UMEM Educational Pearls

Category: Cardiology

Title: ACS and cardiac risk factors

Keywords: acute coronary syndromes, cardiac risk factors (PubMed Search)

Posted: 8/19/2007 by Amal Mattu, MD (Updated: 6/25/2019)
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The presence of "classic" cardiac risk factors (i.e. risk factors identified in the Framingham studies) is most useful for predicting the long-term risk of developing CAD, but they have limited utility at ruling out acute coronary syndrome. A recent study (ref below) from the CRUSADE registry (multicenter registry including tens of thousands of patients with ACS), for example, demonstrated that 10.5% of patients with proven non-STE MI had NONE of the traditional cardiac risk factors. NEVER rule out ACS just because a patient has few or no cardiac risk factors. The decision to admit and risk stratify patients should always be based on your HPI (OLDCAAR). [Roe MT, Halabi AR, Mehta RH, et al. Documented traditional cardiovascular risk factors and mortality in non-ST-segment elevation myocardial infarction. Am Heart J 2007;153:507-514.]

Category: Gastrointestional

Title: Medical Management of Upper GI Bleeds

Keywords: Peptic Ulcer Disease, Omeprazole, Bleeding (PubMed Search)

Posted: 8/19/2007 by Michael Bond, MD (Updated: 6/25/2019)
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Medical Management of Upper GI bleeds. Peptic Ulcer Disease: Proton pump inhibitors are the main stay of therapy. Use is based on the observation that pH over 6 is required for platelet aggregation whereas pH below 5 results in clot lysis. High dose IV therapy should be reserved with those that have high risk stigmata of rebleeding as seen on endoscopy. Regular dose IV or PO omeprazole can be used in most patients. Variceal Bleeding: Consider octreatide (50 mcg bolus followed by 50 mcg/hr IV) and non-selective beta blocker therapy to reduce bleeding. Human recombinant activated factor VII has gotten a lot of press lately though it did not reduce the risk of death at either 5 or 42 days in patients with liver related GI bleeds.A Wong T. The management of upper gastrointestinal haemorrhage. [Review] [31 refs] [Journal Article. Review] Clinical Medicine. 6(5):460-4, 2006 Sep-Oct. Marti-Carvajal AJ. Salanti G. Marti-Carvajal PI. Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases. [Review] [45 refs] [Journal Article. Review] Cochrane Database of Systematic Reviews. (1):CD004887, 2007. Martins NB. Wassef W. Upper gastrointestinal bleeding. [Review] [87 refs] [Journal Article. Review] Current Opinion in Gastroenterology. 22(6):612-9, 2006 Nov.

Category: Pediatrics

Title: Neonatal Hypoglycemia

Keywords: Hypoglycemia, Neonate, Glucagon, Dextrose (PubMed Search)

Posted: 8/18/2007 by Sean Fox, MD (Updated: 6/25/2019)
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Pediatric Hypoglycemia Hypoglycemia = <45mg/dL in symptomatic neonate; = <35mg/dL in asymptomatic Symptoms = jitteriness, tachycardia, apnea, cyanosis, tachypnea, hypotonia, temperature instability, lethargy, irritability, or abnormal cry. (almost anything!) - So check the Sugar EARLY Fasting (often from gastroenteritis and dehydration) - the most common etiology of ketotic hypoglycemia in nondiabetic kids Glucagon has diagnostic and therapeutic role If it improves hypoglycemia, then glycogen stores are sufficient. Remember to draw extra tubes for future endocrine work-up PRIOR to giving dextrose! Rule of 50 For neonates: 5ml/kg of D10; For children: 2ml/kg of D25. - 5x10=50, 2x25=50 Claudius, I., C. Fluharty, and R. Boles, The emergency department approach to newborn and childhood metabolic crisis. Emerg Med Clin North Am, 2005. 23(3): p. 843-83.

Category: Toxicology

Title: Local Anesthetics

Keywords: lidocaine, allergic reaction, toxicity (PubMed Search)

Posted: 8/16/2007 by Fermin Barrueto, MD (Updated: 6/25/2019)
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- Allergic reactions are extremely rare to local anesthetics but may occur with the "Amides". - If they occur, it is more likely due to a preservative found in some multi-dose vials: methylparaben. - Either switch to a single dose vial without preservative or change to an "Ester" where there is no cross-reactivity Amides: Bupivacaine, Etidocaine, Lidocaine, Mepivacaine, Prilocaine, Ropivacaine Esters: Chloroprocaine, cocaine, procaine, tetracaine

Category: Neurology

Title: Coagulation Disorders Causing Ischemic Stroke

Keywords: coagulopathy, stroke (PubMed Search)

Posted: 8/15/2007 by Aisha Liferidge, MD (Updated: 6/25/2019)
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-polycythemia rubra vera -sickle cell disease -essential thrombocytosis - TTP - Heparin-induced thrombocytopenia -Antithrombin III deficiency - Protein C or S deficiency - Factors V, VII, XII, or XIII deficiency -heparin cofactor II deficiency - dysfibrinogenemias -antiphospholipid/anticardiolipin antibodies -nephrotic syndrome -malignancy -pregnancy -oral contraceptives -dehydration

Category: Critical Care

Title: Acalculous cholecystitis

Keywords: acalculous cholecystitis, HIDA, cholecystectomy (PubMed Search)

Posted: 8/14/2007 by Mike Winters, MD (Updated: 6/25/2019)
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-Think about acalculous cholecystitis in the critically ill patient with fever, abdominal pain, and elevation of LFTs and bilirubin -Pathophys thought to be due to SIRS, biliary stasis, and ischemia -Abdominal pain is not always in the right upper quadrant -Patients have a high rate of complications - gangrene or perforation (40% to 60%) -Diagnostic studies: ultrasound (sens. 70%), HIDA (sens. 80% to 90%), CT (sens. 90%) -Consult surgery early because treatment of choice is surgical cholecystectomy; some can be treated with percutaneous cholecystostomy but this is up to your consultant

Category: Vascular

Title: mesenteric ischemia

Keywords: mesenteric ischemia, elderly, geriatric, abdominal pain (PubMed Search)

Posted: 8/12/2007 by Amal Mattu, MD (Updated: 6/25/2019)
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Suspect acute mesenteric ischemia in any older patient with risk factors (atrial fibrillation) who presents with ACUTE onset abdominal pain with a paucity of physical findings. And, don't be fooled by "gut emptying" symptoms of vomiting and diarrhea. If you think grandma has acute onset gastroenteritis, think again. The only way to pick up this diagnosis more is to think about it more often. (sent on behalf of Dr. Rob Rogers)

Category: Cardiology

Title: amiodarone agony

Keywords: amiodarone, adverse effects, arrhythmias (PubMed Search)

Posted: 8/12/2007 by Amal Mattu, MD (Updated: 6/25/2019)
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Times when amiodarone should be avoided in wide complex tachycardias: 1. prolonged QT or torsade de pointes -- amiodarone prolongs QT and may induce torsade or cause torsade to become intractable 2. pregnancy -- amio is the only class D antiarrhythmic...use anything else, even electricity! 3. rapid Afib with WPW -- the only published literature says this causes hemodynamic deterioration 4. AIVR -- turns it into asystole...a clean kill! 5. pseudo-VTach caused by hyperK, TCAs, and similar meds -- these are actually not VT but just wide complex tachycardias (that look like VT) caused by poisoned sodium channels...amiodarone further blocks the sodium channels and can cause asystole 6. pulseless VT or VFib cardiac arrest -- you won't actually make the patient worse, but the ONLY evidence indicates that all amio does is increase survival to ICU without improved mental status and without increasing survival to discharge...so essentially you take up more ICU beds and increase costs

Category: Med-Legal

Title: ED Chart Documentation (Part 2)

Keywords: Documentation, Charting, Legal (PubMed Search)

Posted: 8/11/2007 by Michael Bond, MD (Updated: 6/25/2019)
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ED Chart Documentation (Part 2) ==> If writing an addendum after-the-fact, identify the note by date and time. ( late entry ). Otherwise, NEVER alter the chart after-the-fact. ==> Always address the patient s documented complaints. ==> Don t write incident report filed. ==> Be specific about times for follow-up. (eg:2 days, 1 week, next available) ==> Provide a warning about sedatives (eg: Don t drive ). ==> Whenever possible, document past tolerance of toxic drugs when prescribed (eg: NSAIDs). ==> Document a warning not to drive when treating patients for a seizure, or when refilling anti-epileptic drugs. Courtesy of Larry Weiss, MD, Jd Disclaimer:This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Category: Pediatrics

Title: Pseudosubluxation

Keywords: Pseudosubluxation, swischuk Line, Hangman's Fracture, Cervical Injury (PubMed Search)

Posted: 8/10/2007 by Sean Fox, MD (Updated: 6/25/2019)
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Pseudosubluxation Refers to the normal mobility of the cervical vertebrae, IN FLEXION, which may appear pathologic Distinguishing between Pseudosubluxation and Pathologic - The displacement should only occur in flexion (Not extension) (1) most pediatric c-spine films are in flexion due to the relatively larger occiput - Swischuk Line (1) Line that is drawn from anterior aspects of C1 to C3 spinous processes (2) This line should be within 2 mm of the anterior aspect of the C2 spinous process - Spinal-Laminar Line (1) The line drawn connecting the lamina of C1, C2, and C3 should remain intact even in flexion If you suspect that the misalignment represents pseudosubluxation, than you can reposition in extension; if it resolves, it is consistent with pseudosubluxation. But be careful, if mechanism warrants it, obtain CT to r/o hangman s fracture instead. Anterior displacement of C2 in children: physiologic or pathologic. LE Swischuk. Radiology. Vol 122(3) 1977. p 759-763.

Attachments

Swischuck Line.ppt (518 Kb)


Category: Toxicology

Title: Toxic Findings on CxR

Keywords: Chest radiograph, poisoning, amiodarone (PubMed Search)

Posted: 8/9/2007 by Fermin Barrueto, MD (Updated: 6/25/2019)
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Here are some chest x-ray findings and cool toxins that can cause them (not an all-inclusive list): Diffuse airspace filling: salicylates, opioids, paraquat, phospgene, doxorubicin - Disease Process: Acute Lung Injury Focal airspace filling: hydrocarbons - Disease Process: Aspiration pneumonitis Pleural Effusion: Procainamide, hydralazine, INH, methyldopa - Disease Process: Drug-induced SLE Pneumothorax/Pneumomediastinum: "crack" cocaine and marijuana, IVDA into subclavian vein - Disease Process: Barotrauma Lymphadenopathy: Phenytoin, methotrexate - Disease Process: Pseudolymphoma Interstitial Patterns: Amiodarone - Disease Process: Phospholipidosis [Adapated from Goldfrank's Textbook of Toxicologic Emergencies, 8th Edition, Table 6-3, p. 74]

Category: Neurology

Title: TIA

Keywords: TIA, stroke (PubMed Search)

Posted: 8/8/2007 by Aisha Liferidge, MD (Updated: 6/25/2019)
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While TIA has historically been defined as lasting less than 24 hours, recent data clearly demonstrates that ischemic attack lasting longer than one hour is often associated with actual brain infarction. Most TIA's last less than 5 minutes. Evidence of acute infarction can be identified by MRI in up to 50% of patients who meet the 24 hour criteria for TIA. Diffusion MRI in patients with transient ischemic attacks. Kidwell CS; Alger JR; Di Salle F; Starkman S; Villablanca P; Bentson J; Saver JL. Stroke 1999, Jun;30(6):1174-80. Transient ischemic attack--proposal for a new definition. Albers GW; Caplan LR; Easton JD; Fayad PB; Mohr JP; Saver JL; Sherman DG. New England Journal of Medicine 2002, Nov 21;347(21):1713-6.

Category: Critical Care

Title: Post-intubation hypotension

Keywords: hypotension, pneumothorax, dynamic hyperinflation (PubMed Search)

Posted: 8/7/2007 by Mike Winters, MD (Updated: 6/25/2019)
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-Post-intubation hypotension can occur in a substantial proportion of patients -Before attributing this to the effects of your sedative medications, you must think about pnemothorax, hyperinflation from overzealous bag-valve mask ventilation, and hypovolemia -Pneumothorax - auscultate the lungs and repeat the CXR -Hyperinflation - disconnect the patient from the ventilator and allow them to "deflate" -Hypovolemia - give a fluid bolus

Category: Vascular

Title: Aortic Occlusion Masquerading as Cauda Equina Syndrome

Keywords: Aortic, Cauda Equina Syndrome (PubMed Search)

Posted: 8/6/2007 by Rob Rogers, MD (Updated: 6/25/2019)
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Beware older patients who present with lower extremity weakness and evidence of cauda equina syndrome. Patients with aortic occlusive syndromes (thrombosis) can look exactly like a spinal cord patient. Pearl: Always perform a good pulse check and examination of the skin (looking for skin mottling, i.e. livedo) in older patients who for all practicle purposes look like cord compression. The two conditions can lool a lot alike. And missing aortic occlusion may be fatal.

Category: Cardiology

Title: heparins in ACS

Keywords: enoxaparin, heparin, bleeding, complications (PubMed Search)

Posted: 8/5/2007 by Amal Mattu, MD (Updated: 6/25/2019)
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The risk of bleeding complications related to enoxaparin increases in patients with renal insufficiency. In fact, many recommend that unfractionated heparin be used instead of low molecular weight heparin in these patients because there is more safety data regarding unfractionated heparin. If enoxaparin is used, the dose should be cut in half (or given only once per day instead of every 12 hours) when the GFR is < 30 mL/min (GFR can be easily calculated by google-able GFR calculators on the internet).

Category: Med-Legal

Title: ED Documentation

Keywords: Documentation, Legal, Chart (PubMed Search)

Posted: 8/4/2007 by Michael Bond, MD (Updated: 6/25/2019)
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ED Chart Documentation ==> Provide documentation that you ruled out the worst possible outcome. ==> Read and acknowledge the nurse s notes especially if a conflict exists. ==> Always address abnormal vital signs. ==> Provide times for all notes. ==> Don t use demeaning terminology to describe patients. ==> Write interval progress notes when a patient s condition changes. ==> Document lab, EKG, and x-ray abnormalities. Disclaimer:This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Category: Procedures

Title: Lumbar Puncture

Keywords: Meningitis, Lumbar Puncture, (PubMed Search)

Posted: 7/28/2007 by Michael Bond, MD (Emailed: 8/3/2007) (Updated: 6/25/2019)
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Lumbar Puncture Pearls On obese patients, it can be easier to obtain a lumbar puncture with the patient in the sitted position. If you require an opening pressure (eg, pseudotumor cerebri), replace the stylet and have an assistant help the patient into the left lateral recumbent position

If the CSF flow is too slow, ask the patient to cough or bear down as in the Valsalva maneuver, or intermittently press on the patient s abdomen to increase the flow. The needle can also be rotated 90 degrees such that the bevel faces cephalad.

In children, a recent study has shown that performing an LP can be more successful by using adequate analgesia and advancing the needle through the dura without the stylet.

In adults with suspected meningitis, a CT scan of the head does NOT need to be done prior to the lumbar puncture unless the patient has one of the following
  • Immunocompromised state: HIV infection or AIDS, receiving immunosuppressive therapy, or after transplantation
  • History of CNS disease: Mass lesion, stroke, or focal infection
  • New onset seizure: Within 1 week of presentation;
  • Papilledema: Presence of venous pulsations suggests absence of increased intracranial pressure
  • Abnormal level of consciousness...
  • Focal neurologic deficit


Nigrovic LE et al. Risk factors for traumatic or unsuccessful lumbar punctures in children. Ann Emerg Med 2007 Jun; 49:762-71.

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267 84.

Category: Pediatrics

Title: Painless Neck Masses

Keywords: Neck Mass, thyroglossal duct cyst, Second Brachial Cleft Cyst, ectopic Thyroid tissue (PubMed Search)

Posted: 8/3/2007 by Sean Fox, MD (Updated: 6/25/2019)
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Painless Neck Masses Thyroglossal Duct Cyst = most common congenital midline mass ==> Concern that it may be ectopic thyroid tissue ==> Painless ==> Elevates with the tongue during swallowing (It is attached to the base of the tongue) ==> Requires ultrasound. Thyroid Scan if thyroid is abnormal. ==> Tx; Sistrunk procedure excsion of cyst and and mid-portion of the hyoid bone (not removing the portion of the hyoid leads to high rate of recurrence). Second Branchial Cleft Cyst = Most common branchial anomaly (90%) ==> Painless fluctuant mass in the anterior triangle ==> Arise due to failure of the embryonic branchial cleft to obliterate. ==> Ultrasound or CT may be useful to define mass and for pre-operative evaluation. Both are mostly asymptomatic, but may cause symptoms due to compression of local structures. Both may become infected secondarily, at which time they will no longer be painless. Treat with Abx if infected. Surgical excision should be delayed until active infection is resolved.

Category: Toxicology

Title: Opioids with Unique Toxicity

Keywords: opioids, adverse drug effect, methadone (PubMed Search)

Posted: 8/2/2007 by Fermin Barrueto, MD (Updated: 6/25/2019)
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Opioids Opioids in general cause respiratory depression, miotic pupils and some mild hypotensions and bradycardia when the patient is comatose. All opioids can cause varying degrees of histamine release. However, not all opioids are similiar, here are the unique toxicities of some various opioids - keep them in mind when you prescribe them: 1) Propoxyphene - seizures and TCA like effects, also not very effect analgesic 2) Meperidine - seizures, serotonergic (thus increased abuse potential) 3) Methadone - long half-life (30+hrs) and QT prolongation 4) Hydromorphone - rare seizures and most common opioid that causes iatrogenic overdose because of its potency. (Easy to write 2 mg of "Dilaudid" but that is equivalent to 14 mg of morphine!) 5) Tramadol - seizure (common) and serotonergic, this is only 20% opioid 6) Fentanyl - rigid chest syndrome with rapid IV administration causes intercostal muscle contraction - not good

Category: Neurology

Title: Stroke Mimics

Keywords: stroke, stroke mimics, complex migraine (PubMed Search)

Posted: 8/1/2007 by Aisha Liferidge, MD (Updated: 6/25/2019)
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One study found that the top 4 stroke mimics confused for a true stroke are: 1) Unrecognized seizure with post-ictal phase 2) Systemic infections 3) Brain tumor 4) Metabolic disturbances Complex migraine, specifically hemiplegic migraine, is also a common stroke mimic. This diagnosis is especially difficult to make on initial presentation and should be a diagnosis of exclusion. The hemiparesis associated with the migraine can actually outlast the actual headache. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Archives of Neurology. 1995;52:1119-1122.