Three groups of patients are at especially high risk of bleeding from excessive anticoagulation with renally-excreted medications: women, the elderly, and patients with chronic renal insufficiency. For all of these patients, ALWAYS dose their renally-cleared medications based on creatinine clearance, NOT just the creatinine.

Which medications in ACS does this apply to?--enoxaparin and G2B3A inhibitors are the most prominent here to consider.

The literature not only demonstrates increased bleeding complications but also increased MORTALITY if you don't dose based on creatinine clearance!

Review of the Appearance of Ossification Centers in Children's Elbows

Determing if a child's elbow has a fracture or if you are looking at an ossification center is easier if you remember the mnemonic CRITOE.  This is the order that the ossification centers appear:

• Capitellum 1 to 8 months
• Radial Head 3 to 5 years
• Internal (medial) Epicondyle 5 to 7 years
• Trochlea 7 to 9 years
• Olecranon 8 to 11 years
• External (Lateral) Epicondyle 11 to 14 yeras

• the most common cause of stridor in the newborn
• the laryngeal skeleton is not stiff enough to resist the negative pressure during inspiration causing narrowing and stridor
• can occur at birth but most commonly seen at 2 weeks of age, and is more pronounced with agitation
• for most, close observation is sufficient as the cartilage becomes more rigid with age
• usually outgrown by 12-18 months of age
• in severe cases, feeding may be affected and nighttime obstructive hypoxia may occur

• Etiologic causes of hearing loss can be categorized into three groups:  (1) Sensorineural, (2) Conductive, and (3) Sensorineural and Conducitve.
• Sensorineural hearing loss results from problems with the vestibulocochlear nerve (cranial nerve VIII), inner ear, or central processing centers of the brain.
• When performing the Weber Test on patients with sensorineural hearing loss (tuning fork touched to midline of skull), sound localizes to the normal ear (i.e. sound conducts normally through bone, which measures sensorineural function, on the side without the abnormality).
• Examples of conditions that cause sensorineural hearing loss include:  Acoustic neuroma and other cerebellopontine angle tumors, perilymph fistula, noise trauma, and ototoxic medications.     

Catheter-related bloodstream infections occur in 3-8 percent of insertions, and are the highest cause of nosocomial bloodstream infections in the ICU. 

The most effective measures to prevent catheter-related infections are as follows:

Especially applicable to those of us placing these lines in the ED or in the ICU is the last recommendation, based on a prospective study from Greece

-adequate knowledge and use of care protocols

-qualified personnel involved in changing and care

-use of biomaterials that inhibit microorganism growth and adhesion

-good hand hygiene

-use of an alcoholic formulation of chlorhexidine for skin disinfection and manipulation of the vascular line

-preference for subclavian route for placement

-use of full barrier protection during placement

-removal of unnecessary catheters

-use of ultrasound for placement of central lines

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Complications of Liver Biopsy

Some considerations for the patient who presents with pain after a liver biopsy:

• Hemothorax
• Pneumothorax
• Biopsy of other organ
• Hemorrhage (subcapsular hematoma, intraperitoneal bleeding, hemobilia)
• AV Fistula

Consider getting a chest xray and a RUQ ultrasound to evaluate for these complications if they show up in the ED. CT scanning might also be required.

Also consider getting Interventional Radiology  involved early in cases of bleeding as this is often the preferred treatment for biopsy site bleeding. In addition, a surgical consult is wise

in case the patient requires operative intervention. 

Although supplemental oxygen has long been considered standard care for patients with ACS, the evidence supporting this concept is largely based on animal studies in which acute MI was artificially induced. Should these studies be extrapolated to humans? Maybe not....


Further review of the animal and human literature actually indicates that the routine use of supplemental oxygen and induction of hyperoxia can actually induce adverse hemodynamic consequences such as increased coronary artery tone and reduction in coronary artery blood flow; reductions in cardiac output and increased systemic vascular resistance; and potentially increased infarction size. It certainly seems prudent to treat hypoxia, but if the patient is not hypoxic, skip the supplemental oxygen!

Wijesinghe M, et al. Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart 2009;95:198-202.
AND
Farquhar H, et al. Systematic review of studies of the effect of hyperoxia on coronary blood flow. Am Heart J 2009;158:371-377.

Critical Care billing is time dependent and includes all time spent caring for and coordinating (i.e.: reviewing records, talking to consultants or family) the care of the patient except for the time spent doing separately billable procedures (i.e. central line, CPR, etc).  The following procedures taken from the ACEP website are included in the Critical Care code so the time spent doing these procedures should BE included in your total Critical Care time . 

They are :

• The interpretation of cardiac output measurements
• Interpretation of chest x-rays
• Interpretation of pulse oximetry
• Interpretation of blood gases, and information data stored in computers
• Placement of Oral or Nasal gastric tube
• Temporary transcutaneous pacing
• Ventilatory management (i.e.: Adjusting the vent, but not the intubation)
• Vascular access procedures (i.e.: peripherial access)

ACADEMIC MEDICINE CAVEAT: For the reporting of time-based services, such as critical care or moderate sedation, the teaching physician must be directly present during the entire reported time period.

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Congenital hypothyroidism (CH) is almost uniformly identified before symptoms develop because of newborn screening.  Though this problem will rarely present to the Emergency Department, it is not uncommon for parents with poor access to care to present to EDs after being notified of an abnormal screen.  Here is what you need to know:

• CH affects 1 / 3,000 live births
• When left untreated, there are many sequelae, but the most important by far is almost certain profound mental retardation
• Children treated within two weeks of birth have NORMAL intellect when followed into adolescence (compared to sibs, age matched controls)
• Children treated after two weeks have measurable declines in cognitive ability and motor skills - even though they may not develop MR, they are at VERY HIGH risk

So:

• Start treatment on ALL infants you encounter with CH, IMMEDIATELY if they are approaching 14 days of age
• Consider admission if there is any chance of a parent having poor access to prescription coverage or close followup
• Goal levels of T4 are >10 mcg/dL; infants with very low levels need IMMEDIATE TREATMENT with high dose-range levothyroxine - any delay can lead to drops of up to 20 IQ points
• Initial dose of Levothyroxine is at least 10-15 mcg/kg/day
• Tablets must be crushed and mixed with breast milk or formula, and NOT with soy, calcium or iron-containing substances which decrease levothyroxine absorption.  Liquid preparations are unreliable.

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When you draw a urine toxicology screen it can mislead more often than help you. Here is a quick list of the test followed by some medications that cause false positives - when in doubt, call your lab to find out specifics since results will vary lab to lab:

TCA - diphenhydramine, carbamazepine, cyclobenzaprine (side note: TCA screen should never be used to determine TCA toxicity, your ECG and physical exam should be enough to determine if the patient is toxic from TCA

Cocaine - the most accurate test on the screen, positive for up to 5 days

PCP - dextromethorphan and ketamine can turn it positive

Amphetamines - pseudoephedrine, ephedrine, phenylephrine and many other OTC cough decongestants can as well, the worst screening test with the largest number of false positives

• The majority of epilepsies (60%) are partial-onset or focal, such that a single, isolated part of the body is affected.
• Seizures arising from the temporal lobe of the brain are the most common type of partial-onset epilepsy and have been associated with childhood febrile seizures.
• Simple temporal lobe seizures, which do not result in a loss of consciousness, typically present as a sensation such as: 

              -- Deja' vu (feeling of familiarity)     -- Jamais vu (feeling of unfamiliarity)

              -- Specific or single set of memories     --  Amnesia

             -- Auditory        --  Gustatory       --  Visual       --  Disphoric     -- Euphoric 

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Warfarin and ICH

• Warfarin causes approximately 10-15% of all intracerebral hemorrhages (ICH)
• Many warfarin-related ICHs occur with INRs in the therapeutic range
• Patients with warfarin-related ICH have higher mortality and typically suffer worse neurologic outcome
• The primary pitfall in treating patients with warfarin-related ICH is the failure to rapidly normalize the INR
• Do not delay treatment while awaiting the results of coagulation labs
• Patients should receive IV vitamin K via slow infusion and FFP
• Prothrombin Complex Concentrate (PCC) is gaining popularity but much of the supporting literature uses agents not available in the US
• Similarly, there is no significant evidence that recombinant factor VIIa improves outcomes in patients with warfarin-related ICH

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A recent study of nearly 800 patients with chest pain evaluated symptoms and signs that are most predictive of ruling in for ACS. The following characteristics made acute MI more likely (likelihood ratios in parentheses): observed diaphoresis (5.18), central location of chest pain (3.29), associated vomiting (3.50), radiation of the pain to bilateral arms (2.69), and radiation of pain to the right arm (2.23).

As we've said before, if your patient sweats, it ought to make YOU sweat!

[BodyR, et al. Resuscitation 2010;81:281-286.]

Knee Dislocation:

• It is not uncommon for a patient to have dislocated their knee and it to spontanously reduce prior to presenting to the ED. 
• Consider the possibility of a spontaneously reduced knee dislocation in any patient with bicruciate (ACL and PCL) ligament instability.  
• Normal pulses and capillary refill does not exclude occult vascular injury to the popiteal artery.
• At a minimum the patient should have Ankle Brachial Indexs performed and if <0.9 serial exams and Doppler ultrasound studies should be obtained.
• Angiography is not absolutely required, and several studies have shown that a selective approach to angiography is acceptable.  As the studies below showed, most patients with findings requiring operative repair on angiography had abnormal physical exams.

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According to the Food Allergy and Anaphylaxis Network, the eight most common food allergies, which account for 90% of the food allergies in the U.S., are: dairy, soy, wheat, shellfish, fish, peanut, tree nut, and egg.

Several medications are formulated with these ingredients and should be avoided in patients with reported allergies.

• Propofol is a lipid emulsion that contains egg.  Avoid in patient with hypersensitivity to eggs, egg products, soybeans, or soy products.
• Ipratropium ± albuterol (Atrovent, Combvient®) inhalers may contain soy lecithin.  This can cause allergic reactions in patients with allergy to soy lecithin or related food products (e.g., soybean and peanut).  Nebulizer solutions (e.g., Duoneb®) seem to be free from this issue.
• Progesterone (Prometrium®) capsules contain peanut oil.

•  Focal seizures, such as those due to frontal lobe epilepsy (FLE), are not always easy to recognize and may be erroneously attributed to peripheral or psychiatric sources.
• FLE seizures may present as abnormal body posturing, sensorimotor tics, and/or other abnormal motor skills, and rarely may be associated with uncontrollable laughing and/or crying.
• Post-seizure confusion >may occur, but typically does not last as long as the post-ictal states associated with other types of epilepsy.

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Primary Intracranial hemorrhage is associated with the following risk factors:

• hypertension, smoking, alcohol, hypocholesterolemia, genetic factors, warfarin, phenylpropylamine, cocaine and methamphetamine. 

Common causes of secondary ICH are as follows:

• vascular malformations, arteriovenous malformations, cavernous angiomas, small arterial telangiectasia, and primary and secondary brain tumors.

The question of how to address elevated blood pressure in spontaneous intracranial hemorrhage has been debated.  High blood pressure may cause hematoma expansion, but this has not been proven.  Lowering blood pressure may help reduce neurologic deterioration, but this has also not been proven in the literature. 

The AHA recommended guidelines for blood pressure management in spontaneous ICH are as follows:

If SBP>200 or MAP>150, consider aggressive reduction of BP with continuous IV infusion, monitoring BP every 5 minutes

If SBP>180 or MAP>130, with evidence or suspicion of elevated ICP, consider monitoring ICP and reducing BP using intermittent or continuous IV medications to keep CPP>60 to 80

If SBP>180 or MAP>130 without evidence or suspicion of elevated ICP, then consider a modest reduction of BP (MAP of 110 or targeted SBP 160/90) using intermittent or continuous IV medications, monitoring BP every 15 minutes

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Splenic Artery Aneurysm (SAA)

Ever scanned someone and the report says "incidental note of a splenic artery aneurysm"? Well, if it hasn't happened yet, it will sooner or later. This type of aneurysm isn't that rare and with the number of abdominal CTs we order we are bound to see this in clinical practice.

Some important points to remember about SAA:

• 3rd most common location of intra-abdominal aneurysm, 1st-aortic aneurysm, 2nd-iliac artery aneurysm
• Most common complication is sudden rupture and occurs in as many as 3-10% of cases
• 80% pf patients with SAA are asymptomatic
• Symptomatic aneurysms may present with left upper quadrant pain, nausea, and vomiting
• Splenic infarct is a rare complication
• Most important is followup: patients will need close followup for asymptomatic splenic artery aneurysms. Consultation with a surgeon will need to be arranged if it is thought that the patient has symptoms due to the aneurysm

Major and minor clinical prognostic predictors for pericarditis have been described as follows:

Major: fever > 38 degrees C, subacute onset, large effusion, tamponade, lack of response to aspirin or NSAIDs after at least 1 week of therapy

Minor: myopericarditis, immunodepression, trauma, oral anticoagulant therapy

Patients with any of these criteria [major or minor] should strongly be considered for admission. In the absence of these factors, studies show that patients managed as outpatients do well.

[Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation 2010;121:916-928.]


 

Pelligrini-Stieda Lesion:

A Pelligrini-Stieda lesion is shown in the radiograph below.  This lesion was originally described in 1905, and is associated with a tear of the Medial Collateral Ligament.  Heterotrophic calcification forms causing chronic pain, which typically needs to be surgically excised.

So for the students out there, it is possible to diagnosis an MCL tear on plain radiographs.  Just not very often.