quick ortho: MUGR

quick refresher for the upcoming in-service and/or boards:

 

MUGR (Monteggia=Ulna fx; Galeazzi=Radial fx)

 

Monteggia Fracture

• Ulnar fracture, radial head dislocation
• Mechanism: direct blow to forearm

 

Galeazzi Fracture

• Radial fracture, ulnar dislocation
• Mechanism: FOOSH with flexed elbow

 

MUGR (Monteggia=Ulna fx; Galeazzi=Radial fx)

• Proximal to distal (Monteggia=>problem near elbow; Galeazzi=>problem near wrist)

 

References: Wheeless Monteggia & Galeazzi; monteggia pic; galeazzi pic

biphasic allergic reactions…

…are RARE.

via this recent ACEP Now article by Dr. Milne

SHORTCUT NUMBERS:

data from 2 urban ED’s over 5 yrs

~2300 allergic reactions + ~500 anaphylaxis cases

185 returned for 2nd visit

5 (0.18% of ~2800 allergic rxns) were clinically important biphasic reactions

• 2 were during the initial ED visit
• 3 were post-discharge (at 28, 35, and 143 hrs s/p)
• no fatalities

 

THEIR BOTTOM LINE:

“Prolonged observation is likely unnecessary in patients whose symptoms resolve with therapy in the ED. Biphasic reactions are rare and can occur anywhere from 10 minutes up to six days after an initial reaction.”

 

Food for thought.

 

References: ACEP Now article; picture

 

ocular ultrasound for elevated ICP

(re-post of an old review, but came up again recently, worth a refresher)

 

from sonoguide.com:

Evaluation of the optic nerve sheath diameter (ONSD) can detect EICP.

On ultrasound a normal optic nerve sheath measures up to 5.0 mm in diameter.

The ONSD is measured 3 mm posterior to the globe for both eyes.  A position of 3 mm behind the globe is recommended because the ultrasound contrast is greatest, the results are more reproducible

Two measurements are averaged.

An average ONSD greater than 5 mm is considered abnormal and elevated intracranial pressure should be suspected.

 

STUDY 1:

35 patients, 14 with elevated ICP on CT

all 14 with elevated ICP were detected with ONSD >5.0mm (mean ONSD was 6.27mm)

 

STUDY 2:

50 patients with brain injury + 26 controls

ultrasounded ONSD, then intraparenchymal catheter to measure ICP

severe brain injured patients (ONSD 6.1 +/- 0.7 mm; ICP 26.2 +/- 8.7 mmHg)

moderate brain injury (ONSD 4.2 +/- 1.2 mm; ICP 12.0 +/- 3.6 mmHg)

controls (ONSD 3.6 +/- 0.6 mm; ICP 10.3 +/- 3.1 mmHg).

best cut-off value of ONSD for predicting elevated ICP was 5.7 mm (sensitivity = 74.1% and specificity = 100%)

 

 

 

References: sonoguide; study 1; study 2; picture

visual aid: knee arthrocentesis

if you’re looking for a 60-second refresher on how to tap a knee, here are some handy pictures and video references:

 

if you only have 30-seconds, tune in at the 2:40 mark for some landmark refreshers.

 

HANDY TRICK (from a recent ALiEM post):

• use one of your usual IV needles, then you can leave in the angiocath (plastic only) and remove the needle, for improved comfort/safety, especially if changing out syringes.

 

 

if you want to see a tap using a 6-inch spinal needle, check out this video 

• 2-second takeaway: with enough swelling, sometimes the joint space can be quite far from the skin surface

 

References: NEJM procedure video; mellick video; ALiEM post

Prolene pros and cons

quick refresher via a handy article from last months EM News mag on eyebrow lac repairs:

PROLENE: (= polypropylene, non-absorbable)

Pros:

• best tensile strength
• least tissue reactivity (vs. nylon and silk)
• its blue! (easier to identify vs. eyebrow hairs, unless your patient has some interesting hair coloring)
• low friction (more knot trouble, but slips easily through tissue)

 

Cons:

• least secure (knot security)
• more “memory” (springs back to its original position); makes it trickier to handle (e.g. with lesser knot security)

 

Food for thought for your next facial lac repair.

 

References: EM News article; FP notebook (& picture)

 

 

Rapid Bedside Diagnosis of Massive PE (Looking for R heart strain)

Caveats:

-RV failure can be seen in massive PE but also in RV infarct and other conditions therefore this is NOT specific for a PE.

-Echo findings NOT sensitive for PE. Increased PA pressure not seen until >30 % obstruction (beyond my US skills- looking at tricuspid regurg jets…) and RV failure not seen until >50% ACUTE obstruction.

-BUT this is a good tool to have for the unstable patient in whom you have a high clinical suspicion for a PE.

 

US findings of increased RV pressure:

1. Large RV
2. Underfilled LV
3. Paradoxical septal wall motion
4. RV apex dominance
5. McConnell’s sign

 

Findings by US view:

1. Parasternal Long
   1. Large RV

 

 

Note: Normal ratio of RV: Aortic outflow: LV should be 1:1:1.

 

1. Underfilled LV

 

 

2. Parasternal Short
   1. Large RV
   2. Underfilled LV
   3. Paradoxical septal wall motion (“D” sign)

 

 The LV should be circular. Increased RV pressure pushes on the LV, causing it to look more like a “D”. Also, will see bowing of the septum toward the LV or flattening of the septum during diastole.

 

3. Apical 4 Chamber
   1. RV apex dominance

 

 

1. McConnell’s sign
   • Acute RV failure, 77% sensitive and 94% specific for PE in RV failure
   • Hypokinetic free wall and hyperkinetic apex (looks like a little person is jumping on a trampoline at the apex)
   • Here is an example: McConnell’s Sign

 

Submitted by Heather Groth.

 

Sources:

-http://circ.ahajournals.org/content/121/21/2329/F2.expansion.html

-http://westernsono.ca/case-of-the-month-3-answer/

-http://www.em.emory.edu/ultrasound/ImageWeek/mcconnells_sign.html

-http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784075/

 

 

Management of Cutaneous Anthrax

*Most commonly from contact with infected animals or animal products. Keep bioterrorism in mind and look for evidence of inhalation or GI tract exposure.  

*Incubation period of 1-12 days

***Call the State Department of Health. This is a reportable disease.***

 

Physical exam: Small, painless, pruritic papules -> central vesicle/bulla -> erosion with painless necrotic ulcer/black eschar

 

*Oftentimes there is extensive surrounding edema and lymphadenopathy (from toxin release).

*May see systemic signs of fever, malaise, HA. If there are any systemic signs or if the lesions involve the head or neck, treatment must be inpatient. These patients need antitoxin, IV antibiotics, usually an LP, infection control (drainage of effusions…)

 

Diagnosis:

-For vesicular lesions- 2 swabs of fluid from an unopened vesicle. Send 1 for Gram stain/culture and the other for PCR.

-For eschars, the edge should be lifted and 2 swabs rotated underneath. Send 1 for Gram stain/culture and the other for PCR.

-For ulcers, the base of the lesion should be sampled with 2 saline moistened swabs. Send 1 for Gram stain/culture and the other for PCR.

-For all lesions, send a full thickness punch biopsy of the lesion in 10% formalin for histopathology and immunohistochemistry. If the patient is not on antibiotics or has been on antibiotics <24 hours, take a second biopsy for Gram stain, culture, and PCR testing.

 

Isolation: Standard precautions (unless there is continued drainage from wound- then contact precautions).

Treatment: (of cutaneous anthrax without systemic s/sx that does not involve the head or neck)=Generally outpatient.  

7-10 days of ciprofloxacin 500 mg q12 hours

OR doxycycline 100 mg q12 hours OR

clindamycin 600 mg q12.

Follow-up in 1-2 days.

 

Submitted by Heather Groth. 

 

Sources: CDC website, Up-To-Date, Vanderbilt Department of Infectious Disease website