UMEM Educational Pearls

Category: Orthopedics

Title: Supracondylar Fractures

Keywords: Supracondylar, Fracture, Pediatric, Ossification (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Supracondylar fractures in children: To assess the likelihood of a supracondylar fracture in a child look at the anterior humeral line. This is a line drawn down the anterior portion of the humerus on the lateral view of the elbow. This line should pass through the center of the capitellum in the distal humerus. If the line does not pass through the center there is a very high likelihood of a supracondylar fracture. Review of the Appearance of Ossification Centers in Children's Elbows CRITOE Capitellum 1 to 8 months Radial Head 3 to 5 years Medial (Internal)Epicondyle 5 to 7 years Trochlea 7 to 9 years Olecranon 8 to 11 years Lateral ( External) Epicondyle 11 to 14 yeras

Category: Airway Management

Title: Airway Management Pearls

Keywords: Intubation, Airway (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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1. 30% of all ETT placed in the field by EMS are esophageal. 2. Patients that will rapidly desaturate - think "POPS" ie Pregnancy, Obesity, Pediatric, Smoke inhalation. 3. In the adult the only absolute contraindication to performing a cricothyroidotomy is a fractured larynx. 4. Post intubation desaturation think "DOPE" ie Displacement, Obstruction, PNTX, Equipment failure.

Category: Obstetrics & Gynecology

Title: OB Pearls

Keywords: Pre-eclampsia, eclampsia, HELLP (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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The best known peripartum complications are pre-eclampsia and eclampsia. However, do not forget about HELLP syndrome which occurs in approximately 0.2 to 0.6 percent of all pregnancies. HELLP is an acronym for: Hemolysis Elevated Liver Enzymes Low Platelet Treatment consists: 1. Seizure prophylaxis with magnesium 2. Blood pressure control 3. Corticosteriods and plasmapheresis may be helpful in severe causes 4. Supportive care. 5. Early delivery of child.

Category: Obstetrics & Gynecology

Title: Shoulder Dystocia Legal Pearl

Keywords: Erb's Palsy, Dystocia, Legal (PubMed Search)

Posted: 7/14/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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In follow up to my Shoulder Dystocia Pearl

Dr. DePriest Whye has some legal pearls for us:

Erbs Palsy( Brachial Plexus Injury) is a known complication of shoulder dystocia and is due to traction on the arm that causes stretching of the brachial plexus.

  • Should an Erb's Palsy result as a consequence of a shoulder dystocia, a medical malpractice suit is inevitable.
  • The medical record documentation is particularly critical in defending the medical care rendered.
  • The medical record should reflect timely recognition of the shoulder dystocia.
  • It is important that appropriate implementation of the maneuvers described last week are done in a timely fashion.
  • Vital documentation should describe the amount of traction placed if any.
  • Terms such as minimal or mild or light traction should be used.
  • Terms such as strong, forceful, significant traction should be avoided.
  • Never state in the record that uterine pressure was used as opposed to suprapubic pressure.
  • Uterine pressure is contraindicated.

Erb's Palsy cases are difficult to defend. They are impossible to defend with improper documentation.


Category: Vascular

Title: Pulmonary Embolism Rule Out

Keywords: D-Dimer, PE, Well's (PubMed Search)

Posted: 7/14/2007 by Rob Rogers, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Update on the Wells Criteria for PE-patients with a score of 4 or less (which means low to moderate probability) can be considered for a "d-dimer negative" rule out approach. This is a bit of a change from the low risk only approach. Additionally, the British Thoracic Society guidelines support the low and moderate risk group patient rule out strategy. So, if you have a low or even moderate risk patient, you can use the approach of obtaining a highly sensitive d-dimer and if it is negative, the hunt for PE is over.

Category: Pediatrics

Title: Neonatal Resuscitation

Keywords: Neonatal Resuscitation, Newborn, Transilluminate, Meconoium Aspiration, Zip Lock Bag (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Neonatal Resuscitation 3 Key Questions to ask of your pregnant patients: ==> Are you having twins (or more)? ==> When is your due date? ==> What color is the fluid? Magic numbers for Neonatal Resuscitation: ==> HR < 100 (or persistent central cyanosis or apnea) = positive pressure ventilation ==> HR < 60 = chest compressions +/- epinephrine If there is meconium present and ==> The infant is depressed, then use meconium aspirator (aspirate the airway via the ETT) ==> The infant is vigorous, then resuscitate as usual (dry, clear airway, assess circulation/color) When resuscitating an infant who is <28wks GA, do not dry with towels as you would an older neonate, instead ==> Place the child in a food grade polyethylene bag (Zip Lock bag), to prevent heat loss and avoid losing valuable time during the resuscitation. For infants not responding to resuscitation, TRANSILLUMINATE the chest to determine if there is a pneumothorax.

Category: Pediatrics

Title: Pediatric Thoracic Trauma

Keywords: Thoracic, Trauma , Traumatic Asphyxia, Pulmonary Contusion (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Pediatric Thoracic Trauma 2nd leading cause of death in Peds Trauma Most injuries in Peds are Blunt Kids are Different ==> More Pliable Chest Walls → Pulm Contusion more likely than rib Fx ==> More Mobile Mediastinum → more susceptible to develop tension ptx ==> More Likely to Hyperventilate → Swallowed Air → compromise Respiratory status ==> Can compensate for significant volume loss with tachycardia Traumatic Asphyxia ==> Primarily in younger children ==> Due to the more pliable chest wall ==> Sudden, severe crushing blow to the chest when the glottis is closed. ==> Petechial Hemorrhages of sclera and skin of the head and upper extremities ==> Neuro deficits and coma due to cerebral edema can occur, although rare Pulmonary Contusion ==> Most Common thoracic Injury in kids ==> Alveolar Hemorrhage, Consolidation, Edema ==> Leads to: (1) V/Q mismatch (2) Decreased Compliance (3) Hypoxemia (4) hypoventilation

Category: Pediatrics

Title: Acute Otitis Media

Keywords: Acute Otitis Media, Amoxicillin, insufflation, Delayed treament (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Acute Otitis Media Make the Diagnosis Properly ==> Acute Onset of Symptoms ==> Signs of Middle Ear Infection (1) Buldging TM, poor mobility c insufflation, otorrhea, air-fluid level ==> Signs of Middle Ear Inflammation (1) TM erythema or otalgia (that interferes with nl activity) Can you wait on the Abx? ==> Older than 6months ==> No severe infections (T>39 C) ==> If yes to both, may hold Abx for 48 hours. Treat Appropriately ==> High-Dose Amoxicillin (80-90mg/kg/D) is 1st line If the decision is made to observe without antibiotic therapy, the parents can be given a prescription for Abx with instructions to fill it if the child does not improve in 48 to 72 hours, or see the PMD in 2 days. (Spiro, D. Tay, K. Wait-to-see prescription for the treatment of acute otitis media. JAMA 2006, 1235.)

Category: Toxicology

Title: Heavy Metal Poisoning Clues for Diagnosis

Keywords: metal, poisoning, thallium (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Heavy Metal Poisoning Clues for Diagnosis Mees lines, indication of arrested nail growth, occurs in lead, arsenic and others Most heavy metals will cause a proteinuria Microcytic anemia and basophilic stippling seen in lead, arsenic, mercury Peripheral neuropathies in otherwise healthy person Thallium causes classic painful paresthesias in lower extremities

Category: Toxicology

Title: Cyanide

Keywords: cyanide, poisoning, hydroxycobalamin (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Cyanide Presents with arterialization of venous blood (venous blood draw looks like ABG) Reason: o Hemoglobin is not able to offload oxygen o CN poisons cytochrome c oxidase preventing conversion of oxygen to water and thus production of ATP Old antidote: sodium thiosulfate New antidote: hydroxycobalamin binds CN producing cyanocobalamin (Vit B12) When you give it expects a dip in pulse because of its blue color. Remember CN will give you a beautiful 100% pulse all the way to death. Lee J, et al. Potential interference by hydroxocobalamin on cooximetry hemoglobin measurements during cyanide and smoke inhalation treatments. Ann Emerg Med. 2007 Jun;49(6):802-5. Epub 2007 Jan 8.

Category: Toxicology

Title: Urine Drug Screens

Keywords: drug abuse, urine drug screen, cocaine (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Urine Drug Screens Though we order them often, be sure you know what your results mean: Cannabinoids: an accurate test though clinically not important information, positive for 5 days to a full month with chronic users. Cocaine: the most accurate and precise test, positive for 3-5 days. Amphetamine: the most imprecise with many false positives and false negatives. Cough/cold preparations that contain pseudephedrine, phenylephrine or other decongestants can turn it falsely positive. BDZ: only benzodiazepines that are metabolized to oxazepam will turn positive. You can see false negatives with alprazolam and even lorazepam. Opioids: Semisynthetics like oxycodone and hydrocodone may give false negatives at low levels. This screen will NOT catch methadone, meperidine, fentanyl, propoxyphene, tramadol. PCP: False positives from dextromethorphan and ketamine

Category: Cardiology

Title: Acute Pericarditis

Keywords: Pericariditis, TB, Viral (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Acute Pericarditis Viral and idiopathic causes account for 80-90% of cases of acute pericarditis (AP) in immunocompetent patients from developed countries. Therefore empiric treatment and extensive search for an underlying cause is unnecessary in the majority of cases we see. However, the etiology of AP in developing countries is very different, with TB-related AP predominating. 70-80% of cases from Sub-Saharan Africa and more than 90% of HIV-related cases of AP are tuberculous. Therefore, in the U.S. tuberculous pericarditis should be strongly considered among immigrants/visitors from developing countries and among patients with HIV.

Category: Cardiology

Title: Cardiac Output After Age 35

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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After the age 35, cardiac output decreases by approximately 1% per year. That means that elderly patients are at much higher risk for CHF, especially when they are stressed in some way. CHF can develop in the elderly as a result of any stype of infection or other non-cardiac insult. If decompensated CHF is diagnosed in an elderly patient, don't forget to evaluate the patient carefully for potential non-cardiac causes.

Category: Cardiology

Title: Syncope

Keywords: Syncope, CHESS, San Francisco (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Syncope Patients with syncope that are considered to be relatively low risk for complications clinically (i.e. those patients that are not clear-cut admissions) should be evaluated for the 5 CHESS criteria (from the San Francisco Syncope Rules). If they meet none of those criteria, then they are considered to be at very low risk for short-term adverse outcomes and they can be discharged for outpatient follow-up. If they do have any CHESS criteria, they are considered to be at higher risk and admission should be strongly considered. CHESS criteria: history of CHF, hematocrit < 30, ECG abnormalities, shortness of breath, presenting systolic pressure < 90.

Category: Cardiology

Title: Helpful clues to distinguishing pericarditis vs. STEMI

Keywords: Pericarditis, STEMI, ECG (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Helpful clues to distinguishing pericarditis vs. STEMI Pericarditis: PR depression in multiple leads, PR elevation > 2 mm in aVR; friction rub (specific though not sensitive) Remember that PR depression mainly only shows up in viral pericarditis, not other types STEMI: horizontal or convex upwards (like a tombstone) STE, ST depression in any lead aside from aVR and V1, STE in III > II

Category: Critical Care

Title: Fungal Infections

Keywords: Fungal, Infection, antifungal (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Fungal Infections * Fungal isolates are an increasingly common source of bloodstream infections in critically ill patients * Mortality ranges from 20% to 60% in some series * 50% are non-albicans species (C.glabrata, C.parapsilosis, C.tropicalis, and C. krusei) * Risk factors include ventilated patients, TPN, high APACHE scores, abdominal surgery, and prolonged ICU stays * Think of fungal infections in the septic patient with hypothermia and bradycardia * Newer antifungal agents such as voriconazole and caspofungin have improved efficacy against n

Category: Critical Care

Title: Critical Illness Neuromyopathy (CINM)

Keywords: Neuropathy, steroids, sepsis, neuromuscular (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Critical Illness Neuromyopathy (CINM) * CINM is the most common peripheral neuromuscular disorder encountered in the ICU * CINM may contribute to delayed weaning and prolonged ventilation * Risk factors for CINM include SIRS/MODS, sepsis, and hyperglycemia (corticosteroid use still controversial) * Current mainstay of management is directed at prevention * EM take home point -> Judicious use of medications associated with the development of CINM (aminoglycosides, neuromuscular blocking agents) Reference: De Jonghe B, Lacherade JC, Durand MC, et al. Critical illness neuromuscular syndromes. Crit Care Clin 2007;23:55-69. (compliments of Dr. Winters)

Category: Cardiology

Title: Cyanide toxicity

Keywords: Cyanide, itroprusside, hypotension (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Be alert for cyanide toxicity when using sodium nitroprusside * Toxicity from sodium nitroprusside can be seen in as little as 2-4 hours with rates > 4.0 mcg/kg/min * Patients with hepatic and renal dysfunction are at greatest risk * Clinical signs of toxicity include altered mental status (agitation, restlessness), tachycardia, ventricular arrhythmias, and eventually hypotension * The classic anion-gap metabolic acidosis is a pre-terminal event - do not wait for this to develop to raise suspicion of toxicity! Reference: Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:148-9.

Category: Airway Management

Title: Plateau Pressure

Keywords: Plateau, Peak, Pressure, airway (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Use plateau pressure, rather than peak inspiratory pressure, as a means of assessing the risk of barotrauma * One mechanism (of many) by which mechanical ventilation can induce acute lung injury in patients with ARDS is overdistention of the alveoli * 2 common parameters used to assess airway pressures are plateau pressure (Pplat) and peak inspiratory pressure (PIP) * Pplat approximates small airway and alveolar pressures more closely than PIP * ARDSnet trial demonstrated a reduction in the number of ventilator days and mortality when Pplat was maintained < 30 cm H2O. References: 1. ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000;342:1301-8. 2. Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:275-6.

Category: Airway Management

Title: Venous Air Embolism

Keywords: Air, Embolism, Catheter (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 5/20/2019)
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Recognize the signs of venous air embolism when inserting a central venous catheter * Although rare, a feared complications of CVC insertion is venous air embolism (VAE) * Conditions that increase the risk of VAE are detachment of catheter connections, failure to occlude the needle hub during insertion, hypovolemia, and upright positioning of the patient * Clinically, VAE presents with acute dyspnea, cough, chest pain, altered mental status, tachypnea, tachycardia, and/or hypotension * Treatment includes placing the patient in a left lateral decubitus position, reverse Trendelenburg, and providing 100% oxygen via NRB * Also consider hyperbaric oxygen therapy * Aspiration of air, as recommended in some textbooks, is rarely successful Reference: Mirski MA. Lele AV. Fitzsimmons L. Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007;106(1):164-77.