UMEM Educational Pearls

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   

 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. 

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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.

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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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.

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• 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

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

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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

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Attachments

• 0807301959_Causes_of_Elevated_D-Dimer.pdf (43 Kb)

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.

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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Pyloric Stenosis

• The cause of the hypertrophied pylorus muscle is unknown, but it is usually not present at birth.  Mean onset of symptoms is 2-3 weeks of life, but range can be birth to 5 months with a 4:1 male to female occurrence.
• Clasic presentation is projectile, nonbilious vomiting of last feed which may be immediate or hours later.
• Pyloric Stenosis is the most common reason for abdominal surgery in the first 6 months of life.
• Textbook lab abnormality is a Hypochloremic hypokalemic metabolic alkalosis but this is a later finding and can not be used to rule out the diagnosis.
• Ultrasonography has become the standard imaging technique for diagnosis. It is reliable, highly sensitive, highly specific, and easily performed.
• Muscle wall thickness 3 mm or greater and pyloric channel length 14 mm or greater are considered abnormal in infants younger than 30 days. 
• DDX includes :  Normal Regurgitation (all babies do it!!!), GERD, Milk Intorerance, Obstruction (antral webs, volvulus,intussusception)

• Elemental Mercury is found in manometers, some mercury switches and thermometers.
• Elemental Mercury is also in the CFLs (Compact Fluoroscent Lightbulbs) that are popular now due to rising energy cost (approx 4 mg)
• Organic mercury found in seafood is only toxic in high consistent doses - though has been catastrophic. See attached picture which was the award winning Time magazine cover of the year showing a mother holding her child who had congenital disfigurement due to mercury being dumped into Minamata Bay
• Elemental Mercury is mostly a neurotoxin causing personality changes, nervousness, shyness and depression.
• Acrodynia is pain and pink discoloration of hands and feet due to mercury poisoning in children.

Attachments

• 0807242206_smith_minimata.jpg (83 Kb)

• Don't forget to check for distal lower extremity neurologic deficit after knee injury, particularly when there is a direct blow to the popliteal fossa.
• The common peroneal and tibial nerves exit from the lateral and middle sections of the popliteal fossa, respectively.
• The common peroneal nerve wraps laterally around the fibula (where it's palpable), primarily supplying the lateral portions of the lower leg and foot.
• The tibial nerve primarily supplies the muscles of the posterior compartment of the lower leg (i.e. gastrocnemius, soleus, popliteus).
• Both the common peroneal and tibial nerve fibres branch into the sural nerve, which supplies the lateral foot.
• Common peroneal also splits into deep and superficial branches which supply the muscles of the anterior lower leg compartment and lateral lower leg compartment, respectively.  The deep branch also provides cutaneous innervation of the cleft between the great and second toes.

--  IN SUMMARY:

• Neurologic deficit of the posterior lower leg muscles likely = tibial nerve injury.
• Neurologic deficit of the anterior and lateral lower leg muscles likely =  peroneal nerve injury.
• Decreased sensation in the web space between the great and 2nd toes likely = (deep) peroneal nerve injury.
• Decreased sensation over the lateral dorsum of the foot likely = sural nerve injury.

*** Speaking of such deficits by naming the affected nerve distribution is particularly helpful when consulting orthopedists, neurologists, etc.

Mechanical Ventilation in Asthma

• Approximately 25,000 asthmatics are intubated each year
• Mismanaged mechanical ventilation in asthma carries significant morbidity and mortality
• One of the primary goals of ventilating the asthmatic is to allow for lung deflation
• The most effective way to allow for lung deflation, and reduce hyperinflation, is to reduce minute ventilation (TV x RR)
• Initial tidal volume settings should be 6 ml/kg of predicted body weight; if plateau pressures are > 30 cm H₂O tidal volume should be decreased to 4 - 5 ml/kg
• Reduced respiratory rates will also allow longer exhalation times; initial recommended rates are 6 - 8 breaths per minute
• If plateau pressures are still high despite lowering tidal volume and respiratory rate, you can then shorten the inspiratory time to allow for longer exhalation

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How good was that CT Pulmonary Angiogram You Ordered?

CT is currently the gold standard imaging modality for pulmonary embolism. Since we order these quite a bit in the ED, we should know some of the important nuances regarding interpretation of the scan. All of us at some point have looked at a pulmonary CTA and thought that it looked a bit "fuzzy" or perhaps it didn't "look right"  This happens more often in obese patients. There is good literature to show that a suboptimal CTA misses clinically significant PE. So, it is important for emergency physicians to know a little about the CT scan ordered for our patients. 

How can you know if the CT scan YOU ordered to rule out PE is really "good enough" to rule out PE?

• Well, you can rely on the radiologist. But remember they may not comment of the quality of the scan. Or, they may simply recommend another test.
• Look at the Hounsfield Units (HU). For those who have PACS or some other computer radiology display,all you need to do is move the cursor to the main pulmonary artery and see what value (usually on the bottom of the screen) is displayed. 
• A HU >280 indicates that the CT is "good" (i.e. good enough contrast bolus to detect clot). By the way, >350 looks white.

So, a 34 yo obese patient who gets a CT scan to rule out PE, who has 170 HU in the main pulmonary artery, has not had an optimal CT. Thus, you really haven't ruled out PE even if the read is "negative." Often this is due to poor bolus timing. 

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Fracture Management:

In order to maximize billing when caring for patients with fractures two things should be done:

1. The physician does not need to place the splint, but the physican must document that they checked the splint for proper placement and alignment for it to be billed appropriately..
2. Emergency physicians also provide a lot of "definitive" care for fractures.  (i.e.: we provide the same care that the treating specialist would provide) and can bill for a higher level if this is documented properly. 
   1. For instance, if you are treating a impacted, stable distal radius fracture with a splint and pain medication this is the same definitive care the orthopedist would do as they are only going to exchange your splint for  a cast. 
   2. Another example is the treatment of rib fractures which may consist only of pain control, incentive spirometry and instructions to prevent pneumonia.
   3. In these patients, have the patients follow up more than 48 hours later.  If you document that the patient will followup in less than 48 hours, most auditors and billing companies will assume you are not providing definitive care and will not code for the higher earning RVU.

Finally,  you should obtain post-reduction x-rays on any fracture that you manipulate and document that the patient is neurovascularly intact prior to discharge.

 The most common misdiagnosis in cases of missed acute MI is reflux esophagitis. Various studies have demonstrated the following factors that lead to this misdiagnosis:
1. 20% of patients with acute MI describe their pain using the words "indigestion" or "burning."
2. Almost 50% of patients with acute MI report an increase in belching during their ischemic symptoms.
3. 15% of patients get some relief of their ischemic pain with antacids and 7% of patients get complete relief of their ischemic pain with antacids.
4. 8% of patients report that their ischemic pain began while eating.

Before you ever write "Reflux esophagitis" or "GERD" on the chart of a patient you are about to send home, think twice about the possibility of acute cardiac ischemia.
 

PEDIATRIC FEVER + SEIZURE = FEVER

When a child has a fever and a seizure, do the age appropriate workup for a fever and you won't go wrong!!!

•  Therapeutic concentration considered 10-20 mg/dL
•  Some hospitals report in "mg/L" thus a level of 110 mg/L is therapeutic
•  Symptoms of Toxicity usually > 40 mg/dL
•  Consider Hemodialysis in any patient with a serum concentration >100 mg/dL

First Line Therapy:  Urine Alkalinization (pH >7.5) by administrating NaHCO3

Other Indications for Hemodialysis in Salicylate Poisoned Patient:

1. Renal Failure
2. CHF
3. Acute Lung Injury
4. Persistent CNS disturbances
5. Refractory metabolic acidosis or electrolyte abnormality
6. Hepatic insufficiency with coagulopathy

• The Sciatic Nerve is commonly injured during intramuscular buttocks injections as well as hip fracture dislocations and posterior dislocations.  In such instances, always confirm and document preserved sciatic nerve function.

• Sciatic nerve injury often results in foot drop due to decreased function of the hamstring, calf, and anterolateral lower leg muscles.

• Sciatic nerve injury may also cause loss cutaneous sensation over the calf , as well as the sole and lateral portions of the foot.