UMEM Educational Pearls

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: 8/11/2020)
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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: 8/11/2020)
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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: 8/11/2020)
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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, MS (Emailed: 7/8/2007) (Updated: 8/11/2020)
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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: 8/11/2020)
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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: Obstetrics & Gynecology

Title: Imminent Delivery

Keywords: Delivery, Imminent, Dystocia (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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If you are facing the imminent delivery of a newborn with shoulder dystocia remember the mnemonic HELPERR. * Help. Call for it. * Episiotomy. o Necessary only to make more room if rotation maneuvers are required. * Legs (the McRoberts maneuver) o This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. * Pressure, Suprapubic o The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction. * Enter maneuvers (internal rotation) o Attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. * Remove o Remove the posterior arm. * Roll the patient. o Rolling the patient on all-fours will often dislodge the shoulder, and the position change allows gravity to aid in the disimpaction of shoulder. Baxley EG, Gobbo RW. Shoulder Dystocia, Am FamPhysician. 2004;69(7):1709-1714.

Category: Airway Management

Title: Airway Pearls

Keywords: Airway, Intubation (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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1. Hyperventilation in the pediatric HI causes an increase in cerebral ischemiaand increases in ICP 2. Cuffed tubes can be used in the pediatric airway 3. The most common cause of bradycardia in pediatric RSI is hypoxia and this is NOT prevented with atropine 4. Patients with an underlining neuromyopathy have an upregulation of neuroreceptors (they actually have more in number) the risk if hyperkalemic cardiac arrest is significant if succynlcholine is administered. 5. During Direct Laryngoscopy; the Mac blade can also be used as a Miller negating changing the blades. 6. Intubation is now a bimanual procedure as the use of External Laryngeal Movement (ELM) significantly increase the intubators view.

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: 8/11/2020)
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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: 8/11/2020)
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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: Pediatrics

Title: SCIWORA

Keywords: SCIWORA, Spinal Cord Injury Without Radiographic Abnormality, MRI, steroids (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) Children <8yrs old can have their spinal cord stretched up to 5cm before rupture. Their cervical spinal columns are more mobile and held together with less stable ligaments allowing for horizontal movement of the vertebrae. The mobility of the spinal column allows for spontaneous reduction of subluxated vertebrae; therefore, CTs and plain radiographs will often appear normal at the time of ED evaluation. Any child with neurologic deficits or a concerning mechanism of injury deserves an MRI to evaluated for SCIWORA. No studies of the utility of steroids in children with spinal cord injury exist; current recommendations are to reserve methylprednisolone for those children who present with persistent or progressive neurologic deficits.

Category: Pediatrics

Title: ALTE

Keywords: ALTE , Apparent Life Threatening Events, color change, apnea, SIDS, Seizure (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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ALTE (Apparent Life Threatening Events) Defined as an episode characterized by some combination of apnea, color change, change in tone, choking, and/or gaging. Vast DDx ==> Get Bedside Glucose Early (should be part of vital signs) ==> Keep Non-accidental Trauma on the list ==> ~50% are classified as Idiopathic Risk Factors associated with Increased Mortality: ==> Sleep Onset ==> Prior Similar Episode ==> Sibling a Victim of SIDS ==> Development of Seizure D/O during monitoring 7.8% of ALTE pt s with a Normal ED evaluation required medical intervention during hospitalization. -Oren, J., D. Kelly, and D.C. Shannon, Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics, 1986. 77(4): p. 495-9. -De Piero, A.D., S.J. Teach, and J.M. Chamberlain, ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med, 2004. 22(2): p. 83-6.

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: 8/11/2020)
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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: 8/11/2020)
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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: Toxicology

Title: Digoxin Toxicity

Keywords: digoxin, cardiac glycoside, toxicity (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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Digoxin Toxicity Most common finding on ECG when digoxin toxic: PVCs Most classic ECG in digoxin toxicity: PAT with block Pathognomonic finding (RARE): Bidirectional ventricular tachycardia Easy formula for administration of digoxin specific Fab (Digibind?? or DigiFab?). Remember to round up even if its 2.3 vials, give 3. [(Dig Serum Concentration(ng/mL)) x wt(kg)] / 100 = # vials

Category: Toxicology

Title: Tricyclic Antidepressants (TCA)

Keywords: tricyclic antidepressant, electrocardiogram, cardiac toxicity (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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Tricyclic Antidepressants (TCA) - Lack of terminal 40msec R wave (R wave in AvR, S wave in I, AvL) means the patient is NOT TCA toxic. - 40msec R wave + QRS >100msec = possible TCA toxicity, treat with NaHCO3 and recheck ECG. - TCA toxicity defined by ECG; if QRS > 100msec, 33% seizures; if QRS > 160msec, 50% v tach Boehnert MT, Lovejoy FH Jr. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med. 1985 Aug 22;313(8):474-9.

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: 8/11/2020)
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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: 8/11/2020)
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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: Cardiology

Title: Calcium Affect on ECG

Keywords: ECG, Calcium, hypercalcemia, hypocalcemia (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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Calcium's main effect on the ECG appears to be on the duration of the ST segment, such that: 1. Hypercalcemia shortens the ST segment, producing also a short QTc. 2. Hypocalcemia prolongs the ST segment, producing also a long QTc. As an aside, there are only three conditions in which a short QTc is typically noted: hypercalcemia, digitalis toxicity, and a recently described syndrome that causes sudden death--"the short QT syndrome" (in which the QTc may be < 300ms...that's REALLY short!). As another aside, there are only two conditions that prolong the QTc via prolongation of the ST segment--hypocalcemia and hypothermia.

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: 8/11/2020)
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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

escharotomy.jpg (5 Kb)


Category: Critical Care

Title: Subclavian central venous access

Keywords: Venous, catheter, subclavian (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 8/11/2020)
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Subclavian central venous access * Many consider the subclavian to be the preferred route for central venous access * Approximately 5-6% of subclavian's are associated with misdirection of the catheter tip into the internal jugular * Directing the J-tip of the guidewire caudally significantly reduces the incidence of malpositioning Reference: Tripathi M, et al. Direction of the J-Tip of the guidewire, in seldinger technique, is a significant risk factor in misplacement of subclavian vein catheters: a randomized, controlled study. Anesth Analg 2005;100:21-4.