UMEM Educational Pearls

Category: Infectious Disease

Title: CAP 2007

Keywords: community acquired pneumonia, CURB-65, empiric antibiotics (PubMed Search)

Posted: 9/18/2007 by Mike Winters, MBA, MD (Updated: 6/14/2024)
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Important EM pearls from the recent 2007 IDSA/ATS guidelines for treatment of community-acquired pneumonia (CAP) Patients should be treated for a minimum of 5 days CURB-65 a new pneumonic; any patient with ? 2 warrants admission Confusion Uremia elevated Respiratory rate low Blood pressure age > 65 Outpatient CAP treatment Healthy + no abx in past 3 months ? macrolide Comorbidities OR use of abx within last 3 months ? a respiratory fluoroquinolone OR ?-lactam + macrolide Inpatient CAP treatment ICU patients ? ?-lactam + either azithromycin or a respiratory fluoroquinolone Non-ICU patients ? respiratory fluoroquinolone OR ?-lactam + macrolide Mandell LA, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults Clinical Infectious Diseases 2007;44:S27-S72

Category: Vascular

Title: Hypertensive Encephalopathy

Keywords: Hypertension, Encephalopathy (PubMed Search)

Posted: 9/17/2007 by Rob Rogers, MD (Updated: 6/14/2024)
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Hypertensive encephalopathy is a condition in which cerebral blood flow and autoregulation are altered in the setting of very high blood pressure. Although there is no evidence-based cutoff for what BP value defines this condition, most people will have a diastolic above 120 mm Hg or so. In many cases, you may not be able to make the diagnosis until BP is reduced and other conditions have been ruled out (meningitis, etc.) Patients with this condition may have: 1. altered mental status of any sort 2. seizures 3. stroke-ischemic or hemorrhagic Pearls: 1. Avoid hydralazine-will bottom some peoples' BP out 2. Forget oral meds-unreliable and may lead to "stacking" and eventual abrupt decline in BP 3. Aim for a 25% reduction in MAP over 2-3 hours....then stop reducing the BP! 4. Early signs of this condition may be subtle (mild confusion, somnolence, seizure)

Category: Cardiology

Title: Acute Pericarditis

Keywords: Acute Pericarditis, Pericardial effusion (PubMed Search)

Posted: 9/16/2007 by Amal Mattu, MD (Updated: 6/14/2024)
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Acute pericarditis Up to 60% of patients with acute pericarditis are asssociated with a pericardial effusion. Grading of the effusion is as follows:
  • "Small" = less than 10 mm of echo-free space (anterior plus posterior)
  • "Moderate" = 10-20 mm
  • "Severe" = > 20 mm.
Ideally, the effusion echo-free space is measured at the onset of the QRS complex in diastole. Small effusions do not mandate admission in and of themselves. Severe effusions mandate admission. For moderate effusions, it's a judgement call and probably depends on how good the follow up is and also the patient's symptoms.

Category: Pediatrics

Title: Supracondylar Fractures

Keywords: Humeral Fracture, Supracondylar Fracture, radius fracture, Compartment Syndrome (PubMed Search)

Posted: 9/14/2007 by Sean Fox, MD (Updated: 6/14/2024)
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Supracondylar Fractures Most common elbow fracture in childhood. Mechanism: Hyperextension (FOOSH) 90-95% Flexion (Fall on Flexed Elbow) 5-10% Posterior Fat Pad suggests intra-articular effusion and fracture. Complications = Ulnar, Median, and Radial nerve injuries, brachial artery injury, Volkmann s ischemic contracture, COMPARTMENT SYNDROME Associated Distal radius Fracture in ~5% of cases Palpate the wrist! Attempts in the ED at partial reduction leads to increase soft tissue injury and swelling, which will complicate the definitive reduction in the OR.

Category: Toxicology

Title: Toxins that cause Diabetes or Hyperglycemia

Keywords: Hyperglycemia, diabetes, poisoning (PubMed Search)

Posted: 9/13/2007 by Fermin Barrueto, MD (Updated: 6/14/2024)
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There are few medications/toxins that can cause clinically significant diabetes or hyperglycemia, here is the list: Vacor (PNU, an off the market rat poison) Streptozocin Alloxan Pentamidine Quinolones (gatifloxacin>moxifloxacin>ciprofloxacin) Olanzapine Antidote for Vacor, streptozocin, Alloxan: Niacinamide Antidote for Quinolones, Olanzapine: Remove agent, supportive care

Category: Neurology

Title: Post-Dural Puncture Headache

Keywords: Lumbar Puncture, Lumbar Puncture headache, headache, dural puncture (PubMed Search)

Posted: 9/12/2007 by Aisha Liferidge, MD (Updated: 6/14/2024)
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Post-dural Puncture Headache (PDPH) PDPH = typically occurs within 3 days after a lumbar puncture (LP), improves when supine, worsens when upright and by any movement that increases intracranial pressure (i.e. sneezing, coughing), most subside within 24 hours. The pain typically distributes to the frontal-occipital region and is usually throbbing or dull. The incidence of PDPH after an ED LP ranges from 5% to 10%. While optimal operator experience, minimizing the amount of CSF removed, and having the patient lie in the recumbent position for at least 30 minutes after the procedure have all traditionally been associated with decreasing the risk of PDPH, only minimizing the bore size of the needle used has consistently been proven to decrease the risk. Treatment options: 1) Opiates, IV fluids, anti-emetics. 2) Caffeine 500 mg in 1 L of NS, IV over 1 hour (80 - 90% effective). 3) Cosyntropin (ACTH analog) 0.25 - 0.75 mg IV (~ 56% success rate). 4) Epidural blood patch, epidural fibrin glue, epidural crystalloid/colloid infusion, caudal saline infusion. Younggren, Merchant. "Post-Dural Puncture Headache." ACEP News, 26:8.

Category: Critical Care

Title: Non-invasive ventilation

Keywords: non-invasive ventilation, acute respiratory failure, intubation prevention (PubMed Search)

Posted: 9/11/2007 by Mike Winters, MBA, MD (Updated: 6/14/2024)
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-Non-invasive ventilation (NIV) is a form of ventilatory support that avoids intubation. -NIV refers to the provision of inspiratory pressure support + PEEP via a nasal or face mask (BiPAP, CPAP). -Strong evidence from randomized trials supports NIV to avoid intubation in patients with acute respiratory failure secondary to COPD exacerbation, acute cardiogenic pulmonary edema, and in immunocompromised patients (AIDS, transplant). -NIV can be considered in asthma exacerbations, pneumonia, and ARDS however the supporting evidence for these conditions is fairly weak. -Contraindications for NIV include respiratory arrest, hemodynamically unstable, unable to protect the airway, excessive secretions, uncooperative/agitated, and recent UGI or airway surgery. -You should expect to see clinical improvement within 1 to 2 hours.

Category: Vascular

Title: Severely Elevated Blood Pressure in the ED

Keywords: Hypertension (PubMed Search)

Posted: 9/11/2007 by Rob Rogers, MD (Updated: 6/14/2024)
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Pearls regarding truly asymptomatic, but severely elevated, BP: 1. Repeat blood pressure a few times in the ED before acting on it. Many patient's blood pressure will regress to the mean. 2. Anyone being discharged with elevated BP should have some type of plan for followup. Avoid "followup with your doctor as needed." 3. No evidence exists that acute lowering of BP in an asymptomatic patient does any good (despite scary BP numbers). Avoid "treating the numbers." and.... 4. Avoid NSAIDS in patients with out of control BPs. NSAIDS induce sodium retention and essentially obliterate the effects of antihypertensive medications.

Category: Cardiology

Title: mitral valve prolapse

Keywords: mitral valve prolapse, mitral regurgitation, endocarditis (PubMed Search)

Posted: 9/9/2007 by Amal Mattu, MD (Updated: 6/14/2024)
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Mitral valve prolapse is one of the most common valvulopathies and, although usually benign, it can predispose to atrial dysrhythmias, bacterial endocarditis with systemic embolization, and sudden death. If these patients have an audible murmur (as opposed to just the click), it implies that there is regurtitant flow and these patients are then generally considered candidates for bacterial endocarditis before procedures which can induce bacteremia. This includes dental extraction!

Category: ENT

Title: Peritonsillar Abscess Pearls

Keywords: PTA, Abscess, ENT, Peritonsillar (PubMed Search)

Posted: 9/9/2007 by Michael Bond, MD (Updated: 6/14/2024)
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With more and more ENT specialist resigning their hospital affiliations in favor of outpatient surgical centers it is getting harder and harder to find an oncall ENT to treat an ENT emergency. Peritonsillar abscesses and the need for drainage are a common reason to initiate a transfer. If you are unable to transfer your patient, here are some tips on how to do a needle aspiration safely.
  • The carotid artery lies lateral and posterior to the tonsil. Any attempts should be done anteriorly, and medial to the peritonsillar pillar.

  • The incision is made superior to the tonsil in the area of the soft palate. The abscess is normally located in the peritonsillar soft tissues of the soft palate.

  • Needle aspiration: Needle aspiration can be therapeutic in itself; in some studies, up to 85% of patients were effectively treated with outpatient needle aspiration and oral antibiotics.

  • Consider cutting the cap of the needle or scalpel so that once it is replaced only a portion of the needle /scalpel is exposed. This will help prevent you from inadvertently inserting the needle//scalpel to deeply.

  • A single high dose of steroid (decadron 10 mg) prior to antibiotic therapy dramatically improves symptoms of patients with PTAs postdrainage.

  • Streptococcus pyogenes (group A beta-hemolytic streptococcus) is the most common aerobic organism, and fusobacterium is the most common anaerobic organism. However, most abscesses contain a mixture of aerobic and anaerobic organisms. Consider Penicillin VK, Clindamycin, or Augmentin. If no response to Penicillin VK in 24 hours consider the addition of metronidazole

Disclaimer: Any and all procedures should only be done by properly trained and qualified individuals. These pearls do not meet the standard for proper training and/or qualification.

Category: Pediatrics

Title: Arnold-Chiari (Chiari II) Malformation

Keywords: Arnold-Chiari (Chiari II) Malformation, Stridor, Sycope, Respiratory Distress, Weakness, Herniation (PubMed Search)

Posted: 9/7/2007 by Sean Fox, MD (Updated: 6/14/2024)
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Arnold-Chiari (Chiari II) Malformation Arnold-Chiari malformation = herniation of cerebellar tissue and the medulla downwards through the foramen magnum into the upper cervical spinal canal causing compression of the upper segments of the spinal cord. Two distinct ages are identified with Chiari II malformations: infants and adolescents ==> Infants often present with Respiratory Distress, Inspiratory Stridor, and/or apnea. -- These herald impeding brainstem compromise. ==> Older children more often present with syncopal episodes or muscle weakness. Chiari Malformation needs to be considered in all children with myelomeningocele, Down s Syndrome, Hydrocephalus, Sacral Dimple, or other neurologic abnormalities presenting with respiratory distress. ==> Myelomeningocele is associated with Chiari Malformation and hydrocephalus in 80-90% of cases. Recognition is critical, since movement of the head and neck can lead to further compression of the CNS structures. Rath GP, Bithal PK, Chaturvedi A: Atypical Presentations in Chiari II Malformation. Pediatric Neurosurgery 2006;42:379-382

Category: Toxicology

Title: Scombroid

Keywords: Fish, scombroid, seafood poisoning (PubMed Search)

Posted: 9/6/2007 by Fermin Barrueto, MD (Updated: 6/14/2024)
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Scombroid is one of the most common seafood poisonings. A classic EM board question. - Caused by ingestion of histamine in fish muscle - Naturally occurring histidine is converted to histamine by bacteria in unrefrigerated fish - Most common fish: tuna, mackerel, bonito, mahi mahi, blue fish and yellow tail - Symptoms: Within minutes to hours - flushing, urticaria, perioral burning, N/V/D - Treatment: Antihistamines, fluids, bronchodilators. Epinephrine and steroid for severe reactions.

Category: Neurology

Title: Transient Global Amnesia

Keywords: amnesia, TIA, memory (PubMed Search)

Posted: 9/5/2007 by Aisha Liferidge, MD (Updated: 6/14/2024)
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Transient Global Amnesia (TGA) is a rare (5 to 11 cases per 100,000 persons per year), but clinically well-defined disorder defined as an acute episode of short-term memory loss, in the absence of any neurologic signs or symptoms, which resolves within 24 hours. TGA is typically triggered by an event such as valsalva, exercise, emotional stress, sexual intercourse, immersion in cold water, painful stimuli, and severe exertion. While there are widely used diagnostic criteria, TGA is primarily a clinical diagnosis and one of exclusion. While TGA is benign, self-limiting, and there is no specific treatment other than reassurance, it is important to recognize and differentiate TGA from TIA, which has different prognostic implications. Agrawal, et al. "Transient Global Amnesia: An Uncommon Differential Diagnosis of Transient Ischemic Attack." Hospital Physician 43:8.

Category: Critical Care

Title: Life threatening hypophosphatemia

Keywords: hypophosphatemia, CHF, respiratory failure (PubMed Search)

Posted: 9/4/2007 by Mike Winters, MBA, MD (Updated: 6/14/2024)
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-Phosphate is predominantly an intracellular ion that is critical for an array of cellular processes -Hypophosphatemia is most commonly seen in alcoholics, DKA, and sepsis: frequency rates of 40%-80% -Severe hypophosphatemia ( < 1.0 mg/dL) in the critically ill can manifest as widespread organ dysfunction: respiratory failure (diaphragmatic weakness), CHF (decreased myocardial contractility), rhabdomyolysis, arrhythmias, seizures, hemolysis, impaired hepatic function, and depressed WBC function -Severe hypophosphatemia should be treated with intravenous replacement: 0.08 - 0.16 mmol/kg over 2-6 hours -Be aware of complications from too rapid intravenous replacement: hypocalcemia, tetany, hypotension, volume excess, and metabolic acidosis

Category: Vascular

Title: Pulmonary Embolism-CT Accuracy vs. Outcome Studies

Keywords: Pulmonary Embolism, CT (PubMed Search)

Posted: 9/3/2007 by Rob Rogers, MD (Updated: 6/14/2024)
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There has been an explosion in recent years in the PE literature on CT scanning. Older literature, and even some current studies, emphasized the sensitivity of CT scanning for pulmonary embolism. In other words, how well does CT detect PE? The current trend in PE research is to report outcomes. So, a patient is evaluated for PE and the CT is negative. What is that patient's outcome (PE, DVT, death) at 30, 60, 90 days, etc? Dozens of studies in recent years have shown that patients generally have a superb outcome after negative CTs. Several recent studies have shown this, and in these studies the only imaging modality was CT (no ultrasound, etc). Pearl: Despite the difference in sensitivity for PE between single slice, multislice, and multidetector CT studies have shown that the outcome rates are relatively equal. Multidetector CT clearly picks up small, subsegmental clots better than single slice or 16, 32 slice CT. This might very well mean (according to some) that subsegmental (small, tiny) clots may not be that significant. We may very well be approaching an era where we don't treat small, peripheral clots. Pulmonary Embolism, second edition, Paul Stein 2007

Category: Cardiology

Title: fondaparinux in ACS

Keywords: fondaparinux, anticoagulation, acute coronary syndromes (PubMed Search)

Posted: 9/2/2007 by Amal Mattu, MD (Updated: 6/14/2024)
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Fondaparinux is a selective factor Xa inhibitor. Benefits of fodaparinux vs. heparin when anticoagulants are used in ACS: 1. It is not associated with heparin induced thrombocytopenia. 2. Significant reduction in 30-day and 6-month mortality vs. enoxaparin. 3. Significant reduction in bleeding complications. 4. Safer in patients with renal insufficiency vs. enoxaparin. Unfractionated heparin should be continued while the patient goes for PCI.

Category: Cardiology

Title: Acute Coronary Syndrome (our number one area of liability) [Part 2]

Keywords: ACS, Legal, documentation (PubMed Search)

Posted: 9/1/2007 by Michael Bond, MD (Updated: 6/14/2024)
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Acute Coronary Syndrome (our number one area of liability) [Part 2]
  • Describing the character of the pain is the most common element of the history (Braunwald and Lee & Goldman).
  • The history is the threshold issue and determines whether the patient enters risk stratification (Braunwald).
  • The most atypical features of chest pain are sharp, pleuritic and positional pain.
  • One-third of all patients with an MI have no chest pain.
  • One set of cardiac enzymes violates a strong national standard of practice.
  • Serial enzymes do not rule out unstable angina.
  • If discharging a patient, document why you felt the patient did not have ACS.
  • The plaintiff attorney literature advises litigators to focus on the history.
Thanks again to Larry Weiss, MD, JD Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Category: Pediatrics

Title: Congenital Heart Disease

Keywords: Pediatric Congenital Heart Disease, Hyperoxia test, Prostaglandin E, Shock, CHF (PubMed Search)

Posted: 8/31/2007 by Sean Fox, MD (Updated: 6/14/2024)
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Congenital Heart Disease Clinical signs and symptoms of pediatric congenital heart disease are often subtle ==> Often misdiagnosed with respiratory illness or sepsis Can progress to CHF and shock ==> CHF in infants = tachypnea, tachycardia, and hepatomegaly (classic triad) -- JVD, Peripheral Edema, rales are UNCOMMON (unlike adults) Hyperoxia Test Is the etiology of the cyanosis cardiac or noncardiac? ==> If pulmonary disesase is the cause, 100% FiO2 will increase PaO2 to ~150mmHg and increase the Pulse Ox by ~10%. ==> If Heart Defect is the cause, there will be minimal improvement in condition and values. PGE1 administration ==> Used to reopen or maintain patency of ductus arteriosus until definitive intervention. ==> Consider it in a neonate presenting in shock (possibly undiagnosed ductal dependent lesion). ==> Side effects are hypotension, bradycardia, seizures, and APNEA. ==> Either intubate before or be prepared to intubate.

Category: Toxicology

Title: Methemoglobinemia

Keywords: pyridium, methemoglobinemia, methylene blue (PubMed Search)

Posted: 8/30/2007 by Fermin Barrueto, MD (Updated: 6/14/2024)
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- Classic Clinical Finding: Cyanosis out of proportion to clinical symptoms (look real blue but not SOB) - Causative Agents: Benzocaine (and other local anesthetics), dapsone, nitrites, phenazopyridine (Pyridium) - When do you treat: significant tissue hypoxia (MI, CVA, Dysrhythmias), and if MetHb >20% asymptomatic - Treatment: Methylene Blue 1-2 mg/kg (0.1 -0.2 mL/kg of 1% methylene blue) over minutes

Category: Neurology

Title: Cheyne Stokes Respirations

Keywords: Cheyne Stokes, stroke, increased intracranial pressure (PubMed Search)

Posted: 8/29/2007 by Aisha Liferidge, MD (Updated: 6/14/2024)
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Cheyne-Stokes (CS) respirations, also known as "periodic breathing," results from the inability of the respiratory center of the brain, the brain stem (i.e. pons and medulla oblongata), to rapidly compensate for changing serum partial pressure of oxygen and carbon dioxide. CS is characterized by respirations of gradually increasing and decreasing tidal volumes, with interspersed periods of apnea. Conditions associated with CS: - Increased ICP (i.e. space occupying brain lesions such as hemorrhage and tumors) - Congestive heart failure - Altitude sickness - Toxic-metabolic encephalopathy - Carbon monoxide poisoning - High-dose morphine administration CS was first described by physicians John Cheyne and William Stokes. Wikipedia Encyclopedia. The Diagnosis of Stupor and Coma by Plum and Posner.