UMEM Educational Pearls

Title: Kawasaki Disease

Category: Cardiology

Keywords: Kawasaki Disease, Mucocutaneous lymph node syndrome (PubMed Search)

Posted: 12/2/2012 by Semhar Tewelde, MD (Updated: 11/24/2024)
Click here to contact Semhar Tewelde, MD

 

Kawasaki disease (KD) is the leading cause of acquired heart disease in North American & Japanese children
Children w/KD should undergo a 2-D echocardiogram and electrocardiogram
In the acute phase, the myocardium, pericardium, endocardium, valves, conduction system, and coronary arteries may all be involved
KD shock syndrome is a cardiovascular manifestation that presents with hypotension, LV systolic dysfunction, coronary artery aneurysm, and a shocklike state
AHA recommends KD tx w/a single dose of 2 g/kg of IVIG infused over 12 hours plus high-dose aspirin at a dose of 80 to 100 mg/kg per day in 4 divided doses
More than 50% of coronary artery aneurysms regress within the first 2 years of onset 
Regression is associated with marked thickening of the intima, which  may later stimulate atherosclerosis with a risk for ischemic heart disease

Show References



Title: Treating PID in a Doxycycline-Allergic Patient

Category: Pharmacology & Therapeutics

Keywords: doxycycline, PID, pelvic inflammatory disease, STD, azithromycin (PubMed Search)

Posted: 11/28/2012 by Bryan Hayes, PharmD (Updated: 12/1/2012)
Click here to contact Bryan Hayes, PharmD

In the rare circumstance you need to treat a patient with suspected PID and an allergy to doxycycline, what is the alternative?

For oral regimens, azithromycin is an option in place of doxycycline.

  • In one randomized trial, azithromycin demonstrated short-term effectiveness when given 500 mg X 1, followed by 250 mg/day for 6 days.
  • In another randomized study, the combination of ceftriaxone 250 mg IM single dose and azithromycin 1 g orally once a week for 2 weeks was effective.

Suggested regimen for PID with doxycycline allergy:

  • Ceftriaxone 250 mg IM X 1
  • Azithromcyin 500 mg IV/PO X 1, then 250 mg PO daily for 6 days
  • plus/minus Metronidazole 500 mg PO twice daily for 14 days

Show References



Title: CT Findings of Tox Cases

Category: Toxicology

Keywords: CT, carbon monoxide, cyanide (PubMed Search)

Posted: 11/29/2012 by Fermin Barrueto (Updated: 11/24/2024)
Click here to contact Fermin Barrueto

It is not often that a CT will be able to give you a hint to a toxicologic diagnosis. The following are CT findings that are either suggestive and even sometimes almost diagnostic for a given to toxin:

1) Intraparenchymal or Subarachnoid Hemorrhage: sympathomimetics or mycotic anuerysm rupture secondary to IV drug abuse

2) Basal Ganglia bilateral focal necrosis: characteristic of carbon monoxide, cyanide, hydrogen sulfide and even methanol

3) Severe advanced atrophy out of proportion for age: alcoholism, toluene

Show References



Title: When Water is Undrinkable

Category: International EM

Keywords: water, international, cryptopsporidium, chlorine, iodine, boiling (PubMed Search)

Posted: 11/28/2012 by Andrea Tenner, MD
Click here to contact Andrea Tenner, MD

General Information:
• Millions of people around the world (including our patients who travel and victims of disasters like Hurricane Sandy) are exposed to non-potable water.
• How to treat contaminated water:
      ♦ Filter cloudy water through a clean cloth or allow to settle prior to treatment
      ♦ The safest method is boiling water vigorously for 1 minute (or, at least 3 minutes at altitudes >6,000ft)
      ♦ Chemical disinfection is not as effective but, if boiling is not possible, use either:
              • 2 drops of unscented bleach (5.52% Cl) per quart/liter of water.  (Unknown strength? Add 10     drops per quart/liter.)
                -Or-
               • 5 drops of tincture of 2% iodine per quart/liter.
                     - If the water is cloudy or cold, double the chlorine or iodine.
                     - Notes: Pregnant women or people with thyroid conditions should not use iodine
       ♦ UV decontamination can be accomplished by leaving clear bottles of water in direct sun for >6 hours or special equipment, but requires clear water
• Boiling, Chlorine/Iodine, and UV will kill viruses, bacteria, and Giardia
• Only Boiling kills Cryptosporidium

Bottom Line:
• If bottled water is available, use it.
• If not, boil your water.
• In order to treat for a wide variety of pathogens, it is best to combine available methods.

University of Maryland Section for Global Emergency Health
Author: Andi Tenner
 

Show References



Title: Management of AKI

Category: Critical Care

Posted: 11/27/2012 by Mike Winters, MBA, MD (Updated: 11/24/2024)
Click here to contact Mike Winters, MBA, MD

Managing Critically Ill Patients with AKI

  • Acute kidney injury (AKI) occurs in almost 50% of hospitalized patients and is an independent risk factor for mortality. 
  • Updated guidelines have recently been published on the management of patients with AKI.
  • Pearls for the management of patients with, or at risk of, AKI include:
    • Optimize volume status and perfusion pressure
      • Crystalloids preferred over colloids
      • Consider vasopressors to maintain MAP > 65 mm Hg
    • Avoid nephrotoxic drugs
    • Control co-factors
      • Monitor intra-abdominal pressure
      • Avoid hyperglycemia - target glucose < 150 mg/dL

Show References



Question

2 year-old male with past medical history of asthma presents with fever and respiratory distress. CXR is shown below. What’s the diagnosis? (Hint: ...look beyond the obvious)

Show Answer

Show References



Title: Rheumatic Heart Disease

Category: Cardiology

Keywords: Rheumatic fever, rheumatic heart disease (PubMed Search)

Posted: 11/25/2012 by Semhar Tewelde, MD (Updated: 11/24/2024)
Click here to contact Semhar Tewelde, MD

 

Rheumatic heart disease (RHD) causes  ~250,000 premature deaths every year
Worldwide RHD is the leading cause of heart failure in children and young adults
RHD manifests as a combination of fever, polyarthritis, carditis, chorea, erythema marginatum, and subcutaneous nodules (major Jones Criteria)
Mitral valve incompetence is the most common valvular lesion and mitral stenosis usually develops later as a result of persistent or recurrent valvulitis with bicommissural fusion
Eradication of group A streptococcus with penicillin prevents the initial acute rheumatic attack
No treatment for RHD exists other than for its complications, including heart failure, atrial fib, ischemic embolic events, and infective endocarditis

Show References



Title: Hematoma blocks

Category: Orthopedics

Keywords: hematoma blocks, fracture analgesia (PubMed Search)

Posted: 11/24/2012 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Hematoma blocks for distal radius fractures

 

Hematoma blocks provide safe, effective analgesia without an increased risk of post procedural infections when compared with other regional blocks

Provide equal reduction quality AND pain control as procedural sedation with Propofol.

However, mean time to reduction (0.9 vs. 2.6 hours) and time to discharge post procedure (0.74 vs. 1.17 hours) were reduced with hematoma blocks.

Consider this option next time the department is busy or the patient is not an ideal procedural sedation candidate.

Show References



Title: Malaria Basics

Category: International EM

Keywords: malaria, Plasmodium, falciparum, quinine, international, fever (PubMed Search)

Posted: 11/21/2012 by Andrea Tenner, MD (Updated: 11/24/2024)
Click here to contact Andrea Tenner, MD

  • General information
    • Organism: 5 Plasmodium species (P. falciparum, P. vivax, P. ovale, P. malariae, P. knowlesi)
      • P. falciparum is responsible for most severe disease.
      • P. vivax and P. ovale are responsible for recrudescent disease.
    • Transmission via the female Anopheles mosquito, which bites at night or in the early morning.
    • Endemic in Asia, Africa, Central America, and South America
  • Clinical presentation
    • Initially, the patient presents with an acute febrile illness: fever, chills, headache, nausea, lethargy, and upper respiratory symptoms.
    • Infection with P. falciparum can further progress to severe organ dysfunction.
    • The disease course is unpredictable in the non-immune individual.
  • Diagnosis
    • Thick and thin peripheral blood smears demonstrating organism
      • Thick smear – confirms Plasmodium parasites
      • Thin smear – allows speciation of Plasmodium parasites
    • Hyperparasitemia is associated with increased mortality
  • Treatment
    • P. falciparum or species unidentified
      • For severe malaria, IV quinine (quinidine if quinine not available)
      • IV artusenate is available from the CDC as a quinidine/quinine alternative.
      • DO NOT USE Chloroquine for severe malaria
    • Patients with evidence of complicated malaria (>3% parasitemia, signs of organ dysfunction, alterations in mental status) should be admitted to an ICU.

 

University of Maryland Section for Global Emergency Health

Author: Emilie J.B. Calvello, MD, MPH

Show References



A low-tidal volume (or protective) strategy of mechanical ventilation (i.e., tidal volume of 6-8cc/kg of ideal body weight) has previously been demonstrated to be beneficial in patients with acute respiratory distress syndrome (ARDS).

A meta-analysis was recently performed to determine whether this strategy of mechanical ventilation is also beneficial for patients without lung injury prior to initiation of mechanical ventilation.

Dr. Neto, et al. performed a meta-analysis of 20 studies (total of 2,822 mechanically ventilated patients) comparing a conventional ventilation strategy (average tidal volume was 10.6 cc/kg) to a protective ventilation strategy (average tidal volume was 6.4 cc/kg) of mechanical ventilation.

The authors concluded that patients ventilated with a protective lung-strategy had reductions in:

  • Mortality
  • Lung injury and ARDS
  • Atelectasis
  • Pulmonary infections          
  • Length of hospital stay

Bottom-line: This meta-analysis supports the notion that a strategy of low-tidal volume ventilation may have benefits for patients without ARDS, however prospective studies are needed.

Show References



Do you like placing ultrasound-guided IV catheters? Check out this trick for covering the probe during the procedure.

http://ultrarounds.com/Ultrarounds/The_Vascular_Probe_Protector.html

or

https://www.youtube.com/watch?v=ZuOq6Ea_FbA&feature=plcp

Show References



Title: Long QT Syndrome Part II

Category: Cardiology

Keywords: Torsades de pointes, prolonged QT syndrome (PubMed Search)

Posted: 11/18/2012 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD

 

When polymorphic ventricular tachycardia (VT) is encountered the 1st step is to examine the QTc interval before/after the VT to see if it's prolonged
Torsades de pointes (TDP) typically begins with a premature ventricular depolarization, followed by a compensatory pause, and then a sinus beat with a markedly prolonged QT interval, subsequently followed by a train of polymorphic VT
The risk of developing TDP correlates with the degree of prolongation of QTc interval
Risk = 1.052x, where X is a 10-ms increase in QTc interval
Tx algorithm: ECG reveals prolonged QTc, review drug hx, discontinue all QT prolonging drugs, suppress early after depolarization (EAD) w/magnesium bolus & infusion, maintain serum K levels >4.5meq/L, consider isoproterenol infusion + cardiac pacing 

Show References



Title: Tarsal Tunnel Syndrome

Category: Orthopedics

Keywords: tarsal tunnel syndrome (PubMed Search)

Posted: 11/17/2012 by Michael Bond, MD (Updated: 11/24/2024)
Click here to contact Michael Bond, MD

Tarsal Tunnel Syndrome (TTS)

Prior pearls have addressed Carpal Tunnel Syndrome and Cubital Tunnel Syndrome, which affect the median and ulnar nerves, respectively.  Tarsal tunnel syndrome, is a similar compression neuropathy of the tibial nerve as it transverses through the tarsal tunnel of the foot.

The tarsal tunnel is located behind the medial malleolus, and is where the posterior tibial artery, tibial nerve and several tendons transverse.  Patients will present complaining of numbness of the foot radiating into  Digits 1-4, pain, burning , and tingling of the base of the foot and heel.  TTS has many causes and is more common in athletes.

Consider the diagnosis in patients with foot pain and numbness.  If interested in more information about TTS please consider reading this eMedicine article, http://emedicine.medscape.com/article/1236852-overview



Title: Fever and neck pain (submitted by Connor Lundy, MD)

Category: Pediatrics

Keywords: meningitis, neck pain, retropharyngeal abscess (PubMed Search)

Posted: 11/16/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Question

A 1 year old gets sent from their pediatrician’s office for rule out meningitis. They presented with fever for 2 days and neck rigidity. Your LP results are normal. What additional test should you consider?
 

Show Answer



·      Explosions can cause a complex series of injuries, which may include subtle or delayed findings.  Repeated evaluations, such as serial abdominal exams, may be required.

·      Blast injuries are divided into 4 categories:

o   Primary blast injuries: Injury from blast wave over-pressure. Found in gas filled structures (ear, lung, hollow organs)

o   Secondary blast injuries: Injury from thrown objects (primarily penetrating trauma, but may blunt)

o   Tertiary blast injuries: Injuries from patient being thrown by blast wave (blunt trauma)

o   Miscellaneous (quaternary) blast injuries: Injuries from other causes, such as burns, crush injuries, rhabdomyolysis, and toxic chemicals.

·      The most common primary blast injury is tympanic membrane rupture.

 

University of Maryland Section for Global Emergency Health

Author: Jon Mark Hirshon

Show References



Burn Patients and Antibiotic Dosing

  • Burn patients have a number of abnormalities in the early postinjury phase that can significantly impact the efficacy of antimicrobial therapy.  These include hypovolemia, hypoalbuminemia, and increasing GFR.
  • A few pearls when dosing select antibiotics in burn patients:
    • Aminoglycosides: in the absence of renal impairment, consider more frequent dosing to achieve adequate concentrations.
    • Beta-lactams: typical doses often don't reach effective concentrations; increase the dose, frequency of administration, or duration of infusion.
    • Vancomycin: the typical dose of 1 gm is usually ineffective; use a larger loading dose (15-20 mg/kg).
    • Linezolid: standard doses are usually ineffective; use a higher initial dose.

Show References



Question

33 year-old male found unconscious by EMS and complains of right shoulder pain upon waking up in the ED. Diagnosis? 

Show Answer

Show References



Bazett's Formula QTc = QT/RR1/2 

Show References



 

Despite advancement of molecular genetics dx of congenital long QT syndrome is based on ECG & clinical characteristics
Typical presentation is that a child/young adult experienced unexplained syncope or sudden death during physical exertion or emotional agitation
Bazett formula (QTc = QT x RR 1/2) is the most widely used method for measuring QTc
A QTc interval longer than 440 ms has been considered prolonged
1st described was QT prolongation w/congenital bilateral neural deafness and SCD (Jervell and Lange-Nielsen syndrome)
The more common form is QT prolongation w/o deafness and SCD (Romano-Ward syndrome)
Beta-blockers remain the mainstay treatment
Implantable cardioverter-defibrillator (ICD) is an effective therapeutic option to reduce mortality

Show References



Injury is often caused by sudden dorsiflexion on a plantar flexed foot w/ the knee in extension or similarly sudden knee extension with the ankle in a dorsiflexed position.

Injury has a predilection for the poorly conditioned middle-aged athlete, with "thick calves" who are engaged in strenuous activity

Strains are treated with ice, analgesics, and compression (decreases hematoma size and facilitates healing)

Also, consider casting/splinting as dictated by injury severity, such as with a night splint or a CAM boot.

Severe strains and ruptures can be splinted in plantar flexion for 3 weeks.

 

Show References