The followings is a list of unique clinical findings related to a certain sedative-hypnotic overdose:

1) Hypothermia:Barbiturates, bromides, ethchlorvynol (others but these more pronounced)

2) Unique odors: chloral hydrate, ethchlorvynol (which is Placidyl)

3) Bradycardia: GHB (again others but pronounced in this OD)

4) Tachydysrhythmias: chloral hydrate

5) Muscular twitching: GHB, methaqualone, etomidate

6) Discolored urine: propofol (green/pink)

• Xanthochromia is the yellowish discoloration of the supernatant from centrifuged cerebrospinal fluid (CSF).

• Xanthochromia is an abnormal finding and results from the lysis of red blood cells.

• Xanthochromia is present is CSF in > 90% of patients within 12 hours of subarachnoid hemorrhage (SAH) onset.

Coagulopathy from Acute Liver Failure

• ALF is defined as
  • absence of chronic liver disease
  • acute elevation in AST/ALT accompanied by INR > 1.5
  • any degree of mental status change (encephalopathy)
  • illness less than 26 weeks duration
• The most common cause is acetaminophen toxicity
• Regarding the coagulopathy that develops with ALF:
  • FFP transfusion is not encouraged, as the volume may exacerbate cerebral edema and it has been shown to be ineffective for improving INR elevations
  • The prophylactic transfusion of platelets for extreme thrombocytopenia is also not recommended for similar reasons

Todays pearl pertains to a great new blog put together by Dr. Michelle Lin, entitled "Academic Life in Emergency Medicine." The blog is superb and is a great resource for anyone interested in academic EM.

Today's posting is about teaching when time is limited and Michelle discusses a really good article written by Irby, et al. This article addresses a topic that is very pertinent to us in the ED, how to teach when it is busy. Isn't it always busy?

Tips from the article:

1. Identify the learner needs (can't be successful without this important step)
2. Teach rapidly (great tips for how to do this in the ED)
3. Provide feedback (students are starving for this)

Want more??? Gotta check out the article....

Here is the link to the site:

http://AcademicLifeinEM.blogspot.com/ 

Enjoy!

Pericarditis is one of the conditions that is often misdiagnosed as STEMI, resulting in "inappropriate" cath lab interventions. In addition to producing STE, pericarditis also may produce dyspnea, diaphoresis, and elevations in TN levels, all of which will mimic true ACS.

On the other hand, pericarditis does NOT produce STE in up to one-third of cases, so the diagnosis may be missed. Non-STE cases of pericarditis occur more often in women, in patients with pericardial effusions, and in patients without preceding viral syndromes.

[Salisbury AC, et al. Frequency and predictors of urgent coronary angiography in patients with acute pericarditis. Mayo Clin Proc 2009;84:11-15.] 

Metacarpal Fractures and Growth Plates:

The growth plates on metacarpals are on the distal end of the bone, except for the 1st metacarpal which is on the proximal end near the carpal bones.

Don't mistake this for a fracture line, however, make sure you get comparison views if they are tender over the area, as this can help you diagnosis a Salter Harris Type 1 fracture.

Noninvasive ventilation use in children has been shown in some trials to be a useful tool to avoid intubation in children with asthma.

Since children with asthma who are intubated have a much higher risk for complications including pneumotharaces and pneumomediastinum this can be a very useful tool.

Bi-Pap is usually started with typical settings of 10 for IPAP and 5 for EPAP and can be titrated up as tolerated to levels of up to 25/20 cm H2O and can be delivered with a set rate or a back up rate.

Albuterol and nebulized epiephrine may be delivered through newer BiPAP machines.  

Signs that BiPAP is working include decreased Respiratory Rate, decreased retractions and accesory muscle use, improved oxygenation saturation

A patient presents to the University of MD ED in generalized convulsive status epilepticus. Continuous seizure activity that is not stopped by any dose of benzodiazepine [This is actually a very rare entity]. What is your next move?

- Check your basics: Fingerstick blood glucose (hypoglycemics can cause SE)

- Phenytoin is not going to work fast enough, the clock is ticking and the patient's brain cannot handle continuous status epilepticus, after 45-60min permanent neurologic sequelae or death will occur. If the cause is toxin induced, it just won't work.

- In an area where HIV is endemic, you have to consider Isoniazid - an antituberculous drug - and administer antidotal therapy: empiric dosing of vitamin B6 (pyridoxine) 5g IV. It is the only thing that will work.

- From the ED perspective, you will also be using a barbituate though there is evidence to support the use of propofol (after intubation for both). This will hopefully stop the seizure

- General anesthesia is the last chance if all else fails.

• Several conditions cause increased intracranial pressure (ICP), requiring lumbar puncture (LP) with opening pressure (OP) measurement for diagnostic and therapeutic management.

• Examples of such include:  pseudotumor cerebri, (cryptococcal) meningitis, intracranial mass, and intracranial hemorrhage.

• In order to ensure an accurate measurement, OP should be assessed while the patient is in the lateral decubitus position with the neck and legs in a neutral position.

• Normal OP ranges from 10 to 100 mm H₂0 in children, 60 to 200 mm H₂0 after age 8, and up to 250 mm H₂0 in the obese.  OP > 250 = intracranial hypertension.

• OP (the meniscus level) can fluctuate by 2 to 5 mm H20 with patient's pulse and by 4 to 10 mm H20 with patient's respirations.

• A patient's symptoms of headache and/or neurologic deficit is often relieved by lowering the ICP through slow removal of CSF during LP.  The pressure level should not be lowered by any more than 50% of the initial OP.

The Maintenance Phase of Therapeutic Hypothermia

Therapeutic hypothermia (TH) has become standard in the care of patients with return of spontaneous circulation from cardiac arrest.  Although the optimal duration of TH is unknown, current literature supports 12-24 hours of cooling to 32-34^oC.  As many of our critically ill patients remain in the ED for seemingly endless lengths of stay, it is likely that most emergency physicians will be managing patients with TH during the maintenance phase of cooling.  Some pearls regarding the maintenance phase:

• Metabolic and hemodynamic homeostasis is critical
• Target volume-cycled mechanical ventilation to maintain a normal pH
• Maintain a MAP > 65 mm Hg
• Maintain blood glucose between 120 - 160 mg/dL
• Frequently check and aggressively replete potassium, magnesium, and phospate

Elderly are more likely to have non-diagnostic ECGs. The proportion of patients > 85 years of age with NSTEACS who had non-diagnostic ECGs was 43% vs. 23% for patients < 65 years of age. [Elderly are also more likely to have LBBB as well as prior evidence of MI, either one of which can cause some problems with interpretation of acute cardiac ischemia.] The lack of CP combined with non-diagnostic ECGs probably leads to delays and under-treatment of many of these patients.

[Alexander KP, et al. Acute coronary care in the elderly, part I: Non-ST-segment elevation acute coronary syndromes. Circulation 2007;115:2549-2569.]

• Characterized by proteinuria, hypoalbuminemia, edema, and hypercholesterolemia


• Abnormal Vitals:  tachypnea (due to pulmlonary edema); tachycardia (intravascular depletion); hypertension


• Abnormal PE:  peripheral edema, ascites, S3 on ausculation


• UA demonstrates significant proteinuria.


• TX is uniformly with oral steroids.

High Pressure Injection Injuries:

• These injuries initially often have a pretty benign appearance which may result in the injuried person seeking medical treatment late, or the initial medical provider not recognizing the seriousness of the injury.
• Even when treated promptly and aggressively most patients will end up with an amputation of thier finger or have permanent loss of funciton, strength, sensation, or chronic pain.
• In a couple of hours, these injuries tend to result in significant swelling that can lead to compartment syndrome. The swelling can be due to the actual disruption of cells from the high pressure, or due to toxic effects of the injected agent.
• Initial Management should consist of:
  • X-rays: Help to evaluate the extent of the injection.  Radio-opaque solvents will be seen on x-ray, but even radio-lucent solvents may be seen as lucency or air on the x-ray
  • Broad Spectrum antibiotics to prevent infection
  • Corticosteroids to decrease the inflammatory response brought on by the injected agent
  • Tetanus Prophylaxis if needed
  • Emergent hand surgery referral
• Most if not all patients will require emergent debridement of the affected area.

You have a patient that is on lithium and a serum concentration is checked: 4.3 mmol/l

Therapeutic range is between 0.5 and 1.5 mmol/l

The patient shows no symptoms - is that possible? what do you do?

Answer: highly unlikely that the patient would asymptomatic, at least nystagmus would be present. Remember the symptoms are cerebellar in nature. What may have happened is the blood was drawn in an inappropriate tube. There are green "Lithium Heparinized" tubes in our Emergency Department. They are typically used for cardiac enzymes. This has been a well reported source of error (1)

.

• 5 to 10% of TIA victims go on to have a complete stroke within 7 days.

• The following validated ABCD clinical prediction rule can be used to risk stratify your next TIA patient in determining who requires an expedited in-patient work-up:

          Risk Factor                                                                        Score

• Age > or = 60                                                                      1

• Blood Pressure (SBP > 140 and/or DBP > or = 90)                    1

• Clinical Features (choose one)

          -- Unilateral weakness                                                           2

          -- Speech impairment w/o weakness                                       1

          -- Other                                                                               0       

• Duration of Symptoms (minutes)

          -- > 60                                                                                2

          -- 10 to 59                                                                           1

          -- < 10                                                                                0

                                                                                              Total 0-6

Acute Hyponatremia and the Critically Ill

• I just left a busy ED shift during which we had a patient with altered mental status and a serum Na of 115 mmol/L.
• Recall that severe hyponatremia may present with lethargy, disorientation, agitation, nausea/vomiting, altered mental status, abnormal respirations, and seizures.
• For severe, symptomatic hyponatremia, the treatment of choice is 3% hypertonic saline
• At a rate of 100 ml/hr, the serum Na should rise approximately 2 mmol/L per hour.
• In general, the duration of treatment with hypertonic saline is based upon sign and sypmtom improvement.
• For those with more longstanding hyponatremia, serum Na should not be increased by more than 12 mmol in the first 24 hours.

The Alcoholic Patient in the ED

Well, we have all been there....EMS rolls in with "another drunk guy" found down in the street. The nurses tell you, "he is here all the time...he is just drunk." You should be scared any time you hear this phrase uttered. Always be a little nervous about this group of patients and you won't fall victim to many of the pitfalls that some of us have experienced.

Pearls and Pitfalls in Caring for the Intoxicated Patient in the ED:

• Get a glucose early. Many of these patients are hypoglycemic when they arrive.
• Assume the worst and NEVER tell yourself or others,"He's just drunk." That statement is the kiss of death. Always assume there is occult trauma present. Did they fall and sustain a head bleed, splenic injury, hip fracture?
• Reevaluate during your shift. There is nothing worse than placing an intoxicated patient in a room and ignoring them, only to find out that hours (or shifts) later that they won't wake up.
• Consider a head CT. Although you can't scan them all, have a low threshold to image them. They fall all the time, and you will be surprised at how many subdural hematomas you pick up when you scan this group of patients. If you don't image, perform reassessments frequently during your shift.

T-wave inversions are commonly found in many conditions other than ACS. Many pulmonary conditions, elevated intracranial pressure, LVH, bundle branch block, and young age are associated with T-wave inversions.

T-wave inversions are especially notable in patients with pulmonary embolism, and one study identified a key difference in T-wave inversion patterns in PE vs. ACS: T-wave inversions in leads III and V1 simultaneously were far more likely to be assocaite with PE, whereas the presence of T-wave inversions in I and aVL were almost always ACS.

A key takeaway point is to maintain a broad differential even in the presence of T-wave inversions...it's not necessarily just ACS!

[ref: Kosuge M, et al. Electrocardiographic differentiation between acute PE and ACS on the basis of negatie T waves. Am J Cardiol 2007;99:817-821.]

Manibular Dislocations:

• Mandibular dislocations can be extremely difficult to reduce at times.
• The classic method of reducing a mandible dislocation is for the provider to wrap his thumbs in guaze (to prevent them from being bitten), and while placing his thumbs bilateraly as far posterior on the mandible as possible, he applies downward, and then posterior pressure to reduce the dislocation.
• Significant muscle spasms can result from the dislocation, requiring procedural sedation, but even with sedation it can be very difficult if not impossible to reduce the mandible.
• Dr. Cheng's article, referenced below, describes a new technique, where the provider use both of his thumbs to press down on a single side of the mandible posterior until the side reduces.
  • For a bilateral dislocation, the technique would be to reduce one side and then the other.

Some authors also recommend using rolled guaze to hold the patient's mouth shut so that they do not inadvertantly dislocate their jaw a second time if they happen to yawn while awakening from their sedation.

• Patients who have recently undergone aneurysmal coiling commonly present to the ED with complaints of new or worsened focal neurologic deficits that may be suggestive of stroke.

• Aneurysms can be stabilized by clipping or coiling them.  Coiling is performed in a minimally invasive manner, wherein platinum (a material that can be visualized radiographically and is flexible) coils are deployed into the bulb of the aneurysm, via femoral artery cannulation.

• The relative risk of mortality or morbidity at one year post-coiling was found to be 22.6% less than that associated with clipping.  The latter is an older, more invasive technique requiring craniotomy and direct manipulation of the brain.

• Hemorrhage is a less likely complication related to aneurysm coiling, thus your indication for a non-contrast Head CT in these patients would most appropriately be "rule out infarct" rather than "rule out bleed." 

• Brain infarct is the more common complication of this treatment, and results from the accidental embolization of plaque during the coiling procedure.

• Here are a couple of great links with illustrated overviews of the process of coiling, including a real time You Tube clip:
  
  http://www.brainaneurysm.com/aneurysm-treatment.html
  
  http://www.youtube.com/watch?v=Mvy8g_oDbbk

Transient Hypotension and Mortality in Sepsis

• Not surprisingly, septic ED patients with persistent hypotension despite fluid resuscitation have increased mortality.
• What about the more common scenario of septic ED patients who have a transient drop in their BP?
• Recent evidence suggests that ED patients with sepsis who have non-sustained decrease in their BP (SBP < 100 mm Hg) have a 3-fold increased risk of in-hospital mortality compared with those who maintain arterial pressure.
• Take Home Point: Any drop in BP in a septic patient, even if it responds to fluids, portends a higher mortality.  Be vigilant and aggressively resuscitate these patients.

Patients who present to the ED with an elevated INR due to vitamin K antagonists many times do not need to be reversed.  Simply holding a dose is all that is usually necessary for patients with an INR < 9.  Fortunately, guidelines published in CHEST are available to help guide management.
 

• INR: >Therapeutic to 5.0 with no bleeding - Lower warfarin dose, or omit a dose and resume warfarin at a lower dose when INR is in therapeutic range
• INR: >5.0 to 9.0 with no bleeding - Omit the next 1 to 2 doses of warfarin, monitor INR more frequently, and resume treatment at a lower dose when INR is in therapeutic range, or omit a dose and administer 1 to 2.5 mg oral vitamin K.* [*This option is preferred in patients at increased risk for bleeding (eg, history of bleeding, stroke, renal insufficiency, anemia, hypertension.]
• INR: >9.0 with no bleeding - Hold warfarin and administer 5 to 10 mg oral vitamin K. Monitor INR more frequently and administer more vitamin K as needed.
• Any INR with serious or life-threatening bleeding - Hold warfarin and administer 10 mg vitamin K by slow IV infusion; supplement with prothrombin complex concentrate, fresh frozen plasma, or recombinant human factor VIIa, depending on clinical urgency. Monitor and repeat as needed.
   

Reference:

Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.

Some Pearls on ED Teaching:

• Don't teach so much. Limiting the number of points taught will lead to increased retention. Quality, not quantity.
• Make sure your learners are "with you." If the learner isn't attentive, forget it. Move and and return to teaching when the learner is ready. You are wasting your time if they are paying attention.
• Be creative in adapting your teaching style when it is busy. You don't have to be at a dry erase board drawing metabolic pathways (sorry Fermin) to be teaching. Simply discussing your thought process outloud is a great way of teaching "on the fly."
• Be flexible and remember: the focus should be on the learner (what they get out of it) and not the teacher. Many forget that when they teach in the ED.

• Rates are highest for children <5yrs and between 15-24 yrs old.


• Most of pathology is related to duration of asphyxia from time of submersion until adequate respiration is restored.


• The brain and heart are most vulnerable to anoxic and ischemic injury.


• Prognosis for near-drowning depends primarily on the degree of brain anoxia.


• Prolonged submersion (>25 min); apnea or coma at presentation to ED; and initial arterial pH <7.0 are all poor prognostic indicators.


• 96% of victims who require <10min of CPR survive with no or only mild neurologic impariment.

Whereas only 6% of young patients with PE present with syncope, 15-20% of elderly patients with PE present with syncope. The simple takeaway point is that whenever an elderly patient presents with syncope, always strongly consider the possibility of PE, even though they may lack classic pleuritic chest pain.
Count that respiratory rate for an inexpensive clue!

Shoulder Dislocations -- Treatment

• Shoulder dislocations once reduced have typically been treated by placing the arm in a sling and swathe which holds the shoulder in adduction and internal rotation. 
• However, several studies have now shown that placing the arm in a splint with the shoulder adducted and in 10 degrees external rotation helps to prevent recurrent shoulder dislocation. 
• Patients should remain in the brace/split for 3 weeks.
• External rotation is not recommended if there is an associated fracture.
• Some commerical splints are now available to hold the shoulder in external rotation, however, you can make a small strut with plaster or fiberglass to achieve the same result.

Oseltamivir (Tamiflu)

• Has low protein binding and does not inhibit CYP450 (resulting in a low incidence of drug interactions)
• Requires dosage adjustment with creatinine clearance of < 30 ml/min
• Does not require dosage adjustment in patients with liver failure or the elderly
• Most common adverse effects are nausea and vomiting
• Serious effects include anaphylaxis and skin reactions. Neuropsychiatric effects reported include hallucinations, delerium and abnormal behavior
• It may be administered to infants and children due to the high potential morbidity associated with influenza

For complete indications and dosing: www.cdc.gov/h1n1flu/recommendations.htm

• Syncope is defined as a transient loss of consciousness and accounts for an estimated 1% to 3% of emergency department (ED) visits.
   
• While syncope typically is of benign origin, it occasionally signals significant mortality and morbidity, which can make determining the disposition of syncope patients a challenge.
   
• The San Francisco Syncope Rule (96% sensitivity, 62% specificity) is a clinical tool used to determine which syncope patients are at low risk for a short-term (7-day) serious outcome (i.e. MI, arrhythmia, PE,  stroke, SAH, significant hemorrhage, any condition causing or likely to cause a return ED visit or hospitalization).
  Specifically, absence of all of the following 5 findings (acronym CHESS) were associated with no serious outcome within 7 days of the syncopal episode according to this rule:
  • Congestive heart failure
  • Hematocrit less than 30
  • EKG Abnormalities
  • Systolic BP less than 90
  • Shortness of breath
     
• While this decision rule, in addition to one's clinical skill, may be used as a guide in caring for and dispositioning syncopal patients, know that its ability to be extrapolated to a general population of ED patients has yet to be validated.

Heparin for Maintaining Arteral Catheter Patency ?

• Arterial catheter placement is common in many critically ill ED patients.
• Typically, a heparin solution is used in arterial catheters based on the belief that it helps to maintain catheter patency.
• In one of the most recent studies (referenced below), the use of a heparinized solution did not improve the functionality, or increase the duration of patency, of arterial catheters when compared to a saline solution.
• As the incidence of heparin-induced thrombocytopenia (HIT) continues to increase, it is worth noting that the routine use of heparin to maintain arterial catheter patency is not well supported by the literature.

With few exceptions, always assume that elderly patients presenting to the ED with an acute illness are very dehydrated. Here are a few reasons why the elderly patient, even on a normal day, may be mildly dehydrated:
1. The elderly have been shown to have decreased total body water.
2. The elderly have a decreased thirst response.
3. The elderly have a decreased renal vasopressin response.

Given these issues, when an elderly patient develops a systemic illness (especially pulmonary process), they lose even more fluid via insensible losses. By the time they arrive in the ED, unless they are presenting because of overt pulmonary edema, they almost always will benefit from generous IV fluid administration.

Amal

Nursemaid Elbow:

It is typically taught that the way to reduce a nursemaid's elbow is to hold the elbow at 90 degrees, then firmly supinate and flex the elbow. Place your thumb over the radial head and apply pressure as you supinate.(Taken from Sean Fox's Pearl on 7/20/2007)

However, there is a growing body of evidence that is showing that hyperpronating the forearm actually has a higher success rate on first attempt, is easier to perform, and is associated with less pain then supinating the forearm.  The overall reducation rates where similar for both methods.

The hyperpronation method consists of hyperpronating the forearm and then flexing the elbow.  Since the child tends to already hold their arm in partial pronation, the hyperpronation technique tends to need less force and has been associated with less pain.

• The majority of those afflicted with bell palsy experience neurapraxia or a local nerve conduction block, which usually predicts a prompt and full recovery.  80% to 90% of Bell Palsy patients experience recovery without any noticeable disfigurement within 6 weeks to 3 months.

• Some Bell Palsy patients experience axonotmesis, disruption of the axons, which increases their risk of an incomplete recovery.

• One is at higher risk of developing sequelae in the following scenarios: 

          --  Age greater than 60 years

          --  Diabetes

          --  Decreased taste or salivary flow on the affected side

          --  Complete paralysis

• Common post-Bell Palsy sequelae that you may see clinically include:

          --  Synkinesis - abnormal contracture of facial muscles with smiling or

               closing eyes; may cause slight chin movement with blinking, eye closure

               with smiling, contracture around mouth with blinking.

          --  Crocodile tears - lacrimation while eating.

          --  Hemifacial muscle spasms - tonic contractures of affected side of face, 

               rare, often seen during times of fatigue, stress, or while sleeping.

NICE-SUGAR and Glucose Control in the Critically Ill

• Hypergycemia is associated with increased morbidity and mortality in hetergeneous populations of critically ill patients.
• Over the past few years there has been great interest in aggressively controlling glucose through the use of continuous insulin infusions.
• Results of recent trials and meta-analyses, however, question the benefit of tight glucose control and highlight the marked increase in severe hypoglycemia rates.
• Recently, the results of the NICE-SUGAR study were published, the largest trial to date (6000 patients)evaluating intensive vs. conventional glucose control in the critically ill.
• Investigators found an INCREASED mortality among adults randomized to intensive glucose control
• Given the lack of benefit, potential harm, risks of severe hypoglycemia, and resource utilization, intensive glucose control should not be a therapy routinely implemented in the ED.

Transvenous pacing

We had a very interesting case the other day in the ED. A 60 yo male presented after a syncopal episode. After arriving in the ED he was awake (with a pulse of 50) but then became asystolic, without warning. He then woke up and 10 minutes later became asystolic again. He then woke up again. So, we decided to put in a transvenous pacer.

Some considerations when putting in a transvenous pacer:

• You need to use a small cordis (e.g. 6 French)
• Right IJ is the preferred approach so that when the balloon is inflated you will have easy entry into the right heart
• You will need transvenous pacing wires, obviously.
• Once you open the wire kit, you will find 2 adaptors that fit over the two ports of the pacemaker wire. Snap them on, then these connect to the ventricular leads of the pacer box-ignore the atrial side. Here is the key: the POSITIVE lead connects to the PROXIMAL port on the pacemaker (PROXIMAL=POSITIVE) and the distal lead connects to the distal port.
• Turn the pacer on then set rate to 80 or so. And start the mAmp at 20.
• Advance the wire through the Cordis and after the wire has cleared the Cordis, blow up the balloon with a syringe and lock it.
• The key is in determining capture: While the patient is on the monitor, and as the wire is being slowly advanced, look for pacer spikes and the development of wide complexes. This indicates electrical capture. Be sure to check for mechanical capture by checking the patient's pulse.
• After capture, the mAmps can be turned down to the capture point.
• DON'T forget that transcutaneous pacing is clearly the first option as this is easy to initiate.

Elbow Dislocation

• The elbow is the second most commonly dislocated joint after the shoulder in adults. 
• It is the most commonly dislocated joint in children.
• 90% of all elbow dislocation are posterior.  A considerable amount of force is required to dislocate the elbow so be highly suspicous for associated fractures of the radial head, or coronoid process of the ulna. 
• The combination of a radial head fracture, coronoid process fracture and elbow dislocation is known as the terrible elbow.
• Anterior elbow dislocations can be associated with injuries to the brachial artery, median and ulnar nerves. 

Quick clinical clues that the elbow is dislocated:

• Posterior dislocation typically will have a prominent olecranon process, the arm is flexed at the elbow, and the forearm will appear shortened.
• Anterior dislocation typically present with the arm in extension and the forearm will appear elongated.

• Bell Palsy is the most common cause of unilateral facial weakness.

• It is caused by edema and ischemia causing compression of the facial nerve (cranial nerve seven).

• While Bell Palsy is by definition an idiopathic facial palsy, the etiology is often infact discovered and attributed to conditions such as Lyme Disease, Herpes Simplex Virus, and HIV.

• Classic symptoms of Bell Palsy include:

          -- acute onset of unilateral upper and lower facial paralysis (over 48 hr. period)

          -- posterior auricular pain

          -- decreased tearing

          -- hyperacusis (due to stapedius muscle weakness)

          -- taste disturbances

• Bell Palsy is a diagnosis of exclusion.  If the facial paralysis is isolated to the lower face, if there is associated contralateral weakness, and/or if there is diplopia, a central cause for the symptoms, rather than Bell Palsy, must be strongly considered.

Platelet Transfusions and the Critically Ill

• Current literature suggests that platelets are given too frequently and inappropriately
• Recall that approximately 50% of platelet transfusions fail to increase counts
• In addition, bacterial contamination of units is a special concern, with sepsis occurring 10x more frequently than with PRBCs
• In general, platelet transfusions in nonbleeding patients can be withheld untl the count reaches 10 x 10³/mm³
• A transfusion trigger of 50 x 10³/mm³ should be used for invasive procedures

Multiple Myeloma + Altered Mental Status=Hyperviscosity Syndrome

Although the differential diagnosis of altered mental status is quite extensive, a patient with multiple myeloma and altered mental status should prompt consideration of one important, albeit not too common, condition.....hyperviscosity syndrome.

Some important pearls:

• This syndrome occurs when excessive amounts of protein (immunoglobulin) are secreted by myeloma (plasma) cells.
• Excessive circulating protein leads to sludging and ischemia in lung and brain tissue, lesding to hypoxia and altered mental status, respectively.
• You will only pick up this diagnosis by thinking about it, so multiple myeloma + altered mental status = hyperviscosity syndrome
• Treatment is with IVF and plasmapheresis (heme onc consult)
• And don't forget common stuff, like stroke, subdural hematomas, meningitis, etc.

There are multiple causes of electrocardiographic ST-segment elevation which are well-known to mimic STEMI and often are a cause of misdiagnosis of STEMI.  These are:

• Benign early repolarization
• Pericarditis
• Left ventricular aneurysm
• Brugada syndrome
• Left ventricular hypertrophy
• Left bundle branch block
• Paced rhythms
• Hyperkalemia

Whenever there is doubt regarding whether you are dealing with a STEMI or a mimic, look for reciprocal ST-depression. Most of these will not produce ST-depression (LVH, LBBB, Pacers, and hyperkalemia WILL). The other key intervention is to perform serial ECGs and look for evolving changes, which strongly points to the presence of a true STEMI.

Trimallelor Fractures:

Bimallelor fracture involve both the medial mallelous of the tibia and the distal fibula.  The third malleloi is the posterior tip of the articular surface of the tibia. Can result in instability in the posterior and lateral directions along with external rotation.

Some indications for Open Reduction Internal Fixation when the posterior mallelous is fractured are:

• > 25% of the posterior articular surface being involved.
• Fractures that allow posterior subluxation of the talus
• Fractures that are displaced more than 2 mm
• Fractures that can not be reduced satisfactorily.

Classic presentation:  breastfeeding failure with umbilical stump and gastrointestinal bleeding by postnatal day 7.  Oozing from circumcision, venipuncture, and heel sticks is also common.  Beware bleeding into the scalp or intracranial space.

Due to essential vitamin K deficiency which exists at birth as the fetus receives little vitamin K from the uteroplacental circulation.  It is responsible for impaired neonatal clotting function (deficiency of factors II, VII, IX, and X).

Prevented by a single intramuscular dose of 1mg vitamin K in the first few hours following delivery.

Your patient presents unresponsive with an empty bottle of alprazolam (Xanax). You order a urine and blood toxicology screen. The blood comes back negative for benzodiazepines but the urine test is positive. How do you interpret this result?

• The benzodiazepine toxicology screen typically looks for oxazepam. If it is present in sufficient quantity, the test will be positive.
• Three benzodiazepines are detected by this test: oxazepam (Serax), diazepam (Valium), and chlordiazepoxide (Librium); [diazepam and chlordiazepoxide are metabolized to oxazepam].
• Other benzodiazepines such as clonazepam, lorazepam, and alprazolam will generally test negative unless there is cross-reactivity or large quantity.
• The urine and blood immunoassays are exactly the same. For this patient, there was probably a low overall quantity of alprazolam in the blood but a concentrated amount in the urine. Therefore, the positive urine and negative blood.

• Neurologic complications affect 30 to 60% of allograft organ transplant recipients.
   
• Many of these complications are related to immunosuppresant medication neurotoxicity.
   
• Calcineurin inhibitors such as tacrolimus (FK-506 or Fujimycin) and cyclosporin are classically associated with the following neurologic disorders:
  • Cranial Nerve Palsy:  Tacrolimus toxicity can cause reversible  internuclear ophthalmoplegia.
  • Movement Disorders:  Tacrolimus and cyclosporin often cause tremor, which can be further compounded by the development of asterixis should the patient also have significant renal or hepatic insufficiency.
  • Visual Abnormalities:  Cortical blindness, visual disturbances, hallucinations, retinal toxicity, and optic neuropathies have all been attributed to calcineurin inhibitor toxicity.  Opsoclonus (rapid, involuntary, uncontrolled, multivectorial eye movements) has specifically been associated with cyclosporin neurotoxicity. 
     

• Neurotoxicity related to immunosuppresant drug therapy is most likely to occur early after transplantation and during a rejection episodes, times at which medication doses are typically at their highest.  Dose adjustment often results in resolution of symptoms.
   
• Be sure to check drug levels of immunosuppresant medications, particularly when a transplant patient presents with a neurologic disorders.

Risk of PE/DVT in patients with microalbuminuria....another risk factor to consider??

Microalbuminuria (protein in the urine) is a known risk factor for arterial thromboembolic disease, and recent studies suggest that arterial thromboembolism and venous thromboembolism (VTE) have common risk factors. In a prospective community-based cohort study in the Netherlands, researchers enrolled 8574 adults (age range, 28-75) who were followed for 9 years. People with insulin-dependent diabetes or pregnancy were excluded.

Of 129 identified episodes of VTE, roughly half were deep venous
thromboses, and half were pulmonary embolisms. The annual VTE incidence
rate was 0.12% in patients with normoalbuminuria (<30 mg/24 hours)
versus 0.40% in those with microalbuminuria. After adjustment for known VTE
risk factors and other factors (including hypertension, known coronary arterydisease, and elevated C-reactive protein level), the hazard ratio for
VTE in people who had microalbuminuria, compared with those who had
normoalbuminuria, was 2.0.

Comment: The importance of this study is not in the clinical value of
usingmicroalbuminuria as a marker for VTE risk, because the absolute risk
conferred by microalbuminuria is very low, and the therapeutic
implicationsare unclear. Rather, this study suggests that microalbuminuria is a
marker for endothelial dysfunction in both arterial and venous systems, and it
suggests a mechanism for how statins interact with the endothelium to
prevent VTE (JW Cardiol Mar 29 2009).

So, does this affect us as emergency physician? Unclear. But it may very well mean that we might be dealing with a new risk factor that needs to be taken into consideration when evaluating patients with chest pain or SOB. Obviously, we might need medical records to find this risk factor...can you imagine asking a patient if they have microalbuminuria?

Ultrasound of the IVC for Volume Assessment

• In a recent pearl, I discussed that a 15% variation in IVC collapsibility could be used as a marker of hypovolemia
• As a follow up and since % variation is sometimes difficult to calculate at the bedside, consider the following numbers:
  • The normal diameter of the IVC is 1.6 - 1.75 cm
  • Patients with hypovolemia typically have an IVC diameter < 0.8 - 1.0 cm
  • In general, the IVC diameter should increase 1 mm for every 100 ml of isotonic fluid

Cardiocerebral resuscitation is a new approach to CPR which has demonstrated improvements in survival and neurological recovery. The main focus is early defibrillation and good compressions with an early dose of EPI, but with a strong de-emphasis on early intubation or bagging. Most patients with sudden cardiac arrest don't need early oxygenation anyway, and the previous emphasis on ventilations only serves to take time and effort away from the important chest compressions. Intubation is deferred for 6-8 minutes after the cardiac arrest in favor of simple passive oxygenation with a non-rebreather.

The bottom line is that when facing a patient in cardiac arrest, the traditional mantra in emergency medicine of "A-B-C" needs to now be changed to emphasize the "C" coming first, second, and third.

Knee Dislocations:

Are relatively rare injuries, but can result in loss of the limb if missed.  Patients will sometimes say they dislocated their knee when they actually mean their patella, so a good history where they describe what their knee looked like, and what they were doing at the time will help differentiated the two.

Some signs that you are dealing with a spontanously reduced knee dislocation are:

• Varus or valgus instability in full extension of the knee is suggestive of a grossly unstable knee
• Pain out of proportion to injury
• Absent or decreased pulse

The loss of limb is due to unrecognized injury to the popiteal artery which as be estimated to occur 7-45% of the time. 

• Normal pulses and a normal capillary refill does NOT rule out as significant vascular injury. 
• Arteriograms are no longer mandatory in all cases, but it is generally recommended that you perform an ankle-brachial index and get a vascular duplex scan of the popiteal artery to exclude dissections, tears, aneurysms and psuedo-anuerysms that can all occur as a result of the dislocation.

If you would like to see some videos of knee injuries in the making follow this link www.csmfoundation.org/Educational_Lower_Extremity.html

• Recently, a study was published which compared adverse drug events in patients who had received either fomepizole or ethanol for ethylene glycol or methanol poisoning.


• Importantly, this is the first trial which has compared these events head to head.


• Retrospectively, 172 charts over a 9 year period were reviewed. Toxicologists identified at least 1 ADR in 74 of 130 ethanol treated cases (57%) versus 5 of 42 fomepizole treated cases (12%).


• Severe ADRs occurred in 20% of ethanol treated patients vs 5% fomepizole treated patients.


• This adds further data to support the use of choosing fomepizole over alcohol for treatment of toxic alcohol poisonings

• Akathisia is an adverse effect sometimes associated with the administration of medications such as neuroleptic anti-psychotics (i.e. chlorpromazine (Thorazine); haloperidol (Haldol); ziprazidone (Geodon)) and dopamine-blocking anti-emetics (i.e. metoclopramide (Reglan); prochlorperazine (Compazine)).

• This unpleasant symptom complex consists of restlessness and agitation, the severity of which correlates with the dose of the causative agent.

• Treatment classically consists of stopping or decreasing the dose of the causative agent and administering diphenhydramine (Benadryl).

• Benzodiazepines, beta blockers, and the antihistamine cyproheptadine have also been used with success.

• The following instrument, a modified version of the Prince Henry Hospital Scale of Akathisia, can be used to clinically assess for akathisia in a standardized fashion:

New Perspectives on Clostridium difficile

• In the past 5 years, C.difficile infection rates have doubled and the overall disease severity appears to be worsening.
• Particularly concerning is the increase in community acquired infections in young patients without antibiotic or nosocomial exposure.
• These epidemiologic changes are likely due to a new strain of C.difficile characterized by increased virulence and quinolone resistance.
• Importantly, the efficacy of metronidazole has waned in recent years.  In fact, > 25% of patients with moderate to severe disease do not respond to metronidazole therapy.
• As a result, vancomycin has become first-line therapy for any critically ill patient with C.difficile.

Giving a Lecture-Pearls and Pitfalls

Giving a lecture is filled with many potential pearls and pitfalls. Here are just a few important points that are frequently discussed:

• Stick to NO MORE than 3-4 take home points (people cannot remember more than that)
• Really spend a lot of time on the opening and closing (know them cold). This is what people will remember.
• Try to divide your talk into 5-10 minute chunks of material and DO NOT try to cover too much material....big mistake
• Perhaps one of the most important aspects of giving a really good talk is practice. You should know your material well enough that you could give it if the power went out and the computer crashes. Practice is essential...and it should "out loud." This is often neglected and it shows when unprepared speakers get up in front of an audience.
• Practice speaking without the use of verbal fillers ("ums"). This will improve as you practice more and more. Getting rid of these fillers may make the difference between a really good talk and an average talk. PRACTICE, PRACTICE, PRACTICE speaking without using them!

For an entertaining discussion of the pearls and pitfalls if giving a presentation check out the May episode of EMRAP: Educators' Edition on iTunes (also on the website www.emrap-ee.com). There is a great discussion by Greg Henry, Mel Herbert, and Amal Mattu. Check it out. It's free!

The distinction between pericarditis and acute MI on ECG can often be difficult. Here are a few things that can help rule in acute MI:
1. If the ST-segment elevation is convex upwards in any leads (e.g. appearing like a tombstone) or flat/horizontal across the top, it very strongly favors AMI. Pericarditis should always demonstrate STE that is concave upwards.
2. If ST-segment depression is present in any lead other than aVR or V1, it strongly favors AMI.
3. If PR-depression is present in multiple leads (not just a 2-3 leads, but in MANY) and PR-elevation > 1-2 mm is present in aVR, it favors pericarditis...but only if rules #1 and #2 above are not present.

Be careful about the HPI and description of chest pain...AMI pain is often described as sharp, and in up to 15% it may be described as sharp, pleuritic, or positional in nature, making you think about pericarditis.

Distal Radius Fractures

• The radius is the most commonly fracutred bone of the arm.
   
• The Colles fracture is a fracture of the distal radius that is angulated dorsally [The distal fragment is angulated towards the back of the hand.]
   
• The Smith fracture is similar but the distal fracture is angulated volarly [towards the palm of the hand]
   
• Other less commonly named fractures are the:
  • Barton's - an intraarticular fracture fo the distal radius with dislocation of the radiocarpal joint.  Typically occrus as a fall on the extended and pronated wrist.
     
  • Chauffeur's fracutre - a fracture of the radial styloid process.  Typically caused by compression of the scaphoid against the styloid.  Also known as a hutchinson fracture.

Pancytopenia manifests as a decrease in the erythroid, myeloid, and megakaryocytic cell lines that appears as a decrease in red blood cells, white blood cells, and platelents on complete blood count analysis. 

• Indicates bone marrow failure
• May be due to invasion of marrow by nonneoplastic (such as drugs, chemicals, irradiation, or infections) or neoplastic conditions
• Clinically manifests as pallor, easy fatigability, and weakness due to anemia; purpura, epistaxis, and bruising due to thrombocytopenia; and increased susceptibility to infection due to leukoopenia.

Pancytopenia is an absolute indication for bone marrow aspiration and biopsy to delineate and treat the cause.

• It is incumbent that emergency physicians be aware of and utilize as appropriate all available tools in the critical, yet challenging evaluation and management of acute ischemic stroke (AIS) patients.
   
• While non-contrast head CT remains the primary modality used in the initial evaluation of these patients, CT angiography (CTA) and MRI with diffusion are rapidly becoming more acutely available because they provide more exact and accurate information, which directly affects the crucial decisions that have to be made in order to provide effective and expedient care.
   
• CTA provides imaging of the entire intra and extra cranial circulation beginning at the aortic arch to the Circle of Willis, and can be performed in less than 20 seconds.  Within minutes, these imags can be re-constructed to reveal vascular stenosis and occlusions.
   
• MRI is typically not as rapidly accessible as CT, but there are scenarios wherein the additional time spent to acquire this modaility yields significant clinical merit.  While a full brain MRI may take up to an hour, acquisition of the MR diffusion portion of the scan (which highlights focal areas of acute infarct) requires less than 10 minutes.    

Questioning Learners in the ED-Wait Times

When teaching medical students and residents, consider that the literature shows that we tend to wait only a few seconds (some studies say 3 seconds-which seems like a long time when you are waiting for a response) for a response. Bottom line, it has been demonstrated that many learners have the answer and will respond if simply given the time. Hard to do sometimes in a busy ED. Learners who aren't given time to respond will quickly learn that if they simply wait long enough the answers will be given to them.

So, when asking a question (NOT pimping) to a medical student or resident, simply wait a little longer. They may very well surprise you with the answer.

Acute Cor Pulmonale and Ventilation In the critically ill,

Acute cor pulmonale (ACP) is usually observed in the setting of massive pulmonary embolism or acute respiratory distress syndrome (ARDS). As we manage more and more critically ill patients in the ED, it is likely that you will manage patients who develop ARDS.

We have discussed in previous pearls that, especially in ARDS, using a low tidal volume and monitoring plateau pressure are key components to mechanical ventilation.

For patients with ARDS who develop ACP, consider lower plateau pressure thresholds (< 26 cm H20) and minimizing PEEP to < 8 cm H2O.

If ACP persists despite lower plateau pressures and low PEEP, consider prone position ventilation as a last resort.

• Fractures of the phalanx are common, and fractures of the proximal phalanx can lead to significant disability if not treated appropriately.

• Be sure to check for malrotation, which is a common problem.  Check for this by examing for the normal cascade in finger flexion with the tips of the fingers pointing toward the proximal portion of the scaphoid

• Acceptable Reduction:
  • No rotational deformity can be accepted
  • No more than 10 deg of angulation should be accepted in any plane
  • Malreduction will cause loss of equilibrium between flexor and extensor tendons.

• Place the splint on the dorsum side of the finger so that the patient can still have sensation of the tip of their finger tip.

• Patients requiring prompt referral to a hand surgeon are those with:
  • Intraarticular fractures
  • Malrotation
  • Unacceptable reductions
  • Unstable fractures

• Increasing use of OTC meds is a worldwide occurence with $3.5 billion each year spent in the US.


• About 4 million children younger than 12 yrs are treated with these meds each week in the US.


• In 2007 the FDA recommended that the use of OTC cold meds (antihistamines-brompheniramine, chlorpheniramine, diphenhydramine, doxylamine; antitussive-dextromethorphan; expectorant-guaifenesin; and decongestants-pseudoephedrine and phenylephrine) be prohibited in children < 6 yrs.


• A recent review of 103 childhood deaths due to OTC meds found that most deaths were from product misuse rather than adverse effects resulting from recommended doses particularly when the product was used with the intent to sedate a child. 


• Children less than 2 years old were most susceptible to death using these products which is why manufacturers voluntarily withdrew the use of OTC meds in this age group.

• Patients with severe or rapidly progressive weakness due to a Myasthenia Graves (MG) exacerbation should be admitted to an intensive care unit.
   
• Acute MG patients' forced vital capacity (FVC) should be monitored every 2 to 4 hours to accurately assess the function of their respiratory muscles.
   
• FVC can easily be measured at the bedside, particularly by a respiratory technician.
   
• Once the patients' FVC is consistently approaching or reaches 15 mL/kg, the patient should be electively intubated in order to ensure protection of their airway.  In an average sized adult, an FVC of 1000 mL is the point at which respiratory failure is eminent.
   
• Arterial blood gas abnormalities are not reliable indicators of respiratory muscle decompensation, and typically occur as a late sign of respiratory failure.
   
• Once the patient is intubated, anticholinesterase medications are typically withdrawn.

Assessing Volume Status in the Critically Ill

• In previous pearls we have discussed the many limitations of central venous pressure as an accurate marker of volume status.
• Importantly, the focus of volume assessment should be on determining which patients are likely to augment their cardiac output in response to additional IVFs, i.e. 'preload responsive'.
• Ultrasound can be used in the ED to assist in identifying which patients are preload responsive.
• In general, a 15% variation in the inferior vena cava diameter with respiration predicts response to additional fluids.

The One Minute Preceptor Model of Teaching in the ED

This is a teaching strategy that most of us are very familiar with. Why? Because many, if not most, of us do it every day. We listen to a case, get a committment from the learner, probe for supporting evidence, and then give a teaching pearl and offer learning resources.

Perhaps one of the biggest pitfalls in teaching is NOT WAITING for the learner to answer to question. How often have you asked a question to a medical student and gave the answer? How often has a student presented a case and then they clammed up and didn't commit to a diagnosis or treatment plan?

A simple strategy for teaching success:

• Make learners "jump out there" and give you a diagnosis and treatment plan, i.e. get a commitment. Do your best to keep your mouth closed for a few seconds
• Give learners time to answer. You will be surprised. A few more seconds of waiting makes a big difference.

Dark chocolate is being touted more and more as being beneficial to vascular health. It contains polyphenols which has been found to exert anti-oxidant effects and improve endothelial and platelet function. The benefit appears to occur anywhere from 2-8 hours after ingestion of dark chocolate. Unfortunately, the same has not been found true for white chocolate or milk chocolate.

The only caveat is that most of the studies seem to originate in Switzerland and are funded by the Mars Company and Nestle...but who care?? Go ahead and have some dark chocolate every day!

[Dark Chocolate Improves Endothelial and Platelet Function (Hermann F, Heart 2006); Cocoa and Cardiovascular Health (Corti R, Circulation 2009)]
 

The French Surgeon Rene Le Fort first described these facial fracture patterns.   Reportedly he made the observations after dropping numerous skulls from the wall of a castle.  This might be why we don't see pure Le Fort fractures in our patients most of the time as they are not likely to be falling off castle falls head first.

The classic fracture patterns are:

1. Le Fort I fractures extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates.
2. Le Fort II fracture has a pyramidal shape and extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.
3. Le Fort III fractures (transverse) are otherwise known as craniofacial dissociation and involve the zygomatic arch.  These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch.

Image obtained from http://radiographics.rsnajnls.org/cgi/content-nw/full/26/3/783/F15

• Scabiess requires sensitization to the organism, Sarcoptes scabiei. 


• It may take weeks before pruritus develps in a child infested for the first time.  On the next exposure, however, INTENSE itching will occur within 24 hours. 


• Burrows in the webs of fingers and toes are common.


• Treatment:  Firstline is permethrin 5% cream on the entire body from the neck down, and wash off after 12 hours.  Alternative is lindane 1% (1oz of lotion or 30g of cream) applied in a thin layer over the entire body from the neck down, and thoroughly washed off after 8 hours OR ivermectin 200ug/kg orally repeated in 2 weeks.


• Many avoid lindane because of neurotoxicity.  Do not apply it after a bath, or to someone with extensive atopic dermatitis as seizures have been reported.


• Decontaminate all bedding and cloting.


• Warn patients that the rash and itching may persist for up to 2 weeks after treatment.

Colchicine is a drug used for the treatment of acute gout attacks. It inhibits microtubule formation vital for cellular mitosis. It is also a drug with a narrow therapeutic index and lethal toxicity:

- Colchicine can be lethal at 0.5 mg/kg or even lower. Though this would be about 50 tablets and seems alot, remember it is prescribed 2 tablets initially then every hour until diarrhea presents (i.e. preliminary toxicity)

- Toxicity presents in 3 stages:

1. 0-24hrs: Nausea, vomiting, diarrhea
2. 1-7days: Sudden cardiac death, pancytopenia, renal failure, ARDS
3. >7days: Alopecia, myopathy, neuropathy (if they survive)

- No antidote, supportive care only available.

- Presentation is similiar to that of a radiation exposure

• Myasthenia Graves (MG) is an autoimmune disorder wherein antibodies, perhaps created by the thymus, block the acetylcholine receptors at the post-synaptic neuromuscular junction.
   
• The term "myasthenia graves" literally means "severe muscle-weakness" from its Greek and Latin origins.
   
• The clinical hallmark of this disorder is muscle weakness and fatiguability, primarily affecting the facial muscles.
   
• In spite of having personally seen about 3 cases of MG in the ED over the past couple months, this disorder is actually one of the less common autoimmune disorders, affecting 200 to 400 per 1 million persons.
   
• Treatment includes cholinesterase inhibitors, immunosuppressants, and at times, thymectomy.

Diagnostic Errors in the Emergency Department

Believe it or not, there is actually a field of medicine that is devoted to examining how physicians think in clinical practice, i.e. how we make diagnostic decisions. Much of the work on this has been done by Pat Croskerry. This is extremely important for emergency physicians because we frequently have to make split second medical decisions with little to no information.

Why is this so important? If we can understand where errors are made, we can actually improve our own diagnostic skills and reduce our errors rates.

Some key pitfalls that we all fall victim to:

• Bias-this refers to the chart that says under past medical history "fibromyalgia, interstitial cystitis, bipolar, chronic constipation." This type of chart has set us up to potentially miss a diagnosis because our thought processes shut down before we have even started. Ever miss a diagnosis or almost make a mistake because of your feelings about a patient (sometimes BEFORE seeing them)? This is bias. Being aware of this dangerous pitfall in practice is the first step in preventing bias-related mistakes.
• Premature closure of the differential diagnosis-Now, we do this a lot in medicine. Some diagnosis falls in our lap (patient gives it to us, or a consultant tells us that is what it is) and we fail to r/o other things on our list. Key mistake we make is related to not considering other entities on the differential diagnosis. Take home point: Don't narrow the differential diagnosis until it is time to do so.

Mechanical Ventilation and Obesity

• Obesity is defined as a BMI of 30 - 34.99 kg/m2, with class II obesity defined as 35 - 39.9 kg/m² and extreme obesity as > 40 kg/m²
• In obese patients:
  • oxygen consumption is increased with a high proportion going to the work of breathing
  • lung volumes are abnormal with reduced expiratory reserve
  • the alveolar - arterial oxygen difference is increased
  • respiratory system compliance is markedly reduced
• These changes are futher exacerbated in the supine position
• To overcome the effects of reduced compliance, higher levels of PEEP are generally needed
• In addition, higher plateau pressures may be necessary to achieve adequate tidal volumes

As we head into the warmer months we should remember that every year there are reports of a toddler left in his car seat for 15 min who comes in uresponsive with hyperthermia. 

Heat related illnesses are a continuum from heat cramps to heatstroke.  The hallmark of heatstroke is hyperthermia with mental status changes and when identified rapid cooling must be initiated.  Mortality for heatstroke is reported as high as 80%. 

Children are more susceptible to heat stroke because of a greater surface area to body mass ratio, higher metabolic rates, less developed sweating mechanisms, and inability to always remove themselves from the hot environment.

The quickest and easiest way to cool a conscious patient is by evaporation.  Changing water from a liquid to a vapor is an endothermic process.  Removal of all clothes, followed by misting or wiping with tepid water of the entire skin is very effective.  Having a fan pointed at the child can enhance this method.   

Glucose-6-Phosphate Dehydrogenase Deficiency

• G6PD Deficiency is a genetic disorder which can cause hemolytic anemia when people with the disorder come into contact with drugs, food and other substances which cause oxidative stress.
• It is the most common genetic enzyme deficiency.
• G6PD is an inherited disorder with over 400 different known variants.
• Oxidative stress can cause the premature distruction of RBC's due to the lack of the enzyme reduced glutathione which G6PD helps produce.
• Drugs that are at high risk for causing hemolytic anemia in those with G6PD deficiency are:
  • NSAIDS (Asprin, Tylenol, Ibuprophen)
  • Quinolones
  • Sulfa drugs
  • Drugs metabolized known to cause blood or liver related problems or hemolysis
  • Primaquine
  • Nitrofurantoin
  • Glyburide
  • Dapsone

Also make sure that you are not G6PD deficiency if you are eating with Hannibal Lecter as Fava beans and other legumes can also cause an episode of hemolysis.

A good reference for G6PD deficiency is http://g6pddeficiency.org/index.php

Overdoses of insulin glargine (Lantus) are rarely reported in the literature.  In fact, there are only 6 case reports.  We recently had a patient in our ED who was hypoglycemic from insulin glargine.  The hypoglycemic episode was quite prolonged (> 24 hours) in the ED before being the patient was transferred to the MICU.  Here are a few points to remember:

• Insulin glargine does not peak; it was designed to mimic basal islet cell insulin secretion.
• In the therapeutic setting, its effects can last up to about 24 hours.  In overdose the hypoglycemic effects have been reported to last up to 60-130 hours!
• Be prepared to give IV dextrose 5% or 10% infusion for the duration of the patient's hypoglycemic effect.  This can be supplemented with food.
• Octreotide will be ineffective for exogenous insulin poisonings because its effect comes from its ability to suppress insulin secretion from the pancreas.

• One may wonder how to determine whether a patient has limb ataxia in the setting of limb weakness when scoring the NIH Stroke Scale (NIHSS).

• The component of the NIHSS that tests for limb ataxia asks that the patient perform finger to nose and shin to heel testing.

• A patient who does not exhibit any ataxia would receive a score of 0 (zero), which is the best score.

• If the patient does not exhibit any ataxia because he/she has neuromuscular weakness and therefore can't perform the tasks at all, they would also receive a score of 0 (zero) on this component of the NIHSS.

Ventilation in the Brain-injured Patient

• As we have discussed in previous pearls, the ARDSnet trial forms the basis for ventilatory management in the ICU.  A primary component to current ventilatory management is the focus on maintaining lower and safer distending pressures through the use of lower tidal volumes.
• Similar to last week's pearl on the obstetric patient, these ventilatory settings may not be applicable to all patients.
• Recall that the use lower tidal volumes results in lower minute ventilation.  This leads to the accumulation of CO₂, termed permissive hypercapnia.  In general, we tolerate higher levels of CO₂ in favor of lower plateau pressures.
• For the brain-injured patient, however, increases in CO₂ may increase intracranial pressure (ICP) causing adverse effects.
• Current recommendations for mechanical ventilation in the brain-injured patient include maintaining a P_aCO₂ between 35 - 40 mm Hg.  Thus, you need to be more vigilant at following P_aCO₂ in this patient population.

The One Minute Preceptor-Microskills in Teaching

Most clinical teaching takes place in the context of busy clinical practice where time is at a premium. Microskills enable teachers to effectively assess, instruct, and give feedback more efficiently. This model is used when the teacher knows something about the case that the learner needs or wants to know.

Most of already do this on a daily basis when a learner (student or resident) presents a case to us.

• Get a commitment (Make them commit to a diagnosis and/or management strategy)
• Probe for supporting evidence (why do they think this patient with CP has an MI?)
• Teach general rules
• Reinforce what was right
• Correct mistakes

One of the biggest pitfalls in teaching, particularly to medical students, is the first skill, getting a commitment. Let (i.e. make) the student commit to a diagnosis and treatment plan and avoid spoonfeeding them.

Adenosine is everyone's favorite drug for SVTs, and it is often even used as a diagnostic maneuver in some tachydysrhythmias of uncertain origin. BUT there are some definite cautions of which we must all be wary:

1. Adenosine CAN convert some types of ventricular tachycardia to sinus rhythm. This "adenosine sensitive VT" is very well reported in the cardiology literature. Don't use adenosine as a diagnostic method of distinguishing VT from SVT (with aberrant conduction).

2. Atrial fibrillation with WPW can sometimes mimic SVT if one doesn't look closely and notice the irregularity. If you misdiagnose these patients as having SVT and give adenosine, you will likely induce VFib. Not good, Mav, not good!

3. Adenosine causes some histamine release (thus the flushing and hot sensation that patients report). That's bad for patients that have reactive airway disease (RAD). Adenosine should be avoided in patients with severe RAD by history (asthma, COPD) or if patients have active wheezing.

4. Concurrent use of adenosine in patients on digoxin or patients that have received digoxin or verapamil has been reported to cause VFib in rare cases.

5. The effects of adenosine appear to be potentiated by dipyridamole and carbamazepine. Lower the dose of adenosine in patients that take these medications.

6. The effects of adenosine are antagonized by methylxanthines such as caffeine or theophylline. You will probably need higher doses of adenosine in these patients.

7. There are rare cases of adenosine inducing atrial fibrillation. I'm not sure what to say about this, except don't be surprised if your patients goes from SVT into atrial fibrillation. Rare, fortunately.

8. And finally...always remember to push adenosine very quickly and follow immediately with saline BOLUS flush (don't just open up the IVF...you must PUSH 10-20cc of NS); and warn your patient that for ~10 seconds they are going to feel like they are about to die while the adenosine takes effect. If you don't warn them, they will never trust you or the drug again.

9. And finally finally...always have your code cart ready to go when you are using potent cardiac drugs such as adenosine. Don't let yourself be unprepared for a side effect.

Bad luck only happens when you are unprepared!

AM

Hemolytic-uremic syndrome (HUS)

• Characterized by hemolytic anemia (pallor on exam), acute renal failure (oliguria or anuria by history), and thrombocytopenia (petechiae).
• HUS is one of the most common causes of acute renal failure in children.
• Two types: diarrhea-associated (shiga toxin+ or D+) which is more common and has a more favorable prognosis, and non diarrhea-associated (atypical or sporadic or D-).
• Most common age at presentation is during infancy or young childhood.
• Pediatric HUS is a true medical emergency.
  • Resuscitation with blood products frequently is required, but it is crucial to provide volume carefully because renal function may be severely compromised.
  • Dialysis is required if anuria persists for 12+ hours or for severe hyperkalemia (>6.5mEq/L) Some patients may benefit from plasmapheresis, but full renal recovery is not certain.

Radial Head Fractures:

Radial head fractures are more common in adults, where radial neck fractures are more common in children.  Remember to look for fat pads to help make the diagnosis if it is not obvious on plain films.  On plain films, a line drawn down the middle of the radial head should always line up with the capitellum of the humerus.  If this does not occur the radial head is dislocated and/or fracture.

Orthopaedics use the Mason classification to help guide treatment, and break down fractures into 3 different types.

• Type I - is undisplaced, generally treated nonoperatively. 
  • Early mobilization prevents chronic elbow stiffness.
• Type II - a single fragment is displaced.
  • May be treated nonoperatively if the displacement is minimal.
  • The rule of threes is used. Nonsurgical treatment can be considered if the fracture involves less than one third of the articular surface, less than 30° of angulation, and if displacement is less than 3 mm
• Type III  - is comminuted.
  • Usually require operative intervention.

• With regard to following commands, the NIH Stroke Scale (NIHSS) assesses this level of consciousness in part 1C by asking the patient to do the following two things:

          1.  "Close your eyes and now open them."

          2.  "Make a fist and now open it."

• You may repeat the command no more than twice in order to avoid the bias of coaching the patient.

• It's fine to provide some prompting by performing the task yourself while asking the patient to do the same.
   
• This component of the NIHSS is scored as follows:

          0 = performs both tasks correctly.
          1 = performs one task corectly.
          2 = performs neither task correctly.

Classical illicit recreational drugs like cocaine, ecstacy, and marajuana are sometimes difficult for teens to acquire. As a result, many are turning to their parents medicine cabinets as a source for recreational drugs.

[From the website drugabuse.gov] In 2008, 15.4 percent of 12th-graders reported using a prescription drug nonmedically within the past year. This category includes:

• amphetamines
• sedatives/barbiturates
• tranquilizers
• opiates other than heroin
  • hydrocodone, oxycodone

When adolescent patient presents to the ED, consider the possibility of a poly-pharmacy overdose. Always query parents about the presence of OTC and Rx medications in their home, and what is within reach of their kids.

While sedatives and analgesics are concerning, be alert for overdoses of more mundane medications like beta blockers and calcium-channel blockers which often pose a much more lethal threat. Consider overdose in adolescent patients with:

• GI or respiratory complaints
• Altered mental status (combative or somnolent)
• Abnormal vital signs
• History of depression or psychiatric illness

Monitoring the Future Study: Trends in Prevalence of Various Drugs for 8th-Graders, 10th-Graders, and 12th-Graders

2005-2008 (in percent)*

Full chart available by clicking link in references.

Mechanical Ventilation of the Obstetric Patient

• In previous pearls, we have discussed ventilatory settings to avoid excessive volumes and limit plateau pressures to < 30 cm H₂O
• Importantly, these settings have not be extensively evaluated in pregnant patients
• Some important pearls when ventilating the pregnant patient:
  • Avoid hyperventilation, as this adversely affects uterine blood flow
  • Optimize oxygenation to ensure adequate fetal oxygen delivery (us 100% F_iO₂)
  • In the presence of adequate oxygenation, P_aCO_s values <= 60 mm Hg do not appear to be detrimental to the fetus

Nitroprusside-Friend or Foe?

Nitroprusside is a direct venous and arteriolar vasodilator and is very effective at lowering blood pressure. It has been used for the treatment of hypertensive emergencies for many years and most of are comfortable with using it.

The problems with the drug:

• May cause precipitous drops in BP and lead to overshoot of BP target goals
• The drug is inactivated by light so the infusion bag and tubing must be protected  from light
• Frequently causes nausea, vomiting, and muscle twitching
• Most importantly, cyanide (CN) is released from nitroprusside in a dose-dependent fashion and may cause clinical toxicity
• Good alternatives exist: Fenoldopam as an example. Just as effective and without any of these side effects.

Patients with catastrophic cardiovascular conditions often manifest with JVD + hypotension. The DDx for this combination is therefore critical to know:

1. large LV MI
2. right ventricular MI
3. cardiac tamponade
4. tension PTX
5. massive PE
6. acute mitral regurgitation
7. acute aortic regurgitation

You can make a diagnosis clinically among these 7 entities by:

1. Listening to the lungs
2. Listening for murmurs
3. Getting an ECG.

Of course if you have bedside U/S, it becomes even easier. ECG is almost always diagnostic with either the large LV MI or RV MI. Wet lungs found in large LV MI, acute MR, and acute AR. Murmur found in MR (systolic) and AR (diastolic).

Hamate Fractures:

• Typically the result of a direct blow, and the hook of the hamate is commonly fractured in batters or golfers.
• Like the scaphoid, the hook is at risk for avascular necrosis and non-union of the hook.
• Fractures of the body are more common than fracture of the hook of the hamate
• On exam you will typically find:
  • Increased pain with axial loading of ring (4th) and little finger (5th) metacarpals
  • Most patients complain of pain and tenderness on ulnar side of palm or on the dorsoulnar aspect of the wrist.
  • Pain also aggravated by grasping items.
• Diagnosis
  • Fracture often missed on routine AP & lateral films
  • Most fractures can be diagnosed by plain films if you as for the "Carpal tunnel view"
  • CT scan can also be used to see the fracture
• Treatment
  • Good Immobilization will often prevent avascular necrosis and allow early healing
    • Volar splint or short arm cast are usually adequate.
  • Excision of the hook of the hamate provides similar results as an ORIF in those that have non-union or displaced fractures.
  • Refer to orthopedics

Serotonin is a neurotransmitter that has central and peripheral effects. It regulates the secretion of ADH from the hypothalamus and also controls the chemoreceptive trigger zone (CTZ) which induces emesis. Here are a list of medications categorized by the way they affect serotonin. Remember, any combination of these agonists could precipitate serotonin syndrome:

Enhance 5-HT synthesis: L-tryptophan

Direct HT agonists: Ergots, metoclopramide, sumatriptan, buspirone

Increase 5-HT release: amphetamines, cocaine, dextromethorphan, MDMA, L-dopa

Inhibit 5-HT breakdown: MAOIs, Linezolid

Inhibit 5-HT re-uptake: SSRIs (paxil), amphetamines, carbamazapine, tramadol, TCAs, citalopram, trazodone, lamotrigine, meperidine

• The first part of the NIH Stroke Scale assesses level of consciousness in 3 parts, 1A, 1B, and 1C.

• Part 1B assesses orientation by having the patient tell the examiner (1) their age and (2) the month.

• Part 1B is scored in the following manner:

          -- Answers both questions correctly = 0

          -- Answers one of the two questions correctly = 1

          -- Answers neither question correctly = 2

• If patient is unable to speak due to being intubated, having orotracheal trauma, dysarthria, a language barrier, or any other reason other than truly being aphasic, a score of 1 should be assigned.

Parainfluenza viruses (types 1, 2, 3) account for more than 65% of all cases. The different serotypes have seasonal patterns, with type 1 and 2 occuring in the autumn and being the most common pathogens associated with croup while type 3 is more frequent in the spring and summer and is associated with pneumonia and bronchiolitis.

Infections are rarely associated with high fever and usually last 4 to 5 days. There are no distinctive laboratory abnormalities, and diagnosis is generally made clinically.  Chest and neck xray may demonstrate a “steeple sign” from narrowing of the subglottic region.  Viral cultures and immunofluorescent rapid antigen identification can be obtained from respiratory secretions.  Specific antiviral therapy is not available. Aerosolized epinephrine can be given to severely affected, hospitalized patients to decrease airway obstruction.  Parental (>0.3mg/kg) and oral ((0.15mg/kg) dexamethasone have been demonstrated to lessen the severity and duration of symptoms and hospitalization in patients with moderate to severe croup.  
 

Critical Illness-Related Corticosteroid Insufficiency (CIRCI)

• CIRCI is defined as inadequate corticosteroid activity for the severity of illness of a patient
• CIRCI arises due to steroid tissue resistance and inadequate circulating levels of free cortisol
• Hypotension refractory to fluids and requirement of vasopressors is the primary manifestation of CIRCI
• In contrast to chronic adrenal insufficiency, hyponatremia and hyperkalemia are uncommon
• Consider CIRCI in all critically ill patients requiring vasopressor support

So, which critically ill patients do you treat with steroids?  Current literature suggests the indications for steroid treatment include vasopressor dependent septic shock and persistent ARDS despite supportive therapy and lung protective ventilation.  A patient who requires only an hour or two of a vasopressor while being fluid resuscitated is unlikely to benefit.  An accepted dosing schedule is hydrocortisone 50 mg IV every 6 hours.

Documentation of the Chest Pain Patient

Chest pain is a high risk entity in emergency medicine. And since many patients we see with chest pain are eventually discharged, we should consider what our charts should look like should we discharge a patient who has a missed life-threatening diagnosis. In other words, what would an attorney look for?

Considerations for the chart:

• Consider documenting some type of medical decision making in the chart. What were you thinking? Why didn't you think the patient needed cardiac enzymes, a CT, or admission? The chart should support your decision to send the patient home.
• Document a thorough history...enough said
• Document risk factors for the deadliy causes of chest pain (ACS, PE, dissection, etc.). This is frequently missing on charts.
• Consider documenting important, pertinent negative "chest pain physical exam findings," such as a normal leg exam (frequently missing on missed PE charts), no murmurs, equal pulses. Comments like this in the chart prove that you were thinking about a differential diagnosis. A question to ask yourself is, "Does my physical exam look like I was searching for the bad players of chest pain?"

Traditional teaching for patients with hypotension in the setting of MI and heart failure (i.e. not just RV MI) is to give dobutamine as a first-line agent when the SBP is 80-100, and to use dopamine when the SBP is 70-80s [note that this recommendation is NOT based on good evidence, but primarily on consensus opinion]. The problem with using these medications, especially at higher doses (e.g >10-15 mcg/kg/min) is that they result in excessive alpha-1 adrenergic stimulation that can produce end-organ ischemia.

However, there is some evidence that rather than using high dosages of dobutamine or dopamine, "the deliberate combination of dopamine and dobutamine at a dose of 7.5 mcg/kg/min each was shown to improve hemodynamics and limit important side effects compared with [high dosages of] either agent [alone]."

[Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation 2008;118:1047-1056.]

Lunate Dislocation and perilunate dislocation are broken down into 4 stages that relates to the progressive disruption of the carpal ligaments due to hyperextension and ulnar deviation of the wrist:

• Stage 1: Scapholunate Dislocation
  • Has the characteristic sign of widening of the scapholunate joint on the PA view known as the Terry Thomas Sign as it resembles the gap between his teeth
  • Gap between scaphoid and lunate should be less than 2 mm
• Stage II: Perilunate dislocation
  • Best seen on lateral view of the wrist
  • Associated with scaphoid fractures
  • Lunate stays in its normal position with the capitate dislocation posterior when you use the distal radius as your reference point
• Stage III: Perilunate dislocation
  • Also includes dislocation or fracture of the triguetrum
  • Triquetrial and scaphoid malrotation
  • In lateral view, all other carpal bones are dislocated posterior with respect to lunate
• Stage IV:  Lunate dislocation
  • On PA view you will see a triangular view of the lunate on the PA view that looks like a "piece of pie". 
  • On the lateral view of the wrist the lunate will look like a tea cup tipped in the volar direction AKA the "spilled teacup sign"
  • Associated with a scaphoid fracture
     

For a good indepth review of lunate and perilunate injuries please read the article by Andy Perron with this attached link.... doi:10.1053/ajem.2001.21306   

If you are interested in seeing some xray examples please visit LearningRadiology.com

Goldfrank's sniffing bar: no this is not a pub where toxicologist's hang out but rather a bar that assists with teaching the recognition of odors related to toxicology. Certain drugs and compounds have a distinct aroma.

The following is a list odors, see if you can name a medication or compound that has that odor - scroll down further to see the corresponding answers (if you really got all 5 email me and convince me):

1) Bitter Almond

2) Rotten Eggs

3) Wintergreen

4) Garlic

5) Sweet, Fruity (acetone)

Answers:

1) Cyanide; 2) N-acetylcysteine or Hydrogen Sulfide; 3) Methylsalicylate (like bengay); 4) Arsenic, organophosphate insecticides; 5) Chloroform, chloral hydrate

• A patient's blood pressure should be maintained at less than 185/110 prior to receiving thrombolytics for stroke.

• The following medications should be used to address blood pressure control in these patients:

               Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat x 1  

               OR

               Nitropaste 1 to 2 inches

               OR

               Nicardipine infusion at 5 mg per hour, titrate by 0.25 mg/hr at 5 to 10 minute intervals up to a maximum

               dose of of 15 mg/hr.  Once desired blood pressure is achieved, titrate down in increments of 3 mg/hr. 

Early Critical Care Management of Aneurysmal SAH

• 30,000 patients per year have an SAH
• Early ED management certainly should focus on airway assessment, emergent CT scanning, continuous caridac monitoring, and serial neurologic exams
• A few other pearls regarding management:
  • Volume management - maintain euvolemia with an isotonic crystalloid fluid
  • Anticonvulsants - routine use is associated with cognitive impairment and is not recommended
  • Steroids - once used to reduce meningeal irritation, however, there is no convincing evidence of a beneficial effect.  As such, corticosteroids are no longer recommended.
  • Rebleeding - risk of rebleeding is highest in first 24 hours after initial SAH.  Definitive prevention is done by repair via surgery or endovascular coiling.  A large, prospective study found outcome was better with endovascular coiling.

Keys to a Successful Intubation

• Use both hands-bimanual laryngoscopy should be a routine part of ED intubations.
• Don't forget that you CAN let up cricoid pressure-this can actually obscure your view and make your job more difficult.
• For obese patients, make sure you elevate them. You want their ear level with their sternal notch. This might require A LOT of pillows or towels.
• Use a "straight-to-cuff" technique for stylet shaping. This is accomplished by making the stylet straight down to the cuff and then making a 15-20 degree bend at the cuff.

A lot of what is taught about fracture patterns in abused children has been extrapolated from post-mortem studies which is a different population then what you will see in the Emergency Department. The study referenced did a metanalysis of all the literature in an attempt to determine what fractures suggest abuse and looked at all comers that had fractures.  Some of the patterns they were able to extrapolate are:

• Fractures from abuse predominately occurred in infants and toddlers
  • In children less than 12 one study showed that 80% of all fractures from abuse occurred in children less than 18 months old.
  • In children over 5 years old 85% of fractures are not caused by abuse
• In children under 3 years old, skull fractures were by far the most common fracture type in both abused and non-abused children.
  • However, the presense of a skull fracture only has a 1:3 chance of being from abuse.
  • Skull fractures location and type are similar between abuse and non-abuse, though multiple fractures and fractures that cross suture lines are more highly associated with abuse.
• There is a strong relationship between multiple fractures and abuse
  • 74% of abused children had two or more fractures compared to 16% of non-abused
• In the absence of a confirmed traumatic case, rib fractures have the highest probability (71%) of being caused by abuse.
• Humeral fractures have a 1:2 chance of being the result of abuse.
• Femur fracture like skull fractures have a 1:3 chance of being the result of abuse.

• For children under 5 years of age the rate of missing an appendicitis remains very high.  (57%-67%)
• The rate of misdiagnosis increases as the age decreases. 
• In cases of missed appendicitis the most common incorrect diagnosis is gastroenteritis.
• Think twice before you label vomiting alone, or diarrhea alone as gastroenteritis.
• If an appendicitis is missed there is an increased risk of perforation, abscess formation, and higher morbidity. 

Add metoclopramide (Reglan) to the laundry list of medications with black box warnings from the FDA. Why was a black box warning added?

• Long-term metoclopramide use has been linked to tardive dyskinesia (involuntary and repetitive body movements) even after the drug is no longer being taken.
• Risk factors: Long-term or high-dose use, elderly, female gender.
• Recommended that metoclopramide treatment not exceed 3 months.

• None really.
• Just be aware of the dopamine antagonist effects (EPS - dystonic reactions) that are possible whenever you order metoclopramide in the acute setting.
• These effects can be treated effectively with an anticholinergic agent, such as diphenhydramine or benztropine.

When performing the NIH Stroke Scale, keep the following conventions in mind:

-- Administer scale items in their exact order.
-- Avoid coaching the patient.
-- Accept the patient's first effort.
-- Be consistent.
-- Score only what the patient actually does.
-- Include all deficits in scoring.

Oxygenation goals

• In recent pearls we have talked about 'lung protective' ventilation strategies to reduce volutrauma, barotrauma, and oxygen toxicity.
• Using 'lung protective' strategies, such as low tidal volumes, results in higher levels of CO₂ and a lower pH.  These are tolerated in favor of lower and safer alveolar pressures.
• In addition to higher pCO₂ values and lower pH, oxygenation goals are slightly lower than conventional teaching.
• In these patients, you want to maintain S_pO₂ > 88% and P_aO₂ > 55 mm Hg.

Follow-up for the Hypertensive Patient

We see hypertensive patients every day, every shift. And, we discharge many of them. So, when do you get them follow-up?

The JNC-7 recommends that patients with BPs > 180/110 mm Hg have follow-up within 7 days. Like most of the HTN recommendations in the primary care setting, this recommendation is based on a "smart person" concensus....and no data.

This is a tremendous issue for us in the ED, because we don't want to see a bad outcome in our discharged hypertensive patients.

Some pearls regarding discharging the very hypertensive (but asymtomatic) patient:

• Since there isn't any realy data on follow-up, it would be wise to use caution and have very high BPs checked the next day and to NOT wait a week.
• Discharge instructions should note when/where (if you have to...use the ED as a recheck) the patient is to follow-up
• ALWAYS warn patients about what can/will happen if they don't seek follow-up: MI, stroke, renal failure/need for dialysis, death, and disability and write this in the chart. The last thing you want to hear is that the patient went on to develop renal failure/stroke, etc. and that they claim they were not warned about what could happen.
• When it is possible, contact the patient's doctor to discuss management

The Galeazzi Fracture:

• It is a fracture of the distal to middle third of the radial shaft with dislocation of the Distal Radio-Ulnar Joint. 
• Typical mechanism of injury is a fall onto a outstretched hyperpronated forearm.
• Estimated to represent 7% of adult forearm fractures.
• This fracture requires surgical repair (Open reduction and internal fixation) in order to prevent presistant or recurrent dislocation of the distal ulnar which typically occurs with closed reduction techniques.
• Associated with injury to the Anterior interosseous nerve which is a purely motor branch of the median nerve.  Injury results in paralys of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger.

To see a photo of a Galeazzi fracture please visit the Learning Radiology Website by clicking on the following link:

http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow157lg.jpg

Rocky Mountain spotted fever (RMSF)

Systemic small vessel vasculitis caused by R rickettsii which is transmitted by a tick bite.

Clinical features: fever, headache, myalgia, nausea, vomiting, and characteristic rash. Rash usually appears before the sixth day of the illness initially on the wrists and ankles, and spreads to the trunk within hours.  Initially. It is erythematous and macular, later becoming petechial.

Laboratory findings: thrombocytopenia, anemia, and hyponatremia.

Complications: meningitis, multiorgan involvement, DIC, shock, and death. 

Treatment: doxcycycline (even despite the risk of dental staining in children younger than 8 years old)

Clevidipine

• A new intravenous antihypertensive agent
• Has a very rapid onset (2-4 min) and offset (5-15 min), in contrast to the available IV calcium channel blocker nicardipine, which has a duration of action of 3-6 hours
• Contraindicated in patients with soy or egg allergies, and in those with defective lipid metabolism
• Most common ADR's reported were headache, nausea, and vomiting
• Initiate at 1-2 mg/hr, most respond at doses between 4-6 mg/hr
• Maximum recommended dose is 16 mg/hr
• Costs between $86 to $140 per 50 mg vial

• Fever is present in 80% of cases.
   

• Treatment includes high dose intravenous antibiotics.  Anti-coagulation therapy is controversial and often held.
   

• Mortality is 30% with an additional 30% enduring sequelae such as oculomotor weakness, blindness, and pituitary insufficiency.

Evaluation of End Organ Damage in Hypertensive Patients

No evidence to date supports the ED workup for end-organ damage in asymptomatic hypertensive patients.

End-Organ Damage Pearls:

• Rarely, if ever, will an aimless search for lab abnormalities lead to any clinically meaningful change in patient management
• An elevated creatinine does NOT define acute, end-organ damage. Most of the time it is due to the effects of chronic hypertension.
• There is some evidence that a UA that has BOTH no protein and no red cells predicts a normal creatinine. The studies that have looked at this, however, are very small. Also, HTN in and of itself may cause some protein leak, even in the setting of normal renal function
• A CXR and/or ECG is not needed in an asymptomatic patient.
• Prompt followup is always necessary especially if no ED workup is started. All of this can be dome in the primary care doctor's office.

Neuromuscular Blocking Agent (NMBA)

• NMBAs are used to facilitate intubation when performing RSI
• Importantly, NMBAs have no analgesic or amnestic effects
• Indiscriminate and repeated dosing of NMBA can lead to prolonged recovery and critical illness polyneuromyopathy, a devastating complication of critical illness that prolongs ventilation, ICU/hospital length of stay, and increases mortality
• Take Home Point: provide adequate amounts of sedation and analgesia to your intubated ED patients rather then reflexively giving repeated doses of NMBA

Most people are familiar with the Ottawa Ankle Rules, but there are also Ottawa Knee and Foot rules.  The Ottawa rules help to limit the number of x-rays you may need in patients that present with ankle, foot or knee pain after an injury.

The Ottawa Ankle Rule

An ankle x-ray is only needed if there pain in the mallelolar area and any of the following:

• Bone tenderness at the posterior tip of the base of the lateral mallelous
• Bone tenderness at the posterior tip of the base of the medial mallelous
• Inability to weight bear immediately and in the Emergency Department

The Ottawa Foot Rule

A foot x-ray is only needed if there is pain in the midfoot and any of the following:

• Bone tenderness at the base of the 5th metatarsal
• Bone tenderness over the navicular
• Inability to weight bear immediately and in the Emergency Department

The Ottawa Knee Rule

A knee x-ray is only needed for knee injury patients when they have any of the following:

• Age 55 or over
• Isolated tenderness of the patella (no bone tenderness of the knee other than the patella)
• Tenderness at the head of the fibula
• Inability to flex to 90 degrees
• Inability to weight bear both immediately and in the Emergency Department (4 steps - unable to transfer weight twice onto each lower limb regardless of limping).

• Pediatric seizures are common and 4-6% of all children will have a seizure by the time they are 16 years old.


• Afebrile neonatal seizures require an evaluation of electrolytes, glucose, calcium, magnesium, LP, blood and urine cultures.


• Simple Febrile seizures usually do not require any lab testing or admission if the child appears well.


• Dilution of formula with too much water is a common cause of hyponatremic seizures in infants.  (Treat with 3ml/kg of 3% hypertonic saline)


• Complex febrile seizures have a higher risk for meningitis than simple febrile seizures, so perform an LP, give antibiotics, and admit.


• When intubating for Status Epilepticus consider using thiopental or propofol for induction given their antiepileptic properties.

The Crashing Intubated ED Patient

• For intubated ED patients who develop respiratory distress and are hemodynamically unstable, perform the following:
  • Immediately disconnect from the ventilator
  • Manually ventilate with 100% F_iO₂
  • Exclude tension pneumothorax (decompress)
  • Exclude auto-PEEP (allow for lung deflation)
  • Check ET tube for kinks, twisting, or obstruction
  • Check for air leak (check pilot balloon and listen for air coming from mouth/nose during manual ventilation)
  • Check the ventilator circuit

Bleeding AV Fistulas

It is not an uncommon complaint for dialysis patients to present with bleeding from their fistula.  They can lose a large amount of blood in a short period of time if not treated promptly, and if treated too agressive their fistula can clot off. Some tips on how to control the bleeding.

Most of the bleeding occurs at the site that the needle puntured the fistula. If it is due to an ulcer eroding into the fistula these tips may not be effective.

• The easiest and safest way to control the bleeding is with simple diret pressure directly over the site of bleeding with a single finger. No guaze.  [Gown up and wear goggles or eye protection]. The use of a big wad of guaze or a pressure dressing tends to just hide the continued bleeding or result in the clotting off of the fistula.
• Injecting lidocaine with epinephrine at the site can also help and helps set you up for the next step,
• A figure eight stitch at the puncture site can help close the puncture wound.
• Of course you should call your vascular surgeon if you are having trouble controlling the bleeding, want close follow up or finger is going numb from holding pressure.

I typically check a CBC and coags.  Once the bleeding is controlled observe the patient for awhile [typically the hour to hour and half to get the labs back] and then road test them with a walk around the Emergency Department to ensure it does not start bleeding again.

• An acute bacterial infection of a joint.


• Peak incidence in children is younger than 2 years of age.


• Risk factors:
  
  
  
  • history of trauma
  
  
  • preceding URI
  
  
  • immunodeficiency
  
  
  • hemoglobinopathy
  
  
  • Diabetes.
  
  
  
  


• Age is the most important determinant of cause.
  
  
  
  • In all age groups, S aureus is the primary organism accounting for more than 50% of cases.
  
  
  • Among neonates, enteric gram-negative organisms and group B Streptococcus are the most frequent causes.
  
  
  • Group A Streptococcus, S pneumoniae, and K kingae are common causes in children younger than 5 years old.
  
  
  
  


• Blood culture, joint fluid aspiration and analysis, gram stain, and culture of fluid is recommended.


• In pyogenic arthritis, the joint fluid is usually cloudy and has a leukocyte count of at least 50 x 10000/mcL, with a predominance of polymorphonuclear cells, low glucose concentrations, and high protein values.


• Treatment involves a combination of parenteral antibiotics, surgical drainage, and decompression of the affected joint.


• All children who have pyogenic arthritis of the hip or shoulder require prompt open surgical drainage and irrigation to prevent permanent joint damage as the increased intra-articular pressure can compromise blood flow resulting in avascular necrosis of the femoral or humeral head and predisposing the patient to dislocations.


• Open surgical drainage of other joints usually is not required.

Rocuronium is fast becoming the agent of choice for RSI in the Emergency Department. Here is a head to head comparison of the two drugs to understand why:

• Cavernous sinus thrombosis, one of the three dural sinus thrombosis syndromes, is extremely rare and results from infection often originating from the face, sinuses, dental cavity, ears, and mastoids.

• Cranial nerves III, IV, V1, V2, and VI course along the walls of the cavernous sinus such that extraocular motion abnormalities (palsy/paralysis) commonly manifest with cavernous sinus thrombosis.

• Headache (usually sharp, unilateral, and in the distribution of V1 and V2 branches) is typically the initial presenting symptom, followed by eom palsy, mydriasis, diplopia, periorbital edema, visual abnormalities, mental status deficit, and coma.

Sepsis in Pregnancy

• Sepsis in the setting of pregnancy is primarily the result of pelvic infections such as chorioamnionitis, endometritis, septic abortion, or urinary tract infection
• In these patients, aerobic gram-negative rods (E. coli, Enterococci, Beta-hemolytic strep) are the principal etiologic agents
• An empiric broad spectrum antibiotic regimen is ampicillin, gentamicin, and clindamycin (or metronidazole)

BEWARE sudden onset thoracic back pain

Just reviewed a case last week of a person who presented with back pain (thoracic) as the sole manifestation of an aortic dissection. No chest pain, belly pain, etc. JUST severe, acute, thoracic back pain.

Keys to staying out of trouble:

• Any sudden onset pain should be explained. Musculoskeletal pain doesn't normally present like this. Look for risk factors like HTN. If a person with HTN (even if not that high in the ED) presents with acute, severe, thoracic back pain the diagnosis of dissection should at the very least be considered.
• The key to making the diagnosis begins with thinking about the diagnosis.
• At the very least, include aortic dissection in EVERY patient you see with back pain, especially if sudden onset. I am not talking about the 95%+ people who don't really have anything wrong with them and who stumble into urgent care asking (begging) for Percocet.
• Sudden onset back pain should also prompt consideration for a AAA
• Just like all else in Emergency Medicine, always ask yourself if a "worst case scenario" could be present?, and the list for acute back pain is pretty short: dissection, AAA, fracture (by history), cancer, infection. Most of these, however, do not present acutely.

Ankle sprains are typically treated with a short period of immbolization and then functional exercises are prescribed to rehabilitate the ankle.  A study published in the Lancet this week might just change that.  Lamb et al looked at 584 people with severe ankle sprains (unable to weight bear 3 days out from injury) that were randomized to be treated with a 10 day below knee cast, Aircast, Bledshoe Shoe or Tubular Compression dressing (similar to Ace Wrap).  Those that were treated with the Cast and Aircast had quicker return to function and less disability at 3 months.  There was no increased risk of DVTs in the cast group.

A commentary in the same issue points out that severe ankle sprains are associated with:

• lower levels of physical activity levels
• recurrent ankle sprains are often reported for months and years after initial injury.
• About 30% of patients with an initial ankle sprain develop chronic ankle instability, or repetitive giving way of the ankle during functional activities.
• There is also emergent evidence to link severe and repetitive ankle sprains to increased risk of ankle osteoarthritis.

Based on this article I think it is prudent to treat all patients with severe Ankle Sprains with a prolonged period of forced immobilzation (Posterior Splint, Short Leg Cast or Aircast).  I would also recommend the Aircast be used to prevent recurrent sprains especially if the patient is involved in sports that require jumping (Basketball, Volleyball) where the risk of reinjury is higher.

You have a 44 y/o female patient with an arterial line monitoring her blood pressure which is reading 302/156 mm Hg.  Her heart rate is 140 bpm.  Her history reveals she is taking a monoamine oxidase inhibitor (MAOI) and has inadvertantly ingested tyramine at her friend's cheese/wine party.   What do you do?

• Conditions producing hypertensive crisis from catecholamine surges (phenylephrine overdose, cocaine, tyramine interactions, pheochromocytoma) can be treated with phentolamine
• Phentolamine is a nonspecifc alpha blocking agent which produces peripheral vasodilation with a resultant fall in blood pressure in most patients.
• Other uses include extravasation of some vasopressors (e.g. norepineprhine)
• May see an increase in HR after administration (once alpha blockade is established, beta-blocker can be administered)
• Dose: 5-15 mg IV/IM
• Duration: 30-45 minutes

Hyphema is an urgent ophthalmologic condition. Due to the high risk of rebleeding and increased intra-ocular pressure, strict follow up with an ophthalmologist is warranted. SELECTED low grade hyphemas in reliable patients may be managed on an outpatient basis. Some pointers that may be helpful for the EM inservice exam: 

• Measurement of intra-ocular pressure (IOP)  is crucial to proper treatment and prognosis.
• Many drugs are available to lower IOP, these are generally used in association with opthalmologic consultation
  ->acetazolamide (has potential to "sickle" RBC's)
  ->aminocaproic acid
  ->B blockers
• Hyphema > 5 days are associated with high incidence of synechiae formation
• Avoid NSAIDs/ ASA
• Eye patching,  HOB (head of bed) elevation recommended
• Corneal bloodstaining indicates a poor prognosis
• Incidence of rebleeding estimated at 30-40%
• Graded from 0-IV. Grade IV hyphemas cover the entire anteror chamber; often called, "8 ball" or "blackball" hyphema. Grade 0=only visible on slit lamp.
• Trauma is most common etiology
• Low IOP and trauma? ---> Rule out globe rupture! 

General indications for "very urgent" ophthalmologic consultation:

• Severely impaired visual acuity=greater rebleeding risk
• Patient with known SCD or sickle cell trait
• Visible blood staining of cornea
• High grade, covering > 1/3 of anterior chamber
• Delayed presentation (risk of synechiae / vision loss due to IOP) 

• Angioedema occurs in less than 1% of stroke cases treated with tPA.
• Particularly associated with ACE inhibitor and beta blocker (less so) use.
• Symptoms are usually mild affecting the lips, tongue, and oropharynx.
• Check the patient for such symptoms at 45, 60, and 75 minutes post tPA administration.
• When present, consider treating with some or all of the following agents: 
   

             -- Diphenhydramine (Benadryl) 50 mg IV
             -- Ranitidine (Zantac) 50 mg IV
             -- Methyprednisolone (Solumedrol) 50 - 100 mg IV
             -- Racemic Epinephrine
             -- Anesthesia consult re: airway management

Pitfalls in ED Teaching

One of the best ways to improve as a teacher is to understand what mistakes expert educators have made in the past.

The following is a short list of pitfalls offered from some of the great teachers in our specialty:

• Trying to teach for too long: "Teaching less is more"-that is to say, more will be remembered if the teaching session is brief.
• Trying to teach too much: Trying to Stick to one main point, the "Educational Hit and Run," and move on
• Failure to be enthusiastic when you teach: You must have some enthusiasm when you teach. Students/Residents won't learn as much or be as enthusiastic about learning without your enthusiasm!

Ventilator Associated Pneumonia (VAP)

• VAP is the leading cause of death among hospital acquired infections
• VAP causes prolongation of mechanical ventilation, ICU/hospital length of stay, and adds about $40,000 to the patient's admission
• As we care for more and more intubated patients for longer and longer periods of time, it is crucial to know some simple preventative measures we can do in the ED to reduce morbidity and mortality
• In the absence of contraindications, elevate the head of the bed to 30-45 degrees for intubated patients
• This is a simple, no cost intervention that has been shown to decrease the incidence of VAP

Torsades de pointes and polymorphic ventricular tachycardia are two terms that are often used interchangeably. However, they are not the same!

Torsades is a type of PVT that is characterized by an undulating appearance of the QRS complexes which give the rhythm the appearance of QRS complexes twisting around a central axis. The defining feature of torsades, however, is the presence of a prolonged QTc on the ECG before or after the run of torsades.

Although either rhythm is usually amenable to cardioversion/defibrillation, post-cardioversion treatment is very different between the two. Torsades should be treated with magnesium, whereas PVT can be treated with lidocaine, amio, or procainamide. Beware that treatment of torsades with any of these sodium channel blockers can actually prolong the QTc further and induce intractable torsades.

Lidocaine with Epinephrine and it use on Fingers and Toes

It has been taught for a long time that Lidocaine with Epinephrine should not be used on fingers, toes, ears and nose [There has to be a kid's song in there somewhere] due to the risk of vasoconstricition/vasospasm and possible digitial infarcation.

The short story is that this practice is not supported by the literature, and there are now numerous publications that have shown that lidocaine with epinephrine is safe for use on the finger tips.  It turns out the the original case reports were submitted with procaine and epinephrine and not lidocaine with epinephrine.  Most of the cases of digital infarction where with straight procaine that is now thought to have been contaiminated or too acidic pH close to 1 when injected.

The effects of epinephrine last approximately 6 hours. This time is well within the accepted limit of ischemia for fingers that has been established in digitial replanation.

So why use Lidocaine with Epinephrine:

1. Provides a longer period of anesthesia
2. Decreases bleeding which:
   1. Improves visualization of tendons and underlying structures
   2. Makes repairs easier
   3. Decreases need for a torniquet

Epstein-Barr virus (EBV)-associated infectious mononucleosis (IM) 

Most commonly presenting clinical findings: fever, fatigue, exudative pharyngitis, lymphadenopathy, and hepatosplenomegaly. 

Self-limited illness that lasts an average of 2 - 3 weeks. 

Treatment is primarily supportive.  Use of ampicillin, amoxicillin, or penicillin during the acute phase not indicated and may result in the development of a morbilliform rash, which studies have suggested may occur in more than 50% of the cases.  Antiviral therapy is not recommended. Splenic rupture occurs in about 1 - 2:1000 cases.  Therefore, avoidance of activities that increase the risk for injury is recommended until splenomegaly has resolved. 

• Always be sure to examine a patient's carotid arteries for bruits when concerned about stroke and/or TIA.  Bruits suggest the presence of stenosis.


• Dijk and colleagues found that patients with > 50% carotid artery stenosis are at high rsk for stroke and TIA.


• Bruits are best ascultated by using the bell of the stethoscope and asking the patient to briefly hold their breath while trying to hear the abnormality.


• The American Heart Association recommends that symptomatic stenosis of > 50% undergo carotid endarectomy (CEA) within 2 weeks.  If CEA is contraindicated, stenting should be pursued.  CEA for stenosis of 70% to 99% is typically recommended regardless of symptomatology.

Sedation and Analgesia in Mechanical Ventilation

• Mechanically ventilated patients routinely experience pain and anxiety from the presence of an endotracheal tube, ventilator strategies, placement of invasive catheters, surgical procedures, and even nursing procedures such as suctioning and repositioning.
• Recent literature highlights that many of our vented patients received inadequate amounts of analgesia and anxiolysis
• When giving anxiolytics and analgesics, focus first on analgesics. 
• Patients given analgesics first, followed by anxiolytics, consistently achieve goals with less amounts of supplemental medications needed.

Pulmonary Embolism-Beware Two Important Atypical Presentations

Seems like we have had several atypical PE presentations recently so I thought it timely to quickly highlight some of the well-reported presentations of pulmonary embolism. Remember, although we won't and can't diagnose every case, these types of presentations should at the very least prompt us to consider the diagnosis.

Atypical PE Presentations:

• Syncope-occurs in as many as 15-20% of patients. Make sure PE is on the differential diagnosis of the syncopal patient, especially if there was any preceeding shortness of breath or chest pain.
• Abdominal pain-we just had a case of this last week. A young female 6 weeks into a course of OCPS developed RUQ pain that radiated to the left shoulder. She had NO shortness of breath. However, the RUQ pain was pleuritic. Remember the movement of the diaphragm as it is responsible for abdominal pain presentations of both PE and pneumonia. A d-dimer was obtained and returned 3000. A CT scan was then ordered which showed a large right lower PE. What's the moral of the story? Well, it isn't to rule out PE in patients with belly pain. The lesson here is that upper abdominal pain may reflect disease in the chest (lower lobe pneumona and PE) and vice versa. To make matters worse an ultrasound of the RUQ was ordered 1st which showed gallstones!

Bradycardia in children is most often caused by hypoxemia but can also be caused by acidosis, elevated ICP, vagal stimulation, heart blocks or overdoses. 

First degree heart block in otherwise healthy children can be caused by infectious diseases, myocarditis, rheumatic fever, Lyme disease and congenital heart disease.

Third degree heart block can be congenital, caused by maternal connective tissue disorders such as Lupus, or may result from cardiac surgery.

Any infant presenting with a third degree heart block should have an investigation for neonatal lupus. 

Rodenticides have taken many forms. The following is a list of some of the more interesting ones either due to the mechanism of toxicity or how it is lethal. All of these are also toxic to people.

1) Strychnine - Glycine Antagonist at the post-synaptic spinal cord neurons - patient or rat will have convulsion of the extremeties but will be awake, alert and in extreme pain. Essentially look like generalized seizure except awake. Treatment: Benzodiazepines, Analgesia, Supportive

2) Brodifacoum - Long Acting Coumarin - rat eats, later develops elevated INR then tries to run through thin cracks in the wall or takes a little too high of a jump, then boom - subdural or some other internal hemorrhage. In human, they can stay anticoagulated for weeks after an overdose. Treatment: Vitamin K and large padded room

3) Cholecalciferol - Vitamin D precursor - there are big blocks of this drug in the NY and other subway systems. Rat nibbles, gets hypercalcemic, then gets thirsty because of this. Rat runs out into middle of subway to drink out of puddle then - splatt - the M train to Brooklyn comes along. Treatment: IVF, Loop Diuretics, Bisphosphonates

• Motor function is one of the three neurologic responses assessed by the Glasgow Coma Scale (GCS).
• This response is scored on a scale of 1 to 6, 6 being the best score:          
  • 6 = Obeys commands (does simple things as asked). 
  • 5 = Localizes to pain (purposeful movements towards  painful timuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied).
  • 4 = Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied. (i.e. pulls part of body away when nailbed pinched)).
  • 3 = Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response).
  • 2 = Extension to pain (adduction of arm, internal rotation of shoulder,pronation of forearm, extension of wrist, decerebrate response).
  • 1 = No motor response. 

Pneumonia and Sepsis

• As we have discussed, one of the most important components in the ED management of sepsis is the administration of early and appropriate broad-spectrum antibiotics
• Pneumonia remains one of the most common causes of sepsis in the US and worldwide
• Given the steady rise in incidence of MRSA, remember to add vancomycin to your empiric treatment of patients with pneumonia and severe sepsis or septic shock

Feedback as a Teaching Tool

Why do we, in general, stink at giving feedback?

• We were never taught how to do it
• We fear we will hurt someone's feelings
• It's painful to give feedback

Consider a few quick pearls that will increase your success at giving valuable feedback:

• Realize that learners (students/residents) crave feedback....proven in multiple studies
• Feedback IS a powerful teaching tool and isn't just a way of evaluating someone.
• Avoid at all cost, the phrase,"good job." Be specific about what you mean
• Praise in public, perfect in private
• Avoid the "complain syndrome" and don't fall victim to it. This refers to the phenomenon in which we complain about a behavior or trait and NEVER actuall tell the person. We have all done it. Set yourself apart from others by giving the learner the needed feedback.
• Learners won't improve without feedback. Just like the Nike commercial says,"Just do it!"

FrostBite

Now that we are in the cold winter months, we are more likely to see patient with frostbite and hypothermia.  Here are some tips for treating frostbite.

• Rapidly rewarm the affected body part.  Never attempt rewarming if there is risk of refreezing.
• An appropriate warming technique tub of water at 40-42°C. Higher temperatures should be avoided secondary to the risk of burns. If a tub is not available, use warm wet packs at the same temperature.
• It can take up to 40 minutes for the affected area to thaw.  Thawing is complete when the distal areas flush.
• The only indication for early surgical intervention is debridement of blisters, necrotic tissue or fasciotomy if there is  compartment syndrome.
• It often takes 1-3 months for frostbitten tissue to be declared viable. The affected area generally heals or shrivels and dries up without surgery. Amputation should be delayed as as long as possible. Early surgical consultation for amputation is rarely needed.

Adapted from Frostbite: Treatment and Medication by C. Crawfor Mechem, MD, MS, FACEP as posted on eMedicine.com.

The most common arrhythmias in children presenting to the ED are:

• Sinus tachycardia (50%)
• SVT (13%)
• Bradycardia (6%)
• Atrial Fibrillation (4.6%)

Atrial fibrillation in children is irregularly irregular with disorganized atrial activity with atrial rates ranging from 350-600 BPM. 

Children at increased risk of developing atrial fibrillation include those with underlying structural heart defects and hyperthyroidism.

Hemodynamically stable children have several treatment options including digoxin, amiodarone, propranolol, esmolol, or procainamide for ventricular rate control.

Hemodynamically unstable children need immediate synchronized cardioversion with 0.5 - 1 J/kg.  (don't forget light sedation.)

References:

Sacchetti A, Moyer V, Baricella R, et al. Primary cardiac arrhythmias in children. Pediatr Emerg Care 1999;15:95-98

Doniger S. Pediatric Dysrhythmias. Pediatric Emergency Medicine Reports. Sept 2008. Vol 13, No 9 (This was edited by a UMMS Combined EM/PEDS graduated Dr. Jim Colletti who is Associate Residency Director, Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN.)

Below is an edited version of this week's neurological clinical pearl. Somehow the scores and their definitions showed up incorrectly matched.  See corrections below.

• Verbal function is one of the three neurologic responses assessed by the Glasgow Coma Scale ( GCS).
• This response is scored on a scale of 1 to 5, 5 being the best response.
  • 5 = Oriented (responds coherently and appropriately to questions such as name, age, situation).
  • 4 = Confused (responds to questions coherently but with some disorientation and confusion).
  • 3 = Inappropriate words (random articulated speech but no conversational exchange).
  • 2 = Incomprehensible sounds (moaning but no words).
  • 1 = No verbal response.

BACKGROUND: 

For the first time since its publication, the centers for disease control has dedicated an entire issue of their Morbidity and Mortality Weekly Report to an emergency medical services topic. Vol 55 RR-1 reviews the, "Guidelines for Field Triage of Injured Patients." The report represents a consensus opinion of national experts in EMS, EM, and trauma care. It outlines which patients may be best served via transport to a trauma center.

CRITERION LINKED TO SEVERE INJURY  (Consider transport to nearest TRAUMA CENTER) 

• GCS < 14, SBP < 90 mm Hg, RR < 10 or > 29 per minute (or less than 20 for infants) 
• Penetrating wounds to neck, torso, head
• Flail chest, two or more proximal long bone fractures
• Proximal extremity amputation
• Paralysis
• Open or depressed skull fracture
• Older patients on anticoagulation

From the MMWR: "The National Study on the Costs and Outcomes of Trauma identified a 25% reduction in mortality for severely injured patients who received care at a Level I trauma facility." 

EXTRAS: 

The remainder of the report details the triage decision making process, explains trauma center capabilities, and provides an interesting and detailed review of trauma transport criteria. Link to the current issue is attached.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm

Octreotide

• Somatostatin-analog that supresses insulin secretion but also treats acromegaly, esophageal varices and secretory diarrhea
• Sulfonylurea-induced hypoglycemia requires frequent monitoring and administration of intravenous dextrose
• Octreotide is considered antidotal therapy since it turns off insulin secretion that is caused by sulfonylureas
• Recent article by Fasano et al Ann Emerg Med 2008 showed that octreotide 75 mcg SQ one-time in the ED was superior to "traditional" therapy with fewer recurrent hypoglycemic episodes during the patient's hospitalization.
• Excellent article worth reading, even if its just the abstract

Teaching in the Emergency Department

Effective ways to teach in the ED:

• Limit the amount of time you spend teaching (more teaching does not = more learning)....Take Home Point: teach a quick pearl about a case and move on. Dont belabor the point and keep teaching for 5-10 minutes. You will loose the learner.
• Make teaching points applicable to the patient. Theoretical stuff is fine but no one cares about the Krebs cycle or ATP.
• Teach "on the fly" (teach as good teaching moments come up on each case). "Board talks" are nice but are often times not practical in a busy ED.
• Above all, be enthusiastic...without this all teaching will be ineffective

Clinical Manifestations of Anaphylaxis

• Importantly, manifestations of anaphylaxis occur along a continuum and are dependent upon the type, route, and quantity of antigen exposure.
• Cutaneous (90%), respiratory (40-70%), cardiovascular (30-35%), gastrointestinal (40%), neurologic (10%), ocular, and genitourinary symptoms can all be seen.
• Include anaphylaxis in the differential of any patient with undifferentiated shock, as 10% will not manifest the cutaneous symptoms of urticaria and/or angioedema.

The use of a glycoprotein 2b/3a receptor antagonist (often inaccurately referred to as a "G2b3a inhibitor") is considered a Class I intervention for patients with unstable angina/non-STE-MI that are going for percutaneous coronary intervention, according to the ACC/AHA 2007 Guidelines.

The exact timing of the initiation of the G2b3aRA is the subject of some debate, but it is certainly worth discussing with your cardiologist consultant/receiving physician whether they want one of these medications initiated in the ED before taking the patient to the cath. lab, and if so which one of these meds they prefer.

Patient with iritis will typically present with a painful red eye and it can sometimes be difficult to tell if it is due to conjunctivitis or a corneal abrasion.  Some tips that can help differentiate iritis from other causes of painful red are:

1. When pain reduction was used as a diagnostic tool, it had a sensitivity of 80% and a specificity of 86% in determining whether a simple corneal injury was present. In iritis, the pain will NOT be relieved with topical anesthetic.
2. In iritis, injection will be localized predominantly around the iris and not diffusely over the conjunctiva.
3. The consensual light reflex can be used to make the diagnosis. Of course, shining a light in the affected eye will cause pain, but in iritis shining a light in the normal, unaffected eye (by causing consensual movement of the other affected iris) will cause pain if iritis is present.

Finally, ensure you document:

1. Visual Acuity corrected in both eyes.  Use a pinhole if they forgot their glasses.
2. That you flipped their eyelids to make sure that no foreign bodies are lurking under the lids
3. Stain their eyes with flouriscen to ensure there are no corneal abrasions in addition to the iritis.

Six indications that would lead you to suspect SVT in children:

• history incompatible (no history fever, volume loss, hemorrhage or pain
• P waves absent /abnormal
• HR does not vary with activity
• Abrubt rate changes
• Infants : rate usually >220
• Children : rate usually >180

Remember in the stable child treat withe Adenosine 0.1mg/kg rapid IV push followed by rapid flush.

In the unstable child treat with synchronized cardioversion 0.5 -1 Joules/kg.

Tetrodotoxin - Sodium Channel blocker - Extremely toxic causes paresthesias, dysrhythmias and paralysis - Found in the sushi called Fugu (From the Pufferfish) - Eating the sushi is considered a delicacy and goal is to get just enough of the toxin to get perioral paresthesias after eating. - Also found in the blue-ringed octopus, angelfish and parrot fish. Enjoy your seafood and take a look at the attached pic of actual fugu.

• Eye function is one of the three neurologic responses assessed by the Glasgow Coma Sacle ( GCS).


• This response is scored on a scale of 1 to 4, 4 being the best response.
  
  
  
  • 4 =  Spontaneous eye opening.
  
  
  • 3 = Eye opening in response to speech (not to be confused with eye opening in an asleep patient when prompted with speech; these would receive a 4, not a 3).
  
  
  • 2 = Eye opening with painful stimuli (i.e. nailbed pressure, supraorbital compression, and/or sternal rub).
  
  
  • 1 = No eye opening.
  
  
  
  

Sepsis and Mechanical Ventilation

• Essential components of the ED management of sepsis include early identification, antibiotics ASAP, fluid resuscitation, and maintaining adequate perfusion pressure.
• If patients continue to have evidence of shock (i.e. high lactate) despite adequate fluids and/or pressors, strongly consider intubation, even in the patient without acute respiratory decompensation.
• The respiratory muscles are avid consumers of oxygen and can use up to 50% of circulating O₂.
• Intubation and paralysis not only increase available O₂ to vital organs, it can also augment cardiac output for patients with persistent septic shock.

Thrombolytic Therapy for Pulmonary Embolism

Indications for administration of fibrinolytic therapy for acute PE:

• Cardiac arrest presumed to be secondary to PE-tPA 50 mg bolus, may be repeated once.
• Massive PE (hemodynamic instability)-arbitrarily defined by BP < 90 mm Hg systolic. Give 10 mg tPA bolus followed by 90 mg over 2 hours. Make sure heparin off during this time frame. tPA is the only FDA approved drug for this but some are starting to use Tenecteplase (single 0.5 mg/kg bolus).
• Submassive PE (normal hemodynamics and evidence of RV strain). This tends to be the most controversial group, although many authorities are now advocating its use. Strongly suspect strain if the Troponin/BNP are elevated and get an ECHO if they are. Most studies that advocate for lytics in this group show significant improvement in PA pressures, RV wall dilatation, etc. What is currently missing is outcome data...i.e. how short of breath and disabled are people with submassive PE at 6, 9, and 12 months? Bottom line, enough evidence exists to support giving to stable patients with RV strain as long as they are carefully screened.
• There is NO evidence that lytics are useful in stable patients without RV strain.
• The administration of thrombolytic therapy for acute PE is within the scope of practice of emergency medicine.

Conjunctivitis:

Patient presenting to the Emergency Department complaining of "Pink Eye" is very common but how can you be sure that they do not have a bacterial conjunctivitis and absolutely need antibiotics or are they just suffering from a viral or allergic conjunctivitis.

• Bacterial conjunctivitis will typically have  a mucopurulent discharge and the patients will complain that their lids are matted shut in the morning. Though this can occur in allergic or viral conjunctivitis, those with bacterial conjunctivitis typically have a wet, sticky mucopurulent material matted to their lids where viral/allergic conjunctivitis typically have crusting on their lids and lashes due to dried tears and serous secretions.  Bacterial conjunctiviits is also an uncommon condition due to the defense systems of the eye. So most patients can be treated with support care (ie: Warm Compresses).
• Allergic conjunctivitis should affect both eyes.  It would be odd for only one eye to be allergic, so if only one eye is infected that diagnosis is most likely viral or bacterial conjunctivitis.
• When treating allergic conjunctivitis go with the drops.  Several studies have now shown that topical therapy is better than systemic (ie: benadryl, zyrtec, allegra, or claritin) in the resolution of symptoms.

• Burn injuries are common in children and are the 3rd leading cause of unintentional injuries in children age 0 to 18 yrs, only behind MVCs and drowning.


• Burns greater than 20% TBSA require agressive fluid resuscitation. Lactated Ringer's is the most commonly used fluid. 


• Parkland Burn Formula:  LR over 24 hours = 4mlxkgx %BSA burned. 1st half over 1st 8 hours, 2nd half over subsequent 16 hours.  Add maintenance fluids to this amount for patients < 30 kg.


• Urine output is the best way to assess adequate fluid resuscitation.  Place a foley and goal output is 1-2 ml/kg/hr in children.  (0.5 to 1 ml/kg/hr in adults)


• Oligoanalgesia is very common in pediatric patients.  Use morphine 0.1 mg/kg IV/IM or Oxycodone 0.1 mg/kg po.


• 6% of burned children < 12 years old are victims of abuse.  So keep a high index of suspicion in children with burns. 

• Glasgow Coma Scale (GCS) is a validated score intended to provide a reliable and objective method for recording and communicating a patient's consciousness.
  

• It was originally created to assess head injury patients' neurologic status/deficit.
  

• The scale ranges from 3 (deeply unconscious) to 15 (fully awake).
  

• It tests the following three responses:  (1) eye, (2) verbal, and (3) motor, listed in order of increasing functional significance with regard to status (i.e. optimal eye response assigned lower score (best score = 4), followed by a best score of 5 for verbal response, and optimal motor function being scored at 6.

A few previous pearls have touched on identifying drugs that cause QT prolongation.  In our patient population, methadone is one of the more common causes of drug-induced prolonged QT syndrome.  Of 692 physicians surveyed (35% family practitioners, 25% internests, 22% psychiatrists, and 8% self-identified addiction specialists) only 41% were aware of methadone's QT-prolonging properties and just 24% were aware of methadone's association with torsade de pointes.

Now that you know, what do you do when a patient on methadone presents with a QTC of 580 msec and intermittent runs of vtach and torsade de pointes?

The answer is... the exact same thing you would do with any other patient who presents this way, regardless of the cause.

• Give magnesium sulfate 2 gm IV for torsade de pointes
• Check magnesium and potassium levels.  If low (which they often are), replete.
• Monitor continuous EKG.

Buprenorphine, an alternative to methadone, is not associated with prolonged QT syndrome.

Intracerebral hemorrhage and fluid management

• Isotonic fluids (0.9% saline) are the standard IV fluid for patients with ICH
• The goal for fluid management is to maintain euvolemia with a urine output > 0.5 cc/kg
• Importantly, 0.45% saline and dextrose containing IVFs should be avoided, as they can exacerbate cerebral edema and increase ICP
• Hypertonic saline has become a popular aternative to normal saline in patients with significant perihematomal edema and mass effect
• Goals when using hypertonic saline are to maintain serum osmolality between 300 - 320 mOsm/L and serum sodium between 150 - 155 mEq/L

Neurologic Manifestations of Acute Aortic Dissection

A myriad of neurologic presentations of acute aortic dissection have been reported in the literature. Although classic CVA symptoms may occur, nonspecific neurologic symptoms are much more common

These include:

• Classic stroke-like/TIA symptoms
• Encephalopathy (may look like a drug overdose)
• Seizures (ask Mike Abraham about his abdominal pain/seizure case)

Take Home Point:

• Consider the diagnosis of acute aortic dissection in patients with these findings who ALSO HAVE chest, back, or abdominal pain +/- risk factors for the disease (i.e. HTN, family history, Marfans, cocaine, etc.)

Otitis Externa:

Infections of the external ear canal are common and can typically be treated with topical antibiotic solutions (Cortisporin Otic, Cipro Otic, etc...) or antibiotic solutions mixed with topical steroids (Cortisporin HC Otic, Cipro HC Otic, etc...).  Most patients should not require PO or IV antibiotics.

However, you need to always be on the look out for malginant otitis externa (MOE) which is a more deep seated infeciton extending into the temporal bone and can have a mortality rate as high as 50%.  Patients that are diabetic, immunospressed, or have had radiation therapy to the base of the skull are at increased risk.  Patients with MOE typically have pain out of proportion to clinical findings and granulation tissue may be present in the ear canal.  Suspect this diagnosis in patients that have cellulitis or extreme tenderness over the mastoid process.

If you suspect MOE the patient should be started on antibiotics that cover pseudomonas. Consider obtaining a CT scan with temporal bone cuts and an Otolaryngology consultation.

Next time you have to do a full septic work up on a 2 month old with a fever of 104 F consider giving Ketamine 3mg/kg IM before even starting.  Then you can obtain your cath urine, IV, and LP with a calm pain free patient!!

Ketamine induces a catatonic state that provides sedation, analgesia, and amnesia.  It does not affect pharyngeal-laryngeal reflexes and the patient maintains a patent airway.  This makes it very useful when fasting is not assured.   

Route          Onset          Duration             Dose

  IM            3-5 min         20-30min         3-5 mg/kg

  IV             1 min            5-10 min          1-2 mg/kg

Although we tend to think of ACS with cocaine use, there are many other serious complications, including:

• Agitation, psychosis, and anxiety
• Hyperthermia
• Vascular headache of withdrawal
• Seizures
• Hemorrhagic stroke (many of these patients have an underlying vascular abnormality)
• Ischemic stroke
• Acute Renal Failure
• Crack Lung: acute pulmonary syndrome that occurs after inhaling freebase cocaine presents as fever, dyspnea, hypoxemia, diffuse alveolar infiltrates, and respiratory failure
• Intestinal perforations

Blood Pressure Control in ICH

• Aggressive BP reduction after ICH is currently the focus of an ongoing NINDS study (ATACH Study)
• Current literature recommends that extreme levels of BP after ICH be treated to reduce hematoma expansion
• Mean arterial pressures (MAP) > 130 mmHg should be treated with continous IV medications
• Current recommended medications include labetalol, esmolol, nicardipine, and fenoldopam
• Nitroprusside is avoided by many given its tendency to increase ICP
• Oral and sub-lingual medications are not indicated for immediate and precise BP control

This pearl is dedicated to Dr. Michael Rolnick....

Infections That Cause Temperature-PulseDissociation

Certain infections may cause temperature-pulse dissociation (relative bradycardia in association with fever).

Remember that normally there will be an increase in pulse rate by 10 bpm for every 1 degree increase in temperature. So, if a patient has a temperature of 103 F, expect them to be tachycardic.

Any intracellular organism has the potential to cause a relative bradycardia (Faget's sign)

Infections that cause dissociation:

• Salmonella typhi
• C burnetii (agent of Q fever)
• Chlamydia infections
• Dengue fever

It is almost impossible to get through a shift these days with out seeing an abscess that is caused by CA-MRSA.  As of the 2007 Antibiotic nomogram (2008 data not yet available) at University of Maryland CA-MRSA was only 70% sensitive to clindamycin, and >98% sensitive to bactrim and > 96% sensitive to doxcycline.  A local community hospital in Baltimore is showing only 55% sensitivity to clindamycin.

As a New Year's resolution to yourself I recommend that you check with your local hospital's Micrology department to see what the sensitivities are to bactrim, clindamycin, doxycycline.  If sensitivities are less than 80% it would generally be recommended that these medications not be used as initial empiric treatment.

For Baltimore bactrim and doxycycline should probably be the preferred treatment options.

Have a Great New Year.

Propofol is an IV hypnotic that is made in a soy-based emulsion containing soybean oil, egg lecithin, and glycerol.  It has a very rapid onset time (10-50 seconds) and a brief duration of action making it ideal for ED sedation.  Children have a more rapid metabolism of propofol than adults.  Propofol has been shown to be safe and effective for Pediatric ED sedation in several studies.  

Pearls on Propofol

• Dosing is 1mg/kg bolus than 0.5 mg/kg IV q 1-2 min until desired sedation occurs
• Due to high lipid concentration can cause pain at injection site in up to 70% of patients.  This can be prevented by applying a rubber tourniquet well above IV site and injecting 0.5 mg/kg of lidocaine 30 seconds before injecting the propofol. 
• Use is contraindicated in those with allergies to Eggs, Soy, or sulfites, or those with mitochondrial disorders
• PRIS (Propofol Infusion Syndrome) was described in 1992 with case reports of children dying due to metabolic acidosis, rhabdomyolysis, and refractory heart failure when receiving high doses (>4mg/kg/h) for >48 hours.  And it is more associated with children < 4 years old. 
• So while safe for pediatric procedural sedation don't use propofol as a drip for intubated children.

Watch out for tradename and generic name's of medications.

They can get the patient and yourself into trouble:

• coumadin: warfarin, jantoven
• diphenhydramine: unisom, benadryl, tylenol PM

Classic example is my own case: Insert a central line in a patient - subclavian - and shortly after completion am alerted the patient's INR is 25. No adverse outcome but when I reviewed the med list, I did not see coumadin or warfarin and assumed I was in the clear. Patient was on jantoven.

Happy Holidays

• The most common anatomical locations for ischemic stroke are in the internal capsule and the basal ganglia.


• Look for hypodensity (i.e. darkening which suggests edema) in these parts of the brain on CT when trying to locate areas of stroke.


• Acute stroke typically takes at least 3 hours to manifest in the form of edema on Head CT.  The larger the stroke, the quicker the abnormality is seen.

Hemofiltration

• Renal replacement therapy (RRT) involves the use of semipermeable membranes to remove fluid and toxic substances from the bloodstream
• The basic methods of RRT are hemodialysis (HD) and hemofiltration (HF)
• There have been a few cases in our ED in which our Renal consultants have used HF
• Hemofiltration can remove large volumes of fluid (up to 3 Liters per hour)
• Major advantages to HF: less likely to produce hypotension than HD, can remove larger molecules than HD
• Disadvantages to HF: must be done continuously to provide effective dialysis, requires anticoagulation to maintain circuit patency, not well suited for hypotensive patients (requires a hydrostatic pressure gradient for solute clearance)

A neutropenic cancer patient that presents with right lower quadrant abdominal pain, fever, and bloody diarrhea should raise suspicion for typhlitis (necrotizing colitis, cecal inflammation). This most commonly occurs in patients with hematologic malignancies who have been treated with cytotoxic agents. This condition is high risk and is associated with high morbidity and mortaiity.

Treatment:

• Broad-spectrum antibiotics
• CT scan of the abdomen and pelvis
• Surgical consultation
• Usually requires ICU admission

An increasing amount of attention in the literature is now being paid to ways of optimizing care of patients that are post-cardiac arrest. Simple things to focus on for us in the ED are the following:
1. induction of therapeutic hypothermia
2. aggressively manage hypotension and cardiac ischemia
3. treat hyperglycemia aggressively
4. avoid hyperventilation, though maintain adequate oxygenation

 

Critical Care Billing Pearls:

As the table shows Critical Care billing will earn you approximately 25% more with no additional overhead.  Critical care time must be at least 30 minutes, and the following procedures are included in the critical care code:   

• Interpretation of ABG and labs
• Interpretation of CXR
• IV insertation
• Transcutaneous pacing
• Blood Draws
• NG Tube placement

The following procedures are not bundled into critical care time, so they can be billed separately, therefore the time you spend doing these procedures can not be included in your total critical care time:

• Central Line Placement
• Lumbar Puncture
• Intubation
• Transvenious pacemaker placement
• Arterial Line Placement
• Chest Tube Placement
• CPR

Remember critical care time does not need to be continuous but you need to be immediately available to the patient for the time to count.  You can not count time going off the floor to review an xray or CT, but this time can be counted if you do it in the immediate vacinity of the patient.

FINAL CAVEAT  To help your coders bill appropriately it helps to include a statement such as "Critical Care time XX minutes where I was directly involved in the care of this patient exclusive of all other separately billable procedures."

• Bronchiolitis is the most common lower respiratory tract disease in infants, and RSV (Respiratory syncytial virus) bronchiolitis is the leading cause of hospitalization in infants.  It will infect 90% of children by 2 years of life.
• Bronchiolitis "season" in the US is typically December to March but it does occur year round. 
• Pathology is caused by respiratory epithelial cell death that results in inflammation, edema, smooth muscle contraction, bronchoconstriction and mechanical obstruction by cellular debris and mucus plugging.
• History that suggest Bronchiolitis is cough, rhinorrhea, fever
• Most common PE findings are runny nose, tachypnea, wheezing, cough, crackles, use of accessory muscles,  and/or nasal flaring.
• Respiratory distress, dehydration, sepsis, and RSV associated apnea are feared severe complications.
• RSV associated apnea may be the presenting symptom in some infants. 
  • Infants at greatest risk for this are younger (usually < 3 months), hx of prematurity, hx of apnea of prematurity, and those who are early on in the illness.

• Despite guidelines that recommend against opioid use as first-line treatment for migraine headaches,  meperidine (Demerol) is still administered in 36% of all migraine headache ED visits in the U.S.

• Meperidine's lack of efficacy, adverse effects such of seizure, and toxic metabolic accumulation all contribute to its use for migraine headaches being discouraged.

• A recent meta-analysis out of New York again supports the avoidance of using meperidine for migraine headaches, and instead, encourages clinicians to use anti-emetic and dihydroergotamine regimens.

Catheter Positioning

• Central venous catheters (CVC) inserted from the left side must make an acute angle downward when the enter the SVC from the innominate vein
• CVCs that do no make this turn can end up with the tip pointing directly at the lateral wall of the SVC
• CVCs in this position can cause perforation of the SVC
• If the catheter tip is pointing at the SVC, then advance the catheter further down

There is clearly no way you can document everything on a chest pain chart. However, there are some pretty important things that should be on the chart.

Some key things to consider documenting:

• Why you did not work up someone's chest pain, i.e. what would you want your chart to look like if the patient went home to have an MI and an attorney looked at your chart? You don't think a ECG is warranted? Fine. Just document why. The chart tells all.
• Documentation of risk factors for the three deadly causes of chest pain: ACS/MI, aortic dissection, and PE. Documenting these is proof you were thinking about a differential diagnosis.
• Documenting key chest pain physical exam findings and pertinent negatives-Documenting "legs normal, no DVT" is proof you were thinking about PE the whole time, even if it isn't in your medical decision making section. Writing "no diastolic murmur" is proof you thought about aortic dissection. These kinds of documentation pearls will serve to make the chart defensible. Obviously, you should perform this part of the exam and not just write it on the chart.
• Documentation of why you didn't go after ACS, aortic dissection, or PE. We will all make mistakes in our careers. And remember, we can't diagnose every MI, dissection, and PE. But, remember that you want your chart to show that you thought about these bad boys and WHY you didn't go after them. What is frequently missing on charts of missed MI, AD, and PE is exactly this!

It seems to come up about once or twice a month about the safety of metronidazole in pregnancy.  This has been very controversial over the years, but the current stance is that it is safe in pregnancy.  In fact, untreated vaginal infections, bacterial vaginosis and trichomonas, have been associated with miscarriages and preterm labor, so the benefits outweigh the risks.

Below are two good references to add to your file in case you get into a debate with somebody quoting old data.

Organization of Teratology Information Specialists Information on Flagyl and Pregnancy

Safety of metronidazole during pregnancy: a cohort study of risk of congenital abnormalities, preterm delivery and low birth weight in 124 women. J Antimicrob Chemother 1999; 44: 854-855 http://jac.oxfordjournals.org/cgi/content/full/44/6/854

Important things to document in acute ischemic stroke cases from a medicolegal aspect:

-- time of onset
-- time of diagnosis
-- why tPA given or not given (the longer note for NOT giving it; 90% of related litigation cases based on NOT giving tPA.)
-- date and time on each side of note of every page
-- make it legible
 

Central Venous Catheter Occlusion

• Many of us care for patients that present with pre-existing CVCs
• Catheter occlusion is the most common complication associated with CVC
• Thrombosis is the most common cause of obstruction of CVCs
• Thrombosis is often be due to insoluble precipitates; meds such as diazepam, digoxin, phenytoin, and TMP-SMX can cause these precipitates
• Local instillation of a thrombolytic agent (tPA) can be effective in restoring CVC patency
• One protocol for use of tPA in CVC occlusion is to:
  • reconstitute a 50 mg vial with 50 mL sterile water (1 mg/mL)
  • draw up 2 mL in a 5 cc syringe and inject into the CVC - total tPA dose 2 mg
  • leave in place for approximately 2 hours
  • attempt to flush the CVC with a saline solution
• If the catheter remains obstructed, a new CVC should be placed at a new site
• The total drug dose in this regimen (4 mg) is too small to cause systemic thrombolysis

Hypertension and Epistaxis

We commonly encounter patients with epistaxis who are found to be hypertensive. Some have taught over the years that hypertension causes nosebleeds and that some nose bleeds won't stop until the BP is lowered...

Some pearls about HTN/Epistaxis:

• Most patients we see with hypertension are not experiencing epistaxis, casting serious doubt on a causal relationship
• Studies show that the degree of blood pressure elevation does not correlate with risk of nose bleed
• No studies have ever shown that acute BP reduction in the ED for a nose bleed is beneficial or reduces bleeding
• Much of the debate is sparked by our ENT colleagues who swear that hypertension leads to nose bleeds and that bleeding will not stop until the BP is "treated." Much of this is based on experience with patients in the OR or IR suite. These blood pressures tend to be treated with IV antihypertensives by the ENT folks, and they feel pretty strongly about this relationship.