UMEM Educational Pearls

Category: Cardiology

Title: new upright tall T wave in lead V1 (NUTTV1)

Keywords: electrocardiography, cardiac ischemia (PubMed Search)

Posted: 10/28/2007 by Amal Mattu, MD (Updated: 5/21/2024)
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The T-wave in lead V1 is usually inverted or flat. When the T-wave is upright, especially if it is tall (taller than the T-wave in lead V6), be worried about cardiac ischemia...especially if the large upright T-wave is a new finding compared to prior ECGs.

LVH, LBBB, and misplaced precordial leads are the other causes of tall upright T-waves in lead V1. In the absence of any of these three conditions, worry about ischemia.

Marriott described this finding many years ago and refers to it as "loss of precordial T-wave balance."

Category: Trauma

Title: Abdominal Trauma

Keywords: Seatbelt Sign, Abdominal, Trauma (PubMed Search)

Posted: 10/28/2007 by Michael Bond, MD (Updated: 5/21/2024)
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Seat Belt Sign:

  • Patients with a seat belt sign have a high risk of hollow viscus injury
  • Often have a negative CT scan
  • Admit for serial exams and observation, at an absolute minimum patient should be watched 6 hours.
  • Look for associated Lumbar Chance Fractures.

Category: Pediatrics

Title: Severe Asthma in Pediatrics

Keywords: Severe Asthma, Refractory to standard therapy, intubation, atrovent, magnesium, noninvasive ventilation, heliox, ketamine, singulair (PubMed Search)

Posted: 10/26/2007 by Sean Fox, MD (Updated: 5/21/2024)
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Severe Asthma in Pediatrics (Using “the kitchen sink” when all else fails)

Every effort should be made to avoid intubating an asthmatic pt.  Here are some possible options to consider:

  • Atrovent - Multiple doses should be preferred to single doses of anticholinergics. The available evidence only supports their use in school-aged children with severe asthma exacerbation. (reference #1)
  • Magnesium - Magnesium sulfate appears to be safe and beneficial in patients who present with severe acute asthma (based on 5 adult and 2 pediatric studies)
  • Noninvasive ventilation - The application of NPPV in patients suffering from status asthmaticus, despite some interesting and very promising preliminary results, still remains controversial. (only one trial met criteria.  No pediatric studies)
  • Heliox – No good evidence to support its use, but it is relatively safe to use, provided the patient doesn’t need more than 30% FiO2 (70%Helium)
  • Ketamine – Cases suggest that for children experiencing severe asthma exacerbations, intravenous ketamine may be an effective temporizing measure to avoid exposing children to the risks associated with mechanical ventilation.
  • Singulair - Intravenously administered montelukast, in addition to standard therapy, provided rapid benefits and was well tolerated among patients with acute asthma. (Study population 15yrs – 54yrs).


  • References:
  1. Plotnick LH, Ducharme FM. Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children. Cochrane Database of Systematic Reviews 1997, Issue 2. Art. No.: CD000060.
  2. Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database of Systematic Reviews 1999, Issue 2. Art. No.: CD001490.
  3. Ram FSF, Wellington SR, Rowe B, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004360.
  4. Rodrigo, GJ. et al. Use of Helium-Oxygen Mixtures in the Treatment of Acute Asthma. Chest. 2003;123:891-896. 2003
  5. T. Kent Denmark, Heather A. Crane, Lance Brown. Ketamine to avoid mechanical ventilation in severe pediatric asthma. Journal of Emergency Medicine. Volume 30, Issue 2. pages 163-166


Category: Toxicology

Title: Toxicity of SSRIs

Keywords: SSRI, serotonin, toxicity (PubMed Search)

Posted: 10/25/2007 by Fermin Barrueto, MD (Updated: 5/21/2024)
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SSRI Toxicity

Things to watch for in patients that are taking SSRI:

  • Therapeutic administration usually safe
  • Hyponatremia is a common adverse effect (ADH secretion regulated by serotonin)
  • Serotonin Syndrome is a possibilty in combination with other serotnergic drugs
  • One SSRI is more problematic than the rest => Citalopram and Escitalopram
    • The only SSRI that can cause QT prolongation (even 24hrs after OD) and can cause seizures
    • This is the only SSRI with significant toxicity and unfortunately is the most commonly Rx by psych

Category: Neurology

Title: Deep Tendon Reflexes

Keywords: DTR's, deep tendon reflexes (PubMed Search)

Posted: 10/25/2007 by Aisha Liferidge, MD (Updated: 5/21/2024)
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Don't forget to do  thorough assessment of deep tendon reflexes on physical examination when appropriate.  DTR assessment can help localize a lesion and determine a diagnosis (i.e. thyroid disease, Guillain Barre, spinal cord and peripheral nerve lesions).

DTR Assessment Scale:

  • 4+ - very brisk, hyperactive with clonus<
  • 3+ - brisker than normal
  • 2+ - average, normal
  • 1+ - somewhat diminished, low normal
  • 0 - no response

Major DTR Assessment Locations:

  • Triceps (C6, C7)
  • Supinator or Brachioradialis (C5, C6)
  • Knee (L2, L3, L4)
  • Ankle (mainly S1)
  • Plantar (L5, S1)

Category: Critical Care

Title: Vasopressors and acidosis

Keywords: vasopressors, acidosis, bicarbonate (PubMed Search)

Posted: 10/23/2007 by Mike Winters, MBA, MD (Updated: 5/21/2024)
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  • Binding of vasopressor agents to their receptors is influenced by pH (and temperature and concentration)
  • Acidic conditions have been shown to alter receptor numbers on cell surfaces as well as alter binding affinity
  • Overall, pH values > 7.15 do not have an appreciable clinical effects on vasopressors
  • At pH values < 7.1 reductions in effectiveness become apparent
  • Routine administration of bicarbonate remains controversial
  • Aggressively search for and treat the underlying cause of the acidosis


Category: Vascular

Title: Blue Toe Syndrome

Posted: 10/22/2007 by Rob Rogers, MD (Updated: 5/21/2024)
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Blue Toe Syndrome

This syndrome refers to acute digital ischemia caused by athero-microembolism and is associated with cool, painful, cyanotic toes in the presence of palpable distal pulses.

Presence of this syndrome should prompt the Emergency Physician to search for the proximal source. Failure to identify the source and aggressively treat may lead to limb loss.

Common etiologies include:

  • AAA
  • Iliac artery aneurysm
  • Popliteal artery aneurysm


Category: Cardiology

Title: creatinine clearance

Keywords: creatinine clearance, medication adverse effects (PubMed Search)

Posted: 10/22/2007 by Amal Mattu, MD (Updated: 5/21/2024)
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Recent  studies have identified that a significant cause of morbidity and mortality in women, elderly, and patients with renal failure is the failure to consider renal insufficiency in dosing certain anticoagulants and anti-platelet medications, resulting in bleeding complications. Medications should be based on creatinine clearance, NOT SERUM CREATININE. When the creatinine clearance is < 30 mL/min, the dose of any renally-excreted medications should be decreased.

For example, an 85 yo woman that is 110 lbs and has a serum creatinine of 1.2 (sounds normal!) actually has a creatinine clearance < 30, which means that she has relative renal insufficiency. Her dosages of medications (e.g. enoxaparin) should be adjusted for this.

 Creatinine clearance can easily be calculated via computer programs that you can "google" (e.g. just google "creatinine clearance calculation"). If you enter the patient's gender, age, weight, and serum creatinine, the programs will calculate the value for you.

Category: Obstetrics & Gynecology

Title: Placental Abruption

Keywords: Placenta, Abruption, Vaginal Bleed, Third Trimester (PubMed Search)

Posted: 10/20/2007 by Michael Bond, MD (Updated: 5/21/2024)
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Placental Abruption

  • Leading cause of fetal death (1-80 pregnancy)
  • Evaluation
    • Ultrasound has very poor sensitivity
    • Can check D-Dimer, Coags, Fibrinogen and Fibrin Split Products
    • For a stable patient MRI can make diagnosis.
    • Fetal monitoring (minimum four hours) where fetal distress and uterine contractions are seen.
  • Risk factors for Placental Abruption
    • Hypertension
    • Pre-eclampsia
    • Diabetes
    • Trauma
    • Smoking
    • Cocaine
    • Advanced maternal age
  • Treatment
    • C-Section

Category: Pediatrics

Title: Pediatric Septic Shock

Keywords: Sepsis, Shock, Tachycardia, Hypotension (PubMed Search)

Posted: 10/19/2007 by Sean Fox, MD (Updated: 5/21/2024)
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Pediatric Septic Shock

  • Sepsis is the most common cause of pediatric deaths worldwide.
  • Recognition is paramount!  Delayed Dx = Higher Mortality
    • Hypotension is a late finding. 
    • Look for other signs of End Organ Hypoperfusion
      • Prolonged Cap Refill, Change in MS
      • Tachycardia, Tachypnea
      • Elevated Lactate / unexplained metabolic acidosis
  • Management strategy is similar to that of adults
    • Get access (Don’t forget your I/O’s if necessary)!
    • Fluid Resuscitation is the most important aspect of the management
      • Get 20-60ml/kg infused within the first 15 minutes
      • Children with septic shock who get >40ml/kg before the first hour have increased survival compared to those who do not.
        • They may require 60-200ml/kg over the first few hours.
    • Get your Abx on board quickly
    • Currently there are Protocols that are based on the Adult Surviving Sepsis Campaign.

Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.  Pediatr Crit Care Med. 2005 Jan;6(1):2-8.

Category: Toxicology

Title: "Liquid X" or Gamma-Hydroxybutyrate (GHB)

Keywords: Gamma-Hydroxybutyrate, GHB, Liquid X, date rape, overdose (PubMed Search)

Posted: 10/18/2007 by Fermin Barrueto, MD (Updated: 5/21/2024)
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  • Sedating and amnestic, has become notorious in chemical submission (date rape)
  • Very fast onset and rapid resolution though respiratory depression can occur 
  • Difficult to test for with few labs and quickly eliminated through urine 
  • Best chance to catch it is if the patient's first urine void is collected and tested

Category: Airway Management

Title: Indications for CT in Mild TBI

Keywords: TBI, Traumatic Brain Injury, Head CT (PubMed Search)

Posted: 10/18/2007 by Aisha Liferidge, MD (Updated: 5/21/2024)
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According to ACEP's clinical policy, a non-contrast head CT is only indicated in mild traumatic brain injury under the following circumstances:  

1)  headache
2)  vomiting
3)  age over 60
4)  drug or alcohol intoxication
5)  short-term memory deficits
6)  physical evidence of injury above the clavicle
7)  seizure

Category: Infectious Disease

Title: MRSA in Baltimore City

Keywords: MRSA, resistant bacteria, sepsis, antiobiotics, baltimore (PubMed Search)

Posted: 10/17/2007 by Daniel Lemkin, MS, MD (Updated: 5/21/2024)
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A recent study came out which confirms what we already knew... that MRSA infections are no longer confined to ICUs but are spreading to the community. What the new study does show, is that it affects particular populations disproportionately and Baltimore City, more than any other study population. The full article is attached below, or can be obtained for free from the JAMA website.

"Unadjusted incidence rates of all types of invasive MRSA ranged between approximately 20 to 50 per 100 000 in most ABCs sites but were noticeably higher in 1 site (site 7, Baltimore City) (TABLE 2)."

"... we calculated interval estimates excluding site 7 (Baltimore City) to allow the reader to interpret a range of estimates reflecting different metropolitan areas. Regarding the high observed incidence rates reported by site 7, we conducted an evaluation to determine whether these results were valid, including a review of casefinding methods, elimination of cases to include only those with zip codes represented in the denominator, contamination in any laboratory, and other potential causes for increased rates; however, none were in error."


0710170948_jama_mrsa.pdf (129 Kb)

Category: Critical Care

Title: Hyperammonemia in the Critically Ill

Keywords: hyperammonemia, hepatic failure, cerebral edema (PubMed Search)

Posted: 10/16/2007 by Mike Winters, MBA, MD (Updated: 5/21/2024)
Click here to contact Mike Winters, MBA, MD

Hyperammonemia in the Critically Ill

  • Patients with acute hyperammonemia have significant morbidity and mortality 
  • Fulminant hepatic failure is the most common cause of acute hyperammonemia in adult ICUs
  • Other causes include TPN, GI hemorrhage, steroid use, trauma, multiple myeloma, infection with urease-splitting organisms, and drugs (salicylates, valproate) 
  • Cerebral edema, intracranial hypertension, seizures, and herniation are the most significant effects
  • Initial management should focus on treating intracranial hypertension - mannitol, hypothermia, N-acetylcysteine have been used
  • Lactulose has not been shown to reduce mortality in acute hyperammonemia but is unlikely to be harmful

Clay AS, Hainline BE. Hyperammonemia in the ICU. Chest 2007;132:1368-1378.

Category: Vascular

Title: Workup of End Organ Damage from Hypertension

Keywords: Hypertension (PubMed Search)

Posted: 10/16/2007 by Rob Rogers, MD (Updated: 5/21/2024)
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There is no good evidence for what type of workup an asymptomatic hypertensive patient should get in the ED.  An ECG is likely to show LVH, a cxr will be normal in most cases, and many patients will have some degree of proteinuria.

So, what is a safe and reasonable strategy to workup these patients?

  • Consider checking a serum creatinine. I say consider because even this recommendation isn't terribly evidence-based. Elevated creatinine may NOT indicate that a hypertensive emergency is present, but if the creatinine is elevated it might persuade you to choose a different antihypertensive agent (HCTZ won't lower BP effectively if the creatinine near 2.0, and many of us would be a little hesitant to start an ACE-I if the creatinine is elevated). Although there is one study that showed absence of proteinuria and hematuria was correlated with a normal serum creatinine, many patients with asymptomatic HTN will have proteinuria.
  • Repeat the BP several times. One study has shown that as many as 1/3 of patients with high BP in the ED do not have elevated BP when followed up as an outpatient. Many patients' BPs will spontaneously decline (regression to the mean).
  • In the asymptomatic patient a CXR and ECG will likely not help you manage a patient, so don't waste your time and the patient's money getting it.

American College of Emergency Physicians 2006 Guidelines on the evaluation of asymptomatic HTN.



Category: Cardiology

Title: Atrial Fibrillation

Keywords: atrial fibrillation, myocardial infarction (PubMed Search)

Posted: 10/14/2007 by Amal Mattu, MD (Updated: 5/21/2024)
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New onset atrial fibrillation is rarely the sole manifestation of myocardial infarction. In other words, in the absence of accompanying chest pressure, dyspnea, diaphoresis, or other anginal equivalents, a rule-out ACS workup in not supported by the literature and is not cost-effective.

The two exceptions to the statement above are elderly and diabetic patients, in whom subtle presentations of ACS are common with or without atrial fibrillation.

Category: Orthopedics

Title: Pediatric Strains versus Fractures

Keywords: Salter Harris, Fracture, Strain, pediatric (PubMed Search)

Posted: 10/13/2007 by Michael Bond, MD (Updated: 5/21/2024)
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Pediatric Strain versus Fracture

  • Due to the fact that tendons are much stronger than the physeal growth plate in pre-pubescent children, one should be extremely cautious when diagnosing a strain/sprain. 
  • Pre-pubescent pediatric patients should be treated as if they have a Salter Harris I fracture with an appropriate splint and close follow up.

Review of Salter Harris Fractures

  1. A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened.
  2. A fracture through the physeal growth plate and metaphysis.
  3. A fracture through the physeal growth plate and epiphysis.
  4. A fracture through the physis, physeal growth plate and metaphysis.
  5. A crush injury of the physeal growth plate.

Please click here for a pictorial of Salter Harris Fractures from FP Notebook.

Category: Pediatrics

Title: Foreign Bodies

Keywords: Foreign Body, Button Battery, Heliox, Respiratory Distress (PubMed Search)

Posted: 10/12/2007 by Sean Fox, MD (Updated: 5/21/2024)
Click here to contact Sean Fox, MD

Foreign Bodies
•    No object should be left in the esophagus for >24 hrs
•    Unusual FB’s:
        ==>    Very Sharp or pointed objects may perforate the GI tract and should be removed endoscopically.
        ==>    Long objects (>6cm) or wide (>2cm) objects may not pass and should  be remove  endoscopically.
•    Button Batteries
        ==>    9% of cases involve more than one battery (x-ray mouth to anus)
        ==>    Hazards:
                    (1)    Heavy metal leakage (Mercury) – low risk but real
                    (2)    Electrical Discharge (Local tissue injury)
                    (3)    Pressure Necrosis
                    (4)    Leakage of Corrosives
        ==>    85% Pass without symptoms
                    (1)    No intervention if pass the esophagus and pt is without symptoms

•    Consider Heliox as a temporizing measure in children with respiratory distress, while awaiting endoscopy/bronchoscopy.

Category: Toxicology

Title: Valproic Acid and its Unique Antidote

Keywords: valproic acid, poisoning, carnitine (PubMed Search)

Posted: 10/11/2007 by Fermin Barrueto, MD (Updated: 5/21/2024)
Click here to contact Fermin Barrueto, MD

Valproic Acid (Depakote) - Increased use for both seizure disorder, migraine prophylaxis and bipolar disorder - Causes hyperammonemia with or without hepatic insufficiency (Liver enzymes could be normal!) - Hyperammonemia can occur at therapeutic concentrations and overdose - If the patient is sedated and has hyperammonemia, consider carnitine therapy antidotal - Carnitine IV or PO: 50-100 mg/kg bolus or divided bid, safe to give

Category: Neurology

Title: Subarachnoid Hemorrahage

Keywords: SAH, subarachnoid hemorrhage, aneurysm (PubMed Search)

Posted: 10/10/2007 by Aisha Liferidge, MD (Updated: 5/21/2024)
Click here to contact Aisha Liferidge, MD

  • The most common (80%) cause of non-traumatic subarachnoid hemorrhage (SAH) = ruptured saccular (berry) aneurysm.
  • Saccular aneuryms are thought to be present in up to 5% of the population.
  • There is a strong familial association with cerebral aneurysms, and prevalence is increased in people with Marfan Syndrome and Polycystic Kidney Disease.
  • Other causes of non-traumatic SAH include:  AV malformation, cavernous angioma, mycotic aneurysm, and blood dyscrasia.