Category: Orthopedics
Keywords: compartment syndrome, diagnosis (PubMed Search)
Posted: 7/18/2015 by Michael Bond, MD
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Compartment Syndrome
Compartment syndrome is a diagnosis that needs to be made quickly in order to prevent long term muscle, nerve, and vascular compromise.
Two pieces of information are needed to determine if the patient has compartment syndrome.
Diastolic Pressure - Compartment pressure < 30 makes the diagnosis of compartment syndrome
So if a diastolic blood pressure is 80 and the compartment pressure is 40 the difference is 40 mmHg and the patient likely does not need a fasciotomy. The diagnosis can only be 100% onfirmed by a trip to the OR so these values should still be discussed with your local orthopaedist. When calling them just make sure you know both the DBP and the compartment pressure so that it can be interpreted correctly.
Category: Pediatrics
Keywords: Alvarado score, ultrasound (PubMed Search)
Posted: 7/17/2015 by Jenny Guyther, MD
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Category: Toxicology
Keywords: physostigmine, anticholinergic toxicity, TCA overdose, asystole (PubMed Search)
Posted: 7/16/2015 by Hong Kim, MD
(Updated: 11/27/2024)
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Physostigmine is a cholinergic agent (acetylcholine esterase inhibitor) that can be used to reverse anticholinergic toxicity. Its use has been declining since the publication of several case reports of physostigmine induced cardiac arrest in tricyclic antidepressant (TCA) overdose.
The first case report (and often cited) was by Pental P. et al. (Ann Emerg Med 1980), who presented 2 cases (32 and 25 year old) of asystole after administration of physostigmine (2 mg) in severe TCA overdose. These two cases both had widened QRS interval (120, 240 msec) due to TCA poisoning. Bradycardia preceded the asystole.
The second case report (Shannon M Pediatr Emerg Care 1998) reported a 15 year-old girl with QRS widening (120 msec) received 2 mg of physostigmine and developed severe bradycardia and then asystole.
Another case series (Knudson K et al. BMJ 1984) of 41 patients with overdose of maprotiline showed that physostigmine administration was associated with higher incidence of seizures. No asystole was noted.
Today physostigmine is contraindicated in TCA poisoning. But if we think about it, physostigmine administration probably wasn’t a good idea in the first place. Correcting anticholinergic toxicity of TCA has limited benefit; mortality from TCA overdose is usually associated with cardiac toxicity (Na-channel blockade) and should be treated with NaHCO3 administration
Physostigmine still has a role in treating isolated anticholinergic toxicity (e.g. diphenhydramine, benztropine, dimenhydrinate, scopolamine, jimson weed overdose). Prior to physostigmine administration:
Bottom line: If you suspect isolated anticholinergic toxicity, think about physostigmine. Like any medication, risk and benefit of administration should be considered prior to administration.
Category: International EM
Keywords: Tuberculosis, infectious disease, drug resistance, treatment (PubMed Search)
Posted: 7/15/2015 by Jon Mark Hirshon, PhD, MPH, MD
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Tuberculosis (TB) remains a deadly scourge killing approximately 1.5 million each year (see Pearl from 7/2/2105). Recognition by astute clinicians in the emergency department is key, as there is no readily available rapid test.
Current testing options:
1) Tuberculin skin test (also known as the Mantoux tuberculin skin test). A small amount of fluid (tuberculin purified protein derivative) is placed intradermally, usually in the left forearm. A positive test means the person was infected with TB. (Alternatively, if they grew up outside the US, they could have been vaccinated with Bacillus Calmette–Guérin or BCG.) A positive test is determined by the size of the reaction, but this can vary depending on the patient’s immune status.
2) Two interferon-gamma release assays or IGRA blood tests are approved for TB. While not readily available in all institutions, this is the preferred method for someone vaccinated with BCG.
Diagnosis of TB disease is based upon:
Treatment:
TB treatment depends on the susceptibility of the organism and the immune status of the patient. For a susceptible organism in a non-HIV patient, the first-line anti-TB agents regimens include
Typical treatment has an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months. Further information can be found at the CDC website on tuberculosis
Bottom Line
As stated previously, in the emergency department, maintain a strong clinical awareness for tuberculosis for someone with night sweats, cough, chest pain, and intermittent fever lasting for 3 weeks or longer. In particular, consider this diagnosis for someone from a low- or middle-income country or if he or she is HIV positive.
http://www.cdc.gov/tb/topic/testing/default.htm
http://www.cdc.gov/tb/publications/factsheets/testing/diagnosis.htm
http://www.cdc.gov/tb/publications/factsheets/treatment/treatmenthivnegative.htm
Category: Critical Care
Posted: 7/14/2015 by Mike Winters, MBA, MD
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Blood Pressure Management in Severe Preeclampsia
Leone M, Einav S. Severe preeclampsia: what's new in intensive care? Intensive Care Med 2015; 41:1343-6.
Category: Visual Diagnosis
Posted: 7/13/2015 by Haney Mallemat, MD
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7 year-old male "jammed" 5th finger while playing basketball with pain and swelling over finger. What's the diagnosis?
Salter-Harris fracture (type II):
Salter-Harris Fracture (remember mnemonic SALTR)
For more on Salter-Harris fractures, check out this and that
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Category: Orthopedics
Keywords: Hernia, abdominal pain (PubMed Search)
Posted: 7/11/2015 by Brian Corwell, MD
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A sports hernia is a painful musculotendinous injury to the medial inguinal floor.
It is the result of repetitive eccentric overload to the abdominal wall stabilizers of the pelvis.
It is common in sports that require sudden changes of direction or intense twisting movements.
Despite the term "hernia" in the title, it is not a true hernia as there is no "herniation" of abdominal contents
http://www.ssorkc.com/wp-content/uploads/2014/09/publagia.gif
Figure description: The upward and oblique pull of the abdominal muscles on the pubis fights against the downward and lateral pull of the adductors on the inferior pubis. This imbalance of forces can lead to injury.
PE: Evaluation of other GU/GYN/other intra-abdominal pathology comes first.
Clinician may note tenderness of the pubic ramus and medial inguinal floor.
Pain is more severe with resisted hip adduction and with resisted sit-up.
Combining these maneuvers (resisted situp while adducting hips) recreates the pathophysiology described above and is a good exam maneuver.
Sports hernia: the experience of Baylor University Medical Center at Dallas
Proc (Bayl Univ Med Cent). 2011 Apr; 24(2): 89 91
Category: Toxicology
Keywords: dabigatran, bleeding, idarucizumab, reversal (PubMed Search)
Posted: 7/6/2015 by Bryan Hayes, PharmD
(Updated: 7/9/2015)
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The New England Journal of Medicine and Lancet both published studies evaluating idarucizumab for reversal of dabigatran. It is a monoclonal antibody fragment that binds dabigatran with high affinity. Dr. Ryan Radecki summarizes the two articles on his EM Lit of Note blog.
Here are a few take home points from these early studies:
Pollack CV, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015 Jun 22. [Epub ahead of print, PMID 26095746]
Glund S, et al. Safety, tolerability, and efficacy of idarucizumab for the reversal of the anticoagulant effect of dabigatran in health male volunteers: a randomised, placebo-controlled, double-blind phase 1 trial. Lancet. 2015 Jun 15. [Epub ahead of print, PMID 26088268]
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Category: Neurology
Keywords: CSF shunts, VP shunt, VA shunt, LP shunt (PubMed Search)
Posted: 7/8/2015 by WanTsu Wendy Chang, MD
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Cerebrospinal Fluid (CSF) Shunts
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Category: Visual Diagnosis
Posted: 7/6/2015 by Haney Mallemat, MD
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15 year-old female field hockey player presents with left shoulder pain. Besides fatigue over several weeks, she has no past medical history and there is nothing remarkable on physical exam. What's the diagnosis?
Mediastinal mass (lymphoma confirmed on biopsy)
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Category: Pharmacology & Therapeutics
Keywords: diabetic ketoacidosis, insulin, glargine, DKA (PubMed Search)
Posted: 6/29/2015 by Bryan Hayes, PharmD
(Updated: 7/4/2015)
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Transitioning Diabetic Ketoacidosis (DKA) patients off an insulin infusion can be challenging. If a long-acting insulin, such as glargine or levemir, is not administered at the correct time to provide extended coverage, patients can revert back into DKA.
Pilot Study
A prospective, randomized, controlled pilot study in 40 patients evaluated administration of glargine within 2 hours of insulin infusion initiation compared to waiting until the anion gap (AG) had closed.
What they did
What they found
Mean time to closure of AG, mean hospital LOS, incidents of hypoglycemia, rates of ICU admission, and ICU LOS were all similar between the groups.
Application to Clinical Practice
Although just a pilot study (using a convenience sample), early glargine administration seemed to be absorbed adequately (based on time to AG closure) and was not associated with increased risk of hypoglycemia. If confirmed in a larger study, this technique could help optimize care of DKA patients in the ED by eliminating the often-mismanaged transition step later on.
Doshi P, et al. Prospective randomized trial of insulin glargine in acute management of diabetic ketoacidosis in the emergency department: a pilot study. Acad Emerg Med 2015;22(6):657-62. [PMID 26013711]
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Category: International EM
Keywords: Tuberculosis, infectious diseases (PubMed Search)
Posted: 7/2/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
As noted in a previous pearl (see 1/7/2015), tuberculosis (TB), caused by Mycobacterium tuberculosis, is the second greatest infectious killer after HIV/AIDS globally. While the incidence and death rate from TB is decreasing, it is still a widespread problem.
Mycobacterium tuberculosis primarily attacks the lungs. However, it can attack any part of the body such as the kidney, spine, and brain. TB is primarily spread person to person through the air, for example when a person with TB coughs, sneezes, speaks, or sings.
Once a person is infected with TB, the likelihood of developing disease is greater if the person:
Classic symptoms for pulmonary TB include:
Other TB symptoms can also include:
Bottom line
In the emergency department, maintain a strong clinical awareness for tuberculosis for someone with night sweats, cough, chest pain, and intermittent fever lasting for 3 weeks or longer. In particular, consider this diagnosis for someone from a low- or middle-income country or if he or she is HIV positive.
Next time: Testing and treatment for TB.
Also see prior pearls on TB: Multidrug Resistant Tuberculosis (MDR TB) (1/21/2015), Tuberculosis (1/7/2015); XDR Tuberculosis (8/14/2013); PPD positive? Good news... (2/6/2013)
http://www.cdc.gov/tb/topic/basics/default.htm
http://www.who.int/mediacentre/factsheets/fs104/en/
http://emedicine.medscape.com/article/230802-overview
Category: Critical Care
Keywords: tlc, triple lumen, cordis, catheter, central line, icu, critical care (PubMed Search)
Posted: 6/30/2015 by Feras Khan, MD
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With a new academic year starting, it is important to review some details on central lines
Complications of central lines (TLC-Triple lumen catheter)
Avoiding infections: hand hygiene, chlorhexidine skin antisepsis, maximal barrier precautions, remove unnecessary lines, full gown and glove w/ mask and sterile technique.
Catheter position: 16-18cm for Right sided and 18-20 cm for Left sided. But can vary based on height, neck length, and catheter insertion site. Approximate length based on these factors.
Flow rates: Remember that putting in a central line does not necessarily improve your flow rates in resuscitation
16 G IV: 220 ml/min
Cordis/introducer sheath: 126 ml/min
18 G IV: 105 ml/min
16G distal port TLC: 69 ml/min
Ports (Can vary with type of catheter)
1. Distal exit port (16G)
2. Middle port (18G)
3. Proximal port (18G)
Arterial puncture: hold pressure for 5 mins and evaluate for hematoma formation (harder for subclavian approach)
Arterial cannulation: Has decreased due to ultrasound use but if you do cannulate an arterial site, don’t panic. Don’t remove the line. You can check a blood gas or arterial pulse waveform to confirm placement. Call vascular surgery for open removal and repair or endovascular repair. You could potentially remove a femoral arterial line and hold pressure but seek vascular advice regarding possible closure devices to use after removal.
Category: Visual Diagnosis
Posted: 6/29/2015 by Haney Mallemat, MD
(Updated: 6/30/2015)
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25 year-old male falls from 10 feet and lands on his right shoulder, what's the diagnosis?
Yes, the shoulder is dislocated...but did you notice anything else (see below)?
Bankart lesion (a.k.a. fracture of the glenoid fossa)
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Category: Cardiology
Posted: 6/28/2015 by Semhar Tewelde, MD
(Updated: 11/27/2024)
Click here to contact Semhar Tewelde, MD
Giant Cell Myocarditis
Giant cell myocarditis (GCM) is an infrequent, but often fatal form of acute myocarditis that has been shown to respond to cyclosporine-based immunosuppressive therapy
Even after heart transplantation GCM recurrence in the donor heart has been cited as high as 20% to 25%
Patients are surviving longer without transplantation because of efficacious medical therapy
A multi-institutional prospective data set revealed several novel findings in GCM:
· Long-term immunosuppression appears capable of lengthening transplantation-free survival ~19 years beyond initial diagnosis
· Cessation and/or reduction of immunosuppression are associated with GCM recurrence
· Patients who developed cyclosporine associate renal failure were able to be switched to a sirolimus-based regimen
Maleszewski J, Orellana V, et al. Long-Term Risk of Recurrence, Morbidity and Mortality in Giant Cell Myocarditis. Am J Cardiol 2015;115:1733e1738
Category: Orthopedics
Keywords: wrist injury, FOOSH, Distal radius fracture (PubMed Search)
Posted: 6/27/2015 by Brian Corwell, MD
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Colles fracture
Almost 90% of distal radius fractures
Mechanism: Fall on the outstretched, hyperextended, radially deviated wrist with the forearm in pronation
Often seen in older patients and in those with osteoporosis
Distal radius fracture with dorsal angulation/displacement and/or radial shortening. "Dinner fork deformity"
https://en.wikipedia.org/wiki/Colles'_fracture#/media/File:Colles_fracture.JPG
Smith fracture (aka reverse Colles fracture)
Mechanism: Fall on the outstretched, flexed, radially deviated wrist with the forearm in pronation
Usually younger patients with high energy mechanism
Distal radius fracture with volar angulation or volar displacement. "Garden spade" deformity
Often unstable requiring ORIF
http://www.radiologyassistant.nl/data/bin/w440/a50979780ec887_Smith'-tek.jpg
Radial styloid fracture aka Chauffeur fracture
Fall causing compression of scaphoid against the styloid with wrist in dorsiflexion and ulnar deviation
Often associated with intercarpal ligamentous injuries (i.e., scapholunate dissociation, perilunate dislocation)
Often requires ORIF
http://images.radiopaedia.org/images/611818/cc52cce7bcfd8c905bcc7b5d2b6a65.jpg
Category: Neurology
Keywords: psych, conversion, nonorganic, physical exam (PubMed Search)
Posted: 6/25/2015 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Stone J, Carson A. Functional Neurologic Disorders. Continuum 2015;21(3):818 837
Category: Visual Diagnosis
Posted: 6/22/2015 by Haney Mallemat, MD
(Updated: 6/23/2015)
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30 year-old patient presents with palpitations. A parasternal long-axis clip is shown below along with the rhythm strip. What's the diagnosis and what drug was given during this clip?
This was SVT and adenosine was given; notice how the heart pauses in the echo and in the rhythm strip.
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Category: Orthopedics
Keywords: Steroids, Sciatica (PubMed Search)
Posted: 6/20/2015 by Michael Bond, MD
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Steroid Use in the treatment of Acute Sciatica
Have you used oral steroids in the treatment of your patient with acute sciatica thought to be secondary to a herniated disk.
Well a recent randomizaed, double-blind, placebo-controlled trial from 2008 to 2013 in a large integrated health care system in Northern California enrolled 269 patients to look at whether steroids improved pain or function. The intervention arm (twice as large as placebo arm) received a tapering 15-day course of oral prednisone (5 days each of 60 mg, 40 mg, and 20 mg; total cumulative dose = 600 mg; n = 181).
In the end there were no differences in surgery rates at 52-week follow-up, and the steroid arm had a modest improvement in function but no improvement in pain. There were also more adverse events at 3-week follow-up in the prednisone group than in the placebo group.
Conclusion: Giving steroids for acute sciatica does not appear to improve the patients pain, only has a modest improvement in function, and was associated with more adverse events. Put another way there was minimal benefit and more harm.
You can check out the full article at http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2015.4468
Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, Smith W, Carver R, Maratukulam A, Won LA, Carragee E, Avins AL. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23. doi: 10.1001/jama.2015.4468.
Category: Pediatrics
Keywords: migraine, sodium valproate, headache (PubMed Search)
Posted: 6/19/2015 by Jenny Guyther, MD
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Sodium valproate (VPA) had been studied and found to be effective in the adult population for migraines, but not in the pediatric population. This article was a small (12 patient) retrospective study of pediatric migraine patients looking at pain scores before and after VPA administration. Prior to VPA, patients received NSAIDs, dopamine antagonists, IV fluids and narcotics. Mean pain reduction prior to VPA was 17%. After VPA, pain scores were reduced by an additional 36%.
Sheridan, D, Sun, B, O’Brien, BS, and Hansen, M. Intravenous Sodium Valproate for Acute Pediatric Headache. The Journal of Emergency Medicine. Article in Press. Accepted February 2015.