Category: Orthopedics
Keywords: tensor fascia latae, hip, pain (PubMed Search)
Posted: 5/16/2015 by Michael Bond, MD
Click here to contact Michael Bond, MD
Tensor Fascia Latae (Iliotibial Band) Pain Syndrome:
Some patients will complain of hip and back pain and can have multiple visits before somebody considers Tensor Fascia Latae Pain Syndrome AKA Iliotibial Band Syndrome.
The tensor fascia latae helps with thigh flexion at the hip, abduction, and medial rotation; and stabilizes the knee laterally
When this muscle/fascia gets tight and overcontracted it will lead to dysfunction of the gluteus and rectus femoralis muscles leading to increased hip pain due to abnormal movement of the joint.
Patients often complain of increased pain with running, especially downhill and exam is notable for local tenderness (approx. 2cm above lateral joint line) & occasional swelling over the distal lateral thigh.
Most patients respond to conservative treatment involving NSAIDs, stretching of the iliotibial band, physical therapy, strengthening of the gluteus medius, and altering their running regimens.
Category: Pediatrics
Keywords: head lice (PubMed Search)
Posted: 5/15/2015 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
Lice are spread through direct contact as they crawl. Indirect contact (through brushes or hats) is less likely. One study showed that live lice were found in only 4% of infested volunteers pillowcases.
During an initial infestation, lice can reside on the head for up to 4 to 6 weeks before becoming symptomatic. Therefore, when lice are detected at school, there is no need to send the child home (or to the ED). Children also do not need to be kept out of school while receiving treatment.
Bonus: First line treatment is 1% Permethrin applied on day 0 and 9. The patient should wash their hair first with a non conditioned shampoo, apply Permethrin for 10 minutes and then rinse.
Devore CD and Schutze G. Head Lice. Pediatrics. 2015; 135 (5) e1355 -e1365.
Category: Toxicology
Keywords: Dabigatran, Hemodialysis, Renal Replacement Therapy (PubMed Search)
Posted: 5/14/2015 by Kishan Kapadia, DO
Click here to contact Kishan Kapadia, DO
Dabigatran is an orally administered, potent, direct thrombin inhibitor approved for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, and for the treatment and secondary prevention of venous thromboembolism.
Several pharmacokinectic studies have suggested that dabigatran possesses a number of ideal properties for expedited removal via extracorporeal methods. Dabigatran has low oral bioavailability (3-7%) and is predominantly cleared (80%) by the kidneys. It is not significantly protein bound, low-to-moderate steady state volume of distribution, and has a low molecular weight. All of these attributes make it a candidate for extracorporeal removal. Low protein binding may suggest redistribution into the plasma post extracorporeal removal.
Dabigatran is a substrate for the multidrug efflux transporter P-glycoprotein. Administration of the drug with potent P-glycoprotein inhibitors (ketoconazole, verapamil, amiodarone, quinidine) may significantly increase risk of toxicity, i.e. bleeding.
Most of the current evidence is based on case reports/case series where HD was the primary mode of removal.
Caution: Redistribution effect in plasma dabigatran concentration was also observed in several cases within 20 min to 12 hours post cessation of renal replacement therapy. Other limitations include:
1) Hemodynamic instability such as hypotension that may make initiation of extracoporeal removal difficult
2) Availability of indicators demonstrating effectiveness of extracorporeal removal
3) Amount of time needed to prepare patient to receive extracorporeal therapy
4) Use of extracorporeal removal as a treatment modality has not been prospectively evaluated
Bottom line: Extracorporeal removal may be an option for patients in the setting of life-threatening bleeding but with consideration of several limitations and should not preclude or delay use of other supplemental hemostatic therapies.
Awad NI, Brunetti L, Juurlink DN. Enhanced Elimination of Dabigatran Through Extracorporeal Methods. J Med Toxicol 2015;11:85-95.
Category: Neurology
Keywords: Glasgow Coma Scale, GCS, traumatic brain injury, TBI, survey (PubMed Search)
Posted: 5/13/2015 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
Are We Using the Glasgow Coma Scale Reliably?
Reported by Responders | |
Patient population in which GCS is used | Traumatic brain injury (96%) Other neurological disorders (78%) |
Intended purpose of GCS | Classification of severity of injury (51%) Serial evaluation of patient over time (33%) Clinical decision making (44%) Prognostication (17%) |
Application of stimulus | Both arms and legs (62%) Only arms (37%) |
Type of stimuli used | Nail bed pressure (57%) Lateral side of finger (22%) Supra-orbital nerve pressure (52%) Trapezius or pectoralis pinch (50%) Sternal rub (53%) Retromandibular stimulation (24%) Earlobe stimulation (16%) |
Reporting of GCS | Description in words, e.g. no eye opening, no motor (19%) Numerical report, e.g. E1V1M1 (46%) Sum score, e.g. EVM=3 (35%) |
Bottom line: There are variations in the application, assessment, and reporting of the GCS. A standardized approach is needed for it to be a reliable assessment and communication tool.
Reith FCM, Brennan PM, Maas AIR, Teasdale GM. Lack of standardization in the use of the Glasgow Coma Scale: Results of international surveys. J Neurotrauma. 2015; May 7. [Epub ahead of print]
Category: Critical Care
Posted: 5/12/2015 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD
There is little debate that ultrasound-guided central lines are safer, faster, and more reliable compared to a landmark technique; there is some debate, however, as to whether the short axis (SA) or long axis (LA) approach is the best (see clips below).
The referenced study compared the SA and the LA technique for both the internal jugular (IJ) and subclavian (SC) venous approach. The authors measured number of skin breaks, number of needle redirections, and time to cannulation for each method.
This study demonstrated that the LA technique for subclavian placement had fewer redirections, decreased cannulation time, and fewer posterior wall punctures as compared to the SA. With respect to the IJ approach, the LA was also associated with fewer redirections than the SA view.
Bottom line: Consider the long-axis technique the next time you place an ultrasound guided central line.
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)
Category: Visual Diagnosis
Posted: 5/11/2015 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD
40 year-old male sustains a blunt force injury the left side of his lead. What's the diagnosis and what structure was injured?
Epidural Hematoma with mid-line shift from middle meningeal artery injury; see image below for comparison of subdural and epidural
Epidural hematoma
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)
Category: Cardiology
Posted: 5/10/2015 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD
Ischemic ECG Findings: Significance of the U-wave
The U-wave is a small deflection immediately following the T-wave, commonly with the same polarity as the T-wave and most prominently seen in precordial leads V2–V3.
Prominent U-waves are most often seen with bradycardia and hypokalemia, but can also be secondary to other electrolyte imbalances and medications.
Typically, T- and U-wave polarities are concordant; discordant U-waves have been identified several hours prior to other ECG changes in acute myocardial infarction.
Some studies note that exercise induced U-wave inversion is highly predictive of CAD; negative U -waves in the precordial leads during exercise had a higher specificity (88% vs. 70%) & positive predictive value (77% vs. 61%) for ischemia than ST-depression.
Reinig et al. 2005 showed that negative concordance of T- and U-waves have poor prognosis & is quite specific for ischemia.
· ECG’s were divided into 3 groups:
o Type 1 T-U discordance (negative T waves + positive U waves)
o Type 2 T-U discordance (positive T waves + negative U waves)
o Negative T-U concordance (both T & U waves negative)
* Significantly higher rate of CAD (88% vs. 58%) (P-value <. 0001) in the negative T-U concordance group
Sovari AA, Farokhi F, et al. Inverted U-wave, a specific electrocardiographic sign of cardiac ischemia. Am J Emerg Med. 2007 Feb;25(2):235-7.
Reinig MG, Harizi R, et al. Spodick Electrocardiographic T- and U-wave discordance. Ann Noninvasive Electrocardiol. 10 (1) (2005), pp. 41–46.
Category: Orthopedics
Keywords: Radiology, orthopedics, shoulder (PubMed Search)
Posted: 5/9/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Posterior Shoulder Dislocations are uncommon (strong supporting structures vs. anterior)
But commonly missed by physicians
Mechanism: Direct blow anterior shoulder/FOOSH with shoulder internally rotated and ADDucted)
May also see with seizure/electric shock (tetanic contraction)
Clinical findings subtle
Shoulder held in ADDuction and internal rotation. Patient unable to externally rotate arm from this position. If habitus allows, anterior shoulder depression/posterior fullness.
Radiology: Decreased overlap between humeral head and glenoid fossa. Proximal humerus fixed in internal rotation looks like a light bulb on a stick.
Y view will show subtle posterior displacement of humeral head (not as dramatic as is in anterior dislocations!)
http://cdn.lifeinthefastlane.com/wp-content/uploads/2009/06/posterior_shoulder_dislocation_005.jpg
http://eorif.com/Shoulderarm/Images/Shoulder-dislocationP1.jpg
Category: Toxicology
Keywords: ketamine, alcohol withdrawal, ethanol (PubMed Search)
Posted: 4/10/2015 by Bryan Hayes, PharmD
(Updated: 5/7/2015)
Click here to contact Bryan Hayes, PharmD
In addition to the down regulation of GABA receptors in chronic ethanol users, there is an upregulation in NMDA receptor subtypes. Although the pathophysiology is much more complex, when ethanol abstinence occurs, there is a shortage of GABA-mediated CNS inhibition and a surplus of glutamate-mediated CNS excitation. If GABA agonists are the mainstay of treatment, why not also target the NMDA receptor? Enter ketamine.
Only one study exists and was published recently.
While the dexmedetomidine studies should not be using reduction in benzodiazepine requirements as an endpoint, it may be acceptable for ketamine since it actually works on the underlying pathophysiology. More studies are needed but it's good to see we’re starting to look at it.
Wong A, et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother 2015;49(1):14-9. [PMID 25325907]
Follow me on Twitter (@PharmERToxGuy) or Google Plus (+bryanhayes13)
Category: International EM
Keywords: Death, communicable diseases, noncommunicable diseases (PubMed Search)
Posted: 5/6/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
Introduction:
There were approximately 56 million deaths worldwide in 2012. The causes of death vary significantly based upon the income level of the country.
High-income Countries:
Low-income Countries:
Bottom Line:
Acute care services in the US and high-income countries need to acknowledge the growing number of individuals with chronic diseases and the rapidly growing elderly population. In low-income countries, acute care services still need to primarily address maternal/child infections and problems as well as infectious diseases.
www.who.int. Fact sheet- Death: Top 10 causes
Category: Critical Care
Keywords: thoracentesis, pleural effusion, critical care (PubMed Search)
Posted: 5/4/2015 by Feras Khan, MD
Click here to contact Feras Khan, MD
Safety of Thoracentesis
Results after 24 hours of followup post-procedure
Other interesting points:
Bottom line: Use your ultrasound to direct your tap and dont take out more than 1500 mL routinely
Ault MJ et al. Thoracentesis outcomes: a 12-year experience. Thorax 2015;70:127-132.
Category: Visual Diagnosis
Posted: 5/4/2015 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)
Category: Pharmacology & Therapeutics
Keywords: sodium, piperacillin/tazobactam, ampicillin, moxifloxacin, metronidazole (PubMed Search)
Posted: 4/13/2015 by Bryan Hayes, PharmD
(Updated: 5/2/2015)
Click here to contact Bryan Hayes, PharmD
Aside from sodium chloride and sodium bicarbonate, several commonly used emergency department medications (namely IV antibiotics) contain a significant amount of sodium. In patients with heart failure or other conditions requiring sodium restriction, judicious use should be considered.
Notes:
Ampicillin/sulbactam [package insert]. Metronidazole [package insert]. Moxifloxacin [package insert]. Nafcillin [package insert]. Piperacillin/tazobactam [package insert]. Ticarcillin/clavulanate [package insert].
Follow me on Twitter (@PharmERToxGuy) or Google Plus (+bryanhayes13)
Category: Toxicology
Keywords: morphine, clopidogrel (PubMed Search)
Posted: 4/30/2015 by Fermin Barrueto
Click here to contact Fermin Barrueto
There are some studies that have shown that NSTEMI patients have done worse when administered opioids. Most studies were not well controled and the exact mechanism was not clear. This study adds a biological mechanism to these fidnings.
Hobl et al. showed clopidogre concentrations delayt peak yhours, have overall decrease AUC and actually decrease active metabolites when morphine is administered IV. Morphine may not be the right choice in any ACS that receives clopidogrel.
Hobl et al. Morphine Decreases Clopidogrel Concentrations and Effects: A Randomzed Double-Blid, Placebo-Controlled Trial. Journal of the American College of Cardiology 2014; 63(7): 630-635.
Category: International EM
Keywords: Surgey, anesthesia, trauma (PubMed Search)
Posted: 4/29/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
A Lancet Commission on Global Surgery has just published a 56 page article about the need to improve access to surgery and anesthesia care. Its five key messages are:
The need for high quality acute care, both for urgencies and emergencies, is clearly an important component of providing “universal access to safe, affordable surgical and anaesthesia care”- the vision of the Commission.
Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development: http://dx.doi.org/10.1016/S0140-6736(15)60160-X
Global surgery—going beyond the Lancet Commission: http://dx.doi.org/10.1016/S0140-6736(15)60465-2
Category: Critical Care
Posted: 4/28/2015 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
SIRS and Severe Sepsis Screening
Kaukonen KM, Bailey M, Pilcher D, et al. Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. NEJM 2015;372:1629-38.
Category: Visual Diagnosis
Posted: 4/27/2015 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD
70 year-old female presents from a nursing home with fever and abdominal pain. A right upper quadrant ultrasound is shown, what's the diagnosis?
Acalculous cholecystitis
Acalculous Cholecystitis
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)
Category: Orthopedics
Keywords: back pain, ESR, CRP, malignancy (PubMed Search)
Posted: 4/25/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
In cases of suspected spinal infection, the sensitivity of an elevated WBC count (35-61%), ESR (76-95%) and CRP (82-98%) may help guide further evaluation or consideration of other entities.
Incorporation of ESR/CRP into an ED decision guideline may help differentiate those patients in whom MRI may be performed on a nonemergent basis.
An elevated ESR (>20 mm/hour) also has a role in the diagnostic evaluation of occult malignancy (sensitivity 78%, specificity 67%).
Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain: Clinical article. Journal of Neurosurgery: Spine. 2011;14(6):765-770.
Deyo RA, Diehl AK. Cancer as a cause of back pain. Journal of general internal medicine. 1988;3(3):230-238.
Category: Neurology
Keywords: tumor, seizure, stroke (PubMed Search)
Posted: 4/23/2015 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Some medical issues arise in patients with brain tumors:
// Steroids are used to decrease vasogenic edema, especially preop or during radiation therapy. Patients are ideally gradually weaned off steroids. Dexamethasone is most commonly used. 1-2% of patients are at risk for adrenal suppression.
// Infections: Post-op wound infections can be delayed up to months, especially in patients on steroids.
// Antiepileptics: Although technically not recommended in patients with brain tumors who have not had seizures (American Academy of Neurology 2010), many surgeons continue to prescribe antiepileptics preoperatively and then discontinue them by 1 month postop if the patients remain seizure-free. Levetiracetam is emerging as the drug of choice due to favorable side effect profile.
// Thromboembolism: Brain tumors are considered very high risk for venous thromboembolism. Low-molecular-weight heparin is the treatment of choice, with warfarin being an acceptable substitute.
// Arterial thrombosis and ischemic stroke: Risk is increased with certain medications, and thrombolysis is contraindicated.
Pruitt AA. Medical Management of Patients with Brain Tumors. Continuum 2015;21(2):314 331
Category: Critical Care
Keywords: large hemispheric infarct, acute ischemic infarct, stroke (PubMed Search)
Posted: 4/20/2015 by John Greenwood, MD
(Updated: 4/21/2015)
Click here to contact John Greenwood, MD
Updates in the Management of Large Hemispheric Infarction
Large hemispheric infarctions (LHI) are estimated to occur in 2-8% of all hospitalized ischemic strokes and 10 15% of all MCA territory infarcts. LHI carry high rates of morbidity and mortality, in fact, if left untreated associated cerebral edema can rapidly progress to transtentorial herniation and death in 40 80% of patients.
Recognized risk factors for progressive cerebral edema include:
Evidence based medical strategies for LHI include:
Prophylactic hemicraniectomy
Bottom Line: Early recognition of large hemispheric stroke is critical as it is associated with a high rate of morbidity and mortality. Aggressive medical management and early neurosurgical involvement may improve outcomes.
References
Follow me on Twitter @JohnGreenwoodMD