Category: Vascular
Keywords: subarachnoid hemorrhage (PubMed Search)
Posted: 12/13/2010 by Rob Rogers, MD
(Updated: 3/29/2024)
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Diagnosing Subarachnoid Hemorrhage-6 Pitfalls
1. Subarachnoid hemorrhage (SAH) doesn't always present as the "worst ever" headache. Don't most of our patients say their headache is the worst headache anyway? Be suspicious of the diagnosis if your patient has acute onset of an unusual or atypical headache. Diagnoses starts with the history.
2. The neuro exam may be completely normal in some cases, especially early on.
3. The headache due to SAH may get better with analgesics. This is a huge pitfall. Don't rule this diagnosis out if analgesics help.
4. The CT scan may be negative. Enough said.
5. Be careful with interpretation of the CSF. We all want the number of red cells in tube 4 to be zero. Be careful with this. Although the rbcs may have dropped by 50% from tubes 1 to 4, the diagnosis hasn't been excluded unless the cells clear completely. Although there have been some case reports of SAH with rbcs < 100, this is pretty uncommon.
6. CT Angiography and/or MRI with FLAIR is not a substitute for the lumbar puncture.
Stuart Swadron, Emergency Physicians Monthly
Category: Medical Education
Keywords: education, quality improvement (PubMed Search)
Posted: 12/13/2010 by Dan Lemkin, MD, MS
Click here to contact Dan Lemkin, MD, MS
Dear Readers,
Thank you for your continued interest in the University of Maryland's EM Pearls program. We are conducting a survey to assess whether our pearls are meeting your needs. Data collected will be used to refine and improve our educational program. Please take 1 minute to complete our survey by clicking the link below.
http://umem.org/surveyor/index.php?sid=86815&newtest=Y&lang=en
If you regularly forward pearls to other readers, please forward this message as well. We wish to capture as many readers' opinions as possible.
If you have any questions or problems, please contact: admin@umem.org
Sincerely,
Dan Lemkin, MD MS
EM Pearls Development Team
University of Maryland School of Medicine
Department of Emergency Medicine
Category: Orthopedics
Keywords: cervical, neck, radiculopathy (PubMed Search)
Posted: 12/10/2010 by Brian Corwell, MD
(Emailed: 12/11/2010)
(Updated: 12/18/2010)
Click here to contact Brian Corwell, MD
Cervical Radiculopathy
The most commonly affected level is C7 (31-81%), followed by C6 (19-25%), C8 (4-12%) and C5 (2-14%)
Anterior compression can selectively affect motor fibers
Posterior compression can selectively affect sensory fibers
-More common due to posterior lateral disc herniation or facet degeneration
Signs and symptoms: Sensory complaints (findings are in a root distribution) and possible weakness and reflex changes.
Wilbourn & Aminoff, 1998.
Category: Pediatrics
Keywords: Pediatric Intubation, Airway Control, Cuff Pressure (PubMed Search)
Posted: 12/10/2010 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
In the past several years it has become common practice to use cuffed tubes for pediatric intubations. However, a recent study suggests that cuff pressures are not as well regulated in pediatric patients, particularly when the patients are quickly intubated prior to aeromedical transport. Cuff pressures >30 cm H2O are associated with tracheal damage, however, up to 41% of pediatric patients transferred had cuff pressures >30 cm H2O, and 30% of those had pressures >60 cm H2O!
So:
Check your cuff pressures in all patients, particularly prior to transport
Cuff pressures must be <30cm H2O
Recall that for years uncuffed tubes were the standard, so as long as effective ventilation is achieved, it is best to err on the low side...
If you work at a facility that routinely transfers out the sickest pediatric patients, you will save their life by securing an airway in this most stressful of circumstances, but careful attention to this seemingly small detail can save your patient from long term complications.
Tollefsen, William W. et al. Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated Before Aeromedical Transport. Pediatric Emergency Care: May 2010 - Volume 26 - Issue 5 - pp 361-363
Category: Toxicology
Keywords: anion gap, metabolic acidosis (PubMed Search)
Posted: 12/8/2010 by Bryan Hayes, PharmD
(Emailed: 12/9/2010)
(Updated: 12/9/2010)
Click here to contact Bryan Hayes, PharmD
Most cases of normal anion gap metabolic acidosis result from either urinary (RTA) or gastrointestinal HCO3- losses (diarrhea). A number of xenobiotics can also cause this disorder:
Category: Neurology
Keywords: transverse myelitis, spinal cord, demyelinating, neurologic condition (PubMed Search)
Posted: 12/8/2010 by Aisha Liferidge, MD
(Updated: 3/29/2024)
Click here to contact Aisha Liferidge, MD
Category: Critical Care
Keywords: Antibiotics, linezolid, serotonin syndrome, delirium, critical care (PubMed Search)
Posted: 12/7/2010 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD
Linezolid is used for gram-positive infections resistant to conventional therapy (e.g., Vancomycin-resistant enterococcus and Methicillin Resistant Staph Aureus). Linezolid is an oxazolidinone, but more importantly it is a weak monoamine oxidase inhibitor (MAOI) and serotonin syndrome (e.g., altered mental status, neuromuscular abnormalities, autonomic instability) may occur when combined with selective serotonin re-uptake inhibitors (SSRIs) or with recent discontinuation of SSRI.
Be aware that the following drugs can precipitate serotonin syndrome when combined with Linezolid:
Mirtazpine Buproprion Fentanyl
Trazodone Buspirone Bromocryptine
Levodopa Lithium Amphetamines
Cocaine Codeine Reserpine
Ergots MAOI's
Narita, M. Linezolid-Associated Peripheral and Optic Neuropathy, Lactic Acidosis, and Serotonin Syndrome Pharmacotherapy (2007) vol. 27 (8) pp. 1189-97
Category: Vascular
Keywords: hypertension (PubMed Search)
Posted: 12/6/2010 by Rob Rogers, MD
(Updated: 3/29/2024)
Click here to contact Rob Rogers, MD
Got Symptomatic Hypertension? Why not try Fenoldopam?
Fenoldopam is a rapid-acting vasodilator.
Dosing (Adult): After a starting dose of 0.1 to 0.3 mcg/kg/minute, the dose is titrated at 15 minute intervals, depending on the BP response. May be increased in increments of 0.05 to 0.1 mcg/kg/minute every 15 minutes until target blood pressure is reached. Maximal infusion rate reported in clinical studies: 1.6 mcg/kg/minute.
Onset/duration: 5-10 minutes/~ 1 hour.
The Clinician's Ultimate Reference
Category: Cardiology
Keywords: end tidal CO2 monitoring (PubMed Search)
Posted: 12/5/2010 by Amal Mattu, MD
Click here to contact Amal Mattu, MD
In order to minimize interruptions in compressions due to pulse checks, continuous end tidal CO2 (ETCO2) monitoring during compressions is recommended. Before spontaneous circulation returns, the ETCO2 is likely to be on the order of < 10 mmg Hg. At the moment spontaneous circulation returns, the ETCO2 is expected to abruptly increase to at least 35-40 mm Hg. Be wary, though, that the administration of sodium bicarbonate may transiently increase the ETCO2 even in the absence of return of spontaneous circulation (ROSC).
Use of ETCO2 in this manner allows one to assess the patient for ROSC without ever having to stop compressions for pulse checks.
Category: Orthopedics
Keywords: spondyloysis, spondylosis, spondylolistesis, spondylitis (PubMed Search)
Posted: 12/4/2010 by Michael Bond, MD
(Updated: 3/29/2024)
Click here to contact Michael Bond, MD
Dr. Corwell covered Spondyloysis in July 2010 https://umem.org/res_pearls_referenced.php?p=1134 but if you are like me you might have trouble remembering the differences between the following terms:
Category: Pediatrics
Keywords: pediatric, lumbar puncture, positioning, interspinous space (PubMed Search)
Posted: 12/3/2010 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
We've all been there. It's 2am, and a 4 week old with a temperature of 38.1 rolls in the door. You grab the LP kit and your "best holder." This person then holds the baby's head and neck flexed with one hand, while the other brings the bottom and legs up to the chest as much as possible...all, usually, without pulse oximetry monitoring.
Category: Toxicology
Keywords: holly, berry, poinsettia, mistletoe, berries (PubMed Search)
Posted: 12/2/2010 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Toxic Holiday Plants
Of the three plants listed, which is NOT poisonous?
1. Holly plant
2. Poinsettia
3. Mistletoe
Poinsettia plants were once thought to be very poisonous. Contrary to popular belief, poinsettias are safe to have in the home during the holidays.
Although there are reported cases of death with ingestion of Holly plants in older literature, recent experience shows gastrointestinal effects in small doses, and serious toxicity such as CNS depression in large ingestions.
Mistletoe ingestion of few of the berries would, at most, produce mild gastroenteritis; however, ingesting concentrated extracts of the plant, including the berries, may produce serious effects such as seizures, mental confusion, drowsiness, and hallucinations.
Happy holidays!
Poisondex.
Category: Neurology
Keywords: MS, multiple sclerosis, oligoclonal banding, brain MRI, ovoid plaques (PubMed Search)
Posted: 12/1/2010 by Aisha Liferidge, MD
(Updated: 3/29/2024)
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Category: Critical Care
Posted: 11/30/2010 by Mike Winters, MD
(Updated: 3/29/2024)
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Beware Trendelenburg Positioning in the Critically Ill Obese Patient
Rahman O, Willis L. Vascular procedures in the critically ill obese patient. Crit Care Clin 2010;26:647-60.
Category: Cardiology
Keywords: pregnancy, cardiac arrest, compressions (PubMed Search)
Posted: 11/28/2010 by Amal Mattu, MD
(Updated: 3/29/2024)
Click here to contact Amal Mattu, MD
In the second half of pregancy, we've traditionally learned that the gravid uterus compresses the inferior vena cava and therefore decreases cardiac output when patient is in a supine position. Therefore, we've learned that patients in the second half of pregnancy the patient should be placed in a left lateral tilt position.
However, it is difficult to perform good quality chest compressions when the patient is in a titled position.
Therefore, the optimal position for chest compressions on the patient in cardiac arrest in the second half of pregnancy is to have the patient in a supine position; and have another rescuer manually deflect the uterus to the patient's left side. This provides optimal compressions + optimal venous return.
Category: Orthopedics
Keywords: Bursitis, heel pain (PubMed Search)
Posted: 11/27/2010 by Brian Corwell, MD
(Updated: 3/29/2024)
Click here to contact Brian Corwell, MD
Chief complaint: “Posterior heel pain”
http://www.aidmybursa.com/_img/ankle-retrocalcaneal-subcutaneous-bursitis.jpg
Retrocalcaneal bursitis
The retrocalcaneal bursa is located between the Achilles tendon and the posterior superior border of the calcaneus.
H&P: Inflammation and pain may follow repetitive dorsi/plantar flexion of the ankle (excessive running, jumping activities). Tenderness anterior and superior to the Achilles insertion on the heel.
Treatment: Minimize weight bearing. ½ inch elevation. NSAIDs.
Posterior calcaneal bursitis
This bursa is subcutaneous, just superficial to the insertion of the Achilles tendon.
H&P: Inflammation and pain may follow irritation from the upper border of the heel counter of a shoe. Posterior heel pain. Tender “bump” (the inflamed and swollen bursa) on the back of the heel.
http://podiatry.files.wordpress.com/2006/12/patient2.jpg
Treatment: Opened-heeled shoes, sandals, or placement of a “U-shaped” pad between the heel and the counter. NSAIDs. Advance to shoes with soft or less convex heel counters.
Category: Pediatrics
Posted: 11/26/2010 by Rose Chasm, MD
(Updated: 3/29/2024)
Click here to contact Rose Chasm, MD
MedStudy Pediatric Board Review
Core Curriculum
Category: Toxicology
Keywords: sleep (PubMed Search)
Posted: 11/25/2010 by Fermin Barrueto, MD
(Updated: 3/29/2024)
Click here to contact Fermin Barrueto, MD
As we eat our turkey today and the myth that we are tired because of the tryptophan content is propagated further - nothing to do with the 2000kcals that we just ate - I would like to share an interesting and controversial study.
Use of stimulants and and sedatives by EM residents. Incidence is as follows:
In a study of 485 residents with 47% response rate:
Prescription Stimulants: 3.1%
Sleep Aids (all): 89%
Use of Nonbenzodiazepines (zolpidem): 14%
Use of Melatonin: 10%
Benzodiazepines: 9%
Difficult job with difficult hours. What is the appropriate medication or is there a medication that truly assists with performance? Are they doing harm to themselves? to patients?
Disrupted circadian rhythm, addiction tendencies and the hardship of a stressful nightshifts are the price we pay for this specialty. Awareness and education are needed for the residents as well as the attendings.
Shy BD, Portelli I, Nelson LS. Emergency Medicien residents use of psychostimulants and sedative to aid in shift work and circadian transitions. Am J Emerg Med 2010.
Category: Neurology
Keywords: vertigo, cerebellar stroke, stroke, dizziness (PubMed Search)
Posted: 11/24/2010 by Aisha Liferidge, MD
(Updated: 3/29/2024)
Click here to contact Aisha Liferidge, MD
Category: Critical Care
Keywords: Status epilepticus, non-convulsive, altered mental status, seizure, critical care, ICU, neurology (PubMed Search)
Posted: 11/23/2010 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD
Non-Convulsive Status Epilepticus (NCSE) is generally under reported. An ICU study found 10% admissions for altered mental status (AMS) were eventually diagnosed as NCSE.
Pearls:
- Include NCSE in the AMS differential
- NCSE may occur with or without convulsive seizures
- Difficult to distinguish from a post-ictal state (14% of convulsive seizures convert to
NCSE)
- Reported mortality is up to 44%
Consider NCSE when:
- Seizure history / recent seizures
- Post-ictal period >1 hour
- Odd behaviors (e.g., chewing, blinking, personality change) and abnormal eye
movements (86% specific)
- AMS without structural, metabolic or traumatic etiology
- Patient intubated for status epilepticus
If you are unsure but suspicious of NCSE order a STAT EEG. Treat NCSE like a convulsive status.
Slattery, D. Seizures as a cause of altered mental status. Emerg Med Clin North Am. 2010 Aug;28(3):517-34.