visual aid: ultrasound for pneumothorax

21 Jul

great visual aid reminders for the ultrasound findings for a normal lung vs. pneumothorax via June’s Emed Journal:

Linear probe

2nd intercostal space, mid-clavicular, anterior chest wall

NORMAL LUNG (“waves on the beach”)

 

PNEUMOTHORAX (barcode sign)

References: emed journal article

What is Palcohol?

17 Jul

some tidbits for the near-the-horizon coming of Powdered ALCOHOL (Palcohol), via this month’s EM News:

 

concentrated powdered alcohol

>= 55% alcohol by weight, 10% by volume

palcohol

the idea:

mix with warm water, imbibe

the concerns:

hidden ingestion (e.g. slipping it into drinks, spiking food)

non-PO routes (e.g. snorting, IV)

 

deterrents (hopefully)

volume — packet says 200ml with water added, so would take a lot powder to spike/snort/shoot 1 shot of liquor’s worth

pain — snorting or IV injection seems caustic and painful

 

There you go.  Be on the lookout.

 

References: EM News article + picture; SA article

 

ACUTE LIMB ISCHEMIA

14 Jul

manifests as:

  • ischemic rest pain
  • ischemic ulcers
  • gangrene

 

ETIOLOGY 

  • Embolus from a proximal source lodging into a more distal vessel
  • dissection of an artery or direct trauma to an artery

 

RISK FACTORS

  • atrial fibrillation,
  • Recent myocardial infarction
  • Aortic atherosclerosis,
  • aneurysmal disease (eg, aortic aneurysm, popliteal aneurysm)
  • Prior lower extremity revascularization (angioplasty/stent, bypass graft),
  • Risk factors for aortic dissection (HTN, etc)
  • Arterial trauma
  • Deep vein thrombosis (paradoxical embolism)
  • left ventricular dysfunction
  • debris from prosthetic valves and infected cardiac valves (septic emboli)

 

Arterial Trauma — Acute arterial occlusion following interventional procedures has become a more frequent cause — the incidence of arterial complications following interventional cardiac catheterization is ~1.5 to 9 percent 

 

6 P’s

  • paresthesia,
  • pain,
  • pallor,
  • pulselessness,
  • poikilothermia,
  • paralysis

 

Variations Blue toe syndrome — sudden appearance of a cool, painful, cyanotic toe(s) or forefoot in the often perplexing presence of strong pedal pulses and a warm foot.  The blue toe syndrome is usually due to embolic occlusion of digital arteries with atherothrombotic material from proximal arterial sources.

IMAGING 

First LineComputed tomographic angiography with runoff, noninvasive duplex ultrasonography, or magnetic resonance angiography

 

MANAGEMENT

intravenous heparin bolus followed by a continuous heparin infusion 

Preoperative eval, including blood tests (PT/PTT, CBC) and electrocardiography (ECG)

Surgical thromboembolectomy and bypass grafting – Were the mainstays of therapy for many years. Subsequently, thrombolytic therapy and percutaneous transluminal angioplasty (PTA) have become treatment options for selected patients. 

Consult Vascular Surgery.

Submitted by Christina Brown.

 

References: uptodate.com, Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5Nasser TK, Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheral vascular complications following coronary interventional procedures. Clin Cardiol 1995; 18:609.Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e669S.Yeager RA, Moneta GL, Taylor LM Jr, et al. Surgical management of severe acute lower extremity ischemia. J Vasc Surg 1992; 15:385.; picture 

Humeral Shaft Fracture

9 Jul

Important anatomy:

-insertion for pectoralis major, deltoid, coracobrachialis

-origin for brachialis, triceps, brachioradialis

-radial nerve courses along spiral groove

 

Important to evaluate for radial nerve palsy (wrist extension)

 

Non-operative treatment: cooptation splint

-arm flexed to 90 degrees

-splint just distal to the elbow up to the AC joint (sugar tong)

-no sling; instead use a “cuff and collar”, which supports the arm, while applying traction (see picture)

ELBOW DISLOCATION 1

Acceptable reduction:

  • <20 degrees of anterior angulation;
  • <30 degrees of varus/valgus angulation;
  • < 3 cm shortnening

 

Source: orthobullets.com, picture: rch.org.au; anatomy picture

 

Submitted by K Estes.

Useful Tool: Necrotizing fasciitis score

6 Jul

the LRINEC = laboratory risk indicator for necrotizing fasciitis

 

-the score is based off of a retrospective observational study comparing laboratory results of patients with confirmed necrotizing fasciitis and those with severe cellulitis or abscess

 

-six criteria: CRP, WBC, hemoglobin, sodium, creatinine, glucose

 

-each of the criteria are weighted with a point value

 

-values totaling a LRINEC score >6 had a sensitivity of 90% and specificity of 95%; PPV 92% and NPV 95%

 

-useful tool? Sure. But also keep in mind this cut-off still missed 10% of patients with necrotizing fasciitis

 

-Summary: a LRINEC score > 6 could be used as a potential tool to rule in necrotizing fasciitis, but a score <6 should not be used to rule out the diagnosis

 

Sources:

Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (laboratory risk indicator for necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul; 32 (7):1535-41. PubMed PMID: 15241098.; MDCalc site; picture

 

Submitted by K Estes

 

 

Quick Hit: D-Dimer false positives

30 Jun

Thinking about ordering a D-Dimer for PE rule-out? What are the clinical conditions to consider thatmay make your D-Dimer falsely elevated?

  • Myocardial infarction
  • Stroke
  • Atrial fibrillation
  • Preeclampsia and eclampsia
  • Cardiovascular disease
  • Congestive heart failure
  • Severe infection
  • Surgery/trauma
  • Sickle cell disease
  • Severe liver disease (decreased clearance)
  • Malignancy
  • Renal disease
  • Pregnancy

 

Source: uptodate.com; picture

 

Submitted by K Estes.

Hypertrophic Cardiomyopathy (HCM)

25 Jun

QUICK HITS:

-only about 50% of patients will have positive family history

-average age of diagnosis is 30-40 years -> not always a teenager or young adult!

-clinical features: syncope, chest pain, palpitations, dyspnea

systolic murmur at apex or LLSB

  • increases with valsalva and standing
  • decreases with trendelenburg and squatting

-ECG abnormalities present >85% of the time

            high left ventricular voltage, left atrial enlargement

            tall R wave in V1 (mimics posterior MI)

            deep, narrow Q-waves in inferior, lateral leads

-definitive diagnosis Doppler ECHO

-treatment: beta blockers, calcium channel blockers; these patients should be urgently referred to cardiology and be counseled to avoid strenuous activity

Source: lifeinthefastlane.com, Mattu A, Brady W. ECGs for the Emergency Physician 2, BMJ Books 2008.; picture

Submitted by K Estes.

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