalez BE, Mason EO
Jr, Kaplan SL. Infective pyomyositis and myositis
in children in the era of community-acquired,
methicillin-resistant Staphylococcus aureus infection.
Clin Infect Dis. 2006 Oct 15;43(8):953-960.
22. Fernandez M, Carrol CL, Baker CJ. Discitis and
vertebral osteomyelitis in children: an 18-year review.
Pediatrics. 2000 Jun;105(6):1299-1304.
23. de Inocencio J, Carro MÁ, Flores M, Carpio C,
Mesa S, Marín M. Epidemiology of musculoskeletal
pain in a pediatric emergency department.
Rheumatol Int. 2016 Jan;36(1):83-89.
24. Frush DP, Frush KS. The ALARA concept in pediatric
imaging: building bridges between radiology
and emergency medicine: consensus conference
on imaging safety and quality for children in the
emergency setting, Feb. 23-24, 2008, Orlando, FL
— Executive Summary. Pediatr Radiol. 2008 Nov;38
Suppl 4:S629-S632.
25. Baker N, Woolridge D. Emerging concepts in
pediatric emergency radiology. Pediatr Clin North
Am. 2013 Oct;60(5):1139-1151.
26. Milla SS, Coley BD, Karmazyn B, et al. ACR
Appropriateness Criteria® limping child—ages 0 to 5
years. J Am Coll Radiol. 2012 Aug;9(8):545-553.
27. Baron CM, Seekins J, Hernanz-Schulman M, Yu C,
Kan JH. Utility of total lower extremity radiography
investigation of nonweight bearing in the young child.
Pediatrics. 2008 Apr;121(4):e817-e820.
28. Hatzenbuehler J, Pulling TJ. Diagnosis and
management of osteomyelitis. Am Fam Physician.
2011 Nov 1;84(9):1027-1033.
29. Jarrett DY, Matheney T, Kleinman PK. Imaging SCFE:
diagnosis, treatment and complications. Pediatr
Radiol. 2013 Mar;43 Suppl 1:S71-S82.
30. Callahan MJ. Musculoskeletal ultrasonography of
the lower extremities in infants and children. Pediatr
48 hours. Culture results from
aspirated joint fluid showed
growth of methicillin-sensitive
Staphylococcus aureus. Pediatric
infectious disease specialists were
consulted, and a 6-week antibiotic
course was initiated, followed by
serial CRP tests.
■ CASE THREE
Although the teenaged soccer
player’s previous imaging reports
were normal, the clinician remained
concerned about the patient’s hip.
AP and frog-leg views of the pelvis
confirmed SCFE on the left with
approximately 15% slippage.
Pediatric orthopedics was
consulted and determined the need
for operative repair. The girl was
admitted to the hospital and taken to
the operating room the next day for
in-situ fixation. She did not require
prophylactic contralateral pinning.
Radiol. 2013 Mar;43 Suppl 1:S8-S22.
31. Gordon JE, Huang M, Dobbs M, Luhmann SJ,
Szymanski DA, Schoenecker PL. Causes of false-
negative ultrasound scans in the diagnosis of septic
arthritis of the hip in children. J Pediatr Orthop. 2002
May-Jun;22(3):312-316.
32. Gaeta M, Minutoli F, Scribano E, et al. CT and MR
imaging findings in athletes with early tibial stress
injuries: comparison with bone scintigraphy findings
and emphasis on cortical abnormalities. Radiology.
2005 May;235(2):553-561.
33. White PM, Boyd J, Beattie TF, Hurst M, Hendry GM.
Magnetic resonance imaging as the primary imaging
modality in children presenting with acute non-
traumatic hip pain. Emerg Med J. 2001 Jan;18(1):25-29.
34. Averill LW, Hernandez A, Gonzalez L, Peña AH,
Jaramillo D. Diagnosis of osteomyelitis in children:
utility of fat-suppressed contrast-enhanced MRI. AJR
Am J Roentgenol. 2009 May;192(5):1232-1238.
35. Flynn JM, Widmann RF. The limping child: evaluation
and diagnosis. J Am Acad Orthop Surg. 2001 Mar-
Apr;9(2):89-98.
36. Cutler L, Molloy A, Dhukuram V, Bass A. Do CT scans
aid assessment of distal tibial physeal fractures?
J Bone Joint Surg Br. 2004 Mar;86(2):239-243.
37. Connolly LP, Connolly SA, Drubach LA, Jaramillo D,
Treves ST. Acute hematogenous osteomyelitis
of children: assessment of skeletal scintigraphy-
based diagnosis in the era of MRI. J Nucl Med. 2002
Oct;43(10):1310-1316.
38. Kocher MS, Zurakowski D, Kasser JR. Differentiating
between septic arthritis and transient synovitis
of the hip in children: an evidence-based clinical
prediction algorithm. J Bone Joint Surg Am. 1999
Dec;81(12):1662-1670.
39. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C,
Kasser JR. Validation of a clinical prediction rule
for the differentiation between septic arthritis and
transient synovitis of the hip in children. J Bone Joint
Surg Am. 2004 Aug;86-A(8):1629-1635.
40. Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG,
Dormans JP. Factors distinguishing septic arthritis
from transient synovitis of the hip in children. A
prospective study. J Bone Joint Surg Am. 2006
Jun;88(6):1251-1257.

Betz ME, Boudreaux ED. Managing suicidal patients in the emergency department. Ann Emerg Med. 2016 Feb;67(2):276-282.
Managing Suicidal Patients
As many as 8% of all emergency
department patients report recent
suicidal ideations. Clinicians can
use a suicide risk stratification tool to
identify those who are most vulnerable.
The intent to self-harm is not always
readily admitted, however, so patients
at risk should be appropriately
screened. The evaluation should be
conducted only in those who are sober
and have a capacity for decision-
making. Preliminary risk stratification
contains questions about plan, intent,
past attempts, mental health history,
substance abuse, and issues with
irritability or agitation. Example
questions include:
n Have you been thinking about how
you might kill yourself recently?
n Do you intend to kill yourself?
n Have you ever tried to kill yourself?
n Have you ever been treated for
mental health problems?
n Has drinking or drug use been a
problem for you?
n Have you been feeling anxious or
agitated recently?
Patients who answer “no” to all
of the above questions may not need
further psychiatric assessment and can
be discharged with a careful outpatient
follow-up plan. A “yes” answer to
any of the above questions warrants
a comprehensive risk assessment
with a mental health specialist (eg,
psychiatrist, psychologist, or social
Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2018 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.
The LLSA
Literature
Review
By Lulu Wang, MD; and Andrew Eyre, MD, MHPEd
Departments of Emergency Medicine at Massachusetts
General Hospital, Brigham and Women’s Hospital, and
Harvard Medical School, Boston, MA
worker). From there, inpatient admission
may be warranted.
In the absence of a specialist, an
emergency provider can perform a more
thorough assessment using a tool such
as the Suicide Assessment Five-Step
Evaluation and Triage (SAFE-T) protocol.
This includes, but is not limited to, the
identification of risk factors (psychiatric
history, prior suicide attempts, substance
use, family history, stressors), protective
factors, suicide inquiry (ideation, plan,
intent), determination of risk level (low
risk can be addressed on an outpatient
basis; high risk requires psychiatric
assessment and likely admission), and
documentation.
A number of quick, directed
interventions can be quite impactful.
These include patient education
(instilling hope, reducing shame and
stigma, providing clear follow-up and
return instructions), safety planning
(creating a structured plan with the
patient, including coping strategies
and people to contact), lethal means
counseling (reducing access to guns,
toxic medications, etc.), rapid referral
(arranging for follow-up within 7 days),
and identifying a social safety net
(communicating with family and other
providers regarding the visit).
Finally, it is crucial to establish a
thera­peutic alliance. This can be done
by communicating directly, expressing
empathy, explaining the anticipated
course of emergency department
treatment, and providing basic comforts.
Attempts at verbal de-escalation should
be made before resorting to chemical or
physical restraints. High-risk patients
should be protected from self-harm;
dangerous objects should be removed;
and the patient should be observed closely
and prevented from leaving without
psychiatric clearance. As with any case,
a focused medical evaluation should be
performed to assess for problems that
may be contributing to the patient’s
psychiatric complaints.
KEY POINTS
n Not every patient with suicidal
ideations requires a comprehen­
sive psychiatric consultation in
the emergency department.
The proper use of validated
screening and risk stratification
tools, including the SAFE-T, can
help identify the small subset of
patients at high risk for suicide.
n Patients with suicidal thoughts
represent an extremely vulnerable
population that benefits from a
therapeutic alliance, empathy, and
open communication.
n High-risk signs include suicidal
intention, having a plan, previous
attempts, alcohol or drug use,
psychiatric history, and recent
anxiety, irritability, or aggression.
May 2018 n Volume 32 Number 5 15
 The Critical Image
A 74-year-old woman presents with right hip pain that has prevented By Joshua S. Broder, MD, FACEP
her from walking for several weeks. She says her symptoms began Dr. Broder is an associate professor and the
2 months earlier, after she fell out of bed. Her daughters report that the residency program director in the Division of
Emergency Medicine at Duke University Medical
patient complained of some hip pain preceding her fall; in fact, she visited Center in Durham, North Carolina.
an orthopedist 1 year earlier for the same complaint. The patient also notes
Case contributor: Lindsey Rowe, MHS, PA-C
some weight loss.
Her vital signs are blood pressure 162/71, heart rate 67, temperature 36.9°C (98.4°F), respiratory rate 16, and oxygen saturation
100% on room air. The patient appears to be in no distress. Although she complains of severe right hip pain with flexion, the limb
is normal in length compared with the unaffected left side and has normal pulses. Her distal sensation and motor examinations
are normal. Suspecting a hip fracture, the emergency physician orders radiographs of the right hip and pelvis and compares
these with prior images. Following x-rays, a computed tomography scan is also obtained.

A. Radiograph of the pelvis

A
from 1 year earlier. The pelvic
Bowel gas
Bowel ring is intact, and both femoral
gas necks are normal, without
signs of fracture. The femoral
heads have a normal, rounded
appearance, without significant
evidence of degenerative
Normal changes. Scattered bowel
femoral neck gas creates a rounded lucent
appearance over the pelvis.

The normal pelvis

forms a complete
ring

B. Radiograph of the pelvis B

on the date of the emergency
department visit. The femoral
necks are intact. A lucent area
over the right iliac wing resembles Lytic
bowel gas; however, it interrupts lesion
Intact iliac
the normal ring of the pelvis, of iliac
bone
confirming the presence of a bone
lytic lesion. Lytic lesion
interrupts
pelvic ring

16 Critical Decisions in Emergency Medicine

C. CT with
C
KEY POINTS
intravenous
n Following a low-mechanism fall from
contrast,
standing, hip injuries such as femoral
soft-tissue
neck and intertrochanteric fractures
windows.
This image are common in older patients. These
shows a high-risk areas should be inspected
soft-tissue closely, but in addition, x-rays of the
mass pelvis should be read systematically,
replacing with attention paid to the bony ring of
the right the pelvis. Disruption of this ring can
iliac bone. indicate fracture, or — as in this case
Soft tissue
— a destructive lytic lesion. Lucencies
mass
replacing from bowel gas can simulate lytic
iliac bone findings, but do not usually interrupt
the pelvic ring.
n When previous images are available,
D. CT with comparison is useful; bowel gas
intravenous D
will move over time, and other new
contrast, findings may be evident. When
bone uncertainty exists, CT or magnetic
windows.
resonance imaging can provide
Again, a
additional information.
lytic lesion
of the right
iliac bone is
seen.
CASE RESOLUTION
The patient underwent a CT-
Lytic lesion Normal
iliac bone guided needle biopsy, which
of iliac
bone
demonstrated a diffuse large
B-cell lymphoma.

E F Lytic
lesion
Normal of iliac
iliac bone
bone

Lytic
lesion
of iliac
bone

E. 3D CT reconstruction, frontal view of pelvis. The lesion is F. 3D CT reconstruction, posterior view of pelvis. From this
seen as a small erosion in the iliac bone. vantage point, the much larger destructive extent of the lesion
is seen.

May 2018 n Volume 32 Number 5 17

 The Critical
Helix

Triangular fossa

Procedure
Scapha Ant
i he lix

Concha

Tragus
He
lix

Intertragical By Harish Kotipoyina, MD; and Steven Warrington, MD, MEd, FACEP
notch Dr. Kotipoyina is a family medicine resident at North Florida Regional Hospital in Gainesville,
FL. Dr. Warrington is director of the Emergency Medicine Residency Program and academic
Antitragus chair of the Department of Emergency Medicine at Orange Park Medical Center in Orange
Lobule Park, FL.

AURICULAR HEMATOMA INCISION AND DRAINAGE

Auricular/perichondrial hematomas generally occur when the auricle of the ear suffers blunt
trauma, leading to the tearing of blood vessels. The bleeding can cause a hematoma to form in the
subperichondrial space. Such injuries require early management to prevent permanent deformity.

Benefits and Risks One alternative to incision and TECHNIQUE

Although incision and drainage can
prevent permanent cosmetic deformities
of the ear and further damage to the
cartilage, hematomas older than 7 days
require ENT management. Risks of
the technique include infection
(perichondritis), scar formation, procedure
failure, and hematoma recurrence. The
risk of a poor cosmetic outcome also
should be discussed with the patient.
Alternatives
Various materials may be used to
create a pressure dressing, which acts as
a splint/bolster and prevents hematoma
accumulation. Although the author
recommends rolled gauze due to its ready
accessibility, other alternatives include
cotton, plastic bolsters, silicone splints,
and dental kit materials. Several of these
items may offer better support and lead to
improved cosmetic outcomes.
Some clinicians opt for a tie-over
dressing that involves a through-and-
through stitch of the antihelix or helix.
The suture can help position the splint
material (gauze) snug to the ear, enabling
better compression. In addition, the
punctures caused by the stitch may allow
further drainage of the hematoma and help
prevent recurrence. It should be noted,
however, that such dressings can increase
the risk of a poor cosmetic outcome.
drainage of the hematoma is needle
aspiration; however, this approach is
associated with a higher recurrence
rate. When using this route, the patient
should be aware of the potential need for
repeated drainage.
Reducing Side Effects
An auricular block can provide
excellent anesthesia without creating
further difficulties when re-approxi­
mating the anatomy.
While there is no clear evidence
regar­ding the efficacy of antibiotics
in such cases, prophylactic antibiotics
may be considered when managing
certain patients, including those who are
immunocompromised. Pseudomonas
aeruginosa and Staphylococcus aureus
are among the most common offending
organisms.
The ear requires time to heal. During
the first week, patients should refrain
from risky activities and encouraged to
wear headgear to protect against future
injury.
It may be beneficial to re-evaluate
the patient every 24 hours for 3 to 5
days to monitor for the reaccumulation
of blood and signs of infection. If
possible, antiplatelet and anticoagulant
medications should be avoided while the
injury heals.
1. Gather supplies: No. 15 scalpel,
5-mL syringe with a 23- or 27-gauge
needle for anesthesia, 1% lidocaine
(with or without epinephrine),
irrigation setup (if using), suction (if
using), scissors, iodine or ChloraPrep,
sutures (4-0 vicryl), suturing kit,
splint material, gloves, and eye
protection.
2. Place the patient in the supine or
lateral decubitus position on the
unaffected side.
3. Clean, prep, and anesthetize the area;
consider an auricular block.
4. Make a small incision on the edge of
the base of the hematoma, along the
natural curve of the skinfold.
5. Suction the hematoma, or use direct
pressure to express it out.
6. Consider saline irrigation.
7. Reapproximate the perichondrium
with the cartilage, and suture the
incision closed.
8. Apply the compression dressing/splint
and secure. This can be achieved with
a through-and-through suture or with
a circum­ferential head wrap. Note
that the dressing should not be so tight
as to cause vascular compromise.
9. Consider prophylactic antibiotics,
and counsel the patient on follow-up
and return precautions.

18 Critical Decisions in Emergency Medicine

 Bitter Pill
Adverse Drug Events
in Geriatric Patients

LESSON 10

By Thuy Van Pham, MD

Dr. Pham is an attending emergency physician at Good Samaritan Hospital in
Puyallup, Washington.
Reviewed by Steven J. Warrington, MD, MEd

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Understand the physiological changes that arise with
n Which age-related physiological changes affect
aging that affect how the body absorbs, metabolizes,
how drugs are absorbed, metabolized, and
and eliminates drugs.
eliminated from the body?
2. Identify circumstances that contribute to polypharmacy.
n What circumstances contribute to polypharmacy,
3. Define adverse drug events (ADEs) and recognize them
in the emergency department. and what can you do to help prevent it?

4. Describe the drugs most commonly implicated in ADEs
in geriatric patients.
5. Identify ways to prevent ADEs and educate elderly
patients about medication compliance.
n How can adverse drug events be recognized and
managed in the emergency department?
n What medications should raise suspicion for
adverse drug events in geriatric patients?

FROM THE EM MODEL n What steps can be taken to prevent adverse drug
17.0 Toxicologic Disorders events?
17.1 Drug and Chemical Classes

Senior citizens, who constitute one of the fastest growing segments of our society, are visiting emergency
departments more frequently for drug-related complications. By understanding the unique physiological
factors that affect geriatric patients, however, emergency clinicians can minimize the risk of these potentially deadly
complications.

May 2018 n Volume 32 Number 5 19

 CASE PRESENTATIONS
■ CASE ONE
A 76-year-old Caucasian woman
presents with progressively worsening
lower abdominal and back pain. She
describes the discomfort as an ache,
and nothing seems to make it better
or worse. She denies any trauma or
injury. She complains of nausea and
cold sweats, but has no fever, chills, or
vomiting.
The patient’s medical history
includes hypertension, hyperlipidemia,
and atrial fibrillation. Her
medications include metoprolol,
hydrochlorothiazide, atorvastatin,
and warfarin. Her last international
normalized ratio (INR) was checked
2 weeks ago and is reported as 2.1.
She was recently diagnosed with a
urinary tract infection (UTI) by her
primary care physician and is on Day
3 of 5 of ciprofloxacin. She has had no
prior surgeries.
The patient is alert, awake, and
oriented; she is uncomfortable but not
in any acute distress. Her vital signs
are temperature 37.9°C (100.2°F),
blood pressure 102/67, pulse rate
115, and respiratory rate 17. Her
examination is only significant for
a diffusely tender abdomen without
evidence of guarding, rebound, or
rigidity.
She has no costovertebral angle
tenderness or midline tenderness to
palpation of her back. She is given 1 L
of normal saline. Her blood test results
are hemoglobin 9.3 g/dL, hematocrit
28%, sodium 138 mmol/L, potassium
4.5 mmol/L, bilirubin 1.5, BUN
60 mg/dL, and creatinine 1.2 mg/dL.
In the emergency department, her
INR is 8.5, and an ECG shows normal
sinus tachycardia. A CT scan of her
abdomen is ordered.
According to the US Census Bureau,
adults 65 years and older comprise
13% of the country’s population.1-3 By
the year 2030, the number of elderly
Americans is expected to grow to
20%.1,2 Geriatric patients, who are
particularly complex to manage in the
acute setting, often suffer from multiple
20 Critical Decisions in Emergency Medicine
■ CASE TWO
A 68-year-old African American
man arrives via ambulance for altered
mental status. His family called 911
when he began slurring his words.
EMS found him to be awake and alert
but disoriented to self, place, and time,
with no obvious neurological deficits.
His initial vital signs were temperature
37°C (98.6°F), blood pressure 145/65,
pulse rate 84, respiratory rate 14, and
fingerstick glucose 40. EMS also noted
that the patient is hypoglycemic and
gave him 50 mL of dextrose 50%.
His medical history includes
hypertension, diabetes, chronic venous
stasis, chronic kidney disease, high
cholesterol, a prior cerebral vascular
accident with no residual deficits, and
coronary artery disease. He takes
lisinopril, glipizide, simvastatin,
metoprolol, clopidogrel, and 81 mg
of aspirin. He started taking
cephalexin and sulfamethoxazole/
trimethoprim (SMZ/TMP) 2 days ago
for uncomplicated lower-extremity
cellulitis.
On arrival, he is alert, awake,
and oriented to self. He denies any
pain. The patient’s repeat vital signs
at triage are temperature 36.4°C
(97.5°F), blood pressure 162/75,
pulse rate 98, respiratory rate 20, and
fingerstick glucose 77. His neurological
examination is normal, and he has
no facial droop, slurring of speech,
or asymmetry. His lower extremities
show chronic venous stasis with pitting
edema up to the knees bilaterally,
with overlying erythema that is
nonpurulent. The erythema appears
chronic in nature, and there is obvious
hyperpigmentation and thickening of
the skin. Otherwise, his examination
is unremarkable. His blood test results
comorbidities for which they are taking
multiple medications.2 This population
consumes 32% of all prescription
drugs and contributes to 35% of the
nation’s total drug expenditure.4 More
than 90% of elderly patients use at
least one medication; on average, they
use four drugs per person.4 Two-thirds
are hemoglobin 12 g/dL, hematocrit
36%, sodium 138 mmol/L, potassium
5.2 mmol/L, BUN 60 mg/dL, and
creatinine 1.7 mg/dL.
■ CASE THREE
An 85-year-old woman presents
with epigastric abdominal pain, She
explains that her symptoms began
about a week ago, but are much worse
today. The pain is exacerbated by
movements and taking deep breaths.
She has been taking ibuprofen with
no significant relief. She denies any
dysuria, but states that her stool has
been darker for weeks.
Her medical history includes
hypertension, high cholesterol, and
osteoarthritis. She takes amlodipine,
meloxicam, atorvastatin, and a
multivitamin daily. She is otherwise
healthy and independent and lives in
a senior living facility. Her vital signs
are temperature 37.3°C (99.1°F), blood
pressure 170/100, pulse rate 110,
respiratory rate 16, and fingerstick
glucose 102. She appears clammy and
is tripoding on the bed.
The patient’s lung and cardiac
examinations are unremarkable, other
than tachycardia. Her abdomen is soft,
but is diffusely tender to palpation.
Her stool is tarry black and guaiac
positive, but otherwise unremarkable.
Her blood test results are hemoglobin
7.8 g/dL, hematocrit 22%, platelet
200, sodium 142 mmol/L, potassium
4.5 mmol/L, bilirubin 1.5, BUN
60 mg/dL, creatinine 1.1 mg/dL,
aspartate aminotransferase (AST) 55,
alanine transaminase (ALT) 58, and
alkaline phosphatase 130.
of these patients take at least one
over-the-counter (OTC) medication.4
Unfortunately, indiscriminate
prescribing practices often lead to
an overlap of prescription and OTC
medications, which increases the risk
of drug-drug interactions and adverse
drug events (ADEs).5,6
CRITICAL DECISION
Which age-related physiological
changes affect how drugs are
absorbed, metabolized, and
eliminated from the body?
Aging is a natural inevitability
associated with an increased risk of
morbidity and mortality; however, it
is not a simple process generalizable
to everyone. The geriatric population
is a heterogeneous group of people
with substantial varia­bility in health,
disability, and comorbidities.4,5,7
While one’s biological age is
influenced by specific factors such as
comorbidities, genetics, and social
circumstances, chronological aging
coincides with important — and
universal — physiological changes
(Figure 1). Some of these changes
affect how medications are absorbed,
metabolized, and eliminated from the
body: As people age, lean body weight
FIGURE 1. Physiological Changes Associated with Aging
Liver function tests
Liver mass
Overall liver function
Total body fat
(adipose)
Total body weight
Lean body weight
Bone mass
Total body water
decreases, as does bone mass and total
body water.2 While total body fat
increases, total body weight decreases.4
Age-related changes in gastric absorption
increase gastric pH, decrease motility,
and reduce splanchnic blood flow, all
of which affect drug absorption rates.8
Natural declines in kidney and liver
function also affect the body’s ability to
process medications.
Pharmacokinetics, the means
by which drugs are metabolized, is
affected by a patient’s ability to absorb,
distribute, and eliminate them.8 The
distribution of drugs in elderly patients
is particularly affected by decreased
lean body weight and an increase in
central adipose tissue.8 Water-soluble
agents such as digoxin and alcohol
have a reduced volume of distribution,
which causes an increase in the initial
drug concentration.4,8 Fat-soluble drugs,
on the other hand, have an increased
volume of distribution, leading to
Gastric pH
H. pylori infection
Peristalsis/gastric motility
Hepatic cell mass and
function
Prostatic
hypertrophy (men)
Pelvic floor weakness
(women)
Glomerular filtration
rate
Urine concentration
capacity
an increased elimination half-life
and a prolonged effect.8 Examples of
common fat-soluble agents include
benzodiazepine and phenytoin.8
The aging process also causes an
overall decrease in serum albumin. This
change affects medications that are
bound to the protein, increasing the free
drug concentration and thus the risk of
toxicity, even at recommended dosing.
Examples of drugs that are albumin-
bound include warfarin, phenytoin, and
salicylic acid.4,8
The liver is the primary metabolizer
of most medications, while the kidneys
are responsible for the majority of drug
excretion and elimination. After 40 years
of age, glomerular function falls 6%
to 10% per decade. Tubular function
is reduced 30% to 40% by the time a
patient reaches 90 years of age. Keeping
these changes in mind, the dosage of
drugs that are excreted by filtration in
the kidneys or renal tubules may need to
be reduced.4,8
Pharmacodynamics, the way drugs
affect the body, encompasses complex
processes that are not well understood.
Changes in drug response with aging
are assumed, but have not been well
explained in the literature. An elderly
patient may demonstrate an inadequate
response to certain medications at
regular doses, yet be overly sensitive
to others. For example, it is well
documented that elderly people have
reduced inotropic and chronotropic
responses to β1-adrenergic stimulation
but an increased sensitivity to drugs
such as warfarin, benzodiazepines, and
opiates.8
CRITICAL DECISION
What circumstances contribute
to polypharmacy, and what can
you do to help prevent it?
Geriatric patients tend to seek
help from an array of practitioners,
which can lead to polypharmacy,
in which a single patient with one
or more conditions uses multiple
drugs simultaneously. Treatment by
multiple practitioners often leads
to uncoordinated care, overlapping
prescriptions and, ultimately, an
increased risk of ADEs. “Prescribing
May 2018 n Volume 32 Number 5 21
 cascades” are all too common, with Additionally, many pills look of an ADE is 35%; when a patient is
multiple providers prescribing various similar, which can lead to confusion. taking seven or more medications, the
medications for several comorbidities As these situations arise, clinicians risk increases to 82%.6,13
while having little or no communication should consider ordering medications in ADEs can be vague and nonspecific,
with each other.5 Moreover, duplicates bottles that can be opened easily by the so it is important for emergency
within the same class of drugs may be patient and should consider requesting clinicians to keep this diagnosis in
prescribed and/or drug-drug interactions larger print on labels. The incidence mind when managing any geriatric
may go unrecognized, leading to of mistakes increases 15-fold when the patient. Take an additional few minutes
treatment with yet more drugs.6 number of prescriptions increases from to ask about any medication-related
The inappropriate use of medication one drug to four.9 habits and/or changes, and to review
and noncompliance with dosage the patient’s current prescription
CRITICAL DECISION list, if available. If you have access
instructions contribute to polypharmacy
and concomitant ADEs.4 Nonadherence, How can adverse drug events be to pharmacists, request medication
most commonly in the form of omission recognized and managed in the reconciliations for your geriatric
(seen in ≤90% of cases), can be either emergency department? patients.
intentional or unintentional. Patients
often have little understanding of
ADEs include any injury related to CRITICAL DECISION
medication use. They can be caused
their medications and the indications What medications should raise
by the side effects or interactions of
for each, and may not take them as
medications. These reactions constitute suspicion for adverse drug
instructed. One-fourth to one-half of events in geriatric patients?
the fourth to sixth greatest causes of
elderly patients do not adhere to the death in the US and contribute to 5% Several guidelines have been
medication instructions they receive; to 10% of all hospital admissions.7,11 published to help physicians avoid
about two-thirds of this noncompliance Approximately 10% to 20% of all prescribing dangerous drugs to elderly
is intentional, resulting from the desire hospital admissions involving the elderly patients. The best-known publication is
to avoid side effects they experience stem from an iatrogenic cause, the the American Geriatrics Society 2015
with the full dose, an attempt to boost most common being an ADE from a Updated Beers Criteria for Potentially
the therapeutic response, or concern cardiovascular or psychotropic drug.10 Inappropriate Medication Use in Older
about the high cost of the medication.4 In elderly patients, these events Adults (also known as the Beers List),
Moreover, patients might take an are more likely to be under- which was first published in 1991. The
incorrect dose, hoard drugs for future reported, severe, and less likely to be list, which was most recently revised in
use, or self-prescribe OTC and herbal recognized.7,12,13 Older patients are 2015 (Table 1), includes medications
medications.8 seven times more likely than younger that should be avoided in nursing homes
Health care providers should consider patients to experience an ADE requiring because of their potential danger to
factors such as the patient’s literacy level; hospitalization.14,15 Approximately half geriatric patients.16 It was compiled
the presence of arthritic pain, which can of these cases occur in patients older using data from common drugs taken
make it difficult to open pill bottles; the than 80 years; ADEs are more than by office-based clinic patients, nursing
tendency of some patients to transfer three times as common in those older home patients, and community-dwelling
pills to nonoriginal bottles or to combine than 90 years.12 The more medications elderly individuals who experienced
pills into fewer bottles; and diminished a patient takes, the greater the risk of a possible ADEs.17 Examples of side effects
eyesight, which can hamper the ability to drug-drug or drug-disease interaction. range from hypotension to dizziness
read and comprehend labels.8 When two drugs are prescribed, the risk to altered mental status from central
nervous system suppression. However,
this study did not include drugs that are
prescribed in acute care settings.17
Although the Beers List has been
somewhat useful in guiding emergency
department practice, approximately
n Though aging is a process that affects everyone differently, consider how 90% of ADEs in acute care settings stem
common physiological changes may affect the absorption, metabolism, and from medications excluded from the
elimination of drugs on a patient’s current medication list. list.15,17 Nine out of 10 acute visits for
n Polypharmacy is common; the risk of ADEs increases with every additional ADEs are related to oral anticoagulants/
medication. antiplatelets, diabetic medications,
n Consider ADEs when assessing any patient complaint, especially in the elderly or drugs with a narrow therapeutic
population. window.15
n The most common drugs involved in ADEs in geriatric patients include
Three medications — warfarin,
anticoagulants, diabetic medications, and digoxin.
insulin, and digoxin — are the most

22 Critical Decisions in Emergency Medicine

TABLE 1. 2015 American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use16
Strength of
Organ System, Therapeutic Quality of Recommen­
Category, Drug Rationale Recommendation Evidence dation
ANTICHOLINERGICS
First-generation antihistamines Highly anticholinergic; clearance reduced with Avoid Moderate Strong
Brompheniramine advanced age, and tolerance develops when used as
Carbinoxamine a hypnotic; risk of confusion, dry mouth, constipation,
Chlorpheniramine and other anticholinergic effects or toxicity
Clemastine
Cyproheptadine
Dexbrompheniramine
Dexchlorpheniramine
Dimenhydrinate
Diphenhydramine (oral) Diphenhydramine may be appropriate in some
Doxylamine situations (eg, for the acute treatment of severe
Hydroxyzine allergic reactions)
Meclizine
Promethazine
Triprolidine
Antiparkinsonian agents Not recommended for prevention of extrapyramidal Avoid Moderate Strong
Benztropine (oral) symptoms with antipsychotics; more-effective agents
Trihexyphenidyl available for treatment of Parkinson disease
Antispasmodics Highly anticholinergic; uncertain effectiveness Avoid Moderate Strong
Atropine (excludes ophthalmic)
Belladonna alkaloids
Clidinium-chlordiazepoxide
Dicyclomine
Hyoscyamine
Propantheline
Scopolamine
ANTITHROMBOTICS
Dipyridamole (oral short-acting) May cause orthostatic hypotension; more effective Avoid Moderate Strong
(does not apply to the extended-release alternatives available; intravenous form acceptable
combination with aspirin) for use in cardiac stress testing
Ticlopidine Safer, effective alternatives available Avoid Moderate Strong
ANTI-INFECTIVE
Nitrofurantoin Potential for pulmonary toxicity, hepatotoxicity, Avoid in individuals with Low Strong
and peripheral neuropathy, especially with long-term creatinine clearance <30
use; safer alternatives available mL/min or for long-term
suppression of bacteria
CARDIOVASCULAR
Peripheral alpha-1 blockers High risk of orthostatic hypotension; not Avoid use as an Moderate Strong
Doxazosin Prazosin recommended as routine treatment for hyper­tension; antihypertensive
Terazosin alternative agents have superior risk-benefit profile
Central alpha blockers High risk of adverse CNS effects; may cause Avoid clonidine as first- Low Strong
Clonidine Guanabenz bradycardia and orthostatic hypotension; not antihypertensive; avoid
Guanfacine Methyldopa recommended as routine treatment for others as listed
Reserpine (>0.1 mg/d) hypertension
Disopyramide Disopyramide is a potent negative inotrope and Avoid Low Strong
therefore may induce heart failure in older adults;
strongly anticholinergic; other antiarrhythmic drugs
preferred
Dronedarone Worse outcomes have been reported in patients Avoid in individuals High Strong
who have permanent atrial fibrillation or severe or with permanent atrial
recently decompensated heart failure fibrillation or severe or
recently decompensated
heart failure

May 2018 n Volume 32 Number 5 23

 TABLE 1. 2015 American Geriatrics Society (AGS) Beers Criteria (continued)
Organ System, Therapeutic
Category, Drug
Digoxin
Nifedipine (immediate release)
Amiodarone
CENTRAL NERVOUS SYSTEM
Antidepressants
(alone or in combination)
Amitriptyline Amoxapine
Clomipramine Desipramine
Doxepin (>6 mg/d) Imipramine
Nortriptyline Paroxetine
Protriptyline Trimipramine
Antipsychotics
(first- and second-generation)
Barbiturates
Amobarbital Butabarbital
Butalbital Mephobarbital
Pentobarbital Phenobarbital
Secobarbital
Benzodiazepines
(short- and intermediate-acting)
Alprazolam Estazolam
Lorazepam Oxazepam
Temazepam Triazolam
Benzodiazepines (long-acting)
Clorazepate Clonazepam
Diazepam Flurazepam
Quazepam
Chlordiazepoxide
(alone or in combination with disorders, rapid eye movement sleep disorders,
amitriptyline or clidinium)
24 Critical Decisions in Emergency Medicine
Strength of
Quality of Recommen­
Rationale Recommendation Evidence dation
Use in atrial fibrillation: should not be used as a first- Avoid as first-line therapy Moderate Strong
line agent in atrial fibrillation because more-effective for atrial fibrillation
alternatives exist and it may be associated with
increased mortality
Use in heart failure: questionable effects on risk of Avoid as first-line therapy Low Strong
hospitalization and may be associated with increased for heart failure
mortality in older adults with heart failure; in heart
failure, higher dosages are not associated with
additional benefit and may increase risk of toxicity
Decreased renal clearance of digoxin may lead to If used for atrial Dosage Dosage
increased risk of toxic effects; further dose reduction fibrillation or heart >0.125 mg/d: >0.125 mg/d:
may be necessary in patients with Stage 4 or 5 chronic failure, avoid dosages Moderate Strong
kidney disease >0.125 mg/d
Potential for hypotension; risk of precipitating Avoid High Strong
myocardial ischemia
Amiodarone is effective for maintaining sinus rhythm Avoid amiodarone as High Strong
but has greater toxicities than other antiarrhythmics first-line therapy for atrial
used in atrial fibrillation; it may be reasonable first-line fibrillation unless patient
therapy in patients with concomitant heart failure has heart failure or
or substantial left ventricular hypertrophy if rhythm substantial left ventricular
control is preferred over rate control hypertrophy
Highly anticholinergic, sedating, and cause Avoid High Strong
orthostatic hypotension; safety profile of low dose
doxepin (6 mg/d) comparable with that of placebo
Increased risk of cerebrovascular accident (stroke) Avoid, except for Moderate Strong
and greater rate of cognitive decline and mortality schizophrenia, bipolar
in persons with dementia. Avoid antipsychotics disorder, or short-term
for behavioral problems (eg, dementia, delirium) use as antiemetic during
unless nonpharmacological options (eg, behavioral chemotherapy
interventions) have failed or are not possible and
the patient is threatening substantial harm to self
or others
High rate of physical dependence and tolerance Avoid High Strong
to sleep benefits; greater risk of overdose at low
dosages
Older adults have increased sensitivity to Avoid Moderate Strong
benzodiazepines and decreased metabolism of long-
acting agents; in general, these drugs increase risk of
cognitive impairment, delirium, falls, fractures, and
motor vehicle crashes in older adults
Avoid Moderate Strong
Chlordiazepoxide may be appropriate for seizure
benzodiazepine withdrawal, ethanol withdrawal,
severe generalized anxiety disorder, and
periprocedural anesthesia
TABLE 1. 2015 American Geriatrics Society (AGS) Beers Criteria (continued)
Strength of
Organ System, Therapeutic Quality of Recommen­
Category, Drug Rationale Recommendation Evidence dation
Meprobamate High rate of physical dependence; very sedating Avoid Moderate Strong
Nonbenzodiazepine, benzodiazepine Benzodiazepine receptor agonists have adverse Avoid Moderate Strong
receptor agonists effects similar to those of benzodiazepines in older
Eszopiclone adults (eg, delirium, falls, fractures); increased
Zolpidem emergency department visits and hospitalizations;
Zaleplon motor vehicle crashes; minimal improvement in sleep
latency and duration
Ergoloid mesylates Lack of efficacy Avoid High Strong
(dehydrogenated ergot alkaloids)
Isoxsuprine
ENDOCRINE
Androgens Potential for cardiac problems; contraindicated in Avoid unless indicated Moderate Weak
Methyltestosterone men with prostate cancer for confirmed
Testosterone hypogonadism with
clinical symptoms
Desiccated thyroid Concerns about cardiac effects; safer alternatives Avoid Low Strong
available
Estrogens (with or without progestins) Evidence of carcinogenic potential (breast and Avoid oral and topical Oral and patch: Oral and
endometrium); lack of cardioprotective effect patch; acceptable to use High patch:
and cognitive protection in older women. Vaginal low-dose intravaginal Strong
estrogens for the treatment of vaginal dryness are estrogen (eg, cream or
safe and effective; women with a history of breast tablets) for management Vaginal cream Topical
cancer who do not respond to nonhormonal therapies of dyspareunia, lower or tablets: vaginal
are advised to discuss the risk and benefits of low- urinary tract infections, Moderate cream or
dose vaginal estrogen (estradiol <25 µg twice weekly) and other vaginal tablets:
with their health care provider symptoms Weak
Growth hormone Impact on body composition is small and associated Avoid, except as High Strong
with edema, arthralgia, carpal tunnel syndrome, hormone replacement
gynecomastia, and impaired fasting glucose after pituitary gland
removal
Insulin (sliding scale) Higher risk of hypoglycemia without improvement Avoid Moderate Strong
in hyperglycemia management, regardless of care
setting; refers to sole use of short- or rapid-acting
insulins to manage or avoid hyperglycemia in absence
of basal or long-acting insulin; does not apply to
titration of basal insulin or use of additional short- or
rapid-acting insulin in conjunction with scheduled
insulin (ie, correction insulin)
Megestrol Minimal effect on weight; increases risk of thrombotic Avoid Moderate Strong
events and possibly death in older adults
Sulfonylureas (long-duration) Avoid High Strong
Chlorpropamide Chlorpropamide has a prolonged half-life in older
adults; can cause prolonged hypoglycemia; causes
syndrome of inappropriate antidiuretic hormone
secretion

Glyburide Glyburide poses a higher risk of severe prolonged

hypoglycemia in older adults
GASTROINTESTINAL
Metoclopramide Can cause extrapyramidal effects, including tardive Avoid, unless for Moderate Strong
dyskinesia; risk may be greater in frail older adults gastroparesis
Mineral oil (given orally) Potential for aspiration and adverse effects; safer Avoid Moderate Strong
alternatives are available

May 2018 n Volume 32 Number 5 25

 TABLE 1. 2015 American Geriatrics Society (AGS) Beers Criteria (continued)
Strength of
Organ System, Therapeutic Quality of Recommen­
Category, Drug Rationale Recommendation Evidence dation
Proton-pump inhibitors Risk of Clostridium difficile infection and bone loss Avoid scheduled use for High Strong
and fractures >8 weeks unless for high-
risk patients (eg, oral
corticosteroids or chronic
NSAID use), erosive
esophagitis, Barrett’s
esophagitis, pathological
hypersecretory
condition, or
demonstra­ted need for
maintenance treatment
(eg, due to failure of drug
discontinuation trial or
H2 blockers)

PAIN MEDICATIONS

Meperidine Not effective in dosages commonly used; may pose Avoid, especially in Moderate Strong
higher risk of neurotoxicity, including delirium, than patients with chronic
other opioids; safer alternatives exist kidney disease

Non-cyclooxygenase-selective NSAIDs Increased risk of gastrointestinal bleeding or peptic Avoid chronic use, unless Moderate Strong
(oral) ulcer disease in high-risk groups, including those other alternatives are not
Aspirin (>325 mg/d) >75 years or taking oral or parenteral corticosteroids, effective and patient can
Diclofenac Diflunisal anticoagulants, or antiplatelet agents; use of proton- take gastroprotective
Etodolac Fenoprofen pump inhibitor or misoprostol reduces but does not agent (proton-pump
Ibuprofen Ketoprofen eliminate risk. Upper gastrointestinal ulcers, gross inhibitor or misoprostol)
Meclofenamate Mefenamic acid bleeding, or perforation caused by NSAIDs occur in
Meloxicam Nabumetone approximately 1% of patients treated for 3–6 months
Naproxen Oxaprozin and in ~2%–4% of patients treated for 1 year; these
Piroxicam Sulindac trends continue with longer duration of use
Tolmetin

Indomethacin Of all the NSAIDs, indomethacin has the most Avoid Moderate Strong
adverse effects

Ketorolac (includes parenteral) Ketorolac increases risk of GI bleeding, peptic ulcer Avoid Moderate Strong
disease, and acute kidney injury in elderly patients

Pentazocine Causes CNS adverse effects, including confusion Avoid Low Strong
and hallucinations, more commonly than other
opioid analgesic drugs; is also a mixed agonist and
antagonist; safer alternatives exist

Skeletal muscle relaxants
Carisoprodol Chlorzoxazone
Cyclobenzaprine Metaxalone
Methocarbamol Orphenadrine
Most muscle relaxants are poorly tolerated by Avoid Moderate Strong
geriatric patients due to drug-related complications
(eg, anticholinergic adverse effects, sedation,
increased risk of fractures); effectiveness at dosages
tolerated by older adults is questionable

GENITOURINARY

Desmopressin High risk of hyponatremia; safer alternatives exist Avoid for treatment of Moderate Strong
nocturia or nocturnal
polyuria

The intentions of the criteria are to improve the selection of prescription drugs by clinicians and patients; evaluate patterns of drug use within
populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality-of-care, cost, and utilization data.

26 Critical Decisions in Emergency Medicine

commonly implicated drugs in
emergency department visits. Warfarin,
insulin, oral antiplatelets, and oral
hypoglycemic agents are responsible for
most ADEs requiring hospitalization.
The combined hospitalization rate for
this group of drugs is 17 times higher
than the rate for all drugs on the Beers
List.15 These medications account for
50% of all ADE-related emergency
department visits, despite being
prescribed to only 9% of outpatients.15
Eighty-eight percent of
hospitalizations for ADEs are associated
with hematological, endocrine,
cardiovascular, central nervous system,
and anti-infective agents.15 ADEs
stemming from the use of digoxin are
the third most common reason for
hospitalization; in fact, the exclusion
of digoxin cuts the hospitalization rate
associated with the Beers List in three.15
At this time, limited data exist about
ADEs relating to newer anticoagulants,
as compared to warfarin.
CRITICAL DECISION
What steps can be taken to
prevent adverse drug events?
Many things can be done both
institutionally and in the emergency
department to prevent ADEs in the
geriatric patient population. Hospitals
can can help identify potential risks by
establishing a computer system to flag
duplicate prescriptions and potential
drug interactions/reactions based on
physiological factors such as kidney
disease.19,20
For example, a hospital in Salt Lake
City established a computer program
called the HELP system (Health
Evaluation through Logical Processing),
which monitors for clinical signs and
symptoms indicative of possible ADEs.18
These red flags, as determined by the
program, include rash, changes to vital
signs, seizures, anaphylaxis, diarrhea,
fever, and others.18
Moreover, medication reconciliation
with the patient is an important process
that can be initiated during every visit.
A safety mechanism can be established
in which the pharmacist must approve
certain drugs that are prone to adverse
interactions. The involvement of a
pharmacist in the prescribing process
has been shown to decrease ADEs
and medication errors.19 Moreover,
pharmacists can be an extra resource
for patient education by providing
information about medications, their
side effects, and possible interactions.19
Before prescribing any new drug
to a geriatric patient, several steps
should be taken to prevent potential
ADEs. Consider nondrug therapies
such as physical therapy or massage
therapy for pain issues. Assume that all
medications have potential side effects.
Consider the patient’s physiological
age and how it affects the ability to
absorb, metabolize, and eliminate the
drug. Take a few minutes to assess
the patient’s current medication list
to look for common high-risk drugs
with potential interactions. Explain
to the patient the indication and most
common side effects associated with
each medication, as well as the risks of
noncompliance.
Start at the lowest possible dosage,
increasing it as necessary and as
tolerated. Create a clear plan for
primary care follow-up, and instruct
the patient to have a low threshold for
adverse signs and symptoms and to
return to the emergency department for
any possible interactions.
Summary
The elderly constitute one of the
fastest growing segments of our society.
It is important to understand the body’s
changing physiology due to the aging
process, and to recognize the challenges
n Failing to consider OTC drugs and herbal medications as possible culprits for
ADEs.
n Overlooking a patient’s current prescription list and recent changes in
medications.
n Discounting a geriatric patient’s changing physiology, which may affect the way
drugs are metabolized, leading to side effects and adverse reactions.
n Administering a high drug dosage to a geriatric patient, rather than starting with
a low dosage and slowly increasing it.
that come with treating the ever-
growing geriatric population, including
comorbidities and polypharmacy.
Emergency care providers can take
small and reasoned steps to minimize
the risk of potentially dangerous
ADEs by being aware of common
drug interactions, educating patients
about the importance of medication
compliance, and maintaining a high
index of suspicion when evaluating any
geriatric patient.
REFERENCES
1. US Census Bureau, 2004. US interim projections by
age, sex, race, and Hispanic origin. www.census.gov/
population/projections/data/national/usinterimproj.
html. Accessed June 6, 2015.
2. Blanda M. Pharmacology in the elderly. In: Kahn
JH, Magauran BG Jr, Olshaker JS, eds. Geriatric
Emergency Medicine: Principles and Practice.
Cambridge, UK: Cambridge University Press; 2014.
3. Alexander-Magalee MA. Addressing pharmacology
challenges in older adults. Nursing. 2013
Oct;43(10):58-60.
4. Vestal RE. Aging and pharmacology. Cancer. 1997
Oct 1;80(7):1302-1310.
5. Fialová D, Onder G. Medication errors in elderly
people: contributing factors and future perspectives.
Br J Clin Pharmacol. 2009 Jun;67(6):641-645.
6. Gallagher P, Barry P, O’Mahony D. Inappropriate
prescribing in the elderly. J Clin Pharm Ther. 2007
Apr;32(2):113-121.
7. McLean AJ, Le Couteur DG. Aging biology and
geriatric clinical pharmacology. Pharmacol Rev. 2004
Jun;56(2):163-184.
8. Hughes SG. Prescribing for the elderly patient: why
do we need to exercise caution? Br J Clin Pharmacol.
1998 Dec;46(6):531-533.
9. Parkin DM, Henney CR, Quirk J, Crooks J. Deviation
from prescribed drug treatment after discharge from
hospital. Br Med J. 1976 Sep 18;2(6037):686-688.
10. Vogt-Ferrier N. Older patients, multiple comorbidities,
polymedication… should we treat everything? Eur
Geriatr Med. 2011 Feb;2(1):48-51.
11. Lazarou J, Pomeranz BH, Corey PN. Incidence of
adverse drug reactions in hospitalized patients: a
meta-analysis of prospective studies. JAMA. 1998
Apr 15;279(15):1200-1205.
12. Walker J, Wynne H. Review: the frequency and severity
of adverse drug reactions in elderly people. Age
Ageing. 1994 May;23(3):255-259.
May 2018 n Volume 32 Number 5 27
 CASE RESOLUTIONS
■ CASE ONE
The elderly woman with
abdominal and back pain was
tachycardic on presentation. After
reviewing her medication list, the
emergency clinician believed the
most likely explanation for her
symptoms was an adverse reaction
caused by ciprofloxacin and
warfarin. (Ciprofloxacin affects the
hepatic metabolism of warfarin and
increases the circulating level.)
A CT scan of her abdomen and
pelvis with IV contrast revealed a
large retroperitoneal bleed, with
no obvious arterial extravasation.
Vascular surgery and interventional
radiology agreed that the patient
should be transferred to a tertiary
hospital for further intervention.
While waiting for transport, she was
given IV vitamin K and 2 units of
FFP, and continuously monitored.
She remained stable and was
transferred via advanced life support
ambulance.
The patient was monitored in the
ICU and did not require any surgical
intervention. Her INR was reversed, and
the hematoma stabilized without further
treatment.
■ CASE TWO
The elderly diabetic man with slurred
speech and hypoglycemia improved
transiently with the administration of
dextrose 50%. He had a prescription
for glipizide, a sulfonylurea, which is
known to cause hypoglycemia. A review
of his current medication list, indicated
that the patient had recently started
taking SMZ/TMP for lower-extremity
cellulitis. The emergency clinician
recognized that the concurrent use
of a sulfonylurea and co-trimaxazole
increases the risk of hypoglycemia
fourfold. (Sulfamethoxazole inhibits the
metabolism of many drugs, including
sulfonylurea.)
Due to a rapid drop in his glucose
level despite the administration of
dextrose 50%, the patient required
an IV dextrose 10% drip and was
admitted to the Progressive Care Unit for
observation and serial fingerstick glucose
tests. He did well and was discharged
the next day.
■ CASE THREE
The 85-year-old woman with
abdominal pain and black, tarry
stool was noted to have a history
of osteoarthritis. Her medication
list included meloxicam, and
she reported that she had also
been taking OTC ibuprofen for
the last few weeks. The clinician
suspected that the drugs (both
NSAIDs) had led to a worsening
upper-GI bleed.
An upright chest radiograph
was negative for free air. A
gastroenterologist was called
to the emergency department
to perform an endoscopic
examination, which revealed a
large duodenal ulcer (3 % 4 cm)
with raw borders that were
actively bleeding. There were no
obvious signs of perforation, so
the ulcer was cauterized and the
patient was admitted to the ICU
for further workup. One unit of
blood was administered in the
ICU.

13. Klein LE, German PS, Levine DM, Feroli ER Jr, Ardery J.

Medication problems among outpatients. A study
with emphasis on the elderly. Arch Intern Med. 1984
Jun;144(6):1185-1188.
14. Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn
AB, Schroeder TJ, Annest JL. National surveillance of
emergency department visits for outpatient adverse
drug events. JAMA. 2006 Oct 18;296(15):1858-1866.
15. Budnitz DS, Shehab N, Kegler SR, Richards CL.
Medication use leading to emergency department visits
for adverse drug events in older adults. Ann Intern Med.
2007 Dec 4;147(11):755-765.
16. American Geriatrics Society 2015 Beers Criteria Update
Expert Panel. American Geriatrics Society 2015 Updated
Beers Criteria for Potentially Inappropriate Medication
Use in Older Adults. J Am Geriatr Soc. 2015 Nov ;63(11):
2227-2246.
17. Caterino JM, Emond JA, Camargo CA Jr. Inappropriate
medication administration to the acutely ill elderly: a
nationwide emergency department study, 1992-2000.
J Am Geriatr Soc. 2004 Nov;52(11):1847-1855.
18. Evans RS, Pestotnik SL, Classen DC, Horn SD, Bass
SB, Burke JP. Preventing adverse drug events in
hospitalized patients. Ann Pharmacother. 1994
Apr;28(4):523-527.
19. Fairbanks RJ, Rueckmann EA, Kolstee KE, et al. Clinical
Pharmacists in Emergency Medicine. Agency for
Healthcare Research and Quality. http://www.ahrq.gov/
downloads/pub/advances2/vol4/advances-fairbanks_20.
pdf. Accessed March 2016.
20. Geriatric Emergency Department Guidelines. American
College of Emergency Physicians, The American
Geriatrics Society, Emergency Nurses Association, and
the Society for Academic Emergency Medicine. 2013.
21. Paauw D. Drug Interaction in the Elderly: Beware the
Antibiotics. Medscape. http://www.medscape.com/
viewarticle/848870_2. Accessed March 2016.

28 Critical Decisions in Emergency Medicine

 A 55-year-old man with palpitations and lightheadedness.

The Critical ECG

Ventricular tachycardia (VT), rate 190. The differential diagnosis of a wide QRS By Amal Mattu, MD, FACEP
complex tachycardia includes VT, supraventricular tachycardia (SVT) with aberrant Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
conduction (eg, bundle branch block), and sinus tachycardia (ST) with aberrant
Fellowship in the Department of
conduction. In the absence of an obvious and repeating P-QRS pattern, ST can Emergency Medicine at the University
be excluded. This patient’s ECG demonstrates several features that exclude the of Maryland School of Medicine in
Baltimore.
diagnosis of SVT and confirm VT: a taller left “rabbit ear” morphology of the QRS
complex in lead V1, S > R in lead V6, atrioventricular dissociation, and the presence of fusion complexes. Even in the absence
of these diagnostic features, however, VT should always be preferentially chosen and treated. Treating an SVT as if it were VT is
generally safe; however, if VT is mistakenly diagnosed and treated as SVT, the results can be deadly.

a) Right bundle branch block–type of à Features suggestive of VT in this b)

morphology with RsR’ configuration. wide QRS complex tachycardia.
Note that the R wave is larger than R’ Wave
a)
the R’ wave (taller left “rabbit ear”),
R Wave
consistent with VT.
b) The R wave is larger than the R’
wave in the QRS complex, a finding
consistent with VT.
c) Fusion beats (a combination of
supraventricular and ventricular
beats, indicated by arrows) strongly c) R > R’ Wave
suggestive of VT.

From Mattu A, Brady W, ECGs for the Emergency Physician

2. London: BMJ Publishing; 2008:11,23. Reprinted with
permission.

May 2018 n Volume 32 Number 5 29

 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any
time within 3 years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1 Which of the following is a feature of the pediatric

bony skeleton when compared to adult bones?
A. Pediatric bones are less elastic
B. Pediatric bones are more porous
C. Pediatric bones are strongest at the physis
D. Pediatric patients are less likely to sustain bowing
fractures
5 A 2-month-old boy is brought in for the evaluation of
right-leg pain. He parents explain that he rolled off a
table at home. He is fussy, and swelling and bruising are
noted on the right thigh. An x-ray reveals a midshaft
femur fracture. He has no other signs of injury. What is
the most appropriate next step in his management?
A. Closed reduction in the emergency department
followed by casting

2
An 8-year-old boy presents with left-knee pain and
a limp. He has had subjective fevers at home, but
denies trauma. His temperature is 38.8°C (101.8°F);
his left leg has significant warmth, swelling, and
tenderness with restricted active and passive
range of motion. He is unable to bear weight. His
laboratory studies show a WBC count of 25,000
cells/hpf with 90% neutrophils, and a CRP of
12.0 mg/dL. Orthopedic surgery is consulted, and
a joint aspirate is obtained. What organism is most
likely to grow on culture?
B. Skeletal survey, blood work, and orthopedic
consultation
C. Orthopedic consultation for spica casting
D. Posterior long-leg splint and orthopedic follow-up
6 Where is the location of pain in a patient with Osgood-
Schlatter disease?
A. Calcaneal apophysis
B. Inferior pole of the patella
C. Posterior aspect of the medial tibial epicondyle
D. Tibial tuberosity

7
A. Neisseria gonorrhoeae What is the most sensitive and specific imaging modality
B. Pseudomonas aeruginosa for the evaluation of bone and joint infections?
C. Salmonella enterica A. CT
D. Staphylococcus aureus B. MRI
C. Plain films
3
A 9-year-old boy presents with bilateral heel pain
and limping, which has worsened since basketball
D. Ultrasound

8
season started 1 month ago. He is in no acute
distress, but has moderate tenderness over
the Achilles’ tendon insertion to the calcaneus
bilaterally. What is the most appropriate next step
in his management?
A. Discharge home with rest, scheduled NSAIDs, and
primary care physician follow-up
B. Obtain blood work, including a CBC, a CRP, an
ESR, and a blood culture
C. Obtain an MRI of the bilateral feet
D. Obtain an urgent orthopedic consultation
A 16-year-old boy presents with a right tibial shaft
fracture caused by a direct blow sustained during a
basketball game. In the emergency department, he
becomes increasingly agitated, asks to go home, and
has worsening pain, requiring IV morphine. He has
right lower-extremity swelling, point tenderness, and
worsened pain with passive movement of his foot. His
distal pulses are intact, and he has normal sensation to
the foot. However, he is unable to ambulate secondary
to worsening pain. What next steps should be taken?
A. Admit to the hospital for serial examinations
B. Initiate an emergent orthopedic consultation

4 Which of the following is characteristic of Legg-

Calvé-Perthes (LCP) disease?
C. Initiate posterior long-leg splinting and routine
orthopedic surgery referral
A. It carries a low risk for subsequent fracture D. Provide a repeat dose of morphine and continue to
B. It commonly occurs in adolescents observe
C. It often responds to conservative therapy
D. Most cases are bilateral on presentation

30 Critical Decisions in Emergency Medicine

 9 Which of the following is an advantage of CT
when compared to MRI?
A. CT generally does not require sedation
15 Which drugs are responsible for the largest
B CT has improved sensitivity for detecting
inflammatory conditions
C. CT is more easily interpreted by radiologists
D. CT provides lower levels of ionizing radiation
number of adverse drug reactions in geriatric
patients?
A. Glipizide, insulin, and aspirin
B. Insulin, hydralazine, and clonidine
C. Warfarin, amiodarone, and insulin
D. Warfarin, insulin, and digoxin

10 Which of the following is characteristic of a

toddler’s fracture?
A. Immobilization is not necessary in most cases
16 Which of the following strategies is unlikely to
decrease adverse drug reactions in the acute
setting?
B. Plain films are often normal on initial A. Computer system safety triggers
evaluation B. Consultation with an emergency department
C. Significant force is required to cause this type pharmacist
of injury C. Implementing protocols that allow ancillary staff
D. The most common mechanism is a direct to place medication orders on your behalf
blow to the tibia D. Medication reconciliation

11 Which of the following is an expected

physiological change in the geriatric
population?
A. Increased GFR and creatinine
B. Increased adipose tissue
C. Increased gastric motility
D. Increased lean body weight
17 How can ciprofloxacin affect warfarin?
A. Decreases its clearance
B. Decreases its effectiveness
C. Increases its clearance
D. Increases pharmacodynamics

12 Which of the following describes

pharmacokinetics?
18 Which of the following factors affects
pharmacokinetics?
A. Cardiac function
A. The means by which drugs are eliminated B. GI function
B. The means by which drugs are metabolized C. Liver function
C. The means by which the body interacts with D. Pulmonary function
medications

19
D. The way medications affect one another What can pharmacists do to help prevent ADEs?
A. Arrange follow-up with a primary care physician

13
How are adverse drug events (ADEs) best
B. Arrange home health care
defined?
C. Double check both inpatient and outpatient
A. Any drug-related side effects or interactions medication orders
B. Events that require drug intervention D. Prescribe medications on the treating
C. Mortality from drug interactions physician’s behalf
D. Taking too many medications at once

14 Which of the following drug classes contribute

to the majority of ADEs in geriatric patients? 20
What is the risk of ADEs in a patient taking seven
or more prescribed medications?
A. 27%
A. Antiarrythmic medications and
anticoagulants B. 54%
B. Anticoagulants and diabetic medications C. 82%
C. Antihypertensive medications and D. 98%
anticoagulants
D. Diabetic medications and antihypertensive
medications

ANSWER KEY FOR APRIL 2018, VOLUME 32, NUMBER 4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
D A D D C C A A A D C C A D B B A A D D

May 2018 n Volume 32 Number 5 31

 Drug Box
BIOTIN (VITAMIN B7)
By Frank LoVecchio, DO, MPH, FACEP,
Maricopa Medical Center/Banner Poison and
Drug Center, Phoenix, AZ
Biotin is a water-soluble vitamin found in
common foods such as nuts, whole grains,
fruits, and vegetables. It also is found in multi-
and prenatal vitamins and dietary supplements
marketed for hair, skin, and nail growth.
Laboratory Abnormalities
High doses can interfere with hundreds of
common blood tests. Of particular note,
troponin levels can be either falsely low or
high. The US Food and Drug Administration
has reported an increase in the number of
adverse events related to biotin interference
in laboratory tests, including one death.
Vitamin B7 Deficiency
Although biotin deficiency is fairly rare,
some patients (eg, pregnant women) may
experience mild forms. The excessive
consumption of raw eggs can also lead to
a deficiency. (Raw egg whites contain a
protein called avidin, which binds to biotin
and prevents its absorption. The protein is
deactivated during the cooking process.)
Mechanism
Biotin-containing enzymes participate in
important metabolic pathways such as the
production of glucose and fatty acids.
Dosing
The recommended daily intake of biotin
for men, women, and pregnant females is
30 mcg.
Abnormal blood tests have been reported
in patients taking high levels (eg, ≥300 mg
per day).
Tox Box
AMNESTIC SHELLFISH POISONING
By Richard A. Koch, MD, FACEP; and Christian A. Tomaszewski, MD, MS, MBA,
FACEP, University of California, San Diego
Amnestic shellfish poisoning results from consuming mussels and clams containing
domoic acid. Even marine animals can succumb to the neurotoxin’s effects. Alfred
Hitchcock’s classic thriller, The Birds, is said to have been inspired by a 1961
outbreak.
Mechanism
Domoic acid is a tasteless, odorless, heat-stable, water-soluble, polar, nonprotein
amino acid mainly produced by Pseudo-nitzschia diatoms. Filter-feeding shellfish
(eg, mussels, clams) accumulate the toxin. It is excitatory at mammalian glutamate
receptors, leading to excessive influx of Ca2+ and Na2+ into neurons and apoptosis.
Presentation
Usually manifests <5 hours (up to 38 hours) after shellfish ingestion. Most patients
report initial gastrointestinal symptoms followed by neurological symptoms:
• Abdominal cramps, nausea, vomiting, diarrhea
• Confusion, memory loss, disorientation
• Hemiparesis, ophthalmoplegia, purposeless chewing, grimacing
• Seizures, status epilepticus, cranial nerve palsies, coma
• Cardiac dysrhythmias and/or hemodynamic instability
Mortality ≤2%, usually in older patients. Seizures resolve over weeks, but <10%
have permanent neurological problems.
Evaluation
• Electrolyte levels to assess for losses due to vomiting and diarrhea
• Orthostatic vital signs to assess for fluid loss or direct toxic effect
• Electrocardiogram to rule out other causes of cardiac dysrhythmias
• Computed tomography to rule out other causes of neurological injury
• Enzyme-linked immunosorbent assay or high-performance liquid
chromatography testing to test shellfish
Treatment
Supportive care includes IV fluids, vasopressors for hypotension, antiemetics,
and the correction of electrolyte abnormalities. Benzodiazepines, propofol,
and barbiturates for seizures. The benefit of activated charcoal is unclear
(contraindicated if altered consciousness).
Disposition
• Patients with an unclear diagnosis, significant neurological symptoms, or
electrolyte/fluid loss require further treatment or evaluation.
• Patients with mild symptoms can be discharged with follow-up care.