Archive | August, 2013

auricular hematoma repair

30 Aug

Nice procedure review back in April’s EP Monthly article.  Click through for the full read.

 

HIGHLIGHTS:

“Our job in the emergency department is three fold: early identification, early drainage, and using various splints and bandaging techniques to prevent the re-accumulation of blood. “

 

NEAT TRICK:

“…simply placing two to three absorbable mattress sutures along the involved portion of ear both prevents accumulation of blood and spares the patient buttresses that require future removal…”

 

ONLY PICTURE I COULD FIND TO ILLUSTRATE:

ear

 

10-SECOND TAKEAWAY:

I’m probably still going to pad (as a compressive dressing) the ear after repair, but might consider just putting in absorbable sutures, instead of suturing in padding/etc.  

 

References: EP monthly article; picture

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random review: Insall-Salvati ratio for patella alta

29 Aug

(a.k.a. something i looked up again recently)

 

Insall-Salvati ratio = ratio of the patella tendon length to the patella length

measured on a lateral knee xray (Ideally knee is 30 degrees flexed)

 

traditional normal ratio = tendon length:patella length < 1.2 (between 0.8 and 1.2)

ratio >1.2   –> patella alta (a.k.a. high riding patella)

 

WHY THIS MATTERS:

patella alta concerning for patella tendon rupture

remember this when looking at your lateral knee X-rays

 

References: Insall-Salvati ratio; patella alta; picture

why we look for hydronephrosis

28 Aug

one quick abstract review on the utility of hydro(nephrosis) in a suspected kidney stone patient:

 

Study by Goetz & Lotterman: 

  • retrospective study, ED patients who got a bedside renal ultrasound and had a stone on non-con CT
  • 177 ultrasounds
    • patients with none or mild hydronephrosis (72.9%)
    • rest were moderate to severe hydro

 

  • no or mild hydro: 12.4% with ureteral stone > 5 mm 
  • moderate or severe hydro:  35.4% with ureteral stone > 5 mm 

 

  • negative predictive value of 0.876 (with no or mild hydro)

 

THEIR CONCLUSION:

“Patients with less severe hydronephrosis were less likely to have larger ureteral calculi.”

 

BOTTOM LINE:

no-to-little hydro doesn’t rule out other badness in your differential, but if you’re only worried about a kidney stone, minimal hydro is less likely to mean a big (>5mm) stone.  

moderate to severe hydro, might be big enough that it might need some help from urology.

 

References: articlepicture

 

 

Acute Angle Closure Glaucoma

27 Aug

Re-post, but came up on a recent shift lately, was on the mind, good for a quick review:

 

Definition

characterized by narrowing or closure of the anterior chamber angle

 

Anatomy/Physiology

The normal anterior chamber angle provides drainage for the aqueous humor, the fluid that fills the eyeball.

When this drainage pathway is narrowed or closed, inadequate drainage of the aqueous humor leads to elevated intraocular pressure and damage to the optic nerve.

Normal intraocular pressure is 8 to 21 mm Hg.

In acute episodes of closed angle glaucoma, pressures are often 30 mm Hg or higher.

 

Risk Factors

Family history of angle closure

Age older than 40 to 50 years

Female

Hyperopia (farsightedness)

Certain medications, particularly over-the-counter decongestants, motion sickness medications, adrenergic agents, antipsychotics, antidepressants, and anticholinergic agents

 

Clinical Presentation (Signs/Symptoms)

Decreased vision or halos around lights

Headache

Severe eye pain

Nausea and vomiting

Conjunctival redness

Corneal edema or cloudiness

A shallow anterior chamber

A mid-dilated pupil (4 to 6 mm) that reacts poorly to light

 

Management

Obtain emergent ophthalmology consultation for immediate evaluation and to discuss appropriate medical treatment

Place the patient supine

For patients with significant decline in vision (eg, with affected eye, patient cannot read text they would normally be able to, or cannot count fingers), provide immediate treatment to reduce IOP:

 • Give timolol 0.5 percent, 1 drop to the affected eye, wait one minute, then

 • Give apraclonidine 1 percent, 1 drop to the affected eye, wait one minute, then

 • Give pilocarpine 2 percent, 1 drop to the affected eye every 15 minutes for 2 total doses; wait one minute after first dose, then

 • Give prednisolone acetate 1 percent, 1 drop to the affected eye every 15 minutes for 4 total doses

 • Give acetazolamide 500 mg IV (may give by mouth if IV medication not available)

 • If IOP remains significantly elevated (≥40 mmHg) 30 minutes after giving this regimen and an ophthalmologist is not immediately available to assume care, give mannitol 1 to 2 g/kg IV

• For all patients, relieve associated symptoms with analgesics (eg, morphine, titrate to effect) and antiemetics (eg, ondansetron, initial dose 8 mg IV)

 

Submitted by K. Dabrowski.

Sources: Uptodate.com: angle-closure glaucoma; picture

dietary potassium content

26 Aug

Your differential for your next hyper (or hypo) -kalemic patient can be broad (renal, meds, rhabdo, release/shift, etc), but when you think dietary, what foods do you need to know about?

 

Banana’s and OJ are usually the most commonly referenced, but here are some other common foods with high potassium content:

  • Squash, potato, spinach, beans
  • Watermelon, raisins, OJ, bananas

(try not to let your renal patient use this as an excuse to eat tons of fried foods and avoid the fruits & veggies).

 

Check out this handy chart (with serving-size-ish mEq’s) from the Mayo Clinic site for a more complete listing:

Food (amount) Milligrams
of potassium
Milliequivalents
of potassium
Acorn squash, cooked 
(1 cup)
896 23
Potato with skin, baked 
(1 long)
844 22
Spinach, cooked 
(1 cup)
838 21
Lentils, cooked 
(1 cup)
731 19
Kidney beans, cooked 
(1 cup)
713 18
Split peas, cooked 
(1 cup)
710 18
White navy beans, cooked 
(1 cup)
669 17
Butternut squash, cooked 
(1 cup)
583 15
Watermelon 
(1/16)
560 14
Raisins 
(½ cup)
553 14
Yogurt, low-fat, plain 
(1 cup)
531 14
Orange juice, frozen 
(1 cup)
503 13
Brussel sprouts, cooked 
(1 cup)
494 13
Zucchini, cooked, sliced 
(1 cup)
456 12
Banana 
(medium)
451 12
Collards, frozen, cooked 
(1 cup)
427 11
Cantaloupe 
(¼)
412 11
Milk, low-fat 1% 
(1 cup)
348 9
Broccoli, frozen, cooked 
(1 cup)
332 9

 

References:  mayoclinic site; webmd; picture

in-flight emergencies

23 Aug

Some interesting info from a couple ACEP News articles:

YOU TOO, MAY BE CALLED TO HELP ON YOUR NEXT FLIGHT:

Rare, but can happen:

  • one report: 1 in-flight emergency per 11,000 passengers
  • another data set: ~16 emergencies per million passengers (0.0016%)
    • 31% resolved issue before landing
    • ~1/3 of the rest were taken to a hospital ED, and half of those were discharged

On board assistance provided by:

  • physicians 48%
  • nurses 20%
  • EMS providers 4.4%
  • other health care professionals 3.7%

 

ITS OKAY TO HELP:

“The 1998 Aviation Safety Medical Assistance Act includes a Good Samaritan provision, protecting passengers from liability other than liability for gross negligence or willful misconduct”

“Volunteers must be “medically qualified,” render care in good faith, and receive no monetary compensation to be protected under this Act.” (so don’t take that first class upgrade)

 

WHAT DO YOU HAVE TO WORK WITH?

Aside from your wits, you have your in-flight medical kit (hopefully), which includes:

Medications

  • Epinephrine 1:1,000
  • Antihistamine, injectable (inj.)
  • Dextrose 50%, inj. 50 mL (or equivalent)
  • Nitroglycerin tablets or spray 
  • Major analgesic, inj. or oral
  • Sedative anticonvulsant, inj.
  • Antiemetic, inj. 
  • Bronchial dilator inhaler 
  • Atropine, inj. 
  • Corticosteroid, inj. 
  • Diuretic, inj. 
  • Medication for postpartum bleeding 
  • Normal saline 
  • Acetylsalicylic acid for oral use 
  • Oral beta-blocker 
  • Epinephrine 1:10,000 
  • List of medications: generic name plus trade name if indicated on the item

Equipment

  • Stethoscope 
  • Sphygmomanometer (BP cuff)
  • Airways, oropharyngeal 
  • Syringes 
  • Needles 
  • IV catheters 
  • Antiseptic wipes 
  • Gloves 
  • Sharps disposal box 
  • Urinary catheter 
  • Intravenous fluid system 
  • Venous tourniquet 
  • Sponge gauze 
  • Tape adhesive 
  • Surgical mask 
  • Flashlight and batteries 
  • Thermometer (nonmercury) 
  • Emergency tracheal catheter 
  • Umbilical cord clamp 
  • Basic life support cards 
  • Advanced life support cards

“While most domestic airlines carry this kit, there are no international regulations requiring the complete kit to be available.”

 

References: acep news stats article; equip reference; picture

 

tegaderm fingertip dressing

22 Aug

Neat “Trick of the Trade” in August’s ACEP News mag:

Click through the link to read the whole thing, but here are some highlights:

 

For fingertip avulsions or minor bleeding lacs not great for suturing:

 

PREP:

Tegaderm (sticky side up)

glob of antibiotic ointment (e.g. bacitracin)

small ‘gelfoam’ absorbant dressing

 

PROCEDURE:

patient puts finger down

wrap it up

benzoin then steri-strip around to hold in place

 

Nice idea.  Add it to the toolbox.

 

References: acepnews article.