UMEM Educational Pearls - By Michael Bond

Sternoclavicular Dislocation:

• A rare cause of chest/shoulder pain following trauma, but one that can be associated with serious vascular injuries.
• Anterior dislocations of the Sternoclavicular(SC) Joint are much more common  than posterior and  usually resulting from  blow to the anterior shoulder that rotates the shoulder backward and transmits the stress to the medial clavicle and SC joint.
• A blow to the posteior shoulder that drives the shoulder forward or a direct blow to the medial clavicle can cause a posterior dislocation.
• Anterior SC dislocations
  
  • Generally not associated with any underlying injury and can be safely reduced in the ED. 
  • Ligaments and joint capsule entrapment can make it difficult to reduce the joint, and often it is difficult to maintain the reduction. 
  • It is not uncommon for these to require open reducation and internal fixation.
  • Can be reducted by abducting, extending, and applying traction to the ipsilateral arm/shoulder while applying posterior and inferior pressure on the medial clavicle.
• Posterior SC dislocations
  
  • Rare
  • Associated with injuries to the underlying vasculature,  dyspnea due to tracheal compression, and parasthesias.
  • Often missed on plain films (CXR, Shoulder Series or Clavicular Series)
  • Best visualized with enhanced CT Scan of the Chest.  IV enhancement recommended to ensure that their is no associated vascular injury.
  • Can be reducted by abducting, extending, and applying traction to the ipsilateral arm/shoulder while pulling the clavicle forward.  Several references recommend using a towel clip to grasp the clavicle if you are unable to grab it effectively with your fingers. 

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Dental Emergency -- Avulsed Tooth

• Never reimpant a primary tooth.  If replaced, primary teeth have a high likelihood of fusing to underlying alveolar bone, which causes dentoalveolar ankylosis and can result in facial deformities
• Never wipe off a tooth, or hold it by the root. The periodontal ligament is easily wiped off and the tooth will not reimplant without it.
• For maximal success, the tooth should be reimplanted within 60 minutes.
• Avoid allowing the periodontal ligament from drying out.  Transport the tooth in (listed in order of preference):
  • Hanks Solution or EMT Tooth Saver
  • Milk
  • Saline
  • Saliva
• Once the tooth is reimplanted it should be held in place with a wire splint or Coe-Pak that bridges the avulsed tooth to the ones on either side of it.
• Place the patient on antibiotics (Penicillin or Clindamycin) in order to prevent any infections.
• If the avulsed tooth can not be found a Chest X-ray should be obtained to ensure that the tooth was not aspirated.

Post-MI cardiogenic shock, while traditionally thought to carry a mortality > 80%, actually has perhaps half that mortality when patients are treated aggressively with prompt invasive therapy (PCI, possibly CABG). Fibrinolytics have traditionally been discouraged, but authors now indicate that they should be given if all of the following three conditions are present:

1. PCI will take greater than 90 minutes,
2. Less than 3 hours have elapsed since onset of STEMI
3. No contraindications to lytics are present.

Sent on behalf of Dr. Amal Mattu

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 Trigeminal Neuralgia

• A neuropathic disorder of the trigeminal nerve that causes episodes of intense pain.
• Also known as Tic Douloureux
• Many cases are associated with vascular compression and subsequent demyelination of the trigeminal nerve, though other causes include compression by a tumor, and multiple sclerosis.
• Classic Trigeminal Neuralgia is a clinical diagnosis that has the following criteria:
  • Paroxysmal attacks of pain lasting from a fraction of a second to two minutes that affect one or more divisions of the trigeminal nerve
  • Pain has at least one of the following characteristics: intense, sharp, superficial, or stabbing precipitated from trigger areas or by trigger factors
  • Attacks are similar in individual patients
  • No neurological deficit is clinically evident
  • Not attributed to another disorder
• Treatment options include:
  • Medical:
    • Carbamazepine (most common and drug of choice)
    • Gabapentin (lacks evidence in trigeminal neuralgia but widely used for other neuropathic pain)
    • Lamotrigine
    • Baclofen
  • Surgical:
    • Microvascular decompression: posterior fossa is explored and the culprit blood vessel is moved off the trigeminal nerve. Typically the nerve is padded with a teflon sheet in order to provide additional protection. 80-90% successful with little or no facial numbness.
    • Ablative: Attempts are made to just incapacitate the pain fibers but these techniques can result in facial numbness as other sensory fibers can be damaged.  Common methods include:
      • Glycerol or alcohol injection
      • Radiofrequency rhizotomies
      • Stereotactic radiation therapy
      • Complete severing of the nerve.

Show References

It has become standard that close contacts of individuals being treated for bacterial meningitis be treated prophalacticly with antibiotics to prevent additional cases.  Fluoroquinolones, in particular ciprofloxicin, have been the drug of choice as a single dose provided adequate protection.

Now the CDC is reporting the first cluster of fluoroquinolone-resistant meningococcal disease in North America have been documented along the Minnesota-North Dakota border.  As of now, the CDC still recommends ciprofloxacin for all parts of the country except for a 34-county area in the Minnesota-North Dakota area.  In that area the CDC is recommending rifampin, ceftriaxone or azithromycin be used.

This needs to be followed closely as the resistant organism is extremely likely to spread across the country and it will probably this time next year when nobody can use ciprofloxacin anymore.

Ultrasound in Pregnancy

1.  A full bladder is needed for Transabdominal Ultrasound and an empty bladder for transvaginal ultrasound.
2. A gestational sac should be visible on transabdominal ultrasound with a quantative HcG of 5000-6000 mIU/ml, and a quant of 1500-2000 mIU/ml on transvaginal.
3. When taking photos, ensure that you show all of the applicable landmarks.  [i.e.: bladder, and uterus]  If you just zoom in on the pregnancy anybody else (i.e.: your expert witness) reading the scan will not be able to confirm that the pregnancy is in the uterus.
4. To confirm an IUP, you must see the yolk sac within the gestational sac.  A double decidual sign is an early sign of pregnancy but it is not always seen and should not be relied upon.
5. If you have a confirmed IUP an additional ectopic pregnancy is extremely unlikely unless the patient was taking medication to stimulate their ovaries (i.e. Infertility treatment).  If on stimulation therapy a very thorough exam needs to be done to look for additional pregnancies.
6. If Quant >2000 mIU/ml and there is no evidence of an IUP, patient needs to be treated as an ectopic pregnancy.

Most of use remember that Fifth disease is a viral infection presenting with a distinctive rash (slapped check) caused by Parvovirus B19.  But do you know the numbering of the other six Contagious Illnesses that are associated with rashes:

1. First Disease – Measles caused by the rubeola virus
2. Second Disease – Scarlet Fever caused by Streptococcus pyogenes Group A
3. Third Disease – German Measles caused by rubella virus
4. Fourth Disease – Dukes Disease – In the late 1880-1900’s it was widely published about but in the 1960’s it was not proven to exist by either epidemiologic criteria or isolation of an etiologic agent.  Now felt to be a mild form of scarlet fever.  Some reports of it being caused by a Coxsackvirus or Echovirus
5. Fifth Disease - Erythema infectiosum caused by Parvovirus B19. Slapped Check
6. Sixth Disease - Exanthem subitum (meaning sudden rash), also referred to as roseola infantum (or rose rash of infants), sixth disease. Presents as rapid onset high fever, followed by a fine red rash when the fever subsides. Caused by Herpes Virus 6.

Rhogam 

• Remember to administer Rhogam to any Rh negative mother that has the following conditions:
• Pregnancy/delivery of an Rh-positive baby
• Abortion/threatened abortion at any stage of gestation
• Ectopic pregnancy
• Antepartum fetal-maternal hemorrhage (suspected or proven) resulting from antepartum hemorrhage (e.g., placenta previa), amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, other obstetrical manipulative procedure (e.g., version) or abdominal trauma
• Transfusion of Rh incompatible blood or blood products (i.e.: platelets)

Dosing:

• 300 mcg IM
• Can give 50 mcg IM within 72 h of exposure of a therapeutic or spontaneous abortion if gestation age is 12 weeks or less. (Order as MICRhogam)
• Additional doses of Rhogam may be necessary when the patient has been exposed to > 15 mL of Rh-positive red blood cells. This may be determined by use of qualitative or quantitative tests for fetal maternal hemnorrhage but generally will only occur during a full term delivery or if incompatible blood products are given.

Trivial Fact: Rhogam is Pregnancy Class C

Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5^th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

• 2^nd and 3^rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
• 4^th Metacarpal fracture <20۫ angulation allowed
• 5^th Metacarpal fracture <30۫ angulation. 
  • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
  • Normal excursion of the 5^th MCP is 15۫ to 25۫.
• No amount of rotation deformity should be allowed.

Migraines and Pregnancy

• Typically headache frequency will increase during the first 2 to 3 months of pregnancy
• 70% of women report significant improvement in headaches during their second and third trimester.
• Most migraine medication should NOT be given to pregnant woman.  Verify prior to prescribing.
  • Class X/D drugs include
    • Cafergot (ergotamine)
    • Depakote
    • Dihydroergotamine (DHE)
  • Class C drugs include
    • Imitrex
    • Zomig
    • Midrin
    • Relapex
• Some headache centers will prophalax pregnant woman with Vitamin B2 and Magnesium.

So you are getting sued.  Here are some tips to handle your Deposition:

• Don’t bring any documents
• You may charge an expert witness fee if you are not a party and the deposing attorney asks your opinion, rather than just asking you to testify about facts.
• Say “yes” or “no,” rather than making gestures.
• Absolute honesty is the best policy.
• Listen carefully and only answer what is asked.  Don’t try to educate the deposing attorney.
• Don’t argue or interrupt
• Nothing is “authoritative.”
• Pause before answering
• Avoid saying “always” or “never.”
• Be brief.  Long-winded answers will get you in trouble.
• Rather than guessing exactly what you did, its okay to testify what you do “as a matter of habit.”
• Don’t exaggerate, over-emphasize, or speak in absolute terms.
• Don’t answer the same question twice.
• Don’t let the plaintiff attorney refer to you as an employee if you are an independent contractor.
• Don’t agree with the inane statement “if it wasn’t documented it wasn’t done.”

Courtesy of Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

 Ludwig’s Angina:

Ludwig’s angina is most commonly a polymicrobial disease of mixed aerobic / anaerobic bacterial origin. Dental disease is the most common cause of Ludwig’s angina.

Diagnosis is usually made after obtaining a CT scan of the Neck and upper chest. 

Once the diagnosis is made, treatment should consist of broad spectrum antibiotics and surgical evaluation by ENT or Oral Surgery for possible I&D. Aggressive management of the patient’s airway is a must, and the patient should be intubated early in the course of the illness if there is any sign of airway compromise. Nasal intubation may be preferred by ENT/Oral Surgery.

Typical Antibiotics include a Penicillin with clindamycin or metronidazole.

Ludwig’s Angina Trivia:

• Initially described in 1836 by the German physician Wilhelm Frederick von Ludwig.
• It was called angina, which finds its origin from the Greek word, anchone, which means strangulation.  The term, angina was used to connote throat pain and infection as angina originates from the Greek word, anchone, that means strangulation.
• It is believed that Elizabeth I of England died of Ludwig's angina in 1603.

Some quick facts about Knee Injuries:

• The most common cause of acute traumatic hemarthrosis of the knee is an anterior cruciate ligament tear.
  • Most patients with an ACL injury will give a history of immediate pain, disability, knee swelling and audible pop.
• The most common ligament injuried in the knee is the medial collateral ligament.
• Patella dislocations
  • Usually lateral dislocations and often spontaneous reduce.
  • Hyperextend the knee to make the reduction easier.
• Dislocation of the knee:
  • Anterior is the most common and usually secondary to hyperextension
  • Popliteal artery injury is commonly seen and must be looked for.  Easy bedside test is Ankle Brachial Indexs.

Fraud (PATH audits)    (PATH = physicians at teaching hospitals)

• As a general rule, faculty may not bill Medicare for the work of residents.
• Faculty may bill for their own work, and may repeat a resident examination if necessary.
• To appropriately bill under PATH audit guidelines, faculty may make reference to a resident’s history, may simply document the variance between their exam and the resident’s exam, and should document medical decision making.
• Faculty may bill for a procedure if:
  • faculty performs the procedure
  • faculty was present for the entire procedure
  • faculty was present for the key portion of the procedure
  • faculty actively assisted the resident in performance of the procedure.

So for the residents, a lot of attendings will want to be present when you do a procedure, not because they think you will need their assistance, but because, procedures are a large revenue stream that can be lost if the attending is not present.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

The insurance companies are always trying to down code our visits so that they can save money, and unless we diagnosis the patients with the appropriate jargon it can cost us a lot of money.  Here are some coding suggestions as written by Sharon Nicks, President and CEO of Nicks & Associates in EP Monthly .

The moral of this pearl is try to use words like Acute, Severe, Sudden, Serious, Distress, Pain, or Fever so that it is clearer to the insurance companies that the patient warranted a visit to a physician (i.e.: an ED) before their PCP could see them in a week.

EMTALA (Part Two)

• Hospitals may not delay screening examinations to inquire about payment.
• Emergency departments should not contact HMOs before completion of the screening examinations and stabilizing treatment.
• Triage does not constitute a MSE.
• For the purposes of EMTALA, a patient has come to the ED when he arrives on hospital property.
• EMTALA does not apply to offsite clinics unless (1) the clinic is licensed as an emergency department, (2) the hospital advertises the clinic as an ED, or (3) during the preceding year, 1/3 of all outpatient visits were for EMCs.
• EMTALA does not apply to inpatients, unless the hospital admitted the patient in bad faith.
• Since Nov. 2003, a specialty represented at the hospital does not always have to be on call.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

EMTALA (Part One):

• The three general duties created by EMTALA are to provide (1) an appropriate medical screening examination (MSE), (2) stabilizing care, and (3) appropriate transfer of unstable patients.
• An appropriate MSE is an exam comparable to similarly situated patients (ie: non-discrimatory).
• Patients are stable if it is reasonably likely they will not deteriorate during a transfer.
• The duty to stabilize arises only if the physician diagnoses an emergency medical condition (EMC).
• Once stabilized, the hospital and physician have fulfilled their duties under EMTALA.
• The transfer criteria only apply to unstable patients.
• Receiving hospitals may get fined if they fail to report an inappropriate transfer.
• A hospital with specialized capabilities must accept appropriate transfers if it has the capacity to care for the patient.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

Volvulus Quick Facts

• Volvulus causes 10-15% of large bowel obstructions and occurs most commonly in the elderly.
• The most common type of volvulus is sigmoid volvulus.
• Midgut volvulus is most common in the neonatal period.
• Cecal volvulus:
  • Occurs in all ages, but most commonly in the 25- to 35-year-old age group
  • Associated with:
    • previous abdominal surgeries
    • young, healthy marathon runners.
• Sigmoid volvulus most commonly occurs in two groups of individuals:
  • Inactive elderly persons with a history of severe chronic constipation
  • Patients with severe psychiatric or neurologic disease.

Malpractice insurance may not cover the following activities:

• Practicing outside the scope of your specialty (eg: writing admission orders, running upstairs to run resuscitations).
• Undocumented treatment (ie: no ED chart generated)
• Prehospital orders
• EMTALA violations
• Hospital committee work
• Contract violations
• Fraud (including billing mistakes)
• Defamation
• Violation of privacy
• Harassment
• Sexual misconduct
• Assault and battery
• Other crimes

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Thanks to Larry Weiss, MD, JD

What should I do about this finding on the MRI I ordered

Now tha ta lot of EDs are getting MRIs on a more urgent basis, we will need to know what to do with the resutls.  However, the natural history of findings on MRI has not been well studied, so what should we do with that small meningioma you find.  Well some researchers in the Netherlands have attempted to address your question. In a population-based study [Rotterdam Study] , 2000 adults aged 45 or older underwent a brain MRI.

Some of the common findngs were:

• Asymptomatic brain infarcts were observed in 7%.
• Aneurysms and benign tumors (mostly meningiomas) were each found in nearly 2%.
• The two most urgent findings were a chronic subdural hematoma and a 12-mm aneurysm. Both required surgey.
• Only two out of the 2000 (0.001%) people had symptoms related to their MRI findings (hearing loss in both).
• The prevalence of asymptomatic brain infarcts and meningiomas increased with age, as did the volume of white-matter lesions, whereas aneurysms showed no age-related increase in prevalence.

Most of the study patients were white and middle class so these results may not be generalized to the general public.  I am sure more studies are in the works, but for now don't be two suprised if you find an asympomatic infarct or meningioma.

Vernooji MW, Ikram MA, Tanghe HL. Incidental Findings on Brain MRI in the General Population. NEJM. 2007;357(18):1821-1828.