Archive | January, 2014

idiopathic intracranial hypertension (aka pseudotumor cerebri)

31 Jan



  • Headache (92 percent)
  • Transient visual obscurations (72 percent)
  • Intracranial noises (pulsatile tinnitus) (60 percent)
  • Photopsia (54 percent) — flashes of light perception
  • Retrobulbar pain (44 percent)
  • Diplopia (38 percent)
  • Sustained visual loss (26 percent)



mostly common sense

  • signs/symptoms increased ICP
  • normal neuro exam, no altered LOC
  • elevated ICP/opening pressure
  • normal cerebrospinal fluid (CSF) composition
  • neuroimaging negative
  • No other apparent cause



  • upper limit of normal in adults is 200 mmH2O.  (=20 cmH2O)
  • Some believe that obese patients may have a higher upper limit of normal, ~250 mmH2O



  • Permanent vision loss is the major morbidity associated with IIH.



  • carbonic anhydrase inhibitors,
  • loop diuretics,
  • corticosteroids.   
  • low-sodium weight reduction program
  • last resort–surgical intervention.


Submitted by Heather Reed-Day.


References: Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis; picture

diagnostic accuracy of Bohler’s angle

27 Jan

from the April JEM:


normal Bohler’s angle 30-35 degrees

reduction in this angle suggest calcaneal fracture

424 patients, angle measured by 2 independent observers

  • mean Böhler’s angle without calcaneal fracture was 29.4°
  • In those patients with calcaneal fractures, Böhler’s angle…
    • < 25° (sensitivity = 100%, specificity = 82%),
    • < 23° (sensitivity = 100%, specificity = 89%),
    • < 21° (sensitivity = 99%, specificity = 99%).
    • < 15-20° (sensitivity 90-99%, specificity 100%)boehlers

There you go.

see this previous post by Dr. J. Sequeira for a quick review on Bohler’s Angle and another angle of note.

References: JEM article; picture


can you glue a tongue lac?

24 Jan

case report from JEM, but neat idea:



pediatric tongue lac

parent didn’t want suturing due to pain/local anesthesia/sedation risks

triple coated Dermabond (2-octyl cyanoacrylate) with compressed air drying assist 

needed a repeat coating the next day after a hot tea encounter

good cosmesis 14 days later


just a case report, but dermabond adhesive closure is a nice trick to keep in the back pocket, potentially

not officially recommended for mucosal use, but probably low-risk (article discusses it in depth)

tip: to help dry quick, compressed air, or maybe high-flow nasal cannula?


References: JEM article; picture

Nebulized Lidocaine

23 Jan

(repost, but came up again lately, worth a re-visit)

–not a ton of evidence for use, but sounds cool, probably safe (in the appropriate non-toxic dose)
–reminder: max dose of lidocaine (without epinephrine) = 4.5mg/kg

–some benefit in daily long-term therapy for asthma, but doesn’t apply to us in the ED
lidocaine can cause bronchospasm in asthmatics, so one study pretreated with albuterol
–one study’s sample dose: 1ml of 1% lido in 4 ml NS
–may be useful for cough suppression

–apparently, not much proof that it helps or makes it less painful

NG tubes are one of the most painful procedures with limited utility, anyways

Reference(s): asthma long-term, cough suppression, more cough suppression, ng tube, more ng tube

7 syndromes of TCA toxicity

21 Jan

came across some old notes and found a helpful mnemonic taught to me back in residency by Dr. Heather Borek.

good way to remember what TCA (tricyclic antidepressants) can do in overdose:

7 SYNDROMES (grouped by effects):

  • Seizures!
    • 1: GABA antagonist
    • 2: antihistamine (H1-blocker)
  • EKG changes!
    • 3: Sodium-channel blocker (wide QRS)
    • 4: Potassium-channel blocker (long QT)
  • Hypotension!
    • 5: alpha-1 blocker
    • 6: SNRI effects (serotonin/norepinephrine reuptake inhibition) ->surge first -> then depletion ->hypotension
  • wacky/tachy/etc!
    • 7: anticholinergic (AMS, tachycardia, mydriasis, etc).


Grouping tends to help memorization. I remember an old trick from elementary school remembering strings of numbers.  Hard to remember 19721492 as a string of eight numbers, but those who parsed it as ‘1972’ & ‘1492’ seemed to recall much easier.

hope that helps.


References:; LITFL post; epocrates online



agitated patient? Vitamin A (ativan), Vitamin H (haldol), or both?

20 Jan

common practice for agitated patients, but is there evidence for one or the other?

2012 Cochrane Review highlights:

  • Three trials (n = 205) compared haloperidol with lorazepam.
  • no significant differences between the groups with regard to the number of participants asleep at one hour
  • by three hours, significantly more people were asleep in the lorazepam group vs. haloperidol group
  • no differences in numbers requiring more than one injection 


1997 Annals study:

  • 98 psychotic, agitated, and aggressive patients (73 men and 25 women)
  • IM lorazepam (2 mg), haloperidol (5 mg), or both
  • evaluated hourly after the first injection until at least 12 hours after the last.
  • Efficacy was assessed on many different assessment scales
  • tranquilization was most rapid in patients receiving the combination treatment.
  • Side effects did not differ significantly between treatment groups


Most common risk/benefit considerations:

Haldol (haloperidol) 

  • prolongs QT (like every other drug)
  • dystonic reactions

Ativan (lorazepam)

  • risks respiratory depression



both Haldol (haloperidol) and Ativan (lorazepam) are decent options for agitation->sedation

both seem to work alone, work a bit better together

consider the risk benefits, but there’s a reason we’ve used these for a while.


References: cochrane review; article; picture

Lateral canthotomy (part 2) – doing the deed

17 Jan

Ok, so you decided to do a lateral canthotomy (likely due to some combo of orbital trauma and unilateral vision loss, unilateral proptosis, and ocular pressure greater than 40 mm hg, thanks to an expanding retro-orbital hematoma)


How do I actually go about this? (see sources below for more detailed descriptions of the procedure and images)

[description missing]
  • Clean and prep the site. Use sterile technique if time permits.


  • Inject 1 cc of lidocaine with epinepherine into the lateral canthus for control of pain and bleeding. Take care not to inject or injure the globe.


  • Using hemostats, clamp the soft tissue between the lateral canthus and the lateral rim of the orbit (approx 1 cm) for 30-60 seconds to further improve hemostasis and mark the site of incision.


  • With blunt tipped scissors make an incision laterally from the canthus to the rim of the orbit.


  • Using a hemostat or pickups retract the inferior portion of the lid in order to visualize the inferior lateral canthal tendon.


  • With blunt tipped scissors directed inferiorly and posteriorly carefully cut the inferior canthal tendon. If the tendon is correctly severed the lower lid will drop away from the eye. 


  • Recheck ocular pressure. If pressure remains above 40 mm Hg consider repeating the procedure if you suspect the inferior canthal tendon has not been fully released. Additionally the superior lateral canthal tendon may be cut in a similar fashion to the inferior tendion if ocular pressure remains above 40 mm Hg after inferior cantholysis.
There you go.  Add it to the toolbox.
Submitted by Lee Cunningham.