UMEM Educational Pearls

Category: Infectious Disease

Title: Tuberculosis Screening

Keywords: TB, PPD, Conversion (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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PPD is considered positive: >= 15 mm Induration: Anybody >= 10 mm induration: Born in a high-revalence country, are in a medically underserved population ( e.g.:Blacks, Hispanics, and Native Americans), individuals with a medical condition that increases risk of TB (e.g.; silicosis, gastrectomy, chronic renal failure, immunosuppressant therapy, malignancy, IV drug abusers, and those that work in the medical field. >=5mm induration: HIV or suspected HIV-positive, close contacts of newly diagnosed TB Cases (everybody on the plane), and abnormal CXR with fibrotic changes suggesting old TB MMWR September 08, 1995/ 44(RR-11);18-34

Category: Orthopedics

Title: Supracondylar Fractures

Keywords: Supracondylar, Fracture, Pediatric, Ossification (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Supracondylar fractures in children: To assess the likelihood of a supracondylar fracture in a child look at the anterior humeral line. This is a line drawn down the anterior portion of the humerus on the lateral view of the elbow. This line should pass through the center of the capitellum in the distal humerus. If the line does not pass through the center there is a very high likelihood of a supracondylar fracture. Review of the Appearance of Ossification Centers in Children's Elbows CRITOE Capitellum 1 to 8 months Radial Head 3 to 5 years Medial (Internal)Epicondyle 5 to 7 years Trochlea 7 to 9 years Olecranon 8 to 11 years Lateral ( External) Epicondyle 11 to 14 yeras

Category: Airway Management

Title: Airway Management Pearls

Keywords: Intubation, Airway (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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1. 30% of all ETT placed in the field by EMS are esophageal. 2. Patients that will rapidly desaturate - think "POPS" ie Pregnancy, Obesity, Pediatric, Smoke inhalation. 3. In the adult the only absolute contraindication to performing a cricothyroidotomy is a fractured larynx. 4. Post intubation desaturation think "DOPE" ie Displacement, Obstruction, PNTX, Equipment failure.

Category: Obstetrics & Gynecology

Title: OB Pearls

Keywords: Pre-eclampsia, eclampsia, HELLP (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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The best known peripartum complications are pre-eclampsia and eclampsia. However, do not forget about HELLP syndrome which occurs in approximately 0.2 to 0.6 percent of all pregnancies. HELLP is an acronym for: Hemolysis Elevated Liver Enzymes Low Platelet Treatment consists: 1. Seizure prophylaxis with magnesium 2. Blood pressure control 3. Corticosteriods and plasmapheresis may be helpful in severe causes 4. Supportive care. 5. Early delivery of child.

Category: Obstetrics & Gynecology

Title: Shoulder Dystocia Legal Pearl

Keywords: Erb's Palsy, Dystocia, Legal (PubMed Search)

Posted: 7/14/2007 by Michael Bond, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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In follow up to my Shoulder Dystocia Pearl

Dr. DePriest Whye has some legal pearls for us:

Erbs Palsy( Brachial Plexus Injury) is a known complication of shoulder dystocia and is due to traction on the arm that causes stretching of the brachial plexus.

  • Should an Erb's Palsy result as a consequence of a shoulder dystocia, a medical malpractice suit is inevitable.
  • The medical record documentation is particularly critical in defending the medical care rendered.
  • The medical record should reflect timely recognition of the shoulder dystocia.
  • It is important that appropriate implementation of the maneuvers described last week are done in a timely fashion.
  • Vital documentation should describe the amount of traction placed if any.
  • Terms such as minimal or mild or light traction should be used.
  • Terms such as strong, forceful, significant traction should be avoided.
  • Never state in the record that uterine pressure was used as opposed to suprapubic pressure.
  • Uterine pressure is contraindicated.

Erb's Palsy cases are difficult to defend. They are impossible to defend with improper documentation.


Category: Pediatrics

Title: ALTE

Keywords: ALTE , Apparent Life Threatening Events, color change, apnea, SIDS, Seizure (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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ALTE (Apparent Life Threatening Events) Defined as an episode characterized by some combination of apnea, color change, change in tone, choking, and/or gaging. Vast DDx ==> Get Bedside Glucose Early (should be part of vital signs) ==> Keep Non-accidental Trauma on the list ==> ~50% are classified as Idiopathic Risk Factors associated with Increased Mortality: ==> Sleep Onset ==> Prior Similar Episode ==> Sibling a Victim of SIDS ==> Development of Seizure D/O during monitoring 7.8% of ALTE pt s with a Normal ED evaluation required medical intervention during hospitalization. -Oren, J., D. Kelly, and D.C. Shannon, Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics, 1986. 77(4): p. 495-9. -De Piero, A.D., S.J. Teach, and J.M. Chamberlain, ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med, 2004. 22(2): p. 83-6.

Category: Pediatrics

Title: Intussusception

Keywords: Intussusception, Abdominal Pain, bloody stools, vomitting, change in mental status (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Intussusception Age: 3months to 6 years, most common among 3-12 months The classic triad: colicky abdominal pain, vomiting, and red currant jelly stools ==> Occurs in only 21% of cases. ==> Currant jelly stools are observed in only 50% of cases. ==> 75% without obviously bloody stools will have positive occult blood. A child vomiting without diarrhea should raise suspicion. Consider it in infant/toddler with change in mental status/lethargy (TIPS AEIOU one of the I s is for Intussusception). Choice of Radiographic Evaluation is often based upon your institutional resources ==> U/S is the modality of choice for imaging, but cannot treat. ==> Air contrast enema (now preferred over saline contrast) is useful for diagnosis and treatment. ==> Both are operator dependent

Category: Pediatrics

Title: Neonatal Resuscitation

Keywords: Neonatal Resuscitation, Newborn, Transilluminate, Meconoium Aspiration, Zip Lock Bag (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Neonatal Resuscitation 3 Key Questions to ask of your pregnant patients: ==> Are you having twins (or more)? ==> When is your due date? ==> What color is the fluid? Magic numbers for Neonatal Resuscitation: ==> HR < 100 (or persistent central cyanosis or apnea) = positive pressure ventilation ==> HR < 60 = chest compressions +/- epinephrine If there is meconium present and ==> The infant is depressed, then use meconium aspirator (aspirate the airway via the ETT) ==> The infant is vigorous, then resuscitate as usual (dry, clear airway, assess circulation/color) When resuscitating an infant who is <28wks GA, do not dry with towels as you would an older neonate, instead ==> Place the child in a food grade polyethylene bag (Zip Lock bag), to prevent heat loss and avoid losing valuable time during the resuscitation. For infants not responding to resuscitation, TRANSILLUMINATE the chest to determine if there is a pneumothorax.

Category: Pediatrics

Title: Pediatric Thoracic Trauma

Keywords: Thoracic, Trauma , Traumatic Asphyxia, Pulmonary Contusion (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Pediatric Thoracic Trauma 2nd leading cause of death in Peds Trauma Most injuries in Peds are Blunt Kids are Different ==> More Pliable Chest Walls → Pulm Contusion more likely than rib Fx ==> More Mobile Mediastinum → more susceptible to develop tension ptx ==> More Likely to Hyperventilate → Swallowed Air → compromise Respiratory status ==> Can compensate for significant volume loss with tachycardia Traumatic Asphyxia ==> Primarily in younger children ==> Due to the more pliable chest wall ==> Sudden, severe crushing blow to the chest when the glottis is closed. ==> Petechial Hemorrhages of sclera and skin of the head and upper extremities ==> Neuro deficits and coma due to cerebral edema can occur, although rare Pulmonary Contusion ==> Most Common thoracic Injury in kids ==> Alveolar Hemorrhage, Consolidation, Edema ==> Leads to: (1) V/Q mismatch (2) Decreased Compliance (3) Hypoxemia (4) hypoventilation

Category: Pediatrics

Title: Acute Otitis Media

Keywords: Acute Otitis Media, Amoxicillin, insufflation, Delayed treament (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Acute Otitis Media Make the Diagnosis Properly ==> Acute Onset of Symptoms ==> Signs of Middle Ear Infection (1) Buldging TM, poor mobility c insufflation, otorrhea, air-fluid level ==> Signs of Middle Ear Inflammation (1) TM erythema or otalgia (that interferes with nl activity) Can you wait on the Abx? ==> Older than 6months ==> No severe infections (T>39 C) ==> If yes to both, may hold Abx for 48 hours. Treat Appropriately ==> High-Dose Amoxicillin (80-90mg/kg/D) is 1st line If the decision is made to observe without antibiotic therapy, the parents can be given a prescription for Abx with instructions to fill it if the child does not improve in 48 to 72 hours, or see the PMD in 2 days. (Spiro, D. Tay, K. Wait-to-see prescription for the treatment of acute otitis media. JAMA 2006, 1235.)

Category: Toxicology

Title: Tricyclic Antidepressants (TCA)

Keywords: tricyclic antidepressant, electrocardiogram, cardiac toxicity (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Tricyclic Antidepressants (TCA) - Lack of terminal 40msec R wave (R wave in AvR, S wave in I, AvL) means the patient is NOT TCA toxic. - 40msec R wave + QRS >100msec = possible TCA toxicity, treat with NaHCO3 and recheck ECG. - TCA toxicity defined by ECG; if QRS > 100msec, 33% seizures; if QRS > 160msec, 50% v tach Boehnert MT, Lovejoy FH Jr. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressants. N Engl J Med. 1985 Aug 22;313(8):474-9.

Category: Toxicology

Title: Urine Drug Screens

Keywords: drug abuse, urine drug screen, cocaine (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Urine Drug Screens Though we order them often, be sure you know what your results mean: Cannabinoids: an accurate test though clinically not important information, positive for 5 days to a full month with chronic users. Cocaine: the most accurate and precise test, positive for 3-5 days. Amphetamine: the most imprecise with many false positives and false negatives. Cough/cold preparations that contain pseudephedrine, phenylephrine or other decongestants can turn it falsely positive. BDZ: only benzodiazepines that are metabolized to oxazepam will turn positive. You can see false negatives with alprazolam and even lorazepam. Opioids: Semisynthetics like oxycodone and hydrocodone may give false negatives at low levels. This screen will NOT catch methadone, meperidine, fentanyl, propoxyphene, tramadol. PCP: False positives from dextromethorphan and ketamine

Category: Cardiology

Title: Acute Pericarditis

Keywords: Pericariditis, TB, Viral (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Acute Pericarditis Viral and idiopathic causes account for 80-90% of cases of acute pericarditis (AP) in immunocompetent patients from developed countries. Therefore empiric treatment and extensive search for an underlying cause is unnecessary in the majority of cases we see. However, the etiology of AP in developing countries is very different, with TB-related AP predominating. 70-80% of cases from Sub-Saharan Africa and more than 90% of HIV-related cases of AP are tuberculous. Therefore, in the U.S. tuberculous pericarditis should be strongly considered among immigrants/visitors from developing countries and among patients with HIV.

Category: Cardiology

Title: Cardiac Output After Age 35

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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After the age 35, cardiac output decreases by approximately 1% per year. That means that elderly patients are at much higher risk for CHF, especially when they are stressed in some way. CHF can develop in the elderly as a result of any stype of infection or other non-cardiac insult. If decompensated CHF is diagnosed in an elderly patient, don't forget to evaluate the patient carefully for potential non-cardiac causes.

Category: Cardiology

Title: Infective endocarditis (IE)

Keywords: Endocarditis, treatment, vancomycin (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Infective endocarditis (IE) The most common overall cause of IE is Streptococcus viridans. The most common cause of IE in injection drug users is Staphylococcus aureus. The most common cause of IE in patients with prosthetic valves is also Staphylococcus species; in the first two months postop coag-negative Staphylococcus predominates, and after that the most common causes are Staphylococcus aureus, Streptococcus viridans, and enterococcus. In treating IE of prosthetic valves and/or in injection drug users, the addition of rifampin to the standard regimen of nafcillin/vancomycin + gentamycin is often recommended in order to add additional gram positive coverage.

Category: Cardiology

Title: Helpful clues to distinguishing pericarditis vs. STEMI

Keywords: Pericarditis, STEMI, ECG (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Helpful clues to distinguishing pericarditis vs. STEMI Pericarditis: PR depression in multiple leads, PR elevation > 2 mm in aVR; friction rub (specific though not sensitive) Remember that PR depression mainly only shows up in viral pericarditis, not other types STEMI: horizontal or convex upwards (like a tombstone) STE, ST depression in any lead aside from aVR and V1, STE in III > II

Category: Critical Care

Title: Fungal Infections

Keywords: Fungal, Infection, antifungal (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Fungal Infections * Fungal isolates are an increasingly common source of bloodstream infections in critically ill patients * Mortality ranges from 20% to 60% in some series * 50% are non-albicans species (C.glabrata, C.parapsilosis, C.tropicalis, and C. krusei) * Risk factors include ventilated patients, TPN, high APACHE scores, abdominal surgery, and prolonged ICU stays * Think of fungal infections in the septic patient with hypothermia and bradycardia * Newer antifungal agents such as voriconazole and caspofungin have improved efficacy against n

Category: Critical Care

Title: Critical Illness Neuromyopathy (CINM)

Keywords: Neuropathy, steroids, sepsis, neuromuscular (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Critical Illness Neuromyopathy (CINM) * CINM is the most common peripheral neuromuscular disorder encountered in the ICU * CINM may contribute to delayed weaning and prolonged ventilation * Risk factors for CINM include SIRS/MODS, sepsis, and hyperglycemia (corticosteroid use still controversial) * Current mainstay of management is directed at prevention * EM take home point -> Judicious use of medications associated with the development of CINM (aminoglycosides, neuromuscular blocking agents) Reference: De Jonghe B, Lacherade JC, Durand MC, et al. Critical illness neuromuscular syndromes. Crit Care Clin 2007;23:55-69. (compliments of Dr. Winters)

Category: Cardiology

Title: Cyanide toxicity

Keywords: Cyanide, itroprusside, hypotension (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Be alert for cyanide toxicity when using sodium nitroprusside * Toxicity from sodium nitroprusside can be seen in as little as 2-4 hours with rates > 4.0 mcg/kg/min * Patients with hepatic and renal dysfunction are at greatest risk * Clinical signs of toxicity include altered mental status (agitation, restlessness), tachycardia, ventricular arrhythmias, and eventually hypotension * The classic anion-gap metabolic acidosis is a pre-terminal event - do not wait for this to develop to raise suspicion of toxicity! Reference: Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:148-9.

Category: Airway Management

Title: Plateau Pressure

Keywords: Plateau, Peak, Pressure, airway (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/24/2019)
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Use plateau pressure, rather than peak inspiratory pressure, as a means of assessing the risk of barotrauma * One mechanism (of many) by which mechanical ventilation can induce acute lung injury in patients with ARDS is overdistention of the alveoli * 2 common parameters used to assess airway pressures are plateau pressure (Pplat) and peak inspiratory pressure (PIP) * Pplat approximates small airway and alveolar pressures more closely than PIP * ARDSnet trial demonstrated a reduction in the number of ventilator days and mortality when Pplat was maintained < 30 cm H2O. References: 1. ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000;342:1301-8. 2. Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:275-6.