WikEM - User contributions [en]

User:Mattd

2013-09-25T07:35:15Z

Mattd:

Matthew J Dunn FCEM

Emergency Physician

Warwick Hospital

UK

User:Mattd

2013-09-25T07:34:28Z

Mattd: Created page with "Emergency Physician Warwick Hospital UK"

Emergency Physician
Warwick Hospital
UK

Ultrasound: lungs

2013-09-09T15:49:40Z

Mattd: Created page with " ==Pulmonary edema== *A lines and B lines **A lines: ***Appear as horizontal lines ***Indicate dry interlobular septa. ***Predominance of A lines has 90% sensitivity, 67% sp..."

==Pulmonary edema==
*A lines and B lines
**A lines:
***Appear as horizontal lines
***Indicate dry interlobular septa.
***Predominance of A lines has 90% sensitivity, 67% specificity for pulmonary artery wedge pressure <= 13mm Hg
***A line predominance suggests that intravenous fluids may be safely given without concern for pulmonary edema
**B lines ("comets"):
***White lines from the pleura to the bottom of the screen
***Highly sensitive for pulmonary edema, but can be present at low wedge pressures

Vertigo

2013-09-09T15:19:52Z

Mattd:

== Background ==
*Perception of movement (rotational or otherwise) where no movement exists
*Pathophysiology
**Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
*Must distinguish peripheral from central cause
**Peripheral: 8th CN, vestibular apparatus
**Central: Brainstem, cerebellum

== Clinical Features==

{| width="400" border="1" cellpadding="1" cellspacing="1"
|-
|
| Peripheral
| Central
|-
| Onset
| Sudden
| Sudden or slow
|-
| Severity
| Intense spinning
| Ill defined, less intense
|-
| Pattern
| Paroxysmal, intermittent
| Constant
|-
| Aggravated by position/movement
| Yes
| Variable
|-
| Nausea/diaphoresis
| Frequent
| Variable
|-
| Nystagmus
| Rotatory-vertical, horizontal
| Vertical
|-
| Fatigue of symptoms/signs
| Yes
| No
|-
| Hearing loss/tinnitus
| May occur
| Does not occur
|-
| Abnormal tympanic membrane
| May occur
| Does not occur
|-
| CNS symptoms/signs
| Absent
| Usually present
|}

==Diagnosis==
===Algorithm===
[[File:Vertigo_and_Dizziness.jpg]]

===HINTS Exam===
Can reliably^ distinguish peripheral cause from cerebellar/brain stem CVA in the Emergency Department population
#Head Impulse Testing
##Tests vestibulo-ocular reflex
##Have pt fix their eyes on your nose
##Move their head in the horizontal plane to the left and right
###If reflex is intact their eyes will stay fixed on your nose
###If reflex is abnormal eyes will move w/ their head and won't stay fixed on your nose
##It is reassuring if the reflex is abnormal!(due to dysfunction of the nerve)
#Nystagmus
##Benign nystagmus only beats in one direction no matter which direction their eyes look
##Bad nystagums beats in every direction their eyes look
###If pt looks left, get left nystagmus, if looks right, get right-beating nystagmus
#Test of Skew
##Vertical dysconjugate gaze is bad
##Alternating cover test
###Have pt look at your nose w/ their eyes and then cover one eye
###When rapidly uncover the eye look to see if the eye quickly moves to re-align
##If any of the above 3 tests are consistent w/ CVA obtain full work-up (including MRI)

^Sensitivity (for posterior ischemic CVA):
*HINTS = 100%?
*MRI <48hrs after symptom onset = 83%
*MRI >48hrs = 100%?
*CT = 16%

== DDX ==
#Vestibular/otologic
##[[Benign Paroxysmal Positional Vertigo (BPPV)]]
##Traumatic (following head injury)
##Infection
###[[Labyrinthitis]]
###[[Vestibular Neuritis (Neuronitis)]]
###Ramsay Hunt syndrome
#Syndrome
##[[Meniere Disease]]
##Neoplastic
##Vascular
##Otosclerosis
##Paget disease
##Toxic or drug-induced: aminoglycosides
#Neurologic
##Vertebrobasilar insufficiency
###Head turning causes vertigo, diplopia, dysarthria, b/l loss of vision, syncope
##Lateral Wallenberg syndrome
##Anterior inferior cerebellar artery syndrome
##Neoplastic: cerebellopontine angle tumors
##Cerebellar disorders: hemorrhage, degeneration
##Basal ganglion diseases
##Multiple sclerosis
##Infections: neurosyphilis, tuberculosis
##Epilepsy
##Migraine (basilar)
##Cerebrovascular disease
#General
##Hematologic: anemia, polycythemia, hyperviscosity syndrome
##Toxic: alcohol
##Chronic renal failure
##Metabolic
###[[Thyroid Disease]]
###[[Hypoglycemia]]

==Work-up==
#Glucose check
#Full neuro exam
#TM exam
#?CT/MRI - if symptoms consistent with central cause

== Peripheral Vertigo Treatment ==

Symptomatic control
#Antihistamines
##Meclizine (antivert) 25mg PO QID
##Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr
#Anticholinergics
##Scopolamine transdermal patch 0.5mg (behind ear) QID
#Antidopaminergics
##Metoclopramide 10-20 IV or PO TID

Cause Reversal
#Epley maneuver (see [[BPPV]])

==Central Vertical Treatment==
#R/O CVA
#MRI
#R/O Vascular inssufficency

== Disposition ==
*Most pts w/ peripheral vertigo can be discharged home
*Most pts w/ central vertigo require urgent imaging and consultation while in the ED

==See Also==
*[[Dizziness]]

== Source ==
*Tintinalli

[[Category:Neuro]]

Sgarbossa's criteria

2013-09-09T10:47:27Z

Mattd: /* Criteria */

==Background==
*Assesses likelihood that pt w/ chest pain and baseline LBBB has myocardial damage (+CK-MB)
**Criteria also applies to LBBB due to paced rhythm
*Low Sn, High Sp
**Still consider PCI/t-PA for pts w/ LBBB and "good story" despite not meeting the criteria

==Criteria==
*ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points
*ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
*ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points
*(See [[#Example | below]] for example of all 3 criteria)

*Smith's modification of the third rule of the Sgarbossa criteria to ST depression or elevation discordant with the QRS complex and with a magnitude of at least 25% of that of the QRS complex increases sensitivity from 52% to 91% at the expense of reducing specificity from 98% to 90%.

==Points==
*≥3 points = 98% probability of [[STEMI]]

==Example==
[[File:Sgarbossa.jpg]]

==See Also==
[[ST-Elevation Myocardial Infarction (STEMI)]]

==Source==
*Sgarbossa, American Heart Journal 2006
*Sgarbossa, NEJM, February, 1996

[[Category:Cards]]

Greenstick fracture

2013-09-09T10:40:18Z

Mattd: /* Treatment */

==Background==
*Cortical disruption and periosteal tearing on convex side of bone only
*More stable / less painful than complete fx

==Diagnosis==

* These fractures may be apparent clinically. For patients without obvious significant deformity, ultrasound scanning seems to be as sensitive as plain x-rays and may be better at demonstrating the degree of cortical deformity.

==Work-Up==

==Treatment==
*Need for reduction is determined by angulation, location, and age of child

*As a general rule, manipulation may be considered for deformity obvious to the naked eye or dorsal angulation of more than 10 degrees of the joint line in the lateral projection (if plain x-rays are used)

*Traditionally these fractures have been treated by immobilisation in plaster for a period of around 3 to 6 weeks. However fractures not requiring manipulation have a universally good outcome regardless of treatment and more recent research shows higher levels of patient satisfaction with a Futura type splint

==Disposition==
* Patients not requiring manipulation can be discharged with a backslab and advice to remove in 3 weeks or a Futura type splint and advice to remove when comfortable. There is no evidence that routine follow up is necessary.

==See Also==
[[Torus Fracture]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:Ortho]]

Greenstick fracture

2013-09-09T10:38:58Z

Mattd: /* Treatment */

==Background==
*Cortical disruption and periosteal tearing on convex side of bone only
*More stable / less painful than complete fx

==Diagnosis==

* These fractures may be apparent clinically. For patients without obvious significant deformity, ultrasound scanning seems to be as sensitive as plain x-rays and may be better at demonstrating the degree of cortical deformity.

==Work-Up==

==Treatment==
*Need for reduction is determined by angulation, location, and age of child

*Traditionally these fractures have been treated by immobilisation in plaster for a period of around 3 to 6 weeks. However fractures not requiring manipulation have a universally good outcome regardless of treatment and more recent research shows higher levels of patient satisfaction with a Futura type splint

==Disposition==
* Patients not requiring manipulation can be discharged with a backslab and advice to remove in 3 weeks or a Futura type splint and advice to remove when comfortable. There is no evidence that routine follow up is necessary.

==See Also==
[[Torus Fracture]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:Ortho]]

Greenstick fracture

2013-09-09T10:37:44Z

Mattd: /* Disposition */

==Background==
*Cortical disruption and periosteal tearing on convex side of bone only
*More stable / less painful than complete fx

==Diagnosis==

* These fractures may be apparent clinically. For patients without obvious significant deformity, ultrasound scanning seems to be as sensitive as plain x-rays and may be better at demonstrating the degree of cortical deformity.

==Work-Up==

==Treatment==
*Need for reduction is determined by angulation, location, and age of child

Traditionally these fractures have been treated by immobilisation in plaster for a period of around 3 to 6 weeks. However fractures not requiring manipulation have a universally good outcome regardless of treatment and more recent research shows higher levels of patient satisfaction with a Futura type splint

==Disposition==
* Patients not requiring manipulation can be discharged with a backslab and advice to remove in 3 weeks or a Futura type splint and advice to remove when comfortable. There is no evidence that routine follow up is necessary.

==See Also==
[[Torus Fracture]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:Ortho]]

Greenstick fracture

2013-09-09T10:37:17Z

Mattd: /* Diagnosis */

==Background==
*Cortical disruption and periosteal tearing on convex side of bone only
*More stable / less painful than complete fx

==Diagnosis==

* These fractures may be apparent clinically. For patients without obvious significant deformity, ultrasound scanning seems to be as sensitive as plain x-rays and may be better at demonstrating the degree of cortical deformity.

==Work-Up==

==Treatment==
*Need for reduction is determined by angulation, location, and age of child

Traditionally these fractures have been treated by immobilisation in plaster for a period of around 3 to 6 weeks. However fractures not requiring manipulation have a universally good outcome regardless of treatment and more recent research shows higher levels of patient satisfaction with a Futura type splint

==Disposition==
Patients not requiring manipulation can be discharged with a backslab and advice to remove in 3 weeks or a Futura type splint and advice to remove when comfortable. There is no evidence that routine follow up is necessary.

==See Also==
[[Torus Fracture]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:Ortho]]

Greenstick fracture

2013-09-09T10:34:18Z

Mattd: /* Diagnosis */

==Background==
*Cortical disruption and periosteal tearing on convex side of bone only
*More stable / less painful than complete fx

==Diagnosis==

These fractures may be apparent clinically. For patients without obvious significant deformity, ultrasound scanning seems to be as sensitive as plain x-rays and may be better at demonstrating the degree of cortical deformity.

==Work-Up==

==Treatment==
*Need for reduction is determined by angulation, location, and age of child

Traditionally these fractures have been treated by immobilisation in plaster for a period of around 3 to 6 weeks. However fractures not requiring manipulation have a universally good outcome regardless of treatment and more recent research shows higher levels of patient satisfaction with a Futura type splint

==Disposition==
Patients not requiring manipulation can be discharged with a backslab and advice to remove in 3 weeks or a Futura type splint and advice to remove when comfortable. There is no evidence that routine follow up is necessary.

==See Also==
[[Torus Fracture]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:Ortho]]

Greenstick fracture

2013-09-09T10:30:23Z

Mattd: /* Disposition */

==Background==
*Cortical disruption and periosteal tearing on convex side of bone only
*More stable / less painful than complete fx

==Diagnosis==

==Work-Up==

==Treatment==
*Need for reduction is determined by angulation, location, and age of child

Traditionally these fractures have been treated by immobilisation in plaster for a period of around 3 to 6 weeks. However fractures not requiring manipulation have a universally good outcome regardless of treatment and more recent research shows higher levels of patient satisfaction with a Futura type splint

==Disposition==
Patients not requiring manipulation can be discharged with a backslab and advice to remove in 3 weeks or a Futura type splint and advice to remove when comfortable. There is no evidence that routine follow up is necessary.

==See Also==
[[Torus Fracture]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:Ortho]]

Greenstick fracture

2013-09-09T10:29:06Z

Mattd: /* Treatment */

==Background==
*Cortical disruption and periosteal tearing on convex side of bone only
*More stable / less painful than complete fx

==Diagnosis==

==Work-Up==

==Treatment==
*Need for reduction is determined by angulation, location, and age of child

Traditionally these fractures have been treated by immobilisation in plaster for a period of around 3 to 6 weeks. However fractures not requiring manipulation have a universally good outcome regardless of treatment and more recent research shows higher levels of patient satisfaction with a Futura type splint

==Disposition==

==See Also==
[[Torus Fracture]]

==Source==
Tintinalli

[[Category:Peds]]
[[Category:Ortho]]