UMEM Educational Pearls

Category: Toxicology

Title: Christmas Eve

Keywords: christmas rose (PubMed Search)

Posted: 12/24/2009 by Fermin Barrueto, MD (Updated: 12/8/2022)
Click here to contact Fermin Barrueto, MD

A quick christmas one:

The Christmas Rose (Helleborus niger)

Actually containes cardioactive steroids - eating it will help your A fib with RVR as it will act like digoxin, as well as kill like it.


Attachments

christmasrose.jpg (30 Kb)


Category: Neurology

Title: Elevated Intracranial Pressure and Herniation

Keywords: ICP, intracranial pressure, stroke, herniation (PubMed Search)

Posted: 12/23/2009 by Aisha Liferidge, MD (Updated: 12/8/2022)
Click here to contact Aisha Liferidge, MD

  • Elevated intracranial pressure (ICP) can sometimes be associated with focal symptoms related to mass lesions or herniation syndromes.
  • Herniation is the result of pressure gradients between two regions of the cranial vault, such as that related to cerebral edema from an acute stroke.
  • The following list describes areas most commonly affected by herniation syndromes

          --- subfalcine

          --- central transtentorial

          --- uncal transtentorial

          --- upward cerebellar

          --- cerebellar tonsillar/foramen magnum

          --- transcalvarial


Appropriate Antimicrobial Therapy for Sepsis

  • In previous pearls, we have discussed the importance of early antimicrobial administration for patients with sepsis.
  • In patients with septic shock, current guidelines recommend empiric antimicrobial therapy be initiated within 1 hour.
  • Equally as important as early administration is the selection of appropriate antimicrobial therapy (i.e. choosing an antibiotic that is effective against the presumed or identified pathogen).
  • In one of the most recent studies, investigators found a 5-fold reduction in survival (52% vs. 10.3%) between patients who received appropriate antibiotics compared to those who received antibiotics that were ineffective against the identified pathogen.
  • In fact, choosing the right antibiotic is one of the strongest factors associated with patient outcome in sepsis.
  • When selecting empiric antimicrobial therapy for patients with septic shock consider patient history, co-morbidities, the clinical site of infection, and local resistance data.

Show References


Category: Misc

Title: Wernicke's Encephalopathy

Keywords: altered mental status (PubMed Search)

Posted: 12/21/2009 by Rob Rogers, MD (Updated: 12/8/2022)
Click here to contact Rob Rogers, MD

 Wernicke's Encephalopathy

Wernicke's encephalopathy, considered a unique complication of alcoholism, is also seen in malnourished patients, bariatric surgery patients, and patients who have undergone bone marrow transplantation.

Some pearls about Wernicke's encephalopathy:

  • The classic triad of confusion, ataxia, and opthalmoplegia is seen in only about 10-15% of cases
  • The diagnosis is made before death in only about 10_15% of cases
  • Most authorities on the disease have suggested that opthalmoplegia be replaced by ocular, since many ocular findings may be seen in these patients (nystagmus, retinal hemorhages, cranial nerve palsies)
  • Essentially any alcoholic who presents with confusion (ever see these patients in your ED?) could have the disease, so give Thiamine liberally when the patient arrives. 
  • It is a myth that administration of thiamine before glucose will precipitate Wernicke's. This dogma is based on a case series of 4 patients from the Irish Journal of Medical Sciences

Category: Cardiology

Title: syncope in the elderly

Keywords: syncope, testing, cost-effectiveness (PubMed Search)

Posted: 12/20/2009 by Amal Mattu, MD (Updated: 12/8/2022)
Click here to contact Amal Mattu, MD

Although we tend to "shotgun" when ordering labs in elderly patients with syncope, the literature actually indicates that we can be very selective in testing with this group, letting the history and PE determine whether any tests are indicated. The most recent literature supporting this concept demonstrated that even cardiac enzyme testing and head CTs in elderly syncope patients were helpful in only 0.5% of cases. The only test that should routinely be obtained is the ECG...a good history and PE should be sufficient to determine when any other tests are indicated.

[Mendu, et al. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med 2009]


Category: Misc

Title: Hypothermia

Keywords: Hypothermia (PubMed Search)

Posted: 12/19/2009 by Michael Bond, MD (Updated: 12/8/2022)
Click here to contact Michael Bond, MD

Hypothermia Pearls:

  • Lidocaine is generally ineffective in preventing ventricular arrhythmias, as is cardiac pacing or atropine to increase the heart rate.
  • Should the patient fully arrest be prepared to perform CPR for a long time.  If your ED does not have a automatic CPR device consider calling your local fire department or ambulance service as they might have one that can be loaned to your department.
  • Warm fluids, heated blankets and heat lamps will typically increase a patients temperature about 1' C an hour.
  • Gastric lavage, peritoneal lavage and heated IV fluids can warm as much as 3' an hour.
  • To rewarm quickly as high as 18'C an hour requires cardiac bypass or thoracic lavage.

Finally, remember to monitor the patient closely when you first start rewarming as this can induce cardiac arrest.  This is thought to occur as colder peripherial blood returns to the central circulation as peripherial veins and arteries dilated from the warm fluid.


Category: Pediatrics

Title: Pediatric Genital Foreign Bodies

Keywords: Pediatric, Genital, Foreign Body (PubMed Search)

Posted: 12/18/2009 by Reginald Brown, MD (Updated: 12/8/2022)
Click here to contact Reginald Brown, MD

  • 4-5% of Prepubertal Vaginal Complaints are the result of foreign body.
  • Vaginal bleeding is the most sensitive (93%), and specific (82%)
  • Discharge usually foul-smelling is only seen in 18% of patients
  • Undiagnosed symptoms may be chronic, (case reports lasting years).
  • Complications of delayed removal include infection, toxic shock syndrome, fistulas, adhesions and even infertility
  • Exam in knee chest position, and removal with irrigation or tissue forceps.
  • Failure to remove FB may require exam under anesthesia.

Show References


Category: Toxicology

Title: Drug Induced Parkinsonism

Keywords: manganese, parkinsons, tremor (PubMed Search)

Posted: 12/17/2009 by Fermin Barrueto, MD (Updated: 12/8/2022)
Click here to contact Fermin Barrueto, MD

Here is a table adapted from Goldfrank's Textbook of Toxicologic Emergencies 8th Edition - Drugs that May Induce Parkinsonism. MPTP is the story that everyone hears about and actually has links to Maryland. In 1976, Barry Kidston, a 23-year-old chemistry Maryland graduate student, synthesized MPPP (Meperidine or Demerol) incorrectly and injected the result. It was contaminated with MPTP, and within three days he began exhibiting symptoms of Parkinson's disease. Ooops - permanent.

Reversible

  • Chemotherapeutics (several)
  • Cyclosporine
  • Calcium Channel Blockers
  • Dopaminergic withdrawal
  • Kava Kava (with manganese)
  • Progesterone
  • Sertraline
  • Valproic Acid
  • Trazodone

Irreversible

  • Carbon Monoxide
  • Cyanide
  • Heroin
  • Manganese
  • MPTP

  • Frank hypointensity (i.e. dark hue) on CT of the brain, particularly if involving greater than one-third of the middle cerebral artery (MCA) territory, is a contraindication to treating acute ischemic stroke with tPA.
  • Early signs of infarct on brain CT, regardless of extent, are NOT contraindications to treatment.

Show References


Red blood cell transfusion in the critically ill patient has been and continues to be surrounded by controversy and lack of hard data.  Up to 90 percent of transfusions in the ICU are given for anemia, an indication which is least supported by the data.  The joint taskforce of EAST, ACCM and SCCM has published a clinical practice guideline which outlines recommendations and rationale.  These recommendations are summarized as follows:

  • RBC transfusion is indicated for patients with evidence of hemorrhagic shock.
     
  • RBC transfusion may be indicated for patients with acute hemorrhage and hemodynamic instability or inadequate DO2.
     
  • Transfusion triggers for Hb<7 are as effective as those for Hb<10 in hemodynamically stable critically ill patients, except for those with AMI or USA.
     
  • Hb used as a sole trigger is not advised; transfusion decisions should be based on intravascular volume status, evidence of shock, duration and extent of anemia, and cardiopulmonary physiologic parameters.
     
  • Consider RBC transfusion if Hb<7 in resuscitated critically ill patients, patients who are being mechanically ventilated or critically ill patients with stable cardiac disease.
     
  • RBC transfusion should not be considered as an absolute method to improve tissue oxygen consumption in critically ill patients.
     
  • RBC transfusion may be beneficial in patients with acute coronary syndromes with Hb<8 on hospital admission.

Show References


Category: Pediatrics

Title: Sexual Assauit in Children

Keywords: Sexual Assault, Children, Herpes, Gonorrhea, Chlamydia (PubMed Search)

Posted: 12/14/2009 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD

The Emergency Department is often the first line in detecting the sexual abuse of a child.  Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.


1. Know your region's dedicated sexual abuse center, if one exists.  These centers have personnel trained in interviewing and forensic evidence collection.  There may be different centers for children of different ages.

2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse.  GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.

3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence.  Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.

4. Any sexually transmitted disease in a child warrants further workup and investigation.  Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.

5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly.  Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.


Category: Cardiology

Title: chest pain radiation

Keywords: acute coronary syndromes, radiation, chest pain (PubMed Search)

Posted: 12/13/2009 by Amal Mattu, MD (Updated: 12/8/2022)
Click here to contact Amal Mattu, MD

Yet another publication demonstrates that chest pain radiating to the right arm has the highest predictive value for ruling in ACS. In this study, radiation of the pain to the right arm had a higher predictive value than age, gender, comorbidites or traditional risk factors, specific descriptors of pain (e.g. "pressure" or "crushing"), or associated symptoms (e.g. diaphoresis, nausea, dyspnea). The bottom line....beware chest pain that radiates to the right arm!

[Goodacre S, Pett P, Arnold J, et al. Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram. Emerg Med J 2009;26:866-870.]


Category: Airway Management

Title: Patella Fractures

Keywords: Patella, Fracture (PubMed Search)

Posted: 12/13/2009 by Michael Bond, MD (Updated: 12/8/2022)
Click here to contact Michael Bond, MD

Patella fractures are typically due to direct trauma as in a fall or direct blow to the knee.

Fractures may be missed on the AP view or misdiagnosed as a bipartate fracture.  To avoid these pitfalls look closely at the lateral view and consider getting a sunrise view of the knee (better visualizes the patella).  Finally,  unilateral bipartate patella are very rare so consider an x-ray of the contralateral knee if you are considering this as your diagnosis.

Surgery should be considered for:

  • Fractures with displacement greater than 3 mm.
  • Individuals that have lost there externsor mechanism as it is indicative of a tear in the extensor retinacula.

Category: Toxicology

Title: Intranasal Naloxone

Keywords: naloxone, intranasal (PubMed Search)

Posted: 12/10/2009 by Bryan Hayes, PharmD (Updated: 12/8/2022)
Click here to contact Bryan Hayes, PharmD

 

When IV access is not immediately available and you don’t want to rely on the erratic absorption of IM administration, naloxone can be given by the intranasal (IN) route.
 
Kinetics are similar to IV: Onset 1-2 minutes, duration 40-50 minutes.
 
Dose is the same as IV: Up to 1 mL (0.4 mg) can be given in each nostril.
 
Advantage of needleless administration.
 
To use: Draw up dose of nalxone and simply add an atomizer to the end of a syringe (see picture).  Administer half of final dose in each nostril.
 
Atomizers are now available in the UMMC ED.


Attachments

MADnasal.jpg (64 Kb)


Category: Neurology

Title: Unilateral Headaches

Keywords: headaches, cluster headache, migraine headache, glaucoma, temporal arteritis (PubMed Search)

Posted: 12/10/2009 by Aisha Liferidge, MD (Updated: 12/8/2022)
Click here to contact Aisha Liferidge, MD

The following is a differential diagnosis for unilateral headaches with typical associated features:

  • Migraine headache ->  throbbing pain preceded by aura; nausea; photophobia; chronicity.
  • Cluster headache ->  piercing eye pain; ipsilateral lacrimation and rhinorrhea; group of headaches come periodically in waves.
  • Temporal arteritis ->  dull ache over temporal artery; associated with arthralgia, myalgia, and anemia; typically in older populations.
  • Glaucoma ->  eye pain with cloudy appearing cornea; eyeball feels hard; pupillary dilitation may worsen pain.
  • Sinusitis ->  associated with sinus congestion; tenderness over sinus with or without swelling; typically only relieved with decongestants and/or antibiotics.
  • Subarachnoid hemorrhage ->  pain may be diffuse or unilateral; sudden onset of severe pain; may be associated with a stiff neck.

Category: Critical Care

Title: Shock Index

Posted: 12/8/2009 by Mike Winters, MD (Updated: 12/8/2022)
Click here to contact Mike Winters, MD

Early Recognition of Shock

  • Early recognition, and thus early treatment, of shock is crucial in reducing morbidity and mortality in the critically ill ED patient.
  • Traditionally, the diagnosis of shock has been based on vital sign abnormalities such as tachycardia, tachypnea, oliguria, etc.
  • Vital sign abnormalities have been shown to be insensitive markers of shock in the critically ill.
  • The Shock Index, although clearly not 100% sensitive, can assist in the detection of shock compared to heart rate and blood pressure alone.
  • Shock Index is simply heart rate divided by systolic blood pressure.
  • Values greater than 0.9 are abnormal and suggest markedly impaired cardiac output.

Show References


Category: Vascular

Title: Effort Thrombosis

Keywords: Thrombosis (PubMed Search)

Posted: 12/7/2009 by Rob Rogers, MD (Updated: 12/8/2022)
Click here to contact Rob Rogers, MD

Effort Thrombosis

Effort thrombosis, also called Paget von Schrotter disease, occurs when either the axillary and or subclavian veins thrombose. The condition is more common in young, healthy (>males) patients and presents with the usual DVT symptoms of arm pain, swelling, and pain.

The disease was originally described in patients performing vigorous activities, like weight lifting or repetitive over-the-head lifting. This type of activity has been reported to kink the subclavian vein and lead to clot formation.

Diagnosis and therapy is the same for any other type of DVT.


Category: Cardiology

Title: NSAIDS after MI

Keywords: NSAIDs, myocardial infarction (PubMed Search)

Posted: 12/6/2009 by Amal Mattu, MD (Updated: 12/8/2022)
Click here to contact Amal Mattu, MD

When patients present with acute MI, all NSAIDS should be discontinued (e.g. ibuprofen, COX-2 inhibitors, etc.) during the hospitalization. Continued use of NSAIDs during the hospitalization increases the risk of CHF, myocardial rupture, hypertension, reinfarction, and mortality.

 

 


Category: Ophthamology

Title: Sudden Vision Loss Causes

Keywords: Sudden Vision Loss (PubMed Search)

Posted: 11/28/2009 by Michael Bond, MD (Emailed: 12/5/2009) (Updated: 12/5/2009)
Click here to contact Michael Bond, MD

Some of the causes of acute vision loss are:

  • Cardiac Causes include:
    • Emboli -- causes can be atherosclerotic plagues, atrial fibrillation, endocarditis.
    • Arteritis
    • Dissection
  • Hematologic causes
    • Hypercoaguable state
    • Hyperviscosity
    • Anemia
  • Ocular Causes
    • Angle-closure glaucoma
    • Papilledema/neoplasm: Intracranial hypertension
    • Intraocular foreign bodies:
    • Central retinal artery occlusion
    • Anterior ischemic optic neuropathy
    • Ruptured globe
  • Miscellaneous
    • Migraine
    • Hysteria
    • Drugs (i.e.: viagra and its counterparts)

Show References


Category: Pediatrics

Title: Ductal-Dependent Congenital Heart Disease

Keywords: congenital heart disease, cyanosis, neonate, prostaglandin (PubMed Search)

Posted: 12/4/2009 by Heidi-Marie Kellock, MD (Updated: 12/8/2022)
Click here to contact Heidi-Marie Kellock, MD

Ductal-Dependent Cardiac Lesions in the Neonate

  • Often present in the first 1-2 weeks of life (children born prematurely tend to be at the upper end of the spectrum as they may have delayed closure of the ductus arteriosus)
  • May present with tachypnea, sudden onset of cyanosis or pallor (often worse with crying), diaphoresis with feeds, lethargy, or failure to thrive
  • Oxygen challenge - place baby on 100% 02 via NRB;  10% improvement in SpO2 (or 30mmHg increase in PaO2 on ABG) suggests a pulmonary issue;  no or minimal change suggests a congenital heart defect
  • If congenital heart disease is suspected, start PGE-1 infusion at a rate of 0.05-0.1ug/kg/minute;  improvement may be drastic and is usually seen within 15 minutes
  • Side effects of PGE-1 infusion include apnea, fever, hypotension, and seizures;  have your code cart and intubation equipment ready to go prior to beginning infusion