Spinal Epidural Abscess Pitfalls
Take Home Point: In the patient with risk factors for spinal epidural abscess (IVDU, DM, indwelling catheters, etc) do not exclude the diagnosis based upon the absence of a fever, a normal WBC count, and a normal neurologic exam.
Ring-removal is a dreaded problem in pediatric hand and finger injuries. Removal can be difficult and time consuming. The relatively recent introduction of Tungsten into the jewelry market has further complicated this problem:
However, it is:
This video explains how. Of course, this works on adults as well.
http://www.youtube.com/watch?v=poM423pewRE
I have no relationship with the copany which made this video - it was simply chosen for its clear explanation of the solution described in this pearl.
Myocardial infarctions involving the left circumflex artery are often associated with ECGs that lack any ST-segment changes (38% in one representative study). Oftentimes when there are ST-changes, there may simply be anterior lead ST-segment depression. In these patients, acquisition of a few posterior leads frequently demonstrates STEMI. Some data does exist that failure to diagnose these posterior STEMIs (e.g. simply diagnosing anterior "ischemia" rather than posterior "STEMI") results in increased mortality.
So what's the bottom line?
1. In patients with isolated anterior lead ST-segment depression, always check for posterior STEMI with a couple of posterior leads.
2. In patients with non-significant ECGs but concerning persistent symptoms, always check for posterior STEMI with a couple of posterior leads.
This is always a great time to use that 80-lead ECG if your ED has one.
Amal
MEWDS (Multiple Evanescent White Dot Syndrome)
There is no prospective, randomized study to elucidate propofol’s effect on the critically ill patient. By definition, Propofol Infusion Syndrome (PRIS) has the following characteristics:
It has been thought that PRIS was limited to patients with prolonged use, but we now know that this is not necessarily true.
It has been shown that PRIS is more likely with the following risk factors:
The treatment for suspected PRIS is:
Well, this monday's pearl is a bit different than prior pearls. I wanted to let you know about a very cool website I came across recently called Clinical Reader. There is a whole lot in the recent medical education literature that discusses "Web 2.0." Web 2.0 involves learning through interactive websites, blogs, podcasts, etc. Medical education is really starting to head out of the classroom, and I wanted to mention a newer website that a lot of folks are talking about.
Clinical Reader is a new medical RSS aggregator. What, you might ask, does this mean?
An RSS aggregator is a site that puts together information for you, that's right, for you. It actually does the work for you. Did I mention that it does the work for you? On this site, for example, if you are interested in "Emergency Medicine," the site finds all (or almost all) EM journals and brings you all of the latest information and updated articles. If you are into "Medical Education," you simply choose that category from a drop down menu and poof, you have all of the latest publications/reviews from the major medical education journals. Just choose your category and/or specialty and you are off and running.
Try it out. It isn't 100% perfect, but it is very cool.
http://clinicalreader.com/
During this season of the ever-present viral respiratory illness, we must be on the lookout for the potentially-deadly -entity of myocarditis. A recent study suggests some clues to when the diagnosis should more strongly be considered in patients presenting with viral respiratory symptoms.
1. Most cases of myocarditis were not initially recognized by primary care MDs or emergency health care providers. 84% of patients needed more than one visit within 2 weeks before the diagnosis was made. This highlights the difficulty in Dx and frequent misdiagnosis rate.
2. The most common presenting symptom was dyspnea (69%) and most common sign was tachypnea (60%).
3. Although resting tachycardia is often taught as a common finding, 66% of patients had a normal HR.
4. The most helpful findings in terms of helping distinguish myocarditis from benign common viral URIs was hepatomegaly (present in 50%) and cardiomegaly (present in 60%).
5. An abnormal ECG was present in 100% of cases. The most common abnormalities were tachycardia, ventricular hypertrophy, and ST or T wave changes.
6. 54% of patients had elevated troponin levels.
So what's the bottom line?
1. If your patient has tachypnea or dyspnea, strongly consider getting a CXR. In that case, look carefully for cardiomegaly.
2. Always assess for and document the presence or absence of hepatomegaly.
3. A completely normal ECG is strong evidence against myocarditis.
[Durani Y, Egan M, Baffa J, et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med 2009;27:942-947.]
Scaphoid Fractures in Children:
Because of the high (30%) fracture rate seen on followup films it is recommended that all children be placed into a thumb spica splint until followed up.
The newest antidote for cyanide poisoning, hydroxocobalamin, has several advantages over the older Cyanide Antidote Kit (amyl nitrite, sodium nitrite, sodium thiosulfate). Hydroxocobalamin works rapidly, does not induce methemoglobinemia, and does not cause vasodilation/hypotension.
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Severe Acute Pancreatitis
Slipped Capital Femoral Epiphysis (SCFE)
SCFE can present as hip, thigh or knee pain in the young adolescent. Risk factors include hypogonadism, hypothyroidism, hypopituiratism, and obesity. One way to make the diagnosis is to obtain a AP view of the pelvis and draw a line(Klein's line) along the superior border of the neck of the femur. This line should intersect the femoral epiphysis. If it does not the diagnosis of SCFE can be made.
However, this is only about 40% sensitivity. Green et al recently published a study that demonstrated that if you measure the distance from Klein's line and the lateral edge of the femoral epiphysis on both sides, and the difference between the two is more than 2mm you can make the diagnosis of SCFE more accurately and sooner.
FIGURE 1. Measurement methods on an anterior-posterior radiograph of a right slipped capital femoral epiphysis. White lines indicate Klein’s line for each hip. A and B, indicate maximum epiphyseal width lateral to Klein’s line. As A is 2mm narrower than B, the right (A) hip qualifies as a slip using our modification but not Klein’s original definition.
Conjunctivitis in Children:
HOWEVER... remember to consider other common etiologies of a red eye in a child!
Hypoxemia in the Intubated Asthmatic
A varicocele is a collection of venous varicosities in the spermatic veins in the scrotum. This is caused by imcomplete drainage for the pampiniform plexus. This may be seen is up 20% of males and is asymptomatic most of the time. Most are found on the left side.
Why should you care, you might ask? Well, the right spermatic vein drains into the IVC and then into the renal vein, whereas the left spermatic vein drain drains directly into the renal vein.
In the patient with new onset, unilateral varicocele, consider an IVC thrombus/tumor if right sided and a left renal clot if left sided.
A case we had recently was a 30 yo male with nephrotic syndrome (a HUGE risk factor for renal vein thrombosis) who presented with left-sided scrotal swelling. He was found to have a left-sided varicocele. Based on this finding, a renal sono was performed and the diagnosis of left renal vein thrombosis was made.
Increasing literature has demonstrated that patients post-cardiac arrest benefit from induced hypothermia (IH). In addition, increasing literature has demonstrated that patients with cardiac arrest associated with STEMI are best treated with rapid percutaneous intervention (PCI) after their resuscitation. But what about the combination of IH + PCI in resuscitated cardiac arrest patients with STEMI?
There's now growing support for this concept as well. Wolfrum et al. demonstrated an improved mortality at 6 mos. (35% vs. 25%) in patients that had the combination of IH + PCI vs. patients receiving PCI alone after cardiac arrest and they also had better neurological outcomes.
Next time you have a STEMI patient that has a cardiac arrest who you resuscitate, talk to your cardiologists about the literature demonstrating the improved outcomes with combination IH plus PCI.
[Wolfrum S, Pierau C, Radke PW, et al. Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-segment elevation myocardial infarction undergoing immediate percutaneous coronary intervention. Crit Care Med 2008;36:1780-1786.]
Wound Irrigation
A recent article by Thomas et al showed that any concentration of betadiene and hydrogen peroxide used to irrigate a wound was more toxic to fibroblasts (required for wound healing) then it was to bacteria. Low concentrations of chlorhexidine remained bactericidial while having minimal affects on fibroblasts.
WIth the addition of this study the routine practice of soaking a wound in betadiene or hydrogen peroxide should be abandoned. Good irrigation with normal saline or even tap water is all that is really needed to decontaminiate a wound. If a bactericidal agent is needed then low concentrations of chlorhexidine should be used.
