UMEM Educational Pearls

Category: Critical Care

Title: Life- or Limb-saving Escharotomy

Keywords: Escharotomy, burn, ischemia (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 7/17/2024)
Click here to contact Mike Winters, MBA, MD

Life- or Limb-saving Escharotomy * At some point in your career you may have to perform an emergent escharotomy to safe a life or limb * Deep thickness circumferential chest burns act like a straight jacket and impair respiration * Circumferential limb burns act like a tourniquet and impairs both venous output and arterial input resulting in ischemia * Limb escharotomy should be performed as soon as pulses diminish - do not wait for them to disappear * The picture illustrates the incision lines for escharotomy (note the bold lines highlight the importance of going across any involved joint)

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Category: Critical Care

Title: Subclavian central venous access

Keywords: Venous, catheter, subclavian (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 7/17/2024)
Click here to contact Mike Winters, MBA, MD

Subclavian central venous access * Many consider the subclavian to be the preferred route for central venous access * Approximately 5-6% of subclavian's are associated with misdirection of the catheter tip into the internal jugular * Directing the J-tip of the guidewire caudally significantly reduces the incidence of malpositioning Reference: Tripathi M, et al. Direction of the J-Tip of the guidewire, in seldinger technique, is a significant risk factor in misplacement of subclavian vein catheters: a randomized, controlled study. Anesth Analg 2005;100:21-4.

Category: Critical Care

Title: Intubated Patients HOB Recommendations

Keywords: Intubation, ventilation, VAP, bed (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Emailed: 7/8/2007) (Updated: 7/17/2024)
Click here to contact Mike Winters, MBA, MD

In the absence of contraindications, keep the head of the bed elevated 30 degrees for intubated patients * Mechanical ventilation places patients at risk for ventilator-associated pneumonia (VAP) * ICU mortality for VAP ranges from 30% to 70% * Elevating the head of the bed has been shown to decrease the frequency of VAP Reference: Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004;141:305-13.

Category: Toxicology

Title: Opioid Prescription Drug Abuse - The Pattern of Abuse

Keywords: opioids, toxicology (PubMed Search)

Posted: 11/20/2014 by Fermin Barrueto, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Fermin Barrueto, MD

The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep.  The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.

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Category: Toxicology

Title: Opioid Prescription Drug Abuse - The Pattern of Abuse

Keywords: opioids, toxicology (PubMed Search)

Posted: 11/20/2014 by Fermin Barrueto, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Fermin Barrueto, MD

The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep.  The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.

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Category: Toxicology

Title: Valproic acid toxicity

Keywords: Valproic acid (PubMed Search)

Posted: 10/16/2014 by Hong Kim, MD (Emailed: 7/17/2024)
Click here to contact Hong Kim, MD

Valproic acid (VPA) is often used to treat seizure disorder and mania as a mood stabilizer. The mechanism of action involves enhancing GABA effect by preventing its degradation and slows the recovery from inactivation of neuronal Na+ channels (blockade effect).

VPA normally undergoes beta-oxidation (same as fatty acid metabolism) in the liver mitochondria, where VPA is transported into the mitochondria by carnitine shuttle pathway.

In setting of an overdose, carnitine is depleted and VPA undergoes omega-oxidation in the cytosol, resulting in a toxic metabolite.

Elevation NH3 occurs as the toxic metabolite inhibits the carbomyl phosphate synthase I, preventing the incorporation of NH3 into the urea cycle.

Signs and symptoms of acute toxicity include:

  • GI: nausea/vomiting, hepatitis
  • CNS: sedation, respiratory depression, ataxia, seizure and coma/encephalopathy (with serum concentration VPA: > 500 mg/mL)

Laboratory abnormalities

  • Serum VPA level: signs of symptoms of toxicity does not correlate well with serum level.
  • NH3: elevated
  • Liver function test: elevated AST/ALT
  • Basic metabolic panel: hypernatremia, metabolic acidosis
  • Complete blood count: pancytopenia

Treatment: L-carnitine

  • Indication: hyperammonemia or hepatotoxicity
  • Symptomatic patients: 100 mg/kg (max 6 gm) IV (over 30 min) followed by 15 mg/kg IV Q 4 hours until normalization of NH3 or improving LFT
  • Asymptomatic patients: 100 mg/kg/day (max 3 mg) divided Q 6 hours.

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Category: Pediatrics

Title: Visual Diagnosis Pediatrics: Case thanks to Ari Kestler MD (@KestlerMD) and Haney Mallemat MD (@CriticalCareNow)

Keywords: non-accidental trauma, clavicle fracture, neonate, pediatrics, abuse (PubMed Search)

Posted: 10/4/2014 by Ashley Strobel, MD (Emailed: 7/17/2024)
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Question

Q: What is wrong with this baby? And what Dx should you entertain?

Previously healthy 7d old presents after difficulty feeding, one episode of vomiting and now with intermittent apneic episodes.

 

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Category: Neurology

Title: Phantoms in EMS

Keywords: Stroke, EMS, prehospital care, tPA, emergency medical services, fibrinolysis (PubMed Search)

Posted: 5/15/2014 by Ben Lawner, MS, DO (Emailed: 7/17/2024) (Updated: 7/3/2014)
Click here to contact Ben Lawner, MS, DO

The Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S) was a randomized prehospital  clinical trial. On certain days, a dedicated Stroke Emergency Mobile (STEMO) responded to possible ischemic stroke incidents. Outcomes measured included time to thrombolysis and adverse events such as intracerebral hemorrhage. As opposed to usual prehospital care, a STEMO ambulance was equipped with a CT scanner, point of care laboratory, and a neurologist. According to the study, STEMO use resulted in reduced time to treatment (tPA) without adverse events. 

Though this trial did not specifically measure clinical endpoints, it addresses issues central to the delivery of specialized prehospital care:

1) Are there certain conditions which might warrant a tailored, super-specialized EMS response?
2) Are EMS systems capable of delivering definitive care to the patient as opposed to delivering the patient to definitive care? 

Stateside study has already started.  The Houston Fire Department, in partnership with UTHeath, has already loosed a "Mobile Stroke Unit" on the streets. Like the STEMO, the specialized ambulance will be University hospital based, carry a neurologist, and have the capability to administer tPA. 

STEMO pictures courtesy of the "NeuroEMS Blog"
http://www.neuroems.com/2014/05/14/tpa-in-the-truck-results-of-the-phantom-s-trial/

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Category: Visual Diagnosis

Title: What's the Diagnosis? Case by Dr. Ali Farzad

Posted: 4/7/2014 by Haney Mallemat, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Haney Mallemat, MD

Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

 

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Category: Orthopedics

Title: Sports Hernia/Athletic pubalgia

Keywords: Sports Hernia, groin pain (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 7/17/2024)
Click here to contact Brian Corwell, MD

Sports Hernia/Athletic pubalgia

 

Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.

Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.

Bilateral symptoms not uncommon.

PE:  Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms. 

If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.

Fluoroscopic guided injections can be helpful to isolate the site of pain generation.

First line therapy is rest, non-narcotic analgesia and physical therapy.

With surgery, >80% return to pre injury level of play.

 

http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg

 

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Category: International EM

Title: Fever and Polyarthralgia

Keywords: International, Chikungunya, vector-borne, (PubMed Search)

Posted: 3/5/2014 by Andrea Tenner, MD (Emailed: 7/17/2024)
Click here to contact Andrea Tenner, MD

Case Presentation:

53 yo male presents with fever, myalgia, maculopapular rash, and severe polyarthralgia. He just returned from a cruise to the Caribbean islands.

Clinical Question:

What is the diagnosis?

Answer:

Chikungunya Virus

  • Travelers who go to the Caribbean are at risk of getting chikungunya. Cases have been reported in Saint Martin, Martinique, and Guadeloupe. In addition, travelers to Africa, Asia, and islands in the Indian Ocean and Western Pacific are also at risk.
  • Mosquito vector, incubation 3-7 days
  • Joints involved are typically hands and feet, usually symmetric, severe arthralgia often debilitating
  • Dx: serology - ELISA, IgM
  • Treatment: IVF, NSAIDS, supportive

Bottom Line:

  • Include Chikungunya in your differential of non-specific fever, rash, headache and arthralgia in travelers the Caribbean and endemic areas.

University of Maryland Section of Global Emergency Health

Author: Veronica Pei, MD

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Category: Critical Care

Title: Adrenal Insufficiency

Posted: 4/12/2013 by Haney Mallemat, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Haney Mallemat, MD

Adrenal insufficiency (AI) can be a life-threating condition and is classified as primary (failure of the adrenal gland) or secondary (failure of hypothalamic- pituitary axis).

Common causes of primary adrenal insufficiency include autoimmune destruction, infectious causes (TB and CMV), or interactions with drugs (e.g., anti-fungals, Etomidate, etc.). Secondary causes are usually due to abrupt withdrawal of steroids after chronic use, although sepsis and diseases of the hypothalamus or pituitary (e.g., CVA) may occur.

Signs and symptoms include fatigue, weakness, skin pigmentation, dizziness, abdominal pain, and orthostatic hypotension; it should be suspected with any of the following: hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia, low free-cortisol level, and hemodynamic instability despite resuscitation.

Treatment:
• Correct underlying the disorder
• Resuscitation and hemodynamic support
• Correct hypoglycemia and electrolyte abnormalities
• Treat with hydrocortisone, cortisone, prednisone, or dexamethasone +/- fludrocortisone (Note: dexamethasone is attractive choice in the ED because it will not interfere with ACTH stimulation test)


 

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Category: Infectious Disease

Title: Avian Influenza H7N9

Posted: 4/12/2013 by Andrea Tenner, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Andrea Tenner, MD

General Information:

-As of April 5th, 14 confirmed cases of a new influenza A virus (H7N9) have occurred in China.  Six of those have died. 

-Presumed transmission via infected poultry in bird markets, and thus far no person-to-person transmission has occurred.

-Likely susceptible to oseltamavir or inhaled zanamivir

 

Area of the world affected:

-China

Relevance to the US physician:

- Suspect in patients with a respiratory illness and appropriate travel history.

- Refer to CDC within 24 hours if test positive for flu A but cannot be subtyped

- If H7N9 is suspected, patients should be under droplet and airborne precautions

 

Bottom Line:

No human-to-human transmission from H7N9 thus far, but the possibility exists.  Any unsubtypeable influenza A patient should be placed on droplet and airborne precautions and oseltamavir or zanamivir started immediately.

 

University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH

 

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Category: Toxicology

Title: Octreotide for Pediatric Sulfonylurea Poisoning

Keywords: octreotide, sulfonylurea (PubMed Search)

Posted: 4/12/2013 by Bryan Hayes, PharmD (Emailed: 7/17/2024) (Updated: 4/13/2013)
Click here to contact Bryan Hayes, PharmD

Methods: A large retrospective case series evaluated 121 children under 6 years old with hypoglycemia from a sulfonylurea ingestion.

Results:

  • In addition to dextrose, patients who received octreotide had a median of zero hypoglycemic episodes after octreotide (compared to 2 before treatment, p < 0.0001).
  • Median blood glucose concentrations after receiving octreotide were also higher (62 mg/dL vs 44, p < 0.001).
  • Most required only 1 dose of octreotide with no reported adverse effects.


Authors' Conclusion: Octreotide administration decreases the number of hypoglycemic events and increases blood glucose concentrations in children with sulfonylurea ingestion.

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Category: Pediatrics

Title: Tinea Capitis

Posted: 3/9/2013 by Rose Chasm, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Rose Chasm, MD

  • Tinea capitis (ringworm of the scalp) is caused by dermatophytic fungi
  • Trichophyton tonsurans is the most common species in the US, and does NOT flouresce under Wood's lamp
  • Griseofulvin (20-25mg/kg/ day orally) is the standard first-line therapy in children older than 2 years, and has a good safety profile
  • Both tablet and suspension formulations are available, and it should be taken with food that are high in fat to increase drug concentrations
  • NO laboratory assessment of hepatic enzymes is required during the 8-week therapy course in children who have no history or clinical examination findings concerning for liver disease.
  • Topical antifungal agents are ineffective because they do not penetrate sufficiently into the hair shaft.

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Question

50 year-old male with cough and dyspnea. What's the diagnosis?

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Category: Visual Diagnosis

Title: An alcoholic with fever and cough

Keywords: fever, cough, alcoholic (PubMed Search)

Posted: 5/7/2012 by Rob Rogers, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Rob Rogers, MD

Question

An alcoholic patient presents with a cough, fever, and very foul smelling breath (worse than usual)

What's the diagnosis? And what are the risk factors?

 

 

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Category: Toxicology

Title: Hydrofluoric Acid Burns

Keywords: hydrofluoric acid, burn, chemical burn, HFA, calcium gluconate (PubMed Search)

Posted: 9/5/2010 by Dan Lemkin, MS, MD (Emailed: 7/17/2024) (Updated: 10/2/2010)
Click here to contact Dan Lemkin, MS, MD

Hydrofluoric acid is a weak acid used primarily in industrial applications for glass etching and metal cleaning/plating. It is contained in home rust removers. Although technically a weak acid, it is very dangerous and burns can be subtle in appearance while having severe consequences.

Hydrofluoric acid burn

Wilkes G. Hydrofluoric Acid Burns. Jan 28, 2010. 
http://emedicine.medscape.com/article/773304-overview

  • 2 mechanisms that cause tissue damage*
    • corrosive burn from the free hydrogen ions
    • chemical burn from tissue penetration of the fluoride ions
  • Clinical features*
    • Cutaneous burns - absent findings to white-blue appearance
    • Pulmonary edema
    • Hypocalcemia, hyperkalemia, hypomagnesemia
  • Treatment*
    • Decontaminate by irrigation with copious amounts of water.
    • With any evidence of hypocalcemia, immediately administer 10% calcium gluconate IV.
    • Cutaneous burns:
      • Apply 2.5% calcium gluconate gel to the affected area. If the proprietary gel is not available, constitute by dissolving 10% calcium gluconate solution in 3 times the volume of a water-soluble lubricant (eg, KY gel). For burns to the fingers, retain gel in a latex glove.
      • If pain persists for more than 30 minutes after application of calcium gluconate gel, further treatment is required. Subcutaneous infiltration of calcium gluconate is recommended at a dose of 0.5 mL of a 5% solution per square centimeter of surface burn extending 0.5 cm beyond the margin of involved tissue (10% calcium gluconate solution can be irritating to the tissue).
        • Do not use the chloride salt because it is an irritant and may cause tissue damage.

*Extracted from emedicine article.

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Category: Critical Care

Title: Oxygenation goals

Posted: 3/11/2009 by Mike Winters, MBA, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Mike Winters, MBA, MD

Oxygenation goals

  • In recent pearls we have talked about 'lung protective' ventilation strategies to reduce volutrauma, barotrauma, and oxygen toxicity.
  • Using 'lung protective' strategies, such as low tidal volumes, results in higher levels of CO2 and a lower pH.  These are tolerated in favor of lower and safer alveolar pressures.
  • In addition to higher pCO2 values and lower pH, oxygenation goals are slightly lower than conventional teaching.
  • In these patients, you want to maintain SpO2 > 88% and PaO2 > 55 mm Hg.


Category: Vascular

Title: D-Dimer in Pregnancy

Keywords: D-Dimer, Pregnancy (PubMed Search)

Posted: 7/9/2008 by Rob Rogers, MD (Emailed: 7/17/2024) (Updated: 7/17/2024)
Click here to contact Rob Rogers, MD

D-Dimer levels are known to be elevated in pregnancy. But how high is too high and can this test be used in the workup of VTE in pregnant patients?

Recent literature indicates that D-dimer levels in each of the three trimesters are approximately 39% higher: 700, 1000, and 1400 ng/dL for each trimester (normal cutoff 500 ng/dL). So, figure out what trimester your patient is in and use the corresponding D-Dimer level for that trimester.

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