UMEM Educational Pearls

Title: Compartment Syndrome - Making the diagnosis

Category: Orthopedics

Keywords: compartment syndrome, diagnosis (PubMed Search)

Posted: 7/18/2015 by Michael Bond, MD
Click here to contact Michael Bond, MD

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.

  1. The patient's diastolic blood pressure (DBP) value
  2. The pressure value obtained from the compartment of concern (Compartment pressure)

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.



Previous pearls have focused on diagnosing appendicitis in children including the use of the pediatric appendicitis score and the Alvarado score. Many facilities have begun using focused ultrasound as the initial step in diagnosing appendicitis whilean aging to avoid radiation. The question remains what to do with an indeterminate ultrasound (when the appendix can not be visualized)? The retrospective study cited looked at combining a low Alvarado score (less the 5) with an indeterminate ultrasound and showed a negative predictive value of 99.6%. A total of 522 children were included in this study. 390 of these children had inconclusive ultrasounds. Only 1 patient with a low Alvarado score and inconclusive ultrasound has appendicits. Only children who had surgery or clinical follow up were included.

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Title: How did physostigmine get a bad rap?

Category: Toxicology

Keywords: physostigmine, anticholinergic toxicity, TCA overdose, asystole (PubMed Search)

Posted: 7/16/2015 by Hong Kim, MD (Updated: 11/27/2024)
Click here to contact Hong Kim, MD

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:

 

  1. Get a screening EKG to demonstrate there is no evidence of Na-channel blockade. Even diphenhydramine can cause Na-channel blockade and seizures in severe OD.
  2. Have atropine at bedside. Physostigmine is a cholinergic agent. When given too much, your patient will develop cholinergic toxicity.
  3. Administer 0.5 mg IV over 3-5 min. repeat as needed (every 3-5 min) to max dose of 2.0 mg for clinical effect (improvement of mental status).

 

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. 

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Title: Tuberculosis: Testing and Treatment

Category: International EM

Keywords: Tuberculosis, infectious disease, drug resistance, treatment (PubMed Search)

Posted: 7/15/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

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:

  • Medical history
  • Physical exam
  • A positive TB test
  • Chest radiograph
  • Other appropriate laboratory test (such as acid fast bacilli on sputum smear followed by culture)

 

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

  • isoniazid (INH),
  • rifampin (RIF),
  • ethambutol (EMB), and
  • pyrazinamide (PZA).

 

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.

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Blood Pressure Management in Severe Preeclampsia

  • Severe preeclampsia (preeclampsia + at least one severe complication) accounts for almost 40% of deaths in obstetrical ICU admissions.
  • Systolic arterial hypertension is the most important predictor of morbidity in patients with severe preeclampsia.
  • First-line agents to reduce blood pressure in severe preeclampsia are nicardipine and labetalol.
  • Hydralazine is no longer recommended as first-line therapy.
  • Magnesium is used as an anticonvulsant and should not be considered an antihypertensive.

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Question

7 year-old male "jammed" 5th finger while playing basketball with pain and swelling over finger. What's the diagnosis?

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Title: Sports hernia

Category: Orthopedics

Keywords: Hernia, abdominal pain (PubMed Search)

Posted: 7/11/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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.

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Title: Reversing Dabigatran with Idarucizumab

Category: Toxicology

Keywords: dabigatran, bleeding, idarucizumab, reversal (PubMed Search)

Posted: 7/6/2015 by Bryan Hayes, PharmD (Updated: 7/9/2015)
Click here to contact Bryan Hayes, PharmD

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:

  1. Both studies were funded by Boehringer Ingelheim, who not suprisingly also markets dabigatran. Skepticism is always welcome when the same company makes the drug and the antidote.
  2. The Lancet study was conducted in healthy volunteers, while the NEJM study was conducted in patients needing reversal but lacked a control group.
  3. Idarucizumab seems to reverse laboratory markers of anticoagulation from dabigatran rapidly and completely, including dilute thrombin time and ecarin clotting time. Not all institutions have these assays available.
  4. The dose that seems to 'work' the best is 5 gm given IV (two-2.5 gm infusions given no more than 15 minutes apart).
  5. Median investigator-reported time to cessation of bleeding was 11.4 hours in the NEJM study.
  6. 21 of the 90 patients in the NEJM study had 'serious adverse effects' including thrombotic events.
  7. The acquisition cost of this medication will most assuredly be high if and when it is FDA-approved in the U.S.

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Title: Cerebrospinal Fluid (CSF) Shunts

Category: Neurology

Keywords: CSF shunts, VP shunt, VA shunt, LP shunt (PubMed Search)

Posted: 7/8/2015 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 

Cerebrospinal Fluid (CSF) Shunts

  • CSF shunts are used to manage hydrocephalus by diverting CSF from either the ventricles within the brain or the subarachnoid space around the spinal cord to another body region. (Figure 1)
  • Several types of CSF shunts exist; common types are:
    • Ventriculoperitoneal shunt
    • Ventriculoatrial shunt
    • Ventriculopleural shunt
    • Lumboperitoneal shunt
  • A CSF shunt consists of 3 parts:
    • An inflow catheter directly draining CSF.
    • A one-way valve mechanism regulating the amount of CSF drainage.
    • An outflow catheter directing CSF to the drainage site.
  • There are 2 types of valve mechanisms:
    • Fixed pressure valves regulate CSF drainage by a predetermined pressure threshold (i.e. low, medium, high).
    • Adjustable pressure valves can be non-invasively adjusted, via specially designed magnetic tools, to set the pressure threshold.
    • Some valves include a reservoir that can be used to test shunt function or to sample CSF for laboratory studies. (Figure 2)
  • Shunt-related complications include:
    • Shunt malfunction (disconnection, migration, breaks, obstruction)
    • Shunt infection / ventriculitis / meningitis
    • Over-drainage
  • A special consideration for adjustable pressure valves is precaution around magnetic devices.  If a patient is undergoing a MRI, it is recommended for the valve setting to be checked and adjusted afterwards if necessary.

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Attachments



Question

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? 

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Title: Early Glargine Administration at Start of DKA Treatment

Category: Pharmacology & Therapeutics

Keywords: diabetic ketoacidosis, insulin, glargine, DKA (PubMed Search)

Posted: 6/29/2015 by Bryan Hayes, PharmD (Updated: 7/4/2015)
Click here to contact Bryan Hayes, PharmD

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

  • All patients received IV insulin.
  • Experimental: Subcutaneous insulin glargine given within 2 hours of diagnosis.
  • Control: Patients subsequently transitioned to long-acting insulin upon closure of AG.

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.

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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.

  • 9 million people fell ill with TB in 2013
  • 1.5 million deaths
  • Most deaths (95%) occur in low- and middle-income countries
  • Among the top 5 causes of death in women aged 15 to 44

 

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:

  • Is HIV infected;
  • Has recently acquired TB infection (past 2 years);
  • Has other health problems, like diabetes, that impair the immune response;
  • Is a substance abuser (alcohol or illegal drugs);
  • Was not adequately treated in the past for TB.

 

Classic symptoms for pulmonary TB include:

  • A prolonged (> 3 weeks) bad cough
    • coughing up blood or sputum
  • Pain in the chest
  • weakness/ fatigue
  • weight loss
  • anorexia
  • chills
  • fever
  • sweating at night

 

Other TB symptoms can also include:

  • Prolonged headaches and mental status changes (TB meningitis),
  • Prolonged back pain/stiffness leading to lower extremity paralysis, or single joint arthritis (skeletal TB)
  • Flank pain, frequent urination, scrotal mass or epididymo-orchitis, pelvic inflammatory disease (genitourinary TB)

 

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)

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Title: Central venous catheters

Category: Critical Care

Keywords: tlc, triple lumen, cordis, catheter, central line, icu, critical care (PubMed Search)

Posted: 6/30/2015 by Feras Khan, MD
Click here to contact Feras Khan, MD

With a new academic year starting, it is important to review some details on central lines

Complications of central lines (TLC-Triple lumen catheter)

  • Pneumothorax (more common with subclavian)
  • Arterial puncture (more common with femoral)
  • Catheter malposition
  • Subcutaneous hematoma
  • Hemothorax
  • Catheter related infection (historically more with femoral)
  • Catheter induced thrombosis
  • Arrhythmia (usually from guidewire insertion)
  • Venous air embolism (avoid with Trendelenburg position)
  • Bleeding

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.

 



Question

25 year-old male falls from 10 feet and lands on his right shoulder, what's the diagnosis?

 

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Title: Giant Cell Myocarditis

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

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Title: Fractures of the distal radius

Category: Orthopedics

Keywords: wrist injury, FOOSH, Distal radius fracture (PubMed Search)

Posted: 6/27/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

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



Title: Why Won't It Move? - Functional Neurologic Disorders

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

Functional neurologic disorders, also referred to as psychogenic or nonorganic, comprise a significant part of neurological "emergencies", and can be difficult to diagnose in the emergency department, leading to a significant over-utilization of resources.
Accurate diagnosis emphasizes on the presence of positive physical signs that are internally inconsistent or incongruent with recognized disease. The presence of an identifiable stressor is not necessary for diagnosis.
Exam findings may show:
a) Improvement of symptoms temporarily with focused attention on a different body part, such as:
- Hoover sign and hip abductor sign for functional limb weakness
- Entrainment sign for functional tremor
- Improved standing balance with distractions
b) Clinical phenotype that is typical for the diagnosis, such as:
- Eyes tightly shut while "unresponsive"
- Dragging gait with hips internally or externally rotated, with the forefoot remaining in contact with ground
- Fixed dystonic posture with ankle inversion and plantar flexion
- Global weakness, affecting extensors and flexors equally
- Unilateral facial weakness with platysma overactivity, jaw deviation and/or contraction of orbicularis oris.
That being said, functional and organic disease may co-exist in some patients and it may be worthwhile to refer them to a neurology clinic for possible further workup.

The original article has links to multiple videos demonstrating those signs. It can be accessed on http://journals.lww.com/continuum/Abstract/2015/06000/Functional_Neurologic_Disorders.22.aspx

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Question

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? 

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Title: Steroids and Sciatica

Category: Orthopedics

Keywords: Steroids, Sciatica (PubMed Search)

Posted: 6/20/2015 by Michael Bond, MD
Click here to contact Michael Bond, MD

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

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Title: Pediatric Migraine Therapy

Category: Pediatrics

Keywords: migraine, sodium valproate, headache (PubMed Search)

Posted: 6/19/2015 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

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%.

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