UMEM Educational Pearls

Category: Orthopedics

Title: Distal radius fracture

Keywords: Wrist fracture, splinting (PubMed Search)

Posted: 5/27/2017 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Distal Radius Fractures

High energy mechanism in younger patients

Falls more common in older patients

Higher incidence in older women due to osteoporosis

     May indicate overall poor bone health

  Avoid splinting in positions of flexion (palmer) and ulnar deviation

    Palmer flexed positions may have a higher rate of displacement

Non operative treatment

Extra-articular fx, less than 5mm shortening of radius, Less than 5 degrees of dorsal angulation.

     Consider fractures than are only stable in extreme positions to be unstable

If fx involves the ulnar styloid or DRUG (distal radial ulnar joint) place in long area posterior splint with arm in mid supination (anatomic position of forearm)

 

 


Takeaways

Botulism is a rare neurologic condition characterized by GI symptoms that progressed to cranial nerve dysfunction and symmetric descending paralysis. Foodborne botulism is due to ingestion of botulinum toxin that is produced by clostridium botulinum, an ubiquitous bacterium in our environment. 

Bottom line:

  • Foodborne botulism presents with GI symptoms that is followed by symmetric descending flaccid paralysis.
  • Botulinum antitoxin prevents further progression of neurologic deficit; it does not reverse the neurologic deficit that is present prior to administration. 
  • Contact your local poison center, and state health department & CDC regarding management and access to botulinum antitoxin.

Maryland Department of Health and Mental Hygiene

  • During business hours: 410-767-6700
  • After hours: 410-795-7365

CDC Emergency Operations Center: 770-488-7100

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Category: Neurology

Title: Neurally Mediated Syncope - Part 2

Keywords: syncope, vasovagal, orthostatic, blood pressure (PubMed Search)

Posted: 5/24/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

 

Vasovagal syncope is a subtype of neurally mediated syncope, and it is distinctly different from orthostatic hypotension. 

Patients with orthostatic syncope have severe orthostatic hypotension that results in transient loss of consciousness immediately or within moments of standing up. This is different from neurally mediated syncope, which develops gradually under conditions of prolonged orthostatic stress such as standing for several minutes. Tilt table testing is useful for true orthostatic syncope, but not for neurally mediated syncope. In addition, checking for “orthostatic hypotension” may not capture patient with orthostatic syncope, because the hypotension occurs so quickly after standing up. Of note, patients may still have orthostatic tachycardia or intolerance with neurally mediated syncope. 

 
 

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Antibiotics in Sepsis

  • Currently international guidelines for the management of sepsis and septic shock recommend antibiotic administration within 1 hour of recognition.
  • With the persistent problem of ED boarding, many patients with sepsis and septic shock remain in the ED long after the initial dose of broad-spectrum antibiotics.
  • A recent single center, retrospective cohort study demonstrated that 1 out of 3 patients with sepsis or septic shock experienced major delays in the time to the second dose of antibiotics.  In fact, over 70% of patients who were given an initial antibiotic with a 6-hr recommended dosing interval experienced major delays.
  • Inpatient boarding in the ED was found to be an independent risk factor for major delays.
  • Take Home Point: Don't forget to write for additional doses of antibiotics in your boarding patients with sepsis.

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Category: Orthopedics

Title: Reverse Segond Fracture

Keywords: Reverse Segond Fracture (PubMed Search)

Posted: 5/21/2017 by Michael Bond, MD (Updated: 9/26/2017)
Click here to contact Michael Bond, MD

Takeaways

It is common teaching that a Segond Fracture is associated with ACL tears.  A reverse Segond fracture, avulsion fracture of the knee due to avulsion of the deep fibers of the medial collateral ligament, has also been described that was initially reported as associated with PCL tears.  However,  a more recent study has not been able to collaborate the PCL connection, but has shown that a reverse Segond fracture is associated with multiple ligamentous injuries to the knee.

Take home point:  If you note a Reverse Segond fracture on your plain flips have the patient followup with orthopedics for a possible MRI, as they probably have other ligamentous injuries that might need treatment.
 

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Takeaways

IM ziprasidone (Geodon) has a relatively quick onset of action with a half-life of 2-5 hours.  Although commonly used in adults, there has not been a study looking at an effective dose in pediatrics. Based on the study referenced, the suggested pediatric dose of ziprasidone is 0.2 mg/kg (max 20mg).

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Currently, Nigeria is having the worst outbreak of bacterial meningitis in almost 10 years, involving 23 states, 13,420 suspected cases, and 1,069 deaths, as of May 9.

 

Bacterial meningitis outbreaks frequently occur in West Africa.  The area most frequently struck by epidemics of bacterial meningitis is in the sub-Saharan region of Africa. This includes 26 countries and over 400 million people. Epidemics most often occur in the dry season  from December-June. Neisseria meningitides serogroup A historically accounts for approximately 90% of the cases.

 

The U.S. Centers for Disease Control and Prevention recommends quadrivalent vaccines (protects against four serogroups A, C, W, and Y) for individuals traveling or living in countries in which meningococcal disease is hyperendemic or epidemic.

 

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Takeaways

High flow nasal cannula (HFNC) is a valid option in the management of acute hypoxic respiratory failure (AHRF) without hypercapnia, as evidenced by multiple studies including the FLORALI trial. Failure of HFNC, however, may result in delayed intubation and worsened clinical outcomes. 

Factors predicting HFNC failure and subsequent intubation include:

  • Lack of RR improvement at 30 and 45 minutes after initation of HFNC
  • Lack of SpO2% improvement at 15, 30, and 60 minutes
  • Persistence of paradoxic breathing (thoracoabdominal dyssynchrony) at 15, 30, 60, and 120 minutes
  • Presence of additional organ system failure, especially hemodynamic (shock) or neurologic (depressed mental status)

Consider whether or not HFNC is appropriate in your patient with AHRF, and if you use it, reevaluate your patient to ensure improvement, or escalate their respiratory support. 

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Category: Orthopedics

Title: IT band tendonitis

Keywords: Lateral knee pain (PubMed Search)

Posted: 5/13/2017 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

 

Iliotibial band tendonitis

IT band is the continuation of the tensor fascia lata and inserts on the tibia at Gerdy's tubercle

Common cause of lateral knee pain seen in Primary care/Sports med clinics

Mechanism: May be due to excessive friction between the IT band and the lateral femoral condyle

Second most common overuse injury of the knee (PF syndrome). Not an acute event.

Affects up to15% of active individuals

Impingement zone is at 30 degrees of knee flexion

Most common in runners and cyclists

Pain localized over the lateral femoral condyle. Better w/ rest. Often occurs at a predictable distance into the run and not at onset.

Exacerbated with changes to mileage or running terrain.

Additional risks include poor shoes (best to change every 300 to 500 miles), excessive foot pronation (pes planus), quad versus hamstring strength asymmetry, weak hip ABductors, leg length discrepancy, tight IT band.

 


Category: Neurology

Title: Neurally Mediated Syncope - Part 1

Keywords: syncope, vasovagal, seizures, orthostatic, blood pressure (PubMed Search)

Posted: 5/10/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

"Neurally mediated syncope" is the most common cause of syncope in all age groups, and includes various overlapping entities, such as neurocardiogenic syncope, vasovagal syncope, and vasodepressor syncope. These are distinctly different from orthostatic hypotension and seizures. 
A careful history is the most important “test” to diagnose neurally mediated syncope. It is frequently preceded by a characteristic prodrome with symptoms such as nausea, dizziness, feelings of warmth or coldness, visual dimming or blurring, clammy skin, facial pallor, general weakness, decreased hearing, or fecal urgency. Symptoms last 30 seconds to several minutes prior to syncope. 
Differentiating syncope from seizures:
Brief, multifocal,arrhythmic, myoclonic jerks are observed in up to 90% of patients at the time of syncope. These are caused by brainstem hypoperfusion and may be mistaken for seizures. The jerks follow the LOC (rather than immediate) and the eyes deviate upward (rather than lateral). If tongue biting occurs, it’s the tip (rather than the side, which is what occurs with seizures).
 

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Category: Orthopedics

Title: Lisfranc Fracture

Keywords: Lisfranc Fracture (PubMed Search)

Posted: 4/29/2017 by Michael Bond, MD (Updated: 5/1/2017)
Click here to contact Michael Bond, MD

Takeaways

Lisfranc Fracture: Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.

Pearls:
  • Fracture findings on plain films may be subtle.
  • If in doubt obtain weight bearing AP views of the foot to demonstrate dislocation/fracture.
  • If weight bearing films are negative and you are still suspicious consider a CT scan of the foot.

Click below see image of fracture

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Takeaways

The FDA recently announced restrictions on the use of Tramadol and Codeine in children and breastfeeding mothers due to possible harm in infants.  Essentially, codeine will now be contraindicated for the treatment of cough and/or pain, and tramadol contraindicated to treat pain for children under age 12 years. Tramadol will be also be contraindicated in children younger than 18 years for treatment of pain after tonssillectomy/ adenoidectomy. 
 
These medicines carry serious risks, including slowed or difficulty breathing and death. These medicines also should be limited in some older children.
 
Additional warnings apply for children 12 to 18 years who are obese, have severe lung disease, or sleep apnea as they may increase the risk of serious breathing problems. 
 
Please be aware of these new restrictions to protect the health and safety of our patients.
 
A summary statement from the American Hospital Association (AHA) is posted below.

Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.

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Category: Toxicology

Title: "Triple C" Overdose

Keywords: Dextromethorphan, Robotripping (PubMed Search)

Posted: 4/20/2017 by Kathy Prybys, DO (Emailed: 4/27/2017)
Click here to contact Kathy Prybys, DO

Takeaways

A 17 y/o male presented for altered mental status. His mother stated she was contacted by neighbor concerned that her son was wandering down the middle of a local roadway. His friends stated he had taken 16-17 "triple C's" in an attempt to "get high". No other coingestants were identified. At presentation, the patient appeared to be in an toxic delirium. VS : 187/112, 116, 16, 98.9, 100% RA. Patient  was awake with eyes open but slowly responsive.GCS was 12. No evidence for trauma. Pupils were dilated and slowly reactive. The rest of the exam was essentially negative.
 
  • Coricidin Cough & Cold medicine also known by street name 'Triple C" is the most commonly reported abused dextromethorphan-containing product.
  • Dextromethorphan at high doses acts as a dissociative general anesthetic and hallucinogen similar to Ketamine and Phencyclidine (PCP) by antagonizing the NMDA receptor in a dose dependent manner.
  • Detromethorphan-containing products are appealing to teens as they are easily available (OTC), legal, inexpensive, and preceived as safe. 
  • Street names for dextromethorphan products include DXM, CCC, Trile C, Skittles, Robo, Poor Man's PCP,. Abuse of Robitussin products is referred to as "Robotripping"
  • Additional toxicity can occur from the coingredients (pseudoephedrine, acetaminophen, and antihistamines such as Chlorpheniramine) is a serious concern of taking large amounts of OTC cough and cold medications for the Dextromethorphan content. Chlorpheneriamine is a  first generation H1-histamine receptor antagonist with potent antimuscarinic properties.
  • Dextromethorphan is not detected by basic drug screens and should be considered when evaluating patients with a dissociative toxidrome. Acetaminophen levels should be obtained.
  • No specific antidote exists for dextromethorphan toxicity. Benzodiazepines should be administered for seizures and aggressive cooling measures for hyperthermia. Naloxone can be considered for use in patients in a coma or with respiratory depression but variable results are reported.
 

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Takeaways

Haloperidol has a higher D2 receptor antagonist effect than standard antiemetic treatment agents such as metoclopramide. In addition, newer antipsychotic agents such as Olanzapine have a high affinity at multiple antiemetic sites such as the dopamine and serotinergic receptors.

While formal RCT's are still in the works, multiple sources including palliative care, emergency medicine, and pain journals support their use in refractory emesis.


Consider Haloperidol 3-5 mg IV. 
Check an EKG for long QTc prior to use. Consider dose reduction of haloperidol in those with hepatic impairment. Also consider dose reduction in patients taking carbamazepine, phenytoin, phenobarbital, rifampicin, or quinidine due to that pesky CYP3A4 inhibition. 

Consider Olanzapine 2-5 mg IV.

Several case reports have shown a higher rate of success with olanzapine for refractory emesis. Olanzapine has similar precautions as those to haloperidol (EKG, hepatic impairment), although it's CYP drug interactions are less common. Additionally, use olanzapine cautiously in hyperglycemic patients as there are several case reports of olanzapine prompting episodes of DKA. Consider frequent blood sugar checks or small doses of insulin in hyperglycemic patients. 

 

Take Home Points:

Consider the antipsychotic agents Haloperidol or Olanzapine for patients with refractory emesis, they may be more effective than traditional antiemetics. 

Get an EKG prior to administration to check for QTc prolongation. As the classical and atypical antipsychotic agents are sedating, use caution in conjunction with other sedating medications (such as benzodiazepines).  

 

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Category: Neurology

Title: Vasogenic Cerebral Edema

Keywords: vasogenic cerebral edema, white matter, blood-brain-barrier, steroids (PubMed Search)

Posted: 4/26/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 
Vasogenic Cerebral Edema
  • Vasogenic cerebral edema is most commonly seen with brain tumors and cerebral abscesses.
  • It mainly involves the white matter.
  • Gray-white differentiation is maintained, so the edema has a finger-like pattern on CT (see Figure).
  • It is caused by disruption of the blood-brain-barrier, thus responds to treatment with steroids.

 

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Attachments

20170426_Figure.jpg (60 Kb)


Ventilator Settings for the Post-Arrest Patient

  • The majority of patients with ROSC from OHCA require intubation and mechanical ventilation.
  • Correctly managing the ventilator in the post-arrest patient is critical for improving outcomes.
  • As patients are at high risk for ARDS, use lung-protective ventilation with tidal volumes between 6 to 8 ml/kg of ideal body weight and PEEP of 5 to 8 cm H2O.
  • There is a U-shaped relationship between neurologic outcomes and both PaO2 and PaCO2.
    • Target normoxia (SpO2 94% to 96%) and avoid hyperoxia and hypoxia.
    • Target normocapnia (PaCO2 40 to 50 mm Hg) and avoid hypercapnia and hypocapnia.
  • Use an analgosedation approach with short-acting analgesics and sedatives, such as fentanyl and propofol.

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Category: Orthopedics

Title: Septic Arthritis in Children

Keywords: Hip, pediatrics, arthritis (PubMed Search)

Posted: 4/22/2017 by Brian Corwell, MD (Updated: 9/26/2017)
Click here to contact Brian Corwell, MD

Septic Arthritis in Children

Classic presentation: Pain, fever (may not always be present)

Limited range of motion of joint or refusal to bear weight,

 Joint swelling (difficult to visualize in hip or shoulder),

Limb held in position that allows greatest capsular volume (elbow held in 30° flexion for example)

Diagnostic testing may include diagnostic markers (ESR, CRP) or imaging (US/MRI)

Most common organisms: Staph and Strep, Neisseria (adolescents), HACEK organisms, consider gram negatives in immunocompromised children

DDX: Transient synovitis, osteonercrosis or osteomyelitis, Psoas abscess, acute leukemia, Lyme disease

A common ED presentation is the child with the painful limp

               35% of all cases of septic arthritis

>50% of cases occur in children younger than 2yo

Hip held in flexion, Abduction, external rotation

Fever and inflammatory markers are more sensitive than WBC count and refusal to bear weight

Kocher criteria:

1)     Refusal to weight bear on affected side

2)     Sed rate greater than 40mm/hr

3)     Fever (>38.5°C

4)     WBC count of >12,000 mm3

 

IF
                 - 4/4 criteria are met, there is a 99.6% chance of septic arthritis; 
                 - when 3/4 criteria are met, there is a 93% chance of septic arthritis; 
                 - when 2/4 criteria are met, there is a 40% chance of septic arthritis; 
                 - when 1/4 criteria are met, there is a 3% chance of septic arthritis; 

 

CRP can also be incorporated into a diagnostic algorithm

CRP>2.0 (mg/dl) in a child who refuses to bear weight yields a 74% probability of septic arthritis

 

 

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Takeaways

Predictive factors of asthma development in patients diagnosed with bronchiolitis include:

- Male sex (OR 1.3)

- Family history of asthma (OR 1.6)

- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)

- More than 2 episodes of bronchiolitis (OR 2.4)

- Allergies (OR 1.6)

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Category: Toxicology

Title: Drug induced lactic acidosis.

Keywords: lactic acidosis (PubMed Search)

Posted: 4/20/2017 by Hong Kim, MD, MPH (Updated: 9/26/2017)
Click here to contact Hong Kim, MD, MPH

Lactic acids are often elevated in critical care patients (e.g. septic shock). It can be also elevated in setting of drug overdose or less frequently in therapeutic use due to interference of oxidative phosphorylation. Some of the agents include:

 

  • Carbon monoxide
  • Cyanide
  • Propofol
  • Metformin
  • Propylene glycol
  • Salicylates
  • Beta-2 agonists
  • Thiamine deficiency/alcoholic ketoacidosis
  • Ethylene glycol/toxic alcohols
  • Nucleoside reverse-transcriptase inhibitors

 

Bottom line:

  • Although elevated lactic acid levels are often associated with underlying medical conditions, it is important to recognize drug-induced etiologies of lactic acidosis. 

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Category: International EM

Title: Reduced Shigella Susceptibility to Ciprofloxacin

Keywords: CDC, Shigella, antibiotic, health advisory (PubMed Search)

Posted: 4/19/2017 by Jon Mark Hirshon, MD, MPH (Updated: 9/26/2017)
Click here to contact Jon Mark Hirshon, MD, MPH

Takeaways

The Centers for Disease Control and Prevention (CDC) just released an official health advisory through the Health Alert Network entitled: “CDC Recommendations for Diagnosing and Managing Shigella Strains with Possible Reduced Susceptibility to Ciprofloxacin”

 

Concerning treatment, one key point is:

Do not routinely prescribe antibiotic therapy for Shigella infection. Instead, reserve antibiotic therapy for patients for whom it is clinically indicated or when public health officials advise treatment in an outbreak setting.

o   Shigellosis is generally a self-limited infection lasting 5-7 days.

o   Unnecessary treatment with antibiotics promotes resistance.

o   Treatment can shorten the duration of some illnesses, though typically only by 1-2 days

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