Osteomyelitis – Making the Diagnosis

In the patient population at Parkland, osteomyelitis (OM) usually results from direct extension of adjacent soft tissues (i.e. diabetic foot ulcers, or sacral decubitus ulcers), but can also result from hematogenous spread, or direct inoculation as a result of trauma or surgery.  Given the lack of sensitive physical exam findings, and the unavailability of time-consuming imaging modalities in the ED (magnetic resonance and/or bone scintigraphy), OM can be a difficult and sometimes elusive diagnosis to make in the Emergency Department.

Thrombolytics in PE

Last night, I had a patient present with acute dyspnea, tachy in the 150s.  She had a h/o prior PE 5 years ago that she completed anticoagulation for.  EKG shown below has some TWI in anteroinferior leads (c/w RHS), and a nice Q wave in III (not really an S1, but impressive Q3T3).

Patient was started on a heparin ggt even prior to CT (slice shown below).  Bedside echo also revealed enlarged RV.  She had b/l PEs.  She was hemodynamically stable, so this was considered a submassive PE.