UMEM Educational Pearls

Category: Cardiology

Title: hyperglycemia and ACS

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

Posted: 7/22/2007 by Amal Mattu, MD (Updated: 12/7/2019)
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--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: 12/7/2019)
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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: 12/7/2019)
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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 http://www.wheelessonline.com/ortho/nursemaids_elbow_radial_head_subluxation

Category: Toxicology

Title: Activated Charcoal

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

Posted: 7/19/2007 by Fermin Barrueto, MD (Updated: 12/7/2019)
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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.

Category: Critical Care

Title: Mechanical Ventilation "Knobology" - respiratory failure

Keywords: mechanical ventilation, assist control, SIMV, pressure support (PubMed Search)

Posted: 7/17/2007 by Mike Winters, MD (Updated: 12/7/2019)
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-One of the most common reasons for intubation/mechanical ventilation in the ED is patient fatigue -Essentially, patients are unable to keep up with the work of breathing -Patient work of breathing can be significant in CPAP, SIMV, and Pressure Support modes of mechanical ventilation -Avoid these as initial modes if your patient has respiratory fatigue

Category: Vascular

Title: Aortic Dissection

Keywords: aortic dissection, chest, abdominal, pain, malpractice (PubMed Search)

Posted: 7/16/2007 by Rob Rogers, MD (Updated: 12/7/2019)
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Most common themes in medical malpractice cases involving missed aortic dissection: -Some combination of chest/back, chest/abdomen, or abdomen/back -Symptoms "above and below" the diaphragm (neck pain and abdominal pain, for e.g.) Sullivan, SullivanGroup.com 2006 Acute Aortic Disease, Elefteriades 2007

Category: Cardiology

Title: treatment of acute pericarditis

Keywords: pericarditis, treatment, colchicine, steroids (PubMed Search)

Posted: 7/15/2007 by Amal Mattu, MD (Updated: 12/7/2019)
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-Most patients with acute pericarditis are effectively treated with high-dose aspirin or NSAIDS + colchicine - Aspirin dose: 2-4 gms/day - Colchicine dose: 1-2 mg for first day, then 0.5-1 mg/day for 3 months - The use of steroids in first-time acute pericarditis should be avoided, as it has been found to increase the chances of recurrence

Category: Trauma

Title: Traumatic Ankle Pain

Keywords: Ankle, Maisonneuve, Jones, Fracture (PubMed Search)

Posted: 7/14/2007 by Michael Bond, MD (Updated: 12/7/2019)
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Traumatic Ankle Pain When examining a patient who presents with Ankle Pain, make sure that you examine/palpate the proximal fibula and the base of the fifth metatarsal. Pain over the proximal fibula will necessitate a full Tibia/Fibula x-ray to rule out a Maisonneuve Fracture [a proximal fracture of fibula resulting from external rotation; injury may occur with medial or posterior malleolus fracture, a ligament rupture, as well as rupture of interosseous membrane. Pain over the base of the 5th metatarsal suggests a Jones Fracture [ involves fx at base of fifth metatarsal at metaphyseal-diaphyseal junction, which typically extends into the 4-5 intermetatarsal facet; is located w/in 1.5 cm distal to tuberosity of 5th metatarsal & should not be confused w/ more common avulsion fx (Dancer s Fracture) of 5th metatarsal styloid]

Category: Pediatrics

Title: Bronchiolitis

Keywords: Bronchiolitis, Bronchodilators, Steroids, Supplemental Oxygen (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/13/2007) (Updated: 12/7/2019)
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Bronchiolitis The most common lower respiratory infection in infants Diagnosis is based on clinical history and physical. No lab test is useful. Management - Bronchodilators should not be used routinely. They can be continued if the pt has a positive response after a trial. - Corticosteroids have not been found to be of benefit. - Antibiotics should not be used, unless indicated for other reasons. - Ribaviran has not demonstrated any benefit. - Use Supplemental oxygen if the patient is persistently sat'ing <90%. Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of Bronchiolitis. PEDIATRICS Vol. 118 No. 4 October 2006, pp. 1774-1793

Category: Toxicology

Title: One Pill Killers for Children

Keywords: pediatric, poisoning, overdose (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/12/2007) (Updated: 12/7/2019)
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One Pill Killers for Children Drug Class Mechanism of Action that Kills Sulfonylureas These hypoglycemic agents (ie. Glyburide) also have a long t Opioids Respiratory depression Imidazoline Clonidine and Oxymetazolone (nasal spray) cause bradycardia and respiratory depression Ca Channel Blockers Bradycardia & hypotension, especially diltiazem and verapamil Beta Blockers Extended release preparations are problematic There are some others but these are the most commonly prescribed pharmaceuticals. Remember, children under age 6 will not be able to swallow a pill and the pill itself is choking hazard. Proper poison prevention education for the parents is also needed.

Category: Critical Care

Title: Pearl of the Day - Critical Care

Keywords: PEEP, oxygenation, ventilator (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/10/2007) (Updated: 12/7/2019)
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Mechanical Ventilation "Knobology" - Oxygenation -FiO2 and PEEP are used to improve oxygenation in the ventilated patient -Immediately following intubation, start with an FiO2 of 100% -Increase PEEP by 2-3 cm H2O every 10-15 minutes to achieve the desired saturation -As you titrate PEEP, have respiratory therapy provide you with plateau pressures (maintain Pplat < 30) Mike

Category: Misc

Title: Test of new education blog/listserv

Keywords: Listserv, mailing list, test (PubMed Search)

Posted: 7/10/2007 by Dan Lemkin, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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I am redesigning the way the educational pearls are sent. You will still receive them via email to the education list. This will not change. What will change, is that a record will be available for review on the website in the residency --> pearls section. Currently you can browse the posts as the come in. In the very near future, you will be able to search by keywords and review several pearls at once. This should serve as a really handy review tool. Please bear with me as I test the email system to ensure it comes across ok. thanks dan

Category: ENT

Title: Epistaxis Control

Keywords: Epistaxis, Nose, Bleeding (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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Direct Pressure: Can be held with two fingers pinching the nares, or you can tape 4 tongue blades together and make your own "clothes pin" that can then be used to pinch the nares. Vasoconstrictor and Anesthesia: Use a 1:1 mixture of topical lidocaine 4% and oxymetazoline can often be mixed together in the same oxymetazoline spray container and then just spray it into the nares. Some IV/IM narcotic pain medication will also help increase patient cooperation. Visualize the bleeding site: Use a HEAD LAMP with an appropriate sized nasal speculum. You may look like Marcus Welby, MD but nothing works as well to see into the nose. Cauterization It is best to cauterize circumferential around the bleeding site prior to directly cauterizing the actual site. Be careful with electrical cautery so has not to perforate the septum. Nasal Packing: Instead of surgilube use Muprion, Bactroban or Bacitracin ointment to lubricate the packing. This will reduce the chance of Toxic Shock Syndrome.

Category: Pediatrics

Title: Kawasaki s Disease

Keywords: Kawasaki s, Coronary Artery Aneurysm, fever (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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Kawasaki s In the US, Kawasaki Disease is the leading cause of Acquired Heart Disease in Children (surpassing Acute Rheumatic Fever). ==> 15-25% of untreated pts develop coronary artery aneurysm or ectasia. Diagnosis is a clinical one. ==> 5 days of fever PLUS 4/5 clinical features (rash, inflammation of lips/mouth, bilateral conjunctivitis, edema or erythema of hands/feet, and peeling of fingers/toes). No lab values are diagnostic; however, they can strengthen clinical suspicion. ==> CRP and ESR are usually elevated. Thrombocytosis is also common after 1 week of illness. Symptoms are often transient and require careful history. Considered it in the DDx of every child with fever of at least several days duration, rash, and nonpurulent conjunctivitis, especially in children <1 year old and in adolescents, who often have incomplete Kawasaki Disease and are likely to be missed. Newburger, JW. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease. Circulation. 2004;110:2747-2771.

Category: Pediatrics

Title: NewBorn Resuscitation

Keywords: NewBorn Resuscitation, Neonate, Transilluminate, Bradycardia (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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NewBorn Resuscitation Important numbers to remember: ==> HR <100, start Positive Pressure Ventilation ==> HR <60, start Chest Compressions Bradycardia and Hypotonia are symptoms of Poor Ventilation and Acidosis With an infant who is not responding to resuscitation measures, TRANSILLUMINATE the chest to help detect a pneumothorax.

Category: Toxicology

Title: Hyperthermia

Keywords: hyperthermia, serotonin syndrome, neuroleptic malignant syndrome (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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Hyperthermia Neuroleptic Malignant Syndrome (Dopamine Inhibition): treat with bromocriptine Serotonin Syndrome (5-HT1A agonism): treat with serotonin antagonist Malignant Hyperthermia (Genetic): treat with dantrolene

Category: Toxicology

Title: Lithium Toxicity Management

Keywords: lithium, renal failure, neurologic (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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Lithium Toxicity Management Initial Therapy: 2x maintenance fluid with normal saline Hemodialysis is controversial but will remove lithium quickly Association of permanent neurologic sequelae with elevated lithium level(1) o Looks like a cerebellar stroke 1- Adityanjee. The syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). Pharmacopsychiatry. 1989 Mar;22(2):81-3.

Category: Cardiology

Title: Rapid Atrial Fibrillation Treatment

Keywords: Afib, Atrial Fibrillation, Treatment (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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Rapid Atrial Fibrillation Treatment 50% of patients with new AF spontaneously convert within 48 hours AF > 48 hours --> chances of spontaneous conversion decreases and chance of embolization increases significantly Most EM texts and lecturers still recommend diltiazem as first line medication for early rate control Patients in whom beta blockers are preferred: AMI, thyrotoxicosis, or if patient is already on BBs NEVER combine IV beta blockers and IV calcium channel blockers --> synergistic effect will cause hemodynamic compromise; start with one type of medication and stay with it

Category: Cardiology

Title: Blunt Chest Trauma

Keywords: Chest, Trauma, Aortic, murmur (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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The most common valvulopathy after blunt chest trauma is acute aortic insufficiency. These patients will present with a new diastolic murmur. Stability depends on the degree of AI. On the other hand, if a chest trauma patient presents with a new systolic murmur, think about acute septal rupture. These patients are much more often unstable, or may die before arrival. These diagnoses may be missed in the unstable patient because physicians focus on the abdomen in the unstable patient. Pay attention to the heart sounds also!

Category: Critical Care

Title: Life- or Limb-saving Escharotomy

Keywords: Escharotomy, burn, ischemia (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 12/7/2019)
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Life- or Limb-saving Escharotomy * At some point in your career you may have to perform an emergent escharotomy to safe a life or limb * Deep thickness circumferential chest burns act like a straight jacket and impair respiration * Circumferential limb burns act like a tourniquet and impairs both venous output and arterial input resulting in ischemia * Limb escharotomy should be performed as soon as pulses diminish - do not wait for them to disappear * The picture illustrates the incision lines for escharotomy (note the bold lines highlight the importance of going across any involved joint)

Attachments

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