UMEM Educational Pearls

• Characterized by proteinuria, hypoalbuminemia, edema, and hypercholesterolemia
• Abnormal Vitals:  tachypnea (due to pulmlonary edema); tachycardia (intravascular depletion); hypertension
• Abnormal PE:  peripheral edema, ascites, S3 on ausculation
• UA demonstrates significant proteinuria.
• TX is uniformly with oral steroids.

High Pressure Injection Injuries:

• These injuries initially often have a pretty benign appearance which may result in the injuried person seeking medical treatment late, or the initial medical provider not recognizing the seriousness of the injury.
• Even when treated promptly and aggressively most patients will end up with an amputation of thier finger or have permanent loss of funciton, strength, sensation, or chronic pain.
• In a couple of hours, these injuries tend to result in significant swelling that can lead to compartment syndrome. The swelling can be due to the actual disruption of cells from the high pressure, or due to toxic effects of the injected agent.
• Initial Management should consist of:
  • X-rays: Help to evaluate the extent of the injection.  Radio-opaque solvents will be seen on x-ray, but even radio-lucent solvents may be seen as lucency or air on the x-ray
  • Broad Spectrum antibiotics to prevent infection
  • Corticosteroids to decrease the inflammatory response brought on by the injected agent
  • Tetanus Prophylaxis if needed
  • Emergent hand surgery referral
• Most if not all patients will require emergent debridement of the affected area.

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You have a patient that is on lithium and a serum concentration is checked: 4.3 mmol/l

Therapeutic range is between 0.5 and 1.5 mmol/l

The patient shows no symptoms - is that possible? what do you do?

Answer: highly unlikely that the patient would asymptomatic, at least nystagmus would be present. Remember the symptoms are cerebellar in nature. What may have happened is the blood was drawn in an inappropriate tube. There are green "Lithium Heparinized" tubes in our Emergency Department. They are typically used for cardiac enzymes. This has been a well reported source of error (1)

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• 5 to 10% of TIA victims go on to have a complete stroke within 7 days.

• The following validated ABCD clinical prediction rule can be used to risk stratify your next TIA patient in determining who requires an expedited in-patient work-up:

          Risk Factor                                                                        Score

• Age > or = 60                                                                      1

• Blood Pressure (SBP > 140 and/or DBP > or = 90)                    1

• Clinical Features (choose one)

          -- Unilateral weakness                                                           2

          -- Speech impairment w/o weakness                                       1

          -- Other                                                                               0       

• Duration of Symptoms (minutes)

          -- > 60                                                                                2

          -- 10 to 59                                                                           1

          -- < 10                                                                                0

                                                                                              Total 0-6

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Acute Hyponatremia and the Critically Ill

• I just left a busy ED shift during which we had a patient with altered mental status and a serum Na of 115 mmol/L.
• Recall that severe hyponatremia may present with lethargy, disorientation, agitation, nausea/vomiting, altered mental status, abnormal respirations, and seizures.
• For severe, symptomatic hyponatremia, the treatment of choice is 3% hypertonic saline
• At a rate of 100 ml/hr, the serum Na should rise approximately 2 mmol/L per hour.
• In general, the duration of treatment with hypertonic saline is based upon sign and sypmtom improvement.
• For those with more longstanding hyponatremia, serum Na should not be increased by more than 12 mmol in the first 24 hours.

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The Alcoholic Patient in the ED

Well, we have all been there....EMS rolls in with "another drunk guy" found down in the street. The nurses tell you, "he is here all the time...he is just drunk." You should be scared any time you hear this phrase uttered. Always be a little nervous about this group of patients and you won't fall victim to many of the pitfalls that some of us have experienced.

Pearls and Pitfalls in Caring for the Intoxicated Patient in the ED:

• Get a glucose early. Many of these patients are hypoglycemic when they arrive.
• Assume the worst and NEVER tell yourself or others,"He's just drunk." That statement is the kiss of death. Always assume there is occult trauma present. Did they fall and sustain a head bleed, splenic injury, hip fracture?
• Reevaluate during your shift. There is nothing worse than placing an intoxicated patient in a room and ignoring them, only to find out that hours (or shifts) later that they won't wake up.
• Consider a head CT. Although you can't scan them all, have a low threshold to image them. They fall all the time, and you will be surprised at how many subdural hematomas you pick up when you scan this group of patients. If you don't image, perform reassessments frequently during your shift.

T-wave inversions are commonly found in many conditions other than ACS. Many pulmonary conditions, elevated intracranial pressure, LVH, bundle branch block, and young age are associated with T-wave inversions.

T-wave inversions are especially notable in patients with pulmonary embolism, and one study identified a key difference in T-wave inversion patterns in PE vs. ACS: T-wave inversions in leads III and V1 simultaneously were far more likely to be assocaite with PE, whereas the presence of T-wave inversions in I and aVL were almost always ACS.

A key takeaway point is to maintain a broad differential even in the presence of T-wave inversions...it's not necessarily just ACS!

[ref: Kosuge M, et al. Electrocardiographic differentiation between acute PE and ACS on the basis of negatie T waves. Am J Cardiol 2007;99:817-821.]

Manibular Dislocations:

• Mandibular dislocations can be extremely difficult to reduce at times.
• The classic method of reducing a mandible dislocation is for the provider to wrap his thumbs in guaze (to prevent them from being bitten), and while placing his thumbs bilateraly as far posterior on the mandible as possible, he applies downward, and then posterior pressure to reduce the dislocation.
• Significant muscle spasms can result from the dislocation, requiring procedural sedation, but even with sedation it can be very difficult if not impossible to reduce the mandible.
• Dr. Cheng's article, referenced below, describes a new technique, where the provider use both of his thumbs to press down on a single side of the mandible posterior until the side reduces.
  • For a bilateral dislocation, the technique would be to reduce one side and then the other.

Some authors also recommend using rolled guaze to hold the patient's mouth shut so that they do not inadvertantly dislocate their jaw a second time if they happen to yawn while awakening from their sedation.

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Patients who present to the ED with an elevated INR due to vitamin K antagonists many times do not need to be reversed.  Simply holding a dose is all that is usually necessary for patients with an INR < 9.  Fortunately, guidelines published in CHEST are available to help guide management.
 

• INR: >Therapeutic to 5.0 with no bleeding - Lower warfarin dose, or omit a dose and resume warfarin at a lower dose when INR is in therapeutic range
• INR: >5.0 to 9.0 with no bleeding - Omit the next 1 to 2 doses of warfarin, monitor INR more frequently, and resume treatment at a lower dose when INR is in therapeutic range, or omit a dose and administer 1 to 2.5 mg oral vitamin K.* [*This option is preferred in patients at increased risk for bleeding (eg, history of bleeding, stroke, renal insufficiency, anemia, hypertension.]
• INR: >9.0 with no bleeding - Hold warfarin and administer 5 to 10 mg oral vitamin K. Monitor INR more frequently and administer more vitamin K as needed.
• Any INR with serious or life-threatening bleeding - Hold warfarin and administer 10 mg vitamin K by slow IV infusion; supplement with prothrombin complex concentrate, fresh frozen plasma, or recombinant human factor VIIa, depending on clinical urgency. Monitor and repeat as needed.
   

Reference:

Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.

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• Patients who have recently undergone aneurysmal coiling commonly present to the ED with complaints of new or worsened focal neurologic deficits that may be suggestive of stroke.

• Aneurysms can be stabilized by clipping or coiling them.  Coiling is performed in a minimally invasive manner, wherein platinum (a material that can be visualized radiographically and is flexible) coils are deployed into the bulb of the aneurysm, via femoral artery cannulation.

• The relative risk of mortality or morbidity at one year post-coiling was found to be 22.6% less than that associated with clipping.  The latter is an older, more invasive technique requiring craniotomy and direct manipulation of the brain.

• Hemorrhage is a less likely complication related to aneurysm coiling, thus your indication for a non-contrast Head CT in these patients would most appropriately be "rule out infarct" rather than "rule out bleed." 

• Brain infarct is the more common complication of this treatment, and results from the accidental embolization of plaque during the coiling procedure.

• Here are a couple of great links with illustrated overviews of the process of coiling, including a real time You Tube clip:
  
  http://www.brainaneurysm.com/aneurysm-treatment.html
  
  http://www.youtube.com/watch?v=Mvy8g_oDbbk

Transient Hypotension and Mortality in Sepsis

• Not surprisingly, septic ED patients with persistent hypotension despite fluid resuscitation have increased mortality.
• What about the more common scenario of septic ED patients who have a transient drop in their BP?
• Recent evidence suggests that ED patients with sepsis who have non-sustained decrease in their BP (SBP < 100 mm Hg) have a 3-fold increased risk of in-hospital mortality compared with those who maintain arterial pressure.
• Take Home Point: Any drop in BP in a septic patient, even if it responds to fluids, portends a higher mortality.  Be vigilant and aggressively resuscitate these patients.

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Some Pearls on ED Teaching:

• Don't teach so much. Limiting the number of points taught will lead to increased retention. Quality, not quantity.
• Make sure your learners are "with you." If the learner isn't attentive, forget it. Move and and return to teaching when the learner is ready. You are wasting your time if they are paying attention.
• Be creative in adapting your teaching style when it is busy. You don't have to be at a dry erase board drawing metabolic pathways (sorry Fermin) to be teaching. Simply discussing your thought process outloud is a great way of teaching "on the fly."
• Be flexible and remember: the focus should be on the learner (what they get out of it) and not the teacher. Many forget that when they teach in the ED.

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• Rates are highest for children <5yrs and between 15-24 yrs old.
• Most of pathology is related to duration of asphyxia from time of submersion until adequate respiration is restored.
• The brain and heart are most vulnerable to anoxic and ischemic injury.
• Prognosis for near-drowning depends primarily on the degree of brain anoxia.
• Prolonged submersion (>25 min); apnea or coma at presentation to ED; and initial arterial pH <7.0 are all poor prognostic indicators.
• 96% of victims who require <10min of CPR survive with no or only mild neurologic impariment.

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Whereas only 6% of young patients with PE present with syncope, 15-20% of elderly patients with PE present with syncope. The simple takeaway point is that whenever an elderly patient presents with syncope, always strongly consider the possibility of PE, even though they may lack classic pleuritic chest pain.
Count that respiratory rate for an inexpensive clue!

Shoulder Dislocations -- Treatment

• Shoulder dislocations once reduced have typically been treated by placing the arm in a sling and swathe which holds the shoulder in adduction and internal rotation. 
• However, several studies have now shown that placing the arm in a splint with the shoulder adducted and in 10 degrees external rotation helps to prevent recurrent shoulder dislocation. 
• Patients should remain in the brace/split for 3 weeks.
• External rotation is not recommended if there is an associated fracture.
• Some commerical splints are now available to hold the shoulder in external rotation, however, you can make a small strut with plaster or fiberglass to achieve the same result.

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Oseltamivir (Tamiflu)

• Has low protein binding and does not inhibit CYP450 (resulting in a low incidence of drug interactions)
• Requires dosage adjustment with creatinine clearance of < 30 ml/min
• Does not require dosage adjustment in patients with liver failure or the elderly
• Most common adverse effects are nausea and vomiting
• Serious effects include anaphylaxis and skin reactions. Neuropsychiatric effects reported include hallucinations, delerium and abnormal behavior
• It may be administered to infants and children due to the high potential morbidity associated with influenza

For complete indications and dosing: www.cdc.gov/h1n1flu/recommendations.htm

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• Syncope is defined as a transient loss of consciousness and accounts for an estimated 1% to 3% of emergency department (ED) visits.
   
• While syncope typically is of benign origin, it occasionally signals significant mortality and morbidity, which can make determining the disposition of syncope patients a challenge.
   
• The San Francisco Syncope Rule (96% sensitivity, 62% specificity) is a clinical tool used to determine which syncope patients are at low risk for a short-term (7-day) serious outcome (i.e. MI, arrhythmia, PE,  stroke, SAH, significant hemorrhage, any condition causing or likely to cause a return ED visit or hospitalization).
  Specifically, absence of all of the following 5 findings (acronym CHESS) were associated with no serious outcome within 7 days of the syncopal episode according to this rule:
  • Congestive heart failure
  • Hematocrit less than 30
  • EKG Abnormalities
  • Systolic BP less than 90
  • Shortness of breath
     
• While this decision rule, in addition to one's clinical skill, may be used as a guide in caring for and dispositioning syncopal patients, know that its ability to be extrapolated to a general population of ED patients has yet to be validated.

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Heparin for Maintaining Arteral Catheter Patency ?

• Arterial catheter placement is common in many critically ill ED patients.
• Typically, a heparin solution is used in arterial catheters based on the belief that it helps to maintain catheter patency.
• In one of the most recent studies (referenced below), the use of a heparinized solution did not improve the functionality, or increase the duration of patency, of arterial catheters when compared to a saline solution.
• As the incidence of heparin-induced thrombocytopenia (HIT) continues to increase, it is worth noting that the routine use of heparin to maintain arterial catheter patency is not well supported by the literature.

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With few exceptions, always assume that elderly patients presenting to the ED with an acute illness are very dehydrated. Here are a few reasons why the elderly patient, even on a normal day, may be mildly dehydrated:
1. The elderly have been shown to have decreased total body water.
2. The elderly have a decreased thirst response.
3. The elderly have a decreased renal vasopressin response.

Given these issues, when an elderly patient develops a systemic illness (especially pulmonary process), they lose even more fluid via insensible losses. By the time they arrive in the ED, unless they are presenting because of overt pulmonary edema, they almost always will benefit from generous IV fluid administration.

Amal

Nursemaid Elbow:

It is typically taught that the way to reduce a nursemaid's elbow is to hold the elbow at 90 degrees, then firmly supinate and flex the elbow. Place your thumb over the radial head and apply pressure as you supinate.(Taken from Sean Fox's Pearl on 7/20/2007)

However, there is a growing body of evidence that is showing that hyperpronating the forearm actually has a higher success rate on first attempt, is easier to perform, and is associated with less pain then supinating the forearm.  The overall reducation rates where similar for both methods.

The hyperpronation method consists of hyperpronating the forearm and then flexing the elbow.  Since the child tends to already hold their arm in partial pronation, the hyperpronation technique tends to need less force and has been associated with less pain.

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