Clinical Pearls

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Posted on 05/06/2010

What are the signs of a cranial nerve III deficit?

Answer

A patient with a cranial nerve III deficit will have diplopia, ptosis, a dilated pupil, and a pupil that is "down and out" (the pupil will be position inferiorly and laterally as the lateral rectus and superior oblique muscles will take over).

If this is encountered in the ED, your first thought should be to rule out a PICA aneurysm/ SAH. CT--> CTA-->LP!

Posted on 04/28/2010

The following are all risk factors for community acquired MRSA in soft tissue infections EXCEPT?

a. "Doc I have a spider bite!"

b. Patients who reside in prison

c. History of MRSA infections

d. Contact sports

e. Patients with DM

Answer

In a study conducted by Moran et. al. in 2006 the following are characteristics of patients with culture positive community acquired MRSA in their soft tissue infections.

Characteristic	Odds Ratio
Pt complains they think the have a Spider Bite	2.8
Contact MRSA	3.4
Prior MRSA	3.3
ABX in last month	2.4
Abscess	1.8
Jail	1.7
Homeless	1.3
IVDU	1.3
Sports	1.5

Diabetes is a risk factor for serious soft tissue infections, but there is no correlation with culture positive CA-MRSA. But if they are diabetic and have any of the above; one should cover for CA-MRSA.

Moran GJ, et al. NEJM 355;7 Aug 17 06

Posted on 04/21/2010

What are the signs of infectious tenosynovitis?

Answer

(1) fusiform swelling of the finger (swelling along the whole digit)

(2) flexed position of the finger

(3) severe pain with passive extension of the finger

(4) tenderness and swelling along and limited to the flexor tendon sheath

Posted on 02/12/2010

Which of the following drugs are contraindicated in TCA overdose related ventricular dysrhythmias?

a: NaHCO3

b: Lidocaine

c: Metoprolol

d: Bretylium

e: Procainamide

Answer

TCA induced ventricular dysrhythmias are caused by the Na channel blocking effect of the drug in toxic doses. Ventricular dysrhythmias are uncommon, but in severe toxic states my present as v-tach, v-fib or torsades de pointes. Drugs that potentiate the Na channel blocking effects of TCAs should be avoided and are contraindicated. These drugs are all class Ia, Ic, and III drugs. Of course Ca channel blockers and beta blockers should never be used in ventricular dysrhythmias.

So Metoprolol (Beta blocker) and Procainamide (Ic) should not be used. NaHCO3, Lidocaine, and Bretylium -in this order- are the drugs of choice in this situation.

Posted on 02/05/2010

The following is true about malignant otitis externa EXCEPT?

a: Inpatient management with ENT consultation, IV antibiotics and possible surgical debridement is the rule

b: Patients always have a fever

c: It is osteomyelitis of the temporal bone

d: It is more common in patients with DM and other immunocompromised states

e: It is treated with topical otic antibiotic drops

Answer

Answer: B and E

Malignant Otitis Externa is an ENT emergency. It is usually found in patients with DM, HIV, Cancer patients on chemotherapy or patients on chronic steroids. It is an infection of the temporal bone and needs surgical treatment. Diagnosis is usually with CT scan and/or MRI. An emergency ENT consultation should be called, IV broad spectrum antibiotics should be initiated, and the patient should be admitted to the hospital. Topical antibiotic drops are useless in these patients. This entity may present without a fever or elevation of WBC... so be on the look out!

Posted on 01/19/2010

Which of the following regarding nontraumatic compression fractures in the elderly is false?

1. Intranasal calcitonin is a useful adjuct medication

2. Most patients with nontraumatic compression wedge fractures can be managed with pain control.

3. Loss of vertebral height greater than 50% on xray is an indication for CT scan.

4. Multiple myeloma is the most common primary tumor of the spine.

5. All of the above is true.

Answer

All of the above is true.

1. Intranasal calcitonin may reduce pain and return to baseline function by almost 1 week. Considered anecdotal until recently, studies had to be stoppedearly because it worked so well. Watch for

hypocalcemia.

2. True

3. True. Even without neurologic symptoms, greater than 50% loss in height can indicate spinal instability. CT scan is an adequate screening tool.

4. True

Posted on 12/22/2009

What is Well's Criteria for the diagnosis of PE?

Answer

Clinical Signs and Symptoms of DVT? Add +3

PE Is #1 Diagnosis, or Equally Likely? Add +3

Heart Rate > 100? Add +1.5

Immobilization at least 3 days,

or Surgery in the Previous 4 weeks Add +1.5

Previous, objectively diagnosed PE or DVT? Add +1.5

Hemoptysis? Add +1

Malignancy w/ Treatment within 6 mo, or palliative? Add +1

A score of 2 or more puts the patient at moderate risk for PE = 16.7% chance of PE. Moderate risk or higher mandates imaging to rule out PE. D-Dimer may be used in cases of low probability. In cases of moderate to high risk; D-Dimer is useless.

Posted on 12/14/2009

What is the Parkland formula?

Answer

Total Burned Surface area (%) * Body Weight (Kg) * 4ml = total amount of fluid loss from second/third degree burn that needs to be replaced in 24 hours. 1/2 of the volume should be given in the first 8 hours and the remainder over the next 16 hours. Remember to account for other insensible fluid losses and add to the above number.

Posted on 12/06/2009

What are the Ottawa Ankle and Foot Rules?

Answer

These are ankle and foot rules; to be used in patients older than 5 years old that have had trauma below the ankle. When used appropriately they reduce unnecessary imaging by as much as 30%.

The following are the Ottawa Ankle Rules. Get films if:

Bone tenderness along the posterior aspect of the tibia/ medial malleolus
Bone tenderness along the area 6 cm posterior to the distal fibula or lateral malleolus
Inability to bear weight or walk 4 steps in the ED or immediately after the injury

The following are the Ottawa Foot Rules. Get films if:

Tenderness along the base of the fifth metatarsal
Tenderness on the navicular
Inability to bear weight or walk 4 steps in the ED or immediately after the injury

Posted on 11/17/2009

What are the NEXUS criteria when clearing a C-spine in head and neck trauma?

Answer

Radiography is indicated for patients with trauma unless they meet ALL of the following criteria:

1. No posterior midline c-spine tenderness

2. No evidence of intoxication

3. A normal level of alertness

4. No focal neurologic deficit

5. NO painful distracting injuries

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