UMEM Educational Pearls

Title: Mechanical Ventilation "Knobology" - respiratory failure

Keywords: mechanical ventilation, assist control, SIMV, pressure support (PubMed Search)

Posted: 7/17/2007 by Mike Winters, MBA, MD (Updated: 11/26/2024)
Click here to contact Mike Winters, MBA, MD

-One of the most common reasons for intubation/mechanical ventilation in the ED is patient fatigue -Essentially, patients are unable to keep up with the work of breathing -Patient work of breathing can be significant in CPAP, SIMV, and Pressure Support modes of mechanical ventilation -Avoid these as initial modes if your patient has respiratory fatigue

Title: Aortic Dissection

Category: Vascular

Keywords: aortic dissection, chest, abdominal, pain, malpractice (PubMed Search)

Posted: 7/16/2007 by Rob Rogers, MD (Updated: 11/26/2024)
Click here to contact Rob Rogers, MD

Most common themes in medical malpractice cases involving missed aortic dissection: -Some combination of chest/back, chest/abdomen, or abdomen/back -Symptoms "above and below" the diaphragm (neck pain and abdominal pain, for e.g.) Sullivan, SullivanGroup.com 2006 Acute Aortic Disease, Elefteriades 2007

Title: treatment of acute pericarditis

Category: Cardiology

Keywords: pericarditis, treatment, colchicine, steroids (PubMed Search)

Posted: 7/15/2007 by Amal Mattu, MD (Updated: 11/26/2024)
Click here to contact Amal Mattu, MD

-Most patients with acute pericarditis are effectively treated with high-dose aspirin or NSAIDS + colchicine - Aspirin dose: 2-4 gms/day - Colchicine dose: 1-2 mg for first day, then 0.5-1 mg/day for 3 months - The use of steroids in first-time acute pericarditis should be avoided, as it has been found to increase the chances of recurrence

Title: Traumatic Ankle Pain

Category: Trauma

Keywords: Ankle, Maisonneuve, Jones, Fracture (PubMed Search)

Posted: 7/14/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

Traumatic Ankle Pain When examining a patient who presents with Ankle Pain, make sure that you examine/palpate the proximal fibula and the base of the fifth metatarsal. Pain over the proximal fibula will necessitate a full Tibia/Fibula x-ray to rule out a Maisonneuve Fracture [a proximal fracture of fibula resulting from external rotation; injury may occur with medial or posterior malleolus fracture, a ligament rupture, as well as rupture of interosseous membrane. Pain over the base of the 5th metatarsal suggests a Jones Fracture [ involves fx at base of fifth metatarsal at metaphyseal-diaphyseal junction, which typically extends into the 4-5 intermetatarsal facet; is located w/in 1.5 cm distal to tuberosity of 5th metatarsal & should not be confused w/ more common avulsion fx (Dancer s Fracture) of 5th metatarsal styloid]

Title: Bronchiolitis

Category: Pediatrics

Keywords: Bronchiolitis, Bronchodilators, Steroids, Supplemental Oxygen (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/26/2024)
Click here to contact Sean Fox, MD

Bronchiolitis The most common lower respiratory infection in infants Diagnosis is based on clinical history and physical. No lab test is useful. Management - Bronchodilators should not be used routinely. They can be continued if the pt has a positive response after a trial. - Corticosteroids have not been found to be of benefit. - Antibiotics should not be used, unless indicated for other reasons. - Ribaviran has not demonstrated any benefit. - Use Supplemental oxygen if the patient is persistently sat'ing <90%. Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of Bronchiolitis. PEDIATRICS Vol. 118 No. 4 October 2006, pp. 1774-1793

Title: One Pill Killers for Children

Category: Toxicology

Keywords: pediatric, poisoning, overdose (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto (Updated: 11/26/2024)
Click here to contact Fermin Barrueto

One Pill Killers for Children Drug Class Mechanism of Action that Kills Sulfonylureas These hypoglycemic agents (ie. Glyburide) also have a long t Opioids Respiratory depression Imidazoline Clonidine and Oxymetazolone (nasal spray) cause bradycardia and respiratory depression Ca Channel Blockers Bradycardia & hypotension, especially diltiazem and verapamil Beta Blockers Extended release preparations are problematic There are some others but these are the most commonly prescribed pharmaceuticals. Remember, children under age 6 will not be able to swallow a pill and the pill itself is choking hazard. Proper poison prevention education for the parents is also needed.

Title: Pearl of the Day - Critical Care

Category: Critical Care

Keywords: PEEP, oxygenation, ventilator (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MBA, MD (Updated: 11/26/2024)
Click here to contact Mike Winters, MBA, MD

Mechanical Ventilation "Knobology" - Oxygenation -FiO2 and PEEP are used to improve oxygenation in the ventilated patient -Immediately following intubation, start with an FiO2 of 100% -Increase PEEP by 2-3 cm H2O every 10-15 minutes to achieve the desired saturation -As you titrate PEEP, have respiratory therapy provide you with plateau pressures (maintain Pplat < 30) Mike

Title: Test of new education blog/listserv

Category: Misc

Keywords: Listserv, mailing list, test (PubMed Search)

Posted: 7/10/2007 by Dan Lemkin, MS, MD (Updated: 11/26/2024)
Click here to contact Dan Lemkin, MS, MD

I am redesigning the way the educational pearls are sent. You will still receive them via email to the education list. This will not change. What will change, is that a record will be available for review on the website in the residency --> pearls section. Currently you can browse the posts as the come in. In the very near future, you will be able to search by keywords and review several pearls at once. This should serve as a really handy review tool. Please bear with me as I test the email system to ensure it comes across ok. thanks dan

Title: Airway Management Pearls

Category: Airway Management

Keywords: Intubation, Airway (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

1. 30% of all ETT placed in the field by EMS are esophageal. 2. Patients that will rapidly desaturate - think "POPS" ie Pregnancy, Obesity, Pediatric, Smoke inhalation. 3. In the adult the only absolute contraindication to performing a cricothyroidotomy is a fractured larynx. 4. Post intubation desaturation think "DOPE" ie Displacement, Obstruction, PNTX, Equipment failure.

Title: OB Pearls

Category: Obstetrics & Gynecology

Keywords: Pre-eclampsia, eclampsia, HELLP (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

The best known peripartum complications are pre-eclampsia and eclampsia. However, do not forget about HELLP syndrome which occurs in approximately 0.2 to 0.6 percent of all pregnancies. HELLP is an acronym for: Hemolysis Elevated Liver Enzymes Low Platelet Treatment consists: 1. Seizure prophylaxis with magnesium 2. Blood pressure control 3. Corticosteriods and plasmapheresis may be helpful in severe causes 4. Supportive care. 5. Early delivery of child.

Title: Shoulder Dystocia Legal Pearl

Category: Obstetrics & Gynecology

Keywords: Erb's Palsy, Dystocia, Legal (PubMed Search)

Posted: 7/14/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

In follow up to my Shoulder Dystocia Pearl

Dr. DePriest Whye has some legal pearls for us:

Erbs Palsy( Brachial Plexus Injury) is a known complication of shoulder dystocia and is due to traction on the arm that causes stretching of the brachial plexus.

Should an Erb's Palsy result as a consequence of a shoulder dystocia, a medical malpractice suit is inevitable.
The medical record documentation is particularly critical in defending the medical care rendered.
The medical record should reflect timely recognition of the shoulder dystocia.
It is important that appropriate implementation of the maneuvers described last week are done in a timely fashion.
Vital documentation should describe the amount of traction placed if any.
Terms such as minimal or mild or light traction should be used.
Terms such as strong, forceful, significant traction should be avoided.
Never state in the record that uterine pressure was used as opposed to suprapubic pressure.
Uterine pressure is contraindicated.

Erb's Palsy cases are difficult to defend. They are impossible to defend with improper documentation.

Title: Bougie-Facilitated Intubation

Category: Airway Management

Keywords: Intubation, Bougie, Difficult Airway, Wound Care, Irrigation (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

Bougie-Facilitated Intubation Using the Bougie as a rescue device can sometimes be complicated with difficulty advancing the endotracheal tube as the tip can get hang up at the level of the glottis. Two things that can help advance the tube: Rotate the tube 90 degrees counterclockwise. Stop holding Cricoid Pressure, especially in female patients A recent study looking at cricoid pressure showed that the frequency of impingement was 38% with sham pressure and 60% with true cricoid pressure. This statistically significant difference was entirely attributable to an effect in female patients. Original Article: McNelis U et al. The effect of cricoid pressure on intubation facilitated by the gum elastic bougie. Anaesthesia 2007 May; 62:456-9. Forget about Sterile Saline and Use Tap Water Irrigation In a multicenter prospective trial of 715 patients, Moscati et al have shown that rates of wound infection were similar (3.3% compared to 4.0%) in patients that received clinician-administered sterile saline irrigation or at least 2 minutes of self-administered tap-water irrigation. The amount (volume) of irrigation is more important than whether the irrigate is sterile or not. Moscati RM et al. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med 2007 May; 14:404-9.

Title: Pulmonary Embolism Rule Out

Category: Vascular

Keywords: D-Dimer, PE, Well's (PubMed Search)

Posted: 7/14/2007 by Rob Rogers, MD (Updated: 11/26/2024)
Click here to contact Rob Rogers, MD

Update on the Wells Criteria for PE-patients with a score of 4 or less (which means low to moderate probability) can be considered for a "d-dimer negative" rule out approach. This is a bit of a change from the low risk only approach. Additionally, the British Thoracic Society guidelines support the low and moderate risk group patient rule out strategy. So, if you have a low or even moderate risk patient, you can use the approach of obtaining a highly sensitive d-dimer and if it is negative, the hunt for PE is over.

Title: Inborn Errors of Metabolisn

Category: Pediatrics

Keywords: Inborn Errors of Metabolism, Hypoglycemia, organomegaly (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/26/2024)
Click here to contact Sean Fox, MD

Inborn Errors of Metabolism For the child with neurologic abnormalities, vomiting, acidosis, hypoglycemia, organomegaly, or cardiopulmonary arrest remember to consider Inborn Errors of Metabolism (IEM) on your DDx. There are over 300 disorders of the various biochemical pathways, and while the individual incidence for each disorder may be rare, the collective incidence for IEM is 1-2 / 1,000 births. Treat dehydration and hypoglycemia promptly but FIRST, draw EXTRA blood samples (at UMMS, two adult Green Tops and one adult Red Top) in addition to the basic labs. ==> Once you begin therapy to correct the acid/base disturbance, hypoglycemia, and dehydration the abnormal metabolites present in their serum will be reduced and possibly confound the diagnosis. ==> Draw the extra blood, before your give the NS bolus or the Dextrose! ==> Basic Labs (1) ABG, BMP, Ammonia, U/A are helpful immediately (2) CBC, Blood and Urine Cultures (look for concurrent infection, possibly the inciting event) (3) Urine Reducing Substances, serum organic acids, urine and serum amino acids are also useful

Title: Bacterial tracheitis

Category: Pediatrics

Keywords: Bacterial tracheitis, stridor, croup, epiglottitis (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Updated: 11/26/2024)
Click here to contact Sean Fox, MD

Bacterial Tracheitis Considered bacterial tracheitis in a patient who has fever, stridor, and symptoms that do not respond to therapy for croup (racemic epinephrine and steroids). The epidemiology of acute infectious upper airway disease in pediatrics has been altered with immunization against Haemophilus influenza- b and the widespread use of corticosteroids for the treatment of viral croup. Bacterial Tracheitis has replaced epiglottitis and croup as the most common cause of acute respiratory failure. One study found it to be 3 times more likely to cause respiratory failure than croup and epiglotittis combined. The mortality rates had been reported as high as 18% to 40%. Hopkins, A., et al., Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics, 2006. 118(4): p. 1418-21.

Title: Supracondylar Fractures

Category: Orthopedics

Keywords: Supracondylar, Fracture, Pediatric, Ossification (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

Supracondylar fractures in children: To assess the likelihood of a supracondylar fracture in a child look at the anterior humeral line. This is a line drawn down the anterior portion of the humerus on the lateral view of the elbow. This line should pass through the center of the capitellum in the distal humerus. If the line does not pass through the center there is a very high likelihood of a supracondylar fracture. Review of the Appearance of Ossification Centers in Children's Elbows CRITOE Capitellum 1 to 8 months Radial Head 3 to 5 years Medial (Internal)Epicondyle 5 to 7 years Trochlea 7 to 9 years Olecranon 8 to 11 years Lateral ( External) Epicondyle 11 to 14 yeras

Title: Tuberculosis Screening

Category: Infectious Disease

Keywords: TB, PPD, Conversion (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

PPD is considered positive: >= 15 mm Induration: Anybody >= 10 mm induration: Born in a high-revalence country, are in a medically underserved population ( e.g.:Blacks, Hispanics, and Native Americans), individuals with a medical condition that increases risk of TB (e.g.; silicosis, gastrectomy, chronic renal failure, immunosuppressant therapy, malignancy, IV drug abusers, and those that work in the medical field. >=5mm induration: HIV or suspected HIV-positive, close contacts of newly diagnosed TB Cases (everybody on the plane), and abnormal CXR with fibrotic changes suggesting old TB MMWR September 08, 1995/ 44(RR-11);18-34

Title: Airway Pearls

Category: Airway Management

Keywords: Airway, Intubation (PubMed Search)

Posted: 7/12/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

1. Hyperventilation in the pediatric HI causes an increase in cerebral ischemiaand increases in ICP 2. Cuffed tubes can be used in the pediatric airway 3. The most common cause of bradycardia in pediatric RSI is hypoxia and this is NOT prevented with atropine 4. Patients with an underlining neuromyopathy have an upregulation of neuroreceptors (they actually have more in number) the risk if hyperkalemic cardiac arrest is significant if succynlcholine is administered. 5. During Direct Laryngoscopy; the Mac blade can also be used as a Miller negating changing the blades. 6. Intubation is now a bimanual procedure as the use of External Laryngeal Movement (ELM) significantly increase the intubators view.

Title: Imminent Delivery

Category: Obstetrics & Gynecology

Keywords: Delivery, Imminent, Dystocia (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

If you are facing the imminent delivery of a newborn with shoulder dystocia remember the mnemonic HELPERR. * Help. Call for it. * Episiotomy. o Necessary only to make more room if rotation maneuvers are required. * Legs (the McRoberts maneuver) o This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. * Pressure, Suprapubic o The hand of an assistant should be placed suprapubically over the fetal anterior shoulder, applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the fetal shoulder. This maneuver should be attempted while continuing downward traction. * Enter maneuvers (internal rotation) o Attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. * Remove o Remove the posterior arm. * Roll the patient. o Rolling the patient on all-fours will often dislodge the shoulder, and the position change allows gravity to aid in the disimpaction of shoulder. Baxley EG, Gobbo RW. Shoulder Dystocia, Am FamPhysician. 2004;69(7):1709-1714.

Title: Epistaxis Control

Category: ENT

Keywords: Epistaxis, Nose, Bleeding (PubMed Search)

Posted: 7/10/2007 by Michael Bond, MD (Updated: 11/26/2024)
Click here to contact Michael Bond, MD

Direct Pressure: Can be held with two fingers pinching the nares, or you can tape 4 tongue blades together and make your own "clothes pin" that can then be used to pinch the nares. Vasoconstrictor and Anesthesia: Use a 1:1 mixture of topical lidocaine 4% and oxymetazoline can often be mixed together in the same oxymetazoline spray container and then just spray it into the nares. Some IV/IM narcotic pain medication will also help increase patient cooperation. Visualize the bleeding site: Use a HEAD LAMP with an appropriate sized nasal speculum. You may look like Marcus Welby, MD but nothing works as well to see into the nose. Cauterization It is best to cauterize circumferential around the bleeding site prior to directly cauterizing the actual site. Be careful with electrical cautery so has not to perforate the septum. Nasal Packing: Instead of surgilube use Muprion, Bactroban or Bacitracin ointment to lubricate the packing. This will reduce the chance of Toxic Shock Syndrome.