Archive | July, 2013

Priapism (quick review)

31 Jul

Definition

 –Prolonged and persistent penile erection unassociated with sexual interest or stimulation.

-Persists > 4 hours, although there is really a spectrum of time less than this up to months

 -priapism of the clitoris also reported

 -corpora cavernosa typically engorged, although spongiosum also observed

 -pain not required

 

Complications of priapism if left untreated are penile fibrosis, urinary retention, impotence

 

Conditions associated with priapism

Ischemic (“low-flow”, more common, 2/2 decreased venous outflow, +pain)

  • sickle cell disease,
  • vasoactive drugs,
  • ED drugs,
  • antihypertensives (hydralazine, prazosin),
  • antiphsychotics,
  • antidepressants (trazodone),
  • ETOH,
  • cocaine,
  • neoplastic disease,
  • spinal cord injury

 

Nonischemic (high-flow, e.g. laceration of penile artery w/ excessive inflow of arterial blood, typically painless)

  • trauma,
  • straddle injury,
  • vasoactive drugs,
  • neurologic conditions

 

Laboratory testing

-CBC to eval for infections/hematologic abnormalities

-reticulocyte count to eval for sickle cell disease

 

Diagnosis

aspirated blood from corpus cavernosum

-> dark = ischemic (officially test with ABG, PO2 <30mmHg, PCO2 >60mmhg, Ph <7.25)

 -> bright red = non-ischemic (Po2>90mmhg, PCO2 <40mmhg, Ph 7.4)

 

Treatment

ischemic priapism = true emergency, requires evacuation of blood and irrigation of the corpora cavernosa.

Followed by IV injection of an alpha-adrenergic sympathomimetic agent (phenylephrine 100-200 microgm every 5-10 min until detumescence).  40-80% resolution rate,

if refractory then surgical shunting

*parenteral vasodilators (terbutaline) have been used with varying success

 

non-ischemic => observation, 62% have spontaneous resolution

 

Submitted by K. Estes.

 

References: 1. Priapism: Current Principles and Practice. Urologic clinics of North America. Vol 34, Issue 4. November 2007.; 2. Rosen’s Emergency Medicine. 7th Edition

hyponatremia and hyperglycemia: quick hits, quick math

30 Jul

 

Symptoms (VAGUE, NON-SPECIFIC) include:

  • nausea, vomiting,
  • anorexia,
  • muscle cramping,
  • lethargy,
  • confusion,
  • eventually seizure/coma/death

 

1st step is to determine the ECF volume status.

 

Hypertonic hyponatremiamost commonly hyperglycemia, each 100 mg/dL reduces serum Na by 1.7mEq/L

  • quick guesstimation/rule of thumb: add 1 to the sodium level for every 50 mg/dL glucose over 100
    • e.g. glucose 200, sodium 140 -> add 2 to 140 -> corrected Na~=142
    • e.g. glucose 500, sodium 140 -> add 8 to 140 -> corrected Na~=148
  • quick internet cheat: mdcalc’s Sodium Correction for Hyperglycemia

 

———————————-

30 seconds of the other stuff….

 

Isotonic hyponatremia—often referred to as factitious and does not require treatment.

 

Hypotonic Hyponatermia—Results from intracellular volume expansion with derangement of cellular functions (e.g. SIADH)

  • Six criteria of SIADH 
    • 1. Hypotonic hyponatremia
    • 2. Innappropriately elevated elevated urine osms (>200)
    • 3. elevated urinary Na
    • 4. Clinical Euvolemia
    • 5. Normal adrenal, renal, cardiac, hepatic, and thyroid fxn
    • 6. Correctable with water restriction

 

Submitted by J. Stanton.

 

References: uptodate.com; mdcalc.com; picture

 

Adult epiglottitis: what are the signs?

29 Jul

PRESENTING SIGNS/SYMPTOMS:

  • sore throat or odynophagia (90 to 100 %)
  • Fever ≥37.5ºC (26 to 90 %)
  • Muffled voice (50 to 80 %)
  • Drooling (15 to 65 %)
  • Stridor or respiratory compromise (33 %)
  • Hoarseness (20 to 40 %)

progression of symptoms in adults is slower than that in children

one series of 106 patients,

  • 65% presented within two days of symptom onset,
  • 9% (a decent number) presented more than one week later

 

TREATMENT OPTIONS:

Use of glucocorticoids is controversial without clear evidence either way

Empiric abx should be combination therapy with 3rd gen cephalosporin and MRSA coverage

 

Submitted by J. Stanton.

 

References: uptodate.com; picture

 

low back pain: clinical exam pearls

26 Jul

Straight leg raise

useful to help confirm radiculopathy.

BASICS:

  • patient supine.
  • examiner raises the patient’s extended leg with the ankle dorsiflexed (passive)
  • test is positive when the sciatica is reproduced between 10 and 60 degrees of elevation.

A positive straight leg test is sensitive, but not specific, for herniated disc.

 

crossed straight leg raise test

test is positive when lifting the unaffected leg reproduces the sciatica in the affected leg.

less sensitive for herniated disks, but 90 percent specific.

 

neurologic testing should focus on the L5 and S1 nerve roots, since 98 percent of clinically important disc herniations occur at L4-5 and L5-S1

 

L5

  • motor testing evaluates strength of ankle and great toe dorsiflexion.
  • sensory: numbness in the medial foot and the web space between the first and second toe.

S1 nerve root

  • ankle reflexes and sensation at the posterior calf and lateral foot.
  • weakness of plantar flexion, but is difficult to detect until quite advanced (tip: have the patient raise up on tip-toe three times in a row, on one foot alone and then the other)
  • absence of ankle reflexes becomes increasingly common with age; Unilateral absence of ankle reflexes is uncommon, though (10% of those >60 yo)
  • therefore, unilateral absence of an ankle reflex is rare enough to be a clinically useful sign (specificity of 89 percent)

 

Nonorganic signs or Waddell’s signs

In patients with chronic pain, psychological distress may amplify low back symptoms, and may be associated with anatomically “inappropriate” physical signs.

 

The most reproducible of these signs are

  • superficial tenderness,
  • distracted straight leg raising (ie, discrepancy between seated and supine straight leg raising tests)
  • the observation of patient overreaction during the physical examination, also known as Waddell’s signs.

 

Other Waddell’s signs suggestive of symptom enhancement include

  • nondermatomal distribution of sensory loss,
  • sudden giving way or jerky movements with motor examination,
  • inconsistency in observed spontaneous activity (dressing, getting off table) and formal motor testing,
  • pain elicited by axial loading (pressing down on top of head, or rotating the body at hips or shoulders).

However, systematic reviews have not found an association between Waddell’s signs and psychological distress, or claims for disability compensation or litigation.

 

Submitted by J. Stanton.

 

References: uptodate.com; picture

Transverse myelitis: quick hits

25 Jul

BASICS

segmental spinal cord injury caused by acute inflammation

RARE (1-5 cases per million)

Most are idiopathic, presumably result from an autoimmune process

up to half have a preceding infection

can also occur in multiple sclerosis (MS) and can be the presenting demyelinating event

also associated with connective tissue diseases (e.g. lupus, Sjogren’s, scleroderma, RA, etc).

 

inflammation of TM is generally restricted to one or two segments, usually in the thoracic cord.

 

SYMPTOMS:

Symptoms typically develop rapidly over several hours (~37 percent worsen maximally within 24 hours)

Typically bilateral, producing weakness and sensory disturbance below the level

 

In addition to diminished sensation, pain and tingling are common and frequently include a tight banding or girdle-like sensation around the trunk, which may be very sensitive to touch.

Back and radicular pain are also common.

Bowel and bladder dysfunction, reflective of autonomic involvement, also occur.

 

Diagnosis:

MRI

Cerebrospinal fluid (CSF)

  • elevated protein level (usually 100 to 120 mg/100 mL)
  • moderate lymphocytosis (usually <100 /mm3).
  • Glucose levels are normal.
  • Oligoclonal bands are usually not present in isolated TM, and when present suggest a higher risk of subsequent MS.

 

TREATMENT OPTIONS:

often treated with corticosteroids, though there is limited evidence

other immunosuppressive drugs

 

Most patients have at least a partial recovery, after 1-3 months

Some degree of persistent disability is common (~ 40%)

Significant recovery is unlikely if there is no improvement by three months.

a small percentage may suffer a recurrence.

 

Submitted by J. Stanton.

 

References: uptodate.com; picture

detox: inpatient or out?

24 Jul

CRITERIA FOR AMBULATORY DETOX

  • no symptoms of delirium tremens (DT):
    • fever,
    • disorientation,
    • seizures,
    • drenching sweats,
    • severe tachycardia or hypertension
  • Able to take oral medications
  • reliable family member or close contact who can stay with the patient (usually three to five days) 
  • Able to commit to daily medical visits
  • No unstable medical condition
  • Not psychotic, suicidal, or significantly cognitively impaired
  • Not pregnant
  • No concurrent other substance abuse that may lead to withdrawal 
  • No history of DTs or alcohol withdrawal seizures

 

Relative contraindications for ambulatory detox

  • age >60 years
  • evidence of end organ damage from alcohol
    • bone marrow toxicity as evidenced by an elevated MCV
    • renal insufficiency,
    • ascites
    • cirrhosis

 

Submitted by J. Stanton.

 

References: uptodate.com; picture

percentages and subarachnoid hemorrhages

23 Jul

SOME NUMBERS FOR THOUGHT:

The cornerstone of SAH diagnosis is the noncontrast head CT scan.

 

Clot in the subarachnoid space in 92 percent of cases if CT < 24 hours of the bleed.

 

Intracerebral extension is present in 20 to 40 percent

intraventricular may be seen in 15 to 35 percent

subdural blood may be seen in 2 to 5 percent

 

distribution of blood on CT (performed within 72 hours after the bleed) is a poor predictor of the site of an aneurysm except in patients with ruptured anterior cerebral artery or anterior communicating artery aneurysms and in patients with a parenchymal hematoma

 

The sensitivity of head CT for detecting SAH is highest in the first 6 to 12 hours after SAH (nearly 100 percent)

then progressively declines over time to about 58 percent at day five.

 

The sensitivity of head CT is also reduced with more minor bleeds. In one study, a minor SAH was not diagnosed by CT scan in 55 percent of patients; lumbar puncture was positive in all cases .

 

Submitted by J. Stanton.

 

References: uptodate.com; picture