UMEM Educational Pearls

• Parkinson's Disease is a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination due to deficient levels of intra-cerebral dopamine.
• Many of these patients experience motor fluctuations which consists of periods of being "on," which is when they experience a good or hyper response to their medication, and periods of being "off," which is when the parkinson's condition itself is exacerbated.  Differentiating between these two modes is important in terms of managment, but may be challenging.  
• "On time" typically presents with relatively normal or dyskinetic involuntary  ballistic movements, chorea, dystonia, or myoclonus.  These episodes are best treated by avoiding levodopa, carefully administering low-dose benzodiazepines, or perhaps amantadine(possibly effective).
• "Off time"typically presents with sometimes painful dystonia, intorsion of limbs, spasm, and stiffness, and often relates to a period wherein the effects of parkinson's medications such as levodopa are wearing off.   These episodes are best treated by gradually increasing dopamine agonist medication such as bromocriptine, pramipexole, and ropinirole, and likely admission to the hospital. 

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Boxer's (or Brawler's) Fracture

• Fifth metacarpal neck fracture, usually secondary to a direct blow or closed-fist impact.
• Potentially an unstable fracture and difficult to maintain reduction due to tension from tendons and muscles in the hand.
• Up to forty degrees of angulation can be tolerated without repair, although there is potential for reduced hand function without repair. Any rotational deformity, however, must be corrected.
• Non-displaced fractures: RICE therapy, gutter splint, and Ortho follow-up.
• Displaced, rotated, or angulated fractures (>40 degrees): closed reduction may be attempted but surgical fixation usually required.

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Up to 30-40% of patients with infective endocarditis have neurological symptoms as a result of embolization. This is a good reminder of the frequency of embolization, and also that infective endocarditis should always be part of the differential when you are evaluating a patient with fever + neurological abnormalities.

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FARES Method for Reduction of Anterior Shoulder Dislocations.

This method that was recently highlighted in a publication had a ~78% success rate with the authors able to reduce the shoulder in an average of 2.36 ±1.24 minutes  without having to give the patients any analgesics or sedatives. The technique is done by:

• Placing the patient in the supine position.
• Hold the hand of the affected arm while the arm is at the patient’s side with the elbow extended and the forearm in neutral position.  
• Apply gentle longitudinal traction and slowly move the arm into abduction while oscillating the forearm with continuous, brief (two to three full cycles per second) and short range (approximately 5 cm above and beneath the horizontal plane) vertical  movements of the arm.  These oscillations should be done during all   all stages of the reduction as it helps that patient relax their muscles.
• Once the arm is abducted past 90º, gently externally rotate the arm while continuing to abduct it.  Continue the oscillations.
• Reduction is usually achieved at ~ 120º of abduction.  
• Once reduction is achieved, move the arm gently until it is internally rotated and resting on the patients chest.

Consider trying this with your next shoulder dislocation.  No single method of reduciton is 100% successful, but methods like this that only require a single provider and do not require analgesics are extremely helpful in improving patient flow as they do not utilize a lot of ED resources..

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The Rumack-Matthew nomogram is a well studied and validated tool to help assess the potential for liver toxicity following acute acetaminophen poisoning.  Here is a brief review of when it is best utilized.

• Prior to 4 hours post-ingestion: Not helpful to determine likelihood for toxicity.  Only use is to confirm an ingestion took place.
• Between 4 and 24 hours post-ingestion: Plot the patient's level vs. time after ingestion.  If above the toxicity line, treat with acetylcysteine.
• More than 24 hours post-ingestion: Any elevated acetaminophen level is toxic and should be treated with acetylcysteine.

Outside-the-box situations:

• Chronic exposures: Nomogram not indicated.
• Overdoses with co-ingestants that slow GI motility (e.g., opioids, diphenhydramine) OR extended release products (e.g., Tylenol Arthritis): If the level at 4 hours post-ingestion is not toxic, repeat it at 8 hours post-ingestion.  If either level is toxic, treat with acetylcysteine.

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• Using the neurological examination to test coordination primarily assesses cerebellar function.
• The cerebellum is important for motor learning and timing of motor activity.  It fine-tunes agonist and antagonistic forces of muscle activity, simultaneously and sequentially, across multiple joints which results in smooth and purposeful movements.
• Cerebellar dysfunction causes deterioration of movements, with subsequent under-shooting and over-shooting of purposeful movement, also known as dysmetria.
• Deterioration of movement and dysmetria are precursors to the development of ataxia.

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Dexmedetomidine for Sedation in Acute Neurologic Disease

• Critically Ill patients with acute neurologic disease are managed daily in the ED.
• Due to the need for frequent neurologic assessments, these patients can be challenging should they require sedation.
• Dexmedetomidine, a selective alpha-2 adrenergic receptor agonist, has emerged as an alternative to traditional sedatives (i.e. opioids and benzodiazepines).
• Dexmedetomidine provides sedation and anxiolysis, while producing little effect on level of arousal and cognitive function.  In essence, it reduces discomfort while permitting the patient to arouse for a neurologic examination.
   

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FILE RESEND. This was tested via email and will hopefully work. I apologize for errors - Dlemkin (webmaster)

What is the diagnosis? (DON'T LOOK DOWN AT THE ANSWER)

50 year-old male prisoner s/p assault, + LOC

CT shows right-sided traumatic subarachnoid hemorrhage

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Therapeutic hypothermia is generally accepted as a useful intervention that should be employed in patients that are resuscitated after cardiac arrest. Many protocols for cooling are relatively complicated, involving endovascular catheters, cooling blankets, cooling helmets, or other devices that are expensive and not widely available. The cooling process can actually be fairly simple, however, with ice and cool IV fluids. The most recent study that demonstrated this used nothing more than application of ice to the groin, neck, and axillae; and administration of 4^o C IVF infused at 30cc/kg at 100ml/min via two peripheral catheters. Sedation or paralysis + intubation was used as per the norm.

Patients receiving this simple intervention were able to achieve goal temperature of 32^o-34^o C within 3-4 hours, and hypothermia was maintained for a full 24 hours before rewarming.

The study shows that expensive equipment and complicated protocols are not necessary for therapeutic hypothermia.

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                Involves an avulsion of the flexor digitorum profundus  (FDP) tendon from its insertion on the distal phalanx.

     Ring finger is most commonly involved.

                Usually occurs from a grabbing attempt (resulting in forced DIP extension during maximal FDP contraction) as would occur while attempting to grab someone’s jersey such as in football or rugby.

Clinically, there is normal passive DIP ROM with loss of active flexion. Examine this by asking the patient to flex the fingertip at the DIP while the PIP joint is held in extension.

*Remember that patients with a 90% full-thickness tendon laceration may still have normal (albeit painful) range of motion. The examiner must evaluation the strength of the tendon against resistance. This injury is commonly missed as it is diagnosed as a “jammed” finger.

Plain films may show a bony avulsion, but are often negative.

Treatment is primary repair especially with large bony fragments. Partial ruptures can be treated nonoperatively at the discretion of the hand surgeon.

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Hyponatremic seizures are a frightening entity.  Anticonvulsants don't work well, and will likely cause apnea well before they halt the seizure.  Hypertonic saline carries with it the fear of inducing central pontine myelinolysis (CPM) with overly rapid correction of the hyponatremia.  

However:

• CPM usually occurs at sodium level corrections of >8 mEq/L/day
• Hyponatremic seizures are usually stopped with a correction of only 3-5 mEq/L

So, you can safely correct hyponatremia rapidly in the setting of seizures. Do it like this:

Give 2-3 mL/kg of 3% NaCl in rapid sequential boluses, until seizures stop.  A theoretical maximum dose is 100mL/kg, but recall that only a relatively small correction is required to stop the seizure.  

After you've stopped the seizure, correct the hyponatremia slowly, as you would otherwise.

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• Vitamin K can be used intravenously for management of the NON bleeding patient with a high INR (>9).
• Although anaphylactoid reactions have been described, most cases occurred with large doses of vitamin K, administered rapidly, and with little dilution.
• It is estimated that the incidence of anaphylaxis is 3:10,000 doses.
• The subcutaneous route of administration is not recommended because of its delayed and unpredictable responses.

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• The National Institute of Health Stroke Scale (NIHSS) is a well-validated, highly reproducible tool that is widely used to measure neurologic deficit and as a scoring system for stroke intervention.
• This scale is heavily weighted toward recognizing deficit due to anterior circulation strokes, however, while that due to posterior circulation strokes receives fewer points.
• One study found that nearly 1% of patients with MRI-confirmed acute ischemic stroke patients scored zero points on the NIHSS, and that the majority of these were posterior strokes.  These types were more likely to present with truncal ataxia (most commonly), headache, vertigo, and nausea.
• Take home points:  (1) The NIHSS should not replace a thorough neurological examination.  (2) Consider posterior stroke as the source of persistent symptoms in patients with an NIHSS score of zero. 

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Posterior reversible encephalopathy syndrome (PRES) is a syndrome of visual loss, headache, altered mental status, and seizures, typically with severe hypertension. PRES usually occurs with hypertensive encephalopathy or ecclampsia, although cyclosporin and tacrolimus use have been implicated. 

PRES is due to a combination of endothelial damage, impaired auto-regulation and increased cerebral perfusion pressure. Classic CT and MRI findings are parietal-occipital, cerebellar, or brainstem cortical and subcortical edema. 

Early recognition and symptomatic treatment is key; IV anti-hypertensives (hypertensive encephalopathy), anti-epileptics (seizures), IV magnesium and emergent delivery (ecclampsia), and discontinuing offending medications (cyclosporin and tacrolimus).  

With treatment, partial to complete recovery is normal, although residual neurological and visual deficits may persist.

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60 year-old male s/p assault. + LOC. Awake and normal neuro examination on arrival. Deteriorates in the ED after about an hour....

Diagnosis: Epidural Hematoma

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Induced hypothermia is associated with a decline in serum potassium levels. The cold myocardium is already mildly predisposed to arrhythmias, and the combination of hypokalemia + hypothermia appears to increase the risk of polymorphic ventricular tachycardia. Two simple measures should be taken during post-arrest therapeutic hypothermia:
1. Correct hypokalemia before and during cooling.
2. Monitor the patient's potassium level and QT interval during cooling, and correct as needed.

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Peroneal Tendon Subluxation: The Other Ankle Sprain

• Peroneal tendon subluxation is an uncommon cause of lateral ankle pain that is often misdiagnosed as a simple ankle sprain.
• It is commonly associated with sports that require cutting such as skiing, basketball, soccer, and football.
• The subluxation occurs when there is a forceful contraction of the peroneal tendon while the foot is dorsiflexed and inverted.
• Patients will often complain of pain at the posterolateral ankle that started as a forceful pop.  They may also complain of snapping or popping around the lateral malleolus as it continues to sublux.
• On clinical exam, the patient will often have pain along the  retrofibular groove. The peroneal tendon can be tested by actively dorsiflexing and everting the ankle from a plantar-flexed and inverted position.  You should be able to see or feel the subluxation. Passive circumduction of the ankle may also recreate the subluxation.
• Conservative management (i.e.: ankle brace, cast or walking boot) is associated with a low success rate; therefore, these patients should be referred to sports medicine or orthopaedics for possible operative repair.

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Naloxone is the epitomy of an antidote with complete reversal of opioid toxicity within 60 seconds of administration. Remember your clinical endpoint should be respiratory effort. If you utilize "the vial" of either 0.4mg or 2mg and there is a higher probability of withdrawal and for acute lung injury. Here are some tips for administration:

1) IV Access: Try 0.1 mg or even 0.05 mg - anesthesiology typically doses naloxone in micrograms. Reversal is slower so you have to be patient. It is also not as dramatic so closely monitor respirations to see if you have improvement, that may be all that you get. These are probably patients that you don't want that awake anyways.

2) No IV Access: advantage of naloxone is it is bioavailable IV, intranasal and even by nebulizer.  Here you want the dose to be 0.4mg to start for intranasal. Nebulizer is difficult to measure and probably safe to start with 2mg in the nebulizer container.

There is a difference when you know it is an opioid overdose and are reversing apnea versus a diagnostic administration to determine if it is opioid toxicity. In the latter instance you can rationalize the large dose - just be ready and be sure you are not in line of the possible projectile vomiting.

• While seizure patients are often treated with common antiepileptics such as phenytoin and levetiracetam, those with severe refractory disorders may be treated with less frequently used medications such as felbamate.
• Felbamate is reserved as monotherapy or adjunctive therapy for refractory, partial seizures in adults with or without secondary generalized seizure, and as adjunctive therapy for children with partial and generalized seizures due to Lennox-Gastaut Syndrome (condition that causes seizures and developmental delay).
• In patients who present to the ED on felbamate, consider checking a CBC with differential and liver function tests, as it can cause aplastic anemia (relatively rare but 30% fatal) and liver damage (rare but 40% fatal), respectively.
• Signs and symptoms of aplastic anemia include:  fever, sore throat, chills, other signs of infection, bleeding, easy bruising, extreme fatigue, weakness, or lack of energy.
• Signs and symptoms of liver failure include: nausea, extreme fatigue, unusual bleeding or bruising, lack of energy, anorexia, right upper quadrant pain, jaundice, or flu-like symptoms.

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