UMEM Educational Pearls - By Michael Bond

Some of the causes of acute vision loss are:

• Cardiac Causes include:
  • Emboli -- causes can be atherosclerotic plagues, atrial fibrillation, endocarditis.
  • Arteritis
  • Dissection
• Hematologic causes
  • Hypercoaguable state
  • Hyperviscosity
  • Anemia
• Ocular Causes
  • Angle-closure glaucoma
  • Papilledema/neoplasm: Intracranial hypertension
  • Intraocular foreign bodies:
  • Central retinal artery occlusion
  • Anterior ischemic optic neuropathy
  • Ruptured globe
• Miscellaneous
  • Migraine
  • Hysteria
  • Drugs (i.e.: viagra and its counterparts)

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Vision loss whether acute or chronic is a common presenting complaint to the ED.  This will be the first in a series of pearls on the subject.  This pearl will address the nomenclature used by ophthalmology based on the length of vision loss.

    •    Transient visual obscuration - Episodes lasting seconds. Usually associated with papilledema and increased intracranial pressure.
    •    Amaurosis fugax - Brief, fleeting attack of monocular partial or total blindness that lasts seconds to minutes
    •    Transient monocular visual loss  or transient monocular blindness - A more persistent vision loss that lasts minutes or longer
    •    Transient bilateral visual loss - Episodes affecting one or both eyes or both cerebral hemispheres and causing visual loss
    •    Ocular infarction - Persistent ischemic damage to the eye, resulting in permanent vision loss

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MEWDS (Multiple Evanescent White Dot Syndrome)

• A rare, unilateral, self-limiting inflammatory disease
• Afflicts young women more than men in a 4:1 ratio.
• Patients typically present complaining of
  • Sudden, painless, monocular decline in central acuity
  • Photopsias-- def. appearance as of sparks or flashes in retinal irritation
  • Dyschromatopsia-- def> disorder of color vision
  • Central/paracentral scotomas
• Visual acuity usually in the  20/40-20/400
• Fluorescein angiography of active lesions typically demonstrate a "wreath-like" hyperfluorescence of the white dots
• Disease is usually self limited (resolves in weeks to months) with an excellent prognosis.
• There are no known treatment options.

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Scaphoid Fractures in Children:

1. Rare before the age of 11.
2. Make up less than 0.34% of all pediatric fractures
3. Scaphoid fractures may be missed 12.5% - 37% on the initial presentation.
4. 30% of patients will have an radiographically apparant fracture on repeat films done 2 weeks later.
5. These physical exam findings are more specific for fracture:
   1. Volar tenderness over the scaphoid
   2. Pain with radial deviation
   3. Pain with active wrist range of motion.  
6. Though snuff box tenderness was seen in 100% of patients eventually proven to have a fracture, it was also seen in 92% of the patients that did not have a fracture at follow-up making it non-specific but sensitive.
    

Because of the high (30%) fracture rate seen on followup films it is recommended that all children be placed into a thumb spica splint until followed up.

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Slipped Capital Femoral Epiphysis (SCFE)

SCFE can present as hip, thigh or knee pain in the young adolescent. Risk factors include hypogonadism, hypothyroidism, hypopituiratism, and obesity. One way to make the diagnosis is to obtain a AP view of the pelvis and draw a line(Klein's line) along the superior border of the neck of the femur.  This line should intersect the femoral epiphysis. If it does not the diagnosis of SCFE can be made.

However, this is only about 40% sensitivity. Green et al recently published a study that demonstrated that if you measure the distance from Klein's line and the lateral edge of the femoral epiphysis on both sides, and the difference between the two is more than 2mm you can make the diagnosis of SCFE more accurately and sooner.

FIGURE 1. Measurement methods on an anterior-posterior radiograph of a right slipped capital femoral epiphysis. White lines indicate Klein’s line for each hip. A and B, indicate maximum epiphyseal width lateral to Klein’s line. As A is 2mm narrower than B, the right (A) hip qualifies as a slip using our modification but not Klein’s original definition.

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Wound Irrigation

A recent article by Thomas et al showed that any concentration of betadiene and hydrogen peroxide used to irrigate a wound was  more toxic to fibroblasts (required for wound healing) then it was to bacteria.  Low concentrations of chlorhexidine remained bactericidial while having minimal affects on fibroblasts. 

WIth the addition of this study the routine practice of soaking a wound in betadiene or hydrogen peroxide should be abandoned.  Good irrigation with normal saline or even tap water is all that is really needed to decontaminiate a wound.  If a bactericidal agent is needed then low concentrations of chlorhexidine should be used.

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Snuff Box Tenderness:

It has become the standard of care that individuals with snuff box tenderness, or pain with axial loading of the thumb, be placed in a thumb spica splint for 1-2 weeks until follow up x-rays can be done.  This is done to rule out an occult scaphoid fracture.  However, this practice can be hugely inconvenient to the patient and result in some atrophy of their forearm.

An alternative approach is to obtain a CT scan through the wrist to look specifically at the scaphoid bone.  If the CT scan is negative you can send them home with some pain control, RICE (Rest, Ice, Compression, Elevation) treatment and let them use thier thumb.  No splint is needed.  If it is positive then you can splint them and have them follow up with orthopedics or hand surgery.

Reimburshment Pearls:

Often charts are down coded as it is not clear from the documentation that your medical decision making was complex.

For instance, if your final diagnosis is GERD, and you do not document that you were also concerned about angina or a pneumothorax your level 5 chart could be coded as a level 3, since the final diganosis does not seem that complex.  In order to prevent this document:

• Your differential diagnosis and ideally why you were concerned about them
• Instead of just checking a box stating that you reviewed old records take 5 seconds to summarize their last visit.  (i.e.: Admitted in May for CHF exacarebation, EF 50% by Echo, discharge on lasix).  This helps the coders prove that you looked at the chart and gives you 2 points for medical decision making.
• Document the response or initial lack of response to therapy. (i.e.: Asthmatics might get discharged home and still qualify for critical care time or a level 5 chart if you document how they initially responded to nebulizers and it was the magnesium that finally broke the cycle.)

I realize that when you are busy this might be the last thing on your mind, but the difference between a level III chart and a level V chart is about $100, and the only additional work is the 3 minutes it would take to document what you did for the patient.

More to come...

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I am sure everybody has received a patient from a nursing home that had a malfunctioning PEG tube.  Now if they would only crush the tablets before putting them down the tube, or better yet use liquid medications our life would be easier.

But what do you do if it is Friday and the GI lab is not open to Monday.  The answer is that you can remove the PEG and replace it with another PEG tube or even a foley catheter will do for the weekend.  The original PEG tube has a semi-rigid plastic ring (as shown in photo) and does not have a balloon that can be default.  You can pull these out by placing counter traction on the abdominal wall and pulling with steady firm pressure.  This may take a little more force than you are initially comfortable with.

Please see the attached photo of a PEG tube, and remember the other option is to admit these patients for IV fluids until the GI lab opens.

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AC Joint Dislocations

The acromioclavicular (AC) Joint is commonly injured when a person falls onto their shoulder.

The AC Joint consists of three ligaments:

• acromioclavicular ligament (AC)
• coracoacromial ligament (CA)
• coracoclavicular ligament (CC)

Injuries to this joint are classified as Type I – Type VI and involve sprain or tears of the AC or CC ligaments

• Type I – Is a sprain of the joint without complete tear of either the AC or CC ligament
• Type II – Does not show significant elevation of the lateral end of the clavicle but is due to a tear of the AC ligament.
• Type III – Results from tears in the AC and CC ligament. Noted by > 5 mm elevation of the AC joint.
• Types IV – VI : are associated with complications of a Type III injury.

Medical Treatment of Hyperparathyroidism

• Hyperthyroidism will typically only need to be treated in the Emergency Department when they present with Hypercalcemia. 
• Outpatient management of hyperthyroidism consists of serial PTH measurements, Calcium, and Creatinine.
• Hypercalcemia should be treated with normal saline hydration. 
  • Once the patient is determined to be euvolemic you can enhance diuresis and excretion of calcium by giving the patient furosemide. 
  • Remember hydrochlorathiazide can actually increase serum calcium by preventing its excretion.
  • This patients should receive 4-10 liters of normal saline in the first day.
  • You can also give bisphosphonates and calcitonin. 
  • For high calcium levels with mental status changes consider hemodialysis.

Hyperparathyroidism results in elevated PTH and typically results in elevated calcium levels (hypercalcemia). 

• Primary hyperthryoidism is due to hyperfunction of the parathyroid glands, while secondary hyperthyroidism is a reaction of the parathyroid glands to hypocalcemia caused by another etiology, most commonly chronic renal failure. 
• Tertiary hyperthyroidism is due to hyperplasia of the parathyroid glands due to loss of response to serum calcium levels and this too is seen in chronic renal failure

Though most cases are asymptomatic, symptomatic patients can present with:

• weakness and fatigue
• depression
• aches and pains
• decreased appetitie
• constipation
• polyuria and polydipsia
• kidney stones
• osteoporosis.

Treatment options to be discussed next week....Stay tuned.

Rhogam Dosing:

Though most textbooks recommend Micro-Rhogram (50mcg) for woman that have miscarried and are less than 12 weeks gestation, you might find it a real challenge to get that dose from your pharmacy or blood bank.

The cost difference between microRhogram and Rhogam is minimal so most hospitals have decided to only stock full dose (300 mcg) Rhogam.  The full dose can be given to woman in their 1st trimester without any deleterious effects. 

Just remember if you are giving it as a result of a delivery you should order a Kleihauer-Betke test to determine if additional doses of Rhogam are needed.

Apathetic Hypothyroidism AKA Hypothyroidism in the Elderly

Remember that elderly do not present with classic signs and symptoms of hypothyroidism, but rather it is more common for them to have atypical presentations.

Things that make the diagnosis more difficult in the elderly are:

• The thyroid gland is often difficult to palpate.
• Symptoms like weight gain, cold intolerance, and mental and physical decline are often attributed to the normal aging process.
• Symptoms are often attributed to medications, or medications mask some of their symptoms.

Consider the diagnosis in elderly patients with:

• Arrthymias
• New onset dementia or increased “forgetfulness”
• Depression
• Failure to thrive
• Anemia
• Hyponatremia

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Cushing Syndrome

The most common cause of Cushing syndrome is the use of exogenous glucocorticoids, and it is rarer to have a problem with the hypothalamic-pituitary-adrenal axis.

These patients can present with:

• proximal muscle weakness
• easy bruising
• weight gain
• hypertension
• diabetes
• impaired immune function
• infertility or menstrual irregularities

For the emergency department we need to be worried about those on chronic steroids that can not increase their native steroid production in a time of stress which will lead them to adrenal crisis.

Pearls for those with Cushing Syndrome:

• May have perforated viscous with minimal peritoneal signs
• Suspectable to fungal infections so consider adding fluconazole to those that are septic
• Give a large dose of hydrocortisone 100mg PO/IV every 8 hours if you suspect adrenal crisis.

Monteggia's Fracture

• Fracture of the proximal 1/3 of the ulna with an associated radial head dislocation.
• Mechanisms of injury include direct blow, hyperpronation and hyperextension.
• Radial head is dislocated anteriorly in 60% of the cases.
• can be associated with Posterior Interosseous Nerve (PIN) palsy. 
• PIN is the deep motor branch of the radial nerve and supplies the wrist extensors except for Extensor Carpi radialis Longus.  The palsy can be delayed so be sure to document wrist extenson strength.
• Most patients will require operative repair of the ulna fracture.
• Splint the  forearm in neutral rotation with slight supination, keeping the elbow flexed at 90 degrees.

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Postpartum Headaches:

• Occurs in up to 40% of woman during the first week after delivery.
• Though thoughts of Sheehan's syndrome (pituitary infarction), and SAH might come to mind the most common causes are due to migranes and tension headcaches.
• About 5% are spinal  (postdural) headaches due to a persistant CSF leak from spinal anesthesia or a complication of their epidural catheters.
• Rare causes include embolic stroke, carotid and vertebral artery dissections, SAH, Central Venous Sinus Thrombosis and Sheehan syndrome.

• Most headaches can be treated the same as any other person.
• Make sure you inquire about breast feeding and ensure the medications you are giving will not be excreted into the breast milk. 
• If your patient has signs of hypopituitarism an MRI scan will be needed to make the diagnosis of Sheehan syndrome.

NG Tubes and Foleys:

Dovetailing off Dr. Hayes Lidocaine pearl on Thursday I thought we could provide an additional pearl on how to decrease pain with the insertion of Foleys and NG tubes.

Most providers use regular surgilube and coat the tip of the NG  tube and foley with it prior to inserting it.  Unfortunately this tends to only lubricate the first several centimeters of the passage you are trying to transverse, making the rest of the way a little uncomfortable.

Using a Uroget of viscious lidocaine allows you to actually inject the lubricant into the nares or urethral meatus.  This will provide better lubrication of the entire passage and also provide some anesthesia.

Even if you do not want to use lidocaine most foley kits come with a syringe full of surgilube that can be injected into the urethral meatus helping to lubricate the passage.

Blast Injuries:

In honor of the 4th of July holiday, here is a quick pearl about blast injuries.

• Blast injuries due to fireworks most often affect the hands. 
• Other than the obvious superficial wounds that are seen on exam, the EP should be aware of significant cavitation and destruction of muscles that can occur in the forearm, thenar and hypothenar muscle groups which may be distal from the gross wound seen. 
• The energy from the blast is often transmitted through the carpal tunnel leading to an acute carpal tunnel syndrome from contusion of the median nerve.
• Patients should also be monitored for compartment syndrome.
• These patients can have significant injruies that are not immediately apparent. Consider observing these patients for awhile, or have them seen by hand surgery in case complications develop later on.

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Metacarpal Fractures and Growth Plates:

The growth plates on metacarpals are on the distal end of the bone, except for the 1st metacarpal which is on the proximal end near the carpal bones.

Don't mistake this for a fracture line, however, make sure you get comparison views if they are tender over the area, as this can help you diagnosis a Salter Harris Type 1 fracture.