Archive | August, 2015

SVC Syndrome

27 Aug

RAGING HYPOTHETICAL:

Your next patient is a 70 yo M with neck swelling and syncopal episode, who said he “felt like couldn’t breathe” when bending forward, then passed out. 

Vital Signs – WNL

Physical exam – Awake, ambulating male with chest wall venous distention, b/l neck swelling, facial plethora when leaning forward and trace peripheral, LE edema. 

 

WHAT DOES THAT MEAN?svc

Superficial venous distention in superior vena cava syndrome  —>

 

 

Imaging – In ED, CT chest and neck (w/ contrast) to evaluate for obstructing mass (e.g. something compressing the SVC)

 

Etiology – In the preantibiotic era, syphilitic thoracic aortic aneurysms, were frequent causes of the SVC syndrome.  More recently, intrathoracic malignancy is responsible for 60 to 85 % of cases of SVC syndrome.  Non-small cell lung cancer (NSCLC) is the most common, accounting for 50 %  of all cases.

Clinical Manifestations – Interstitial edema of the head and neck is visually striking, but generally of little clinical consequence.  However, edema may narrow the lumen of the nasal passages and larynx –> dyspnea, stridor, cough, hoarseness, and dysphagia.  Cerebral edema can also occur (not awesome).

Cardiac output may be diminished transiently by acute SVC obstruction, but, within a few hours, blood return is reestablished by increased venous pressure and collaterals. Hemodynamic compromise, if present, more often results from mass effect on the heart than from SVC compression.

 

Submitted by Christina Brown.

 

References: Up to Date: malignancy related SVC syndromeWilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862.SCHECHTER MM. The superior vena cava syndrome. Am J Med Sci 1954; 227:46.Yellin A, Rosen A, Reichert N, Lieberman Y. Superior vena cava syndrome. The myth–the facts. Am Rev Respir Dis 1990; 141:1114.Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85:37.Chee CE, Bjarnason H, Prasad A. Superior vena cava syndrome: an increasingly frequent complication of cardiac procedures. Nat Clin Pract Cardiovasc Med 2007; 4:226.picture

topical NSAIDs

13 Aug

quick hit review in July’s EP Monthly:

 

topical NSAIDs:

  • as effective as oral NSAIDs for pain relief (NNT for 50% pain relief with topical gel = 11)
  • adverse GI side effects less common
  • risk of renal injury not clearly defined, but less systemic absorption (6-10% vs. 85% oral)

 

1% diclofenac gel (Voltaren):

  • typically QID, up to 32 g/day
  • 100g tube costs ~$45  (the 1.5% solution costs way more)

 

BOTTOM LINE:

Worth knowing about, especially in those with significant GI issues taking NSAIDs, with focal musculoskeletal issues.  Keep the cost in mind, though.

 

References: EPmonthly mag + picture

 

 

deep tendon reflexes: which test for which nerve root?

11 Aug

Some quick reminders and visual aids on which reflexes test which nerve roots:

C5 – Biceps

C6 – Biceps, Brachioradialis

C7 – Triceps

L4 – Patellar (knee jerk)

S1 – Achilles (ankle jerk)

 

This NYU site has some good pictures for each tendon reflex, but here’s a quick & dirty picture for those short on time:

reflexes

 

There you go.  Add it to the mental rolodex.

 

References: neuroexam.com, NYU neuro exam site, picture

tissue adhesive for fingertip avulsions

3 Aug

nice idea from a recent JEM article:

 

The Idea:

  • distal fingertip avulsions bleed, hard to dress
  • variable efficacy/availability of bandaging/surgicel/lido+epi/etc
  • gluing it is quick, cosmetic, and even a bit antimicrobial

 

The Procedure:

  • irrigate well, as usual
  • digital block might help (for irrigation, and ’cause the adhesive will sting a bit)
  • no ointments before or after (will break down the adhesive)
  • tourniquet, direct pressure/milking, elevation — to staunch bleeding
  • apply layer of tissue adhesive
  • let dry, apply another layer
  • let dry, apply another layer

 

Might consider this trick from a previous post to accelerate drying, especially if you didn’t quite stop the bleeding completely.

 

Boom, there you go.  

 

References: JEM article; picture