UMEM Educational Pearls

Category: Cardiology

Title: heparins in ACS

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

Posted: 8/5/2007 by Amal Mattu, MD (Updated: 8/25/2019)
Click here to contact Amal Mattu, MD

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: 8/25/2019)
Click here to contact Michael Bond, MD

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: 8/25/2019)
Click here to contact Michael Bond, MD

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: 8/25/2019)
Click here to contact Sean Fox, MD

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: 8/25/2019)
Click here to contact Fermin Barrueto, MD

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: 8/25/2019)
Click here to contact Aisha Liferidge, MD

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.

Category: Critical Care

Title: Mechanical Ventilation "Knobology" - tidal volume

Keywords: mechanical ventilation, tidal volume, ideal body weight (PubMed Search)

Posted: 7/31/2007 by Mike Winters, MD (Updated: 8/25/2019)
Click here to contact Mike Winters, MD

-When setting the ventilator, many of us use an initial tidal volume of 6 ml/kg -This number comes from ARDSnet data that demonstrated improved mortality with low tidal volumes in patients with ARDS/ALI -It is important to note that your calculation of 6 ml/kg is based upon IDEAL BODY WEIGHT (not total body weight) -For males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. -For females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.

Category: Vascular

Title: Serum Markers of Right Ventricular Dysfunction in PE

Keywords: PE, Right Ventricular Dysfunction (PubMed Search)

Posted: 7/30/2007 by Rob Rogers, MD (Updated: 8/25/2019)
Click here to contact Rob Rogers, MD

Elevation of Troponin I and BNP have been shown to be reliable serum markers of right ventricular dysfuncion in pulmonary embolism. Two pearls: 1. Don't forget PE in patients with chest pain and or dyspnea who have elevated troponins. 2. Elevation of serum BNP and Troponin in PE has been linked to worse outcomes. Get that ECHO early and consider lytics for PE patients who have elevated biomarkers.

Category: Neurology

Title: Migraine Headaches

Posted: 7/29/2007 by Michael Bond, MD (Emailed: 7/30/2007) (Updated: 8/25/2019)
Click here to contact Michael Bond, MD

*Hormone-related migraine headaches are largely related to changes in levels of estrone glucuronide (EIG). *Studies have shown that in addition to an increase in symptoms for female migraneurs during the menstrual phase (during first 3 days of menses), there are also 3 distinct midcyle (around day 14) phases during which migraines are most prevalent. They are: 1) Late follicular phase (LF) (rapid rise in estrodiol level) 2) Early follicular 1 phase (rapid drop in estrodiol level) 3) Early follicular 2 phase (rapid rise in progesterone level) American Headache Society 49th Annual Scientific Meeting: Abstract 150. June 7-10, 2007.

Category: Neurology

Title: Stroke

Keywords: Stroke, Carotid Artery Lesion, CVA (PubMed Search)

Posted: 7/29/2007 by Michael Bond, MD (Emailed: 7/30/2007) (Updated: 8/25/2019)
Click here to contact Michael Bond, MD

Learn the Lingo for Stroke Manangement: Patients with acute stroke due to a carotid artery thrombotic lesion that then embolizes to a cerebrovascular artery, have two problems that can be addressed with one coordinated intervention. * "Triple Play" = (1) Carotid artery lesion stenting followed by (2) retrieval of the embolic clot from the cerebrovascular artery via the Merci device followed by (3) intra-arterial tPA (the latter prevents complications that could result from removal of embolic clot). * "Double Play" = (1) Retrieval of the clot from the cerebrovascular artery via the Merci device followed by (2) intra-arterial tPA. Merci Device information:

Category: Neurology

Title: Migraine Headache Diagnosis

Keywords: Migraine, Headache, Diagnostic Criteria (PubMed Search)

Posted: 7/29/2007 by Michael Bond, MD (Emailed: 7/30/2007) (Updated: 8/25/2019)
Click here to contact Michael Bond, MD

Diagnostic Criteria for Migraine Headaches: * Migraine w/o aura- A. At least five headache attacks lasting 4 - 72 hours, with at least two of the four following characteristics: 1. Unilateral location. 2. Pulsating quality. 3. Moderate or severe intensity (inhibits or prohibits dailyactivities). 4. Aggravated by walking stairs or similar routine physical activity. B. During headache, at least one of the two following symptoms occur: 1. Phonophobia and photophobia. 2. Nausea and/or vomiting. * Migraine w/ aura (remember: aura is not always visual) - A. At least two attacks with at least three of the following: 1. One or more fully reversible aura symptoms indicating focal cerebralcortical and/or brain stem functions. 2. At least one aura symptom develops gradually over more than four minutes,or two or more symptoms occur insuccession. 3. No aura symptom lasts more than 60 minutes; if more than one aura symptomis present, accepted duration is proportionally increased. 4. Headache follows aura with free interval of at least 60 minutes (it mayalso simultaneously begin with the aura). B. At least one of the following aura features establishes a diagnosis ofmigraine with typical aura: 1. Homonymous visual disturbance. 2. Unilateral paresthesias and/or numbness. 3. Unilateral weakness. 4. Aphasia or unclassifiable speech difficulty. Headache 44(5):426-435, 2004. Headache classification committee of the IHS. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988 8: 1-96.

Category: Cardiology

Title: post-MI complications

Keywords: myocardial, infarction, complications, papillary, VSD, murmur (PubMed Search)

Posted: 7/29/2007 by Amal Mattu, MD (Updated: 8/25/2019)
Click here to contact Amal Mattu, MD

Post-MI patient develops acute pulmonary edema + hypotension + new systolic murmur = VSD or paplillary muscle rupture Treatment = inotropic support + afterload reduction (as tolerated) + OR ASAP (balloon pump is temporizing)

Category: Pediatrics

Title: Hirschsprung Disease

Keywords: GI, Hirschsrung Disease, Constipation (PubMed Search)

Posted: 7/26/2007 by Sean Fox, MD (Updated: 8/25/2019)
Click here to contact Sean Fox, MD

Hirschsprung Disease Is the absence of parasympathetic ganglion cells in the rectum and colon. May present in neonates or young children. Consider it in any child with constipation, bilious emesis, delayed passage of meconium (after the first 48-72 hrs), abdominal distension, or enterocolitis. Classic physical finding: tight anal sphincter, empty rectal vault, followed by an explosive bowel movement (due to releasing the pressure by loosening the anal sphincter). Definitive Dx made by rectal biopsy. May be complicated by bacterial overgrowth causing enterocolitis.

Category: Toxicology

Title: Chemical Weapons of Mass Destruction

Keywords: Nerve agents, organophosphates, blistering agents (PubMed Search)

Posted: 7/26/2007 by Fermin Barrueto, MD (Updated: 8/25/2019)
Click here to contact Fermin Barrueto, MD

Chemical Weapons of Mass Destruction There are a variety of chemicals utilized as WMD and can be categorized as: nerve agent, blistering agent or incapacitating agent: Nerve Agents: (Sarin, VX) cause a parasympathetic toxidrome due to inhibition of Acetylcholinesterase. Antidote is pralidoxime, benzodiazepines and atropine. Blistering Agents: (Mustard Gas) Must be treated like a severe burn patient causing extreme pain and sloughing of the skin. Incapacitating Agents: (BZ) Causes anticholinergic toxidrome, your whole army starts to hallucinate and develop urinary retention. People armed, hallucinating and needing to pee makes for a highly ineffective military force.

Category: Critical Care

Title: Mechanical Ventilation "Knobology" - ventilation

Keywords: mechanical ventilation, pCO2, tidal volume, pH (PubMed Search)

Posted: 7/24/2007 by Mike Winters, MD (Updated: 8/25/2019)
Click here to contact Mike Winters, MD

-Remember that oxgenation is affected by changes in PEEP and/or FiO2 -For changes needed in ventilation (pH and pCO2), you alter the respiratory rate (RR) and/or tidal volume (TV) -Changes in RR produce a greater effect on pH and pCO2 than changes in TV -Focus more on maintaining a pH between 7.3 - 7.4, rather than on returning pCO2 to normal

Category: Vascular

Title: Thrombolytic Therapy for Pulmonary Embolism

Keywords: Pulmonary Embolism, Thrombolytic (PubMed Search)

Posted: 7/23/2007 by Rob Rogers, MD (Updated: 8/25/2019)
Click here to contact Rob Rogers, MD

The only FDA-approved thrombolytic drug for the treatment of pulmonary embolism is tPA. Current studies (including studies by Jeff Kline-"Dr. PE") are investigating the use of TNKase and other agents. For hemodynamically unstable PE (hypotension, RV dysfunction): tPA- give 100 mg over two hours as a drip (no bolus). Heparin must be stopped during infusion and restarted after the tPA has finished. More on serum markers of RV dysfunction next week...

Category: Cardiology

Title: hyperglycemia and ACS

Keywords: hyperglycemia, ACS, STEMI, coronary, ischemia (PubMed Search)

Posted: 7/22/2007 by Amal Mattu, MD (Updated: 8/25/2019)
Click here to contact Amal Mattu, MD

--50% of all STEMI patients have elevated admission glucose levels (>140 mg/dL) --hyperglycemia at the time of admission is an independent risk factor for in-hospital and 1-year mortality in patients wih STEMI --hyperglycemia induces reduced microvascular perfusion and has adverse effects on platelet function, fibrinolysis, and coagulation --tight control of glucose levels during and after STEMI is recommended by the ACC/AHA guidelines and appears to lower acute and 1-year mortality rates

Category: Misc

Title: Medical Management Ureteral Stones

Keywords: Ureteral, stone, tamsulosin, management (PubMed Search)

Posted: 7/21/2007 by Michael Bond, MD (Updated: 8/25/2019)
Click here to contact Michael Bond, MD

Medical Management of Ureteral Stones Tamsulosin (Flomax ) has been shown to help increase the passage of ureteral calculi. According to a metaanalysis compared to patients receiving conservative therapy only, patients receiving conservative therapy plus α -blockers were 44% more likely to spontaneously expel the stones (RR 1.44, 95% CI 1.31 to 1.59, p0.001), and stone expulsion incidence increased significantly (RD 0.28, 95% CI 0.22 to 0.34, p0.001). Mechanism of action: Alpha blockage results in ureteral smooth muscle relaxtion and subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen. Erturhan S. Erbagci A. Yagci F. Celik M. Solakhan M. Sarica K. Comparative evaluation of efficacy of use of tamsulosin and/or tolterodine for medical treatment of distal ureteral stones. [Comparative Study. Journal Article. Randomized Controlled Trial] Urology. 69(4):633-6, 2007 Apr. Parsons JK. Hergan LA. Sakamoto K. Lakin C. Efficacy of alpha-blockers for the treatment of ureteral stones. [Journal Article. Meta-Analysis] Journal of Urology. 177(3):983-7; discussion 987, 2007 Mar.

Category: Pediatrics

Title: Nursemaid's Elbow

Keywords: Nursemaid's Elbow, Radial Head Subluxation (PubMed Search)

Posted: 7/20/2007 by Sean Fox, MD (Updated: 8/25/2019)
Click here to contact Sean Fox, MD

Nursemaid's Elbow PRESENTATION ==> Radial head subluxation is VERY common; most often seen in ages of 1-4 yrs. ==> Arm is held close to the body, elbow flexed and forearm pronated. MANAGEMENT ==> If the history and physical are classic, no X-rays are needed. Obtain x-rays if there is pain to palpation of long bones (rule out Monteggia fx) or the story is not classic. ==> Hold elbow at 90 degrees, then firmly supinate and simultaneously flex the elbow. ==> Place thumb over region of radial head and apply pressure as you supinate. May also need to extend elbow to help screw radial head back in place. POST-REDUCTION ==> Immobilation is not necessary for 1st episode ==> If delayed reduction (>12 hours), place in long arm posterior splint in full supination and elbow @90 degrees

Category: Toxicology

Title: Activated Charcoal

Keywords: Gastrointestinal decontamination, activated charcoal, poisoning (PubMed Search)

Posted: 7/19/2007 by Fermin Barrueto, MD (Updated: 8/25/2019)
Click here to contact Fermin Barrueto, MD

Gastrointestinal Decontamination - Activated Charcoal Pharmacist P.f. Touery, in 1831, making a demonstration of the effectiveness of charcoal before the French academy of Medicine, survived after swallowing 15 g of strychnine (10x lethal dose) and an equal amount of charcoal - 3 tablespoons. (That's for you Dr. Rolnick) - Assess the patients' chance of becoming unresponsive or vomiting in relation to the ingestion if known. - Maximal benefit if given within 1 hour of ingestion, drug is likely still in the stomach. - No study has yet to show decrease in morbidity or mortality when empirically given to all ingestions. - Only one study has shown multi-dose activated charcoal to decrease morbidity and mortality and that was with a drug (oleander is like digoxin) that is enterohepatically metabolized. de Silva HA, et al. Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial. Lancet. 2003 Jun 7;361(9373):1935-8.