UMEM Educational Pearls

The Emergency Department is often the first line in detecting the sexual abuse of a child.  Unfortunately, what you do or don't say/ask/test can significantly affect the legal protection of the abused child.

1. Know your region's dedicated sexual abuse center, if one exists.  These centers have personnel trained in interviewing and forensic evidence collection.  There may be different centers for children of different ages.

2. Know your state laws regarding what is and is not admissible as evidence of sexual abuse.  GC/CT urine testing (NAAT), though more sensitive than swab cultures, is not currently admissible as evidence in many states.

3. Withhold prophylactic antibiotic treatment when possible - antibiotics work well, and often eliminate evidence.  Withholding antibiotics is acceptable if the child is asymptomatic or only has very mild symptoms.

4. Any sexually transmitted disease in a child warrants further workup and investigation.  Primary genital HSV in a young child warrants testing for Gonorrhea and Chlamydia, and appropriate referral as well as police involvement.

5. Finally, if trained personnel is available to conduct the interview of a child, limit the questions you ask the child directly.  Any evidence in your note that you may have suggested something to the child in your line of questioning could negate the validity of their testimony.

Yet another publication demonstrates that chest pain radiating to the right arm has the highest predictive value for ruling in ACS. In this study, radiation of the pain to the right arm had a higher predictive value than age, gender, comorbidites or traditional risk factors, specific descriptors of pain (e.g. "pressure" or "crushing"), or associated symptoms (e.g. diaphoresis, nausea, dyspnea). The bottom line....beware chest pain that radiates to the right arm!

[Goodacre S, Pett P, Arnold J, et al. Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram. Emerg Med J 2009;26:866-870.]

Patella fractures are typically due to direct trauma as in a fall or direct blow to the knee.

Fractures may be missed on the AP view or misdiagnosed as a bipartate fracture.  To avoid these pitfalls look closely at the lateral view and consider getting a sunrise view of the knee (better visualizes the patella).  Finally,  unilateral bipartate patella are very rare so consider an x-ray of the contralateral knee if you are considering this as your diagnosis.

Surgery should be considered for:

• Fractures with displacement greater than 3 mm.
• Individuals that have lost there externsor mechanism as it is indicative of a tear in the extensor retinacula.

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The following is a differential diagnosis for unilateral headaches with typical associated features:

• Migraine headache ->  throbbing pain preceded by aura; nausea; photophobia; chronicity.
• Cluster headache ->  piercing eye pain; ipsilateral lacrimation and rhinorrhea; group of headaches come periodically in waves.
• Temporal arteritis ->  dull ache over temporal artery; associated with arthralgia, myalgia, and anemia; typically in older populations.
• Glaucoma ->  eye pain with cloudy appearing cornea; eyeball feels hard; pupillary dilitation may worsen pain.
• Sinusitis ->  associated with sinus congestion; tenderness over sinus with or without swelling; typically only relieved with decongestants and/or antibiotics.
• Subarachnoid hemorrhage ->  pain may be diffuse or unilateral; sudden onset of severe pain; may be associated with a stiff neck.

Early Recognition of Shock

• Early recognition, and thus early treatment, of shock is crucial in reducing morbidity and mortality in the critically ill ED patient.
• Traditionally, the diagnosis of shock has been based on vital sign abnormalities such as tachycardia, tachypnea, oliguria, etc.
• Vital sign abnormalities have been shown to be insensitive markers of shock in the critically ill.
• The Shock Index, although clearly not 100% sensitive, can assist in the detection of shock compared to heart rate and blood pressure alone.
• Shock Index is simply heart rate divided by systolic blood pressure.
• Values greater than 0.9 are abnormal and suggest markedly impaired cardiac output.

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Effort Thrombosis

Effort thrombosis, also called Paget von Schrotter disease, occurs when either the axillary and or subclavian veins thrombose. The condition is more common in young, healthy (>males) patients and presents with the usual DVT symptoms of arm pain, swelling, and pain.

The disease was originally described in patients performing vigorous activities, like weight lifting or repetitive over-the-head lifting. This type of activity has been reported to kink the subclavian vein and lead to clot formation.

Diagnosis and therapy is the same for any other type of DVT.

When patients present with acute MI, all NSAIDS should be discontinued (e.g. ibuprofen, COX-2 inhibitors, etc.) during the hospitalization. Continued use of NSAIDs during the hospitalization increases the risk of CHF, myocardial rupture, hypertension, reinfarction, and mortality.

Some of the causes of acute vision loss are:

• Cardiac Causes include:
  • Emboli -- causes can be atherosclerotic plagues, atrial fibrillation, endocarditis.
  • Arteritis
  • Dissection
• Hematologic causes
  • Hypercoaguable state
  • Hyperviscosity
  • Anemia
• Ocular Causes
  • Angle-closure glaucoma
  • Papilledema/neoplasm: Intracranial hypertension
  • Intraocular foreign bodies:
  • Central retinal artery occlusion
  • Anterior ischemic optic neuropathy
  • Ruptured globe
• Miscellaneous
  • Migraine
  • Hysteria
  • Drugs (i.e.: viagra and its counterparts)

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Ductal-Dependent Cardiac Lesions in the Neonate

• Often present in the first 1-2 weeks of life (children born prematurely tend to be at the upper end of the spectrum as they may have delayed closure of the ductus arteriosus)
• May present with tachypnea, sudden onset of cyanosis or pallor (often worse with crying), diaphoresis with feeds, lethargy, or failure to thrive
• Oxygen challenge - place baby on 100% 02 via NRB;  10% improvement in SpO2 (or 30mmHg increase in PaO2 on ABG) suggests a pulmonary issue;  no or minimal change suggests a congenital heart defect
• If congenital heart disease is suspected, start PGE-1 infusion at a rate of 0.05-0.1ug/kg/minute;  improvement may be drastic and is usually seen within 15 minutes
• Side effects of PGE-1 infusion include apnea, fever, hypotension, and seizures;  have your code cart and intubation equipment ready to go prior to beginning infusion

NEW TREATMENT in diabetes

It was discovered that glucose given ORALLY caused more insulin release than glucose administered INTRAVENOUSLY. This led to the discovery of the incretin hormones, which are secreted by the gut (INtestinal SECRETion of INsulin), GIP and GLP-1.

The incretin-based therapies increase levels of GLP-1, either by providing an incretin mimetic (exenatide and liraglutide), or by inhibiting their breakdown by DPP-4 (sitagliptin, saxagliptin, vilagliptin)

Their administration results in:

• Stimulation of glucose dependent insulin secretion
• Suppression of glucagon secretion
• Slowing of gastric emptying
• Improvement if b-cell functioning

Causing:

• Improved glycemic control
• Decrease in A1C
• Mild weight loss
• Mild decrease in BP

                 STAY TUNED FOR DOSING AND ADVERSE EVENTS!

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Optimal brain imaging for diagnosing and managing acute ischemic stroke should address the presence of 4 essential issues:

• hemorrhage
• intravascular thrombus
• core irreversibly infarcted tissue and its size, and
• hypoperfused tissue at risk for subsequent infarction if not rescued.

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Optimal brain imaging for diagnosing and managing acute ischemic stroke should address the presence of 4 essential issues:

• hemorrhage
• intravascular thrombus
• core irreversibly infarcted tissue and its size, and
• hypoperfused tissue at risk for subsequent infarction if not rescued.

Show References

Calciphylaxis is a rare disorder caused by systemic arteriolar calcification which leads to ischemia and necrosis.  It is characterized by painful ischemic necrotic lesions on adipose tissue areas such as abdomen, buttock and thighs.  This commonly occurs in patients with ESRD on hemodialysis or after transplant, but can also occur with other patients, such as those with hyperparathyroidism.

Diagnosis is made clinically, with the help of a skin biopsy as needed.  Differential diagnosis includes cholesterol embolization, warfarin necrosis, cryoglobulinemia, cellulitis and vasculitis.  There are no specific laboratory findings, although patients may manifest elevated PTH, phosphorous, calcium or calcium x phosphorous product. 

Infection is usually the cause of the high mortality rate of this condition, which has a reported mortality of 46%, or 80% if ulceration is present.

Treatment includes local wound care, trauma avoidance, electrolyte correction, increased frequency of dialysis or parathyroidectomy as needed.  Surgical debridement is controversial; as the risk of infection may outweigh the benefit in terms of outcome. 

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The Art of Pimping-And How to Protect Against

This monday's pearl (ok, I know, it's tuesday now) comes from Michelle Lin's blog: academic life in emergency medicine. It is more gem than pearl, and it discusses what medical students and residents do to avoid being pimped. It is a must read!

Here is the link to the discussion on Michelle Lin's blog:

http://academiclifeinem.blogspot.com/2009/11/trick-of-trade-essential-skills-for.html

Just a few note worthy "pimping protection procedures":

• The "Muffin"-person being pimped raises a muffin (or some other food item) to their mouth as they are being pimped. And if the person with the muffin stills gets the question, the pimpee pretends to choke, thus avoiding future pimp questions
• The "Eclipse"-eclipsing your head with someone in front of you, that way the pimper can't see you.
• The "Politician's" approach-answering the question you wished you were asked.

Happy pimping!

Up to 10% of elderly patients in the ED meet criteria for acute delirium, though misdiagnosis rates are very common.
The most common cause of delirium in the elderly, overall, is medication effects. Other common causes are infections (UTIs most common), CNS abnormalities, cardiovascular abnormalities, electrolyte/metabolic abnormalities, and temperature abnormalities (fever or hypothermia).

Vision loss whether acute or chronic is a common presenting complaint to the ED.  This will be the first in a series of pearls on the subject.  This pearl will address the nomenclature used by ophthalmology based on the length of vision loss.

    •    Transient visual obscuration - Episodes lasting seconds. Usually associated with papilledema and increased intracranial pressure.
    •    Amaurosis fugax - Brief, fleeting attack of monocular partial or total blindness that lasts seconds to minutes
    •    Transient monocular visual loss  or transient monocular blindness - A more persistent vision loss that lasts minutes or longer
    •    Transient bilateral visual loss - Episodes affecting one or both eyes or both cerebral hemispheres and causing visual loss
    •    Ocular infarction - Persistent ischemic damage to the eye, resulting in permanent vision loss

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• Neuroleptic Malignant Syndrome (NMS) is a rare, but true neurological emergency which is today associated with much lower mortality given heightened awareness about the condition.

• It typically initially begins with muscle rigidity resulting in rhabdomyolysis, followed by high fever, and delirium.

• Always check creatinine phosphokinase (CPK) and white blood cell levels when concerned about NMS, as these typically elevate in response to muscle breakdown.

• The following mnemonic (FEVER) serves as a reminder of the signs and symptoms associated with NMS:

           F - Fever (anything over 100.4 F counts)

            E - Encephalopathy

           V - Vital signs instability

           E - Enzymes elevation (i.e. CPK)

            R - Rigidity of muscles

Spinal Epidural Abscess Pitfalls

• The classic triad of back pain, fever, and neurologic deficits are found in < 15% of patients at the time of presentation
• Up to 75% will be afebrile
• Up to 67% will have a normal initial neurologic exam
• < 40% have a WBC greater than 12,000 cells/mm³
• < 33% will have an abnormality on plain film in the first 7-10 days

Take Home Point: In the patient with risk factors for spinal epidural abscess (IVDU, DM, indwelling catheters, etc) do not exclude the diagnosis based upon the absence of a fever, a normal WBC count, and a normal neurologic exam.

Ring-removal is a dreaded problem in pediatric hand and finger injuries.  Removal can be difficult and time consuming.  The relatively recent introduction of Tungsten into the jewelry market has further complicated this problem:

• The hardest metal used in jewelry - cannot be scratched, much less cut, by common tools
• Cheap, easy to buy online, attractive to adolescents

However, it is:

• Extremely brittle
• May be safely and quickly broken with locking pliers (also cheap), by sequentially, gradually tightening the locking plier grip

This video explains how.  Of course, this works on adults as well.

http://www.youtube.com/watch?v=poM423pewRE

_{I have no relationship with the copany which made this video - it was simply chosen for its clear explanation of the solution described in this pearl.}