UMEM Educational Pearls

Category: Toxicology

Title: Trends in Drug Abuse

Keywords: drugs of abuse, heroin (PubMed Search)

Posted: 7/3/2008 by Ellen Lemkin, MD, PharmD (Updated: 10/31/2024)
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 ADOLESCENT DRUG ABUSE

  • "Pharming" is prescription drug abuse
  • Teens will take medications from their home medicine cabinets, mix them in bags together indiscriminately and make "trail mix" to pass around parties
  • "Cheese" is a combination of heroin with cough and cold preparations. The heroin concentration in cheese is typically between 2-8% compared to 30% found in black tar heroin, and is considered "starter heroin"

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Category: Neurology

Title: Differentiating Delirium from Dementia

Keywords: delirium, dementia, CAM, MMSE (PubMed Search)

Posted: 7/2/2008 by Aisha Liferidge, MD (Updated: 10/31/2024)
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  • The Confusion Assessment Method (CAM) and Mini-Mental State Exam (MMSE)  can be used in combination to effectively differentiate delirium from dementia, respectively.
  • CAM relies on observations by family members, caregivers, and clinicians to assess the following four symptoms:
    1. acute confusional onset
    2. inattention
    3. disorganized thinking
    4. ltered level of consciousness
  •  

  • Using CAM, the diagnosis of delirium requires the presence of both the first and second features, plus one of the two other features.
  • CAM is 95-100% sensitive and 95% specific for diagnosing delirium in the elderly.
  • MMSE is not a diagnostic tool but identifies cognitive impairment suggestive of delirium by assessing orientation, short-term memory, calculation ability, and language (score 18-26 = mild dementia).
  • A positive CAM and an MMSE score of > 25 is predictive of delirium.
  •  



Category: Infectious Disease

Title: Diabetes and Osteomyelitis

Keywords: diabetes, osteomyelitis, temperature, white blood cell count (PubMed Search)

Posted: 7/1/2008 by Mike Winters, MBA, MD (Updated: 10/31/2024)
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Does this Patient with Diabetes have Osteomyelitis?

  • Diagnosis of lower extremity osteomyelitis in the diabetic patient remains challenging
  • Bone biopsy with culture remains the gold standard for diagnosis but is not always obtainable
  • What clinical features, therefore, raise the likelihood of osteomyelitis?
  • In this review, an ulcer size > 2 cm2 (LR 7.2), ability to probe to bone using a sterile stainless steel probe (LR 6.4), and an ESR > 70 mm/h were found to be useful in predicting the presence of osteomyelitis
  • Clinical features NOT found to be useful included fever (sensitivity 19%), presence of erythema, swelling, or purulence (LR 1), elevated white blood cell count (sensitvity 14%-54%), and superficial swab culture
  • A note about radiographic studies:
    • bony changes on plain films may take up to 2 weeks to develop
    • plain films alone are only marginally useful if positive (LR 2.3)
    • MRI is more accurate than bone scan or plain films
    • If you are going to order a radiographic study, your best bet is the MRI

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Category: Vascular

Title: Does a Normal D-Dimer rule out Aortic Dissection?

Keywords: Aortic Dissection, D-Dimer (PubMed Search)

Posted: 6/24/2008 by Rob Rogers, MD (Emailed: 6/30/2008) (Updated: 10/31/2024)
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Does a normal d-dimer rule out aortic dissection?

A lot of research seems to be focused on using d-dimer as a rule-out strategy for acute aortic dissection. The idea is that a d-dimer <500 (which is what we use for ruling out PE in low-mod risk patients) rules out dissection as well.

A few pearls and pitfalls regarding this:

  • Studies look very promising, but NO accepted cutoff point (d-dimer) has been defined
  • This practice has NOT been widely accepted yet
  • A d-dimer <100 ng/dL rules out aortic dissection with a sensitivity of 100%
  • A d-dimer of <500 ng/dL rules out aortic dissection with a sensitivity of 98%
  • Experts in this area seem to be advocating this as a potential rule out strategy
  • Critics of this approach point out the fact that a subset of patients with dissection (those with intramural hematomas-i.e. no intimal tear) may not release d-dimer into the circulation. But almost all studies include patients with this variant and their d-dimers are almost always elevated.

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Category: Airway Management

Title: Pregnancy and Acute Pulmonary Embolism

Keywords: Pregnancy, Pulmonary Embolism (PubMed Search)

Posted: 6/30/2008 by Rob Rogers, MD (Updated: 10/31/2024)
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 Pregnancy and Acute Pulmonary Embolism

Women who are pregnant or in the postpartum period and women who take hormonal therapy are at an increased risk of pulmonary embolism.

Some facts:

  • Risk of first episode of venous thromboembolism is 15 times as high in the postpartum period as during pregnancy
  • Diagnostic workup and initial ED therapy is the same as it is for non-pregnant patients
  • Although there are still some concerns about pulmonary CTA, both the American College of Obstetrics & Gynecology and the American College of Radiology agree that it is safe. It is unknown what happens to fetal nephrons after exposure to circulating contrast in the mother. Despite this, CTA can be used without fear if indicated. 
  • Warfarin is a teratogen and should not be used for anticoagulation.

 

Show References



Category: Cardiology

Title: low voltage on ECG

Keywords: low voltage, electrocardiography, effusion (PubMed Search)

Posted: 6/30/2008 by Amal Mattu, MD (Updated: 10/31/2024)
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Low QRS voltage on the ECG has various definitions; here's my simple definition for low voltage...either one of the following:
     If the added QRS amplitudes (whole R wave + S wave) in leads I + II + III total < 15 mm, OR
     If the added QRS amplitudes (whole R wave + S wave) in leads V1 + V2 + V3 total < 30 mm.

The potential causes of  low QRS voltage includes pericardial effusions, pleural effusions, obesity, COPD, infiltrative cardiac diseases (e.g. sarcoid, amyloid), end-stage cardiomyopathies, severe hypothyroidism.

If the patient has NEW low voltage compared to an old ECG, the only real possibilities are pericardial effusion, pleural effusion, and severe hypothyroidism (e.g. myxedema).



Category: Orthopedics

Title: Calcaneus Fractures

Keywords: calcaneus, fracture, compartment (PubMed Search)

Posted: 6/29/2008 by Michael Bond, MD (Updated: 10/31/2024)
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Calcaneus Fractures

Normally occur due to axial loading mechanism such as:

  •     Fall from height
  •     Motor Vehicle collisions
  •     Repetitive impacts on a hard surface such as seen with running or jumping.

Miscellanous Facts:

  1. 70% of calcaneal fractures are intra-articular
  2. 10-15% are associated with spinal compression fractures
  3. Estimated that 7-10% will have a fracture of the contralateral foot
  4. Monitor for compartment syndrome of the foot.  Deep central compartment is most commonly affected with calcaneus fractures

Pearls:

  1. Strongly consider getting Lumbar Spine Films and x-rays of the opposite foot in anybody that has a calcaneus fracture.
  2. Perform frequent reassessments, and do not hesitate to check compartment pressures if you suspect they might be elevated.


Category: Pediatrics

Title: The Whooping Cough

Keywords: Pertussis (PubMed Search)

Posted: 6/27/2008 by Don Van Wie, DO (Updated: 10/31/2024)
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Pertussis means "violent cough". 

Think of it with prolonged coughing, inspiratory whoop, absolute lymphocytosis, or chronic cough.

Don't Use cough suppressants.

Pertussis can be a life threatening Infection!!  Especially in infants and young children.

 

 

  • Factors that should prompt a consideration of admitting the patient are the following:
    • Age younger than 1 year
    • Pneumonia
    • Apneic or cyanotic spells or hypoxia
    • Moderate-to-severe dehydration
  •  

     

    Pertussis is a reportable infectious disease in the United States.



    Category: Toxicology

    Title: Dapsone-Induced Methemoglobinemia

    Keywords: dapsone, methemoglobinemia, methylene blue (PubMed Search)

    Posted: 6/27/2008 by Fermin Barrueto (Updated: 10/31/2024)
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    •  Dapsone has been used to treat leprosy but more commonly to in brown recluse spider bites and to prevent PCP pneumonia and toxoplasmosis in our HIV population
    • It can cause methemoglobinemia: a reduced form of iron (ferrous to ferric) in the Hb molecule that decreases your oxygen carrying capacity. 
    • Due to its color, cyanosis is a predominant symptom out of proportion to symptoms.
    • Treatment: Methylene Blue 1-2 mg/kg IV
    • Pitfall: Dapsone's long half-life may cause reoccurrence of MetHb and require retreatment

     



    Category: Neurology

    Title: Types of Confusion in the Elderly

    Keywords: confusion, dementia, delirium, elderly (PubMed Search)

    Posted: 6/25/2008 by Aisha Liferidge, MD (Updated: 10/31/2024)
    Click here to contact Aisha Liferidge, MD

    • Poor differentiation of the type and cause of confusion in the elderly is associated with poor outcomes (i.e. increased mortality/morbidity, prolonged hospital stays, and functional decline).
    • Confusion in the elderly can be categorized into three types with the following typical features:
    1. Delirium - caused by organic illness, acute onset, agitated or drowsy, variable short-term memory, disorganized thoughts, hallucinations.
    2. Dementia - chronic confusion due to long-term neurologic illness like Alzheimer's disease, progressive, irreversible, short-term memory loss, simple task performance and language impairment, aggression, personality changes.
    3. Acute or Chronic Confusion - treatable illness (i.e. infection) triggers delirium in patient with baseline dementia.


    Category: Cardiology

    Title: pericarditis and cancer

    Keywords: pericarditis, cancer, pericardial effusion, metastastic (PubMed Search)

    Posted: 6/22/2008 by Amal Mattu, MD (Updated: 10/31/2024)
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    Patients with cancer that present with pleuritic chest pain often have pulmonary emboli, but don't forget about pericarditis. Lung and breast cancer, especially, are known to metastasize to the pericardium and produce pericarditis or pericardial effusions. Anticoagulation for presumed PE in patients with pericardial mets. can produce hemorrhagic tamponade, a disastrous iatrogenic complication, so think twice before starting empiric anticoagulation on patients...make sure your patient doesn't have pericarditis or an pericardial effusion.

    The ECG in patients with cancer-related pericarditis or pericardial effusion does not always demonstrate the classic ST elevation wtih PR depression (which is most commonly seen in viral pericarditis). Patients with pericardial effusions often demonstrate low voltage and tachycardia. Electrical alternans, though "classic," only appears in 1/3 of patients with pericardial effusions.



    Category: Orthopedics

    Title: Hip Fractures

    Keywords: hip, fracture, mri, plain films (PubMed Search)

    Posted: 6/21/2008 by Michael Bond, MD (Updated: 10/31/2024)
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    Hip Fractures:

    Typically divided into four types:

    1. Intracapsular,
      1. femoral head and neck fractures
    2. Extracapsular
      1.  trochanteric,
      2. Intertrochanteric
      3. subtrochanteric fractures. 
    • Non-displaced fractures, especially in osteoporotic elderly patients, may be missed on plain films. This is estimated to occur in 2-9% of cases. 
    • It can take up to 72 hours for a fracture to be seen on bone scan. And it is estimated that only 80% of fractures will be seen at 24 hours.
    • MRI is now the preferred imaging modality (100% sensitivity and specificity) to confirm a hip fracture when plain films are negative and equivocal. A MRI will have positive findings in as little as 4 hours after a fracture.
    • Consider CT scan of the hip if MRI is not available at your center.

    Here is a link to a picture with a good representation of the different types of fractures.

    Show References



    Category: Toxicology

    Title: Antagonize Anticoagulation

    Keywords: coumadin, vitamin K, anticoagulation (PubMed Search)

    Posted: 6/19/2008 by Fermin Barrueto (Updated: 10/31/2024)
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    Here is a short list of medications that will actually prevent a patient from being anticoagulated by coumadin. These medications will make it difficult for the patient to reach therapeutic levels and need to be warned about this drug-drug interaction with coumadin:

    • Antacids
    • Antihistamines
    • Barbituates
    • Carbamazepine
    • Cholestyramine
    • Corticosteroids
    • Griseofulvin
    • OCPs
    • Phenytoin
    • Rifampin
    • Vitamin K

    Reference: Goldfrank's Textbook of Toxicologic Emergencies, 6th Edition



    Category: Neurology

    Title: Scales to Assess Acute Risk of Stroke after TIA

    Keywords: Stroke, TIA, ABCD, ABCD2 (PubMed Search)

    Posted: 6/19/2008 by Aisha Liferidge, MD (Updated: 10/31/2024)
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    • The ABCD and ABCD2 scores are validated scales based on both prospective and retrospective data to assess patients' risk of stroke at 7 and 2 days after a TIA, respectively.  The biggest difference between the two is that the ABCD2 Scale includes diabetes as a factor.
    • ABCD Scale
    • Age:  at least 60 = 1 point
    • BP:  SBP > 140 and/or DBP > 90 = 1 point
    • Clinical features:  unilateral weakness = 2 points; speech disturbance w/o weakness = 1 point;  any other neurologic  finding = 0 points.
    • Duration:  at least 60 min. = 2 points; 10-59 min. = 1 point; < 10 min. = 0 points. 
    • Score:  4 points = 1.1% risk;  5 points = 12.1% risk;  6 points = 31.4% risk.
    • ABCD2 Scale
    • Age:  same as ABCD Scale
    • BP:  same as ABCD Scale
    • Clinical features:  same as ABCD Scale except "any other neurologic finding = 0 points" component is omitted.
    • Duration:  same as ABCD Scale except  "< 10 min. = 0 points" component is omitted.
    • Diabetes:  1 point
    • Score:  4-5 points = 4% risk;  6-7 points = 8% risk;  0-3 points = 1% risk.
    • Question = When considering sending a patient home prior to a thorough and appropriate TIA/stroke work-up, how low of a percent risk is acceptable?

    Show References



    Category: Critical Care

    Title: Passive Leg Raising

    Keywords: passive leg raising, fluid responsiveness (PubMed Search)

    Posted: 6/17/2008 by Mike Winters, MBA, MD (Updated: 10/31/2024)
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    Passive Leg Raising (PLR)

    • We have discussed that static measures of volume (CVP, PA wedge pressures) are not reliable markers of fluid responsiveness
    • PLR has recently gained interest as a simple and transient way to assess fluid responsiveness in the critically ill
    • Patients are placed in the horizontal position (not Trendelenburg) and the legs are raised to 45 degrees
    • A hemodynamic response should be seen in 30 - 90 seconds
    • Patients who have improvement in hemodynamics with PLR are said to be fluid responsive (i.e on the ascending portion of their Starling Curve) and require additional volume resuscitation

    Show References



    Category: Airway Management

    Title: Thrombolytic Therapy for Pulmonary Embolism

    Keywords: Thrombolytic, Pulmonary Embolism (PubMed Search)

    Posted: 6/16/2008 by Rob Rogers, MD (Updated: 10/31/2024)
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     Thrombolytic Therapy for PE

    Mike Abraham and I had a very interesting PE case a few nights ago:

    30's yo female presented with a two week history of slow onset, progressive DOE. Initially placed in the asthma room because she had a history of asthma. CXR negative. ECG inverted precordial T-waves and S1Q3T3. CT showed massive central, saddle embolus. Troponin 1.2. Normal BP and a pulse of 110. The patient actually laughed when informed of her diagnosis. She was admitted to the PCU.

    Now, let me share with you how big her clot burden was...it was huge. Biggest I have seen in years. Approximately 70% or so of her total pulmonary circulation was occluded! And, she was laughing. Her BP, though, was never low. The question came up: is this patient a candidate for thrombolytics? After all, she wasn't unstable.

    Our plan in the ED was to administer tPA based on her clot burden, but she was admitted quickly to the PCU in stable condition and they continued the workup and therapy. 

    Considerations for giving lytics to a PE patient:

    • It is within the scope of Emergency Medicine to give lytics without permission
    • If hypotensive-----give lytics
    • If there is evidence of RV dysfunction (which our patient had based on her Troponin)----give lytics
    • Other indications include severe hypoxemia (our patient's SpO2 was normal!!!), free-floating RV thrombus, and a patent foramen ovale
    • Despite the ability (in some centers) to consult Interventional Radiology for catheter-directed lytics, there really isn't data that shows benefit over peripherally infused thrombolytics: Give 100 mg tPA over 2 hours (Heparin is turned off for the drip. Currently only FDA approved regimen. Heparin is restarted without a bolus after the tPA infusion when the aPTT falls to < twice normal

    Show References



    Category: Cardiology

    Title: normal or non-specific ECG in acute MI

    Keywords: ECG, electrocardiogram, acute myocardial infarction (PubMed Search)

    Posted: 6/15/2008 by Amal Mattu, MD (Updated: 10/31/2024)
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    Just a reminder...an initially normal or non-specific ECG can certainly occur in patients that are actively having chest pain from acute MI. A 2001 study published in JAMA nicely pointed this out:

    7.9% of patients having an acute MI had an initial normal ECG.
    35.1% of patients having an acute MI had non-specific abnormalities on ECG.
    57% of patients having an acute MI had diagnostic changes on ECG.

    The greater the abnormality on the ECG, the worse the prognosis, but note that even when the ECG was normal, the in-hospital mortality in acute MI patients was 5.7%.

    Although serial ECGs won't detect 100% of acute MIs, the diagnostic yield does certainly increase, and so whenever a patient has a concerning presentation, especially in the presence of on-going pain, make sure to get repeat ECGs!

    [ref: Welch RD, et al, JAMA 2001]



    Category: Infectious Disease

    Title: Food Poisoning

    Keywords: Food Poisoning, Diarrhea (PubMed Search)

    Posted: 6/14/2008 by Michael Bond, MD (Updated: 10/31/2024)
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    Now that we have entered the session of cookouts, picnics, and family get togethers I thought I would review some of the more common causes of food poisoning and the typical foods that they are found in.

    Bacteria

    Foods Typically Found In

    Onset of Symptoms

    Staphylococcus aureus

    Meat and seafood salads, sandwich spreads and high salt foods.

    4-6 hours

    Salmonella

    Meat; poultry, fish and eggs and now tomatoes

    12 to 24 hours. Assoociated with fever

    Clostridium perfringens

    Meat and poultry dishes, sauces and gravies.

    12 to 24 hours.

    Vibrio parahaemolyticus

    Raw and cooked seafood.

    12 to 24 hours.  Associated with fever

    Bacillus cereus

    Starchy food. Typically Chinese Fried Rice in test questions

    12 to 24 hours.

    Campylobacter jejuni

    Meat, poulty, milk, and mushrooms.

     24 hours

     



    Category: Pediatrics

    Title: Pediatric Septic Shock

    Keywords: Pediatric Septic Shock (PubMed Search)

    Posted: 6/14/2008 by Don Van Wie, DO (Updated: 10/31/2024)
    Click here to contact Don Van Wie, DO

    Remember to save childrens lives be aggressive with septic shock treatment early!

    Do NOT allow long delays at IV attempts before moving to central lines or IOs.

            Goal in the first 0 to 15 minutes from presentation:

    • Recognize decreased perfusion and mental status, maintain airway, and obtain access.
    • Push 20 ml/kg of Isotonic bolus (up to and over 60 ml/kg) and reassess shock after each.*
    • Correct Hypoglycemia and hypocalcemia if present. 

    When community ED physicians successfully achieved shock reversal (defined by return of normal systolic blood pressure and capillary refill time) in the first 75 min from arrival there was an associated 96% survival and a > 9-fold increased odds of survival.  Each additional hour of persistent shock was associated with >2-fold increased odds of mortality.

    *To push this amount of fluid in an infant or young child it may be easier to use 60 ml syringes for boluses rather than pumps

    Show References



    Category: Toxicology

    Title: Toxicity of Patches

    Keywords: transdermal, fentanyl, clonidine (PubMed Search)

    Posted: 6/12/2008 by Fermin Barrueto (Updated: 10/31/2024)
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    Trandermal Delivery Systems

    • Uses a gradient (high concentration drug in patch) and a matrix to facilitate transdermal absorption
    • Patch often contains up to 100x the amount of drug that is on the label (ex: fentanyl 100mcg/hr actually = 10 MILLIGRAMS of fentanyl in patch)
    • When prescribing the following will increase absorption: sweating, heat, swallowing the patch, trying to eat the gel in the patch
    • Fentanyl and clonidine are the two most lethal patches on the market in regards to toxicity.
    • Rarely needed in the ED, shouldn't be prescribed except in rare instances