UMEM Educational Pearls

What should I do about this finding on the MRI I ordered

Now tha ta lot of EDs are getting MRIs on a more urgent basis, we will need to know what to do with the resutls.  However, the natural history of findings on MRI has not been well studied, so what should we do with that small meningioma you find.  Well some researchers in the Netherlands have attempted to address your question. In a population-based study [Rotterdam Study] , 2000 adults aged 45 or older underwent a brain MRI.

Some of the common findngs were:

• Asymptomatic brain infarcts were observed in 7%.
• Aneurysms and benign tumors (mostly meningiomas) were each found in nearly 2%.
• The two most urgent findings were a chronic subdural hematoma and a 12-mm aneurysm. Both required surgey.
• Only two out of the 2000 (0.001%) people had symptoms related to their MRI findings (hearing loss in both).
• The prevalence of asymptomatic brain infarcts and meningiomas increased with age, as did the volume of white-matter lesions, whereas aneurysms showed no age-related increase in prevalence.

Most of the study patients were white and middle class so these results may not be generalized to the general public.  I am sure more studies are in the works, but for now don't be two suprised if you find an asympomatic infarct or meningioma.

Vernooji MW, Ikram MA, Tanghe HL. Incidental Findings on Brain MRI in the General Population. NEJM. 2007;357(18):1821-1828.

Seat Belt Sign:

• Patients with a seat belt sign have a high risk of hollow viscus injury
• Often have a negative CT scan
• Admit for serial exams and observation, at an absolute minimum patient should be watched 6 hours.
• Look for associated Lumbar Chance Fractures.

Placental Abruption

• Leading cause of fetal death (1-80 pregnancy)
• Evaluation
  • Ultrasound has very poor sensitivity
• Can check D-Dimer, Coags, Fibrinogen and Fibrin Split Products
• For a stable patient MRI can make diagnosis.
• Fetal monitoring (minimum four hours) where fetal distress and uterine contractions are seen.
• Risk factors for Placental Abruption
  • Hypertension
  • Pre-eclampsia
  • Diabetes
  • Trauma
  • Smoking
  • Cocaine
  • Advanced maternal age
• Treatment
  • C-Section

Pediatric Strain versus Fracture

• Due to the fact that tendons are much stronger than the physeal growth plate in pre-pubescent children, one should be extremely cautious when diagnosing a strain/sprain. 
• Pre-pubescent pediatric patients should be treated as if they have a Salter Harris I fracture with an appropriate splint and close follow up.

Review of Salter Harris Fractures

1. A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened.
2. A fracture through the physeal growth plate and metaphysis.
3. A fracture through the physeal growth plate and epiphysis.
4. A fracture through the physis, physeal growth plate and metaphysis.
5. A crush injury of the physeal growth plate.

Please click here for a pictorial of Salter Harris Fractures from FP Notebook.

Low Back is one of the most common complaints that we see in the Emergency Department.  Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…).  However, most of the back pain that we will see is musculoskeletal in origin.

The American College of Physicians (ACP) and the American Pain Society (APS) recently released some joint recommendations on the evaluation of treatment of individuals with back pain.

In summary their key recommendations are:

1. Routine imaging is not required. However, diagnostic imaging and testing should be obtained for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.
2.  For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
3. Medications that have good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain).

Links to the Clinical Guidelines are listed below:

• Evaluation and Treatment
• Nonpharmacologic Therapies for Acute and Chronic Low Back Pain
• Medications for Acute and Chronic Low Back Pain

How many times a day are you told "I need antibiotics I coughed up some yellow/green stuff" Neither the color nor the consistency of nasal secretions helps to predict whether there is a bacterial infection. One should only consider treating sinus infections with antibiotics if the patient has:

1. Purulent nasal drainage for more than 10 days
2. Or if symptoms less than 10 days and one or more of the following significant facial pain, facial/periorbital swelling, dental pain, or temperature greater than 39'C

Antibiotic of first choice is Amoxicillin for 10-14 days. [Also consider Bactrim, Augmentin or Cipro for recurrent sinus infections]

Gastrointestional Bleeding Pearls. [Quick Facts]

• Peptic ulcer disease has 2 main etiologies: 1) Helicobacter pylorus infection and 2) NSAID use. Zollinger Ellison Syndrome causes 1% of peptic ulcer disease.
• Hemorrhage is the most common complication of peptic ulcer disease, occurring in 15% of patients
• 25% of patients over the age of 60 years have an AV malformation.
• The most common cause of significant lower GI bleeding in the elderly is diverticulosis or angiodysplasia. That typically presents as painless bright red rectal bleeding.
• AV malformations are the number 2 cause of massive lower gastrointestinal hemorrhage.
• Rectal bleeding following AAA repair is from aortoenteric fistula until proven otherwise.

With more and more ENT specialist resigning their hospital affiliations in favor of outpatient surgical centers it is getting harder and harder to find an oncall ENT to treat an ENT emergency. Peritonsillar abscesses and the need for drainage are a common reason to initiate a transfer. If you are unable to transfer your patient, here are some tips on how to do a needle aspiration safely.

• The carotid artery lies lateral and posterior to the tonsil. Any attempts should be done anteriorly, and medial to the peritonsillar pillar.


• The incision is made superior to the tonsil in the area of the soft palate. The abscess is normally located in the peritonsillar soft tissues of the soft palate.


• Needle aspiration: Needle aspiration can be therapeutic in itself; in some studies, up to 85% of patients were effectively treated with outpatient needle aspiration and oral antibiotics.


• Consider cutting the cap of the needle or scalpel so that once it is replaced only a portion of the needle /scalpel is exposed. This will help prevent you from inadvertently inserting the needle//scalpel to deeply.


• A single high dose of steroid (decadron 10 mg) prior to antibiotic therapy dramatically improves symptoms of patients with PTAs postdrainage.


• Streptococcus pyogenes (group A beta-hemolytic streptococcus) is the most common aerobic organism, and fusobacterium is the most common anaerobic organism. However, most abscesses contain a mixture of aerobic and anaerobic organisms. Consider Penicillin VK, Clindamycin, or Augmentin. If no response to Penicillin VK in 24 hours consider the addition of metronidazole

Disclaimer: Any and all procedures should only be done by properly trained and qualified individuals. These pearls do not meet the standard for proper training and/or qualification.

Acute Coronary Syndrome (our number one area of liability) [Part 2]

• Describing the character of the pain is the most common element of the history (Braunwald and Lee & Goldman).
• The history is the threshold issue and determines whether the patient enters risk stratification (Braunwald).
• The most atypical features of chest pain are sharp, pleuritic and positional pain.
• One-third of all patients with an MI have no chest pain.
• One set of cardiac enzymes violates a strong national standard of practice.
• Serial enzymes do not rule out unstable angina.
• If discharging a patient, document why you felt the patient did not have ACS.
• The plaintiff attorney literature advises litigators to focus on the history.

Thanks again to Larry Weiss, MD, JD Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Acute Coronary Syndrome (our number one area of liability) ===>Undiagnosed MI is the number one area of liability in emergency medicine, internal medicine, and family practice. ===>In emergency medicine, undiagnosed MI accounts for approximately 30% of all dollars lost in litigation. ===>MI patients mistakenly discharged have a 25% mortality rate, twice the rate of admitted patients. ===>Emergency physicians miss 2% of MIs. Office practitioners miss about 10% of MIs. ===>Failure-to-diagnose is the most common allegation in litigation following missed MIs. Misinterpretation of EKGs is the second most common allegation. ===>Poor documentation is the most common mistake in failure-to-diagnose cases (ie: failure to document why the physician decided the patient did not have ACS). Thanks to Larry Weiss, MD, JD Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Medical Management of Upper GI bleeds. Peptic Ulcer Disease: Proton pump inhibitors are the main stay of therapy. Use is based on the observation that pH over 6 is required for platelet aggregation whereas pH below 5 results in clot lysis. High dose IV therapy should be reserved with those that have high risk stigmata of rebleeding as seen on endoscopy. Regular dose IV or PO omeprazole can be used in most patients. Variceal Bleeding: Consider octreatide (50 mcg bolus followed by 50 mcg/hr IV) and non-selective beta blocker therapy to reduce bleeding. Human recombinant activated factor VII has gotten a lot of press lately though it did not reduce the risk of death at either 5 or 42 days in patients with liver related GI bleeds.A Wong T. The management of upper gastrointestinal haemorrhage. [Review] [31 refs] [Journal Article. Review] Clinical Medicine. 6(5):460-4, 2006 Sep-Oct. Marti-Carvajal AJ. Salanti G. Marti-Carvajal PI. Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases. [Review] [45 refs] [Journal Article. Review] Cochrane Database of Systematic Reviews. (1):CD004887, 2007. Martins NB. Wassef W. Upper gastrointestinal bleeding. [Review] [87 refs] [Journal Article. Review] Current Opinion in Gastroenterology. 22(6):612-9, 2006 Nov.

ED Chart Documentation (Part 2) ==> If writing an addendum after-the-fact, identify the note by date and time. ( late entry ). Otherwise, NEVER alter the chart after-the-fact. ==> Always address the patient s documented complaints. ==> Don t write incident report filed. ==> Be specific about times for follow-up. (eg:2 days, 1 week, next available) ==> Provide a warning about sedatives (eg: Don t drive ). ==> Whenever possible, document past tolerance of toxic drugs when prescribed (eg: NSAIDs). ==> Document a warning not to drive when treating patients for a seizure, or when refilling anti-epileptic drugs. Courtesy of Larry Weiss, MD, Jd Disclaimer:This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

ED Chart Documentation ==> Provide documentation that you ruled out the worst possible outcome. ==> Read and acknowledge the nurse s notes especially if a conflict exists. ==> Always address abnormal vital signs. ==> Provide times for all notes. ==> Don t use demeaning terminology to describe patients. ==> Write interval progress notes when a patient s condition changes. ==> Document lab, EKG, and x-ray abnormalities. Disclaimer:This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice. The speaker provides this information only for Continuing Medical Education purposes.

Lumbar Puncture Pearls On obese patients, it can be easier to obtain a lumbar puncture with the patient in the sitted position. If you require an opening pressure (eg, pseudotumor cerebri), replace the stylet and have an assistant help the patient into the left lateral recumbent position

If the CSF flow is too slow, ask the patient to cough or bear down as in the Valsalva maneuver, or intermittently press on the patient s abdomen to increase the flow. The needle can also be rotated 90 degrees such that the bevel faces cephalad.

In children, a recent study has shown that performing an LP can be more successful by using adequate analgesia and advancing the needle through the dura without the stylet.

In adults with suspected meningitis, a CT scan of the head does NOT need to be done prior to the lumbar puncture unless the patient has one of the following

• Immunocompromised state: HIV infection or AIDS, receiving immunosuppressive therapy, or after transplantation
• History of CNS disease: Mass lesion, stroke, or focal infection
• New onset seizure: Within 1 week of presentation;
• Papilledema: Presence of venous pulsations suggests absence of increased intracranial pressure
• Abnormal level of consciousness...
• Focal neurologic deficit

Nigrovic LE et al. Risk factors for traumatic or unsuccessful lumbar punctures in children. Ann Emerg Med 2007 Jun; 49:762-71.

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267 84.

*Hormone-related migraine headaches are largely related to changes in levels of estrone glucuronide (EIG). *Studies have shown that in addition to an increase in symptoms for female migraneurs during the menstrual phase (during first 3 days of menses), there are also 3 distinct midcyle (around day 14) phases during which migraines are most prevalent. They are: 1) Late follicular phase (LF) (rapid rise in estrodiol level) 2) Early follicular 1 phase (rapid drop in estrodiol level) 3) Early follicular 2 phase (rapid rise in progesterone level) American Headache Society 49th Annual Scientific Meeting: Abstract 150. June 7-10, 2007.

Learn the Lingo for Stroke Manangement: Patients with acute stroke due to a carotid artery thrombotic lesion that then embolizes to a cerebrovascular artery, have two problems that can be addressed with one coordinated intervention. * "Triple Play" = (1) Carotid artery lesion stenting followed by (2) retrieval of the embolic clot from the cerebrovascular artery via the Merci device followed by (3) intra-arterial tPA (the latter prevents complications that could result from removal of embolic clot). * "Double Play" = (1) Retrieval of the clot from the cerebrovascular artery via the Merci device followed by (2) intra-arterial tPA. Merci Device information: http://www.concentric-medical.com/products_retrieval.html

Diagnostic Criteria for Migraine Headaches: * Migraine w/o aura- A. At least five headache attacks lasting 4 - 72 hours, with at least two of the four following characteristics: 1. Unilateral location. 2. Pulsating quality. 3. Moderate or severe intensity (inhibits or prohibits dailyactivities). 4. Aggravated by walking stairs or similar routine physical activity. B. During headache, at least one of the two following symptoms occur: 1. Phonophobia and photophobia. 2. Nausea and/or vomiting. * Migraine w/ aura (remember: aura is not always visual) - A. At least two attacks with at least three of the following: 1. One or more fully reversible aura symptoms indicating focal cerebralcortical and/or brain stem functions. 2. At least one aura symptom develops gradually over more than four minutes,or two or more symptoms occur insuccession. 3. No aura symptom lasts more than 60 minutes; if more than one aura symptomis present, accepted duration is proportionally increased. 4. Headache follows aura with free interval of at least 60 minutes (it mayalso simultaneously begin with the aura). B. At least one of the following aura features establishes a diagnosis ofmigraine with typical aura: 1. Homonymous visual disturbance. 2. Unilateral paresthesias and/or numbness. 3. Unilateral weakness. 4. Aphasia or unclassifiable speech difficulty. Headache 44(5):426-435, 2004. Headache classification committee of the IHS. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988 8: 1-96.

Medical Management of Ureteral Stones Tamsulosin (Flomax ) has been shown to help increase the passage of ureteral calculi. According to a metaanalysis compared to patients receiving conservative therapy only, patients receiving conservative therapy plus α -blockers were 44% more likely to spontaneously expel the stones (RR 1.44, 95% CI 1.31 to 1.59, p0.001), and stone expulsion incidence increased significantly (RD 0.28, 95% CI 0.22 to 0.34, p0.001). Mechanism of action: Alpha blockage results in ureteral smooth muscle relaxtion and subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen. Erturhan S. Erbagci A. Yagci F. Celik M. Solakhan M. Sarica K. Comparative evaluation of efficacy of use of tamsulosin and/or tolterodine for medical treatment of distal ureteral stones. [Comparative Study. Journal Article. Randomized Controlled Trial] Urology. 69(4):633-6, 2007 Apr. Parsons JK. Hergan LA. Sakamoto K. Lakin C. Efficacy of alpha-blockers for the treatment of ureteral stones. [Journal Article. Meta-Analysis] Journal of Urology. 177(3):983-7; discussion 987, 2007 Mar.

Traumatic Ankle Pain When examining a patient who presents with Ankle Pain, make sure that you examine/palpate the proximal fibula and the base of the fifth metatarsal. Pain over the proximal fibula will necessitate a full Tibia/Fibula x-ray to rule out a Maisonneuve Fracture [a proximal fracture of fibula resulting from external rotation; injury may occur with medial or posterior malleolus fracture, a ligament rupture, as well as rupture of interosseous membrane. Pain over the base of the 5th metatarsal suggests a Jones Fracture [ involves fx at base of fifth metatarsal at metaphyseal-diaphyseal junction, which typically extends into the 4-5 intermetatarsal facet; is located w/in 1.5 cm distal to tuberosity of 5th metatarsal & should not be confused w/ more common avulsion fx (Dancer s Fracture) of 5th metatarsal styloid]

Bougie-Facilitated Intubation Using the Bougie as a rescue device can sometimes be complicated with difficulty advancing the endotracheal tube as the tip can get hang up at the level of the glottis. Two things that can help advance the tube: Rotate the tube 90 degrees counterclockwise. Stop holding Cricoid Pressure, especially in female patients A recent study looking at cricoid pressure showed that the frequency of impingement was 38% with sham pressure and 60% with true cricoid pressure. This statistically significant difference was entirely attributable to an effect in female patients. Original Article: McNelis U et al. The effect of cricoid pressure on intubation facilitated by the gum elastic bougie. Anaesthesia 2007 May; 62:456-9. Forget about Sterile Saline and Use Tap Water Irrigation In a multicenter prospective trial of 715 patients, Moscati et al have shown that rates of wound infection were similar (3.3% compared to 4.0%) in patients that received clinician-administered sterile saline irrigation or at least 2 minutes of self-administered tap-water irrigation. The amount (volume) of irrigation is more important than whether the irrigate is sterile or not. Moscati RM et al. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med 2007 May; 14:404-9.