UMEM Educational Pearls - By Haney Mallemat

Category: Visual Diagnosis

Title: What's the daignosis? Written by Adam Brenner, MD

Keywords: ultrasound, ectopic, free fluid, hypotension, pregnancy (PubMed Search)

Posted: 2/27/2011 by Haney Mallemat, MD (Emailed: 2/28/2011) (Updated: 8/28/2014)
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Question

24 yo woman presents with syncope, abdominal pain, and normal menses 4 days prior. Urine HCG(+) and quantitative beta-HCG is 1300 with the transvaginal ultrasound seen below. Diagnosis?

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Category: Critical Care

Title: How good is the McConnell sign for diagnosing pulmonary embolism?

Keywords: Pulmonary embolism, PE, echocardiography, ultrasound, hemodynamics, McConnell sign, right ventricle (PubMed Search)

Posted: 2/15/2011 by Haney Mallemat, MD (Updated: 2/4/2023)
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  • McConnell sign is right ventricular (RV) free wall hypokinesis with normal apical contraction on echocardiography.
  • Finding McConnell sign has been associated with submassive and massive pulmonary embolism (PE) when moderate to high clinical suspicion exists. This is important if unstable patients are unable to tolerate other diagnostic studies.
  • After its description, the specificity of McConnell sign’s for PE has been questioned, as other pathologies can produce it (e.g., RV infarction and severe pulmonary HTN).
  • The paper referenced below retrospectively found that the sensitivity, specificity, positive predictive value, and negative predictive value of McConnell sign for diagnosing PE was 70, 33, 67, ad 36%, respectively.
  • Bottom line: The McConnell sign must be used with caution if used alone to diagnose PE; especially if thrombolytics are being considered.

 

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Category: Trauma

Title: Find the inconsistencies (UPDATED). Written by Dr. Michael Allison

Keywords: blunt trauma, pneumothorax, CXR supine, ultrasound, seashore, stratasphere (PubMed Search)

Posted: 2/14/2011 by Haney Mallemat, MD (Updated: 8/28/2014)
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Question

(Please note the prior version of this pearl was incorrect with respect to the images referenced. This version is corrected.)

Patient s/p blunt chest trauma. CXR (image 1) vs. lung ultrasound (image 2), do you see any inconsistencies?

 

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Category: Critical Care

Title: Critical illness and hemoglobin concentration

Keywords: hemoglobin, anemia, transfusions, hemorrhage, conservative, liberal, hemorrhaging (PubMed Search)

Posted: 2/1/2011 by Haney Mallemat, MD
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The optimal hemoglobin concentration during critical illness is unknown. Although a liberal transfusion strategy (Hb 10-12 g/dL) was once believed to be beneficial for hemodynamics, evidence suggests targeting a conservative strategy (Hb 7-9 g/dL) does not increase mortality, while the unnecessary transfusion of blood products can cause harm (transfusion associated lung injury, infection, etc.) in the non-hemorrhaging patient. 

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Category: Trauma

Title: What's wrong with this picture? By John Greenwood, MD

Keywords: Apical cap, dissection, blunt aortic injury, chest xray, radiology (PubMed Search)

Posted: 1/31/2011 by Haney Mallemat, MD
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Question

44 y/o female restrained driver s/p motor vehicle crash complaining of chest pain and shortness of breath. 

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Category: Critical Care

Title: Testing for Brain Death

Keywords: Apnea test, brain death, brain stem death, coma, death, cardiopulmonary death (PubMed Search)

Posted: 1/17/2011 by Haney Mallemat, MD
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Brain death is the permanent absence of cerebral and brainstem functions (coma, absent pupillary reflexes, no spontaneous respiration, etc.). Legally, brain death is equivalent to cardiopulmonary death.

  • Prior to brain death testing, ensure the following:
  • SBP > 100, core temp >36 Celsius, and absent brainstem reflexes.
  • An identified cause of brain death.
  • No metabolic abnormalities or intoxication.
  • CNS insult on imaging.

If brain death is suspected, confirmation is necessary. The apnea test is most commonly used, evaluating for spontaneous breaths when disconnected from the ventilator. If apnea testing is not possible (e.g., ambiguous clinical exam or cardiopulmonary instability) ancillary testing is needed:

  • EEG
  • Evoked potentials
  • Cerebral angiography
  • CT Angiogram
  • MR Angiography
  • Transcranial Doppler
  • Nuclear Medicine 

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Category: Visual Diagnosis

Title: What's wrong with this picture? (Don't scroll too far down)

Keywords: boxer's, fracture, orthopedics, hand, brawler's, radiology, xray (PubMed Search)

Posted: 1/17/2011 by Haney Mallemat, MD
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Boxer's (or Brawler's) Fracture

  • Fifth metacarpal neck fracture, usually secondary to a direct blow or closed-fist impact.
  • Potentially an unstable fracture and difficult to maintain reduction due to tension from tendons and muscles in the hand.
  • Up to forty degrees of angulation can be tolerated without repair, although there is potential for reduced hand function without repair. Any rotational deformity, however, must be corrected.
  • Non-displaced fractures: RICE therapy, gutter splint, and Ortho follow-up.
  • Displaced, rotated, or angulated fractures (>40 degrees): closed reduction may be attempted but surgical fixation usually required.

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Category: Critical Care

Title: Posterior Reversible Encephalopathy Syndrome

Keywords: PRES, hypertensive crisis, seizures, visual loss, ecclampsia, hypertensive emergency, cyclopsporine, tacrolimus (PubMed Search)

Posted: 1/4/2011 by Haney Mallemat, MD
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Posterior reversible encephalopathy syndrome (PRES) is a syndrome of visual loss, headache, altered mental status, and seizures, typically with severe hypertension. PRES usually occurs with hypertensive encephalopathy or ecclampsia, although cyclosporin and tacrolimus use have been implicated. 

PRES is due to a combination of endothelial damage, impaired auto-regulation and increased cerebral perfusion pressure. Classic CT and MRI findings are parietal-occipital, cerebellar, or brainstem cortical and subcortical edema. 

 

Early recognition and symptomatic treatment is key; IV anti-hypertensives (hypertensive encephalopathy), anti-epileptics (seizures), IV magnesium and emergent delivery (ecclampsia), and discontinuing offending medications (cyclosporin and tacrolimus).  

 

With treatment, partial to complete recovery is normal, although residual neurological and visual deficits may persist.

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Category: Critical Care

Title: Thrombocytopenia in the Critically-ill

Keywords: thrombocytopenia, critically0ill, sepsis, death, mortality, prognosis (PubMed Search)

Posted: 12/21/2010 by Haney Mallemat, MD
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The incidence and prevalence of thrombocytopenia in the ICU is poorly defined however, it has been found to be an independent predictor of death in the critically-ill. Increased mortality does not appear to be related to bleeding complications. On the other hand, survivors of critical illness tend to recover platelet faster as compared to non-survivors. 

 

Thrombocytopenia in the critically-ill is a marker for systemic inflammation/infection although the exact mechanisms are unknown. Common risk factors associated with thrombocytopenia in the ICU population are:

 

Sepsis

Renal failure

High-illness severity

Organ dysfunction

 

Bottom line:  Thrombocytopenia in the critically-ill is associated with increased mortality. 

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Category: Critical Care

Title: Linezolid and Serotonin Syndrome

Keywords: Antibiotics, linezolid, serotonin syndrome, delirium, critical care (PubMed Search)

Posted: 12/7/2010 by Haney Mallemat, MD
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Linezolid is used for gram-positive infections resistant to conventional therapy (e.g., Vancomycin-resistant enterococcus and Methicillin Resistant Staph Aureus). Linezolid is an oxazolidinone, but more importantly it is a weak monoamine oxidase inhibitor (MAOI) and serotonin syndrome (e.g., altered mental status, neuromuscular abnormalities, autonomic instability) may occur when combined with selective serotonin re-uptake inhibitors (SSRIs) or with recent discontinuation of SSRI. 

 

Be aware that the following drugs can precipitate serotonin syndrome when combined with Linezolid:

 

Mirtazpine       Buproprion       Fentanyl

Trazodone       Buspirone         Bromocryptine

Levodopa        Lithium               Amphetamines

Cocaine           Codeine            Reserpine

Ergots               MAOI's

 

 

 

 

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Category: Critical Care

Title: Beware of Non-Convulsive Status Epilepticus

Keywords: Status epilepticus, non-convulsive, altered mental status, seizure, critical care, ICU, neurology (PubMed Search)

Posted: 11/23/2010 by Haney Mallemat, MD
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Non-Convulsive Status Epilepticus (NCSE) is generally under reported. An ICU study found 10% admissions for altered mental status (AMS) were eventually diagnosed as NCSE.

Pearls:

- Include NCSE in the AMS differential

- NCSE may occur with or without convulsive seizures

- Difficult to distinguish from a post-ictal state (14% of convulsive seizures convert to  

  NCSE)

- Reported mortality is up to 44%

 

Consider NCSE when:

- Seizure history / recent seizures

- Post-ictal period >1 hour

- Odd behaviors (e.g., chewing, blinking, personality change) and abnormal eye 

  movements (86% specific)

- AMS without structural, metabolic or traumatic etiology

- Patient intubated for status epilepticus 

 

If you are unsure but suspicious of NCSE order a STAT EEG.  Treat NCSE like a convulsive status.

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Category: Critical Care

Title: Ocular sonography and elevated intracranial pressure

Keywords: ultrasound, ocular, sonography, intracranial pressure, optic nerve sheath, ICP (PubMed Search)

Posted: 11/9/2010 by Haney Mallemat, MD
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Ocular sonography is a fast, simple, and non-invasive tool to detect elevated intracranial pressure (ICP) by measuring the optic nerve sheath diameter (ONSD). Several studies have shown a positive correlation between increased ONSD (>5.7mm) and elevated ICP (>20mmHg).  Although ultrasound may not replace CT or MRI to diagnose the cause of the increased ICP, its use as a triage tool can expedite these tests.

 

The technique:

  1. Use linear probe on closed eyelid.
  2. Identify the optic nerve sheath.
  3. Measure the optic nerve sheath, 3mm behind globe.
  4. Rotate probe 90 degrees and measure again.
  5. Average both diameters.

Please see the references below for more information and, as with any new technique please consult local experts prior to making clinical decisions

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Category: Critical Care

Title: Long-term complications of ICU Delirium

Keywords: delirium, dementia, ICU, (PubMed Search)

Posted: 10/25/2010 by Haney Mallemat, MD (Updated: 2/4/2023)
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Increasing literature demonstrates ICU delirium is bad. Delirium in mechanically ventilated patients is an independent predictor for long-term cognitive defects (e.g., managing money, following detailed instructions, reading maps, and developing dementia). The cited study found 80% of patients with ICU delirium had cognitive dysfunction at three months, and 70% had residual dysfunction at one year (33% had severe dysfunction).

You must be aggressive to prevent delirium:

-         Implement daily assessment tools (e.g., CAM-ICU)

-         Daily awakening and spontaneous breathing trials

-         Early patient mobilization

-         Aggressive pharmacological treatment of delirium

-         For more information: www.icudelirium.org

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Category: Critical Care

Title: Heliox in severe asthma

Keywords: asthma, heliox, airway (PubMed Search)

Posted: 10/12/2010 by Haney Mallemat, MD (Updated: 2/4/2023)
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Heliox is a mixture of oxygen and helium resulting in a gas less dense than air. In asthma, airway resistance causes turbulent airflow which increases the work of breathing. Heliox reduces airway resistance by increasing laminar airflow. 

 

Benefits: 

Better lung mechanics

Improved nebulizer delivery

Few known side-effects/complications

 

Drawbacks:

Expensive

Contraindicated in hypoxemic patients.

Paucity of large prospective randomized trials.

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Category: Critical Care

Title: Continuing HAART for critically-ill HIV/AIDS patients?

Keywords: HAART HIV AIDS Critical illness (PubMed Search)

Posted: 9/27/2010 by Haney Mallemat, MD (Emailed: 9/28/2010) (Updated: 9/28/2010)
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While you should always involve ID consultants when managing critically-ill HIV/AIDS patients on HAART, consider this; sub-therapeutic levels of anti-retrovirals may promote HIV resistance, potentially invalidating a class of drug for future use. Therefore, it may be advantageous to discontinue the drug(s) during critical-illness to avoid resistance. 

 

Two examples leading to sub-therapeutic HAART levels in critical-illness:

  1. Reduced absorption of PO medications from bowel wall edema and/or decreased splanchnic perfusion.
  2. Interactions with HAART medications and the multitude of other drugs administered in the ICU.

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Category: Critical Care

Title: Necrotizing Soft Tissue Infections (NSTI)

Keywords: Necrotizing Soft Tissue Infections, sepsis, critical care, surgery (PubMed Search)

Posted: 9/13/2010 by Haney Mallemat, MD (Emailed: 9/14/2010) (Updated: 9/14/2010)
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(Sorry for the previously mislabeled pearl...)

Necrotizing soft tissue infections (NSTI) are on the rise and, despite improved surgical and critical care, over the years there has only been a mild reduction in mortality. Survival is associated with early diagnosis and treatment. Unfortunately, NSTI are not always obvious because deeper tissues made be involved first. Despite a validated scoring system and better radiology, our clinical suspicion still rules and relies on a meticulous history and physical exam. 

Here are some subtle signs of NSTI:

 

Pain out of proportion to exam

Edema beyond region of erythema

Skin anesthesia

Skin erythema and/or hyperthermia

Epidemolysis

Skin bronzing

 

If NSTI is suspected, be vigilant! Start broad-spectrum antibiotics, begin appropriate resuscitation and involve your surgeons early.

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Category: Critical Care

Title: Cerebral Salt Wasting Syndrome vs. Syndrome of Inappropriate ADH Secretion.

Keywords: SIADH, CSW, syndrome of inappropriate adh, cerebral salt wasting, hyponatremia, neurosurgery (PubMed Search)

Posted: 8/30/2010 by Haney Mallemat, MD (Emailed: 8/31/2010) (Updated: 2/4/2023)
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Hyponatremia plagues many neurosurgical patients due to the syndrome of inappropriate secretion of ADH (SIADH) or the cerebral salt wasting syndrome (CSW). Both diseases may appear similar (hyponatremia, increased urine osmolarity, increased urine sodium, normal adrenal, renal and thyroid function), but there is one BIG difference. Patients with SIADH are euvolemic or hypervolemic (excess ADH causes fluid retention) whereas patients with CSW are fluid depleted (impaired renal handling of sodium and water). To differentiate, look for signs of hypovolemia: orthostatics, dry mucus membranes, hemoconcentration, pre-renal azotemia, and/or hemodynamics (IVC collapse anyone?).

Bottom line: Distinguish SIADH from CSW because the treatments are exact opposites:

SIADH: Fluid restrict

CSW: Give water and salt (i.e., 0.9% saline)

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Category: Critical Care Literature Update

Title: Ultrasound-Guided Subclavian CVC

Keywords: Subclavian,ultrasound, cvc, central venous catheter (PubMed Search)

Posted: 8/17/2010 by Haney Mallemat, MD (Updated: 2/4/2023)
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Evidence suggests subclavian central venous catheters have fewer complications (e.g., less thrombosis and infection) compared to catheters at other sites. The benefits come at increased risk for potential complications during placement using the landmark technique (e.g., pneumothorax and arterial puncture). Ultrasound-guided subclavian cannulation is gaining popularity and is actively being studied. 
 
How to do it:
 
1. Find the axillary vein; located caudal to the distal third of the clavicle (see reference).

2. Distinguish artery from vein with compression and/or Doppler.* 

3. Sterilely prep the site and ultrasound probe.

4. Cannulate the vein in the transverse or longitudinal plane.

 
*Note: Some recommend following the axillary vein medially until it becomes the subclavian vein and cannulating this site.

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Question

50 year-old male with cough and dyspnea. What's the diagnosis?

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Category: Critical Care

Title: Adrenal Insufficiency

Posted: 4/12/2013 by Haney Mallemat, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
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Adrenal insufficiency (AI) can be a life-threating condition and is classified as primary (failure of the adrenal gland) or secondary (failure of hypothalamic- pituitary axis).

Common causes of primary adrenal insufficiency include autoimmune destruction, infectious causes (TB and CMV), or interactions with drugs (e.g., anti-fungals, Etomidate, etc.). Secondary causes are usually due to abrupt withdrawal of steroids after chronic use, although sepsis and diseases of the hypothalamus or pituitary (e.g., CVA) may occur.

Signs and symptoms include fatigue, weakness, skin pigmentation, dizziness, abdominal pain, and orthostatic hypotension; it should be suspected with any of the following: hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia, low free-cortisol level, and hemodynamic instability despite resuscitation.

Treatment:
• Correct underlying the disorder
• Resuscitation and hemodynamic support
• Correct hypoglycemia and electrolyte abnormalities
• Treat with hydrocortisone, cortisone, prednisone, or dexamethasone +/- fludrocortisone (Note: dexamethasone is attractive choice in the ED because it will not interfere with ACTH stimulation test)


 

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