ERcast: Clinical Perspectives Podcast Preview
The summary below is from an episode of ERcast: Clinical Perspectives
Mastoiditis is a suppurative complication of acute otitis media that can progress to bony destruction, abscess, venous sinus thrombosis, and intracranial infection. Communication impairment in the ED is also easy to misread: aphasia, dysarthria, hearing loss, and cognitive-language deficits can look like confusion or noncooperation and directly affect capacity assessment and disposition.
Mastoiditis Emergency Recognition
- Otitis media progression: Mastoiditis is a suppurative infection of the mastoid air cells that usually follows acute otitis media, and coalescent disease means bony septal destruction rather than a routine persistent ear infection.
- Postauricular danger signs: Postauricular erythema, tenderness, swelling, and fluctuance are the bedside clues that should break routine ear-pain anchoring, with auricular protrusion helping localize more advanced disease.
- Age-based pinna displacement: Auricular displacement has a useful age pattern: down and out in children under 2, up and out in older children. That bedside distinction is worth hearing in the episode.
- Imaging that actually helps: CT of the temporal bones with IV contrast is the first-line ED study when the diagnosis is uncertain or complications are suspected, because mastoid clouding alone is not specific.
- Complication-first mindset: Subperiosteal abscess is the most common extracranial complication, while meningitis, epidural abscess, and venous sinus thrombosis are the intracranial landmines that change urgency fast.
- Early IV therapy and ENT: Ampicillin-sulbactam or ceftriaxone are common first-line IV antibiotics, with vancomycin or antipseudomonal coverage added for specific risk profiles and early ENT involvement mandatory.
Aphasia and ED Communication
- Communication is not capacity: Difficulty communicating should not be equated with lack of decision-making capacity, because aphasia and dysarthria can mask intact understanding and values despite impaired speech output.
- Aphasia versus dysarthria: Aphasia is a language disorder, while dysarthria is a motor speech problem; that simple split changes how you test comprehension and how you structure questions at the bedside.
- Fast bedside identification: Start by asking about baseline communication difficulty, then use collateral history to decide whether the barrier is new or chronic. We walk through the quickest bedside cues in the episode.
- Pacing and visual access: Slowing your speaking rate, pausing between phrases, and facing the patient directly can markedly improve comprehension, especially when visual cues are doing part of the work.
- Closed-ended question design: Binary choices and simplified phrasing outperform open-ended questioning when language production is impaired, and a nod or smile should never be accepted as proof of understanding.
- Writing and AAC supports: Low-tech tools like paper, keyword writing, and a laminated yes-no or symptom board can preserve the patient's role in the conversation instead of defaulting straight to family.
Subscribe to ERcast: Clinical Perspectives to listen to the episode.
References:
- Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Acute mastoiditis. Am J Emerg Med. 2024 May;79:63-69. PMID: 38368849.
Faculty
- Brett Murray, MD
Dr. Murray is an Emergency Medicine physician practicing at a busy community trauma center. After attending Boston University School of Medicine, he completed his residency training at Brown University / Rhode Island Hospital, where he also served as Chief Resident from 2020 – 2021. His clinical interests center on medical education, performance science, and Emergency Medical Services.
- Anne Steckowych, APRN
Emergency medicine is in Anne’s blood; her father has been an Emergency Medicine physician for the last 30 years. After earning her nursing degree from the University of New Hampshire (UNH) in 2018, Anne worked as an EMT at her local fire department, gaining practical experience that prepared her for five years as a nurse in the emergency department. She eventually returned to UNH to become an NP and has spent the last 8 years in the same ED, building relationships with a clinical team dedicated to providing the best possible patient care. Outside of the hospital, she’s usually skiing, hiking, or running in the New Hampshire hills. ERcast is her first podcast, and she’s thrilled to be part of the Hippo team.
- Brit Long, MD
Dr. Brit Long is a Professor of Emergency Medicine at the University of Virginia and an emergency medicine physician with experience in both a community ED and at a military academic center ED. He is the Clinical Editor-in-Chief of emDOCs.His professional interests include medical education, evidence-based medicine, and the FOAMed movement. Outside of work, he enjoys spending time with his wife and two daughters
- Geoffrey Comp, DO, FACEP
Dr. Comp is an Associate Program Director for the Creighton University / Valleywise Health Emergency Medicine Residency Program in Phoenix. A clinician-educator at heart, Geoff spends his time mentoring the next generation of Emergency Medicine residents and advocating for better ways to teach and learn medicine. His professional world revolves around wilderness medicine, clinician wellness, and finding innovative ways to bridge the gap between theory and the bedside. When he isn’t in the ED or the classroom, you’ll likely find him combining his love for medicine with his passion for the outdoors, always looking for a new trail to explore or a new way to collaborate with fellow clinicians.
- Shay Kerbey, M.S., CCC-SLP
