UMEM Educational Pearls

Transient brachial plexopathies aka Burners and Stingers

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes.

49-65% of all college football players have experienced at least one burner with a 87% recurrence rate.

Injuries most commonly occur at C5-C6 but may involve any root level.

3 Mechanisms: Commonly due to

1) Traction caused by lateral flexion of the neck away from the involved side

2) Compression of the upper plexus between shoulder pads and scapula

3) Nerve compression caused by neck hyperextension and ipsilateral rotation.

CC: Burning or numbness in the neck, shoulder and/or arm

Symptoms are UNILATERAL and tend to usually  last seconds to minutes

Symptoms are reproduced by the Spurling maneuver.

Function gradually returns from the proximal muscle groups to the distal muscle groups.

Because most burners are self-limited, the most important goal is to rule out an unstable cervical injury.

Show References

• Ischemic cerebellar strokes are often associated with posterior inferior cerebellar artery (PICA) insufficiencies.   
• Unlike vertebrobasilar strokes which typically present with vertigo accompanied by evidence of of brainstem ischemia like diplopia, dysarthria, dysphagia, and numbness, cerebellar strokes may present with isolated vertigo, making the diagnosis elusive given the challenging task of differentiating a central from peripheral process.  
• Central vertigo, particularly when due to cerebellar infarct, tends to be associated with severe gait instability, such that the patient often falls while walking, nystagmus which may be multi-directional or purely vertical, and deafness or tinnitus tend to be absent.
• Given that edema formation and mass effect are more likely to result from cerebellar infarcts as compared to other types of strokes, these patients are often best served in an intensive care setting for at least the first 24 hours following onset. 

• Necrotizing enterocolitis with predilection for cecum.
• Occurs in the immunosuppressed, especially when neutropenic (<500 PMNs)
• Typically a polymicrobial infection; gram positive cocci, gram negative rods, anaerobes, and/or fungal. 
• Classically, right lower quadrant pain but can present with diffuse abdominal pain and peritoneal signs.
• CT scan with IV and PO contrast is diagnostic (see below)
• Treatment:
  • Culture and begin broad spectrum antibiotics (cover anaerobes) and antifungals (if suspected) 
  • Aggressive resuscitation
  • Surgical consult for GI perforation or clinical deterioration
• High mortality (40-50%)

TIP: Suspect when abdominal pain presents 10-14 after chemotherapy (when PMNs are lowest).

Show References

Question

50 yo female s/p motor vehicle crash. Diagnosis?

Show Answer

Iliopsoas tendonitis and Iliopsoas Syndrome

• Iliopsoas tendonitis is inflammation of the iliopsoas muscle which can also affect the bursa lying under the iliopsoas muscle tendon.  
• Iliopsoas syndrome is a stretch, tear or complete rupture of the iliopsoas muscle and/or iliopsoas tendon.
• The iliopsoas muscle and tendon are commonly injured from acute trauma and/or overuse resulting from repetitive hip flexion.
• The pain may radiate down the anterior thigh to the knee.
• One variant is the internal snapping hip syndrome which results in an audible snap or click in the hip or groin with hip flexion.
• Treatment consists of rest, stretching exercises, physical therapy and NSAIDs.

The following list of medications have been associated with the development of Lupus Anticoagulants. Though it sounds like they should anticoagulate, they interfere with the Protein C system which means that they could induce a pro-thrombotic state - good short list to know:

Chlorpromazine (Thorazine

Procainamide (sorry Amal, I know you love that drug)

Hydralazine

Quinidine

Phenytoin

• Treating stroke patients older than age 80 with intravenous tissue plasminogen activator (IV-tPA) continues to be a controversial topic, primarily due to its perceived association with increased rates of intracranial hemorrhage (ICH).

• Reliable analysis of robust datasets from the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) has shown that, in fact, IV-tPA patients older than age 80:

             (1) do not have increased risk for clinically significant ICH,

             (2) have early clinical improvement similar to younger patients, and

             (3) have poor outcomes related to increased mortality (odds ratio 30% versus 12%), rather than

                   to higher rates of functional dependence (i.e. Modified Rankin Score 3 to 5). 

Show References

Acute Liver Failure (ALF)

• ALF is defined as sudden and severe liver failure in a patient without preexisting liver disease.
• The clinical presentation can include altered mental status, coagulopathy, MODS, & cerebral edema.
• In the US, the most common cause of ALF is drug-induced (e.g. acetaminophen).
• Important components of the ED management of patients with ALF include:
  • Monitoring and correcting hypoglycemia (may need infusion of D20)
  • Monitoring and maintaining a normal sodium concentration
  • Volume resuscitation with isotonic crystalloids or colloids
  • Prophylactic administration of broad spectrum antibiotics (given high incidence of sepsis)
  • Consideration for continuous veno-venous hemodiafiltration (CVVHD) for severe elevations in ammonia and acidosis (even if renal function is normal)
  • Transfer to center capable of liver transplantation

Show References

Ever see that patient who shows up in the ED with blue painful toes? You look at the foot (or feet) and quickly determine that clot has embolized into the foot.

What is the differential diagnosis to consider in patients with evidence of embolic phenomenon in the feet (i.e. blue, painful toes)?

• AAA-many times asymptomatic. Most AAAs have mural thrombi associated with them, and tiny clots can flip off and distally embolize. Common cause of the "blue toe" syndrome.
• Atherosclerotic disease in the aorta, iliacs, femoral arteries. Plaques in these vessels are often chronic and don't always lead to acute occlusion.
• Cardiac sources-atrial fibrillation, mural thrombi in patients with recent MI or in patients with dilated cardiomyopathy.

Things to consider:

• Obviously, a vascular surgery consult
• CT abdomen to r/o a AAA
• Arterial doppler studies to assess for stenosis and arterial disease
• ABIs

Clearly we can't do the complete workup of embolic foot lesions, and many if not most of these patients will need to be admitted to complete their workup.

Show References

It is now well-accepted that induction of hypothermia should be initiated in victims of cardiac arrest who regain spontaneous circulation and remain unresponsive. Studies are now being performed and published that suggest that the earlier that hypothermia is induced, the better the neurological outcome. With this in mind, some experts are now recommending that cool IVF be the initial resuscitation fluid that these patients receive when resuscitation is initiated. It appears that aggressive use of cool IVF right from the initiation of attempted resuscitation results in improvements in survival to hospital admission and discharge.

The bottom line here is that when caring for victims of primary cardiac arrest, we should be certain to cool the patients fast and early!

Show References

Meralgia Paresthetica - caused by entrapment of the lateral femoral cutaneous nerve (LFCN)

The LFCN is responsible for sensation of the anteriorlateral thigh.

http://www.chiropractic-help.com/images/Meralgia-Paresthetica.jpg

NOTE*  It has no motor component!

Associated with pregnancy, wearing tight pants, belts, girdles, and in diabetic and obese patients.

Symptoms include numbness, paresthesias and pain (not weakness). Worse w walking, standing. Better w sitting.

Diagnosis is clinical but may be confirmed with nerve conduction studies

Treatment includes, NSAIDs, injection and surgery for refractory cases.

"Ear to sternal notch" positioning has gained wide acceptance in the emergency medicine and anesthesia literature.  Most often, this teaching is brought up with respect to obese adult patients whose large body habitus requires the raising of the neck and head to achieve airway alignment.

However, the correct anatomic positioning principle applies to all ages.  Specifically, with regard to neonates, a shoulder roll is often placed indiscriminately to put the patient into the now out-dated "sniffing position," usually worsening the view of the airway.  

Though this positioning is frequently misused, it can be easily adapted to apply ear to sternal notch positioning to neonates, whose misaligned airway is the result of a large occiput rather than a large torso.  In all ages, if you follow these positioning principles, you will improve your view of the airway:

1. Align the ear to the sternal notch

2. Keep the face parallel to the ceiling (do NOT hyperextend the neck, as in the sniffing position)

3. In adults, the head usually needs to be raised (Image 1), while in infants, the torso usually needs to be raised (image 3).

Show References

Several patients have recently presented with a medication history including tapentadol (Nucynta), the newest opioid formulation.  It is approved for treatment of acute moderate-severe pain.  Here are some key points:

• Mechanism similar to tramadol: mu-receptor agonist, also inhibits norepinephrine reuptake
• Potency stronger than tramadol, but less then morphine
• Usual dose is same as tramadol 50-100 mg every 4-6 hours prn pain
• Schedule II controlled substance, similar to morphine/oxycodone (tramadol is not a controlled substance)
• Overdose should present like other opioids, but potentially also including tachycardia, serotonergic effects, and seizures (similar to tramadol)

Causes of Pulsatile Tinniitus 

• Pulsatile tinnitus, also known as objective tinnitus, results from altered blood flow or increased blood turbulence near the ear.  People other than the person experiencing the tinnitus are often able to hear this rhythmic, pulse-patterned noise.  
• While there are several benign causes of pulsatile tiniitus such as strenuous exercise, atherosclerosis, and ruptured tympanic membranes, there are only a few serious etiologies.
• It is important that the astute emergency provider be aware of and know the appropriate treatment for the following life-threatening and/or high morbidity-associated causes of pulsatile tinnitus:

1. Idiopathic intracranial hypertension (previously known as pseudotumor cerebri)
2. Carotid artery aneurysm
3. Carotid artery dissection
4. Vasculitis such as giant cell arteritis  

Although oral metronidazole is indicated for mild to moderate Clostridium difficile associated diarrhea, oral vancomycin should be considered first-line therapy in critically-ill patients with moderate to severe disease. Vancomycin dosing should begin at 125mg PO q6 and increased to 250mg q6 if poor enteral absorption exists. Consider adding metronidazole IV if either reduced enteral absorption or severe disease exists. 

Recently, fidaxomicin has been shown to be non-inferior to oral vancomycin in the treatment of mild to moderate C. difficile. While promising, the study population was not critically-ill and extrapolation should be avoided.

Show References

Question

70 yo female from nursing home with fever. RUQ ultrasound is shown below. Diagnosis?

Show Answer

Beck's triad is well known to many physicians, but here's some simple things you may not have known.

Beck actually described two triads, one for acute and one for chronic tamponade.
The triad for chronic tamponade consists of increased CVP (JVD), ascites, and a small quiet heart (muffled heart sounds).
The triad for acute tamponade consists of JVD hypotension, and muffled heart sounds.

Almost 90% of patients have at least 1 of the signs, but only one-third have all 3. Furthermore, it appears that the simultaneous occurrence of all 3 signs is a very late manifestation of tamponade, usually preceding cardiac arrest.
 

Show References

Tendon Lacerations:

• Flexor tendon lacerations have historically not been repaired by emergency providers due to the extensive pulley systems involved and possibility of loss of mobility from scarring.
  • However, if both ends of the tendon can be visualized in the ED it is not unreasonable to place 1 or 2 horizontal mattress sutures between the two ends to prevent retraction of the proximal portion which can make a formal repair more difficult.
• Extensor tendon lacerations can be repaired by emergency providers.
  • One technique is to use a running horizontal mattress suture with non-absorbable nylon sutures. 
  • The ultimate strength of the repair is dependent on the number and size of the sutures placed.
  • Careful placement of the sutures can prevent gap formation between the ends when the tendon is stressed.

A reasonable approach to all tendon lacerations is to close the wound and splint in the hand in the position of function until the patient can be seen by a hand surgeon in the next 1-3 days.  These injuries do not require immediate surgical repair.

Show References

Continuing the theme of endotracheal tube size pearls...  You get a box call for a pre-term baby delivered precipitously by mom at home and baby is blue.  EMS is bagging but unable to secure a definitive airway.  What size ETT do you reach for?  If you try to apply the formula "uncuffed ETT = (age/4) + 4", how much smaller than size 4 can you go?

Show References

IV acetaminophen has been approved for use since November 2010

It is indicated for the:

• Treatment of mild to moderate pain
• Combination therapy with opioids for treatment of moderate to severe pain
• Fever reduction

The results of studies demonstrating opoid sparing effects have been mixed; some studies have not demonstrated either a reduction in opioid dose or opioid side effects.

The dose is the same for acetaminophen administered by other routes.

It must be administered over 15 minutes, and onset of activity is 15 minutes. Peak effect occurs at one hour.

The MAJOR drawback is the cost, which is $13 dollars per vial. This is compared to oral acetaminophen and ibuprofen, which are pennies.

Show References