Archive | December, 2013

holiday weight gain

20 Dec

Updates will be a bit sporadic over the holiday siesta, but here’s a little something light from last year for the layover:

Weight and body composition change over a six-week holiday period:

Change in weight and body composition was assessed over a six-week holiday period, prior to Thanksgiving Day through after New Year’s Day

Thirteen men and 21 women ranging in age from 23-61 years

majority of participants (24 of 34) perceived that they had gained weight, and four did gain ≥2 kg.

on average there was no difference between pre-holiday weight (74.0±17.8 kg) and post-holiday weight (73.9±18.1 kg), nor between pre-holiday body fat percentage (25.4±9.0%) and post-holiday body fat percentage (25.4±8.9%).


Holiday weight gain: fact or fiction?

convenience sample of 195 adults. 6-week winter period from Thanksgiving through New Years

On average, weight gain averaged only 0.37 kg.

weight gain was greater among individuals who were overweight or obese, and 14% gained >2.3 kg (5 lb).

absolute values for weight gain in this study were less than anticipated.



we gain weight, but maybe less than we think


References: weight & body composition article; holiday weight gain article; picture

Postherpetic Pseudohernia: you can’t diagnose it if you’ve never heard of it…

18 Dec


a limited protrusion of the abdominal wall, without structural defect

Causes include:

  • diabetic radiculoneuropathy,
  • Lyme disease,
  • polymyositis,
  • reactivation herpes zoster.


Classically, reactivation herpes zoster infection affects sensory nerve roots

however, it may extend to motor involvement, which can include paresis of diaphragmatic, upper and lower limb, or abdominal musculature.


Natural History:pseudohernia1

Symptoms of abdominal wall pseudohernia typically occur within 2 weeks of the rash and typically include an abdominal bulge in the region of the affected dermatome.

Typically, patients have a good prognosis, with resolution of symptoms within 18 months


Submitted by K. Sullivan.


References: Postherpetic Pseudohernia, Annals of Emergency Medicine July 2012

Not just an foot/ankle sprain: Lisfranc Injuries

17 Dec

 Lisfranc joint complex= the entire tarsometatarsal articulationlis1


Lisfranc joint= articulation of the 1st and 2nd metatarsals with the 1st and 2nd cuneiforms


Why we should care:

*Up to 20-40% of these injuries are missed on initial visit. 

*Chronic pain and disability are fairly common with Lisfranc injuries. 

*Operative management is sometimes needed.


History: Direct or indirect trauma, can be low energy.  Most have midfoot pain, swelling and difficulty bearing weight. These are not sensitive features.



* TTP at the 1st and 2nd metatarsal bases or remainder of Lisfranc joint complex

* Pain with passive abduction and pronation of forefoot when hindfoot is held flexed (specific for tarsometatarsal injuries)

* Plantar ecchymosis

* Of course perform neurologic and vascular exams.  Also consider and evaluate for a compartment syndrome of the foot.


XR findings (order AP, lateral, and oblique views):

 lis2AP or oblique views:

  1. 1.    Medial border of the 2nd metatarsal base and 2nd cuneiform (red line) form a straight line (as do the medial border of the 4th metatarsal base and cuboid)
  2. 2.    Lateral border of the 3rd metatarsal base and lateral border of the lateral cuneiform should form a straight line.
  3. 3.    >2 mm diastasis or >1 mm side to side difference between the metatarsal bases is abnormal (yellow asterix)
  4. 4.    “Fleck sign” or an avulsed bone fragment is a sign of ligamentous injury (yellow asterix)
  5. 5.    Cuneiform or metatarsal fracture



lis3Lateral views:

  1. 1.    A metatarsal shaft should never be more dorsal than its respective tarsal bone (red arrow)

*** If initial x-ray is normal but suspicion is high, order a weight bearing AP view to assess the 1-2 interval of the metatarsals and/or obtain a comparison x-ray of the contralateral foot. 



* If available, orthopedics consultation

* If not available, consider closed reduction if appropriate.  Then apply bulky dressing and posterior splint with very close ortho follow up

* Some mild lisfranc injuries are treated with casting and non-weight-bearing.  Others go on to require surgery such as reduction and fixation (2 mm of displacement and/or greater than 15 deg of talometatarsal angulation typically require surgery). 


Submitted by H. Groth.


Sources: Cvetanovich, Greg; Lieberman, Gillian. “Imaging of Lisfranc Injury”. Lecture at Beth Isreal Deaconess Medical Center November 2011; Nunley, JA. “Classification, investigation, and management of midfoot sprains: lisfranc injuries in the athlete”. Am J Sports Med 2002; 30:871-878; Perron, Andrew D; Brady, William J.; Keat, Theodore E. “Orthopedic pitfalls in the ED: Lisfranc fracture-dislocation” Amer J of Emerg Med 2001; 19(1): 71-75; Tintinalli’s Emergency Medicine; Wheeless’ Textbook of Orthopedics.

Using lactate in lieu of central venous oxygenation for sepsis resuscitation

16 Dec

In the well known Rivers Protocol for Early Goal Directed Sepsis therapy central venous oxygenation (ScvO2) is one of the goals.

In the emergency department ScvO2 is difficult to obtain. Lactates are not.

A non-inferiority study was published in JAMA in 2010 regarding this topic.

  • 300 patients were randomly allocated to either ScvO2 monitoring or serial lactates.
  • ScvO2 group was resuscitated to normalize CVP, MAP, and ScvO2 of at least 70%
  • lactate clearance group was resuscitated to normalize CVP, MAP, and lactate clearance of at least 10%.


  • no significant differences between groups in regard to in-hospital mortality.



In the ED, you can use lactate in lieu of central venous oxygenation as a goal/marker for sepsis resuscitation


Submitted by K. Sullivan.


References: Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010 Feb 24; 303 (8): 739-46; picture



Hyphema (quick review)

13 Dec

hyphema1Hyphema = Blood in the anterior chamber

What causes this? Stretching of the ciliary body or iris during trauma, causing vessels to leak in to the anterior chamber  

Signs/sx: Photophobia, pain, decreased visual acuity, elevated IOP, corneal blood staining (blood layering out in the anterior chamber)  

Grading system:  


 What to do in the ED:

  1. Look for other injuries- obviously ABC’s, intracranial trauma, orbital fractures, globe rupture, retina/vitreous detachment, lens trauma…
  2. Again, make sure there is not an open globe or increased IOP.
  3. Pain control- tetracaine drops +/- cycloplegics (such as cyclopentolate or scopolamine 0.25%- 1 drop).  Do not use either if there is a globe rupture.
  4. Rigid eye shield
  5. Increase HOB to 30 degrees
  6. Certainly an ophthalmology consult.  As discussed below, if the patient is high risk, this is an urgent ophtho consult.
  7. In a patient with a spontaneous hyphema or very trivial injury, consider evaluation for clotting disorder, eye tumor, child abuse, other systemic disease.


High risk features:

  1. Blood filling >1/3 of eye
  2. Sickle cell disease
  3. High initial IOP (>22)
  4. Young child
  5. Anticoagulation or clotting disorder



  1. Increased IOP (blood in anterior chamber clogging trabeculae causing traumatic glaucoma)- can result in permanent vision loss
  2. Rebleeding (2-5 days later)- can result in permanent vision loss
  3. Peripheral anterior synechiae (iris adheres to cornea)
  4. Optic atrophy
  5. Corneal bloodstaining



  1. If high risk- admit patient
  2. If low risk- home with very close f/u
  • a)      Daily ophthalmology checks (for IOP checks)
  • b)      Limited activity-resting at home
  • c)       HOB up to at least 30 degrees
  • d)      Rigid eye shield x1 week
  • e)      Pain control and sometimes other treatments per ophthalmology (steroids, tranexamic acid…)    


Submitted by H. Groth.


Sources: Romano PE et al. “Traumatic hyphema: a comprehensive review of the past half century yields 8076 cases for which specific medical treatment reduces rebleeding 62%, from 13% to 5%”. Binoc Vis Strabismus Q. 2000;15(2):175.; Up-to-date; Walton, W et al. “Management of traumatic hyphema” Surv Opthalmol. 2002; 47(4):297.  

Xray Findings in Subtle Calcaneus Fractures

12 Dec

Interesting Fact

A calcaneus fracture is also known as a Lover’s fracture, Don Juan fracture or Casanova Fracture (consequence of jumping from a bedroom window onto a hard surface).

Calcaneus fractures are most often caused by falling from a significant height onto one’s feet.  ED physicians should always consider the possibility that a fractured calcaneus might be bilateral, and/or associated with thoracic or lumbar fractures. 

X-ray findings to aid in the diagnosis

Subtle calcaneus fractures are sometimes hard to visualize on an xray which is why radiologists, orthopedists and ED physicians sometimes use Boehler’s angle and critical angle of Gissane.


Boehler’s angle

On a lateral view, this angle is formed by the intersection of two lines. 

  • The first line from the upper edge of the calcaneal body posteriorly to the upper edge of the posterior articular facet of the calcaneus at the subtalar joint. 
  • The second line is drawn from this point to the upper edge of the anterior process of the calcaneus.  If the angle is < 30 degrees, most likely there is a calcaneus fracture.


The first image demonstrates a Boehler’s Angle of 21 degrees suggesting that there is a fracture of the calcaneum. Compare this with the normal anatomy on the right.

Critical angle of Gissane

Measured on lateral xray, this is the angle formed by the downward and upward slopes of the calcaneal superior surface. This angle is usually between 95° and 105°. An angle of Gissane of greater than 130° suggests fracture of the posterior subtalar joint surface.


Figure: Normal critical angle of Gissane

In 2006, Knight et al., published a randomized case-control trial in the American Journal of Emergency Medicine evaluating the use and aid of Boehler’s angle (BA) and critical angle of Gissane (CAG).  They found that the BA was somewhat helpful in aiding physicians to make the diagnosis of fracture, whereas the CAG was not helpful.  There have not been many repeat studies done on this topic since.

Submitted by J. Sequeira.

References: Knight JR et al. Boehler’s angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED. 2006. Am J Emerg Med, Jul; 24 (4): 423-427;

Re-implanting avulsed teeth in 6 easy steps

11 Dec

Avulsion= total displacement of tooth from its socket dental1


This is a dental emergency as the periodontal ligament may become necrosed and will be unable to heal to normally attach.  The tooth will then not be viable.


Success rate of re-implantation decreases by ~1% every minute the tooth is out.  There is a ~85-97% chance of success if the tooth is re-implanted within 5 minutes.  If interval is >30 minutes, success rate is <20%. 


Which teeth you should NOT re-implant: primary teeth and avulsed teeth with gross caries or fractures


Also, beware that teeth that are not fixed in place are an aspiration risk.  Do not re-implant teeth in an altered, supine, high risk patient who you cannot splint.


Basic steps:

1.  Prepare tooth.  If tooth has been in Tooth saver solution/milk/other appropriate storage medium, simply rinse the tooth with saline.  Be sure to only hold the tooth by the crown as to avoid damaging the periodontal fibers.  If the tooth has been transported dry, soak the tooth in 2% stannous fluoride solution if available for 20 minutes (or Tooth Saver/Hank’s solution if fluoride is unavailable). 


2. Gently remove clots from socket and gently irrigate with NS. dental2


3. With gentle pressure, re-insert the tooth into the socket.  You may perform a peri-apical block for anesthesia if needed.


4. Splint tooth

*Dentistry may be able to place wire in the ED (they have splinted avulsed teeth for 2 of my pts at UVA)

*Some ED’s have dental splint supplies (I do not think we do)

*One option relayed to me by an OSH attending is using dermabond and the metal clip from the respirator mask as a makeshift dental splint

*On online blogs, some people have used Blu-tac or aluminum foil to mold to the teeth, but this makes me somewhat uneasy if the patient is sleeping with this in before their dentistry appointment…


5. Obtain periapical x-rays to verify position. You may need other views if you are suspicious for fractures.


6. Aftercare:

*Antibiotics-Doxycycline 100 mg PO BID x 7 days or Penicillin V QID x7 days

*Chlorhexidine rinse BID x 7 days

*Tetanus booster if needed


7. Follow up with dentistry as soon as possible


Submitted by H. Groth.


SourcesAO Foundation of Dentoalveolar Trauma websiteMcIntyre J, Lee J, Trope M, Vann WJ, Permanent tooth replantation following avulsion: Using a decision tree to achieve the best outcome. Pediatr Dent 2009;31(2):137-44.; Tintinalli’s Emergency Medicine