UMEM Educational Pearls

Category: Cardiology

Title: HIV and CAD

Keywords: HIV, human immunodeficiency virus, coronary heart disease (PubMed Search)

Posted: 9/14/2008 by Amal Mattu, MD (Updated: 2/24/2020)
Click here to contact Amal Mattu, MD

 HIV positive patients are at increased risk of premature atherosclerosis for at least a few reasons:
1. HIV disease causes increased activation of platelets.
2. HIV produces arterial endothelial dysfunction [which promotes thrombosis formation].
3. Protease inhibitors produce dyslipidemias and insulin resistance.

HIV-associated CAD is also unusual in that the vessel involvement is frequently diffuse and circumferential along the whole artery.

HIV positive patients are known to have their first MI at an earlier age than non-HIV controls, and the effect is not related to CD4 count (not related to severity of disease).

The takeaway point here is to always strongly consider ACS in the differential diagnosis of patients with HIV that are presenting with cardiopulmonary complaints, even in relatively younger patients.

Amal

[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular Manifestations in Human Immunodeficiency Virus-Infected Patients. Am J Cardiol 2008;102:635-642.]


Category: Procedures

Title: Dental Pain and Blocks

Keywords: Dental Blocks (PubMed Search)

Posted: 9/13/2008 by Michael Bond, MD (Updated: 2/24/2020)
Click here to contact Michael Bond, MD

Dental Pain and Blocks:

I am sure that most of us have felt like we should  have attended dental school when we see the fifth toothache of the day, but for those with true dental pain it can be severe and debilitating.  For these patients the only way to truly get their paint under control is to perform a dental block.  This will provide the patient with several hours of excellent pain relief, and may be all they need before seeing a dentist the next day.

For those that are not familiar with dental blocks, a great web page that I found that covers the advantages and disadvantages of the more common blocks is http://www.septodont.ca/Septodont/english/other/cea_di01.html

So for your next dental pain consider performing a dental block instead of just sending them home with a P&P pack (percocet and penicillin)

 


Category: Toxicology

Title: Black Widow Spider

Keywords: latrodectus, black widow, spider (PubMed Search)

Posted: 9/11/2008 by Fermin Barrueto, MD (Updated: 2/24/2020)
Click here to contact Fermin Barrueto, MD

 Latrodectus sp (Black Widow Spider)

  • The only indigenous neurotoxic insect  in the state of Maryland and found through many states in the US
  • The "bite" often not visible and does not cause a necrotic lesion like the brown recluse
  • Causes Acetycholine release from post-synaptic motor and sensory nerves
  • This leads to intense muscle contraction and pain. There have been reports of a black widow spider on the leg and the patient undergoes ex lap surgery for suspected acute abdomen only to find out the abdominal muscles were fasciculating due to envenomation
  • Treat with aggresive analgesia and benzodiazepines.
  • Not often lethal with approximately 60-70 deaths in the US over 30 years

Take a look at a picture of the black widow on the following attachment


Attachments

black-widow-spider-1.jpg (14 Kb)


Category: Neurology

Title: Arteriovenous Malformation (AVM)

Keywords: avm, arteriovenous malformation, intracranial bleed (PubMed Search)

Posted: 9/10/2008 by Aisha Liferidge, MD (Updated: 2/24/2020)
Click here to contact Aisha Liferidge, MD

  • Arteriovenous malformation (AVM) is a congenital defect of the circulatory system, comprised of a nest of blood vessels.
  • AVM is typically detected incidentally during CT or MRI studies.
  • Symptoms vary depending on the location of the AVM and the amount of hemorrhage, but can be as general as a seizure or headache.
  • The following clinical symptoms commonly occur with AVM bleeds:

          - Ataxia                 - Paresthesia/dysesthia

          - Aphasia              - Memory deficits

          - Confusion           - Hallucinations

          - Apraxia               - Papilladema

  • If asymptomatic by the late 40's of life, usually remain stable and asymptomatic.


Category: Vascular

Title: Acute Limb Ischemia

Keywords: Ischemia (PubMed Search)

Posted: 9/9/2008 by Rob Rogers, MD (Updated: 2/24/2020)
Click here to contact Rob Rogers, MD

 Management of acute limb ischemia

Just a few pearls regarding acute limb ischemia

  • Presents with an acutely painful extremity (may be pale and cool as well)
  • Common etiologies include atrial fibrillation, embolism from aortic plaques, and thrombosis of extremity vessels
  • Most patients need to be anticoagulated (heparin) 
  • Vascular surgery should be consulted immediately or the patient needs transfer to a facility that can handle acute vascular emergencies
  • Use caution when performing the physical examination, because there may be a pulse present
  • Perform bedside ABI to the best of your ability and document
  • Diabetics with stiff vasculature may have ABIs of 1 or greater so may be less reliable

Show References


Category: Critical Care

Title: Intraabdominal Hypertension

Keywords: intraabdominal pressure, intraabdominal hypertension, bladder pressure (PubMed Search)

Posted: 9/8/2008 by Mike Winters, MD (Updated: 2/24/2020)
Click here to contact Mike Winters, MD

Intraabdominal Hypertension and the Critically Ill

  • Intraabdominal hypertension (IAH) is increasingly recognized in a wide variety of critically ill patients and is associated with significant morbidity and mortality
  • Normal intraabdominal pressure (IAP) is 5 - 7 mm Hg
  • IAH is defined as the sustained elevation in IAP of at least 12 mm Hg
  • Physical exam is inaccurate in detecting IAP with sensitivities of 40-60%
  • The most common method of measuring IAP is intravesicular (bladder)
  • Importantly, IAP should be measured at end-expiration after ensuring that abdominal muscle contractions are absent, with the patient in the supine position, and with the transducer zeroed in the midaxillary line at the level of the iliac crest

Show References


Category: Cardiology

Title: troponin levels and sepsis

Keywords: troponin, sepsis (PubMed Search)

Posted: 9/7/2008 by Amal Mattu, MD (Updated: 2/24/2020)
Click here to contact Amal Mattu, MD

 Troponin levels are often elevated in patients with sepsis. This doesn't necessarily mean that the patient has suffered an acute Mi or ACS, but rather it seems to correlate with myocardial dysfunction that is caused by sepsis. Much like with true MI, troponin elevations predict a greater risk of in-hospital mortality in these patients.


Category: Pediatrics

Title: When the Sting REALLY hurts!!

Keywords: Pediatric Anaphylaxis (PubMed Search)

Posted: 9/5/2008 by Don Van Wie, DO (Updated: 2/24/2020)
Click here to contact Don Van Wie, DO

When the Sting REALLY hurts!!

  • Anaphylaxis is an acute, potentially life-threatening problem, with multisystemic manifestations.(Remember 2 or more organ systems are required by definition!)
  • In Children, foods (Milk, Eggs, Wheat, and Soy (MEWS) are the most common allergens
  • But...peanuts and fish are among the most potent!!
  • Also children can develop anaphylaxis from the fumes of cooking fish or residual peanut in a candy bar.
  • Other common causes are preservatives, medications (antibiotics), insect venom (bee stings!!!!!!)

Remember the dose of Epinephrine is : 

0.01 mg/kg or 0.01 mL/kg of 1:1,000 IM or

0.01 mg/kg IV or 0.1 mL/kg/dose 1:10,000 IV

to the adult dose or 0.3 mg 

Also

Epipen Jr = 0.15 mg (use for < 30 Kg)

Epipen = 0.3 mg (use for > 30 Kg)

To show patients an instructional video click on the referenced link.

Show References


Category: Airway Management

Title: Intubation "P"earls

Keywords: Intubation, endotracheal intubation, position, laryngoscopy (PubMed Search)

Posted: 8/27/2008 by Ben Lawner, DO (Emailed: 9/4/2008) (Updated: 2/24/2020)
Click here to contact Ben Lawner, DO

To echo Dr. Rogers' fantastic airway tips:

When considering an intubation or managing an emergent respiratory concern, keep the "P"s of intubation in mind:

1. P osition:  No intubating on the floor!  Don't get sucked into the patient's oropharynx! Maintain an appropriate distance. Align the airway axes. Sniffing position is utilized for non traumatic adult airways; this involves flexion of the lower c-spine and a bit of extension at the upper cervical levels. Take off cervical collars. Use pillows / blankets to align the external auditory canal (EAC) with the sternal notch to help w/visualization. Cricoid pressure is NOT designed to facilitate passage of the ETT- it MAY help prevent excessive gastric insufflation.

2. P reparation: Two tubes. Two blades. Two intubators. Plan B(ougie) or Plan C(cric). Though your emergency airway plans may differ, think of ALL airways as potentially difficult ones. Respect the epiglottis. 

3. P reoxygenation: 100% via NRBM when possible to ensure oxygenation and nitrogen washout. In patinets with at least some reserve, this will help to avoid pulse ox pitfalls. True RSI does NOT involve positive pressure ventilation.

4. P remedication: Know your sedatives in advance. Etomidate ? Ketamine ? Diprivan ? Whatever your agent of choice, know indications and drug dosages. Emergent RSI is a less than ideal time to access Epocrates.

5. P aralysis:  This is pretty much the point of no return. Administration of paralytics commits you to securing a patient's airway. Both rocuronium and succynylcholine can be dosed at 1 mg/kg IV.

6. P ass the tube: What Dr. Rogers said.

7. P osition confirmation: Direct visualization of the tube through the glottic opening coupled with end tidal Co2 is ideal.

Show References


Category: Toxicology

Title: Topical Lidocaine for Local Anesthesia

Keywords: Lidocaine, pediatrics, anesthesia (PubMed Search)

Posted: 9/4/2008 by Ellen Lemkin, MD (Updated: 2/24/2020)
Click here to contact Ellen Lemkin, MD

Topical Lidocaine for local anesthesia

  • Zingo® (lidocaine 0.5 mg powder) is a new product designed to reduce pain with IV access
  • Onset of action 1-3 minutes (compared with 30 minutes with lidocaine/prilocaine creams (EMLA®), liposomal lidocaine 4% (LMX®), or lidocaine/tetracaine patches (Synera®)
  • Duration of action is only 10 minutes (procedure must be done in 10 minutes)
  • Uses helium to forcefully deliver drug into the skin
  • Looks like a marker that you press down and you hear a loud pop
  • Cost $20 per dose
  • Approved for children 3-18 years of age

 

Disclosure: I have no financial or invested interest in the product or the company.

Show References


Category: Neurology

Title: Asterixis

Keywords: asterixis, liver failure, elevated ammonia, flapping tremor (PubMed Search)

Posted: 9/3/2008 by Aisha Liferidge, MD (Updated: 2/24/2020)
Click here to contact Aisha Liferidge, MD

  • Asterixis is a tremor of the wrist that occurs when the wrist is extended (dorsiflexed).
  • It is also often referred to as a "flapping tremor" or "liver flap."
  • Asterixis results from arrhythmic, interrruptions of voluntary muscle contraction resulting in brief lapses in posture.
  • It is most often associated with hepatic encephalopathy that results from abnormal metabolism of ammonia to urea, causing brain cell damage.  The subsequent elevated levels of ammonia are due to liver failure.
  • In addition to hepatic enephalopathy, asterixis can also be associated with the following conditions:

               -- azotemia

               -- cardon dioxide toxicity

              -- metabolic encephalopathies

              -- Wilson's Disease


Category: Critical Care

Title: Bicarbonate for lactic acidosis from shock?

Keywords: sodium bicarbonate, lactic acidosis, hypoperfusion, shock (PubMed Search)

Posted: 9/3/2008 by Mike Winters, MD (Updated: 2/24/2020)
Click here to contact Mike Winters, MD

Bicarbonate for severe lactic acidosis from shock?

  • In critically ill patients, one of the most common causes of acidosis is hypoperfusion induced lactic acidosis
  • Importantly, the source of lactic acid during hypoperfusion/shock is intracellular, and the intracellular compartment is not readily accessible to extracellular bicarb
  • Exogenous bicarbonate will certainly raise extracellular pH but does not readily correct intracellular acidosis
  • This increase in pH is transient and typically lasts approximately 30 minutes
  • In studies to date, exogenous bicarbonate did raise pH, serum bicarbonate concentrations, and PaCO2 but importantly did not improve cardiac output, mean arterial pressure, or sensitization to catecholamines
  • Take Home Point: Based on available literature, there is no utility to giving bicarbonate in hypoperfusion induced lactic acidosis when the pH is > 7.0

 

 

 

 

 

 

 

 

 

Show References


Category: Cardiology

Title: HIV and Cardiac Disease

Keywords: HIV, human immunodeficiency virus, pericardial effusion (PubMed Search)

Posted: 8/31/2008 by Amal Mattu, MD (Updated: 2/24/2020)
Click here to contact Amal Mattu, MD

Patients with HIV are at increased risk for several cardiovascular complications of the disease. The most common cardiac manifestation in HIV disease is reported to be pericardial effusion. 

The presence of a pericardial effusion in HIV is a poor prognostic sign, an independent predictor of mortality (62% mortality at 6 mos is reported, compared to 7% in those without effusion).

The pericardial effusion is often associated with TB in endemic areas, but can also be associated with other organisms including Staph, Strep, Chlamydia, and some viruses. HIV itself can cause an effusion as part of a generalized serous effusive process.

Takeaway: In late-stage HIV patients with any cardiopulmonary complaints, it would be prudent to make bedside ED ECHO part of your usual initial evaluation.

[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular manifestations in human immunodeficiency virus-infected patients. Am J Cardiol 2008;102:635-642. Authors are from Michigan State Univ.]


Category: Gastrointestional

Title: Biliary Colic and Narcotics

Keywords: HIDA, narcotics, biliary colic (PubMed Search)

Posted: 8/30/2008 by Michael Bond, MD (Updated: 2/24/2020)
Click here to contact Michael Bond, MD

Biliary Colic and Narcotics:

It is common to give patients with biliary colic narcotics inorder to relieve their pain.  It was common teaching in the past that Morphine should be avoided due to the fact that it could cause spasm of the spincter of Oddi.  It is now known that all narcotics, even meperidine, can cause spasm or irritation of the spincter of Oddi.

So this weeks pearls are:

  1. Morphine and diluadid can be used to relieve the pain associated with biliary colic.
  2. However, narcotics should be avoided at least 4 hours prior to a HIDA scan as it can affect the length of the exam and the sensitivity of it.  A HIDA scan can take up to four hours to perform, however, morphine is typically given during the test as it can shorten the exam time to 1.5 hours by increasing filling of the gallbladder through the cystic duct. 

 


Category: Pediatrics

Title: Pediatric Single Dose Killers

Posted: 8/30/2008 by Don Van Wie, DO (Updated: 2/24/2020)
Click here to contact Don Van Wie, DO

 

Many things can be fatal with only one pill or sip for a young child.  One teaspoonful of Oil of wintergreen (5ml) contains about 7000 mg of salicylate (the equivalent of about 21 adult aspirin).  It would take only one swallow of Oil of wintergreen to be lethal for a young child.

Other Potential single dose killers for your Pediatric patients:

Alchohols

Methanol
Ethylene glycol
Isopropanol

Antidepressants

Monoamine oxidase inhibitors
Cyclic antidepressants

Antihypertensives

Clonidine
Verapamil
Diltiazem

Antimalarials

Chloroquine
Quinine

Benzocaine

Caustics

Hydrofluoric acid
Ammonia fluoride/bifluoride
Boric acid
Selenious acid
Disk batteries

Herbals

Eucalyptus oil
Pennyroyal oil
Camphor
Oil of wintergreen

Hydrocarbons

Imidazolines

Oxymetazoline
Naphazoline
Xylometazoline
Tetrahydrozoline

Insecticides/Rodenticides/Herbicides

Organophosphates
Carbamates
Lindane
Paraquat
Diquat
Nicotine

Opioids

Diphenoxylate
Methadone
Morphine
Oxycodone
Propoxyphene

Sulfonylureas

 

Show References


Category: Toxicology

Title: Buprenorphine - The New Methadone

Keywords: methadone, buprenorphine (PubMed Search)

Posted: 8/28/2008 by Fermin Barrueto, MD (Updated: 2/24/2020)
Click here to contact Fermin Barrueto, MD

Buprenorphine (Suboxone)

  • Use in opioid maintenance therapy programs, doesn't have QT prolongation and less respiratory depression than methandone
  • Patients must been maintained on <40mg of methadone for successful conversion to buprenorphine to take place
  • Primary caregivers can prescribe after taking a course
  • Partial agonist can actual precipitate withdrawal if patient takes a full opioid (say sneaking a little heroin before appointment)
  • Suboxone is buprenorphine+naloxone, since naloxone has poor bioavailability when taken appropriately there is no effect but if the tablet is crushed and injected the patient will go into florid withdrawal.
  • Use and abuse has been steadily increasing and death can still occur from overdose.
  • Pain is difficult to manage in patient on buprenorphine since opioid effect will be blunted, buprenorphine is potent partial agonist.

Category: Neurology

Title: Aniscoria - Unequal Pupils

Keywords: anisocoria, pupillary response, pupils (PubMed Search)

Posted: 8/27/2008 by Aisha Liferidge, MD (Updated: 2/24/2020)
Click here to contact Aisha Liferidge, MD

  • Anisocoria is when pupillary size is assymetric.
  • Anisocoria suggests a lesion in the efferent fibers supplying the pupillary sphinter muscles.
  • In order to localize the causative lesion, you must first determine which pupil is abnormal, the smaller one or the larger one.
  • The smaller pupil is abnormal when the degree of assymetry is more pronounced in darkened settings.
  • The larger pupil is abnormal when the degree of assymetry is more pronounced in bright light.

Category: Airway Management

Title: Bimanual Laryngoscopy

Keywords: laryngoscopy (PubMed Search)

Posted: 8/26/2008 by Rob Rogers, MD (Updated: 2/24/2020)
Click here to contact Rob Rogers, MD

 Quick Pearls for Intubating:

1. When intubating, make sure to use two hands!

  • Have the person holding cricoid pressure let up...cricoid pressure many times makes your job more difficult
  • You as the intubator then swing your right hand around and manipulate the larynx (left, right, up, down, etc)
  • When you get the view you want, have someone take over pressure and then pass the tube
  • Using two hands makes your job so much easier

2. Resist the urge to look for cords

  • Your job is to get the tube in the airway
  • If you can identify the two arytenoid cartilages, you are home free. Aim north of these structures.
  • You don't have to see cords to intubate. All you need are the landmarks that identify the entry into the glottis....just pass the tube north!
  • I had a case just a few days ago where the only thing we saw were the two arytenoids (covered in blood). No cords were seen, but we passed the tube above (i.e. north) the arytenoids and we were in.

3. Stylet shape is crucial

  • Shape your tube with the "straight to cuff" technique
  • The tube is straight and then bent 15-20 degrees at the beginning of the cuff
  • This shape will prevent the tube from actually obscuring your view and will increase your success.

Show References


Category: Critical Care

Title: Vasopressor extravasation

Keywords: norepinephrine, epinephrine, epinephrine, dopamine, phentolamine (PubMed Search)

Posted: 8/26/2008 by Mike Winters, MD (Updated: 2/24/2020)
Click here to contact Mike Winters, MD

 Phentolamine for vasopressor extravasation

I was recently informed of a case from an another institution in which a patient was started on a vasopressor medication via a peripheral IV while attempts at central access where attempted.  The patient unfortunately suffered permanent extremity ischemia due to significant extravasation of the vasopressor medication into the soft tissue.

  • Phentolamine is reportedly the antidote for vasopressor extravasation into the skin and soft tissues (the evidence is not robust and limited primarily to case reports and animal data)
  • Phentolamine is a non-specific alpha-blocking agent that inhibits vasoconstriction and theoretically improves blood flow through the affected area
  • Take 5-15 mg of phentolamine and mix in 10 mL of normal saline - inject this into the affected area as soon as possible
  • Give the patient concurrent IVFs in the event of some systemic absorption

 


Category: Cardiology

Title: bedside ECHO and fluid status

Keywords: bedside ultrasound, bedside echocardiography, fluid status (PubMed Search)

Posted: 8/24/2008 by Amal Mattu, MD (Updated: 2/24/2020)
Click here to contact Amal Mattu, MD

The longitudinal subcostal view on bedside ultrasound can be very helpful at addressing a patient's fluid status. 
Take a look at the diameter of the IVC 2 cm proximal to the hepatic vein on this view and ask the patient to quickly sniff. If the patient has normal fluid status, the diameter of the IVC will collapse approximately 50%.

If you notice that the IVC completely collapses during the sniff, the finding is highly accurate at predicting hypovolemia and a low CVP.

If, on the other hand, the IVC doesn't appear to collapse much at all, the finding is highly accurate at predicting a high CVP and elevated right atrial pressure. This may occur in the presence of fluid overload from decompensated CHF, cardiac tamponade, and conditions associated with RV failure (e.g. massive pulmonary embolism).