UMEM Educational Pearls

Category: Pediatrics

Title: Febrile Seizures

Keywords: Ferbrile Seizures, Bacteremia, Fever (PubMed Search)

Posted: 2/15/2008 by Sean Fox, MD (Updated: 6/19/2024)
Click here to contact Sean Fox, MD

Febrile Seizures

  • Diagnosis: Simple vs Complex
    • Simple Febrile Seizure
      • Age = 6mos to 5yrs
      • Single Seizure
      • Generalized
      • Lasting less than 15 minutes
      • Child returns to baseline and has normal neurological exam.
    • Complex Febrile Seizure
      • Same as above, except can be focal seizure or prolonged or with multiple seizures within 24 hours.
      • May indicate a more serious disease process.
  • Etiologies:
    • Viral illnesses are the predominant cause of febrile seizures.
      • Human herpes simplex virus 6 (HHSV-6) has been associated with about 20% of pts with first febrile seizures.
    • Shigella gastroenteritis also has been associated.
    • The rate of serious bacterial infections is similar to those found in pt’s with fever without a source
  • Key Point:
    • Do NOT forget to work-up the fever as you would for the patient’s age!
    • A lower threshold for performing full-sepsis work-up with LP is advocated in those pt’s less than 12 months of age.

Here are a couple of herbals touted as aphrodesiac's and the toxcity associated with them (the price of love):

Chan Su or "Love Stone" - A chinese herbal that is suppose to be topically applied, unfortunately all of the instructions are in chinese and those who ingest it will die a digoxin-like death. It has a compound that is essentially a potent digoxin-like substance.

Yohimbine - herbals that contain this can cause priapism -  shocker


Category: Neurology

Title: The Brainstem

Keywords: brainstem, cranial nerves (PubMed Search)

Posted: 2/14/2008 by Aisha Liferidge, MD (Updated: 6/19/2024)
Click here to contact Aisha Liferidge, MD

  • The brainstem is the lower extension of the brain that connects the brain to the spinal cord.
  • Neurological functions located in the brainstem include those necessary for survival (breathing, digestion, heart rate, blood pressure) and for arousal (being awake and alert).
  • Most of the cranial nerves come from the brainstem.  The brainstem is the pathway for all fiber tracts passing up and down from peripheral nerves and spinal cord to the highest parts of the brain.

Category: Critical Care

Title: Spontaneous pneumomediastinum

Keywords: spontaneous pneumomediastinum (PubMed Search)

Posted: 2/12/2008 by Mike Winters, MBA, MD (Updated: 6/19/2024)
Click here to contact Mike Winters, MBA, MD


Spontaneous Pneumomediastinum

  • Spontaneous pneumomediastinum is largely a benign disease typically seen in young males ages 18-21 years
  • It is typically caused by activities that increase alveolar pressure such as coughing, sneezing, vomiting, inhalational drug use, and Valsalva maneuver
  • The most common symptoms include chest pain and dyspnea; chest pain is usually centrally located, may radiate to the neck, and may be worse with inspiration
  • CT scan is the "gold standard"; CXR is a good place to start but it is normal in up to 30% of cases
  • The vast majority of patients do not require admission or supplemental O2
  • Advise patients to avoid strenuous activity until after symptom resolution (typically takes about 2 weeks)
  • Any patient with a fever, elevated WBC count, hemodynamic instability, severe dysphagia or odynophagia should first be evaluated for infectious mediastinitis or esophageal perforation (spont. pneumomediastinum is a diagnosis of exclusion in these patients)

Category: Vascular

Title: The Great Masquerader....AAA

Keywords: AAA, aneurysm (PubMed Search)

Posted: 2/12/2008 by Rob Rogers, MD (Updated: 6/19/2024)
Click here to contact Rob Rogers, MD afraid, be very afraid

Abdominal Aortic Aneurysm (AAA)  is known as the great masquerader in the elderly for good reason....

  • May look EXACTLY like a kidney stone
  • May cause vague abdominal and/or back pain....probably one of the reasons we scan older folks with abdominal pain. Presentations of AAA in the older patient may not be impressive!
  • May be associated with the "blue toe syndrome" (where mural thrombus flips distally and occludes small vessels in the feet and toes)
  • A pulsatile mass is frequently absent
  • 10% of urology referrals for older (>65) patients with suspected kidney stones result in a diagnosis of AAA


Category: Cardiology

Title: predictors of ACS

Keywords: acute coronary syndrome, history (PubMed Search)

Posted: 2/10/2008 by Amal Mattu, MD (Updated: 6/19/2024)
Click here to contact Amal Mattu, MD

The 5 most important factors at predicting the presence of ACS in a patient presenting with chest pain (in order of importance):
1. nature of anginal symptoms (i.e. the HPI)
2. prior history of CAD
3. male gender
4. older age
5. increasing number of traditional risk factors

Notice this means that the MOST important factor is the HPI...the OLDCAAAR. If the patient has a concerning HPI, NEVER drop your concerns just because the patient is young or has minimal other risk factors.

Category: Obstetrics & Gynecology

Title: Rhogam Basics

Keywords: Rhogam, Pregnancy (PubMed Search)

Posted: 2/9/2008 by Michael Bond, MD (Updated: 6/19/2024)
Click here to contact Michael Bond, MD


  • Remember to administer Rhogam to any Rh negative mother that has the following conditions:
  • Pregnancy/delivery of an Rh-positive baby
  • Abortion/threatened abortion at any stage of gestation
  • Ectopic pregnancy
  • Antepartum fetal-maternal hemorrhage (suspected or proven) resulting from antepartum hemorrhage (e.g., placenta previa), amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, other obstetrical manipulative procedure (e.g., version) or abdominal trauma
  • Transfusion of Rh incompatible blood or blood products (i.e.: platelets)


  • 300 mcg IM
  • Can give 50 mcg IM within 72 h of exposure of a therapeutic or spontaneous abortion if gestation age is 12 weeks or less. (Order as MICRhogam)
  • Additional doses of Rhogam may be necessary when the patient has been exposed to > 15 mL of Rh-positive red blood cells. This may be determined by use of qualitative or quantitative tests for fetal maternal hemnorrhage but generally will only occur during a full term delivery or if incompatible blood products are given.


Trivial Fact: Rhogam is Pregnancy Class C

Category: Pediatrics

Title: Neonatal Conjunctivitis

Keywords: Neonatal Conjunctivitis, Chlamydia, Gonorrhea, Red Eye (PubMed Search)

Posted: 2/2/2008 by Sean Fox, MD (Emailed: 2/8/2008) (Updated: 6/19/2024)
Click here to contact Sean Fox, MD

Neonate with Red Eye

  • Crusty Eye – Not Red
    • Dacryostenosis - nasolacrimal duct obstruction
    • It is the most common cause of tearing in childhood.  
    • No photophobia, corneal is normal
    • Tx  = Warm compresses and gentle massage
  • Purulent Conjunctivitis - Ophthalmia neonatorum
    • Chemical (due to prophylactic eye drops) - day 1
    • Gonorrhea –
      • Presents early on (day 2-5)
      • OCULAR EMERGENCY – may cause globe perforation
      • Associated Systemic Infection - meningitis
      • Ceftriaxone (25-50mg/kg) – Treat until Cx’s return.
    • Chlamydia –
      • Longer incubation period (day 5-14)
      • Causes Eyelid Scarring leading to blindness
      • Associated Systemic Infection – Pulmonary
      • Ceftriaxone (25-50mg/kg) + Topical Erythromycin
      • If Culture +, then PO erythromycin to prevent late onset pneumonitis.

Category: Neurology

Title: Checking for Peripheral Vision Abnormalities

Keywords: stroke, visual field cuts, peripheral vision (PubMed Search)

Posted: 2/7/2008 by Aisha Liferidge, MD (Updated: 6/19/2024)
Click here to contact Aisha Liferidge, MD

  • Remember that it is important to check a patient's peripheral vision when concerned about stroke, and when performing a neurological exam in general.
  • Recognizing grossly abnormal peripheral vision often suggests the presence of various types of visual field cuts and helps localize a stroke lesion.
  • When performing a general, very gross examination for peripheral vision abnormalities:
  1. It is sometimes helpful to ask the patient to cover the eye that you are NOT checking for abnormality at the time.
  2. Ask the patient to look straight ahead.
  3. Ask the patient to tell you when they are able to see the long, narrow object (i.e. your finger, a pencil, etc.) that you slowly move forward into their view, starting from the point where the finger tips of the patient's laterally abducted arm would be (i.e. the object begins at a distance approximately equal to the patient's arm length).
  4. Using this axis of reference, normal peripheral vision should occur at 45 degrees or less.


Category: Vascular

Title: IVC thrombosis

Keywords: Inferior Vena Cava, Physical Examination, Thrombosis (PubMed Search)

Posted: 2/5/2008 by Rob Rogers, MD (Updated: 6/19/2024)
Click here to contact Rob Rogers, MD

Physical Examination finding in inferior vena cava thrombosis

Consider IVC thrombosis if you ever see vertically oriented, dilated abdominal wall veins, or dilated veins on the back. As opposed to abdominal wall veins that radiate out from the umbilicus in patients with cirrhosis-known as caput medusae.

Etiologies include hepatic tumors abutting the IVC, renal cell tumors, open abdominal surgery, catheter related, IVC filter-related.



Category: Cardiology

Title: new STEMI guidelines

Keywords: clopidogrel, ACS, STEMI, myocardial infarction (PubMed Search)

Posted: 2/3/2008 by Amal Mattu, MD (Updated: 6/19/2024)
Click here to contact Amal Mattu, MD

The ACC/AHA just recently published a "Focused Update" of their guidelines for management of ST-elevation MI. Amongst the changes:

Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI who receive thrombolytics.

Clopidogrel 300-600 mg orally should be added to aspirin in patients that are going for PCI for STEMI. This is listed as a Class I intervention, although the level of evidence is rated "C." In other words, it is judged to be definitely helpful though based on not-so-robust evidence (you figure that one out!).

Glycoprotein receptor antagonists can also be added (Class IIa, level of evidence B).

[I personally believe there is better evidence for the GP2B3A inhibitors than for clopidogrel, but there is a general push for more and more guideline writers to support clopidogrel. The number of writers for these ACC/AHA guidelines who have affiliations with the drug companies, including the ones that manufacture clopidogrel (Plavix), is tremendous; the list of disclosures is listed at the back of the document. Nevertheless, people tend to want to follow guidelines, and the boards will test you on this stuff so it is worth knowing.]

[Also for the record, if I have a STEMI, here's what I want: 162 mg ASA (not 325 mg), unfractionated heparin (not enoxaparin), abciximab/ReoPro (not eptifibitide/Integrilin) in the cath lab (not in the ER), and quick PCI; if I can't get the PCI within 60 minutes (not 90, but 60 minutes!), give me either tenectaplase or retaplase (not tPA) + 162 mg ASA + UFH; if I have a lot of pain that is not responding to NTG, give me dilaudid or fentanyl (not morphine)...and some Bailey's on ice; add oral BBs, ACEIs, and a statin at the 24 hour mark, NOT any earlier (early BBs only if I have Bailey's-resistant hypertension). Thanks.]



Category: Toxicology

Title: Scabies - I am itchy!

Keywords: crotimaton, permethrin, lindane (PubMed Search)

Posted: 1/24/2008 by Fermin Barrueto, MD (Emailed: 2/2/2008) (Updated: 6/19/2024)
Click here to contact Fermin Barrueto, MD

We have seen this lovely  bug infect our patients and have to instutitue therapy. But do you know what is the first line drug and which one has now become second line due to its toxicity? Here is the short list:

First Line Therapy: Permethrin (Nix) - least toxic, only causes local irritation

Second Line Therapy: Crotamiton (Eurax) - again local irritation

Third LIne Therapy: Lindane - SEIZURES if you leave it on too long or put on too much. Children were particularly susceptible and relatively contraindicated.


Category: Orthopedics

Title: Metacarpal Neck Fractures

Keywords: Metacarpal, Fracture, Boxer's Fracture (PubMed Search)

Posted: 2/2/2008 by Michael Bond, MD (Updated: 6/19/2024)
Click here to contact Michael Bond, MD

Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

  • 2nd and 3rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
  • 4th Metacarpal fracture <20۫ angulation allowed
  • 5th Metacarpal fracture <30۫ angulation. 
    • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
    • Normal excursion of the 5th MCP is 15۫ to 25۫.
  • No amount of rotation deformity should be allowed.

Category: Pediatrics

Title: Krazy-Glue in the Eye

Keywords: Laceration, Dermabond, cyanocrylate (PubMed Search)

Posted: 2/1/2008 by Sean Fox, MD (Updated: 6/19/2024)
Click here to contact Sean Fox, MD

Tissue adhesives:

Cyanocrylate Tissue Adhesive is an excellent product to use when repairing linear lacerations.

A few things to remember:

The wound needs to be irrigated as you would any other wound prior to closure.

Gravity works.  Consider where the product may drip to before you apply it (Eyes, Ears, Nose, etc).  

Use Surgi-Lube (or other petroleum product) to create a barrier to limit the flow of the cyanocrylate.

For long lacerations, you may use steri-strips to help approximate edges before applying the tissue adhesive.


What to do if the glue gets out of control and drips onto the eyelids... may also apply to Krazy-Glue:

Use copious irrigation and then Mineral Oil (not acetone or alcohol - which won't go well in the eyes).

Often there will be an associated corneal abrasion... treat it as other corneal abrasion.


Category: Toxicology

Title: Drug-Induced Hyperkalemia

Keywords: hyperkalemia, medications (PubMed Search)

Posted: 1/31/2008 by Fermin Barrueto, MD (Updated: 6/19/2024)
Click here to contact Fermin Barrueto, MD

Here is a list of drugs that can cause hyperkalemia either at therapeutic levels or in overdose:

Amiloride, ACEI, Beta Blockers, Cardiac Glycosides, FLuoride

Heparin, NSAIDS, Penicillin (the Pen VK formulation), Spironolactone

Succinycholine and triamterene

Category: Neurology

Title: Dihydroergotamine (DHE) for Treating Headache

Keywords: DHE, dihydroergotamine, migraine headache, headache, cluster headache (PubMed Search)

Posted: 1/30/2008 by Aisha Liferidge, MD (Updated: 6/19/2024)
Click here to contact Aisha Liferidge, MD

  • Dihydroergotamine (DHE) is an older medication approved for the treatment of intractable migraine and cluster headaches.  Many of our Neurology colleagues still use this drug and its administration could start while the patient is 
    in the ED.
  • Intranasal forms have become popular (i.e. Migranal).  Intramuscular and subcutaneous administration are also possible.
  • The typical intravenous dose is 0.25 to 1 mg IV push over 2-3 minutes q 6 hours for 24 to 72 hours.
  • DHE use is contraindicated in the following patients

       Patients concurrently on a protease inhibitor or macrolide antibiotic because of increased risk of life- threatening 
    peripheral ischemia (**Black Box Warning**) 
    >    Patients with a hypersensitivity to ergot alkaloids 
    >    Patients with increased risk of developing vasospastic events 
    >    Patients who are concurrently taking vasoconstrictors 
       Patients who are pregnant or nursing 
       Patients with hemiplegic or basilar migraines
  • Monitor for the following potential adverse reactions, which are typically related to vasoconstriction/spasm
    and warrant immediate abortion of the drug’s administration: 

    >    Myocardial infarction (check ECG's)
    >    Arrhythmia (place on cardiac monitor)
    >    Stroke (regular neuro. checks)
    >    Hypertension (check often) 
       Ischemia (monitor for clinical signs/symptoms) 

    -- Diener HC, Kaube H, Limmroth V. A practical guide to the management and prevention of migraine. Drugs. 1998;56(5):811-824.
    -- Fisher M, Gosy EJ, Heary B, Shaw D. Dihydroergotamine nasal spray for relief of refractory headache: A retrospective chart review. Curr Med Res Opin. 2007;23(4):751-755.


Category: Critical Care

Title: Complications of Radial Artery Catheters

Keywords: radial arterial line (PubMed Search)

Posted: 1/29/2008 by Mike Winters, MBA, MD (Updated: 6/19/2024)
Click here to contact Mike Winters, MBA, MD

Invasive Arterial Pressure Monitoring - Complications

In critically ill patients with hemodynamic instability we often place arterial catheters to continuously monitor mean arterial pressure.  Since we frequently use the radial artery for cannulation, it is important to know the complications associated with these catheters.  Scheer et al performed, perhaps, the largest review of complications of peripheral arterial catheters.  The results:

  • Radial arterial catheters
    • 19,617 cannulations reviewed
    • temporary occlusions - 19.7%
    • hematoma - 14.4%
    • serious ischemic damage - 0.09%
    • pseudoaneurysm - 0.09%
    • sepsis - 0.13%

Pearl: Although permanent ischemic damage is rare, when placing a radial artery catheter use the non-dominant hand.

Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6:198-204.

Category: Vascular

Title: More Fenoldopam Pearls

Keywords: Fenoldopam, Hypertension (PubMed Search)

Posted: 1/28/2008 by Rob Rogers, MD (Updated: 6/19/2024)
Click here to contact Rob Rogers, MD

Fenoldopam Pearls

Intravenous Fenoldopam has been shown in recent years to be a very effective antihypertensive medication. Studies have compared it to Nitroprusside (Nipride), the older generation "gold standard" antihypertensive, and have found to be just as effective.

  • Think of Fenoldopam as Nipride without the toxicity....taste great, less filling
  • Works by peripheral dopamine agonism
  • Increases renal blood flow and induces a natriuresis (patient pees sodium)-so works well in our chronic kidney disease and ESRD patients
  • Easy to titrate and very well tolerated
  • Contraindication in patients with glaucoma-The drug elevates IOP.

Journal of Hypertension 2007

Category: Cardiology

Title: fluid status and treatment of CHF

Keywords: congestive heart failure, CHF, pulmonary edema (PubMed Search)

Posted: 1/27/2008 by Amal Mattu, MD (Updated: 6/19/2024)
Click here to contact Amal Mattu, MD

Recent literature (Collins, et al, Ann Emerg Med, Jan 2008; and Cotter, et al, Am Heart J, Jan 2008) confirms something that we've been talking about for YEARS....more than 50% of patients presenting with acute cardiogenic pulmonary edema are not fluid overloaded, but rather have fluid mis-distributed into the lungs. Management should focus on fluid re-distribution rather than diuresis. Use of diuretics in these patients is associated with worsening renal function, which is a significant predictor of in-hospital mortality.

The best patients to use diuretics on are patients with slow progression of dyspnea, lower extremity edema, and weight gain over days-weeks. In the absence of a history of this slow progression, don't go crazy with the diuretics!

Category: Obstetrics & Gynecology

Title: Headaches and Pregnancy

Keywords: Migraines, Pregnancy (PubMed Search)

Posted: 1/27/2008 by Michael Bond, MD (Updated: 6/19/2024)
Click here to contact Michael Bond, MD

Migraines and Pregnancy

  • Typically headache frequency will increase during the first 2 to 3 months of pregnancy
  • 70% of women report significant improvement in headaches during their second and third trimester.
  • Most migraine medication should NOT be given to pregnant woman.  Verify prior to prescribing.
    • Class X/D drugs include
      • Cafergot (ergotamine)
      • Depakote
      • Dihydroergotamine (DHE)
    • Class C drugs include
      • Imitrex
      • Zomig
      • Midrin
      • Relapex
  • Some headache centers will prophalax pregnant woman with Vitamin B2 and Magnesium.