Clinical Pearls

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Posted on 01/30/2009

What are the landmarks used to perform arthrocentesis of the wrist?

Answer

Locate the second dorsal compartment of the wrist to perform arthrocentesis.

On the dorsum of your wrist, locate Lister's tubercle, which is the bony prominence of the distal radius just off midline. The location of the dorsal compartment is the depression felt just distal and ulnar to Lister's tubercle.

By the way, flexing the wrist enables one to palpate the lunate bone as it rises to fill the depression.

Posted on 01/26/2009

What is the significance of subchorionic hemorrhage in the setting of first trimester vaginal bleeding?

Answer

Subchorionic hemorrage represents blood collection between the uterine wall and the fetal chorionic membrane.

Up to 20% of first trimester bleeding patients have a subchorionic hemorrhage on ultrasound. Most patients with subchorionic hematoma in the first trimester are asymptomatic.

Small hematoma collections less than 30% of the placenta usually resorb. Larger hematomas have a poorer prognosis and depends on maternal age and how far advanced the pregnancy is when the finding occurs. In general, the older the mother and the more advanced the pregnancy, the worse the prognosis. The incidence of spontaneous abortion in the presence of a hematoma with a normal fetus is approximately 10% in all comers.

Posted on 01/22/2009

Name a few contraindications to platelet transfusion?

Answer

Platelet transfusions, typically administered with levels < 10K, are contraindicated with consumptive, thrombotic microangiopathic processes.

Contraindications include thrombocytopenic thrombotic purpura (TTP), hemotlytic uremic syndrome, and heparin induced thrombocytopenia (Type II HIT).

Platelets given with the above contraindications can worsen microangiopathic processes and lead to worsening ischemia.

Although not contraindicated with idiopathic thrombocytopenic purpura (ITP), platelets are quickly destroyed and last but a few hours and therefore given only with life threatening hemorrhage.

Posted on 01/20/2009

What are the complications associated with short QT syndrome and what are the available treatments?

Answer

Many are familiar with the complications of Long QT syndome, but are less familiar with its shorter brother, the Short QT syndrome. Likely inherited in a autosomal dominant pattern, it presents with a QT interval less than 300ms. Other causes of a shortened QT such as hypercalcemia should be ruled out.

Can frequently cause afib and life threatening ventricular fibrillation. Treatment includes AICD and perhaps sotalol or quinidine (no definitive studies).

Posted on 01/14/2009

What are contraindications to methotrexate therapy in the management of ectopic pregnancy?

Answer

Contraindications include

Gestational sac > 3.5 cm (relative contraindication)
BhCG > 15,000 (relative)
Free pelvic fluid (relative)
Embryonic cardiac motion (relative)
Liver or renal dysfunction (absolute contraindication)
Peptic ulcer disease (absolute)
Immunodeficiency (absolute)
Any blood dyscrasias (absolute)

Posted on 01/12/2009

What are the complications of massive blood transfusions?

Answer

Massive blood transfusion is defined as the replacement of the patient's whole body blood volume in less than 24 hours

Complications include:

Dilutional thrombocytopenia - with greater than 1.5 whole body volume replacement
Dilutional coagulopathy - especially of factors V and VIII (not found in stored blood)
Hypocalcemia - citrate in stored blood binds calcium
Metabolic Alkalosis - citrate is metabolized into bicarbonate
Hyperkalemia - may be mild as potassium levels increase during storage
Hypothermia

Posted on 01/08/2009

How long does free air persist on CXR after open abdominal surgery / laparoscopy?

How long does postop pneumoperitoneum persist on CT scans?

Answer

Evidence of postop pneumoperitoneum on CXR will resolve by day 7 in 95% of patients although most resolve in 3-4 days.

Traces of free air post op can be observed for up to 18 days on CT scanning.

Gayer G, et. al. Postoperative pneumoperitoneum as
detected by CT: prevalence, duration, and relevant
factors affecting its possible significance Abdom
Imaging 2000; 25: 301-5

Posted on 01/08/2009

How would you paralyze a myasthenic patient during rapid sequence intubation?

Answer

Myasthenia results in the destruction of acetylcholine receptors. Since there are fewer receptors, myasthenics have a relative resistance to succinylcholine.

They require roughly 2 times the normal dose of succinylcholine for reliable paralysis.

If a non-depolarizing drug such as vecuronium is to be used, use approx half the normal dosage.

Reference
Abel M, Eisenkraft JB.
Anesthetic Implications of Myasthena Gravis.
Mt Sinai J Med. 2002; 69:31-7

Posted on 01/08/2009

What is the lifetime prevalence of AAA (abdominal aortic aneurysm) among siblings of patients with the disease?

Answer

In a paper from Nova Scotia investigating 375 patients, brothers of patients with AAA had an astounding 29% lifetime prevalence of disease.

Sisters had a 11% lifetime prevalence.

The control group cosisting of their spouses' siblings had only a 2% incidence. Presumably, the spouses of
siblings were not related to the patients.

Posted on 01/08/2009

True or false?

The depth of endotracheal tube insertion in children is estimated by the formula age (yrs)/4 + 4.

Answer

False.

Age (in years)/4 +4 is the estimated endotracheal tube size. The formula for insertion depth in children is estimated by tube size x 3 in centimeters.

By the way age/4 + 4 is equivalent to (age+16)/4. I hope i don't have to explain this to you. I've seen people have arguments over this. It is always fun to watch.

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