UMEM Educational Pearls

Category: Critical Care

Title: Axillary Arterial-Lines

Keywords: Procedures, Arterial lines, Axillary, hemodynamic monitoring (PubMed Search)

Posted: 9/13/2011 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD

Radial and femoral arteries are common sites for arterial-line placement, but are not without complications (e.g., Radial artery: malfunction with positioning and Femoral artery: contamination and infection); an alternative site to consider is the axillary artery.

The axillary artery's superficial location and large size make it a desirable choice for cannulation.

The "anatomical-landmark" and "palpation" methods have been the traditional techniques of axillary arterial cannulation, however these methods may be difficult for to a variety of reasons (e.g., obesity, anasarca, arterial disease, etc.)

Ultrasound allows visualization of the axillary artery and avoids unintended injury to structures in close proximity (e.g., brachial plexus, pleura, axillary vein, etc.); please see figures 1 and 2 in the referenced Sandhu article and http://www.youtube.com/watch?v=Z31YiyV7cNQ.

A recent study (Killu, 2011) found that ultrasound increases success rates when compared to the traditional landmark approach.

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Category: Visual Diagnosis

Title: Interesting Case

Posted: 9/12/2011 by Rob Rogers, MD (Updated: 3/28/2024)
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Question

A 50 year-old patient presents after a self-inflicted eye injury. The patient had taken some type of needle and inserted it into their eye.

What is the diagnosis and what complications might result?

 

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Category: Cardiology

Title: SVT and troponin

Keywords: troponin, supraventricular tachycardia, svt, dysrhythmia, tachydysrhythmia, tachycardia (PubMed Search)

Posted: 9/11/2011 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

SVT is rarely, if ever, the presenting rhythm associated with an acute MI. As a result, physicians should not feel compelled to send troponin levels and perform rule-outs purely based on an SVT presentation. Instead, the decision to rule out a patient presenting with SVT should be based on whether there is a constellation of other concerning symptoms, exclusive of the SVT (e.g. if the patient presented with chest pressure radiating down the arm and diaphoresis, in addition to the SVT).

Two recent studies confirmed that routine troponin testing in patients with SVT is extremely low-yield, and instead often produces false-positive troponin results that lead to unnecessary admissions and workups. In other words, mild troponin elevations may occur in SVT but they do not correlate with true ACS.

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Category: Orthopedics

Title: Knee Dislocation (part 2)

Keywords: knee dislocation, ABI, vascular (PubMed Search)

Posted: 9/10/2011 by Brian Corwell, MD
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Evaluation of circulatory status is the most important aspect of post reduction care.

Look for hard findings such as cool/cold lower extremity, diminished or absent pulses, pale or dusky skin, paralysis, etc.

However, the absence of these findings should not lull the clinician into a false sense of security. The degree of initial joint deformity, presence of full bounding pulses and warm skin over the dorsum of the foot can all be present in the setting of vascular injury.

The next step will be to perform an ABI (ankle-brachial index).

In one small study, no patient with an ABI greater than or equal to 0.9 had a vascular injury.

Patients with a reassuring physical exam and ABIs should be admitted for vascular checks without further imaging.

Patients with a reassuring physical examination but with an abnormal ABI should have an imaging study obtained (arteriogram/CT angiogram).

Patients with hard findings of a vascular injury should have an emergent vascular surgery consultation.

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Category: Pediatrics

Title: Pediatric ECG

Posted: 9/9/2011 by Rose Chasm, MD (Updated: 3/28/2024)
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  • newborns have a thick right ventricle resulting in a mean QRS axis which points anteriorly and to the right demonstrating a right axis deviation (70-180degress) and large R waves in the precordium
  • by 3 months of age, the QRS axis in the frontal plane shifts to the left with a mean of 65degress (0-125degress)
  • by older childhood, the normal mean QRS axis is -30-100degress)
  • thus, with age the R wave decreases in V1 and increases in V6
  • take home:  right-axis deviation is often a normal finding in children and young adults when you see left-axis deviation in children consider tricuspid atresia, atrioventricular septal defects, and LVH as the most associated conditions

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Category: Toxicology

Title: Adenosine in Patients with Only Central Line Access

Keywords: adenosine, central line (PubMed Search)

Posted: 8/29/2011 by Bryan Hayes, PharmD (Emailed: 9/8/2011) (Updated: 9/8/2011)
Click here to contact Bryan Hayes, PharmD

Every so often a patient arrives in PSVT with their only intravenous access being through a hemodialysis port.

Initial dose of adenosine should be reduced to 3 mg if administered through a central line.  Remember a central line delivers the adenosine right where you need it.  This recommendation is supported by the 2010 ACLS guidelines.  Second and third doses should be 6 mg (instead of 12 mg).

Cases of prolonged bradycardia and severe side effects have been reported after full-dose adenosine through a central line.  Other situations to consider lower doses include patients currently receiving carbamazepine or dipyridamole or in those with a transplanted heart.

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Category: Neurology

Title: Encephalitis

Keywords: encephalitis, meningitis, acyclovir, headache, fever (PubMed Search)

Posted: 9/7/2011 by Aisha Liferidge, MD
Click here to contact Aisha Liferidge, MD

  • Encephalitis, inflammation of the brain, is associated with the following signs and symptoms:  fever, headache, altered mental status, neurologic deficit, hallucinations, behavioral changes, photophobia, seizures, neck stiffness (when associated with meningitis), preceding viral prodrome, recent mosquito/tick/animal bites, and/or immunocompromised state/use of immunosuppressant medications.   
  • The presence of focal neurologic deficit and/or altered mental status is more predictive of encephalitis than meningitis.
  • The emergent management goal is to rule out and/or empirically treat bacterial meningitis and other treatable infectious sources such as Herpes Simplex Virus (HSV), Varicella Zoster Virus (VZV), and Cytomegalovirus (CMV); these carry significant mortality and morbidity risks.  Remember to have patient's cerebrospinal fluid (CSF) specifically analyzed for etiologies such as these (i.e. via PCR). 
  • Treat presumed encephalitis aggressively by adding acyclovir to the antibiotic/steroid regimen administered, particularly when there is altered mental status and/or focal neurologic deficit.


Category: Critical Care

Title: Fungal Sepsis

Posted: 9/6/2011 by Mike Winters, MD (Updated: 3/28/2024)
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Fungal Sepsis in the Critically Ill

  • In recent years, the incidence of invasive fungal infections has risen dramatically.
  • Candida species (C. albicans, C. glabrata, C. parapsilosis, C tropicalis, C. krusei) account for the majority of invasive infections in the critically ill patient.
  • Key risk factors for invasive candidal infections include:
    • Exposure to broad spectrum antibiotics
    • Cancer chemotherapy
    • Indwelling catheters
    • TPN administration
    • Neutropenia
    • Hemodialysis
  • Given the significant mortality of invasive fungal infections, early and appropriate antifungal therapy is paramount.
  • First-line empiric antifungal therapy recommendations from the Infectious Disease Society of America include caspofungin, micafungin, or fluconazoleAmphotericin B is now reserved for patients who are either intolerant or not responding to the echinocandins (caspofungin, micafungin).

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Category: Visual Diagnosis

Title: What's the diagnosis? Images by Dr. Mak Moayedi

Posted: 9/4/2011 by Haney Mallemat, MD (Emailed: 9/5/2011) (Updated: 8/28/2014)
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Question

26 year old male presents s/p basketball dunk. Diagnosis?

Show Answer

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Category: Cardiology

Title: non-atherosclerotic causes of ACS

Keywords: atherosclerosis, coronary artery disease (PubMed Search)

Posted: 9/4/2011 by Amal Mattu, MD (Updated: 3/28/2024)
Click here to contact Amal Mattu, MD

Approximately 7-10% of cases of ACS are not related to atherosclerotic coronary disease. Some other causes of ACS include the following:
trauma
vasculitis
congenital abnormalities
emboli (e.g. bacterial)
thoracic aortic dissection
infectious diseases
DIC, TTP

These conditions can produce ST-segment changes that resemble those of true STEMI or non-STEMI, and therefore some of these patients are diagnosed retrospectively after a negative catheterization.

 

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Category: Orthopedics

Title: Sugar Tong Splint

Keywords: Sugar Tong Splint (PubMed Search)

Posted: 9/3/2011 by Michael Bond, MD
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Sugar Tong Splint

The sugar tong splint is ideal for splinting fractures of the radius, ulna, or wrist.  It prevents flexion and extension at the wrist, limits flexion and extension at the elbow, and prevents supination and pronation.  A posterior long arm splint does not prevent supinaton and pronation, therefore, it is of limited use for radius and ulna fractures.

The traditional sugar tong can be difficult to put on a patient without an assistant as it is often hard to hold the splint in position as you begin to ace wrap it. A variation on the sugar tong, the reverse sugar tong, prevents this frustration.  The splinting material is cut so that a small piece suspends the splint from the web space between the thumb and index finger.  The open ends at the elbow are also easily folded under each other, preventing any bulky splint material from extending out.

The reverse sugar tong is on the left, the original sugar tong on the right.

Check out this video showing how to place a reverse sugar tong splint.

http://www.youtube.com/watch?v=r-RHdttOMf0



Category: Pharmacology & Therapeutics

Title: Monitoring dabigatran

Keywords: thrombin,dabigatran,partial thromboplastin,bleeding (PubMed Search)

Posted: 9/1/2011 by Ellen Lemkin, MD, PharmD (Updated: 3/28/2024)
Click here to contact Ellen Lemkin, MD, PharmD

 

Dabigatran is an oral thrombin inhibitor approved for the prevention of thromboembolism in patients with atrial fibrillation and for those undergoing orthopedic surgery.
 
In normal situations, it is not necessary to monitor any laboratory values. However, in the potential overdose situation or in the event of bleeding, it would be useful to assess the anticoagulant status. 
  • The thrombin clotting time (TT) directly assesses the activity of direct thrombin inhibitors (like dabigatran), and displayes a linear dose-response curve over therapeutic concentrations. At high levels, the test frequently exceeds the maximum measurements.
  • The PT and INR are less sensitive and cannot be recommended.
  • The activated partial thromboplastin time can provide qualitative assessment of anticoagulant activity but is not sensitive at supratherapeutic doses. 
 
Bottom Line:
In emergency situations, the aPTT and TT are the most effective qualitative methods widely available for determining the presence or absence of anticoagulant effect in patients receiving dabigatran.

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Category: Neurology

Title: Recognizing Delirium

Keywords: delirium (PubMed Search)

Posted: 8/31/2011 by Aisha Liferidge, MD (Updated: 3/28/2024)
Click here to contact Aisha Liferidge, MD

  • Delirium is a symptom, not a diagnosis; the astute clinician must seek to discover and treat the underlying source of delirious states.
  • It is a transient cognitive condition associated with decreased attention span and waxing and waning symptoms.
  • Three types: (1) Hyperactive, (2) Hypoactive, (3) Mixed (daytime somnolence, nighttime agitation).
  • In young patients, the cause is commonly due to toxins or trauma, while that for the elderly is typically infection or medication related.
  • Five critical causes of delirium that must be recognized and treated immediately:
  1. Hypoxia
  2. Hypoglycemia
  3. Central nervous System infections
  4. Hypertensive encephalopathy
  5. Increased intracranial pressure

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Category: Critical Care

Title: Tracheal Rapid Ultrasound Exam (T.R.U.E.)

Keywords: ultrasound, tracheal intubation, esophageal intubation, critical care, airway (PubMed Search)

Posted: 8/30/2011 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD

  • Multiple methods of confirming endotracheal tube placement exist, however quantitative waveform capnography is the most reliable method. Unfortunately this may not be immediately available at all medical centers.

  • Recent studies demonstrate that bedside ultrasound may assist in the detection of proper endotracheal tube placement.

  • The T.R.U.E. (Tracheal Rapid Ultrasound Exam) was demonstrated to be 99% sensitive, 94% specific, 99% PPV, and 94% NPV during intubation.

  • The basic exam involves placing a high-frequency linear-array probe on the anterior neck above the sternal notch and identifying the trachea and esophagus during intubation.

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Category: Visual Diagnosis

Title: What's the Diagnosis?

Posted: 8/29/2011 by Rob Rogers, MD (Updated: 3/28/2024)
Click here to contact Rob Rogers, MD

Question

 

Patient presents with right-sided chest and shoulder pain....

What's the diagnosis?

 

Show Answer

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Category: Cardiology

Title: post arrest "coma" for hypothermia

Keywords: therapeutic hypothermia, induced hypothermia, cardiac arrest, post arrest care (PubMed Search)

Posted: 8/28/2011 by Amal Mattu, MD (Updated: 3/28/2024)
Click here to contact Amal Mattu, MD

If you're like me, you've been a bit confused about what exactly defines "coma" in the current recommendations for post-arrest hypothermia in "comatose" patients with return of spontaneous circulation. Fortunately, a recent NEJM article has helped clarify this by suggesting that hypothermia should be induced in these post-arrest patients with either:

  1. GCS < 8
  2. "patients who do not obey any verbal command at any time after restoration of spontaneous circulation and before initiation of cooling."

Naturally, if the patient was comatose before the arrest, don't bother.

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Stability from 4 major ligaments (ACL, PCL, MCL and LCL)

Knee dislocation causes injury to multiple ligaments (usually 3 of the above).

Many of these dislocation spontaneously reduce prior to medical evaluation.  Therefore, consider knee dislocation in a patient with multi ligament injury, significant hemarthrosis and bruising.

Vascular injury in up to 40% (popliteal artery)

Nerve injury in up to 23% (peroneal nerve) ((ankle dorsiflexion and sensation to the first web space of the foot))

After reduction, immobilize knee in 15-20 degrees flexion.

The degree of initial deformity, presence of strong pulses, or warm skin cannot be used to rule out popliteal injury.

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Category: Pediatrics

Title: Ipratropium in severe asthma

Keywords: severe asthma, decreased hospitalization (PubMed Search)

Posted: 8/26/2011 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Ipratropium bromide (IB, Atrovent) is most efficacious in improving symptoms and preventing hospital admissions due to severe asthma exacerbations when used early and aggressively.  Even in patients with mild to moderate exacerbations, there is also benefit in symptom reduction, decreased number of treatments and duration of treatment, and improved lung function.
 
The National Asthma Education and Prevention Program (NAEPP) consensus recommends multidose protocol of IB every 20 minutes (either 250 or 500 Kg per dose) for 3 doses, during the initial management of severe exacerbations. For those institutions who prefer to give IB by metered dose inhaler (18 Kg per puff, with face mask and spacer for children younger than 4 years),
 
 
Bottom line:
Give ipratropium bromide (atrovent) early and aggressively to decrease hospitalization rates in severe asthma exacerbation.
 
 
References:
1. Dotson K et al. Ipratropium bromide for acute asthma exacerbations in the emergency setting. PediatrEmergCare. 2009 Oct;25(10):687-92; Review.
2. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (Summary Report 2007). In: BusseW, ed. J Allergy Immunol. 2007;120(5):S94Y138. National Institutes of Health National Heart Lung, and Blood Institute.


End Tidal CO2 continuous capnography is being utilized more in the ED for procedural sedation. One of the best studies is a randomized control trial using propofol that showed you could see signs of hypoventiliation prior to hypoxia by about 60 seconds - which can be plenty of time to get your BVM and airway cart ready.

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Category: Neurology

Title: ROSIER Scale for Emergently Recognizing Stroke

Keywords: ROSIER scale, ischemic stroke (PubMed Search)

Posted: 8/24/2011 by Aisha Liferidge, MD (Updated: 3/28/2024)
Click here to contact Aisha Liferidge, MD

  • While validated diagnostic tools such as the NIH Stroke Scale are often very helpful, particularly in terms of communicating with Neurologists, there are tools such as the ROSIER (Recognition of Stroke in the Emergency Room) Scale which is a brief score designed to facilitate expedited diagnostic testing and treatment of stroke in the emergency department.
  • The ROSIER Scale has been found to recognize stroke with 93% sensitivity, 83% specificity, 90% positive predictive value, and 88% negative predictive value
  • If the total score is > 0 (i.e. 1-6), then stroke is likely. If the total score is < or equal to 0, then stroke is unlikely, but can not be completely excluded.
  • See attached ROSIER Scale for details.

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Attachments

1108241811_ROSIER_Scale_for_Stroke.doc (61 Kb)