UMEM Educational Pearls

Category: Orthopedics

Title: Mallet Finger

Keywords: Mallet Finger, Extensor Tendon Injury (PubMed Search)

Posted: 10/5/2008 by Michael Bond, MD (Updated: 9/27/2021)
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Mallet Finger:

A common injury resulting in a tear or avulsion of the extensor digitorium tendon inserting into  the base of the distal phalanx.  Occurs due to hyperflexion of the finger usually as of a esult of it getting jammed on a ball while playing sports.  Most can be treated non-surgically.

The distal phalanx must be kept in full extension for 6 to 8 weeks. This is one of the few times that the finger should not be splinted in the position of function.

Make sure that patient is informed that if they remove the splint and flex their finger the 6 to 8 week healing window will be reset to day 0.  These patients should not be doing ROM exercises and must wear the splint full time.

Category: Pediatrics

Title: Popsicle Panniculitis

Keywords: popsicle panniculitis, cold panniculitis, child abuse (PubMed Search)

Posted: 10/3/2008 by Don Van Wie, DO (Updated: 9/27/2021)
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Popsicle or cold panniculitis is an inflammation of the subcutaneous fat after prolonged exposure to cold.  It is thought to occur more often in infants and young children because they have a higher percentage of saturated fatty acids than older children and adults.  Pediatric patients may present to you to be evaluated/ruled out for abuse by social workers, schools, or police and if you have the correct history it is easy to dispo quickly.

Clinical Features of Popsicle Panniculitis

  • Absence of systemic signs
  • Minimal pain, with or without
  • Skin is red to purplish, indurated, may have discrete nodules or plaques
  • perioral location for popsicles, but may occur at any other area of skin exposure
  • resolves in 2-3 weeks without scarring
  • hyperpigmentation may persist
  • arises within hours to to 1-2 days after exposure to a cold object

Show References

Category: Toxicology


Keywords: ICP, intracranial pressure, antihypertensive, nitroprusside, nitroglycerin, hydralazine (PubMed Search)

Posted: 10/2/2008 by Ellen Lemkin, MD, PharmD (Updated: 9/27/2021)
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Several antihypertensive agents raise intracranial pressure. Normal cerebral blood flow (CBF) is constant within normal cerebral perfusion pressure (CPP) ranges, recalling that CPP=MAP-ICP.

If CPP is outside the range in which autoregulation occurs, e.g. due to a structural lesion, ischemic stroke, or head trauma, CBF decreases and can adversely affect the patient.

  • Nitroprusside
    • Vasodilates both cerebral arteries and veins, increasing ICP
    • Inhibits the normal vasoconstrictive response to hypocapnia
  • Nitroglycerin
    • Causes cerebral venodilation, increasing ICP
    • Impairs vasodilatory response to hypercapnia
  • Hydralazine (varying effects)
    • Vasodilates cerebral arteries > cerebral veins
    • Impairs cerebral autoregulation
  • Nicardipine
    • Other calcium channel blockers increase ICP by vasodilating arteries
    • Has been used to treat vasospasm in SAH
    • Increases cerebral blood flow in patients with SAH and acute stroke

In patients with ischemic stroke or intracerebral pathology, labetalol or esmolol may be used to lower blood pressure without raising ICP. Nicardipine is recommended for use in patients with ischemic stroke or SAH but not in patients with brain injury

If the patient has NO structural abnormalities, but has hypertensive encephalopathy, nitroglycerin, nitroprusside, labetalol, esmolol, or nicardipine may be used.

Show References

Category: Neurology

Title: Encephalomalacia versus Edema on Brain CT

Keywords: encephalomalacia, brain CT, stroke, brain injury, cerebral edema (PubMed Search)

Posted: 10/1/2008 by Aisha Liferidge, MD (Updated: 9/27/2021)
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  • Encephalomalacia, also known as cerebromalacia, is a softening of brain tissue that results from ischemia or inflammation, most typically due to vascular insufficiency or degenerative changes.
  • On Brain CT, it appears as a darkened area and can be confused for cerebral edema due to acute ischemia (i.e stroke).
  • Unlike edema, encephalomalacia on CT is often accompanied by:

                    ---  well defined, circular vacuoles

                    ---  presence of good gray-white matter differentiation in surrounding areas

                    ---  a lack of significant effacement or lost of sulcus definition

                    ---  a history of prior stroke or head injury

Category: Critical Care

Title: Insulin use in the critically ill

Keywords: insulin, hyperglycemia, critically ill (PubMed Search)

Posted: 9/30/2008 by Mike Winters, MD (Updated: 9/27/2021)
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Subcutaneous Insulin in the Critically Ill

  • Although intensive insulin therapy in the critically ill remains controversial and a matter of much debate, hyperglycemia is common in the critically ill ED patient
  • Hyperglycemia is associated with worse outcomes in this patient population
  • When treating hyperglycemia in the critically ill ED patient, use caution with subcutaneous insulin
  • Absoprtion of insulin administered subcutaneously is slow, erratic, and highly variable often due to poor perfusion, hypotension, and/or vasopressor therapy
  • In these patients, IV insulin is a better route of administration and leads to more reliable control of hyperglycemia
  • Recall that the onset of action of insulin given IV is 10 - 30 minutes, with a duration of action of about 1 hour

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Category: Vascular

Title: Avoidable Pitfalls in Managing the Hypertensive Patient

Keywords: Hypertension (PubMed Search)

Posted: 9/29/2008 by Rob Rogers, MD (Updated: 9/27/2021)
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Avoidable Pitfalls in Managing the Hypertensive Patient

We all see very hypertensive patients on almost every shift. Dr. Winters has an earlier pearl related to pitfalls in treating patients with hypertensive encephalopathy, but I thought it was time to reiterate just a few points.

  • No evidence to date has ever shown a benefit to acutely lowering someone's BP in the ED prior to discharge
  • Probably the best thing you can do for the patient with out of control BP is to arrange (and make sure they have) followup for the next day or two after discharge
  • In patients with severe HTN (eg. admitted patients with pressure to high to go to their inpatient bed), avoid agents like IV Hydralazine. This agent is pretty reliable in being completely unpredictable when it comes to BP response. Some will really bottom out their BPs.
  • Avoid Clonidine unless the patient is on it and stopped taking it recently (rebound HTN). May worsen someone's already crappy mental status.
  • If a patient is being admitted, say to a unit or step down unit, don't bother titrating oral agents for people with pressures > 240/130 mm Hg or so. Consider a drip-oral agents may "stack" and take effect, thus lowering someones BP way lower than you wanted.
  • Don't treat the number, treat the patient.

Category: Cardiology

Title: Normal ECGs and AMI

Keywords: EKG, ECG, electrocardiography, acute myocardial infarction, prognosis (PubMed Search)

Posted: 9/29/2008 by Amal Mattu, MD (Updated: 9/27/2021)
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 A normal ECG should not be a huge source of relief when evaluating patients with possible or confirmed myocardial infarction. 8% of acute myocardial infarctions have a completely normal ECG at the time of presentation, and these patients have a 5.7% in-hospital mortality. Serial electrocardiography can certainly improve the yield of electrocardiography but does not rule out AMI with 100% accuracy.

Like most tests in medicine, the ECG is very useful at ruling in disease, but it is limited at ruling out disease.

[The Prognostic Value of a Normal or Non-specific Initial ECG in AMI. JAMA 2001.]

Category: Procedures

Title: Paracentesis Part II- Ascites Fluid Analysis

Keywords: paracentesis, ascites, analysis (PubMed Search)

Posted: 9/27/2008 by Michael Bond, MD (Updated: 9/27/2021)
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Paracentesis Part II- Ascites Fluid Analysis:

See last weeks procedure pearl for some hints on doing a paracentesis..

Now that you have the fluid what should you send it for:

  • Cell Count
  • Gram Stain and Culture
  • Amylase (normal value is half serum)
  • Albumin
  • Consider cytology if  cancer is a consideration

Now for the analysis:

  • WBC Count >250 PMNs generally accepted as consistent with infection.  Especially if there is more than 70% PMNs which is the upper limit of normal. SAAG (Serum - Ascites Albumin Gradient) an easy calculation to differentiate what the cause of the ascites might be from:
    • Subtract the patient's ascites albumin from the serum albumin (Serum Albumin - Ascites Albumin = SAAG)
    • SAAG > 1.1 mg/dL(Due to items that increase portal pressures)
      • Cirrhosis
      • Alcoholic Hepatitis
      • Cardiac Ascites
      • Hepatic Failure
      • Budd-Chiari Syndrome
      • Portal Vein Thrombosis
      • Myexdema
      • Others
    • SAAG < 1.1 mg/dl (due to intraabdominal forces causing increased oncotic pressure)
      • Tuberculosis Peritonitis
      • Pancreatitic Ascites (typically while have elevated amylase in ascitic fluid)
      • Bowel Obstruction
      • Nephrotic Syndrome
      • Biliary Ascites
      • others

** Corrected definition of SAAG as it was initially reversed.  Thanks to Dr. McCurdy on his proof reading.

Category: Toxicology

Title: China does it to their own children

Keywords: melamine, infant, milk (PubMed Search)

Posted: 9/25/2008 by Fermin Barrueto, MD (Updated: 9/27/2021)
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  • In case you thought the chinese only sent their toxin filled products to the USA, a massive scandal has been occurring with their milk.
  • Adding melamine to their milk, companies were able to get falsely elevated readings of protein which is measured by the government to make sure the milk was not watered down.
  • 53,000 illnesses, over 12,000 hospitilizations and at least 4 infant deaths have been attributed to their milk supply - 20% of China's milk supply is thought to be contaminated
  • Melamine or melamine resin is used to make plastics and involved in other polymeric reactions.
  • Toxicity involves the creation of kidney stones - imagine the pain in these poor children
  • These children died from renal failure from multiple kidney stones.
  • Check the link below to the news article

Show References

Category: Neurology

Title: Diffuse Axonal Injury (DAI)

Keywords: diffuse axonal injury, DAI, coma, head injury, traumatic brain injury, TBI (PubMed Search)

Posted: 9/25/2008 by Aisha Liferidge, MD (Updated: 9/27/2021)
Click here to contact Aisha Liferidge, MD

  • Acceleration, deceleration, and rotational forces cause diffuse axonal injury (DAI).
  • It is characterized by widespread shearing and retraction of axons during traumatic brain injury (TBI).
  • DAI often results in coma and is associated with poor prognosis.
  • In addition to cortical white matter injury, it often also involves the corpus callosum, basal ganglia, brainstem, and cerebellum.

Category: Critical Care

Title: Acute Intestinal Distress Syndrome

Keywords: AIDS, intraabdominal hypertension, abdominal compartment syndrome (PubMed Search)

Posted: 9/23/2008 by Mike Winters, MD (Updated: 9/27/2021)
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AIDS: coming to a critically ill patient in your ED

  • Acute intestinal distress syndrome (AIDS) is a recently coined term used in the continuum of intraabdominal hypertension (IAH) to abdominal compartment syndrome (ACS)
  • In previous pearls we have discussed the importance of IAH in the critically ill and how to measure intraabdominal pressure (IAP)
  • Recall that IAH is defined as a sustained elevation of IAP > 12 mmHg
  • The focus of attention is shifting to "secondary ACS" - it is highly prevalent in the critically ill and is independently associated with increased mortality
  • Sepsis is a cause of secondary ACS and is the most likely condition we will encounter in our critically ill patient population
  • Current recommendations suggest that IAP be measured daily in patients at risk for IAH (i.e. the septic ED patient)

Show References

Category: Vascular

Title: What is the sensitivity of a CXR for aortic dissection?

Keywords: aortic dissection, chest xray (PubMed Search)

Posted: 9/23/2008 by Rob Rogers, MD (Updated: 9/27/2021)
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So, how good is a screening CXR for aortic dissection?

  • Classic CXR finding is a wide mediastinum
  • Pooled literature shows that the overall sensitivity of a CXR is about 67-70% for aortic dissection (even if upright, or PA and Lateral)
  • Most authorities agree that a screening CXR alone is not sufficient to r/o aortic dissection

Show References

Category: Cardiology

Title: dysrhythmias and syncope

Keywords: syncope, arrhythmia, dysrhythmia (PubMed Search)

Posted: 9/22/2008 by Amal Mattu, MD (Updated: 9/27/2021)
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17-18% of cases of syncope are attributable to dysrhythmias.
The best predictors of dysrhythmias in these patients are:
1. abnormal ECG (odds ratio 8.1)
2. history of CHF (odds ratio  5.3)
3. age > 65 (odds ratio 5.4)

[reference: Sarasin FP, et al. A risk score to predict arrhythmias in patients with unexplained syncope. Acad Emerg Med 2003.]

Category: Procedures

Title: Paracentesis

Keywords: Paracentesis (PubMed Search)

Posted: 9/21/2008 by Michael Bond, MD (Updated: 9/27/2021)
Click here to contact Michael Bond, MD


Since we have covered so many other procedures I though I would include paracentesis for completion.

A diagnostic paracentesis (typically 30-60 ml)  is indicated to:

  • Determine etiology of new ascites (transudate vs exudate, cancer, infection)
  • Rule out spontaneous bacterial peritionitis...(suspect this in any patient with a history of ascites that has fever, mental status changes, or diffuse abdominal pain)

A therapeutic paracentesis (large volume >1L) is indicated in the emergency department for:

  • Respiratory distress from abdominal distension
  • Abdominal compartment syndrome.  See Dr. Winters Pearl

Remember large volume paracentesis can result in profound fluid shifts and subsequent hypotension.

Absolute Contraindications to paracentesis include:  Acute abdomen requiring surgery

Relative contraindications are:

  • Platelets <20,000
  • INR > 2
  • Pregnancy
  • h/o adhesions
  • abdominal wall cellulitis (just don't stick the needle through the cellulitis)
  • Distended bowel or bladder

To view a video on how to do a paracentesis please visit the New England Journal of Medicine

Next I will address how to interpret the paracentesis fluid results.

Category: Pediatrics

Title: Oxycodone v. Codeine for Fracture Pain in Children

Keywords: oxycodone pediatrics, codeine pediatrics, fracture pain management (PubMed Search)

Posted: 9/19/2008 by Don Van Wie, DO (Updated: 9/27/2021)
Click here to contact Don Van Wie, DO

Oxycodone v. Codeine for Fracture Pain Management in Children

  • When choosing an oral narcotic to give a child for fracture analgesia oxycodone is a better choice than codeine. 
  • In this study children were randomized to recieve equianalgesic oral doses of either oxycodone (0.2 mg/kg, max 15 mg) or codeine (2mg/kg, max 120 mg) for forearm fractures
  • Children given oxycodone reported a pain score significantly lower than children given codeine
  • And children given oxycodone had less itching than those given codeine

Show References

Category: Toxicology

Title: Cheese Heroin

Keywords: diphenhydramine, heroinI (PubMed Search)

Posted: 9/18/2008 by Fermin Barrueto, MD (Updated: 9/27/2021)
Click here to contact Fermin Barrueto, MD

 Cheese Heroin: a slang term for the combination of heroin with an over-the-counter antihistamine

  • The two are combined and forms a cheesy like powder that is different from pure heroin
  • A string of deaths were reported between 2005-2007 in Texas, many adolscents
  • This concoction is more often insufflated than smoked or injected
  • Combines opioid effect with the anticholinergic confusion and hallucinations
  • Scorpion was a heroin that was combined with scopolamine that had similiar effect


  • Find the anticholinergic toxidrome, place the foley and supportive care are mainstays
  • Consider administration of physostigmine 1mg IV slowly over 2-5 minutes (call toxicologist)
  • The anticholinergic effects will linger much longer than the heroin effects ( <1hr)



Category: Neurology

Title: Coagulopathic Contraindications for tPA use in Stroke

Keywords: coagulopathic, tPA, stroke, coagulopathy (PubMed Search)

Posted: 9/18/2008 by Aisha Liferidge, MD (Updated: 9/27/2021)
Click here to contact Aisha Liferidge, MD

tPA should NOT be used to treat ischemic stroke in the following instances:

  • Platelet count < 100,000
  • INR > 1.7 or PT > 15
  • Heparin administration within past 48 hours with subsequent PTT above upper limits of normal

Category: Infectious Disease

Title: HCAP ?

Keywords: health care associated pneumonia, antibiotics, (PubMed Search)

Posted: 9/16/2008 by Mike Winters, MD (Updated: 9/27/2021)
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Health care-associated pneumonia

  • Health care-associated pneumonia (HCAP) is a distinct entity
  • HCAP includes any patient with pneumonia and 1 or more of the following:
    • hospitalization for 2 or more days in an acute care facility within the preceeding 90 days
    • nursing home patients
    • patients of long-term care facilities
    • patients who attend a hospital or hemodialysis clinic
    • patients who received IV antibiotics, chemotherapy, or wound care within 30 days of infection
  • Data indicate that the mortality for HCAP is higher than CAP
  • The most common organisms in HCAP include S.aureus, P.aeruginosa, Klebsiella species, Haemophilus species, and Escherichia species
  • An initial recommended antibiotic regimen includes a combination of an antipseudomonal cephalosporin plus a fluoroquinolone plus an agent active against MRSA

Show References

Category: Vascular

Title: Cardiovascular Complications of Cocaine

Keywords: Cardiovascular, CocaineC (PubMed Search)

Posted: 9/15/2008 by Rob Rogers, MD (Updated: 9/27/2021)
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Key Cardiovascular complications of cocaine:

  • Myocardial ischemia and infarction
  • Myocarditis and cardiomyopathy
  • Aortic dissection
  • Vessel thrombosis
  • Stroke (usually hemorrhagic) 
  • Visceral ischemia


  • Cocaine and abdominal pain=mesenteric ischemia, hemoperitoneum (described)
  • Cocaine and chest pain=MI, aortic dissection
  • Cocaine and extremity pain=arterial thrombosis, aortic dissection
  • ~ 6% of cocaine chest pain patients rule in for MI

Show References

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: 9/27/2021)
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.


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