My Emergency Medicine Blog

How is a partial flexor tendon injury diagnosed? Treated?

2014-06-22T13:04:00.001-04:00

Partial flexor tendon injuries are diagnosed by visual inspection as motor activity of the finger may not be compromised. It is important to visualize the tendon in its position at the time of injury.

Flexor tendon injuries less than 20% often to don't need to be sutured, however tattered tendinous tissue should be cleaned up to prevent a trigger finger. Lacerations more than 20% should be sutured.

Source

Hart, R. et al. Emergency and Primary Care of the Hand. 2001.

Davenport M. Chapter 47. Injuries to the Arm, Hand, Fingertip, and Nail. In:Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds.Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.

Fill in the blanks: Patients with a history of adrenal insufficiency should increase their home dose of steroids by times the normal dose for days when confronted with an acute illness (fever, URI, tooth extraction, etc ...)

2013-09-11T08:55:00.000-04:00

Patients with a history of adrenal insufficiency should increase their home dose of steroids by two to three times the normal dose for three days when confronted with an acute illness (fever, URI, tooth extraction, etc ...)

Source

Burgess, B. and Roe, J. "Adrenal Insufficiency" Critical Decisions in Emergency Medicine. July 2012.

The pattern of symmetric, proximal weakness without reflex or sensory abnormalities localizes weakness to what location?

2013-08-01T11:16:00.000-04:00

Muscle or neuromuscular junction.

Source

Conwell, W. et al. "Weakness in the Knees" NEJM. Aug 1, 2013.

What are the indications for inotropic agents (dobutamine and/or milrinone) in treatment of acute decompensated congestive heart failure?

2013-03-29T21:22:00.000-04:00

advanced systolic heart failure (reduced left ventricular ejection fraction) with marginal systolic blood pressure (less than 90 mmHg)
advanced systolic heart failure with intolerance or minimal responsive to intravenous vasodilators and/or diuretics

Source

Colucci, W. "Treatment of decomensated heart failure: Components of therapy" Up to Date. 2012 Nov.

What are some clues to help distinguish viral from drug-induced exanthems?

2013-02-11T22:22:00.000-05:00

It is often difficult to distinguish but here are some clues ...

viral exanthems often have associated fever, malaise, sore throat and conjunctivitis; although drug reactions may have these features also
viral exanthems happen more frequently in children; although adults can get them too
a rash that develops within 3 days of a drug being initiated for an infection is more likely secondary to the infection because of the time required for hypersensitivity to develop in a patient not previously sensitized to a particular drug

Selected infections and Other Conditions that Often Include an Exanthem and Characteristics that Help Differentiate Them from an Exanthematous Drug Eruption. (click image to enlarge)

Source

Stern, R. "Exanthematous Drug Eruptions" NEJM. 28 June 2012.

For treatment of burns, why might bacitracin be favored relative to silver sulfadiazine even though its antimicrobial coverage is less broad?

2013-01-31T13:20:00.000-05:00

because silver sulfadiazine causes:

allergy in patients with sulfa sensitivity
permanent silver staining of the skin and therefore should not be used on the face or other cosmetically sensitive areas
severe hemolysis in patients with G6PD
sulfonamide kernicterus in children less than 2 months and therefore should be avoided in pregnant women, newborns and nursing mothers

Source

Hall, R., Watts, L., and Bashiti, S. "Thermal Burns" Critical Decisions in Emergency Medicine. March 2012.

What is the treatment of hemolytic-uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP)?

2013-01-29T12:08:00.002-05:00

Plasma exchange. This will remove antibodies to a von Willebrand factor-cleaving protease (ADAMTS13), deplete very high circulating levels of von Willebrand factor (VWF) multimers, and replace the missing protease (ADAMTS13). If there is a delay in initiating plasma exchange, give FFP which contains ADAMTS13.

Consider the diagnosis of HUS and/or TTP when there is unexplained thrombocytopenia (typically less than 20K) + microangiopathic hemolytic anemia (MAHA) [schistocytes, normal PT/PTT, elevated LDH, elevated indirect bili, dereased haptoglobin)

Source

Kaplan, A. and George, J. "Treatment of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome in adults" Up to Date. Jan 2013.

Sabatine, M. Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. 3rd ed.

How should the hypertensive pregnant patient be evaluated and treated?

2013-01-27T21:45:00.000-05:00

First ask, what is the gestational age?

if less than 20 weeks and blood pressure greater than 150/100, start antihypertensive medication in consultation with obstetrics. Mild hypertension should not be treated as it does not decrease adverse events.
if greater than or equal to 20 weeks and blood pressure greater than 140/90, test urinalysis. If greater than 1+ protein in UA, patient has preeclampsia or associated complication (ecalmpsia, HELLP syndrome); check CBC, basic chemistries, LFTs, uric acid, d-dimer, fibrinogen, coags and consult OB.

Source

Deak, T. and Moskovitz, J. "Hypertension and Pregnancy" Emerg Med Clin N Am. Nov 2012.

Does presence of an elevated anion gap mean that there is a metabolic acidosis?

2013-01-24T11:17:00.002-05:00

Generally yes but not always. Aside from the organic metabolic acidoses, an elevated anion gap can also be caused by hyperalbuminemia, hyperphosphatemia or presence of an anionic paraprotein (IgA monoclonal immunoglobulin) but given that these are fairly rare occurrences, once ruled out, metabolic acidosis is the presumed etiology of an elevated anion gap.

Source

Emmett, M. "Serum Anion Gap in Conditions Other than Metabolic Acidosis" Up to Date. Nov 2012.

What maneuvers may help you manage a shoulder dystocia during vaginal delivery?

2013-01-21T12:55:00.000-05:00

Shoulder dystocia occurs when the anterior shoulder of the infant can't be delivered under the pubic symphysis. Several maneuvers may be helpful.

McRoberts: Mother's hips are placed in hyperflexion against the abdomen while being slightly abducted and externally rotated. Position can be augmented by 2 assistants with each holding one of the patient's legs.

Rubin I: Downward pressure is applied just proximal to the symphysis pubis. Pressure can be applied continuously or in a rocking motion. Success is increased when combined with McRoberts maneuver.

Rotational: Rotate infant slightly clockwise or counterclockwise to try and free up and subsequently deliver the anterior shoulder. If this doesn't work, consider rotating the infant 180 degrees and trying to deliver the posterior shoulder first.

Manual delivery of posterior arm: Insert hand into the vagina and flex the posterior arm of the fetus, bringing it across the chest. The posterior arm is then delivered over the perineum which allows the provider to rotate the fetus to allow delivery of the anterior shoulder once the rotation has disimpacted it from the pubic symphysis.

Gaskin Position: Place mother in a hands-and-knees position, "on all fours."

Here's a video that puts it all together ...

Sources

Image Source (McRoberts): http://altair.chonnam.ac.kr/~tbsong/medical/sh-dyst/McRoberts.htm

Image Source (Rubin I): http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/18.aspx

Image Source (Rotational): http://shoulderdystociainfo.com/resolvedwithoutfetal.htm

Image Source (Manual delivery of posterior arm): http://www.glowm.com/resources/glowm/cd/pages/v2/v2c079.html

Image Source (Gaskin): http://www.sciencedirect.com/science/article/pii/S0889854505700899

Video Source: http://www.youtube.com/watch?v=YB3_fPhgmUM

Silver, D. and Sabatino, F. "Precipitous and Difficult Deliveries" Emerg Med Clin N Am.

Roberts, J. and Hedges, J. "Emergency Childbirth" Clinical Procedures in Emergency Medicine. 2010.

When should hydrocortisone be administered to treat presumed adrenal insufficiency? What is the dose of hydrocortisone?

2013-01-18T15:04:00.000-05:00

hypotension out of proportion to the severity of illness
other clinical features suggestive of primary adrenal insufficiency (where hemodynamic collapse is most prominent secondary to both cortisol and aldosterone depletion) include hyperkalemia, hyponatremia, non-anion gap acidosis, hyperpigmentation and hypoglycemia.

Hydrocortisone dose is 100 mg IV for adults and 1 - 3 mg/kg IV for children.

Source

Burgess, B. and Roe, J. "Adrenal Insufficiency" Critical Decisions in Emergency Medicine. July 2012.

How do you perform a breech delivery?

2013-01-15T09:31:00.000-05:00

Source

Tibbles, Carrie MD. "Emergency Delivery: Are You Prepared?" ACEP Scientific Assembly 2012.

Video Source: http://www.youtube.com/watch?v=PRZ47zdEAzo

What lesion differentiates scabies from other rashes?

2013-01-14T21:09:00.003-05:00

A curved or linear burrow about 1 to 10 mm long (caused by the movement of the mite in the stratum corneum) that often ends in a tiny papule or pustule.

Source

Marco, C. and Soleimani, M. "Cutaneous Infestations" Critical Decisions in Emergency Medicine. Jan 2013.

Image Source: http://www.bpac.org.nz/magazine/2009/february/scabies.asp

According to the Infectious Diseases Society of America , which children with upper respiratory traction infection (URI) symptoms (nasal congestion, rhinorrhea, or cough) should receive antibiotics? Which antibiotic?

2013-01-10T12:58:00.001-05:00

persistent symptoms greater than or equal to 10 days
severe symptoms (temperature greater than 38.5 C or 101.4 F for 3-4 days or purulent rhinorrhea for 3-4 days)
return of symptoms after initial resolution

While viral URIs are common in children, the above symptoms are suggestive of a bacterial infection (sinusitis) and warrant treatment with antibiotics. The antibiotic of choice is amoxicillin-clavulanate. Alternatives include cephalosporins (cefuroxime, cefpodoxime, cefdinir) and levaquin. Macrolides and trimethoprim-sulfamethoxazole are no longer recommended given changing susceptibility patterns.

PS. levaquin is safe in children despite what many of us were taught

Source

DeMuri, G. and Wald, E. "Acute Bacterial Sinusitis in Children" NEJM. 20 Sept 2012.

Playe, S. "Quinolones for Kids? The Good News is the Bad News" Emergency Medicine News. March 2007.

What percentage of patients with Guillain-Barre syndrome (GBS) don't have albuminocytologic dissociation (high levels of protein and normal cell counts) in their spinal fluid? What percentage have don't have decreased reflexes?

2013-01-08T11:21:00.000-05:00

50% with no albuminocytologic dissociation
10% without decreased reflexes

Both of which are generally considered classic findings of GBS

Source

Yuki, N. and Hartung, H. "Guillain-Barre Syndrome" NEJM. 14 June 2012.

What is the probability that a well appearing 18 month old caucasian female infant with fever of 102.2 F (39 C) and URI symptoms has a concurrent UTI? Would you obtain a urinalysis to r/o UTI?

2012-03-09T03:43:00.003-05:00

3% - 8%.


One proposed diagnostic algorithm for febrile female infants aged 3 to 24 months suspected of having a UTI. Click image to enlarge.

Source

Singh, R. and Carpenter, C. "Does This Child Have a Urinary Tract Infection?" Annals of Emergency Medicine. May 2009.

Shaikh N, Morone NE, Lopez L, et al. "Does this child have a urinary tract infection?" JAMA 2008; 298:2895.

I am the most lethal tick-vector illness in the United States and and cause most of my havoc in the southeastern United States. Who am I?

2012-03-05T12:18:00.000-05:00

Rocky Mountain spotted fever

Source

Lowenstein, R. "Deadly viral syndrome mimics" Emerg Med Clin N Am. 2004.

A poignant and insightful essay regarding the evolution of our society's perspective on death and dying

2012-03-04T11:24:00.002-05:00

"Our unrealistic attitudes about death, through a doctor’s eyes" by Dr. Craig Bowron.

78 y/o male with remote history of GI bleeding and IVC filter placement for treatment of previous DVT/PE presents with acute right leg swelling. Doppler notes recurrent DVT. What is the treatment?

2012-03-02T02:33:00.001-05:00

Reevaluate the initial contraindication to anticoagulation and purpose for IVC filter placement, in this case GI bleeding, and determine whether the contraindication still exists or can be mitigated. If the patient can be anticoagulated, he should be. An IVC filter should not be viewed as an equivalent substitute to anticoagulation in the setting of acute VTE and is certainly not an “insurance policy” against subsequent PE. Small thrombi are capable of passing through patent filters or through collaterals around obstructed filters; furthermore, direct thrombus extension can occur through the filter itself.

Source

Greer, J. Wintrobe's Clinical Hematology. 12 ed. 2008.

Fedullo, P. "Inferior vena cava filters" Up to Date. Jan 2012.

Nanda, S. "Inferior Vena Cava Anomalies - A Common Cause of DVT and PE Commonly Not Diagnosed" American Journal of the Medical Sciences. May 2008.

39 y/o male with no significant past medical history presents status post syncopal episode while getting a tattoo. Vitals and physical exam unremarkable. EKG, when compared to prior, notes new changes. Admit or discharge?

2012-02-28T17:47:00.009-05:00

Prior and new EKG. Click image to enlarge.

scroll down for answer

Discharge after correcting left arm - left leg EKG lead reversal and obtaining a repeat EKG which will look exactly like the prior EKG, with no significant change noted. The big tip off here for misplaced leads is the significant change in axis of the QRS complex in leads III and aVF.

Patient likely had vasovagal syncope from painful stimulus of tattoo.

Left arm - left leg lead reversal causes lead I and II to switch places, aVL and aVF to switch places and III to invert. Click image to enlarge.

Source

Codagan, M. "The power of social media leads to reversal." Life in the Fastlane. 26 Sept 2011.

16 y/o female with no significant past medical history presents with sharp/pleuritic chest pain which improves when sitting up and leaning forward. EKG demonstrates changes consistent with pericarditis. Does this patient have pericarditis? If so, what is the work up?

2012-02-27T14:44:00.001-05:00

Yes, she has pericarditis. Acute pericarditis is diagnosed by the presence of at least two of the following four criteria:

typical chest pain
suggestive changes on the EKG
pericardial friction rub
new or worsening pericardial effusion

Workup includes:

EKG
chest x-ray
cbc, troponin, ESR, CRP
echo
if febrile, blood cultures
if on coumadin or at risk of coagulopathy, INR/PT/PTT

Purpose of workup is to identify pericarditis patients at high risk of tamponade (ie malignancy, TB, purulent pericarditis, anticoagulation, large pericardial effusion greater than 20 mm) and arrhythmia (ie patients with concomitant myocarditis as suggested by an elevated troponin or new ventricular systolic dysfunction). High risk patients should be admitted to the hospital for further evaluation.

Source

Imazio, M. "Clinical presentation and diagnostic evaluation of acute pericarditis" Up to Date. Jan 2012.

Is this EKG of a 19 y/o male with chest pain more suggestive of early repolarization or pericarditis?

2012-02-27T00:00:00.002-05:00

click on image to enlarge

Based on this EKG alone it is hard to tell but if I had to guess I would place my bet on early repolarization. Here's why:

There is no PR segment deviation (relative to the TP segment), neither PR elevation in aVR nor PR depression in the other leads.
Compared to an old EKG (not shown) there are no evolving changes. Pericarditis causes a typical progression of EKG changes from onset of disease to resolution.
The ratio of ST elevation to T wave amplitude in V6 is less than 0.24. If it is greater, than pericarditis is present.
Finally, the ST elevations are primarily located in the precordial leads. Pericarditis generally causes diffuse ST elevations in BOTH limb and precordial leads whereas about half of patients with early repolarization have no ST deviations in the limb leads.

Source

Imazio, M. "Clinical presentation and diagnostic evaluation of acute pericarditis" Up to Date. Jan 2012.

78 y/o male presents with intermittent crushing chest pain for the past 20 hours but is now pain free. Vitals stable. EKG notes ST elevation in anterior precordial leads and troponin is significantly elevated. Should patient be taken for immediate percutaneous coronary intervention (PCI)?

2012-02-11T16:54:00.004-05:00

No. PCI should not be performed in asymptomatic patients who present more than 12 hours after symptom onset who are hemodynamically and electrically stable.

If, however, a patient presents within 12 to 24 hours of symptom onset and is hemodynamically or electrically UNstable, has severe congestive heart failure or exhibits evidence of persistent ischemia (chest pain or anginal equivalent), immediate PCI is recommended (class IIa).

Source

Reeder, G. "Overview of the acute management of acute ST elevation myocardial infarction" Up to Date. January 2012.

45 y/o male s/p tracheostomy three days ago presents with massive bleeding of bright red blood from about his trach. A tracheo-arterial fistula is suspected. What is your next move?

2012-02-08T03:39:00.002-05:00

DON'T remove the trach; then, hyperinflate the cuff to tamponade the bleeding. If the trach is removed the patient will aspirate blood and asphyxiate.

Fortunately, tracheo-arterial fistula after trach is a rare complication but can occur from erosion into the brachiocephalic trunk, especially with placement of a low lying trach below the third tracheal ring.

Pressure necrosis from a trach tube can erode into the brachiocephalic artery which runs anterior to the trachea.

Sources

Praveen, CV. "A rare case of fatal haemorrhage after tracheostomy" Ann R Coll Surg Engl. 2007.

Image source: http://www.hawaii.edu/medicine/pediatrics/pemxray/v6c19.html

Identify on this x-ray what is preventing the patient's picc line from being easily removed?

2012-02-05T12:32:00.003-05:00

Arrow denotes knot at distal aspect of picc line. Click image to enlarge.

Removed under fluoroscopy in operating theater by vascular surgery.

My Emergency Medicine Blog

How is a partial flexor tendon injury diagnosed? Treated?

Fill in the blanks: Patients with a history of adrenal insufficiency should increase their home dose of steroids by ______ times the normal dose for ______ days when confronted with an acute illness (fever, URI, tooth extraction, etc ...)

The pattern of symmetric, proximal weakness without reflex or sensory abnormalities localizes weakness to what location?

What are the indications for inotropic agents (dobutamine and/or milrinone) in treatment of acute decompensated congestive heart failure?

What are some clues to help distinguish viral from drug-induced exanthems?

For treatment of burns, why might bacitracin be favored relative to silver sulfadiazine even though its antimicrobial coverage is less broad?

What is the treatment of hemolytic-uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP)?

How should the hypertensive pregnant patient be evaluated and treated?

Does presence of an elevated anion gap mean that there is a metabolic acidosis?

What maneuvers may help you manage a shoulder dystocia during vaginal delivery?

When should hydrocortisone be administered to treat presumed adrenal insufficiency? What is the dose of hydrocortisone?

How do you perform a breech delivery?

What lesion differentiates scabies from other rashes?

According to the Infectious Diseases Society of America , which children with upper respiratory traction infection (URI) symptoms (nasal congestion, rhinorrhea, or cough) should receive antibiotics? Which antibiotic?

What percentage of patients with Guillain-Barre syndrome (GBS) don't have albuminocytologic dissociation (high levels of protein and normal cell counts) in their spinal fluid? What percentage have don't have decreased reflexes?

What is the probability that a well appearing 18 month old caucasian female infant with fever of 102.2 F (39 C) and URI symptoms has a concurrent UTI? Would you obtain a urinalysis to r/o UTI?

I am the most lethal tick-vector illness in the United States and and cause most of my havoc in the southeastern United States. Who am I?

A poignant and insightful essay regarding the evolution of our society's perspective on death and dying

78 y/o male with remote history of GI bleeding and IVC filter placement for treatment of previous DVT/PE presents with acute right leg swelling. Doppler notes recurrent DVT. What is the treatment?

39 y/o male with no significant past medical history presents status post syncopal episode while getting a tattoo. Vitals and physical exam unremarkable. EKG, when compared to prior, notes new changes. Admit or discharge?

16 y/o female with no significant past medical history presents with sharp/pleuritic chest pain which improves when sitting up and leaning forward. EKG demonstrates changes consistent with pericarditis. Does this patient have pericarditis? If so, what is the work up?

Is this EKG of a 19 y/o male with chest pain more suggestive of early repolarization or pericarditis?

78 y/o male presents with intermittent crushing chest pain for the past 20 hours but is now pain free. Vitals stable. EKG notes ST elevation in anterior precordial leads and troponin is significantly elevated. Should patient be taken for immediate percutaneous coronary intervention (PCI)?

45 y/o male s/p tracheostomy three days ago presents with massive bleeding of bright red blood from about his trach. A tracheo-arterial fistula is suspected. What is your next move?

Identify on this x-ray what is preventing the patient's picc line from being easily removed?

Fill in the blanks: Patients with a history of adrenal insufficiency should increase their home dose of steroids by times the normal dose for days when confronted with an acute illness (fever, URI, tooth extraction, etc ...)