Modern Resident - The newsletter of AAEM/RSA
April/May 2011
Volume 2: Issue 5


Your Leadership

We welcome your comments and suggestions. Feel free to get in touch with your elected leaders:

President
Ryan Shanahan, MD

Vice President
Heather Jiménez, MD

Immediate Past President
Michael Ybarra, MD

Secretary-Treasurer
Sandra Thomasian, MD

At-large Board Members
Melissa Halliday, DO
Ketan Patel, MD
Zachary Repanshek, MD
Teresa Ross, MD
Leana Wen, MD

Medical Student Council President
Brett Rosen

Modern Resident Contributors

Copy Editor: Teresa M. Ross, MD
Managing Editor: Jody Bath, AAEM/RSA Staff

Special thanks to this month's contributors: Robert Katzer, MD; Veronica Tucci, MD JD; Tracy Sanson, MD; Michael Holman, MSIII; Steven McGuire, MSIII; Leah Baker, MSIII; and Sunil Medidi.

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by June 1st for the June/July edition.

Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA.


Board Review: Bartholin's Cyst and the Word Catheter
Michael Holman, MSIII
Georgetown University School of Medicine

Abscess or cyst of the Bartholin's gland is said to account for 2% of all gynecological visits per year, often presenting in the emergency department. Knowing a quick, easy and effective way of treating the pathology, as well as preventing recurrence, is valuable.

There are several ways to treat Bartholin's cysts and very few randomized control trials pointing to the most effective method. Insertion of a Word catheter can be easily taught and performed by emergency room (ER) residents and has been shown to be as effective as marsupulization, laser ablation or window procedures, without all the hassle.

In the 1940s, Bufford Word observed that leaving suture behind in the drained abscess promoted re-epithelialization of the cysts, creating a channel for continuous drainage. He later developed the Word catheter, a 3cm long 10-French balloon–tipped catheter that can be left in the cyst to promote proper healing in 4-6 weeks.

This cyst should be drained with a 5mm incision on the mucosal surface of the inner labia minorum, just exterior to the hymen. A hemostat or cotton swab may be used to break up loculations. Once drained, the tip of the catheter is inserted and 2–5ml of saline can be injected to fill the balloon. The end of the catheter is then tucked into the vagina and left in place for at least four weeks. The cysts are usually polymicrobial with chlamydia or gonorrhea being cultured only 10% of the time. Antibiotics are not necessary unless cellulitis is suspected. The most common complication is accidental removal, in which case the catheter can easily be replaced. Surveys have shown that these catheters do not interfere with daily activities such as jogging, riding a bike or having intercourse.

References:

  1. Haider, Z. The simple outpatient management of Bartholin's abscess using the Word catheter: A preliminary study. Aust N Z J Obstet Gynaecol. 2007 Apr; 47(2): 137-40.
  2. Marx: Rosen's Emergency Medicine, 7th Edition, (2010).
  3. Pundir, J. A Review of the management of diseases of the Bartholin's gland. J Obstet Gynaecol. 2008 Feb; 28(2): 161-5.
  4. Wechter, M. Management of Bartholin Duct Cysts and Abscesses: A Systematic Review. Obstet Gynecol Surv. 2009 Jun; 64(6):395-404.

2011-2012 AAEM/RSA Membership Applications
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Clinical Pearl: My Patient has Transient Monocular Loss of Vision
Robert Katzer, MD
Georgetown-Washington Hospital Center Emergency Medicine

Depending on your available resources, loss of vision can be a daunting clinical challenge. Amaurosis fugax is one subcategory of this complaint. The important characteristics of this presentation are that the visual loss is unilateral, involves near-complete or complete loss of visual field in that eye, and is transient (fugax), lasting only seconds to minutes.

The causes are broadly grouped into several categories: embolic, hemodynamic, ocular, neurologic and idiopathic. Embolic causes include thromboembolism, atheroembolism and foreign body embolism from IV drug use such as talc. Hemodynamic etiologies are related to transient hypotension, retinal vascular insufficiency either from atherosclerotic disease or temporal arteritis or from abnormalities of blood viscosity or coagulopathy. Ocular causes include hemorrhage, elevated intraocular pressure and space occupying lesion. The main neurologic etiologies include optic neuritis, papilledema and migraine headache.

Workup should include pursuit of each etiology based on the patient's past history and physical exam. In addition to your TIA–specific physical exam, be sure to include temporal artery palpation, fundoscopic exam, visual acuity and intraocular pressure. Abnormal acuity, pressure or fundoscopic exam necessitate emergent ophthalmologic evaluation. Tests to consider include a CBC, ESR, head CT, ECG, carotid duplex and echocardiogram. If you have concern for optic neuritis or multiple sclerosis, arrange for an MRI of the brain. Need for admission will depend on local resources. As a result of the frequent systemic etiology associated with amaurosis fugax, most diagnoses will be elucidated via thorough history and physical.

References:

  1. Marx: Rosen's Emergency Medicine, 7th Edition, (2010).
  2. Tintinalli: Emergency Medicine: A Comprehensive Study Guide, 6th Edition, (2003).
  3. Current management of amaurosis fugax. The Amaurosis Fugax Study Group. Stroke 1990;21;201-208.

AAEM/RSA is proud to announce the new 2011-2012 AAEM/RSA board of directors:

RSA board officers:
President: Teresa M. Ross, MD – Georgetown-Washington Hospital
Vice President: Zachary Repanshek, MD – Temple University
Secretary/Treasurer: Leana Wen, MD MSc – Brigham & Women's Hospital
Immediate Past President: Ryan Shanahan, MD – Johns Hopkins

At-Large board members:
Ali Farzad, MD – University of Maryland
Stephanie Gardner, MD – Indiana University
Taylor McCormick, MD – LAC+USC Emergency Medicine Residency
Ketan Patel, MD – University of Nevada
Sarah Terez Malka, MD – Indiana University

Medical Student Council
President: Meaghan Mercer – Western University
Vice President: Tiffany Nelson – UT Medical Branch

Regional representatives:
Midwest:
Alan Sielaff – Loyola University Stritch School of Medicine

Northeast:
Michael Holman – Georgetown University School of Medicine

West:
Tyler Morrison – University of California San Diego

International Ex Officio:
Corey Valdary – American University of Antigua

*Terms will run from mid May 2011 through May 2012

We had a very successful election with many qualified candidates and an excellent response in our sixth online election. Thank you for your participation.

In the coming weeks, we will be sending out a call for volunteers for AAEM/RSA committee members and AAEM/RSA representatives to AAEM committees.

Did You Know? - The Evidence Behind Point of Care (POC) Testing
Steven McGuire, MSIII
University of New England College of Osteopathic Medicine

Trauma activation: You have 60 minutes. "The Golden Hour." EMS arrives with a STEMI. You have 90 minutes "Door to Balloon Time." A patient's son says his father first showed signs and symptoms of a stroke an hour ago. You have 120 minutes to evaluate for optimal use of tPA with your "Stroke Code Activation."

We use these dicta in the ED to illustrate the importance of quick decisions and actions. The reality is that many of our most important actions depend on data. A quick look into bedside testing illuminates how far we have come with our ED resources and practice in just the past decade. Bedside ECGs and portable imaging modalities have all become the standard of care in the ED. Lab tests have also come to the bedside with bedside glucometers and, more recently, Point of Care (POC) Testing the i–STAT blood analysis system. Younger providers may even take the i–STAT system for granted, not even remembering a time when it wasn't readily accessible. Here's a quick insight into what the i–STAT has accomplished for us and what it costs.

Each i–STAT machine costs about $7,000–$10,000. A few drops of blood are added to cartridges ($5–$15 each), inserted into the machine, and results are available within 2–10 minutes, depending on the lab test.

But time is money. Several trials have reviewed Point of Care Testing. The DISPO–ACS trial (Ann Emerg Med 2009) showed shorter turn–around–times for lab results for i–STAT vs. central lab analysis. Almost all (98%) of the i–STAT results were available in less than 60 minutes and 87% in < 30 minutes. Central lab achieved those benchmarks in only 46% and 3% of the cases, respectively. Faster lab results correlated with quicker disposition in the DISPO–ACS trial. Both discharges and admissions were accomplished in less time. The RAT–PAC trial (Heart, 2011) also concluded there was no difference in "bouncebacks" to the ED or in major adverse events for patients who received POCT vs. standard care.

In the end, POCT seems to meet both benchmarks of speed and accuracy. And don't forget, we love new toys, especially electronic toys, in the ED. The i–STAT and Point of Care Testing should make us happy on all counts.

References:

  1. Commercial Communication, Abbott Website. Accessed 11 Jan 2011.
  2. Ryan RJ, Lindsell CJ, Hollander JE, et al. A multicenter, randomized, controlled trial comparing central laboratory and point of care cardiac marker testing strategies: the Disposition Impacted by Serial Point of Care Markers in Acute Coronary Syndromes (DISPO–ACS) Trial. Ann Emerg Med 2009 Mar;53(3):321–8.
  3. Goodacre SW, Bradburn M, Cross E, et al.The Randomised Assessment of Treatment using Panel Assay of Cardiac Markers (RATPAC) trial: a randomised controlled trial of point of care cardiac markers in the emergency department. Heart. 2011 Feb; 97(3): 190–6.

AAEM/RSA Exclusive - A Must Have!

Emergency Medicine: A Focused Review of the Core Curriculum
Emergency Medicine:
A Focused Review of the Core Curriculum

22 chapters, 225 board-style questions, 79 images...one way to excel!

To purchase this incredible new resource, visit http://www.aaemrsa.org/bookstore for your member discount!

Image #1 of the Month
Leah Baker, MSIII; Veronica Tucci, MD JD; Tracy Sanson, MD
University of South Florida Emergency Medicine

A four month old male with history of non-accidental trauma, shaken baby syndrome with traumatic subarachnoid, subdural and bilateral retinal hemorrhages is status post status epilepticus treated with Keppra and phenobarbital. The patient was started on phenobarbital twice a day and continuous EEG monitoring for 48 hours. Gauze was then wrapped around the patient's head to secure EEG lead placement. These lesions were noticed in the morning after his EEG leads were removed. They appear to correspond to some of the previous lead placements. Which of the following is the most likely etiology?

  1. Contact dermatitis
  2. Pressure necrosis from EEG leads
  3. Atopic dermatitis
  4. Drug reaction/allergy to medication

Click on image to enlarge photo.

Image #1 of the Month

Click here for the answer


Image #2 of the Month
Sunil Medidi, MSIII; Veronica Tucci, MD JD
University of South Florida Emergency Medicine

A 58 year old male bicycle vs. MVA victim came into the emergency department complaining of left-sided head and neck pain. The patient arrived via EMS on a backboard and was in a C-collar. Patient denied any loss of consciousness, chest pain or shortness of breath. Physical examination was unremarkable except for tenderness on the head and multiple abrasions on extremities. Patient exhibited no focal neurological signs. FAST examination was negative. In view of patient's mechanism of injury, a CT head and C-spine were obtained. One view of the sagittal C-Spine is shown below. This image represents a(n):

  1. Vascular channel
  2. Acute fracture of C-spine
  3. Intravertebral vacuum cleft
  4. Spinal stenosis
  5. Spinal hemangioma

Click on image to enlarge photo.

Image #2 of the Month

Click here for the answer


University of Illinois at Chicago
Department of Radiology (M/C 931)
College of Medicine

Radiology Utilization Management Fellowship
The department of radiology at the University of Illinois College of Medicine has newly established a one year fellowship in radiology utilization management. Curriculum for the fellowship is designed by the department of radiology in conjunction with UIC School of Public Health, UIC School of Business and the Northbrook Institute of Research and Development that specializes in radiology benefit management.

Applicants should be physicians with board certification in any medical/surgical fields, interested in a career in utilization management. For further information and application, please see the UIC Radiology website: www.uic.edu/com/uhrd.

Click here for full description.


Image #1 of the Month

Answer: B

Pressure necrosis (B) occurs due to unrelieved pressure that exceeds capillary filling pressures resulting in tissue ischemia. The resulting hypoxia leads to local cell death and ulceration of the affected area.1

Contact dermatitis (A) is a type IV hypersensitivity reaction that requires prior sensitization. The immunological reaction occurs when the allergen penetrates the epidermis and encounters antigen presenting cells, where it is then processed and presented to T lymphocytes. The T lymphocytes then release lymphokines resulting in the characteristic inflammatory response. Acute contact dermatitis presents as localized erythema and edema and may include vesicles or bullae filled with clear fluid.2

Atopic dermatitis (C) often starts in infancy and characteristic features include dry, thickened skin with eczematous lesions. Pruritus with accompanying excoriations can be difficult to control in infants and children and flares and remissions are frequently unpredictable. Though any part of the body can be affected, lesions of the flexural surfaces of the extremities are characteristically seen.3

Drug reaction or allergy (D) to phenobarbital affecting the skin has been described in the literature. Drug hypersensitivity syndrome is an adverse drug reaction that can occur within the 2-8 weeks of starting the prescription and manifests with fever, skin rash and lymphadenopathy, and may include agranulocytosis, hepatitis, nephritis and myositis. The skin lesions are most commonly exanthems and may or may not be pruritic. Treatment includes discontinuing the drug, symptomatic treatment and systemic steroids. Keppra is rarely associated with a rash.

References:

  1. Kosiak M. Prevention and rehabilitation of pressure ulcers. Decubitus. 1991 May;4(2):60-2.
  2. Kimber I, Basketter D, Gerberick G, Dearman R. Review: Allergic contact dermatitis. Int Immunopharmacol. 2002 Feb; 2(2-3):201-11.
  3. Gibson L. Atopic Dermatitis. Mayo Clin Proc. 2005 Jan; 80(1).
  4. Kumari R, Timshina DK, Thappa D. Drug hypersensitivity syndrome. Indian J Dermatol Venereol Leprol. 2011 Jan-Feb;77(1):7-15.

Image #2 of the Month

Answer: C

Image #2 of the Month

The lesion in the above image was identified as an intravertebral vacuum cleft sign. This finding is common in elderly patients as a result of degenerative disc disease and arises from a decrease in bone volume that produces negative pressure which acts to pull out nitrogen from the surrounding tissues into the cleft and form the pocket of air1. This finding can be confused with a spinal fracture in an acute trauma situation. Emergency physicians can distinguish this from acute fractures by looking for the characteristic hyperlucent area within the vertebral body that is consistent with air. Acute fractures might present with cervical disalignment or subluxation. The take home point is that when presented with an elderly patient who has air in the vertebral body, think degenerative disc disease first.

Other incidental findings to take note of on the spinal cord include vascular channels, spinal stenosis and hemangiomas. Vascular channels, also known as spinal intramedullary cavernous malformations, can be viewed on MRI and would be more horizontal in nature rather than vertical. Spinal stenosis can be diagnosed by determining if there is diminished diameter and cross-sectional area of the spinal canal on imaging. Spinal hemangiomas can present as a polka-dot appearance or with a characteristic trabecular pattern. Distinguishing these findings from more common ones such as fractures/dislocations can definitely be of aid to the physician in the acute care setting.

References:

  1. Golimbu C, Firooznia H, Rafii M. The intravertebral vacuum sign. Spine (Phila Pa 1976). 1986 Dec; 11(10):1040–3.