UMEM Educational Pearls

Category: Cardiology

Title: cardiac ultrasound and PE

Keywords: cardiac ultrasound, pulmonary embolism (PubMed Search)

Posted: 8/17/2008 by Amal Mattu, MD (Updated: 4/22/2024)
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The apical 4-chamber view of the heart on bedside ultrasound gives an excellent comparative view of the sizes of the right ventricle (RV) and left ventricle (LV). The RV is normally ~ 0.5-0.6 the size of the LV. When the RV appears too large, certainly if the RV > LV in size, it indicates RV dilatation.

RV dilatation can be chronic (e.g. COPD or sleep apnea with pulmonary hypertension, etc.) or acute (e.g. PE, RV MI). How can you tell whether the condition is chronic or acute? Just take a look at the RV free wall. If the RV free wall measures < 5 mm, it's a pretty good indication that you are dealing with an acute condition. Think PE or RV MI!

[thanks to Dr. Jim Hwang from Brigham and Women's Hospital for providing this pearl]

Category: Orthopedics

Title: Olecranon Bursitis

Keywords: olecranon, bursitiis, septic, treatment (PubMed Search)

Posted: 8/17/2008 by Michael Bond, MD (Updated: 4/22/2024)
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Olecranon Bursitis is inflammation and swelling of the bursa overlying the olecranon process of the ulna.  Can result from trauma, overuse, or infection. 

Treatment can consist of:

  • Aspiration:  Can be done to rule out infection [send gram stain, culture, and cell count], and be therapeutic by removing the excess fluid.
  • NSAIDs
  • Local injection of corticosteroids into the bursa
  • Wearing of a neopryne elbow sleeve, or ace wraps to provide compression over the bursa and may help prevent reaccumulation of the fluid.

Remember aspiration has some major risks that need to be explained to the paitent:

  • Infection may be introduced during the aspiration.  [Follow aseptic techniques and ensure that the skin is adequately prepped with chlorhexidine or betadiene].
  • Formation of fistula tract with chronic drainage. [Use a Z or zigzap approach to minimize this complication.]
  • Ulnar nerve injury.  Avoided by using a posterior lateral approach and avoiding a medial approach.

They also need to know that the fluid will likely reaccumulate.  So aspiration is not a guaranteed cure. 

Category: Pediatrics

Title: ETT Depth of Insertion

Keywords: Pediatric Intubation (PubMed Search)

Posted: 8/15/2008 by Don Van Wie, DO (Updated: 4/22/2024)
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In the rush of adrenaline that goes hand in hand with a pediatric intubation often the ETT tip can sometimes be coming out of the little guys toes after passing successfully through the vocal cords, so remember once you get it in and confirm with end-title CO2 detection (capnography or on a monitor) always remember:

Depth of insertion (cm at lip) = 3 x  normal size of ETT

Start at this depth, auscultate bilaterally in the axilla to listen for equal breath sounds, and look for equal chest rise.  If all are good then secure tube and get your chest xray. 


Category: Neurology

Title: Cerebral Aneurysms

Keywords: cerebral aneurysm, SAH, intracranial bleed (PubMed Search)

Posted: 8/14/2008 by Aisha Liferidge, MD (Updated: 4/22/2024)
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  • Cerebral aneurysms are usually not congenital, but rather often form over days, weeks, or months.  
  • It is hypothesized that the critical size for rupture is smaller for newly formed aneuryms; thus, treat newly discovered aneurysms that were previously radiographically absent more proactively and cautiously.
  • While hypertension and cigarette smoking are not thought to cause aneurysmal rupture, they do contribute to the problem;  Hypertensive smokers are at a 15-fold increased risk of SAH compared to non-hypertensive non-smokers.

Category: Critical Care

Title: Pressure Regulated Volume Control

Keywords: PRVC, pressure control, volume control, ventilator-induced lung injury (PubMed Search)

Posted: 8/12/2008 by Mike Winters, MD (Updated: 4/22/2024)
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Pressure Regulated Volume Control (PRVC)

  • PRVC is a mode of mechanical ventilation that combines both volume and pressure control modes
  • The main advantage to PRVC is that the tidal volume / minute ventilation is guaranteed while controlling airway pressures, thereby reducing the risk of ventilator induced lung injury
  • In PRVC, the ventilator delivers a pressure-controlled breath, but tidal volume is the key setting
  • The ventilator will automatically adjust inspiratory pressures until the desired TV is achieved
  • When using PRVC you need to set: target TV, RR, peak pressure alarm, inspiratory time, FiO2, and PEEP

Category: Vascular

Title: Currently Approved LMWH for Treatment of PE

Keywords: LMWH, PE, Pulmonary Embolism (PubMed Search)

Posted: 8/11/2008 by Rob Rogers, MD (Updated: 4/22/2024)
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Currently Approved LMWHs for the Treatment of Acute PE:

  • Enoxaparin-1 mg/kg every 12 hours subcut
  • Tinzaparin 175 Units/kg once daily subcut
  • The pentasaccharide: Fondaparinux- at a dose of 5 mg for body weight <50 kg, 7.5 mg for 50-100 kg, and 10 mg for >100 kg, once daily

Make sure to monitor platelet counts regardless of agent chosen.



Show References

Category: Cardiology

Title: cardiac contusion and the EKG

Keywords: blunt cardiac trauma, cardiac contusion, myocardial contusion (PubMed Search)

Posted: 8/10/2008 by Amal Mattu, MD (Updated: 4/22/2024)
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"The most common EKG abnormalities are non-specific ST-T wave changes, followed by RBBB. A normal EKG does not exclude the possibility of cardiac injury, although some investigators report a negative predictive value of up to 80-90%."

[El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med 2008;35:127-133.]

Category: Procedures

Title: Tips for Successful Urinary Catheter Placement

Keywords: Urinary Catheter, Foley, Coude (PubMed Search)

Posted: 8/10/2008 by Michael Bond, MD (Updated: 4/22/2024)
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Placing a foley catheter in a patient with BPH or acute urinary retention can be very difficult at times.  Here are some tips to increase your chance of a successful placement.

  1. Use a Uroject lidocaine gel syringe to help anesthesize the urethra and lubricate the tract.  The lidocaine gel should be slowly expressed (injected) into the urethral meatus.  This helps to provide lubrication further down the urethra, as opposed to just wiping the catheter tip in the lubricant.
  2. When using a Coude catheter, ensure that the curved tip points upward.
  3. Apply gentle continuous pressure to help open the prostrate spincter.  This will be more successful than trying to ram it through which can increase spincter contracture.
  4. Do not inflate the balloon until you have confirmed placement with urine return.
  5. Don't forget the ultrasound.  You can calculate urinary volume (post void residual) prior to catheter placement and confirm placement with ultrasound.

If all else fails, a suprapubic catheter may need to be placed.  For a great review on evaluation and treatment please see Drs. Vilke, Ufberg, Harrigan, and Chan's article in the August edition of Journal of Emergnecy Medicine entitled Evaluation and treatment of acute urinary retention.

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Category: Toxicology

Title: Disulfiram-like reactions

Keywords: drug interactions, disulfiram, bactrim, tinidazole, metronidazole (PubMed Search)

Posted: 8/7/2008 by Ellen Lemkin, MD, PharmD (Updated: 4/22/2024)
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Alcohol-Drug Interactions

  • There are a number of medications that produce the disulfiram-like reaction when ingested with alcohol.
  • The disulfiram reaction is a very uncomfortable reaction characterized by severe flushing, and may be accompanied by tachycardia and hypotension.
  • Although we always think of metronidazole, there have been well described cases of bactrim causing this reaction.
  • Tinidazole, a new antiprotozoal used in the treatment of trichomonas, causes this as well.
  • Patients should be advised to avoid alcohol for 24 hours after metronidazole, and 72 hours after bactrim and tinidazole.

Other common medications that produce this reaction:

1. Sulfonylureas: chlorpropamide, tolbutamide, glyburide

2. Cardiovascular medications: Isosorbide dinitrate, nitroglycerin

Show References

Category: Neurology

Title: Recognizing Cerebral Aneurysms

Keywords: cerebral aneurysms, aneurysm, ACOM, PCOM, SAH (PubMed Search)

Posted: 8/6/2008 by Aisha Liferidge, MD (Updated: 4/22/2024)
Click here to contact Aisha Liferidge, MD

  • About 2% of the adult population have an asymptomatic cerebral aneurysm.
  • Unruptured aneurysms can cause symptoms such as headache, visual acuity loss, cranial neuropathies (particularly thrid nerve palsy), pyramidal tract dysfunction, and facial pain; these are thought to be due to mass effect on the aneurysm.
  • 20 to 30% of people with a cerebral aneurysm, have multiple aneurysms; Don't miss co-existing aneurysms on CTA or MRI. 
  • The majority of intracranial aneurysms are located in the anterior circulation, most commonly in the Circle of Willis.
  • When localizing aneurysm on CTA and MRI, common sites include

              ---  junction of the anterior communicating artery (ACOM) with the anterior cerebral artery (ACA)

              ---  junction of the posterior communicating artery (PCOM) with the internal carotid artery (ICA)

              ---  bifurcation of the middle cerebral artery (MCA)

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Category: Critical Care

Title: DOPE

Keywords: post-intubation hypoxia, pneumothorax, mechanical ventilation (PubMed Search)

Posted: 8/5/2008 by Mike Winters, MD (Updated: 4/22/2024)
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Post-intubation deterioration?  Remember DOPE

  • The pneumonic DOPE can help you remember the most common causes of post-intubation hypoxia or deterioration
  • Displacement: check the endotracheal tube for displacement (right mainstem) or dislodgement
  • Obstruction: check the ETT for obstruction (mucous plug, kink in ventilator tubing)
  • Pneumothorax - get an xray
  • Equipment failure(unusual): disconnect patient from the ventilator and bag manually

Category: Infectious Disease

Title: Necrotizing Fasciitis Pearl

Keywords: necrotizing fasciitis (PubMed Search)

Posted: 8/4/2008 by Rob Rogers, MD (Updated: 4/22/2024)
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 Necrotizing Fasciitis Pearl

A few things to remember about treating necrotizing soft tissue infections:

  • Often polymicrobial and most of the time we in the ED won't have a microbial diagnosis
  • If due to strep, patient may benefit from the addition of Clindamycin. Streptococcal species may stop multiplying in a wound/cellulitis and continue to produce large amounts of tissue toxin. In this case, many antibiotics (like the ubiquitous Zosyn-which works on dividing bacteria) may not work well. Clindamycin will actually affect toxin binding. The phenomenon of Strep species  dividing but continuing to produce toxin is referred to as the Eagle affect. 

So, when shot-gunning the antibiotics in a patient with a really bad soft tissue infection (not the run of the mill cellulitis) consider adding Clindamycin to the regimen. 

Show References

Category: Cardiology

Title: CNS events and the ECG

Keywords: stroke, intracranial, electrocardiography (PubMed Search)

Posted: 8/3/2008 by Amal Mattu, MD (Updated: 4/22/2024)
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Hemorrhagic and ischemic strokes are well-known to produce ECG changes that resemble cardiac ischemia. Large T-wave inversions are the most classic findings, but ST changes, prolonged QT interval, tachydysrhythmias, bradydysrhythmias, and AV blocks have also been described.

The exact cause of these changes is uncertain. One theory is that the strokes can produce catecholamine surges which cause the changes; another theory is that intracranial events produce a vagal response that causes ECG changes. Regardless of the reason, one should always keep stroke in the differential diagnosis for patients with ischemic-appearing ECG changes, especially when the patient has an altered mental status or neurologic deficit.


Category: Orthopedics

Title: Tessaly Test for Meniscal Injuries

Keywords: Tessaly, Meniscal, Tear, Knee Exam (PubMed Search)

Posted: 8/2/2008 by Michael Bond, MD (Updated: 4/22/2024)
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When examining a knee for a meniscal injury the commonly described tests are the McMurray Test and Apley Test.  However, these tests have sensitivities of 48-68% and 41% respectfully, and specificities of 86-94% and 86-93% respectfully.  Depending on whether you are looking at the medical or lateral meniscus.

The Tessaly Test that was first described in 2005 can be performed with knee in either 5 or 20 degrees of flexion and has a senstivity of 89-92% and specificity of 96-97% when performed in 20 degrees flexion.  The test also tends to be easier to perform.

To perform the test:

  1. Stand on affected leg only with the other leg held up in the air.  The examiner holds hands for balance.
  2. Flex knee to be test to 20 degrees, while the other leg is held in the air
  3. Internally and Externally Rotate Knee
  4. Positive test is pain at medial or lateral joint line with possible locking/catching sensation

Essentially you and your patient will look like you are doing the twist as they rotate their knee with you holding their hands.



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Category: Pediatrics

Title: Sever's Disease

Keywords: Sever's Disease (PubMed Search)

Posted: 8/1/2008 by Don Van Wie, DO (Updated: 4/22/2024)
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Sever's Disease

  • Sever's disease is a painful inflammation of the calcaneal apophysis made worse with activity.
  • It is thought to be caused by repetitive trauma to the weaker structure of the apophysis, induced by the pull of the Achilles tendon on its insertion.
  • It occurs most frequently in active 10- to 12-year-old boys.
  • The pain can limit performance and participation, and if left untreated, the pain can significantly limit even simple activities of daily life.
  • Xrays are useful in ruling out other causes of heel pain like fracture or rare tumor but are not diagnostic or prognostic. 
  • Treatment consist of rest, nsaids, wearing a half-inch inner-shoe heel lift (at all times during ambulation), a monitored stretching program, and presport and postsport icing. (rarely casting)
  • Sever disease is a self-limited condition and will resolve after the growth plate fuses.

Show References

Category: Neurology

Title: Seizure associated with Tramadol use

Keywords: tramadol, Ultram, seizure, seizure threshold (PubMed Search)

Posted: 7/31/2008 by Aisha Liferidge, MD (Updated: 4/22/2024)
Click here to contact Aisha Liferidge, MD

  • Tramadol (Ultram) is an uncontrolled substance in the opiod family that binds mu receptors and is indicated for moderate to moderately severe pain.
  • Tramadol lowers seizure threshold to < 1/100,000, likely related to its inhibition of neuronal re-uptake of serotonin and norepinephrine in the CNS.
  • Concurrent use with SSRI's, TCA's, MAOI's, neuroleptics, other opiods, naloxone (when given for tramadol overdose) and alcohol exacerbates the risk of seizure onset.
  • Tramadol-related seizure is independent of dose (i.e. can occur at starting dose of 25 mg), although brisk titration up to maintenance doses does increase seizure risk.
  •  To avoid triggering a seizure, tramadol should not be used in patients with the following conditions:

             --  seizure disorder

             --  alcohol withdrawal

             --  alcoholism

             --  drug withdrawal

             --  CNS infections

             --  metabolic disorder

             --  head trauma


Category: Critical Care

Title: Plateau Pressure

Keywords: acute lung injury, alveolar overdistention, plateau pressure (PubMed Search)

Posted: 7/29/2008 by Mike Winters, MD (Updated: 4/22/2024)
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The Importance of Plateau Pressure

  • Alveolar overdistention is a precursor to the development of acute lung injury (ALI)
  • Plateau pressure is a measurement of alveolar overdistention, and is the pressure equilibration between the airways and the alveoli
  • Plateau pressure is measured by using an inspiratory hold (for at least 3 seconds) at the end of inspiration
  • Based on available data, you want to maintain the plateau pressure < 30 cm H2O
  • Remember that patients should be heavily sedated to obtain this measurement - any patient-ventilator asynchrony may provide inaccurate information

Show References

Category: Vascular

Title: Causes of Elevated D-Dimer

Keywords: D-Dimer (PubMed Search)

Posted: 7/29/2008 by Rob Rogers, MD (Updated: 4/22/2024)
Click here to contact Rob Rogers, MD

Causes of an Elevated D-Dimer 

Don't forget the multiple causes of an elevated d-dimer:

  • PE/DVT
  • Sepsis/infection
  • Malignancy 
  • Renal disease
  • Pregnancy
  • MI
  • Stroke

**See attached PDF-Differential Diagnosis of Elevated D-Dimer



Show References


0807301959_Causes_of_Elevated_D-Dimer.pdf (43 Kb)

Category: Cardiology

Title: rightward axis on the ECG

Keywords: electrocardiography (PubMed Search)

Posted: 7/28/2008 by Amal Mattu, MD (Updated: 4/22/2024)
Click here to contact Amal Mattu, MD

There are many causes of rightward axis on electrocardiography: RVH, COPD, acute (e.g. PE) or chronic (e.g. COPD, cor pulmonale) pulmonary hyptertension, sodium channel blocking drug toxicity (e.g. TCAs), ventricular tachycardia, hyperkalemia, dextrocardia, left posterior fascicular block, prior lateral MI, and of course misplaced leads.

In emergency medicine, however, the causes of acute/NEW rightward axis constitutes a smaller list. Perhaps the two most important causes of acute/new rightward axis in emergency medicine that should be remembered are PE and sodium channel blocker toxicity. In both of these conditions, the rightward axis may be the only obvious finding on the ECG.

The takeaway point is this: when you see new righward axis (compared to an old ECG) and you see nothing else "jumping out" at you, consider PE and consider sodium channel blocker toxicity.

Category: Procedures

Title: Femoral Vein Access

Keywords: Femoral Vein, Access, Cannulation (PubMed Search)

Posted: 7/26/2008 by Michael Bond, MD (Updated: 4/22/2024)
Click here to contact Michael Bond, MD

Most people are now using Ultrasound to aid in cannulation of the femoral and internal jugular veins, but if you find yourself without the ultrasound machine you can increase your chance of successful cannulation of the femoral vein by positioning the leg properly.

Werner et al looked at the common femoral veins of 25 healthy volunteers and noted that the femoral vein was accessable more often when the hip was abducted and external rotated.  This simple position change increased the mean diameter of the vein, and prevented the vein from being directly posterior to the artery.


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