quick tip: easy fluorescein staining

28 Apr

via a recent post from the Procedural Pause:pp20fluoro20clinical20pearl

use a saline ‘bullet’ (dropper), drip a little saline on the fluorescein strip, then draw it back up.

 

handy for peds, or for squirmy adults, too

 

 

I’ve also seen the strip dropped in the back of a 10 cc syringe, or a saline flush used similarly as with the dropper above (see this ALiEM post for more).

dab-650x464

 

There you go. Add it to the toolbox.

 

References: procedural pause post, ALiEM post

 

 

vomiting during intubation? tube the esophagus

13 Apr

quick handy tip from this EMCRIT podcast for a vomit (or blood) laden oropharynx during intubation:jan_08_jems_intubation101

blindly (since you can’t see anything) insert an ETT; if it happens to be tracheal, great.

more likely, it’ll be in the (esopha)gUs.  LEAVE IT THERE.  you can intubate around it shortly, and you now have a landmark to intubate over. 

now here’s the tip: INFLATE the cuff on the esophageal ETT.  Also remember to tilt the now vomit-spewing ETT to the side, but this is now an outlet for the blood/vomit that won’t obscure your DL view

now, suction, and intubate the trachea.

 

Easy concept, handy tip.  Add it to the toolbox.

(check out the podcast for some more tips, but I thought that was the handiest).

 

References: EMCRIT podcast; picture

Torticollis (quick review)

21 Mar

submitted by Christina Brown, M.D. 

 

Definition – “Twisted neck” (L. tortus, twisted + collum, neck).29727

Synonyms: Cervical dystonia, wry neck

Self-limited, symptoms resolve in 1 to 2 weeks

Possible Etiologies:

  • Fracture
  • Dislocation, subluxation
  • Cervical spine disease
  • Infections
  • Spondylosis
  • Tumor
  • Scar tissue–producing injuries
  • Ligamentous laxity in atlantoaxial region
  • Drug induced
  • Otolaryngologic:
    • Vestibular dysfunction, Otitis media
    • Cervical adenitis, Pharyngitis, Retropharyngeal abscess
    • Mastoiditis
  • Esophageal reflux
  • Syrinx with spinal cord tumor

 

Physical Exam

  • Intermittent painful spasms of sternocleidomastoid (SCM), trapezius, and other neck muscles
  • Head is rotated and twisted to one direction

 

Management:

Imaging

  • Plain film if cervical fracture is suspected.
  • CT or MRI of cervical spine if retropharyngeal abscess or tumor suspected

INITIAL STABILIZATION/THERAPY: Cervical spine immobilization if fracture is suspected

ED TREATMENT/PROCEDURES

  • Soft collar and rest,
  • Physical therapy,
  • Massage,
  • Local heat,
  • Analgesics

 

MEDICATION:

  • Diphenhydramine (for drug-related dystonia)
  • Valium: 2–5 mg IV, 2–10 mg PO t.i.d. (peds: 0.1–0.2 mg/kg per dose IV or PO q6h)
  • Botulinum toxin is an option for treating non-drug-induced torticollis, though this is not typically administered in the ED setting.

 

References:
1. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Torticollis. Rosen’s and Barken’s 5-Minute Emergency Medicine Consult. http://www.r2library.com.proxy.its.virginia.edu/Resource/Title/1608316300/ch0020s16613
2. Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol 1997; 111:1183.
3. Soundappan SV, Darwish B, Chaseling R. Traumatic spinal epidural hematoma-unusual cause of torticollis in a child. Pediatr Emerg Care 2005; 21:847.
4. Mutsaers P, Fick M, Plötz FB. Acquired torticollis as the only initially presenting symptom in a child with a brainstem glioma. Eur J Pediatr 2007; 166:1075.
5. Shanker V and Bressman S.: What’s new in dystonia? Curr Neurol Neurosci Rep. 2009; 9:278–284.

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Cauda Equina Syndrome

16 Mar

submitted by Christina Brown, M.D. 

 

Definition – Compression of lumbar and sacral nerve fibers in cauda equina region

back-pain-image-2
RISK FACTORS 

  • Neoplasm
  • IV drug use
  • Immunocompromised state.

ETIOLOGY

  • Herniated disc most common:
    • L4–L5 discs > L5–S1 > L3–L4
    • Most common in 4th and 5th decades of life
    • Mass effect from: Myeloma, lymphoma, sarcoma, meningioma, neurofibroma, hematoma
    • Spine metastases (breast, lung, prostate, thyroid, renal)
    • Epidural abscess (especially in IV drug users
  • Blunt trauma
  • Penetrating trauma

 

SIGNS and SYMPTOMS

  • Low back pain
  • Sciatica/radicular pain (unilateral or bilateral)
  • Lower extremity numbness or weakness
  • Difficulty ambulating owing to weakness or pain
  • Bladder or rectal dysfunction (Retention or incontinence)

 

Physical Exam

  • Lumbosacral tenderness
  • Lower extremity sensory or motor deficits (May be asymmetric)
  • Decreased foot dorsiflexion strength
  • Decreased quadriceps strength
  • Decreased deep tendon reflexes
  • Saddle hypalgesia or anesthesia
  • Decreased anal sphincter tone


Postvoid residual volume (PVR):

  • Estimate by bladder catheterization or using US.
  • >100 mL is considered abnormal.
  • Residual increases with age.

 

Labs – Depends on differential diagnosis. Options include CBC, urinalysis, ESR, and C reactive protein (CRP)

IMAGING – MRI of spine is definitive study. CT myelogram if MRI unavailable

ED Treatment/Procedures:

  • Immediate neurosurgical consultation in all cases
  • Initiate antibiotics for epidural abscess in consultation with neurosurgery.
  • Controversy exists regarding urgency of decompression:
    • Recommendations range from within 6 hr of onset to within 24 hr.

 

Disposition:

  • All patients with acute cauda equina syndrome must be admitted to neurosurgical service.
  • Patients have good prognosis with rapid surgical decompression.
  • Treatment should not be delayed.
  • Patients presenting late (>48 hr) also benefit from surgical decompression.

 

References:

1. Fraser S, Roberts L, and Murphy E.: Cauda equina syndrome: A literature review of its definition and clinical presentation. Arch Phys Med Rehabil. 2009; 90(11):1964–1968.
2. Hussain S A, Gullan R W, and Chitnavis B P.: Cauda equina syndrome: Outcome and implications for management. Br J Neurosurg. 2003; 17(2):164–167.
3. Shapiro S.: Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine. 2000; 25(3):348–352.
4. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Cauda Equina Syndrome. Rosen & Barkin’s 5 Minute Emergency Medicine Consult.

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Peds “step by step”(for FWS)

27 Feb

submitted by Amit Kumar, M.D.

 

“Step by Step”

-Algorithm to identify pediatric patients (<90 days) with fever without a source (38°C, in patients with a normal PE and no respiratory symptoms or a diarrheal process) as low risk for invasive bacterial infection

-Developed by European group of EPs, validated

-Identifies “low risk” group not requiring LP and empiric antibiotics, and fit to be managed outpatient

-Found to be more sensitive than Rochester Criteria and Lab-score

step-by-step-algorithm

(Pediatric Assessment Triangle = appearance, work of breathing, circulation)

(PCT = procalcitonin)

-There, add it to your toolbox!

References:
Gomez, B., Mintegi, S., Bressan, S., Dalt, L. D., Gervaix, A., & Lacroix, L. (2016). Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics, 138(2). doi:10.1542/peds.2015-4381

Pediatric assessment triangle article

NEPHROLITHIASIS (quick review)

10 Feb

submitted by Christina Brown, M.D. 

Kidney stones:anatomy_kidneystones

  • Most common cause of renal colic
  • Stone composition:
    • 80%: Calcium stones (calcium oxalate > calcium phosphate)
    • 5% uric acid
    • Others: Magnesium ammonium phosphate (struvite), cystine
  • Associated with infections caused by urea-splitting organisms (eg, Pseudomonas, Proteus, Klebsiella) along with an alkalotic urine
  • 90% of urinary calculi are radiopaque.

 

Epidemiology and Etiology

  • 1% of the population
  • Twice as common in men as women
  • Theories on stone formation:
    • Urinary supersaturation of solute followed by crystal precipitation
    • Decrease in the normal urinary proteins inhibiting crystal growth
    • Urinary stasis from a physical anomaly, catheter placement, neurogenic bladder, or the presence of a foreign body

 

Pediatric Considerations

  • Rare in children
  • When present, indication of an overt metabolic or genetic disorder
  • Painless hematuria common presentation (up to 30%)

 

Causes of stone formation:

  • Metabolic abnormalities (50%)
  • Urologic abnormalities (20%)
  • Infection (15%)

 

History

  • Sudden onset of severe pain in the costovertebral angle, flank, and/or lateral abdomen
  • Colicky or constant pain: Patient cannot find a comfortable position
  • Hematuria: Gross hematuria in 1/3 of patients
  • Nausea/vomiting

 

ESSENTIAL WORKUP

  • Urinalysis
  • Microscopic hematuria present in >80%
  • Gross hematuria
  • Absent urinary blood in 10–30%
  • No correlation between the amount of hematuria and the degree of urinary obstruction
  • WBC/bacteria suggests infection

 

Imaging – CT:

  • Helical CT has replaced IV pyelogram (IVP) as test of choice.
  • Detects calculi as small as 1 mm in diameter
  • Advantages over IVP:
    • Performed rapidly
    • Does not require IV contrast media
    • Detects other non-urologic causes of symptoms, such as abdominal aortic aneurysms (AAAs)
  • Indications:
    • 1st-time diagnosis
    • Persistent pain
    • Clinical confusion with pyelonephritis

 

Renal Ultrasound:

  • unilateral hydronephrosis suggests possible obstructive stone
  • no radiation involved, but does not eval for non-urologic causes of symptoms

 

ED TREATMENT/PROCEDURES

  • Hydration:
    • Initiate IV crystalloid infusion with 1 L of normal saline infused over 30–60 min followed by 200–500 mL/hr.
    • Bolus volume compromised patients with 500-mL increments until urine output adequate
  • Analgesics (morphine, ketorolac):
    • Combination of IV NSAIDS and opioids decrease ED stay.
  • Antiemetics (prochlorperazine, ondansetron, droperidol, hydroxyzine)
  • α-Blockers (tamsulosin) or calcium-channel blockers (nifedipine) have been shown to decrease time to spontaneous stone passage:
    • Most efficacious for stones <5 mm in diameter
    • Tamsulosin and nifedipine equally effective
    • prescribe on discharge.

 

DISPOSITION

Admission Criteria

  • Obstruction in the presence of infection mandates immediate urologic intervention.
  • Intractable pain with refractory nausea and vomiting
  • Severe volume depletion
  • Urinary extravasation
  • Hypercalcemic crisis
  • Solitary kidney and complete obstruction
  • Relative admission indications (discuss with urologist):
    • High-grade obstruction
    • Renal insufficiency
    • Intrinsic renal disease
    • Stones of size <5 mm usually pass spontaneously; those >8 mm rarely do.

Discharge Criteria

  • Normal vital signs
  • No evidence of concomitant urinary tract infection
  • Adequate analgesia
  • Able to tolerate PO fluids to maintain hydration status

 

PEARLS AND PITFALLS

  • Do not miss a vascular catastrophe mimicking as renal colic.
  • Aggressive pain management and hydration promote passage of stones
  • The absence of hematuria does not exclude the diagnosis of acute renal colic.

 

References:
1. Bartosh S M.: Medical management of pediatric stone disease. Urol Clin North Am. 2004; 31:575–587. [PMID: 15313066]
2. Hollingsworth J M, Rogers M A, and Kaufman S R et al.: Medical therapy to facilitate stone passage: A meta-analysis. Lancet. 2006; 368:1171–1179.
3. Marx J A, Hockberger R S, and Walls R M: eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed.St. Louis, MO:Mosby;2009.

4. picture

VASOPRESSORS & INOTROPES (PEARLS)

2 Feb

Submitted by Amit Kumar, M.D.

RECEPTOR PHYSIOLOGY:

Alpha 1: In vascular walls; causes: vasoconstriction

Beta 1: In heart; causes: increased inotropy & chronotropy

Dopamine: In renal, splanchnic, cerebral, coronary vascular beds; causes: vasodilation

Vasopressin: V1 receptors in vessels; causes: vasoconstriction, V2 receptors in kidney; maintains osmolality via ADH

pressors_tintinallis

AGENTS:

VASOPRESSORS (A-1 adrenergic):

Norepinephrine (Levophed):

  • Works on A1 and B1 receptors
  • Causes: Potent vasoconstriction (+reflex bradycardia) and modest increase in CO; latter negated by reflex tachycardia
  • 1st line treatment for septic shock
  • 0.5-10mcg/min, titrate up

Phenylephrine (Neo-Synephrine):

  • Works on A1
  • Causes: Potent vasoconstriction
  • 100-180mcg/min. Once BP stable, titrate down to 40-60mcg/min

Epinephrine (Adrenalin)

  • Works primarily on B1, some on A1 and B2. Increase A1 activity in higher doses
  • Causes: Increased CO. At higher doses causes vasoconstriction as well.
  • 1st line for anaphylactic shock, 2nd line for septic shock
  • 0.1-4mcg/kg/min

Dopamine (Intropin)

  • Doses 2-5mcg/kg/min: dopaminergic (vasodilation);
  • 5-10mcg/kg/min: B1 (increased CO);
  • >10mcg/kg/min: A1 (increased vasoconstriction)

INOTROPE (B-1 adrenergic):

Dobutamine (Dobutrex)

  • Works on B1
  • Causes: Increased CO (+ reflex vasodilation)
  • 2.5-20mcg/kg/min

INOTROPE (PDE-inhibitor):

Milrinone (Primacor)

  • Optional loading dose: 50mcg/kg over 10 mins, followed by 0.125-0.75mcg/kg/min

ADH:

Vasopressin (Pitressin)

  • 0.03-0.04U/min
  • Causes: vasoconstriction

GENERAL CONCEPTS:

-Avoid reflex hypotension by titrating pressors down

-Gold standard: use central lines. For extravasation, use phentolamine 5-10mg SC including through the infiltrated line.

-Hypovolemia should be corrected first to achieve maximal vasopressor efficacy

-Do not use low-dose dopamine solely for “renal protection”/to increase UOP

REFERENCES:

-Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580.?

-Hollenberg SM. Vasoactive drugs in circulatory shock. Am J Respir Crit Care Med 2011; 183:847.?

-Picture: Tintinalli’s