Archive | June, 2014

more acronyms: MALS (median arcuate ligament syndrome)

30 Jun


Your next patient is a 63 M with intermittent abdominal pains with this being his worst and longest case.  You’re worried about  vascular pathology such as dissection or ischemia, and end up deciding to order a CTA.  


Your patient gets the CTA, and the read comes back as this:

  • median arcuate ligament syndrome (MALS), with high-grade compression/stenosis of the celiac trunk.


So what does actually this mean?



MALS or Celiac Artery Compression (CAC) results from external compression of the celiac artery by the median arcuate ligament

an unusual cause of visceral ischemia.

more common in younger adults and women than men.

usually associated with weight loss

pain is often post-prandial.

Often an epigastric bruit can be heard on exam.

Some compression of the celiac artery is common even in patients without the syndrome, so making a definitive diagnosis can be difficult.

Referral to a vascular surgeon is an appropriate step.


Submitted by J. Stone.


References: (Rapp, Joseph H. , MacTaggart, Jason. Chapter 34. Arteries – in Current diagnosis and treatment : Surgery 13th ed. 2010); picture

Arnold-Chiari malformation

26 Jun


Developmental anomalies affecting the cerebellum and brainstem may present with vestibular or cerebellar symptoms in adulthood.

occurs most commonly with type I Arnold-Chiari malformation-> downward displacement of the cerebellar tonsils through the foramen magnum.

clinical manifestations of this malformation are related to cerebellar involvement, obstructive hydrocephalus, brainstem compression, and syringomyelia.

  • Cerebellar ataxia in the type I malformation usually affects the gait and is bilateral; sometimes asymmetric.
  • Hydrocephalus from blockage of CSF flow leads to headache and vomiting.
  • Compression of the brainstem by herniated cerebellar tissue may be associated with vertigo, nystagmus, and lower cranial nerve palsies. 

diagnosed by CT or MRI studies that demonstrate cerebellar tonsillar herniation.

Patients with symptoms related to compression of the cerebellum or brainstem may benefit from surgical decompression of the foramen magnum.

The treatment for this is suboccipital craniectomy, sometimes with the removal of the posterior ring of C1 vertebrae.


Submitted by J. Stone.


Sources: Pathology the Big Picture., textbook; Clinical Neurology, textbook, Posterior Fossa Malformations. Chapter 8 – disorders of equilibrium.; Schwartz’s Principles of Surgery, chapter 42 Neurosurgery, congenital and developmental anomalies.; picture 1, picture 2

clinical estimation of traumatic wound size

23 Jun

A recent study (Peterson N et al. Size matters: how accurate is clinical estimation of traumatic wound size? Injury. 2014 Jan;45(1):232-6) discussed on May’s Emrap looks at this issue.


This study took 50 doctors across specialties and showed them 7 images of traumatic wounds and among questions was one on wound size estimation.

Interestingly, male doctors were more likely to overestimate wound size and female doctors more likely to underestimate wound size.  (detailed data is quite variable, but check out the article if you want to see the numbers).

Variability was less for smaller sized wounds.


The study is not generalizable to EM doctors (study docs were many different specialties), and it is unclear if we are more or less accurate.


I tried to estimate the size of a “T” on a box with my wife, another EM doctor. It was 1.1cm – I guessed 1.5; she guessed 1.2.


Submitted by J. Stone.


References: article, picture.

ITP (quick hits)

20 Jun

2 requirements:

  • isolated thrombocytopenia
  • absence of another cause.


pathogenesis of immune thrombocytopenia (ITP)

  • increased platelet destruction
  • inhibition of megakaryocyte platelet production via IgG autoantibodies, often directed against platelet membrane glycoproteins such as GPIIb/IIIa.



  • range from bleeding diatheses to petechiae.
  • Gingival bleeding,
  • GI bleeding,
  • epistaxis


Order CBC along with smear to assess for other causes. HIV and HCV testing is recommended as well.


For severe thrombocytopenia and/or bleeding, emergent hem consultation is warranted.

For less severe sx, non urgent f/u.


Submitted by J. Rothstein.


References:; picture

Biceps tendon tear

19 Jun


Can be proximal or distal.

Usually will feel on shoulder anteriorly and radiate down biceps muscle.

If ruptured, a mass may be palpated- “Popeye deformity.”

No indication for emergent surgical consultation. Non emergent surgery may be performed.

Ice, compression, rest may provide some relief, otherwise pain management.


Submitted by J. Rothstein.


References: emedicine article; picture.

pediatric weight reference, in a pinch

17 Jun

handy chart from HMC web site:growth

Body Wt quick reference:

  • 2 mo old – 5 kg
  • 1 yr old – 10kg
  • 3 yr old – 15 kg
  • 5 yr old – 20 kg

Of course, every patient weight is variable, especially with obesity, but in tight spot (e.g. a code), you won’t be off by an order of magnitude.


Submitted by J. Rothstein.


References:  HMC site, CDC growth charts & picture

Left Anterior vs. Posterior Fasicular Blocks

16 Jun

Left Anterior Fasicular Block (more common of the two)

  • Left axis deviation (usually between -45 and -90 degrees)
  • Small Q waves with tall R waves in leads I and aVL
  • Small R waves with deep S waves in leads II, III, aVF



Left Posterior Fasicular Block (almost always associated with RBBB)

  • Right axis deviation (> +90 degrees)
  • Small R waves with deep S waves in leads I and aVL
  • Small Q waves with tall R waves in leads II, III and aVF



Clinical Significance

  • By itself with no symptoms, these blocks are not significant. May indicate underlying CAD which led to impairment or that the patient is at risk for progressing to LBBB.
  • LAFB can be seen in about 4% of acute MI cases. It is the most common type of intraventricular conduction defect seen in acute anterior MI, the LAD usually the involved vessel.
  • LPFB plus RBBB in acute MI associated with high mortality rate.  However, CAD is less common in RBBB with LPFB than in RBBB with LAFB or isolated LAFB.


Submitted by Joran Sequeira.


References: Biagani et al. Prognostic Significance of Left Anterior Hemiblock in Patients With Suspected Coronary Artery Disease. Journal of the American College of Cardiology. Volume 46, Issue 5, 6 September 2005, Pages 858–863; Elizari et al. Hemiblocks revisited. Circulation. 2007; 115: 1154-1163