UMEM Educational Pearls

• newborns have a thick right ventricle resulting in a mean QRS axis which points anteriorly and to the right demonstrating a right axis deviation (70-180degress) and large R waves in the precordium
• by 3 months of age, the QRS axis in the frontal plane shifts to the left with a mean of 65degress (0-125degress)
• by older childhood, the normal mean QRS axis is -30-100degress)
• thus, with age the R wave decreases in V1 and increases in V6
• take home:  right-axis deviation is often a normal finding in children and young adults when you see left-axis deviation in children consider tricuspid atresia, atrioventricular septal defects, and LVH as the most associated conditions

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Every so often a patient arrives in PSVT with their only intravenous access being through a hemodialysis port.

Initial dose of adenosine should be reduced to 3 mg if administered through a central line.  Remember a central line delivers the adenosine right where you need it.  This recommendation is supported by the 2010 ACLS guidelines.  Second and third doses should be 6 mg (instead of 12 mg).

Cases of prolonged bradycardia and severe side effects have been reported after full-dose adenosine through a central line.  Other situations to consider lower doses include patients currently receiving carbamazepine or dipyridamole or in those with a transplanted heart.

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• Encephalitis, inflammation of the brain, is associated with the following signs and symptoms:  fever, headache, altered mental status, neurologic deficit, hallucinations, behavioral changes, photophobia, seizures, neck stiffness (when associated with meningitis), preceding viral prodrome, recent mosquito/tick/animal bites, and/or immunocompromised state/use of immunosuppressant medications.   
• The presence of focal neurologic deficit and/or altered mental status is more predictive of encephalitis than meningitis.
• The emergent management goal is to rule out and/or empirically treat bacterial meningitis and other treatable infectious sources such as Herpes Simplex Virus (HSV), Varicella Zoster Virus (VZV), and Cytomegalovirus (CMV); these carry significant mortality and morbidity risks.  Remember to have patient's cerebrospinal fluid (CSF) specifically analyzed for etiologies such as these (i.e. via PCR). 
• Treat presumed encephalitis aggressively by adding acyclovir to the antibiotic/steroid regimen administered, particularly when there is altered mental status and/or focal neurologic deficit.

Fungal Sepsis in the Critically Ill

• In recent years, the incidence of invasive fungal infections has risen dramatically.
• Candida species (C. albicans, C. glabrata, C. parapsilosis, C tropicalis, C. krusei) account for the majority of invasive infections in the critically ill patient.
• Key risk factors for invasive candidal infections include:
  • Exposure to broad spectrum antibiotics
  • Cancer chemotherapy
  • Indwelling catheters
  • TPN administration
  • Neutropenia
  • Hemodialysis
• Given the significant mortality of invasive fungal infections, early and appropriate antifungal therapy is paramount.
• First-line empiric antifungal therapy recommendations from the Infectious Disease Society of America include caspofungin, micafungin, or fluconazole.  Amphotericin B is now reserved for patients who are either intolerant or not responding to the echinocandins (caspofungin, micafungin).

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Question

26 year old male presents s/p basketball dunk. Diagnosis?

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Approximately 7-10% of cases of ACS are not related to atherosclerotic coronary disease. Some other causes of ACS include the following:
trauma
vasculitis
congenital abnormalities
emboli (e.g. bacterial)
thoracic aortic dissection
infectious diseases
DIC, TTP

These conditions can produce ST-segment changes that resemble those of true STEMI or non-STEMI, and therefore some of these patients are diagnosed retrospectively after a negative catheterization.

 

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Sugar Tong Splint

The sugar tong splint is ideal for splinting fractures of the radius, ulna, or wrist.  It prevents flexion and extension at the wrist, limits flexion and extension at the elbow, and prevents supination and pronation.  A posterior long arm splint does not prevent supinaton and pronation, therefore, it is of limited use for radius and ulna fractures.

The traditional sugar tong can be difficult to put on a patient without an assistant as it is often hard to hold the splint in position as you begin to ace wrap it. A variation on the sugar tong, the reverse sugar tong, prevents this frustration.  The splinting material is cut so that a small piece suspends the splint from the web space between the thumb and index finger.  The open ends at the elbow are also easily folded under each other, preventing any bulky splint material from extending out.

The reverse sugar tong is on the left, the original sugar tong on the right.

Check out this video showing how to place a reverse sugar tong splint.

http://www.youtube.com/watch?v=r-RHdttOMf0

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• Delirium is a symptom, not a diagnosis; the astute clinician must seek to discover and treat the underlying source of delirious states.

• It is a transient cognitive condition associated with decreased attention span and waxing and waning symptoms.

• Three types: (1) Hyperactive, (2) Hypoactive, (3) Mixed (daytime somnolence, nighttime agitation).

• In young patients, the cause is commonly due to toxins or trauma, while that for the elderly is typically infection or medication related.

• Five critical causes of delirium that must be recognized and treated immediately:

1. Hypoxia
2. Hypoglycemia
3. Central nervous System infections
4. Hypertensive encephalopathy
5. Increased intracranial pressure

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• Multiple methods of confirming endotracheal tube placement exist, however quantitative waveform capnography is the most reliable method. Unfortunately this may not be immediately available at all medical centers.

• Recent studies demonstrate that bedside ultrasound may assist in the detection of proper endotracheal tube placement.

• The T.R.U.E. (Tracheal Rapid Ultrasound Exam) was demonstrated to be 99% sensitive, 94% specific, 99% PPV, and 94% NPV during intubation.

• The basic exam involves placing a high-frequency linear-array probe on the anterior neck above the sternal notch and identifying the trachea and esophagus during intubation.

• The following video is an example of what you DO NOT want to see during an intubation: http://www.youtube.com/watch?v=LvfThxhQ93A

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Question

Patient presents with right-sided chest and shoulder pain....

What's the diagnosis?

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If you're like me, you've been a bit confused about what exactly defines "coma" in the current recommendations for post-arrest hypothermia in "comatose" patients with return of spontaneous circulation. Fortunately, a recent NEJM article has helped clarify this by suggesting that hypothermia should be induced in these post-arrest patients with either:

1. GCS < 8
2. "patients who do not obey any verbal command at any time after restoration of spontaneous circulation and before initiation of cooling."

Naturally, if the patient was comatose before the arrest, don't bother.

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Stability from 4 major ligaments (ACL, PCL, MCL and LCL)

Knee dislocation causes injury to multiple ligaments (usually 3 of the above).

Many of these dislocation spontaneously reduce prior to medical evaluation.  Therefore, consider knee dislocation in a patient with multi ligament injury, significant hemarthrosis and bruising.

Vascular injury in up to 40% (popliteal artery)

Nerve injury in up to 23% (peroneal nerve) ((ankle dorsiflexion and sensation to the first web space of the foot))

After reduction, immobilize knee in 15-20 degrees flexion.

The degree of initial deformity, presence of strong pulses, or warm skin cannot be used to rule out popliteal injury.

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End Tidal CO2 continuous capnography is being utilized more in the ED for procedural sedation. One of the best studies is a randomized control trial using propofol that showed you could see signs of hypoventiliation prior to hypoxia by about 60 seconds - which can be plenty of time to get your BVM and airway cart ready.

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• While validated diagnostic tools such as the NIH Stroke Scale are often very helpful, particularly in terms of communicating with Neurologists, there are tools such as the ROSIER (Recognition of Stroke in the Emergency Room) Scale which is a brief score designed to facilitate expedited diagnostic testing and treatment of stroke in the emergency department.

• The ROSIER Scale has been found to recognize stroke with 93% sensitivity, 83% specificity, 90% positive predictive value, and 88% negative predictive value. 

• If the total score is > 0 (i.e. 1-6), then stroke is likely. If the total score is < or equal to 0, then stroke is unlikely, but can not be completely excluded.

• See attached ROSIER Scale for details.

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Attachments

• 1108241811_ROSIER_Scale_for_Stroke.doc (61 Kb)

Re-expansion Pulmonary Edema After Chest Tube Placement

• Tube thoracostomy is a common procedure in the emergency department.
• For patients who develop respiratory distress after chest tube placement, think about re-expansion pulmonary edema.
• While a rare occurrence, re-expansion pulmonary edema is reported to have a mortality rate of up to 20%.
• The mechanism by which edema forms remains controversial, but is thought to be due to increased alveolar-capillary membrane permeability in the expanding lung.
• Treatment is supportive with supplemental oxygen and diuretics.  Some patients may require mechanical ventilation depending on the degree of distress and hypoxia.

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Question

79 y.o. male lung cancer patient with tachypnea, tachycardia, and normal blood pressure. Click here: http://vimeo.com/27973006

Possible diagnosis?

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Elderly patients are high risk for missed MI because of atypical presentations. Though this seems to be relatively common knowledge, it is not always remembered. So here's a reminder....

• Elderly patients present with chest pain during their MI only ~ 50% of the time
• Dyspnea is the most common anginal equivalent (alternative complaint). Other common anginal equivalents are syncope, nausea, vomiting, or diaphoresis
• The ECG in elderly patients with AMI is more frequently non-diagnostic. Only 40% of the time do they present with a STEMI, and when they do have ST elevation it may be less elevation than with younger patients. Furthermore, baseline abnormalities such as BBB, pacers, and prior MIs may make the ECG more difficult to interpret.

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Infantile botulism