UMEM Educational Pearls - By Michael Bond

FrostBite

Now that we are in the cold winter months, we are more likely to see patient with frostbite and hypothermia.  Here are some tips for treating frostbite.

• Rapidly rewarm the affected body part.  Never attempt rewarming if there is risk of refreezing.
• An appropriate warming technique tub of water at 40-42°C. Higher temperatures should be avoided secondary to the risk of burns. If a tub is not available, use warm wet packs at the same temperature.
• It can take up to 40 minutes for the affected area to thaw.  Thawing is complete when the distal areas flush.
• The only indication for early surgical intervention is debridement of blisters, necrotic tissue or fasciotomy if there is  compartment syndrome.
• It often takes 1-3 months for frostbitten tissue to be declared viable. The affected area generally heals or shrivels and dries up without surgery. Amputation should be delayed as as long as possible. Early surgical consultation for amputation is rarely needed.

Adapted from Frostbite: Treatment and Medication by C. Crawfor Mechem, MD, MS, FACEP as posted on eMedicine.com.

Patient with iritis will typically present with a painful red eye and it can sometimes be difficult to tell if it is due to conjunctivitis or a corneal abrasion.  Some tips that can help differentiate iritis from other causes of painful red are:

1. When pain reduction was used as a diagnostic tool, it had a sensitivity of 80% and a specificity of 86% in determining whether a simple corneal injury was present. In iritis, the pain will NOT be relieved with topical anesthetic.
2. In iritis, injection will be localized predominantly around the iris and not diffusely over the conjunctiva.
3. The consensual light reflex can be used to make the diagnosis. Of course, shining a light in the affected eye will cause pain, but in iritis shining a light in the normal, unaffected eye (by causing consensual movement of the other affected iris) will cause pain if iritis is present.

Finally, ensure you document:

1. Visual Acuity corrected in both eyes.  Use a pinhole if they forgot their glasses.
2. That you flipped their eyelids to make sure that no foreign bodies are lurking under the lids
3. Stain their eyes with flouriscen to ensure there are no corneal abrasions in addition to the iritis.

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Conjunctivitis:

Patient presenting to the Emergency Department complaining of "Pink Eye" is very common but how can you be sure that they do not have a bacterial conjunctivitis and absolutely need antibiotics or are they just suffering from a viral or allergic conjunctivitis.

• Bacterial conjunctivitis will typically have  a mucopurulent discharge and the patients will complain that their lids are matted shut in the morning. Though this can occur in allergic or viral conjunctivitis, those with bacterial conjunctivitis typically have a wet, sticky mucopurulent material matted to their lids where viral/allergic conjunctivitis typically have crusting on their lids and lashes due to dried tears and serous secretions.  Bacterial conjunctiviits is also an uncommon condition due to the defense systems of the eye. So most patients can be treated with support care (ie: Warm Compresses).
• Allergic conjunctivitis should affect both eyes.  It would be odd for only one eye to be allergic, so if only one eye is infected that diagnosis is most likely viral or bacterial conjunctivitis.
• When treating allergic conjunctivitis go with the drops.  Several studies have now shown that topical therapy is better than systemic (ie: benadryl, zyrtec, allegra, or claritin) in the resolution of symptoms.

Otitis Externa:

Infections of the external ear canal are common and can typically be treated with topical antibiotic solutions (Cortisporin Otic, Cipro Otic, etc...) or antibiotic solutions mixed with topical steroids (Cortisporin HC Otic, Cipro HC Otic, etc...).  Most patients should not require PO or IV antibiotics.

However, you need to always be on the look out for malginant otitis externa (MOE) which is a more deep seated infeciton extending into the temporal bone and can have a mortality rate as high as 50%.  Patients that are diabetic, immunospressed, or have had radiation therapy to the base of the skull are at increased risk.  Patients with MOE typically have pain out of proportion to clinical findings and granulation tissue may be present in the ear canal.  Suspect this diagnosis in patients that have cellulitis or extreme tenderness over the mastoid process.

If you suspect MOE the patient should be started on antibiotics that cover pseudomonas. Consider obtaining a CT scan with temporal bone cuts and an Otolaryngology consultation.

It is almost impossible to get through a shift these days with out seeing an abscess that is caused by CA-MRSA.  As of the 2007 Antibiotic nomogram (2008 data not yet available) at University of Maryland CA-MRSA was only 70% sensitive to clindamycin, and >98% sensitive to bactrim and > 96% sensitive to doxcycline.  A local community hospital in Baltimore is showing only 55% sensitivity to clindamycin.

As a New Year's resolution to yourself I recommend that you check with your local hospital's Micrology department to see what the sensitivities are to bactrim, clindamycin, doxycycline.  If sensitivities are less than 80% it would generally be recommended that these medications not be used as initial empiric treatment.

For Baltimore bactrim and doxycycline should probably be the preferred treatment options.

Have a Great New Year.

Critical Care Billing Pearls:

As the table shows Critical Care billing will earn you approximately 25% more with no additional overhead.  Critical care time must be at least 30 minutes, and the following procedures are included in the critical care code:   

• Interpretation of ABG and labs
• Interpretation of CXR
• IV insertation
• Transcutaneous pacing
• Blood Draws
• NG Tube placement

The following procedures are not bundled into critical care time, so they can be billed separately, therefore the time you spend doing these procedures can not be included in your total critical care time:

• Central Line Placement
• Lumbar Puncture
• Intubation
• Transvenious pacemaker placement
• Arterial Line Placement
• Chest Tube Placement
• CPR

Remember critical care time does not need to be continuous but you need to be immediately available to the patient for the time to count.  You can not count time going off the floor to review an xray or CT, but this time can be counted if you do it in the immediate vacinity of the patient.

FINAL CAVEAT  To help your coders bill appropriately it helps to include a statement such as "Critical Care time XX minutes where I was directly involved in the care of this patient exclusive of all other separately billable procedures."

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It seems to come up about once or twice a month about the safety of metronidazole in pregnancy.  This has been very controversial over the years, but the current stance is that it is safe in pregnancy.  In fact, untreated vaginal infections, bacterial vaginosis and trichomonas, have been associated with miscarriages and preterm labor, so the benefits outweigh the risks.

Below are two good references to add to your file in case you get into a debate with somebody quoting old data.

Organization of Teratology Information Specialists Information on Flagyl and Pregnancy

Safety of metronidazole during pregnancy: a cohort study of risk of congenital abnormalities, preterm delivery and low birth weight in 124 women. J Antimicrob Chemother 1999; 44: 854-855 http://jac.oxfordjournals.org/cgi/content/full/44/6/854

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Just a quick remainder that Thrombotic thrombocytopenia Purpura, TTP, is typically described as a pentad of symptoms:

1. Neurological symptoms such as altered mental status, stroke, or headache
2. Renal failure
3. Fever
4. Thrombocytopenia (low platelets) associated with purpura
5. Microangiopathic hemolytic anemia

Not all symptoms need to be present and it would be rare for you to see the full pentad.  Consider the diagnosis and request that the lab due a manual differentiation or blood smear.  It is there that they will notice schistocytes, fragmented RBCs, that will help clinch the diagnosis.

Most cases of TTP are idiopathic (~60%) but secondary TTP is known to occur with cancer, pregnancy, HIV, bone marrow transplantation, immunospressive drugs like cyclosporin and tacrolimus, and platelet aggregation inhibitors such as cloperidol.

Treatment consists of plasmapheresis, plasma exchange, immunospression with steroids, Rituximab, and other chemotherapies.

Third Trimester Bleeding:

• Estimated to occur in 4% of Pregnancy
• 50% will have a benign cause, the other 50% will have a life threatening cause
• Life Threatening Causes:
  • Placenta Abruption
  • Placenta Previa
  • Uterine Rupture
  • Vasa Previa (fetal vessels crossing or running in close proximity to the inner cervical os.
    
• Benign or Non-OB Causes
  • Contact Bleeding (local trauma)
  • Cervical Inflammation (i.e. infection)
  • Cervical effacement and dilation
  • Cervical cancer
  • Other sites:
    • rectal bleeding
    • urinary bleeding
• Evaluation:
  • ABC's: Stablilize mother, consider 2 large bore IVs
  • Consult OB/GYN early (most centers with OB/Gyn will have these patients evaluate and treated in Labor and Delivery), if not readily available complete evaluation as listed below:
  • Initially avoid bimanual exam
  • Obtain baseline labs (CBC, Coags, Chemistries, Consider LFTs if suspecting eclampsia or HELLP syndromes). If not known obtain Rh status
  • Fetal Monitioring ideally with continous fetal heart rate and tocometry
  • Sterile Speculum exam for culture and check for active bleeding.
  • Obtain ultrasound.

The glucometer is one of the devices that we quickly reach for in the management of our unresponsive patients, diabetics and in the critically ill.  Recently, I noticed that our Roche Accu-Check has a big sticker on the case stating that results could be affected by therapies that alter the metabolism of galactose, maltose, and xylose.  Since this was a big hole in my fund of knowledge I decided to look up what else affects the accuracy of glucometers.

 Now, Dr. Winters already warned used about the inaccuracy of bedside glucometer readings in the critically ill, but what about the patient that is not septic and/or in shock.

Substances/Drugs that have been reported to affect the accuracy of glucometers are:

• Levodopa
• Dopamine
• Mannitol
• Acetaminophen
• Severe lipemia
• Severe unconguted bilirubin
• Elevated Uric Acid
• Maltose (present in immunoglobin products)
• Patient on peritoneal dialysis secondary to Icodextrin
• Ascorbic Acid (Vitamin C)

Anemia also results in higher values, and a capillary blood sample can differ from venous blood by as much as 70mg/dL.

Most errors are more significant when dealing with hypoglycemia. 

So the moral of the story is be careful with a bedside glucometer when the reading is low, as the venous blood sample sent to the lab may return even lower.  Error on the side of treating the patient with glucose.

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High altitude illnesses is typically called Acute mountain sickness (AMS) and is associated with two major complications high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).

Symptoms associated with AMS are headache, fatigue, nausea and vomiting, anorexia and insomia. Cough, Cyanosis, hypoxia, and dyspnea are associated with HAPE.  HACE is associated with progressive neurologic symptoms and can lead to ataxia and coma.

Factors that increase your risk for altitude illnesses are:

• Rate of ascent
• Elevation obtained
• Exertion on arrival to elevation
• Duration at that altitude
• Recent URI
• Previous symptoms of AMS

Management of Felons

• An abscess of distal finger that involves the pulp. 
• A difficult infection to treat due to fibrous septa that divide the pulp into multiple small compartments. 
• These septa run from the periosteum to the skin increasing the risk of osteomyelitis
• Patients typically present with a lot of pain, redness, and swelling.
• Typically triggered by a puncture wound (i.e.: splinter)
• Incision and Drainage can result in a:
  
  • anesthetic finger tip
  • unstable finger pad
  • neuroma
• If you are going to drain one it is recommended that you do a volar longitudinal incision down the middle of the finger pad or a high lateral incision. 
• The high lateral incision should be at about 5 mm below the nail plate border. This distance should allow for avoiding the more volar neurovascular structures.

For good photos of the incision technique please visit the reference article listed.

Clark, DC. Common Acute Hand Infections. Am Fam Physician 2003;68:2167-76

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Severe Hypothyroidism or Myxedema Coma

• Mortality rate has been as high as 80% now 15-20% with aggressive treatment
• Some common symptoms are:
  • Constipation
  • Depression
  • Lethargy
  • Dry, Brittle hair or Alopecia
  • Weight Gain
  • Cold Intolerance
  • Weight Gain
• Treatment consists of:
  • Rule out aggravating cause (i.e.: infection)
  • Start IV levothyroxine dosing
    • Initial dose 400-500 mcg (Helps to saturate the thyroid receptors)
    • Daily dose 100 mcg/day
  • Consider starting Dexamethasone or doing a Cortisol stimulation test
    • Patients may also have adrenal insufficiency from primary pituitary failure or may have secondary adrenal suppression due to the severe hypothyroidism.  If dexamethasone is not provided they may develop severe adrenal insufficiency once you kick start their metabolism.

Mallet Finger:

A common injury resulting in a tear or avulsion of the extensor digitorium tendon inserting into  the base of the distal phalanx.  Occurs due to hyperflexion of the finger usually as of a esult of it getting jammed on a ball while playing sports.  Most can be treated non-surgically.

The distal phalanx must be kept in full extension for 6 to 8 weeks. This is one of the few times that the finger should not be splinted in the position of function.

Make sure that patient is informed that if they remove the splint and flex their finger the 6 to 8 week healing window will be reset to day 0.  These patients should not be doing ROM exercises and must wear the splint full time.

Paracentesis Part II- Ascites Fluid Analysis:

See last weeks procedure pearl for some hints on doing a paracentesis..

Now that you have the fluid what should you send it for:

• Cell Count
• Gram Stain and Culture
• Amylase (normal value is half serum)
• Albumin
• Consider cytology if  cancer is a consideration

Now for the analysis:

• WBC Count >250 PMNs generally accepted as consistent with infection.  Especially if there is more than 70% PMNs which is the upper limit of normal. SAAG (Serum - Ascites Albumin Gradient) an easy calculation to differentiate what the cause of the ascites might be from:
  • Subtract the patient's ascites albumin from the serum albumin (Serum Albumin - Ascites Albumin = SAAG)
  • SAAG > 1.1 mg/dL(Due to items that increase portal pressures)
    • Cirrhosis
    • Alcoholic Hepatitis
    • Cardiac Ascites
    • Hepatic Failure
    • Budd-Chiari Syndrome
    • Portal Vein Thrombosis
    • Myexdema
    • Others
  • SAAG < 1.1 mg/dl (due to intraabdominal forces causing increased oncotic pressure)
    • Tuberculosis Peritonitis
    • Pancreatitic Ascites (typically while have elevated amylase in ascitic fluid)
    • Bowel Obstruction
    • Nephrotic Syndrome
    • Biliary Ascites
    • others

** Corrected definition of SAAG as it was initially reversed.  Thanks to Dr. McCurdy on his proof reading.

Paracentesis:

Since we have covered so many other procedures I though I would include paracentesis for completion.

A diagnostic paracentesis (typically 30-60 ml)  is indicated to:

• Determine etiology of new ascites (transudate vs exudate, cancer, infection)
• Rule out spontaneous bacterial peritionitis...(suspect this in any patient with a history of ascites that has fever, mental status changes, or diffuse abdominal pain)

A therapeutic paracentesis (large volume >1L) is indicated in the emergency department for:

• Respiratory distress from abdominal distension
• Abdominal compartment syndrome.  See Dr. Winters Pearl

Remember large volume paracentesis can result in profound fluid shifts and subsequent hypotension.

Absolute Contraindications to paracentesis include:  Acute abdomen requiring surgery

Relative contraindications are:

• Platelets <20,000
• INR > 2
• Pregnancy
• h/o adhesions
• abdominal wall cellulitis (just don't stick the needle through the cellulitis)
• Distended bowel or bladder

To view a video on how to do a paracentesis please visit the New England Journal of Medicine http://content.nejm.org/cgi/content/short/355/19/e21

Next I will address how to interpret the paracentesis fluid results.

Dental Pain and Blocks:

I am sure that most of us have felt like we should  have attended dental school when we see the fifth toothache of the day, but for those with true dental pain it can be severe and debilitating.  For these patients the only way to truly get their paint under control is to perform a dental block.  This will provide the patient with several hours of excellent pain relief, and may be all they need before seeing a dentist the next day.

For those that are not familiar with dental blocks, a great web page that I found that covers the advantages and disadvantages of the more common blocks is http://www.septodont.ca/Septodont/english/other/cea_di01.html

So for your next dental pain consider performing a dental block instead of just sending them home with a P&P pack (percocet and penicillin)

Biliary Colic and Narcotics:

It is common to give patients with biliary colic narcotics inorder to relieve their pain.  It was common teaching in the past that Morphine should be avoided due to the fact that it could cause spasm of the spincter of Oddi.  It is now known that all narcotics, even meperidine, can cause spasm or irritation of the spincter of Oddi.

So this weeks pearls are:

1. Morphine and diluadid can be used to relieve the pain associated with biliary colic.
2. However, narcotics should be avoided at least 4 hours prior to a HIDA scan as it can affect the length of the exam and the sensitivity of it.  A HIDA scan can take up to four hours to perform, however, morphine is typically given during the test as it can shorten the exam time to 1.5 hours by increasing filling of the gallbladder through the cystic duct. 

Splinting Pearls:

1. When using plaster of paris remember to use at least 10 layers for upper extremities and 15-20 layers for lower extremities.
2. Always apply the splint so that the joint above and below the fracture is immobilized.
3. On radius and ulnar fractures, a sugar tong splint will provide better immobilzation as it also prevents supination/pronation where a posterior long arm or volar splint only prevent flexion and extension.
4. Remember to make sure that the hand is placed in the position of function.
5. Though not required a stockinette provides an additional layer of skin protection and helps to make the ends of the splint looking cleaner.  It can also help hold the splint in place as you ace wrap it.
6. Finally, make sure that you document neurovascular status pre and post splint placement and if any manipulation is done you should have a follow up xray taken to ensure alignment is satisfactory.

Olecranon Bursitis is inflammation and swelling of the bursa overlying the olecranon process of the ulna.  Can result from trauma, overuse, or infection. 

Treatment can consist of:

• Aspiration:  Can be done to rule out infection [send gram stain, culture, and cell count], and be therapeutic by removing the excess fluid.
• NSAIDs
• Local injection of corticosteroids into the bursa
• Wearing of a neopryne elbow sleeve, or ace wraps to provide compression over the bursa and may help prevent reaccumulation of the fluid.

Remember aspiration has some major risks that need to be explained to the paitent:

• Infection may be introduced during the aspiration.  [Follow aseptic techniques and ensure that the skin is adequately prepped with chlorhexidine or betadiene].
• Formation of fistula tract with chronic drainage. [Use a Z or zigzap approach to minimize this complication.]
• Ulnar nerve injury.  Avoided by using a posterior lateral approach and avoiding a medial approach.

They also need to know that the fluid will likely reaccumulate.  So aspiration is not a guaranteed cure.