UMEM Educational Pearls

Category: Orthopedics

Title: Calcaneus Fractures

Keywords: calcaneus, fracture, compartment (PubMed Search)

Posted: 6/29/2008 by Michael Bond, MD (Updated: 10/16/2021)
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Calcaneus Fractures

Normally occur due to axial loading mechanism such as:

  •     Fall from height
  •     Motor Vehicle collisions
  •     Repetitive impacts on a hard surface such as seen with running or jumping.

Miscellanous Facts:

  1. 70% of calcaneal fractures are intra-articular
  2. 10-15% are associated with spinal compression fractures
  3. Estimated that 7-10% will have a fracture of the contralateral foot
  4. Monitor for compartment syndrome of the foot.  Deep central compartment is most commonly affected with calcaneus fractures

Pearls:

  1. Strongly consider getting Lumbar Spine Films and x-rays of the opposite foot in anybody that has a calcaneus fracture.
  2. Perform frequent reassessments, and do not hesitate to check compartment pressures if you suspect they might be elevated.

Category: Pediatrics

Title: The Whooping Cough

Keywords: Pertussis (PubMed Search)

Posted: 6/27/2008 by Don Van Wie, DO (Updated: 10/16/2021)
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Pertussis means "violent cough". 

Think of it with prolonged coughing, inspiratory whoop, absolute lymphocytosis, or chronic cough.

Don't Use cough suppressants.

Pertussis can be a life threatening Infection!!  Especially in infants and young children.

 

 

  • Factors that should prompt a consideration of admitting the patient are the following:
    • Age younger than 1 year
    • Pneumonia
    • Apneic or cyanotic spells or hypoxia
    • Moderate-to-severe dehydration
  •  

     

    Pertussis is a reportable infectious disease in the United States.


    Category: Toxicology

    Title: Dapsone-Induced Methemoglobinemia

    Keywords: dapsone, methemoglobinemia, methylene blue (PubMed Search)

    Posted: 6/27/2008 by Fermin Barrueto, MD (Updated: 10/16/2021)
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    •  Dapsone has been used to treat leprosy but more commonly to in brown recluse spider bites and to prevent PCP pneumonia and toxoplasmosis in our HIV population
    • It can cause methemoglobinemia: a reduced form of iron (ferrous to ferric) in the Hb molecule that decreases your oxygen carrying capacity. 
    • Due to its color, cyanosis is a predominant symptom out of proportion to symptoms.
    • Treatment: Methylene Blue 1-2 mg/kg IV
    • Pitfall: Dapsone's long half-life may cause reoccurrence of MetHb and require retreatment

     


    Category: Neurology

    Title: Types of Confusion in the Elderly

    Keywords: confusion, dementia, delirium, elderly (PubMed Search)

    Posted: 6/25/2008 by Aisha Liferidge, MD (Updated: 10/16/2021)
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    • Poor differentiation of the type and cause of confusion in the elderly is associated with poor outcomes (i.e. increased mortality/morbidity, prolonged hospital stays, and functional decline).
    • Confusion in the elderly can be categorized into three types with the following typical features:
    1. Delirium - caused by organic illness, acute onset, agitated or drowsy, variable short-term memory, disorganized thoughts, hallucinations.
    2. Dementia - chronic confusion due to long-term neurologic illness like Alzheimer's disease, progressive, irreversible, short-term memory loss, simple task performance and language impairment, aggression, personality changes.
    3. Acute or Chronic Confusion - treatable illness (i.e. infection) triggers delirium in patient with baseline dementia.

    Category: Cardiology

    Title: pericarditis and cancer

    Keywords: pericarditis, cancer, pericardial effusion, metastastic (PubMed Search)

    Posted: 6/22/2008 by Amal Mattu, MD (Updated: 10/16/2021)
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    Patients with cancer that present with pleuritic chest pain often have pulmonary emboli, but don't forget about pericarditis. Lung and breast cancer, especially, are known to metastasize to the pericardium and produce pericarditis or pericardial effusions. Anticoagulation for presumed PE in patients with pericardial mets. can produce hemorrhagic tamponade, a disastrous iatrogenic complication, so think twice before starting empiric anticoagulation on patients...make sure your patient doesn't have pericarditis or an pericardial effusion.

    The ECG in patients with cancer-related pericarditis or pericardial effusion does not always demonstrate the classic ST elevation wtih PR depression (which is most commonly seen in viral pericarditis). Patients with pericardial effusions often demonstrate low voltage and tachycardia. Electrical alternans, though "classic," only appears in 1/3 of patients with pericardial effusions.


    Category: Orthopedics

    Title: Hip Fractures

    Keywords: hip, fracture, mri, plain films (PubMed Search)

    Posted: 6/21/2008 by Michael Bond, MD (Updated: 10/16/2021)
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    Hip Fractures:

    Typically divided into four types:

    1. Intracapsular,
      1. femoral head and neck fractures
    2. Extracapsular
      1.  trochanteric,
      2. Intertrochanteric
      3. subtrochanteric fractures. 
    • Non-displaced fractures, especially in osteoporotic elderly patients, may be missed on plain films. This is estimated to occur in 2-9% of cases. 
    • It can take up to 72 hours for a fracture to be seen on bone scan. And it is estimated that only 80% of fractures will be seen at 24 hours.
    • MRI is now the preferred imaging modality (100% sensitivity and specificity) to confirm a hip fracture when plain films are negative and equivocal. A MRI will have positive findings in as little as 4 hours after a fracture.
    • Consider CT scan of the hip if MRI is not available at your center.

    Here is a link to a picture with a good representation of the different types of fractures.

    Show References


    Category: Toxicology

    Title: Antagonize Anticoagulation

    Keywords: coumadin, vitamin K, anticoagulation (PubMed Search)

    Posted: 6/19/2008 by Fermin Barrueto, MD (Updated: 10/16/2021)
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    Here is a short list of medications that will actually prevent a patient from being anticoagulated by coumadin. These medications will make it difficult for the patient to reach therapeutic levels and need to be warned about this drug-drug interaction with coumadin:

    • Antacids
    • Antihistamines
    • Barbituates
    • Carbamazepine
    • Cholestyramine
    • Corticosteroids
    • Griseofulvin
    • OCPs
    • Phenytoin
    • Rifampin
    • Vitamin K

    Reference: Goldfrank's Textbook of Toxicologic Emergencies, 6th Edition


    Category: Neurology

    Title: Scales to Assess Acute Risk of Stroke after TIA

    Keywords: Stroke, TIA, ABCD, ABCD2 (PubMed Search)

    Posted: 6/19/2008 by Aisha Liferidge, MD (Updated: 10/16/2021)
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    • The ABCD and ABCD2 scores are validated scales based on both prospective and retrospective data to assess patients' risk of stroke at 7 and 2 days after a TIA, respectively.  The biggest difference between the two is that the ABCD2 Scale includes diabetes as a factor.
    • ABCD Scale
    • Age:  at least 60 = 1 point
    • BP:  SBP > 140 and/or DBP > 90 = 1 point
    • Clinical features:  unilateral weakness = 2 points; speech disturbance w/o weakness = 1 point;  any other neurologic  finding = 0 points.
    • Duration:  at least 60 min. = 2 points; 10-59 min. = 1 point; < 10 min. = 0 points. 
    • Score:  4 points = 1.1% risk;  5 points = 12.1% risk;  6 points = 31.4% risk.
    • ABCD2 Scale
    • Age:  same as ABCD Scale
    • BP:  same as ABCD Scale
    • Clinical features:  same as ABCD Scale except "any other neurologic finding = 0 points" component is omitted.
    • Duration:  same as ABCD Scale except  "< 10 min. = 0 points" component is omitted.
    • Diabetes:  1 point
    • Score:  4-5 points = 4% risk;  6-7 points = 8% risk;  0-3 points = 1% risk.
    • Question = When considering sending a patient home prior to a thorough and appropriate TIA/stroke work-up, how low of a percent risk is acceptable?

    Show References


    Category: Critical Care

    Title: Passive Leg Raising

    Keywords: passive leg raising, fluid responsiveness (PubMed Search)

    Posted: 6/17/2008 by Mike Winters, MD (Updated: 10/16/2021)
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    Passive Leg Raising (PLR)

    • We have discussed that static measures of volume (CVP, PA wedge pressures) are not reliable markers of fluid responsiveness
    • PLR has recently gained interest as a simple and transient way to assess fluid responsiveness in the critically ill
    • Patients are placed in the horizontal position (not Trendelenburg) and the legs are raised to 45 degrees
    • A hemodynamic response should be seen in 30 - 90 seconds
    • Patients who have improvement in hemodynamics with PLR are said to be fluid responsive (i.e on the ascending portion of their Starling Curve) and require additional volume resuscitation

    Show References


    Category: Airway Management

    Title: Thrombolytic Therapy for Pulmonary Embolism

    Keywords: Thrombolytic, Pulmonary Embolism (PubMed Search)

    Posted: 6/16/2008 by Rob Rogers, MD (Updated: 10/16/2021)
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     Thrombolytic Therapy for PE

    Mike Abraham and I had a very interesting PE case a few nights ago:

    30's yo female presented with a two week history of slow onset, progressive DOE. Initially placed in the asthma room because she had a history of asthma. CXR negative. ECG inverted precordial T-waves and S1Q3T3. CT showed massive central, saddle embolus. Troponin 1.2. Normal BP and a pulse of 110. The patient actually laughed when informed of her diagnosis. She was admitted to the PCU.

    Now, let me share with you how big her clot burden was...it was huge. Biggest I have seen in years. Approximately 70% or so of her total pulmonary circulation was occluded! And, she was laughing. Her BP, though, was never low. The question came up: is this patient a candidate for thrombolytics? After all, she wasn't unstable.

    Our plan in the ED was to administer tPA based on her clot burden, but she was admitted quickly to the PCU in stable condition and they continued the workup and therapy. 

    Considerations for giving lytics to a PE patient:

    • It is within the scope of Emergency Medicine to give lytics without permission
    • If hypotensive-----give lytics
    • If there is evidence of RV dysfunction (which our patient had based on her Troponin)----give lytics
    • Other indications include severe hypoxemia (our patient's SpO2 was normal!!!), free-floating RV thrombus, and a patent foramen ovale
    • Despite the ability (in some centers) to consult Interventional Radiology for catheter-directed lytics, there really isn't data that shows benefit over peripherally infused thrombolytics: Give 100 mg tPA over 2 hours (Heparin is turned off for the drip. Currently only FDA approved regimen. Heparin is restarted without a bolus after the tPA infusion when the aPTT falls to < twice normal

    Show References


    Category: Cardiology

    Title: normal or non-specific ECG in acute MI

    Keywords: ECG, electrocardiogram, acute myocardial infarction (PubMed Search)

    Posted: 6/15/2008 by Amal Mattu, MD (Updated: 10/16/2021)
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    Just a reminder...an initially normal or non-specific ECG can certainly occur in patients that are actively having chest pain from acute MI. A 2001 study published in JAMA nicely pointed this out:

    7.9% of patients having an acute MI had an initial normal ECG.
    35.1% of patients having an acute MI had non-specific abnormalities on ECG.
    57% of patients having an acute MI had diagnostic changes on ECG.

    The greater the abnormality on the ECG, the worse the prognosis, but note that even when the ECG was normal, the in-hospital mortality in acute MI patients was 5.7%.

    Although serial ECGs won't detect 100% of acute MIs, the diagnostic yield does certainly increase, and so whenever a patient has a concerning presentation, especially in the presence of on-going pain, make sure to get repeat ECGs!

    [ref: Welch RD, et al, JAMA 2001]


    Category: Infectious Disease

    Title: Food Poisoning

    Keywords: Food Poisoning, Diarrhea (PubMed Search)

    Posted: 6/14/2008 by Michael Bond, MD (Updated: 10/16/2021)
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    Now that we have entered the session of cookouts, picnics, and family get togethers I thought I would review some of the more common causes of food poisoning and the typical foods that they are found in.

    Bacteria

    Foods Typically Found In

    Onset of Symptoms

    Staphylococcus aureus

    Meat and seafood salads, sandwich spreads and high salt foods.

    4-6 hours

    Salmonella

    Meat; poultry, fish and eggs and now tomatoes

    12 to 24 hours. Assoociated with fever

    Clostridium perfringens

    Meat and poultry dishes, sauces and gravies.

    12 to 24 hours.

    Vibrio parahaemolyticus

    Raw and cooked seafood.

    12 to 24 hours.  Associated with fever

    Bacillus cereus

    Starchy food. Typically Chinese Fried Rice in test questions

    12 to 24 hours.

    Campylobacter jejuni

    Meat, poulty, milk, and mushrooms.

     24 hours

     


    Category: Pediatrics

    Title: Pediatric Septic Shock

    Keywords: Pediatric Septic Shock (PubMed Search)

    Posted: 6/14/2008 by Don Van Wie, DO (Updated: 10/16/2021)
    Click here to contact Don Van Wie, DO

    Remember to save childrens lives be aggressive with septic shock treatment early!

    Do NOT allow long delays at IV attempts before moving to central lines or IOs.

            Goal in the first 0 to 15 minutes from presentation:

    • Recognize decreased perfusion and mental status, maintain airway, and obtain access.
    • Push 20 ml/kg of Isotonic bolus (up to and over 60 ml/kg) and reassess shock after each.*
    • Correct Hypoglycemia and hypocalcemia if present. 

    When community ED physicians successfully achieved shock reversal (defined by return of normal systolic blood pressure and capillary refill time) in the first 75 min from arrival there was an associated 96% survival and a > 9-fold increased odds of survival.  Each additional hour of persistent shock was associated with >2-fold increased odds of mortality.

    *To push this amount of fluid in an infant or young child it may be easier to use 60 ml syringes for boluses rather than pumps

    Show References


    Category: Toxicology

    Title: Toxicity of Patches

    Keywords: transdermal, fentanyl, clonidine (PubMed Search)

    Posted: 6/12/2008 by Fermin Barrueto, MD (Updated: 10/16/2021)
    Click here to contact Fermin Barrueto, MD

    Trandermal Delivery Systems

    • Uses a gradient (high concentration drug in patch) and a matrix to facilitate transdermal absorption
    • Patch often contains up to 100x the amount of drug that is on the label (ex: fentanyl 100mcg/hr actually = 10 MILLIGRAMS of fentanyl in patch)
    • When prescribing the following will increase absorption: sweating, heat, swallowing the patch, trying to eat the gel in the patch
    • Fentanyl and clonidine are the two most lethal patches on the market in regards to toxicity.
    • Rarely needed in the ED, shouldn't be prescribed except in rare instances

     

     


    Category: Neurology

    Title: Anti-epileptics for Post-stroke Seizure

    Keywords: aed, antiepileptic medication, post-stroke seizure, stroke, seizure (PubMed Search)

    Posted: 6/11/2008 by Aisha Liferidge, MD (Updated: 10/16/2021)
    Click here to contact Aisha Liferidge, MD

    • One large study showed that cerebrovascular diseases represented the most common etiology of secondary epilepsy.
    • Animal studies have shown most antiepileptic drugs to be neuroprotectants.
    • Animal studies have also shown, however, that phenytoin, benzodiazepines, and phenobarbital may impair post-stroke motor recovery.
    • Carbamazepine (Tegretol) has not been found to demonstrate any significant hinderance of  post-stroke recovery.
    • From an anicdotal clinical perspective, levetiracetam (Keppra) is often used to treat post-stroke seizure.

    Show References


    Category: Critical Care

    Title: sepsis, fluids, and ESRD

    Keywords: sepsis, intravenous fluids, chronic kidney disease, end stage renal disease (PubMed Search)

    Posted: 6/10/2008 by Amal Mattu, MD (Updated: 10/16/2021)
    Click here to contact Amal Mattu, MD

    Submitted on behalf of Dr. Winters:

    Sepsis, Fluids, and ESRD
    -ESRD patients are at increased risk of sepsis and bacteremia secondary to
    indwelling devices
    -Many of are hesitant to aggresively fluid resuscitate patients with ESRD
    -Several studies have concluded that volume resuscitation should proceed the
    same as patients without ESRD, even if that means more patients are eventually
    intubated.

    Reference:
    Otero RM, et al. Chest 2006;130:1579-95.
     


    Category: Vascular

    Title: AAA Presentation

    Keywords: AAA (PubMed Search)

    Posted: 6/9/2008 by Rob Rogers, MD (Updated: 10/16/2021)
    Click here to contact Rob Rogers, MD

    Clinical Presentation of AAA

    Everyone is familiar with the "classic," textbook, presentation of AAA:

    • Abdominal pain
    • Pulsatile mass
    • Hypotension

    This presentation, however, is not all that common. Many patients simply present with unexplained abdominal and/or flank pain.

    Consider the diagnosis in anyone with risk factors (i.e. older folks, family history, etc) who presents with abdominal and/or flank pain. In most cases, CT scanning of this group of patients is the way to go.

    And, one last pearl: put the US probe on early. May make a huge difference in time to diagnosis.

    Be afraid, be very afraid.

    Show References


    Category: Toxicology

    Title: Ketofol

    Keywords: sedation, propofol, ketamine (PubMed Search)

    Posted: 6/5/2008 by Ellen Lemkin, MD, PharmD (Emailed: 6/9/2008) (Updated: 10/16/2021)
    Click here to contact Ellen Lemkin, MD, PharmD

    "Ketofol" (Ketamine plus propofol)

    • Given for conscious sedation, for all age groups
    • Takes advantage of properties of both agents
    • Ketamine generally produces hypertension, does NOT produce respiratory depression, has an emergence phenomena, and has analgesic properties
    • Propofol causes hypotension and respiratory depression, has NO analgesic properties, and may blunt both nausea and emergence phenomena seen with ketamine
    • Given as a 1:1 ratio of ketamine and propofol, both 10 mg/ml
    • Dose is usually 1-3 ml aliquots; median dose in a recent study was 0.75 mg/kg
    • Median recovery 15 minutes (5-45 minutes; 80% recovered in less than 20 minutes)

    Show References


    Category: Cardiology

    Title: chronic kidney disease and ACS

    Keywords: renal failure, kidney disease, acute coronary syndrome, myocardial infarction (PubMed Search)

    Posted: 6/8/2008 by Amal Mattu, MD (Updated: 10/16/2021)
    Click here to contact Amal Mattu, MD

    Chronic kidney disease is a risk factor for accelerated atherogenesis. It is also a poor prognostic factor for patients with ACS or after MI. Elevated serum creatinine has been found to be an independent predictor of death after ACS and also a predictor of recurrent cardiovascular events. Cardiovascular death is 10-30 times higher in dialysis patients with ACS than in the general population.

    Show References


    Category: Neurology

    Title: Wernicke's Encephalopathy Treatment

    Keywords: Thiamine, Wernicke, Encephalopathy (PubMed Search)

    Posted: 6/4/2008 by Michael Bond, MD (Emailed: 6/7/2008) (Updated: 10/16/2021)
    Click here to contact Michael Bond, MD

    Treatment of Wernicke's Encephalopathy

    Traditionally the treatment dose of thiamine in those that we suspect to have Wernicke's Encephalopathy is 100mg per day.  The problem is that this does was arbiarily picked by two physicians, Victor and Adams, in the 1950's.  They thought that 100mg a day would be a large dose. They also made their recommendation without fully understanding the pharmacokinetics of thiamine which has a half life of 96 minutes or less.  Compound this with case reports of individuals dying of Wernike's Encephalopathy despite being given 100mg of Thiamine daily.

    Several authors are now advocating that patients with Wernicke's Encephalopathy be treated with 500mg of IV thiamine daily, but with the short half life some are advocating that the thiamine be given 2 to 3 times a day.  There are no good studies to refute or support the claims that higher doses are needed, but there are well documented cases of treatment failures at the lower dose.

    PEARLs: 

    • Consider high dose thiamine 500mg IV in patients that you are treating with Wernike's encephalopathy. 
    • The 100mg dose is still appropriate for those that are just being suppliemented and in who Wernicke's encephalopathy is a consideation but not high up on the differential.

    Show References