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The TFCC (triangular fibrocartilage complex) is a ligamentous/cartilage like complex similar to the meniscus of the knee located on the ulnar side of the wrist.
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Hx: ulnar sided wrist pain following trauma and associated with activity related mechanical symptoms such as clicking.
PE: tenderness to palpation distal to ulnar head or at ulnar styloid . Tenderness against resisted radial deviation.
Plain film may show ulnar styloid avulsion or injury to carpal structures.
Refer to hand/wrist surgeon
Splint in ulnar gutter of long arm spica
MRI or arthrogram are studies of choice.
http://www.cobalthealth.co.uk/MImageGen.ashx?image=%2Fmedia%2F12951%2Fwrist-tfcc-tear-big.jpg&width=170&crop=true
Carbon Monoxide Toxicity and Hyperbaric Oxygen Treatment
CO disrupts cellular function by several mechanisms at a
cellular/mitochondrial level. Ultimately, these disruptions are
manifested as tissue hypoxia and hypoperfusion.
Initial symptoms may be subtle and nonspecific. Be sure to ask about
CO exposure when evaluating “viral syndrome” or patients that present
with non-specific neurological complaints especially during fall and
winter months, when people first start using their heating, or after
power outages and generator use. Dysrhythmias, cardiomopathy, MI and
sudden cardiac arrest are reported in severe CO poisoning.
Lab studies- COHb, base excess, lactate and any other studies based on
presentation.
Supplemental oxygen is the cornerstone of treatment. Oxygen
delivered at hyperbaric pressure (as opposed to sea-level) will
increase the rate of CO dissociation from hemoglobin, and mitigate
damage to cellular and mitochondrial function.
Definite Indications for HBOT: Current evidence supports the use for
HBOT to reduce cognitive sequelae in CO poisoned patients who have:
LOC , seizure, exposure >23 hours, COHb of 25% or more, and age >36.
Relative Indications: persistent symptoms after 100% O2 or change in
mental status, pregnancy, persistent cardiac ischemia, increased COHb
levels.
Disposition: Clinical judgment should guide your decision. Most
patients with mild symptoms can be discharged after treatment. If
patient has a more concerning presentation with several risk factors
(extremes of age, CAD, unconscious at arrival in the ED, etc…)
consider admission.
Differentiating Central Retinal Artery vs. Vein Occlusion Fundoscopically
- While there are several historical and clinical features that differentiate central retinal artery (CRA) occlusion from central retinal vein (CRV) occlusion, the fundoscopic examination can also be used to distinguish between the two.
- In CRA occlusion, the retina appears grossly swollen and pale, with a prominent fovea that would otherwise be obscured by a normal, pinkish-red background (see attached - Image 1).
- In CRV occlusion, the disc is massively swollen with splotches of hemorrhage and cotton wool spots diffusely (see attached - Image 2).
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SAH and Electrolyte Disorders
- Hyponatremia can be seen in up to 40% of patients with a SAH.
- Most often, hyponatremia in patients with an SAH is due to SIADH or the cerebral salt wasting syndrome.
- To date, hyponatremia has not been associated with poor outcome.
- Treatment should focus on the underlying cause and often includes volume replacement with isotonic crystalloids (0.9% NaCl).
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Question
5 year-old male with developmental delay presents with intractable non-bloody and non-bilious vomiting over 10 days; bowel movements are normal. Four weeks ago he was placed in a hip-spica cast following a motor vehicle crash. Abdominal x-ray is below. Diagnosis?
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Elevated BNP levels are found in conditions besides acutely decompensated CHF. These conditions can include:
Older age
Renal failure
Severe sepsis
PE
Chronic CHF
These conditions will often produce BNP elevations in an intermediate range, but if the elevation is markedly positive, the acutely decompensated CHF is much more likely.
[adapted from ACEP speaker Matthew Strehlow, MD]
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Sinus Tarsi Syndrome
- A painful syndrome of the ankle normally due to an inversion injury. Results in pain along the lateral side of the ankle.
- Often misdiagnosed as an ankle sprain.
- Will have pain localized to the sinus tarsi (inferior and anterior to the anterior border of the lateral malleolus.
- Can be diagnosed by injecting lidocaine into the sinus tarsi, which should completely relieve the pain.
- Treatment consists of
- NSAIDs
- Ankle immobilization
- Physical therapy
- Oral or injected steroids in resistant cases
- 0.3-1.5% of all pediatric DKA cases
- 21-24% mortality rate
- usually at 4-12 hours after therapy starts
- risk factors: <5years old, new onset diagnosis, increased BUN at presentation, severity of acidosis at presentation, bicarbonate use
- have low threshold to diagnose and treat: don't wait to treat for the CT!
- The Straight Leg Raise (SLR) test can be used to determine if patient has true sciatica.
- The patient lies supine with one leg either straight or flexed at the knee with the sole of the foot flat on the stretcher.
- The other (affected) leg is kept straight and raised up by the examiner.
- The test is positive when raising the leg between 30 to 70 degrees causes pain to occur and radiate down the leg to at least below the knee, and often all the way down to the great toe (sensitivity 91%, specificity 26%).
- Sensitivity may improve with dorsi-flexion of the foot while the leg is elevated.
- The following do NOT indicate a positive test: pain of lower back only, without radiation to below knee; overtly excessive pain behavior; patient contraction of antagonist muscles that limit examiner's testing; tightness of buttock and hamstring muscles; nonspecific complaints.
- The SLR test can also be performed with the patient in a sitting position, by stretching the sciatic nerve by extending the knee; the test is positive if pain radiates to below the knee.
Lisiteria Monocytogenes is typically transmitted from ingestion of contaminated food such as unpasteurized milk or cheese, raw foods, and recently cantaloupes; transmission from veterinary exposure, infected soil and water have also been reported.
Listeria has a predilection for the central nervous system (CNS) causing several infections including meningioencephalitits, brain or spinal abscess, cerebritis (infection of brain parenchyma), and rhomboencephalitis (encephalitis of the brainstem).
Risk factors include immunosuppression, advanced age, newborns, and pregnancy.
There is no clinical way to distinguish CNS infection with Listeria from other pathogens, therefore blood and cerebrospinal fluid (CSF) culture is required.
CSF analysis demonstrates pleocytosis, elevated protein, and low glucose. CSF gram stain has a low sensitivity (~33%), but consider Listeria in the differential if "diptheroid-like" bacteria are reported on gram stain.
Ampicillin is the drug of choice and should be continued for at least three weeks (sometimes longer). Adding gentamycin is sometimes recommended for synergy in severe infection.
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ST depression in the right precordial leads can be anteroseptal ischemia, but it can also be a posterior STEMI. What are the clues to posterior STEMI?
- tall R waves in these leads is highly suggestive of posterior STEMI
- upright T-waves in these leads is also suggestive of posterior STEMI
Posterior leads (a couple of leads placed in the left mid-back area below the tip of the scapula) can help confirm posterior STEMI if there's STE in those leads. If there's no STE, call it just ischemia!
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Anterolateral dislocation is most common (>85%)
As the tib/fib joint has its own synovial cavity, a knee effusion will not be seen
Mechanism: fall on the flexed knee with foot/ankle inversion
Hx: swelling, variable amount of lateral knee pain (anywhere from mild discomfort to inability to bear weight)
PE: Prominence of the fibular head, ankle motion exacerbates knee pain. no associated neurovascular issues
However with less common dislocations (posterior and superior) peroneal nerve injury may occur
Reduction: Place patient supine with knee flexed to 90 degrees. Ankle should be dorsiflexed and externally rotated.
REVERSE THE INJURY: Apply firm posteriorly directed pressure to the fibular head. May head an audible pop as fibular head reduces. Reassess collateral ligament function.
Peritoneal dialysis (PD) is a commonly used form of dialysis for pediatric patients with end-stage renal disease, particularly in children less than five years of age.
One well known complication to this mode of dialysis is PD-associated peritonitis.
Children may present with fever, abdominal pain and a cloudy dialysate.
If peritonitis is suspected, obtain sample of dialysate fluid and send for cell count, Gram’s stain and culture.
Cell count in PD-associated peritonitis is usually WBC >100 with >50% neutrophils.
Both gram-positive and gram-negative organisms are involved with PD-associated peritonitis . Keep both MRSA and Pseudomonas in mind.
In the ED, empiric therapy should cover both gram-positive and gram-negative organisms. Initiate antibiotic therapy with vancomycin and either a third-generation cephalosporin (ceftazidime) or aminoglycoside, respectively.
For PD-associated peritonitis, intraperitoneal (IP) administration of antibiotics is preferred over IV.
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There are an increasing number of intranasal medications commercially available for use, which is opportune as more and more intravenous medications become scarce.
These now include:
| Generic name | Brand Name | Usage |
| Fentanyl | Instanyl | Opiate analgesic |
| Ketorolac | Sprix | NSAID analgesic |
| Desmopressin (DDAVP) | Stimate | Bleeding |
| Vitamin B12 | Nasobal | Anti-migraine (yes!) |
| Sumatriptan | Imitrex | Anti-migraine |
| Zolmitripran | Zomig | Anti-migraine |
*******In addition, you can administer glucagon, midazolam and narcan intranasally as well.
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- In patients presenting with bilateral miosis (i.e. pinpoint pupils) of unknown etiology, the astute clinician may consider acute pontine injury, opiate overdose, or medication-related causes as the source.
- In such cases, one should consider performing the simple corneal reflex test to evaluate mid and lower pontine function.
- This test consists of lightly touching the cornea with the cotton swab of a Q-tip and observing blink responses in both eyes. It assesses afferent fifth nerve (sensory) and efferent seventh nerve (motor) function.
- A normal response is simultaneous (i.e. consensual) eye blinking. An abnormal response may be manifest by midline deviation, followed by relaxation, of the lower eyelids.
- TAKE HOME POINT: Corneal reflex testing is an easy way to help distinguish pontine injury from an opiate overdose in patients presenting with pinpoint pupils. Confirmatory studies by way of brain imaging should follow.
Fever and ICH
- Fever is a common event in patients with intracerebral hemorrhage (ICH) and is associated with an increased length of ICU stay, cognitive impairment, and poor outcome.
- While much of the management (and controversies) of the patient with ICH focuses on blood pressure control and reversal of oral anticoagulants or antiplatelet agents, don't forget about temperature control.
- Aggressively treat temperatures ≥ 38.3oC in patients with an ICH.
- Importantly, there is currently insufficient evidence to support a superior method of fever control (antipyretics or surface/intravascular cooling devices).
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Question
Question: 50-year-old diabetic female s/p foot burn several weeks ago, now presenting with pain and discharge from a poorly healing wound. Diagnosis?
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Hostile behavior appears to be a predictor of ischemic heart disease and myocardial infarction. Prior studies have demonstrated this association, and now one more study has supported this. In short, researchers from Nova Scotia demonstrated that observed hostility was a predictor of ischemic heart disease and myocardial infarction (2-fold), independent of age, sex, Framingham Risk Score, and other psychosocial risk factors.
The key takeaway point of this fun, but validated concept, is that in addition to exercising and eating right, we all just need to relax a bit more. And the next time you have to deal with an angry consultant, just tell him to chill out or he'll die!