UMEM Educational Pearls

Category: Cardiology

Title: Yamaguchi Cardiomyopathy

Keywords: yamaguchi cardiomyopathy, apical hypertrophic cardiomyopathy, hypertrophic cardiomyopathy (PubMed Search)

Posted: 7/29/2012 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD

Yamaguchi Cardiomyopathy

Yamaguchi cardiomyopathy a.k.a. apical hypertrophic cardiomyopathy (AHCM) was first described 1976 in Japanese patients.

AHCM is a variant of hypertrophic cardiomyopathy that is nonobstructive with predominant involvement of the apex of the heart.

AHCM is frequently misdiagnosed as ACS or STEMI since the typical ECG abnormalities include giant inverted T waves or ST elevation in the mid precordial leads, however coronaries are characteristically clean on cardiac catheterization.

Echocardiography classically used to diagnosis HCM may frequently miss AHCM because hypertrophy is only localized to the apex.

Nuclear magnetic resonance imaging or angiography reveals the pathognomonic "ace of spades" configuration of the left ventricle with systolic obliteration of the apical region.

Unlike HCM sudden cardiac death is very uncommon.

 

Show References



Category: Misc

Title: Jet lag in athletes

Keywords: Travel, jet lag, circadian (PubMed Search)

Posted: 7/28/2012 by Brian Corwell, MD (Updated: 11/10/2024)
Click here to contact Brian Corwell, MD

Travel across time zones is regularly required of profession and collegiate athletes (in addition to the some of us professionally)

Jet lag is defined as insomnia or excessive daytime sleepiness/malaise following travel across at least 2 time zones

                Symptoms usually persist 1 day for each time zone crossed

The sleep schedule is primarily modulated by light and melatonin

Secretion of melatonin helps induce sleep

Exposure to light stimulates arousal and inhibits melatonin secretion

Who is at risk?

Those with more rigid sleep habits have more symptoms

“Morning” people have less difficulty flying eastward

“Evening” people have less difficulty flying west

However, overall, eastward travel causes the most severe symptoms which persist for up to 7 days (versus <3 days with westward travel)

                (The length of the day gets shortened and the circadian system must shorten to reestablish a normal rhythm. The human body demonstrates a natural tendency toward periods longer than 24 hours)

Those with higher levels of physical fitness adjust more quickly

Effects similar in men and women

Midday arrivals experience fewer symptoms than morning arrivals

Symptoms are less in those who have traveled the journey previously

Symptoms are less in those who had a shorter interval their last full nocturnal sleep in the departure city and their first full nocturnal sleep in the destination city



Category: Pediatrics

Title: Neonatal jaundice (submitted by Adam Brenner, MD)

Keywords: hemolysis, bilirubin, kernicterus, jaundice (PubMed Search)

Posted: 7/27/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Emergency physicians must be comfortable evaluating the neonate, and be able to manage, offer guidance to parents, and interpret and discuss bilirubin levels with pediatricians to prevent development of kernicterus
 
1 ) The key is the history, which allows you to risk stratify your patient; Risk factors for rising bilirubin levels include:
- isoimmune hemolytic disease
- G6PD deficiency
- Asphyxia
- Lethergy
- Sepsis
- Albumin < 3.0
Always ask parents about;
- Time of birth (hours matter)
- Maternal and fetal blood type
- Birth hx: term or preterm, GBS, TORCH infections
- Fever
- Poor feeding/ feeding patterns, including whether mom feels engorged and if latching is successful
- Stool color (yellow, acholic)
- Timing of first stool
- Timing of jaundice (jaundice at Day 1 of life is not physiologic)
 
2) Determine direct and total bilirubin level (direct bilirubinemia is always pathologic, and may indicate biliary atresia or hepatitis)
 
3) Determine need for observation, phototherapy, or exchange transfusion- Plot total bilirubin level on bilirubin nomogram- Nomograms can be referenced online or in Harriet- Lane handbook (separate nomograms exist for guidelines regarding phototherapy and exchange transfusion)
 
4) If safe for discharge, arrange for followup, and if no follow up available, the patient should return to the ED for a repeat bilirubin check in 12-24 hrs
 

Bonus pearl:  Types of Jaundice by Age

- < 24 hrs: hemolyis, TORCH, bruising from birth trauma (ie- cephalohematoma), acquired infection
- Day 2-3: Physiologic
- Day 3-7: infection, congenital diseases, TORCH
- >1 week: Breast Milk Jaundice, breast feeding jaundice, drug hemolysis, hypothyroidism, biliary atresia, hepatitis, red cell membrane disorders (SS, HS, G6PD deficiency)

 



Category: Toxicology

Title: Ethanol Withdrawal

Keywords: CIWA, alcohol, withdrawal (PubMed Search)

Posted: 7/26/2012 by Fermin Barrueto (Updated: 11/10/2024)
Click here to contact Fermin Barrueto

CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised)

The use of a scoring system for the disposition of an ethanol withdrawal patient can be helpful. The CIWA-Ar Score can guide both treatment in the ED as well as admission versus discharge. Most studies have verified that a score of <8 can be treated outpatient; 8-15 requires treatment and >15 wil require admission/IV benzodiazepines.

N/V: 0-7 (None to Constant N/V)

Tremor: 0-7 (None to Severe even with arms not extended)

Sweats: 0-7 (None to Drenching Sweats)

Anxiety: 0-7 (None to panic attack/delirium)

Agitation: 0-7 (None to pacing/thrashing during interview)

Tactile Disturbance: 0-7 (Mild itching to Continuous Hallucinations)

Auditory Disturbances: 0-7 (None to Continuous Hallucinations)

Visual Disturbances: 0-7 (None to Continuous Hallucinations)

Headache: 1-7 (Miild to Extremely Severe)

Orientation: 0-4

Go to this website to see the actual tool and how it should be administered:

http://www.regionstrauma.org/blogs/ciwa.pdf



Steroids and Septic Shock

  • Do low-dose steroids improve mortality or shock reversal in patients with septic shock?
  • A recent systematic review published in the Journal of Emergency Medicine found:
    • A statistically significant improvement in shock reversal (RR 1.17)
    • A favorable, but not statistically significant, mortality benefit for patients with refractory septic shock (RR 0.92; CI 0.79-1.07)
  • Most guidelines recommend against steroids for septic patients that are responding to fluid resuscitation and vasopressor therapy.
  • Updated guidelines from the Surviving Sepsis Campaign (soon to be published) will continue to recommend low-dose IV corticosteroids (200 mg over 24hrs) for those who are refractory to fluids/vasopressors.

Show References



Question

Find four abnormalities in the chest Xray below.

Show Answer

Show References



Category: Orthopedics

Title: Humerus Fractures

Keywords: Humerus Fractures (PubMed Search)

Posted: 7/21/2012 by Michael Bond, MD (Updated: 8/28/2014)
Click here to contact Michael Bond, MD

Humerus Fractures, Proximal

  • Proximal fractures of the humerus only account for about 5% of all fractures but account for 45% of all humeral fractures.
  • We should be familar with the Neer Classication System for Humeral fractures, which can also be seen at http://health-7.com/Handbook%20of%20Fractures/15%20-%20Proximal%20Humerus%20Fractures
     
  • The classification system classifies fractures based on
    • 1-part
    • 2-part
    • 3-part
    • 4-part
  • The bony segments that make up the parts are
    • Greater Tuberosity (GT)
    • Lesser Tuberosity (LT)
    • Humeral Head
    • Humeral Surgical Neck (SN)
  • A part is defined as displaced if >1 cm of fracture displacement or >45 degrees of angulation.
  • The greater the number of parts the more likely the patient will require surgery or have increased complications.
    • 3 and 4 part fractures are often fixed surgical due to the increased risk of vascualr compromise to the humeral head.

 



Category: Pediatrics

Title: Childhood cancer (submitted by Semhar Tewelde, MD)

Keywords: leukemia, back pain, cancer (PubMed Search)

Posted: 6/29/2012 by Mimi Lu, MD (Emailed: 7/20/2012) (Updated: 7/20/2012)
Click here to contact Mimi Lu, MD

ED Presentations of Childhood Cancers

Approximately 12,000 children are diagnosed with malignancies in the USA each year.  Cancer is the second leading cause of death in children in the USA. Acute leukemias are the most common type of cancer, 26% of all cancer diagnosis.  Brain tumors and lymphomas are the next most common categories of neoplasm in children.
 
Initial symptoms in children who are diagnosed with cancer often mimic those of other, more common childhood illnesses; fever, vomiting, weight loss, fatigue, and malaise.  Particular attention should be paid to the patient who makes repeated visits for a persistent complaint that has not been fully evaluated.
 
Back pain is a rare complaint in children and should especially concern the ED physician to consider some common childhood tumors i.e. Wilms, Neuroblasoma, Osteosarcoma and Ewing sarcoma, Leukemia and/or Lymphoma

Findings which should prompt further work-up in the ED are: pallor, bleeding: petechiae, purpura, bone pain, limp, painless lymphadenopathy, gingival hyperplasia, abdominal mass, night sweats, pruritis, and unintended weight loss
 
Labs to obtain: CBC with manual differential, peripheral smear, CMP, uric acid, LDH, coagulation profile, and chest radiograph


Wernicke encephalopathy (WE) is a neurologic disorder secondary to prolonged thiamine deficiency; it is characterized by confusion, ataxia, and ocular abnormalities. 

Traditional medical teaching advises against the administration of glucose (or glucose containing fluid) in thiamine deficient patients, without first giving thiamine, as this may precipitate WE. 

This teaching is problematic, however, in hypoglycemic patients who require the immediate administration of glucose while simultaneously being suspected of thiamine deficiency (e.g., malnourished alcoholics). Delays in treating hypoglycemia may be more harmful (e.g., seizures, permanent neurologic deficits, etc.) than the risk of WE.

Schabelman et. al performed a literature search to unearth the origins of this teaching. Nineteen papers related to this topic were found consisting of case reports, animal studies, and expert opinion; there were no randomized trials, cohort studies, or case-control studies.

Bottom-line: The available evidence does not support withholding glucose treatment until thiamine can be administered and educators should consider abolishing this dogmatic teaching until better evidence is available.

Show References



Category: Visual Diagnosis

Title: What's the Diagnosis? Written by Ali Farzad, MD

Posted: 7/15/2012 by Haney Mallemat, MD (Emailed: 7/16/2012) (Updated: 7/16/2012)
Click here to contact Haney Mallemat, MD

Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

 

Show Answer

Show References



Category: Cardiology

Title: Atrial Fibrillation

Keywords: Atrial fibrillation, a fib (PubMed Search)

Posted: 7/15/2012 by Semhar Tewelde, MD (Updated: 11/10/2024)
Click here to contact Semhar Tewelde, MD

Atrial fibrillation is most commonly associated with cardiovascular disease    

Non cardiac causes: pulmonary disease/PE, hyperthyroidism, sympathomimetics, drugs/ETOH

AFFIRM & RACE trials compared outcomes of a fib patients treated w/ rate vs. rhythm control

    - No significant difference in survival between groups

Risk of thromboembolic CVA

   - Rhythm control = Rate control + anticoagulation

New data challenges the need for strict heart rate control

   - Resting heart rate should be <110 bpm

Use CHADS2 score to identify who requires anticoagulation based on %risk of emboli 

   - Chronic heart failure, HTN, Age>75, DM, Stroke/TIA 

  

 

 

 

                                           

 

 

 

Show References



Category: Orthopedics

Title: Ulnar nerve compression neuropathy

Keywords: Ulnar nerve, compression, neuropathy, wrist (PubMed Search)

Posted: 7/14/2012 by Brian Corwell, MD (Updated: 11/10/2024)
Click here to contact Brian Corwell, MD

The median nerve is not the only compression neuropathy of the wrist

The ulnar nerve can become compressed at the level of the wrist as it 1) enters Guyon's canal or 2) or as the deep branch curves around the hook of the hamate

Compression can occur due to carpal bone fractures, local inflammation, ganglias, lipomas, anatomic abnormalities, etc

In sports medicine, the most common mechanism is injury is seen in cyclists (cyclist/handlebar palsy)

http://www.hughston.com/hha/b_15_3_2a.jpg

Also seen in those who participate in racquet sports, baseball, and golf

Symptoms can be isolated motor (claw hand = rare), sensory or both

http://en.academic.ru/pictures/enwiki/85/Ulnar_claw.jpg

Can be associated w/ median nerve compression

Tx: Activity modification such as wearing padded gloves, padding the object, or changing hand position on the handlebars

If above fails, surgical decompression is very effective.



Category: Pediatrics

Title: Laryngomalacia

Posted: 7/13/2012 by Rose Chasm, MD (Updated: 11/10/2024)
Click here to contact Rose Chasm, MD

  • congenital disorder which is the most common cause of stridor in infancy
  • larynx appears disproportionately small, and supporting structures are abnormally soft
  • stridor begins within the first 4 weeks of life, and accentuates with increased ventilation (crying, excitement, URI, etc.)
  • stridor usually resolves by 12 months but may recur with URI until about 3 years of age
  • diagnosis is by fiberoptic bronchoscopy or direct laryngoscopy
  • therapy is usually not needed, but rarely laser therapy of redundant tissue or traceostomy when stridor occurs with failure to thrive or apnea

Show References



Category: Toxicology

Title: Leukoencephalopathy from levamisole adulterant in cocaine (and heroin)

Keywords: cocaine, levamisole, leukoencephalopathy (PubMed Search)

Posted: 7/10/2012 by Bryan Hayes, PharmD (Emailed: 7/12/2012) (Updated: 7/12/2012)
Click here to contact Bryan Hayes, PharmD

Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer.

It has been identified as a cocaine adulterant in the U.S. since 2003, with the DEA estimating that by 2009 up to 70% of cocaine seized contained levamisole.

Leukopenia, agranulocytosis, and vasculitis are well known complications of levamisole use.

One important complication to keep in mind is the possibility of multifocal inflammatory leukoencephalopathy (MIL). Although no formal case of leukoencephalopathy in the setting of cocaine use has yet been reported, various neurological side effects were described with levamisole therapy, the most concerning complication being MIL.

Show References



Category: Critical Care

Title: Anaphylaxis

Posted: 7/10/2012 by Mike Winters, MBA, MD (Updated: 11/10/2024)
Click here to contact Mike Winters, MBA, MD

Anaphylaxis

  • The incidence of anaphylaxis appears to be rising.
  • Recall that death can occur anywhere from 5 to 30 minutes after allergen exposure.
  • A few important pearls in management:
    • Epinephrine is the drug of choice and should be given intramuscularly (not subcutaneous) in the mid-anterolateral thigh.
    • Be aggressive with IV fluids, as up to 35% of circulating volume can be extravasated within 10-15 minutes of symptom onset.
    • Get an ECG ASAP! Mast cells are located around the coronary arteries.  The release of mediators can induce vasospasm and precipitate an acute coronary syndrome.

Show References



Question

A previously healthy 3 year-old male presents with a one-day history of fever, drooling, and refusal to move his neck. The lateral neck x-ray is shown. What's the diagnosis?

 

Show Answer

Show References



Category: Pharmacology & Therapeutics

Title: tPA for Acute Ischemic Stroke Patients on Warfarin

Keywords: alteplase, tPA, warfarin, INR, ischemic stroke (PubMed Search)

Posted: 7/2/2012 by Bryan Hayes, PharmD (Emailed: 7/7/2012) (Updated: 7/7/2012)
Click here to contact Bryan Hayes, PharmD

  • IV alteplase (tPA) has many contraindications when administered for acute ischemic stroke. Among them is a history of warfarin use with INR > 1.7 (0-3 hours) or any history of warfarin use regardless of INR (3-4.5 hours).
  • A recent retrospective analysis of a major stroke registry compared the risk of symptomatic intracerebral hemorrhage (ICH) following tPA in patients on warfarin with an INR < 1.7 (n - 1,802) with patients not on warfarin therapy (n = 21,635).
  • After adjusting for differences in the two populations, the authors found no increased symptomatic ICH risk in patients with preadmission warfarin use (5.7% vs. 4.6%, p = 0.94).

Issue 1: Mean INR in study patients was only 1.22 (median 1.2). An INR of 1.2 represents very little actual anticoagulation.

Issue 2: In the small subgroup of patients with INR 1.5 to 1.7 (n = 269) there was a higher risk of ICH (7.8%), but did not reach statistical significance (it was significant in the unadjusted risk population).

Bottom line: Patients with INRs < 1.5 may be ok to receive tPA. Patients with INRs 1.5 or greater need further study.

Show References



No one treatment has demonstrated consistency of pain relief from jellyfish stings over all species; conversely, a treatment for one species may worsen an envenomation from another.

Deionized water, seawater, meat tenderizer, and urea treatment do not appear to produce any improvement in pain sensation.

Ammonia, acetic acid, and ethanol may cause an increased stinging sensation, and in most species vinegar may cause nematocyst discharge.

Application of topical lidocaine reduced the local sensation of pain (10% and 15% produced immediate pain relief), and hot water results in pain relief in the majority of patients tested.

Show References



Category: Critical Care

Title: Decisions, Decisions...Crystalloid or Colloid?

Keywords: hydroxyethyl starch crystalloid, colloid, lactated ringers, normal saline, resuscitation, sepsis, hypotension (PubMed Search)

Posted: 7/3/2012 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD

Septic patients with hemodynamic instability often require intravenous fluids as part of their resuscitation. Major debate has occurred whether the optimal resuscitation fluids are crystalloids (e.g., normal saline) or colloids (e.g., albumin).

In theory, colloids are more potent intravascular expanders than crystalloids because their oncotic pressure is higher and should increase intravascular volume similarly to larger amounts crystalloid (i.e., colloids require less volume during resuscitation). 

Despite these theoretical benefits, the colloid hydroxyethyl starch (HES), has come under scrutiny after prior studies have linked its use with adverse outcomes. 

A recent prospective randomized-control trial compared the use of HES to lactated acetate for resuscitating septic patients and found that HES significantly increased both the incidence of renal-replacement therapy and mortality at 90 days (both primary end-points in the study).

Bottom line: There is no convincing data that HES performs superiorly to crystalloid for resuscitation in sepsis and there is increased harm with its use. Furthermore, the increased cost of HES compared to crystalloids does not justify its routine use.

Show References



Have you ever had to give a national presentation, but can't find that one ultrasound clip or image that you really need? You could "borrow" it from someone on the internet, but you are secretly afraid that the "owner" of the clip is lurking somewhere in the audience. Well, the guys at the Ultrasound Podcast (www.ultrasoundpodcast.com) have come to your rescue by creating SonoCloud, a free access ultrasound library. At Sonocloud, you will find several categories of ultrasound clips and images for you to view and share,...and again it's FREE. In fact, the only thing you are expected to do is upload some of your own ultrasounds to share. 

So head over to www.sonocloud.org, create your free account, and begin exploring...and while you're there, why don't you upload a clip or two?

Show References