Hx: hyperextension injury (contact and non contact), varus directed blow to flexed knee, direct blow to anteriomedial knee. Report instability symptoms when knee is in full extension.
PE: Varus stress testing
Varus laxity at 0 indicate LCL and cruciate ligament (ACL/PCL) injury
Varus laxity at 30 indicates LCL injury
Dial test - inspects the external rotation at the knee joint/performed in both 30 and 90 knee flexion. The dial test inspects the external rotation at the knee joint
https://www.youtube.com/watch?v=pW4yv0zg4RY
Positive at 30 = > 10 external rotation asymmetry = isolated PCL injury
Positive at 30 & 90 = Posterior lateral corner injury and PCL injury
The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup has published their latest review, this time on extracorporeal treatment for salicylate poisoning. Here are their recommendations on when to dialyze:
What is the ICH Score?
Take Home Point: Communicate the severity of your ICH patient by using either the composite ICH Score or by including details such as the patient's GCS, estimated volume of ICH, presence of IVH, and supra- vs. infratentorial origin.
Intraosseous (IO) placement is a rapid and reliable method for obtaining venous access in critically ill patients; previous studies demonstrated that everything from vasopressors to packed RBCs can be infused through it.
This prospective observational study compared the first-pass success rate and time to successful placement of IO versus landmark-based (i.e., not ultrasound guided) central-line placement (femoral or subclavian access) during medical emergencies (e.g., cardiac arrest) in an inpatient population.
The first pass success rate for IO was found to be significantly higher than the landmark technique (90% vs. 38%) and placement was significantly faster for IOs (1.2 vs. 10.7 minutes).
Despite the fact that this study did not directly compare IO to ultrasound guided line placement, this study demonstrates that IO is a rapid and effective means to obtain central access during patients with emergent medical conditions.
Bottom-line: Consider placing an IO line when rapid central access is necessary.
The following clip is one of three findings found in Beck’s triad. Name all three findings and how often are all 3 signs present for patients with pericardial tamponade?
Vancomycin guidelines recommend an initial dose of 15-20 mg/kg based on actual body weight (25-30 mg/kg in critically ill patients). [1] The MRSA guidelines further recommend a max dose of 2 gm. [2]
But, what dose do you give for an obese patient that would require more than 2 gm?
A new study provides some answers to this question. [3] Obese-specific, divided-load dosing achieved trough concentrations of 10 to 20 g/mL for 89% of obese patients within 12 hours of initial dosing and 97% of obese patients within 24 hours of initial dosing.
Application to Clinical Practice
Caveats
The study used some more specific dosing calculations based on renal function and percentage above IBW. If patient's renal function is abnormal, consultation with a pharmacist is recommended.
Electronic cigarettes are battery-powered devices that deliver nicotine, flavorings, (e.g. fruit, mint, and chocolate), and other chemicals via an inhaled aerosol. E-cigarettes are currently not regulated by the FDA. In many states, there are no restrictions on the sale of e-cigarettes to minors.
Electronic cigarette exposures involving young children are rapidly increasing. Such exposures tend to involve patients aged < 5 years and occur by ingestion of the nicotine-containing liquid. There is a potential for acute nicotine toxicity (nausea, vomiting, pallor, diaphoresis, tachycardia, hypertenstion initially). Respiratory muscle weakness with respiratory arrest is the most likely cause of death.
To date, the overwhelming majority of pediatric ingestions have not resulted in serious medical outcomes. The most commonly reported adverse events were nausea and vomiting.
However, in May of 2014, the first pediatric case of toxicity from ingestion of e-cigarette nicotine liquid was reported. A 10-month old ingested an unknown amount of e-liquid and developed vomiting, tachycardia, grunting respirations, and ataxia. The symptoms resolved by 6 hours after ingestion without specific treatment.
(1) The figure above shows the number of calls to poison centers for cigarette or e-cigarette exposures, by month, in the United States during September 2010 February 2014. E-cigarette exposure calls per month increased from one in September 2010 to 215 in February 2014.
Introduction:
As noted in the previous pearl (May 20, 2015), globally diarrheal diseases are the second leading cause of death for children under five- killing approximately 760,000 annually. What can be done to prevent and treat diarrhea, especially among young children?
Prevention of diarrheal illness:
Treatment of diarrheal illness:
Bottom Line
Diarrheal diseases kill hundreds of thousands of children in developing countries each year. Appropriate prevention measures (clean water, improved sanitation) can markedly decrease the burden of disease. Appropriate treatment (ORS) can save lives for pennies.
High Flow Nasal Cannula (HFNC) in acute respiratory hypoxemia
The Trial:
Results:
Bottom line:
Consider using HFNC prior to or while deciding on intubation in patients with hypoxemic respiratory failure usually due to pneumonia
We all dread performing lumbar punctures on the obese patient. The traditional standard length spinal needle (9 cm) is becoming increasingly inadequate in reaching the subdural space in our overweight society.
Abe et al developed a formula for selecting the proper needle length to reach the middle of the spinal canal from the skin using retrospective CT data from 178 patients.
Length of needle (cm) = 1+ 17 x Weight (kg)/ Height (cm)
Given the average height of the American woman (163 cm or 5’4’’) our standard length spinal needle will FAIL to reach the mid-thecal space if a woman weighs more than 170 lb (75 kg)!!!
Paul Blart Mall Cop, and King of Queens star Kevin James (5’8’’, 285 lb) would require a 13.7 cm spinal needle. This means even our long spinal needles (12.7 cm) would FAIL by 1 cm.
Note that this formula resulted in selection of needles too small (6%) and too long (31%) of the time. Abe’s linear correlation had an R value of 0.81, (p<.001)
Bottom-Line: Consider use of a long spinal needle (12.7 cm) or IR guided LP in overweight /obese patients and the above formula to guide your depth of insertion
Stress-Induced Cardiomyopathy
Do you need to get stuff out of the thorax (like fluid or air) and don't want to place a HUGE chest tube? Consider a pigtail catheter; don't know how to place one? Well check out this video and learn how.
Reperfusion Ventricular Fibrillation
Ventricular fibrillation during reperfusion in STEMI is an infrequent, but serious complication.
Among ~4000 with STEMI between 2007-2012, 71 (1.9%) had reperfusion Vfib.
Increased risk for reperfusion Vfib is associated with: history of MI, aspirin and b-blocker use, Vfib before PCI, left main CAD, inferior MI, symptom-to-balloon time <360 minutes, maximal ST-segment elevation in a single lead >300 μV, and sum of ST-segment deviations in all leads >1,500 μV.
The sum of ST-segment deviations in all leads >1500 μV was an independent predictor of reperfusion Vfib.
Sx: pain to lateral arm, worse with overhead activity and sleeping/lying on arm
Anatomy: Pain generating structures include the rotator cuff, subacromial bursa, labrum and biceps tendon.
http://www.ortho-md.com/images/proceduresImg/SHOULDER2.jpg
Testing: Neer and Hawking tests
https://www.youtube.com/watch?v=U8-yLHQ_JaM
https://www.youtube.com/watch?v=OYK5qL2om-c
Done indepedently, Hawkings is more sensitive, however best to combine both tests.
Imaging: not indicated
Tx: rest, ice, physical therapy (modalities), subacromial steroid injection
Methemoglobin (MetHb) is produce when Fe+2 in heme is oxidized to Fe+3 under oxidative stress (caused by mediation and chemicals). MetHb does not bind to oxygen and thus decrease RBC’s O2 carrying capacity.
Among medication, overdose of local anesthesia - benzocaine, dapsone, and phenazopyridine are often implicated. (Table 1)
Think about methemoglobinemia in presence of low pulse oximetry (~85%) with lack of response to supplemental oxygen, cyanosis, dyspnea, etc. (see Table 2 – signs and symptoms of MetHb) in patients who are taking or overdosed on medication listed in Table 1.
Diagnosis: CO-oximetry detects toxin-induced hemoglobinopathies, including COHb and MetHb.
Treatment: Methylene blue (1 mg/kg over 5 min) in symptomatic patients or MetHb level > 25%. Resolution of methemoglobinemia should be noted in 30 – 60 min.
G6PD deficiency: Prevalence in the U.S. is 4-7% with highest prevalence in African American population (11%). Methylene blue causes hemolytic anemia in patients with G6PD deficiency within 24 hours of administration. However, G6PD status is often unknown in ED patients. When caring for patients with known G6PD deficiency and methemoglobinemia, providers must carefully consider the risk and benefit of treating MetHb (including severity of poisoning/MetHb) with methylene blue.
Table 1. Causes of MetHb
| Medication
| Chemicals |
| Benzocaine, Lidocaine, Prilocaine | Aniline dye |
| Dapsone | Chlorobenzene |
| Phenazopyridine | Organic nitrites (e.g. isobutyl nitrite) |
| Nitroglycerin | Naphthalene |
| Nitroprusside | Nitrates (well water contamination) |
| Quinones (Primaquine & Chloroquine) | Nitrites (food preservatives) |
| Sulfonamides | Silver nitrate |
| Nitric oxide | Trinitrotoluene |
| Amyl nitrite |
|
Table 2. Signs and symptoms
| MetHb level (%) | Signs and symptoms |
| 1-3% (normal)
| · None |
| 3-15% | · Low pulse oximetry (<90%) · Gray cutaneous coloration |
| 15-20% | · Chocolate brown blood · Cyanosis |
| 20-50% | · Dizziness, syncope · Dyspnea · Weakness · Headache |
| 50-70% | · CNS depression, coma, seizure · Dysrhythmias · Tachypnea · Metabolic acidosis |
| >70% | · Death · Hypoxic injury |
Background:
While diarrhea in adults can be inconvenient and briefly debilitating, in children it can be fatal. Globally, diarrheal diseases are the second leading cause of death for children under five.
Clinical types of Diarrhea (with common infectious causes):
Clinical assessment:
*Best indicators of hydration status
Next week: Prevention and Treatment
Advances in Catheter-Directed Therapy for Acute PE - The PERFECT Registry
Earlier this month, initial results from the multicenter PERFECT registry (Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis) were released. In this study, 101 consecutive patients with massive or submassive PE were prospectively enrolled to receive early catheter-directed therapy.
Inclusion criteria:
Therapy provided:
Outcomes: Clinical success (stabilization of hemodynamics, improvement in pulmonary hypertension and/or right heart strain, and survival to discharge) was achieved in 86% of patients with massive PE and 97% of patients with submassive PE. There were no major procedure-related complications or major bleeding events.
Bottom Line: In patients with massive or submassive pulmonary embolism, there is growing evidence that early catheter-directed therapy may become first-line therapy for selected patients.
5 year-old with no past medical history, complains of a limp and mild left knee pain. No history of trauma. Physical exam is significant for a low-grade fever and is otherwise normal. What’s the diagnosis?
