Category: Neurology
Keywords: stroke, ischemic stroke (PubMed Search)
Posted: 12/2/2009 by Aisha Liferidge, MD
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Optimal brain imaging for diagnosing and managing acute ischemic stroke should address the presence of 4 essential issues:
Category: Critical Care
Posted: 11/30/2009 by Evadne Marcolini, MD
(Emailed: 12/1/2009)
(Updated: 4/23/2024)
Click here to contact Evadne Marcolini, MD
Calciphylaxis is a rare disorder caused by systemic arteriolar calcification which leads to ischemia and necrosis. It is characterized by painful ischemic necrotic lesions on adipose tissue areas such as abdomen, buttock and thighs. This commonly occurs in patients with ESRD on hemodialysis or after transplant, but can also occur with other patients, such as those with hyperparathyroidism.
Diagnosis is made clinically, with the help of a skin biopsy as needed. Differential diagnosis includes cholesterol embolization, warfarin necrosis, cryoglobulinemia, cellulitis and vasculitis. There are no specific laboratory findings, although patients may manifest elevated PTH, phosphorous, calcium or calcium x phosphorous product.
Infection is usually the cause of the high mortality rate of this condition, which has a reported mortality of 46%, or 80% if ulceration is present.
Treatment includes local wound care, trauma avoidance, electrolyte correction, increased frequency of dialysis or parathyroidectomy as needed. Surgical debridement is controversial; as the risk of infection may outweigh the benefit in terms of outcome.
Reference:
Category: Medical Education
Keywords: Pimping (PubMed Search)
Posted: 12/1/2009 by Rob Rogers, MD
(Updated: 4/23/2024)
Click here to contact Rob Rogers, MD
The Art of Pimping-And How to Protect Against
This monday's pearl (ok, I know, it's tuesday now) comes from Michelle Lin's blog: academic life in emergency medicine. It is more gem than pearl, and it discusses what medical students and residents do to avoid being pimped. It is a must read!
Here is the link to the discussion on Michelle Lin's blog:
http://academiclifeinem.blogspot.com/2009/11/trick-of-trade-essential-skills-for.html
Just a few note worthy "pimping protection procedures":
Happy pimping!
Category: Geriatrics
Keywords: delirium, elderly (PubMed Search)
Posted: 11/29/2009 by Amal Mattu, MD
(Updated: 4/23/2024)
Click here to contact Amal Mattu, MD
Up to 10% of elderly patients in the ED meet criteria for acute delirium, though misdiagnosis rates are very common.
The most common cause of delirium in the elderly, overall, is medication effects. Other common causes are infections (UTIs most common), CNS abnormalities, cardiovascular abnormalities, electrolyte/metabolic abnormalities, and temperature abnormalities (fever or hypothermia).
Category: Ophthamology
Keywords: Suden Vision Loss (PubMed Search)
Posted: 11/28/2009 by Michael Bond, MD
(Updated: 4/23/2024)
Click here to contact Michael Bond, MD
Vision loss whether acute or chronic is a common presenting complaint to the ED. This will be the first in a series of pearls on the subject. This pearl will address the nomenclature used by ophthalmology based on the length of vision loss.
• Transient visual obscuration - Episodes lasting seconds. Usually associated with papilledema and increased intracranial pressure.
• Amaurosis fugax - Brief, fleeting attack of monocular partial or total blindness that lasts seconds to minutes
• Transient monocular visual loss or transient monocular blindness - A more persistent vision loss that lasts minutes or longer
• Transient bilateral visual loss - Episodes affecting one or both eyes or both cerebral hemispheres and causing visual loss
• Ocular infarction - Persistent ischemic damage to the eye, resulting in permanent vision loss
Category: Neurology
Keywords: neuroleptic malignant syndrome, anti-psychotic medicaiton reactions (PubMed Search)
Posted: 11/25/2009 by Aisha Liferidge, MD
(Updated: 4/23/2024)
Click here to contact Aisha Liferidge, MD
F - Fever (anything over 100.4 F counts)
E - Encephalopathy
V - Vital signs instability
E - Enzymes elevation (i.e. CPK)
R - Rigidity of muscles
Category: Infectious Disease
Posted: 11/24/2009 by Mike Winters, MD
(Updated: 4/23/2024)
Click here to contact Mike Winters, MD
Spinal Epidural Abscess Pitfalls
Take Home Point: In the patient with risk factors for spinal epidural abscess (IVDU, DM, indwelling catheters, etc) do not exclude the diagnosis based upon the absence of a fever, a normal WBC count, and a normal neurologic exam.
Category: Pediatrics
Keywords: Tungsten, ring, removal, hand injury, finger injury (PubMed Search)
Posted: 11/22/2009 by Adam Friedlander, MD
Click here to contact Adam Friedlander, MD
Ring-removal is a dreaded problem in pediatric hand and finger injuries. Removal can be difficult and time consuming. The relatively recent introduction of Tungsten into the jewelry market has further complicated this problem:
However, it is:
This video explains how. Of course, this works on adults as well.
http://www.youtube.com/watch?v=poM423pewRE
I have no relationship with the copany which made this video - it was simply chosen for its clear explanation of the solution described in this pearl.
Category: Cardiology
Keywords: posterior, myocardial infarction, left circumflex, acute coronary syndrome (PubMed Search)
Posted: 11/22/2009 by Amal Mattu, MD
(Updated: 4/23/2024)
Click here to contact Amal Mattu, MD
Myocardial infarctions involving the left circumflex artery are often associated with ECGs that lack any ST-segment changes (38% in one representative study). Oftentimes when there are ST-changes, there may simply be anterior lead ST-segment depression. In these patients, acquisition of a few posterior leads frequently demonstrates STEMI. Some data does exist that failure to diagnose these posterior STEMIs (e.g. simply diagnosing anterior "ischemia" rather than posterior "STEMI") results in increased mortality.
So what's the bottom line?
1. In patients with isolated anterior lead ST-segment depression, always check for posterior STEMI with a couple of posterior leads.
2. In patients with non-significant ECGs but concerning persistent symptoms, always check for posterior STEMI with a couple of posterior leads.
This is always a great time to use that 80-lead ECG if your ED has one.
Amal
Category: Ophthamology
Keywords: MEWDS, White Dot Syndrome (PubMed Search)
Posted: 11/21/2009 by Michael Bond, MD
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MEWDS (Multiple Evanescent White Dot Syndrome)
Multiple Evanescent White Dot Syndrome (MEWDS): 24 y.o. woman with one week duration of central scotoma, OD.
Presented by Sudeep Pramanik, MD, MBA, Hilary A. Beaver, MD http://webeye.ophth.uiowa.edu/eyeforum/cases/37-MultipleEvanescentWhiteDotSyndromeMEWDS.htm
Category: Neurology
Keywords: ICP, intracranial pressure (PubMed Search)
Posted: 11/18/2009 by Aisha Liferidge, MD
(Updated: 4/23/2024)
Click here to contact Aisha Liferidge, MD
Category: Critical Care
Posted: 11/17/2009 by Evadne Marcolini, MD
(Updated: 4/23/2024)
Click here to contact Evadne Marcolini, MD
There is no prospective, randomized study to elucidate propofol’s effect on the critically ill patient. By definition, Propofol Infusion Syndrome (PRIS) has the following characteristics:
It has been thought that PRIS was limited to patients with prolonged use, but we now know that this is not necessarily true.
It has been shown that PRIS is more likely with the following risk factors:
The treatment for suspected PRIS is:
Fudickar A, Bein B Propofol infusion syndrome: update of clinical manifestation and pathophysiology. Minerva Anestesiologica 2009;75:339-44.
Vernooy K, Delhaas T, et al. Electrocardiographic changes predicting sudden death in propofol-related infusion syndrome. Heart Rhythm 2006;3:131-7
Category: Medical Education
Keywords: Clinical Reader (PubMed Search)
Posted: 11/16/2009 by Rob Rogers, MD
(Updated: 4/23/2024)
Click here to contact Rob Rogers, MD
Well, this monday's pearl is a bit different than prior pearls. I wanted to let you know about a very cool website I came across recently called Clinical Reader. There is a whole lot in the recent medical education literature that discusses "Web 2.0." Web 2.0 involves learning through interactive websites, blogs, podcasts, etc. Medical education is really starting to head out of the classroom, and I wanted to mention a newer website that a lot of folks are talking about.
Clinical Reader is a new medical RSS aggregator. What, you might ask, does this mean?
An RSS aggregator is a site that puts together information for you, that's right, for you. It actually does the work for you. Did I mention that it does the work for you? On this site, for example, if you are interested in "Emergency Medicine," the site finds all (or almost all) EM journals and brings you all of the latest information and updated articles. If you are into "Medical Education," you simply choose that category from a drop down menu and poof, you have all of the latest publications/reviews from the major medical education journals. Just choose your category and/or specialty and you are off and running.
Try it out. It isn't 100% perfect, but it is very cool.
http://clinicalreader.com/
Category: Cardiology
Keywords: myocarditis (PubMed Search)
Posted: 11/15/2009 by Amal Mattu, MD
(Updated: 4/23/2024)
Click here to contact Amal Mattu, MD
During this season of the ever-present viral respiratory illness, we must be on the lookout for the potentially-deadly -entity of myocarditis. A recent study suggests some clues to when the diagnosis should more strongly be considered in patients presenting with viral respiratory symptoms.
1. Most cases of myocarditis were not initially recognized by primary care MDs or emergency health care providers. 84% of patients needed more than one visit within 2 weeks before the diagnosis was made. This highlights the difficulty in Dx and frequent misdiagnosis rate.
2. The most common presenting symptom was dyspnea (69%) and most common sign was tachypnea (60%).
3. Although resting tachycardia is often taught as a common finding, 66% of patients had a normal HR.
4. The most helpful findings in terms of helping distinguish myocarditis from benign common viral URIs was hepatomegaly (present in 50%) and cardiomegaly (present in 60%).
5. An abnormal ECG was present in 100% of cases. The most common abnormalities were tachycardia, ventricular hypertrophy, and ST or T wave changes.
6. 54% of patients had elevated troponin levels.
So what's the bottom line?
1. If your patient has tachypnea or dyspnea, strongly consider getting a CXR. In that case, look carefully for cardiomegaly.
2. Always assess for and document the presence or absence of hepatomegaly.
3. A completely normal ECG is strong evidence against myocarditis.
[Durani Y, Egan M, Baffa J, et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med 2009;27:942-947.]
Category: Orthopedics
Keywords: Scaphoid, Children (PubMed Search)
Posted: 11/14/2009 by Michael Bond, MD
(Updated: 4/23/2024)
Click here to contact Michael Bond, MD
Scaphoid Fractures in Children:
Because of the high (30%) fracture rate seen on followup films it is recommended that all children be placed into a thumb spica splint until followed up.
Evenski AJ, Adamczyk MJ, Steiner RP, Morscher MA, Riley PM. Clinically Suspected Scaphoid Fractures in Children. J Pediatr Orthop 2009; 29: 352-355.
Category: Toxicology
Keywords: hydroxocobalamin, cyanokit (PubMed Search)
Posted: 11/12/2009 by Bryan Hayes, PharmD
Click here to contact Bryan Hayes, PharmD
The newest antidote for cyanide poisoning, hydroxocobalamin, has several advantages over the older Cyanide Antidote Kit (amyl nitrite, sodium nitrite, sodium thiosulfate). Hydroxocobalamin works rapidly, does not induce methemoglobinemia, and does not cause vasodilation/hypotension.
Uhl W, Nolting A, Golor G, Rost KL, Kovar A. Safety of hydroxocobalamin in healthy volunteers in a randomized, placebo-controlled study. Clin Toxicol 2006;44:S17-S28.
0911120826_Cyanokit_red_skin.jpg (107 Kb)
Category: Neurology
Keywords: guillain-barre' syndrome, guillain-barre, gbs, polyneuropathy, peripheral neuropathy (PubMed Search)
Posted: 11/11/2009 by Aisha Liferidge, MD
Click here to contact Aisha Liferidge, MD
Category: Critical Care
Posted: 11/10/2009 by Mike Winters, MD
(Updated: 4/23/2024)
Click here to contact Mike Winters, MD
Severe Acute Pancreatitis
Greer SE, Burchard KW. Acute pancreatitis and critical illness: A pancreatic tale of hypoperfusion and inflammation. Chest 2009;136:1413-19.
Category: Orthopedics
Keywords: Klein's line, slipped capital femoral epiphysis (PubMed Search)
Posted: 11/7/2009 by Michael Bond, MD
(Updated: 8/31/2014)
Click here to contact Michael Bond, MD
Slipped Capital Femoral Epiphysis (SCFE)
SCFE can present as hip, thigh or knee pain in the young adolescent. Risk factors include hypogonadism, hypothyroidism, hypopituiratism, and obesity. One way to make the diagnosis is to obtain a AP view of the pelvis and draw a line(Klein's line) along the superior border of the neck of the femur. This line should intersect the femoral epiphysis. If it does not the diagnosis of SCFE can be made.
However, this is only about 40% sensitivity. Green et al recently published a study that demonstrated that if you measure the distance from Klein's line and the lateral edge of the femoral epiphysis on both sides, and the difference between the two is more than 2mm you can make the diagnosis of SCFE more accurately and sooner.
FIGURE 1. Measurement methods on an anterior-posterior radiograph of a right slipped capital femoral epiphysis. White lines indicate Klein’s line for each hip. A and B, indicate maximum epiphyseal width lateral to Klein’s line. As A is 2mm narrower than B, the right (A) hip qualifies as a slip using our modification but not Klein’s original definition.
Green DW, Mogekwu N, Scher DM, Handler S, Chalmers P, Widmann RF. A modification of Klein's Line to improve sensitivity of the anterior-posterior radiograph in slipped capital femoral epiphysis. J Pediatr Orthop. Jul-Aug 2009;29(5):449-453.
Category: Pediatrics
Keywords: conjunctivitis, pinkeye, gonococcal ophthalmia neonatorum (PubMed Search)
Posted: 11/6/2009 by Heidi-Marie Kellock, MD
Click here to contact Heidi-Marie Kellock, MD
Conjunctivitis in Children:
HOWEVER... remember to consider other common etiologies of a red eye in a child!