UMEM Educational Pearls

Saturday night palsy - radial nerve mononeuropathy due to improper arm positioning associated with inebriated sleep.

Physical examination - Wrist and finger drop. 

Patients may have findings suggestive of ulnar nerve co-involvement (interossei testing)  which may falsely lead the examiner to consider a more proximal location for the lesion such as the brachial plexus.

The finger drop caused by the radial nerve lesion places the hand at a mechanical disadvantage.  Adjust for this by examining the hand on a flat surface (stretcher, counter top). With the fingers now supported in extension at the MCP joint  (no longer "dropped"), the interossei can now be tested in isolation and will be normal.

• The Glascow Coma Scale (GCS) was originally derived from data from adult head injuries; its use is therefore not always applicable or reliable in non-traumatic cases (particularly those which are complex) or children under a certain age.
• Scoring Range = 3 to 15.
• Severe is less than 9.
• Scores of 8 or less should prompt strong consideration for airway management via intubation.
• The motor score is the most predictive and clinically useful component.
• See GCS Score below:

EYE OPENING
4 = spontaneous
3 = to voice
2 = to pain
1 = none

VERBAL RESPONSE
5 = orientated
4 = confused
3 = inappropriate
2 = incomprehensible
1 = none

MOTOR RESPONSE
6 = obeys command
5 = localizes pain
4 = withdraw to pain
3 = decorticate
2 = decerebrate
1 = none

Spontaneous Bacterial Peritonitis

• Critically ill patients with end-stage liver disease (ESLD) may be some of the sickest patients you'll ever manage.
• Recall that patients with ESLD have higher rates of infection and worse outcomes.
• Always consider spontaneous bacterial peritonitis (SBP) in the sick patient with ESLD.  In fact, SBP is the most common infection in ESLD patients.
• Physician impression alone has been repeatedly shown to be inaccurate in ruling out SBP.
• In the critically ill patient with ESLD and ascites, tap the belly!

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Question

19 year-old male s/p high-speed MVC with hypotension and diminished breath sounds on left. Diagnosis?

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A patient presents to the ED in pulmonary edema, hypotensive, and has JVD. There's a new systolic murmur. The patient had an acute MI 7-10 days ago and had appropriate treatment and uncomplicated course, then discharge. What's the diagnosis and what do you do?

Step 1: Sign out immediately.

Step 2: If it's not time to sign out (just kidding about step 1), listen carefully to the murmur. If it's heard best at the lower sternal border, it's probably a ruptured papillary muscle with acute MR. If it's a "machinery" type murmur heard throughout the precordium loudly, it's probably an acute VSD.

Step 3: VSD patient is likely to die, but with either one, you've got to move quickly. IMMEDIATELY call cardiology AND cardiac surgery. The patient is in need of a balloon pump and OR.
All you can do is buy time until the patient goes upstairs....pressors for BP, IV NTG as tolerated for preload reduction, and be judicious with diuretics. Vasodilators might help unload the heart also. This patient may end up on 2-3 drips, and make sure ALL meds are titrateable. And just keep your fingers crossed!

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Posterolateral Corner Injuries

The posterolateral corner “PLC” of the knee is becoming increasingly recognized as an extremely important structure to maintain the stability of the knee joint.

PLC injuries occur with hyperextension, varus load and tibial external rotation.  So the most common mechanism is a posterolaterally directed blow to the anteromedial tibia when the knee is hyperextended. PLC injuries are commonly associated with injury to other ligaments (ACL, PCL, LCL) and occur in isolation in <5% of cases.  If suspected make sure to check for other ligamentous injuries.

Since this injury can be missed and is associated with significant disability it is important to test for it.  This YouTube video, http://youtu.be/bnXaTdvZZ6o, demonstrates several examination techniques that can identify the injury. 

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• Bell Palsy is a condition associated with the acute onset of facial paralysis due to palsy of the seventh lower motor neuron (cranial nerve seven).
• The presence of mastoid pain might be a diagnostic clue, as this symptom often precedes the onset of actual facial paresis.
• Other associated findings include:  typically unilateral facial muscle paralysis affecting both the upper and lower parts of the face; tear overflow and dry eyes; altered taste; hyperacusis or sound sensitivity; sensation spared; no other cranial nerves involved.
• It is often associated with viruses such as HIV, Epstein-Barr, and Hepatitis B, but most commonly herpes simplex.
• If facial paralysis is bilateral, consider Lyme disease as a possible etiology.

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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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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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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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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• 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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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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• 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.

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 fluconazole.  Amphotericin B is now reserved for patients who are either intolerant or not responding to the echinocandins (caspofungin, micafungin).

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Question

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

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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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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

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