UMEM Educational Pearls

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

Concussions

• Symptoms
  • HA, Dizziness, Confusion, Tinnitus, Nausea, Vomiting, Vision changes
• 3 grades of Concussions
  • Grade 1 = transient concussion symptoms.  No amnesia.  No LOC. 
  • Grade 2 = transient concussion symptoms with amnesia.  No LOC.
  • Grade 3 = + LOC of any durations
• Return to Play Guidelines 
  • (there is no consensus statement. What follows is based on the most conservative approach)
  • Grade 1: Remove from game, Examine q 5 min.
    Return to game when asymptomatic for 20 minutes.
  • Grade 2: Remove from game until asymptomatic for 1 week.
  • Grade 3: ED evaluation.  No contact sports for 1 month once asymptomatic for 2 weeks. 
    • These apply to first concussions.  Increase concern with 2nd concussion.
• Second-Impact Syndrome
  • Occurs when a player returns to contact sport before symptoms of 1 concussion have fully  resolved.
  • Even a minor blow to the head can result in loss of brain’s autoregulation of blood flow.  
    • Leads to vascular engorgement and subsequent herniation.

Colorado Medical Society School and Sports Medicine Committee. Guidelines for the management of concussion in sports. Colo Med 1990;87:4.

I have made some improvements to the educational pearl interface. This required recoding several sections to change the text formatting from plain text to html...

Why do you care?
Well, many email clients will block html, or messages that have lots of capitals, decorations, etc...

Our first priority is to get you the information and beat anti-spam auto-filtering. If you notice that you are not getting the educational emails. 

• Add admin@umem.org  and umem.org to your safe senders list

Notes to authors Do not use a lot of colors like this post Do not use allcaps, lots of bolding, etc...

thanks
dan

Isopropanol (Commonly Rubbing Alcohol)

• Rubbing alcohol is 70% isopropanol, like drinking Bacardi 151 (151 proof)
• This is NOT a toxic alcohol in the traditional sense
• This causes a large ketosis, large osmol gap but NO anion gap and no acidosis
• This is because isopropanol is metabolized to acetone (a ketone) not an acid
• Toxicity: inebriation, hemorrhagic gastritis, sedation to the point of death/intubation

Horner's Syndrome Deficit in descending sympathetic pathways Miosis + Ptosis + Anhidrosis Associated with lateral medullary infarctions, which are caused by disrupted flow to the posterior inferior cerebral artery (PCA) (i.e. Wallenberg Syndrome)

DIC is the simultaneous occurrence of widespread (micro) vascular thrombosis, leading to compromised blood supply to vital organs Although major bleeding can be seen in some, the more common complication of DIC is organ failure DIC is not a disease itself but secondary to an underlying disorder Sepsis, solid and hematologic malignancies, severe trauma, and obstetrical emergencies (amniotic fluid embolism, abruption) are the most common disorders associated with DIC A prospectively validated scoring system (Toh CH, et al. J Thromb Haemost 2007;5:604-6.) is used for diagnosis and is comprised of platelet count, fibrin split products, PT, and fibrinogen level The key to treating DIC is vigorous treatment of the underlying disorder Platelet transfusion is generally only given for patients with major bleeding (i.e. intracranial) with platelets counts < 50 k

Surgical repair of thoracic aortic aneurysms is generally dictated by size. Aneurysms need repair to prevent rupture. Anything over 6 cm (which is the magic number , according to authorities) will make almost all cardiothoracic surgeons anxious. -For non-marfans patients Most cardiac surgeons will use a cut off for surgery of: ascending aorta > 5.5 cm and descending aorta > 6.5 cm -Patients with Marfans: Threshold to operate is a bit lower. ascending >5 cm and descending > 6 cm So, who cares, you ask? #1-We scan a lot of chests and we will be diagnosing this in the ED. #2-As emergency physicians we should have some familiarity with the aortic size that makes Cardiothoracic surgeons nervous and the size that can get outpatient followup. Calling a CT surgeon to the ED to see a patient with an incidental 4.8 cm ascending aortic aneurysm in many cases is not necessary...depends on the patient, followup, etc. They will definitely not be excited about a 4.8 cm aneurysm. Sure, it looks HUGE on CT, but most won't operate on this size.

Hypertrophic cardiomyopathy is associated with a systolic murmur loudest at the apex, and it may radiate to the base. The murmur increases with maneuvers that cause ventricular filling to decrease (e.g. valsalva, standing). The murmur decreases with maneuvers that cause ventricular filling to increase (e.g. trendelenburg, isometric exercises, squatting). These patients have primarily diastolic dysfunction, and so they should be treated with beta blockers to help improve diastolic filling time.

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]

Growth An infant with failure to thrive will first demonstrate poor weight gain. ==> With continued insult, there will be reduced height/length growth and then, finally, reduced head circumference growth. After birth, infants will normally loose weight initially (particularly breastfed infants). Infants should regain their birth weight by 2 weeks of life. For the first 3 months, infants should gain ~30 grams a day (~1 oz / day). By 6 months, they should have doubled their weight. By 12 months, they should have tripled their weight. By 24 months, they should have quadrupled their weight.

Ciguatera Poisoning - The most commonly reported cause of fishborne poisoning - Most commonly big-game fish: sea bass, grouper, red snapper, yellow-tail, kingfish and sturgeon - Ciguatoxin is bioaccumulated (thus big fish) and is heat and acid stable (unaffected by cooking) - Symptoms: 6-12 hrs post-ingestion GI, paresthesias, metallic taste, ataxia and paresis of legs are possible - The classic symptom is dysesthesias (sensory reversal where cold gives intense burning sensation) - Treatment: Supportive, consider mannitol, calcium, gabapentin - Avoid the following as it may exacerbate symptoms: opioids, barbiturates, steroids

Common causes of stroke in young patients: --> Arterial dissection (most commonly involving the carotids, often trauma related) --> Cardioembolic events (most commonly via a patent foramen ovale (PFO) associated with an atrial septal aneurysm; also atrial septal anuerysms and myxomatous mitral valve prolapse; most common amongst our patient population is likely endocarditis) --> Large vessel disease (typically in 5th decade of life) --> Small vessel disease (typically in 5th decade of life) --> Coagulopathies (i.e. Sickle cell anemia) --> Vasculopathies/Vasculitis Cerrato, et al. "Stroke in young patients: Etiopathogenesis and risk factors in different age classes." Cerebrovascular Diseases 2004;18:154-159.

-Reexpansion pulmonary edema represents a potentially life-threatening complication of tube thoracostomy (mortality rate as high as 20 percent) -It usually occurs after rapid reexpansion of a collapsed lung in patients with a pneumothorax -It may also follow evacuation of large volumes of pleural fluid (>1.0 to 1.5 liters) or after removal of an obstructing tumor -The incidence of edema appears to be related to the rapidity of lung reexpansion and to the severity and duration of lung collapse -The clinical manifestations vary from isolated radiographic changes to complete cardiopulmonary collapse -Treatment is supportive, mainly consisting of supplemental oxygen and, if necessary, mechanical ventilation

Indications for the placement of an IVC filter: 1. Patients with acute VTE who have a contraindication to traditional anticoagulation (surgery, GI bleed, bleeding) 2. Patients with a DVT who have severely compromised cardiopulmonary reserve or who already have pulmonary hypertension 3. Patients with VTE who have developed clot on anticoagulation Reference: Buller, HR, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy, Chest 2004

The consequences of missed MI in the elderly are dramatic: 50% of elderly patients with an MI missed by the ED or primary care doctor will be dead within 3 days.

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.

Henoch-Schonlein Purpura HSP is a small vessel vasculitis ==> Related to IgA nephropathy; however, IgA nephropathy more often involves young adults and predominantly affects the kidneys. Generally, HSP is a benign, self-limited disease. Pt s are NOT TOXIC appearing. ARENA (common symptoms) ==> Abdominal Pain and Vomitting (85%) +/- Bloody Stools ==> Rash (95-100%) ==> Edema (20-50%), peripheral or scrotal ==> Nephritis ==> Arthritis / Arthragias (60-80%) particularly of knees and ankles Steroids are controversial no definitive controlled trials demonstrate their efficacy.

Ethanol withdrawal can be measure objectively with the CIWA-Ar Scale. It is a prospectively validated tool to measure whether or not a patient is in ethanol withdrawal and can assist with management. Score Treatment <10 Does not require treatment 10-15 Treatment with either oral or intravenous benzodiazepines, outpatient > 15 Intravenous benzodiazepines with likely admission You must also take into account the patient's history, comorbidities and previous history of ethanol withdrawal/delirium tremens. ***The CIWA Score Sheet has been attached to this pearl***

Attachments

• 0709201013_ciwa-ar.pdf (10 Kb)

The majority of large cerebral artery infarcts take place in the Middle Cerebral Artery (MCA) because it supplies the largest territory. The MCA supplies most of the temperol, anterolateral frontal lobe, and parietal lobes. Perforating branches supply the posterior limb of the internal capsule and the head and body of the caudate and globus pallidus. Clinical findings can include: ipsilateral facial, upper, and lower extremity deficit/weakness (arm > leg); dysarthria; dysphagia; global aphasia if lesion on left (i.e. dominant hemisphere); neglect.

Important EM pearls from the recent 2007 IDSA/ATS guidelines for treatment of community-acquired pneumonia (CAP) Patients should be treated for a minimum of 5 days CURB-65 a new pneumonic; any patient with ? 2 warrants admission Confusion Uremia elevated Respiratory rate low Blood pressure age > 65 Outpatient CAP treatment Healthy + no abx in past 3 months ? macrolide Comorbidities OR use of abx within last 3 months ? a respiratory fluoroquinolone OR ?-lactam + macrolide Inpatient CAP treatment ICU patients ? ?-lactam + either azithromycin or a respiratory fluoroquinolone Non-ICU patients ? respiratory fluoroquinolone OR ?-lactam + macrolide Mandell LA, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults Clinical Infectious Diseases 2007;44:S27-S72