UMEM Educational Pearls

Title: Thoracic Aortic Aneurysm Size

Category: Vascular

Keywords: aneurysm (PubMed Search)

Posted: 10/1/2007 by Rob Rogers, MD (Updated: 11/22/2024)
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Surgical repair of thoracic aortic aneurysms is generally dictated by size. Aneurysms need repair to prevent rupture. Anything over 6 cm (which is the magic number , according to authorities) will make almost all cardiothoracic surgeons anxious. -For non-marfans patients Most cardiac surgeons will use a cut off for surgery of: ascending aorta > 5.5 cm and descending aorta > 6.5 cm -Patients with Marfans: Threshold to operate is a bit lower. ascending >5 cm and descending > 6 cm So, who cares, you ask? #1-We scan a lot of chests and we will be diagnosing this in the ED. #2-As emergency physicians we should have some familiarity with the aortic size that makes Cardiothoracic surgeons nervous and the size that can get outpatient followup. Calling a CT surgeon to the ED to see a patient with an incidental 4.8 cm ascending aortic aneurysm in many cases is not necessary...depends on the patient, followup, etc. They will definitely not be excited about a 4.8 cm aneurysm. Sure, it looks HUGE on CT, but most won't operate on this size.

Title: Valvular Disorders--Hypertrophic cardiomyopathy

Category: Cardiology

Keywords: Valvular Disorder, Hypertrophic Cardiomyopathy (PubMed Search)

Posted: 9/30/2007 by Amal Mattu, MD (Updated: 11/22/2024)
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Hypertrophic cardiomyopathy is associated with a systolic murmur loudest at the apex, and it may radiate to the base. The murmur increases with maneuvers that cause ventricular filling to decrease (e.g. valsalva, standing). The murmur decreases with maneuvers that cause ventricular filling to increase (e.g. trendelenburg, isometric exercises, squatting). These patients have primarily diastolic dysfunction, and so they should be treated with beta blockers to help improve diastolic filling time.

Title: Sinusitis

Category: ENT

Keywords: Sinusitis, Antibiotics, Viral, URI (PubMed Search)

Posted: 9/29/2007 by Michael Bond, MD (Updated: 11/22/2024)
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How many times a day are you told "I need antibiotics I coughed up some yellow/green stuff" Neither the color nor the consistency of nasal secretions helps to predict whether there is a bacterial infection. One should only consider treating sinus infections with antibiotics if the patient has:

Purulent nasal drainage for more than 10 days
Or if symptoms less than 10 days and one or more of the following significant facial pain, facial/periorbital swelling, dental pain, or temperature greater than 39'C

Antibiotic of first choice is Amoxicillin for 10-14 days. [Also consider Bactrim, Augmentin or Cipro for recurrent sinus infections]

Title: Growth

Category: Pediatrics

Keywords: Growth, Failure to thrive, Weight Gain (PubMed Search)

Posted: 9/28/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Growth An infant with failure to thrive will first demonstrate poor weight gain. ==> With continued insult, there will be reduced height/length growth and then, finally, reduced head circumference growth. After birth, infants will normally loose weight initially (particularly breastfed infants). Infants should regain their birth weight by 2 weeks of life. For the first 3 months, infants should gain ~30 grams a day (~1 oz / day). By 6 months, they should have doubled their weight. By 12 months, they should have tripled their weight. By 24 months, they should have quadrupled their weight.

Title: Ciguatera Poisoning

Category: Toxicology

Keywords: ciguatera, poisoning, fish (PubMed Search)

Posted: 9/27/2007 by Fermin Barrueto (Updated: 11/22/2024)
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Ciguatera Poisoning - The most commonly reported cause of fishborne poisoning - Most commonly big-game fish: sea bass, grouper, red snapper, yellow-tail, kingfish and sturgeon - Ciguatoxin is bioaccumulated (thus big fish) and is heat and acid stable (unaffected by cooking) - Symptoms: 6-12 hrs post-ingestion GI, paresthesias, metallic taste, ataxia and paresis of legs are possible - The classic symptom is dysesthesias (sensory reversal where cold gives intense burning sensation) - Treatment: Supportive, consider mannitol, calcium, gabapentin - Avoid the following as it may exacerbate symptoms: opioids, barbiturates, steroids

Title: Stroke Etiologies in Young Patients

Category: Neurology

Keywords: stroke, cardioembolic events, young patients (PubMed Search)

Posted: 9/27/2007 by Aisha Liferidge, MD (Updated: 11/22/2024)
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Common causes of stroke in young patients: --> Arterial dissection (most commonly involving the carotids, often trauma related) --> Cardioembolic events (most commonly via a patent foramen ovale (PFO) associated with an atrial septal aneurysm; also atrial septal anuerysms and myxomatous mitral valve prolapse; most common amongst our patient population is likely endocarditis) --> Large vessel disease (typically in 5th decade of life) --> Small vessel disease (typically in 5th decade of life) --> Coagulopathies (i.e. Sickle cell anemia) --> Vasculopathies/Vasculitis Cerrato, et al. "Stroke in young patients: Etiopathogenesis and risk factors in different age classes." Cerebrovascular Diseases 2004;18:154-159.

Title: Re-expansion pulmonary edema

Category: Critical Care

Keywords: pulmonary edema, tube thoracostomy (PubMed Search)

Posted: 9/25/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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-Reexpansion pulmonary edema represents a potentially life-threatening complication of tube thoracostomy (mortality rate as high as 20 percent) -It usually occurs after rapid reexpansion of a collapsed lung in patients with a pneumothorax -It may also follow evacuation of large volumes of pleural fluid (>1.0 to 1.5 liters) or after removal of an obstructing tumor -The incidence of edema appears to be related to the rapidity of lung reexpansion and to the severity and duration of lung collapse -The clinical manifestations vary from isolated radiographic changes to complete cardiopulmonary collapse -Treatment is supportive, mainly consisting of supplemental oxygen and, if necessary, mechanical ventilation

Title: Indications for IVC Filters

Category: Vascular

Keywords: IVC, inferior vena cava, Indications (PubMed Search)

Posted: 9/24/2007 by Rob Rogers, MD (Updated: 11/22/2024)
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Indications for the placement of an IVC filter: 1. Patients with acute VTE who have a contraindication to traditional anticoagulation (surgery, GI bleed, bleeding) 2. Patients with a DVT who have severely compromised cardiopulmonary reserve or who already have pulmonary hypertension 3. Patients with VTE who have developed clot on anticoagulation Reference: Buller, HR, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy, Chest 2004

Title: ACS in the elderly

Category: Cardiology

Keywords: myocardial infarction, misdiagnosis (PubMed Search)

Posted: 9/23/2007 by Amal Mattu, MD (Updated: 11/22/2024)
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The consequences of missed MI in the elderly are dramatic: 50% of elderly patients with an MI missed by the ED or primary care doctor will be dead within 3 days.

Title: Gastrointestional Bleeding

Category: Gastrointestional

Keywords: Gi Bleed, Diveriticular, Bleed, (PubMed Search)

Posted: 9/22/2007 by Michael Bond, MD (Updated: 11/22/2024)
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Gastrointestional Bleeding Pearls. [Quick Facts]

Peptic ulcer disease has 2 main etiologies: 1) Helicobacter pylorus infection and 2) NSAID use. Zollinger Ellison Syndrome causes 1% of peptic ulcer disease.
Hemorrhage is the most common complication of peptic ulcer disease, occurring in 15% of patients
25% of patients over the age of 60 years have an AV malformation.
The most common cause of significant lower GI bleeding in the elderly is diverticulosis or angiodysplasia. That typically presents as painless bright red rectal bleeding.
AV malformations are the number 2 cause of massive lower gastrointestinal hemorrhage.
Rectal bleeding following AAA repair is from aortoenteric fistula until proven otherwise.

Title: Henoch-Schonlein Purpura

Category: Pediatrics

Keywords: Henoch-Schonlein Purpura, abdominal pain, Vasculitis, Nephritis (PubMed Search)

Posted: 9/21/2007 by Sean Fox, MD (Updated: 11/22/2024)
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Henoch-Schonlein Purpura HSP is a small vessel vasculitis ==> Related to IgA nephropathy; however, IgA nephropathy more often involves young adults and predominantly affects the kidneys. Generally, HSP is a benign, self-limited disease. Pt s are NOT TOXIC appearing. ARENA (common symptoms) ==> Abdominal Pain and Vomitting (85%) +/- Bloody Stools ==> Rash (95-100%) ==> Edema (20-50%), peripheral or scrotal ==> Nephritis ==> Arthritis / Arthragias (60-80%) particularly of knees and ankles Steroids are controversial no definitive controlled trials demonstrate their efficacy.

Title: Ethanol Withdrawal

Category: Toxicology

Keywords: ethanol, withdrawal, benzodiazepines (PubMed Search)

Posted: 9/18/2007 by Fermin Barrueto (Updated: 11/22/2024)
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Ethanol withdrawal can be measure objectively with the CIWA-Ar Scale. It is a prospectively validated tool to measure whether or not a patient is in ethanol withdrawal and can assist with management. Score Treatment <10 Does not require treatment 10-15 Treatment with either oral or intravenous benzodiazepines, outpatient > 15 Intravenous benzodiazepines with likely admission You must also take into account the patient's history, comorbidities and previous history of ethanol withdrawal/delirium tremens. ***The CIWA Score Sheet has been attached to this pearl***

Attachments

0709201013_ciwa-ar.pdf (10 Kb)

Title: Acute MCA Infarcts

Category: Neurology

Keywords: infarct, stroke, MCA (PubMed Search)

Posted: 9/20/2007 by Aisha Liferidge, MD (Updated: 11/22/2024)
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The majority of large cerebral artery infarcts take place in the Middle Cerebral Artery (MCA) because it supplies the largest territory. The MCA supplies most of the temperol, anterolateral frontal lobe, and parietal lobes. Perforating branches supply the posterior limb of the internal capsule and the head and body of the caudate and globus pallidus. Clinical findings can include: ipsilateral facial, upper, and lower extremity deficit/weakness (arm > leg); dysarthria; dysphagia; global aphasia if lesion on left (i.e. dominant hemisphere); neglect.

Title: CAP 2007

Category: Infectious Disease

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

Posted: 9/18/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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

Title: Hypertensive Encephalopathy

Category: Vascular

Keywords: Hypertension, Encephalopathy (PubMed Search)

Posted: 9/17/2007 by Rob Rogers, MD (Updated: 11/22/2024)
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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)

Title: Acute Pericarditis

Category: Cardiology

Keywords: Acute Pericarditis, Pericardial effusion (PubMed Search)

Posted: 9/16/2007 by Amal Mattu, MD (Updated: 11/22/2024)
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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.

Title: Supracondylar Fractures

Category: Pediatrics

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

Posted: 9/14/2007 by Sean Fox, MD (Updated: 11/22/2024)
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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. -www.Wheelessonline.com

Title: Toxins that cause Diabetes or Hyperglycemia

Category: Toxicology

Keywords: Hyperglycemia, diabetes, poisoning (PubMed Search)

Posted: 9/13/2007 by Fermin Barrueto (Updated: 11/22/2024)
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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

Title: Post-Dural Puncture Headache

Category: Neurology

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

Posted: 9/12/2007 by Aisha Liferidge, MD (Updated: 11/22/2024)
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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.

Title: Non-invasive ventilation

Category: Critical Care

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

Posted: 9/11/2007 by Mike Winters, MBA, MD (Updated: 11/22/2024)
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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.