UMEM Educational Pearls

Category: Neurology

Title: Epilepsy and Driving

Keywords: epilepsy, seizure, driving (PubMed Search)

Posted: 2/3/2010 by Aisha Liferidge, MD (Updated: 12/3/2022)
Click here to contact Aisha Liferidge, MD

  • In states without mandatory physician reporting of patients with seizures, the decision of whether to breach confidentiality and report a poorly controlled epileptic patient who continues to drive an automobile becomes an ethical dilemma.
  • In making this decision, one must consider the probability and magnitude of the potential harm.
  • If the probability and magnitude are both low, or the probability of harm is high but the associated magnitude is low, there is generally no moral obligation to breach confidentiality and report.
  • If the probability of harm is low but the potential magnitude of the harm is high, one should strongly consider reporting the case.
  • Each case should be handled on an individual basis, take into consideration the risks and benefits to the patient and society if reporting is ensued, and perhaps elicit the advice of risk management.

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The Rapid Ultrasound in Shock (RUSH) Exam

  • Evaluating the ED patient with undifferentiated shock can be challenging.
  • Ultrasound can be an invaluable tool in helping to differentiate between hypvolemic, cardiogenic and obstructive shock.
  • The RUSH exam essentially focuses on the evaluation of the "pump", the "tank" and the "pipes".
  • The pump: exclude pericardial effusion, global estimate of LV EF, and determine if RV strain is present.
  • The tank: evaluate the IVC/jugular veins for volume status, look for fluid in the thorax/peritoneum, and exclude pulmonary edema or pneumothorax.
  • The pipes: look for a ruptured AAA or aortic dissection and DVT.

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Category: Vascular

Title: Pulmonary Embolism-Myths

Keywords: Pulmonary Embolism (PubMed Search)

Posted: 2/1/2010 by Rob Rogers, MD (Updated: 12/3/2022)
Click here to contact Rob Rogers, MD

Pulmonary Embolism-Myths and Misconceptions

Just wanted to mention a few myths/misconceptions about acute PE that I have recently heard discussed in the ED.

1. Emergency physicians have to "get help" to give thrombolytic therapy. Sure it makes sense that we consult critical care and perhaps interventional radiology in some cases. But we do not need permission to use this drug by ourselves if indicated. Consider using lytics ESPECIALLY if the patient is unstable or if there is evidence of RV dysfunction (elevated troponin, echo criteria for dysfunction, or CT with large RV and bowing of the septum). What about the patient with RV dysfunction and a normal BP? Evidence is mounting that lytics are indicated to reduce the severity of pulmonary hypertension. 

2. "Just get a d-dimer." Be very careful. Lots of false positives. D-dimer often clouds the picture more often than not. 

3. "The mortality rate of missed PE is high." Often quoted as a 30%+ mortality rate if missed. Recent data suggests that it is < 5%. 


Category: Cardiology

Title: ACS and medicolegal issues

Keywords: acute coronary syndromes, misdiagnosis, risk management, lawsuit (PubMed Search)

Posted: 1/31/2010 by Amal Mattu, MD (Updated: 12/3/2022)
Click here to contact Amal Mattu, MD

Missed cases of ACS account for 10% of all malpractice cases in emergency medicine, yet account for 30% of all the money emergency physicians pay out in malpractice cases. This misdiagnosis is the biggest cause of monetary payout in the specialty.

Three main themes account for the majority of missed cases of ACS:
1. Failure to recognize atypical presentations (e.g. dyspnea)
2. Failure to recognize high-risk groups (e.g. women, diabetics)
3. Over-reliance on negative tests (e.g. negative troponin or recent stress test)


Category: Misc

Title: Temporal Arteritis

Keywords: Temporal Arteritis (PubMed Search)

Posted: 1/30/2010 by Michael Bond, MD (Updated: 12/3/2022)
Click here to contact Michael Bond, MD

Temporal Arteritis (TA) is commonly associated with the sudden onset of a unilateral headache centered around the temporal region.  The most devastating consequence of TA is blindness though this is only reported in up to 50% of cases though can be bilateral in up to 33% of patients.

According to the American College of Rheumatology criteria for classification of temporal arteritis this diagnosis can be made in the ED without a biopsy.  You just need at least 3 of the following 5 items to be present (sensitivity 93.5%, specificity 91.2%) to make the diagnosis :

  1. Age of onset older than 50 years
  2. New-onset headache or localized head pain
  3. Temporal artery tenderness to palpation or reduced pulsation
  4. Erythrocyte sedimentation rate (ESR) greater than 50 mm/h
  5. Abnormal arterial biopsy (necrotizing vasculitis with granulomatous proliferation and infiltration)

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Category: Pediatrics

Title: Umbilical Abnormalitites

Posted: 1/29/2010 by Rose Chasm, MD (Updated: 12/3/2022)
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The umbilical site normally heals by 1 month of age. 

Any fluid draining after this period suggests an abnormal connection between the surface of the abdomen and the underlying structures, and requires further investigation.  Clear yellow fluid could represent a persistent connection of the bladder with the umbilicus called a patent urachus. The fluid that leaks is actually urine. The treatment is surgical closure of the connection.

Pus oozing from the umbilical stump would imply infection, especially if there is concomitant redness of the skin around the umbilicus.  An omphalitis can be life-threatening, and requires admission for invtravenous antibiotics.

Umbilical hernias are common in infants, and are usually noted with diastasis of the rectus muscles.  Most umbilical hernias resovle by school age, and do not require surgical intervention.

An umbilical granuloma is a small piece of bright red, moist flesh that remains in the umbilicus after cord separation. It is scar tissue, usually on a stalk, that did not become normally covered with skin cells. It contains no nerves and has no feeling. Most can be simply cauterised with silver nitrate.


Category: Toxicology

Title: RCIN Continued

Keywords: saline, sodium bicarbonate, acetylcystein (PubMed Search)

Posted: 1/28/2010 by Fermin Barrueto, MD (Updated: 12/3/2022)
Click here to contact Fermin Barrueto, MD

Apologies - last few bullets were cutoff - Continuing - Prophylaxis against RCIN has been attempted with the following:

  • IV saline infusion
  • Sodium Bicarbonate bolus
  • IV acetylcysteine infusion

No one therapy has been show to have superior efficacy.


Category: Toxicology

Title: Radiocontrast Induced Nephropathy

Keywords: RCIN, renal failure (PubMed Search)

Posted: 1/28/2010 by Fermin Barrueto, MD (Updated: 12/3/2022)
Click here to contact Fermin Barrueto, MD

Radiocontrast Induced Nephropathy (RCIN)

  • Occurs within 24 hrs of administration followed by oliguric phase
  • Usually improves within a week and rarely needs dialysis
  • Initial injection is an osmotic load, leads to volume expansion and diuresis. Follwed by intense vasoconstriction suggesting possible ischemic role in pathophysiology.
  • There is also a direct toxic effect to the kidneys however
  • High Risk patients: HTN, DM,  Chronic Renal Insuff, Bence Jones proteinuria and large injections of IV dye
  • Possible prophylaxis: There is almost no data studying this effect in the Emerg Dept patient. One trial look at IV acetylcysteine in the Emergent CT (RAPPID trial) did show benefit but has flaws within the study. IV hydration and sodium bicarbonate

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Category: Neurology

Title: Stem Cell Therapy for Stroke

Keywords: stem cell, stem cell therapy, stroke (PubMed Search)

Posted: 1/27/2010 by Aisha Liferidge, MD
Click here to contact Aisha Liferidge, MD

  • Apart from time and rehabilitation, there is currently no effective treatment for reversing brain damage caused by stroke.

 

  • Clinical recovery after a stroke results from neuro-restorative processes such as neurogenesis, angiogenesis, synaptic plasticity, and/or re-modeled and strengthened connections between neurons. 

 

  • Stem cell therapy for stroke is a novel, but progressive area of research which would potentially facilitate the neuro-restorative processes required for recovery. 

 

  • Despite the extremely complex nature of brain function and central nervous system networks, successful stem cell therapy for brain infarct could become the wave of the future for optimal stroke management.

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Patients in the Critical Care setting may develop HIT as a result of chronic pre-existing risk factors (malignancy, obesity, hypertension, diabetes or medications) or acquired factors secondary to their ICU stay (post-operative state, trauma, central lines or medications such as heparin).

Diagnosis of HIT:

  • platelet count<150,000 or relative decrease of 50% or more from baseline
  • documentation of antibodies binding platelet factor 4 and heparin, as well as a confirmation test
  • typically occurs 5-14 days after initiation of heparin therapy
  • can have a rapid (usually a result of previous exposure) or delayed onset
  • thrombotic complications develop in 20-50 percent of patients

Treatment of HIT:

  • Remove all sources of heparin (including heparin-bonded catheters)
  • initiate a non-heparin anticoagulant
  • Direct thrombin inhibitors:
    • Lepirudin (cleared by kidney)
    • Argatroban (cleared by liver)
    • Bivalirudin (cleared by proteolysis 80% and kidney 20%)
  • Other agents used include:
    • Danaparoid (antifactor Xa activity - not available in North America)
    • Fondaparinux (synthetic selective inhibitor of Xa)

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Category: Vascular

Title: D-Dimer and Aortic Dissection

Keywords: D-Dimer, Aortic Dissection (PubMed Search)

Posted: 1/25/2010 by Rob Rogers, MD (Updated: 12/3/2022)
Click here to contact Rob Rogers, MD

Can you use a serum d-dimer to rule out aortic dissection?

The answer to the question, in 2010, is no.  

There has been a flurry of recent literature about the use of serum d-dimer to rule out aortic dissection. Some studies have shown a sensitivity of nearly 100%, but other studies have shown sensitivities of only 60-70%....pretty abysmal sensitivities. And despite some of the authorities on the subject touting how good the test is, there is not firm literature to support it. Better yet, there are some active medical malpractice cases I am aware of in which the diagnosis of aortic dissection was missed based on a "negative d-dimer."

My suggestion, and the vascular pearl for the day, is to avoid using d-dimer as a aortic dissection rule out strategy until good evidence (if it ever becomes available) exists. I know that people are using this test to rule out the disease, just realize that EVERY time I have ever given a talk on acute aortic disasters, 2-3 people from the audience always share that they had a case of a "d-dimer negative dissection." 

Be careful....


Category: Cardiology

Title: ACS in women

Keywords: acute coronary syndromes, gender, misdiagnosis (PubMed Search)

Posted: 1/24/2010 by Amal Mattu, MD (Updated: 12/3/2022)
Click here to contact Amal Mattu, MD

Women are more likely to be misdiagnosed than men when they present with acute coronary syndromes. There are several possible reasons for this:
1. Women are more often older and more often have diabetes, both of which are factors involved in atypical presentations.
2. Women present with chest pain less often than men. On the other hand, women are more likely to present with nausea, vomiting, indigestion, malaise, loss of appetitie, or syncope than men.
3. When women do have chest pain, they are more likely to report pain that has atypical features, such as radation to the right arm or shoulder, front neck, or back; and the pain is more often described as sharp, stabbing, or tansient.

The bottom line is something that I've believed since high school: women are confusing...!

[the references for this ACS information comes from many different sources, but if anyone needs a good review on this topic, just email me: amattu@smail.umaryland.edu]


Category: Airway Management

Title: Uveitis (Cont'd)

Keywords: Uveitis, Treatment (PubMed Search)

Posted: 1/23/2010 by Michael Bond, MD (Updated: 12/3/2022)
Click here to contact Michael Bond, MD

Uveitis and Iritis Treatment:

  • Once the diagnosis is suspected or made ensure that the patient has ophthamology followup.
  • Antibiotics are not needed as this is not an infectious process.
  • Pain control is the painstay of therapy (no not narcoletics) but cycloplegics like:
    • Cyclopentolate 0.5-2% 1 gtt TID
    • Homatropine 2-5% 1 gtt TID
    • This will relieve pain and photophobia symptoms
  • Topical steroid can be initiated to decrease inflammation but should be done in consultation with the ophthamologist
    • Prednisolone 1% 1 gtt every 1-6 hours.

Category: Toxicology

Title: Quinolone Induced Delirium

Keywords: levofloxacin (PubMed Search)

Posted: 1/21/2010 by Fermin Barrueto, MD (Updated: 12/3/2022)
Click here to contact Fermin Barrueto, MD

Quinolone Induced Deliurim

Just to give you another reason NOT to give a quinolone - aside from the C. diff. This adverse effect occurs with quinolones unlike many other antibiotics. It can prolong hospital stay, cause falls and further medical work ups. Some risk factors are:

  • Elderly
  • Renal Insufficiency
  • Benzodiazepine dependence (will actually precipitate withdrawal since quinolones displace the BDZ from the receptor - you have probably done this to a patient if you think about it, that may be why they went crazy)
  • Epilepsy - can cause seizures especially with NSAIDs

 


Category: Neurology

Title: Alcohol-related Seizures

Keywords: alcohol, seizure, alcohol withdrawal seizure (PubMed Search)

Posted: 1/20/2010 by Aisha Liferidge, MD (Updated: 12/3/2022)
Click here to contact Aisha Liferidge, MD

-- While we typically associate seizures within the context of alcoholism with physiologic withdrawal, studies have shown that there is a dose-dependent relationship between the consumed amount of alcohol and the onset of seizure activity, independent of alcohol withdrawal.

-- Specifically, Ng and colleagues found a 3-fold increase in seizure occurance with 50 to 100 grams of ethanol per day, compared to an 8-fold increase with 101 to 200 grams of ethanol per day.

-- This study further found that ex-drinkers (abstention for >= 1 yr.) were not at any increased risk of seizure and that drinkers who had seizures did so well outside of the conventional window of withdrawal.  

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Category: Critical Care

Title: Defining AKI

Posted: 1/19/2010 by Mike Winters, MD (Updated: 12/3/2022)
Click here to contact Mike Winters, MD

Defining Acute Kidney Injury (AKI)

  • In the pearl from 1/5/10, I highlighted the association of AKI with increased morbidity and mortality in the critically ill along with the avoidance of nephrotoxic medications.
  • Currently, two sets of criteria (RIFLE and AKIN) can be used to identify patients with AKI
  • According to AKIN, the current diagnostic criteria for AKI is:
    • an absolute increase in serum creatinine > 0.3 mg/dL OR
    • a > 50% increase in serum creatinine from patient baseline OR
    • urine output < 0.5 ml/kg/hr for > 6 hours
  • For the critically ill ED patient, the most common causes of AKI include sepsis, hypovolemia, medications, trauma, rhabdomyolysis, obstruction and abdominal compartment syndrome

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Category: Vascular

Title: Evaluation of the acute ischemic limb

Keywords: ischemia (PubMed Search)

Posted: 1/18/2010 by Rob Rogers, MD (Updated: 12/3/2022)
Click here to contact Rob Rogers, MD

Evaluation of the acutely ischemic limb

Some considerations when evaluating/treating patients with acute limb ischemia:

  • Strongly consider anticoagulation (usually with Heparin) early
  • Consider the source of the ischemia (LV/LA thrombus, AAA mural thrombus, in situ limb thrombosis)
  • Always consider aortic dissection as an etiology of acute limb ischemia (chest pain and leg ischemia)
  • Early vascular consult and/or transfer
  • Obtain bedside ABIs on suspected cases and remember that diabetics may have normal to falsely elevated ABIs secondary to calcified vessels.
  • Common theme in laws suits for missed or delayed cases of limb ischemia: failure to perform and document ABIs

Category: Cardiology

Title: ACS and normal ECGs

Keywords: electrocardiography, acute coronary syndromes, ECG, EKG (PubMed Search)

Posted: 1/17/2010 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

Most people know that the ECG is only diagnostic of ACS approximately in 50% of cases, and in fact patients presenting with ACS can have an initially completely normal ECG in up to 10% of cases. However, traditional teaching is that if the patient is actively having chest pain or other concerning symptoms, the patient with ACS will nearly always have ECG abnormalities. NOT SO, according to a recent study. Researchers from Davis medical center evaluated patients with presumed ACS and normal ECGs, comparing the prevalence of ACS in patients with active symptoms (e.g. chest pain) during the normal ECG vs. patients that were asymptomatic at the time of the ECG. Cutting to the chase, they found no difference in ther rule-in rate between the two groups. In other words, don't be reassured at all if a patients has a normal ECG during symptoms.

This study supports other studies which continually show that an abnormal ECG is excellent at ruling-in disease, but a normal ECG is poor at ruling-out disease. In the absence of a diagnostic ECG, it's all about the HPI, the HPI, and the HPI. And also...the HPI.

[Turnipsee SD, Trythall WS, Diercks DB, et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009;16:495-499.]


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Category: Ophthamology

Title: Uveitis and Iritis

Keywords: Uveitis, Iritis (PubMed Search)

Posted: 1/16/2010 by Michael Bond, MD
Click here to contact Michael Bond, MD

Iritis is a common diagnosis in the ED, but did you know it was actually a subset of Uveitis.

Uveitis is an inflammation of one or all parts of the uveal tract which consists of the iris, the ciliary body, and the choroid.
 
The subsets of uveitis are:

  1. anterior
  2. confined to the iris and anterior chamber -- iritis
  3. confined to the iris, anterior chamber, and ciliary body -- iridocyclitis.
  4. Posterior uveitis -- choroiditis and chorioretinitis, is uncommon, with the exception of cytomegalovirus (CMV) retinitis in patients with AIDS.


Treatment of iritis and uveitis next week.

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Pediatric Constipation is a common presentation to PED and large percentage of GI clinic patient volume

Defined as less than 2 stools per week for two weeks with hard, large pellet like stools

Broad Differential includes functional constipation (most common), stricture, obstruction, celiac disease, Hirschsprung, hypothyroid, Cow's milk protein allergy, CF and spina bifida.  Always inspect the spine and perform rectal

Success of treatment is based on the aggressive nature of treatment and timing of treatment.  Ttreatment is longer and more difficult if patient has to wait on referral to GI specialist.

  • Clean out with enema and stool softener (miralax BID for two days, followed by daily maintenance regimen is most common)
  • Cheaper and effective regimens include mineral oil, kondremul or lactulose
  • Encourage behavioral therapy with routine toilet time and rewards
  • Increase fiber in diet to 8-10 grams for toddlers, 12-14 preschool and 14-16 for school age
  • Initial treatment is safe and does not require electrolyte monitoring.
  • Failed treatment and bounceback may require GI consult, inpatient Golytely therapy with electrolyte monitoring