PAINE #PANCE Pearl – Cardiovascular



Question

62yo man, with a history of COPD and 52-pack-year history of smoking, presents to your office to establish care. His shortness of breath has been manageable using tiotropium daily with albuterol 2-3x per month for exacerbation. He denies angina, chest pain, or unreasonable dyspnea with exertion. An EKG was performed and is below.

  1. What does it show?
  2. What are the diagnostic criteria present?

Answer

  • The EKG reveals a right bundle branch block most likely due to his underlying COPD and pulmonary hypertension.
  • Diagnostic criteria for RBBB are:
    • Wide QRS > 120 ms
    • RSR’ pattern in V1-2 (“rabbit ears”) with R’ > R
    • Wide, slurred S wave in I, aVL, or V5-6
  • Other common findings, though not always associated, is ST depression and T wave inversion in the right precordial leads (V1-3)

Ep-PAINE-nym



Beck’s Triad

Other Known Aliases none

Definitionclassic physical examination findings associated with critical cardiac tamponade

Clinical Significance although not seen in every patient with cardiac tamponade, it is a common question on boards and certification examinations. These include: 1) hypotension, 2) JVD, and 3) muffled/distant heart sounds.

HistoryNamed after Claude Schaeffer Beck (1894-1971), an American cardiac surgeon who recieved his medical doctorate from Harvard University in 1921. He would attend surgical residency at Case Western University, where he would spend his entire career. He developed a novel re-circulation technique for cardiac ischemia called the Beck Procedure, where pectoral muscle was implanted in the pericardium, and later placing a vein graft between the aorta to the coronary sinus. He also pioneered the first successful use of a defibrillator in 1947 to restore ROSC in a 14yo patient he was operating on for a congenital heart defect. His eponymous triad was first described in 1935 in an article entitled “Two cardiac compression triads” in the Journal of the American Medical Association.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Beck CS. Two Cardiac Compression Triads. JAMA. 1935;104(9):714-716. [link]
  7. Theruvath P, Ikonomidis JS. Historical perspectives of The American Association for Thoracic Surgery: Claude S. Beck (1894-1971). JTCVS. 2015;149(3):655-660. [link]

PAINE #PANCE Pearl – Cardiovascular



Question

62yo man, with a history of COPD and 52-pack-year history of smoking, presents to your office to establish care. His shortness of breath has been manageable using tiotropium daily with albuterol 2-3x per month for exacerbation. He denies angina, chest pain, or unreasonable dyspnea with exertion. An EKG was performed and is below.

  1. What does it show?
  2. What are the diagnostic criteria present?

Ep-PAINE-nym



Austin Flint Murmur

Other Known Aliases none

Definitionlow-pitched, rumbling, mid-to-late diastolic murmur heard best at the apex

Clinical Significance this murmur is associated with severe aortic regurgitation and is due to two distinct mechanisms. First, the aortic jet flow impinging on the mitral valve causing vibrations from premature closing and second, turbulence of two columns of blood from the left atrium to left ventricle and aorta to left ventricle.

HistoryNamed after Austin Flint I (1812-1886), an American physician who received his medical doctorate from Harvard University in 1833. He would practice in Boston, Buffalo (where he would help found the Buffalo Medical College, and New York City, where he was professor of medicine at the famed Bellevue Hospital. A proponent of European diagnostic methods (as he was mentored by James Jackson at Harvard, who was a follower of Laënnec), he advocated and popularized the use of the binaural stethoscope in physical diagnosis. He was a prolific writer and researcher with his Treatise on the Principles and Practice of Medicine considered as a classic medical text. He is also recognized as having coined the term “broncho-vesicular breathing” in lung auscultation. He would publish the first detailed description his eponymous murmur in 1862 in the American Journal of Medicine Sciences in an article entitled “On cardiac murmurs”.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Flint A. On cardiac murmurs. American Journal of Medical Science. 1862;7;29-54 [link]
  7. The Mitral Valve. Austin Flint. http://www.themitralvalve.org/mitralvalve/austin-flint

PAINE #PANCE Pearl – HEENT



Question

62yo man, with a history of pseudotumor cerebri, presents to your clinic with progressive headache and vision changes. You would like to confirm an increased intracranial pressure before sending him to the neurologist.

  1. What are two (2) ways at the bedside you can confirm and what are the thresholds for positive findings?


Answer

  1. The old and busted bedside way to determine if a patient has increased intracranial pressure is the fundoscopic examination. What you are looking for specifically is the cup:disc ratio of the optic nerve. Normal is around 0.3, or 1/3rd. If it is increased, it suggests increased intracranial pressure.

2. The new, hotness is using bedside POCUS to measure the optic nerve directly. Using the high frequency linear probe with a tegaderm placed over the patient eye, place a generous amount of gel over the globe and measure the optic nerve 3mm from the retina. A normal optic nerve should be < 5mm in diameter and anything over than suggests increased intracranial pressure

Ep-PAINE-nym



Rinne Test

Other Known Aliases – none

Definitionbedside test to evaluate hearing loss using a 512hz tuning fork

Clinical Significance this maneuver is performed by vibrating a 512hz tuning fork and placing it on the mastoid process. The patient then informs the provider when they no longer can hear the ringing, at which point the tuning fork is moved in front of the canal. In normal hearing, the patient should still be able to hear the ringing (although it can also occur in sensorineural hearing loss). If conductive hearing loss is present, bone conduction is greater than air conduction.

HistoryNamed after Heinrich Adolf Rinne (1819-1868), a German otologist who received his medical doctorate from the University of Göttingen. He would practice here for the majority of his career exploring the diseases of the ears, nose, and throat. He first described his eponymous test in 1855, but did not get widespread recognition for it until 1881 when it was further publicized by otologists Bezold and Lucae


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Heck WE. Dr. A. Rinne. Laryngoscope. 1962;72(5):647-652. [link]

#67 – Epistaxis



***LISTEN TO THE PODCAST HERE***



Anatomy

Anterior

  • Kiesselbach’s Plexus (Little’s area)
    • Confluence of three main vessels
      • Septal branch of the anterior ethmoidal artery
      • Lateral nasal branch of the sphenopalatine artery
      • Septal branch of the superior labial branch of the facial artery

Posterior

  • Woodruff’s Plexus
    • Posteriorlateral branches of the sphenopalatine artery
      • Posterior inferior turbinate

Epidemiology

  • Up to 60% of population will experience a significant nosebleed each year
    • Only 10% need to seek attention
  • Common ENT admission condition, but rarely needs surgical intervention
  • Bimodal age distribution
    • Before 10 years or between 45-65 years
  • Male predominance before the age of 49, then equalizes
    • Estrogen has been shown to protective for mucosa
  • Anterior bleeds are significantly more common (>90%) and resolve with minor interventions
  • Posterior bleeds can result in significant hemorrhage

Etiologies

  • Nose picking
  • Low environmental moisture
  • Mucosal hyperemia of viral or allergic rhinitis
  • Trauma
  • Foreign body
  • Anticoagulation
  • Coagulopathies
    • Osler-Weber-Rendu, von Willebrand, hemophilias
  • Connective tissue disease
    • Aneurysm development
  • Neoplasm
    • Squamous cell, inverted papilloma
  • Hypertension
    • Debated as a cause, but has shown to prolong bleeding
  • Nasal medications
    • Steroids, oxymetazoline
  • Heart failure

Patient Assessment

  • Primary
    • Airway assessment
      • RR, O2
    • Cardiovascular stability
      • HR, BP
  • Secondary
    • History
      • Medications
        • Anticoagulation, aspirin, nasal medications
      • PMH
        • Bleeding disorders, HTN, liver disease
        • Recent trauma
        • History of nosebleeds
          • How often, how long do they last, ever been admitted for one
  • Diagnostic Studies
    • Coagulation studies should NOT be routinely ordered
      • Should be in patients on anticoagulation
    • In patients with prolonged bleeds:
      • CBC
      • Type and cross
  • Examination
    • Have patient blow nose to remove clots and blood
    • Examine nasal cavity to see if you can see the bleeding site
      • Otoscope, nasal speculum
      • Don’t have patient tilt head back
        • Nasopharynx lies in anteroposterior plane and this will obscure the majority of the cavity from view

Interventions

  • Initial (Woodpecker/Walrus technique)
    • Have patient blow nose to remove clots
    • In a small basin mix any or all of the following:
      • Oxymetazoline
      • Lidocaine with epinephrine
      • Tranexamic acid
      • If available, soak GelFoam/Surgicel in this fluid and place BEFORE the sponge sticks
    • Trim two oral sponge swabs to better fit in the nasal cavity and soak in the fluid
    • Make a nasal bridge clamp by taping two tongue depressors together on one end
    • Place swabs in nasal cavities and apply nasal clamp for 10-15 minutes
    • Ice pack can also be used
  • Cautery
    • If the bleeding site can be visualized on direct examination
    • Apply topical anesthetic
    • Silver nitrate sticks
      • Start from periphery and roll to center of bleeding
      • No more than 10 seconds
      • A white eschar should form
  • Nasal packing
    • Use if cautery fails
    • Ensure topical anesthesia
    • Soak in sterile water
    • Insert by sliding along the floor of the nasal cavity PARALLEL to floor
    • Insufflate the balloon with air
  • Nasal Balloon Catheters
    • For posterior bleeds
    • Follow same steps for nasal packing
    • Insufflate posterior balloon FIRST and apply gently traction
    • Then insufflate the anterior balloon
  • Foley Catheters
    • If you don’t have a prefabricated nasal balloons, a foley catheter can work
    • Insert the catheter until you can see it in the posterior oropharynx
    • Insufflate with 5-10cc of water
    • Apply traction to seat balloon in posterior choana
    • Add additional water to tamponade
    • Clamp catheter with umbilical clamp or c-clamp from NG tube

Disposition and Follow-up

  • For simple nasal packing, patients should be evaluated by ENT within 24-48 hours
    • Discuss with consultant need for antibiotic prophylaxis
      • No good evidence supports routine use, but ENT often prefers
        • Amoxicillin-Clavulanate is most commonly used
        • Clindamycin or trimethoprim/sulfamethoxazole should be used if concern for nasal carrier of MRSA
  • Posterior bleeds should be immediately assessed by ENT for potential surgical intervention
    • Endoscopic sphenopalatine artery ligation
    • Anterior ethmoid artery ligation
      • Open or endoscopic

1893 Cottage Physician

References

  1. Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005; 71(2):305-11. [pubmed]
  2. Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States JAMA Otolaryngol Head Neck Surg. 2013; 139(12):1279-84. [pubmed]
  3. Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl. 1996; 78(5):444-6. [PDF]
  4. Fishpool SJ, Tomkinson A. Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales, UK. Ann R Coll Surg Engl. 2012; 94(8):559-62. [PDF]
  5. Min HJ, Kang H, Choi GJ, Kim KS. Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2017; 157(6):921-927. [pubmed]
  6. Shakeel M, Trinidade A, Iddamalgoda T, Supriya M, Ah-See KW. Routine clotting screen has no role in the management of epistaxis: reiterating the point. Eur Arch Otorhinolaryngol. 2010; 267(10):1641-4. [pubmed]
  7. Lin G, Bleier B. Surgical Management of Severe Epistaxis. Otolaryngol Clin North Am. 2016; 49(3):627-37. [pubmed]

PAINE #PANCE Pearl – HEENT



Question

62yo man, with a history of pseudotumor cerebri, presents to your clinic with progressive headache and vision changes. You would like to confirm an increased intracranial pressure before sending him to the neurologist.

  1. What are two (2) ways at the bedside you can confirm and what are the thresholds for positive findings?

#66 – How to be a Good Student on Emergency Medicine Rotation



***LISTEN TO THE PODCAST HERE***



Guest for the Episode

John B. Hurt, MPAS, PA-C

Assistant Professor and Director of Academics and Curriculum – Samford University – Department of Physician Assistant Studies


My 10 Rules

  1. Be on time
    • On-time = early
  2. Introduce yourself to the team
    • Preceptor and/or supervising physician
    • Charge nurse
    • Secretary or unit clerk
  3. Be Goal Oriented
    • Shift
      • Have 1-2 objectives for every shift you work
    • Rotation
      • Talk with your preceptor about what you want to see/do/experience
        • Actively seek out these experience
  4. Always Be Doing Something
    • Checking labs/images
    • Ask to draw blood for techs
    • Ask if you can get anything for your preceptor/staff
    • Review cases
      • There is something to be learned about every case we see in the ED
      • Look them up, write them down
      • Ask your preceptor what their decision making looks like
  5. Develop an algorithmic approach to common ED presentations
    • Chest pain, abdominal pain, AMS, fever, dyspnea, back pain, nausea/vomiting, trauma
      • Fast the providers what they do
      • Write these out to reference in the future
      • Get familiar with clinical decision instruments
        • Ottawa Rules, NEXUS, PERC, Canadian C-Spine
  6. 1-minute Presentations are an absolutely must
    • Have your diagnosis and plan ready
    • Differential diagnosis
      • Life threats, most likely, plausible, Zebras
  7. Disposition is the end decision in EM
    • Every patient either gets admitted or discharged
    • Before your preceptor makes the decision, make your own and see if your right
  8. See every type of patient that walks through the door
    • Don’t cherry pick (unless it is on your bucket list)
    • This will help you immensely throughout your career
  9. Go up and see the patients you admit before you leave the hospital after a shift
    • It will benefit your decision in the long run if you see what the inpatient team is doing
    • Your patients will also appreciate you checking on them
  10. Get feedback after every shift (if possible)
    • Plus-Delta approach
      • Things you do well (plus)
      • Things you can change (delta)


Ep-PAINE-nym



Puestow Procedure

Other Known Aliases – Puestow-Gillesby procedure, lateral pancreaticojejunostomy

Definitionside-to-side anastomosis of the main pancreatic duct of Wirsung to the proximal jejunum

Clinical Significance this is a surgical management option for patients with chronic pancreatitis by simultaneously facilitating drainage and preserving physiologic function of the pancreas.

HistoryNamed after Charles Bernard Puestow (1902-1973), an American surgeon who recieved his medical doctorate from the University of Pennsylvania in 1925. He would serve as a military surgeon during the 2nd World War and commanded the 27th Evacuation Hospital providing surgical services to wounded soldiers in Europe and North Africa. His commitment to the veteran population would continue after the war when he established the first surgical residency program based in a veterans hospitals in the United States in 1946. It was at Hines Veterans Hospital in Illinois where he and his partner, William Gillesby, would publish their experience and outcomes on 21 patients with chronic pancreatitis in 1958, which would lead to the creation of his eponymonic surgical procedure.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Bosmia AN, Christein JD. Charles Bernard Puestow (1902-1973): American surgeon and commander of the 27th Evacuation Hospital during the Second World War. J Med Biogr. 2017; 25(3):147-152. [pubmed]
  7. PUESTOW CB, GILLESBY WJ. Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. AMA Arch Surg. 1958; 76(6):898-907. [pubmed]