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M2E Too! Mellick's Multimedia EduBlog by Larry Mellick, MD

​The M2E Too! blog presents important clinical pearls using multimedia. By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.​

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Wednesday, May 1, 2019

Some medications enjoyed years of glory but later ended up on the trash heap of clinical medicine, often put there by a systematic review or small case series of adverse outcomes or complications that led to black box warnings and a culture of fear and rejection. Still, the heyday lasted for years for some medication outcasts, such as acetaminophen with codeine, promethazine (Phenergan), aminophylline, droperidol, and meperidine (Demerol).

Of course, a few of these medications probably deserved their bad rap, but most of them served us well for many years when we had few other options. Medications like racemic epinephrine are still widely used but carry an undeserved negative reputation or have unrecognized benefits. In fact, the malicious and false accusations against racemic epinephrine (or racemic adrenaline; RA) actually occurred on several clinical fronts.

The Rebound Myth

I was taught during my pediatric residency about the dreaded rebound reaction that happens to croup patients treated with RA. Supposedly, these children would transiently improve only to rebound with significantly worse symptoms. This, unfortunately, was not true, and if anything, the croupy child just returned to his initial baseline degree of severity.

I'm not sure why rebound was applied to RA. Its effects eventually wear off, and the term rebound has negative connotations. The debate on mandatory observation after RA for croup has resulted in millions of hours of wasted time for patients who could have easily gone home. Steroids also take some time to take effect, but dexamethasone starts to work about an hour or two after administration. Some children with croup should be observed after RA is given, but it is their disease severity that mandates that, not the risk of rebound.

We debated observation for croup recently in our pediatric ED. Our department is developing a clinical pathway for managing croup, but physicians disagreed on whether it was necessary to observe a child treated with RA for three hours. Those favoring mandatory observation pointed to a study by Smith, et al., on observation times. (Clin Pediatr [Phila] 2018;57[6]:706.) Patients observed for 2.1-3 hours had a higher rate of treatment failure than those observed 3.1-4 hours.

This retrospective study reported that one-third of their patients were managed in under two hours. Of those, 83 percent were promptly admitted and 17 percent were sent home and did not return. Nearly 17 percent of those observed for three hours required admission for a second treatment of RA. (Clin Pediatr [Phila] 2018;57[6]:706.)

The criteria for ordering RA treatments differ among clinicians. I am liberal with RA because I like to package patients nicely for parents before sending them home. Any degree of stridor is enough for me to use steroids and RA, but it would be silly to take up a bed in the pediatric ED for three hours to watch these mildly ill patients. The bottom line is that you can send a child with mild illness home immediately after racemic epinephrine without observation.

An article by Yang, et al., nicely demonstrated that you can use a croup scoring system to know who needs to be admitted, observed, or can go home. (Pediatr Pulmonol 2017;52[10]:1329.) Overall, croup is a relatively minor illness, though it still presents with a spectrum of severity. You can easily document where your patient falls on the severity spectrum using a scoring system such as the Westley Croup Score. You can also determine the most appropriate disposition after treatment. (Pediatr Pulmonol 2017;52[10]:1329.)

RA and Asthma

RA is not commonly used for asthma but can be effective for acute exacerbations. Decades ago subcutaneous epinephrine was one of the few treatments available for acute asthma presentations. Intravenous aminophylline and steroids were generally added for seriously ill children who did not respond to epinephrine. Nebulized RA (11.25 mg of epinephrine) is well documented as an asthma treatment. Interestingly, most of the papers that compared nebulized epinephrine with drugs like albuterol and terbutaline similarly concluded that RA is no better than these other drugs. (Acad Emerg Med 2000;7[10]:1097; J Crit Care 2004;19[2]:99; http://bit.ly/2HqRTKp; Am J Emerg Med 2006;24[2]:217; http://bit.ly/2EKf13p.)

These noninferiority studies never said RA was less effective or didn't work. RA is acknowledged to have a few more minor side effects, but significant hypertension and tachycardia are not among them.

We use RA on asthma patients who have already had multiple doses of albuterol without a response. The goal when we throw RA into the ring is to hit more and other β2 receptors when the β2 receptors appear to be fatigued and less responsive to albuterol. Anecdotally, we have had some dramatic results when adding nebulized RA for airway smooth muscle bronchospasm.

Are there different β2 receptors that these drugs affect or does RA attach to a few extra β2 receptors and dry up secretions in smaller airways? Rodrigo, et al., said epinephrine will activate 20 times more β2 adrenoceptors than salbutamol when both drugs occupy the same number of receptors, causing it to be referred to as a full agonist. (Am J Emerg Med 2006;24[2]:217; http://bit.ly/2EKf13p.)

I'm not completely comfortable using this medication on older adults at risk for coronary vascular disease, but I've had success with adults and children. Nevertheless, be ready! If you use RA on asthma patients, expect to be questioned by residents and staff about the need for observation.

Racemic Epinephrine and Bronchiolitis

Despite what the AAP bronchiolitis guidelines recommend, epinephrine does work for bronchiolitis in outpatients. No new Cochrane guidelines exist for bronchiolitis, but the 2004 and 2011 Cochrane reviews acknowledged the outpatient benefit of epinephrine for this disease. Nevertheless, the AAP guidelines inexplicably discourage using nebulized epinephrine in outpatients. (Read my blog post about the bronchiolitis guidelines at http://bit.ly/2Tp92v1.)

These guidelines selectively address inpatient management while ignoring the benefit of epinephrine in the outpatient. Importantly, newer studies support epinephrine in outpatient management of bronchiolitis. (Ann Emerg Med 2013;61[3]:289; http://bit.ly/2XLYdBN.) A 2015 paper of systematic reviews for bronchiolitis therapies reported that nebulized epinephrine is effective for bronchiolitis in the outpatient setting. (Paediatr Respir Rev 2015;16[4]:267; http://bit.ly/2VIxTqk.)

Not only has racemic epinephrine not received the respect it deserves, it has been the object of false rumors. It is finally time that racemic epinephrine receive respect and attention.

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Watch a video of a baby admitted for croup after being given RA and steroids.

Monday, April 1, 2019

Ganglion cysts are soft tissue, fluid-filled swellings most frequently found in the hand and wrist; their origin is not exactly clear. They are common, however, and can occasionally be associated with surprising morbidity despite their benign nature. The morbidity seems to be related to their tendency to localize in highly mobile and anatomically tight quarters such as the hand and wrist. Nevertheless, they can show up almost anywhere.

Cysts can also have sequelae, such as sciatica from a piriformis ganglionic cyst, compression radiculopathy from a lumbar intraspinal ganglion cyst, foot drop from peroneal nerve cyst, metatarsal stress fractures, temporomandibular joint cysts, and other intratendinous, intraneural, and intraosseous ganglion cysts of the lunate. Ganglion cysts can also cause significant pain, paresthesia, weakness, muscle denervation, and muscle atrophy.

The etiology is not completely defined, but degeneration or softening of the connective tissue such as collagen after long-term irritation or trauma is most commonly reported. These cysts are often found overlying a joint or tendon sheath, and most likely arise from herniation of dense connective tissue from tendon sheaths, ligaments, joint capsules, bursae, and menisci. Some believe there are actually two entities—ganglion and synovial cysts. They are similar, but their different morphostructural characteristics may justify their descriptions as two separate entities. (Rheumatol Int 2015;35[4]:597.) Synovial cysts are thought to be the result of a capsular defect of a joint. The end result is extremely similar. (Neurol Neurochir Pol 2015;49[6]:436.)

Repetitive injury causes ganglion cysts to arise from mesenchymal cells at the synovial capsular junction. This injury to the capsular and ligamentous structures appears to stimulate fibroblasts to produce hyaluronic acid, which accumulates as the mucin jelly-like material commonly found in ganglion cysts.

The majority of ganglion cysts are asymptomatic, but cosmetic concerns will frequently cause patients to seek treatment. Patients also seek medical advice because of fears that the lump may be neoplastic. Transillumination, ultrasound, and MRI are helpful for distinguishing between benign ganglion cysts and neoplastic soft tissue masses.

Definitive treatment is surgical excision characterized by careful dissection to identify the pedicle of the cyst and to remove the capsular attachments and capsule. This meticulous excision is recommended because recurrence is a recognized risk. Surgical excision, however, is not generally recognized as an emergency department procedure. On the other hand, needle aspiration of the ganglion cysts can be done easily in the ED. Despite the estimated 50 percent recurrence rate, simple needle aspiration of the cyst is effective. Needle aspiration is entirely appropriate to perform in the emergency department because half of needle-aspirated ganglion cysts do not return. 

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Watch an ultrasound-guided needle aspiration of a large ganglion cyst on the wrist of a teenager.

Friday, March 1, 2019

Conjunctivitis is a common condition and easy enough to treat, but several uncommon conjunctivitis syndromes require more care and should not be missed.

Conjunctivitis is either infectious (viral or bacterial) or noninfectious (allergic or nonallergic). Viral infections are more common in adults, bacterial ones in children, usually caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Adults tend to have more S. aureus infections, while the other pathogens are more common in children. An adenovirus is typically responsible for viral-associated infections in conjunctivitis.

Acute Hemorrhagic Conjunctivitis

Acute hemorrhagic conjunctivitis is rare but highly contagious and often presents as an epidemic; it occurs much more commonly in developing countries. It was first described in Ghana in 1969. Its prevalence in the United States is lower than that in developing countries, but epidemics have been reported in the Southwest. When contrasted with adenoviral conjunctivitis or herpes simplex keratitis, acute hemorrhagic conjunctivitis is comparatively rare. It affects any age, race, or gender, but appears to have a predilection for adolescents between 11 and 15.

The viruses most commonly responsible for hemorrhagic conjunctivitis are members of the Picornaviridae family, most commonly the coxsackievirus group A24 (CA24) and enterovirus E70 (EV70) strains. The associated conjunctivitis is characterized by the rapid onset of a severely painful infection that quickly develops a dramatic subconjunctival hemorrhage.

The signs and symptoms of acute hemorrhagic conjunctivitis begin after 12-48 hours of incubation and include sudden onset of ocular pain, eyelid swelling, foreign body sensation, excessive tearing, eye discharge, and photophobia. Pinpoint epithelial keratitis is also sometimes described. Depending on the stage at which the patient presents, findings may include swollen lids, conjunctival follicles, chemosis, and subconjunctival hemorrhages. These hemorrhages range from petechiae to large areas of conjunctival involvement.

Despite its dramatic appearance and associated pain, acute hemorrhagic conjunctivitis is usually benign and resolves in five to seven days. A polio-like condition, however, has been reported in approximately one in 10,000 patients infected with enterovirus 70 infections. These patients are extremely contagious, and the virus is transmitted directly from person to person by fingers and fomites. EPs should use proper disinfection techniques, and patients should be warned about the potential for spreading their infection. Palliative therapy with cool compresses and ophthalmic lubricants as well as pain control measures are the available treatment options.

Conjunctivitis-Otitis Syndrome

An article titled "Conjunctivitis-Otitis Syndrome" described this syndrome for the first time. (Pediatrics 1982;69[6]:695; http://bit.ly/2UpwzIo.) It noted an association between purulent bacterial conjunctivitis, otitis media, and highly resistant, nontypeable H. influenzae. Crusted eyes frequently mean a child also has an ear infection about 75 percent of the time.

Later, I became convinced that sinusitis was also commonly associated. The original discussion of this syndrome acknowledged that "the illness started with low-grade to moderate fever, mucopurulent rhinorrhea, and cough." (Pediatrics 1982;69[6]:695; http://bit.ly/2UpwzIo.) Patients presenting with this syndrome often had a mucopurulent drainage for a week or longer. The importance of recognizing this syndrome is that it directs your treatment for the nontypeable Haemophilus influenzae. Treatment is amoxicillin-clavulanate and an appropriate ophthalmic antibiotic like trimethoprim/polymyxin (Polytrim). Others would, however, recommend no topical ophthalmic antibiotics if treating systemically.

Parinaud Oculoglandular Syndrome

Two to eight percent of patients with cat scratch disease present with parinaud oculoglandular syndrome, an atypical form of cat scratch disease characterized by tender regional lymphadenopathy of the preauricular, submandibular, or cervical lymph nodes associated with infection of the conjunctiva, eyelid, or adjacent skin surface. The conjunctivitis causes a unilateral red eye, foreign body sensation, and excessive watering of the eyes, and is described as granulomatous.

The infecting bacterium, Bartonella henselae, a small, fastidious, gram-negative bacillus, is the most common cause of this condition, but it is also seen with rodent-associated infections (tularemia or rabbit fever) by the bacterium Francisella tularensis. Sporotrichosis, caused by infections with Sporothrix schenckii, a dimorphic fungus existing in the mycelial and yeast phase, is another less common cause of parinaud oculoglandular syndrome and is seen more commonly in tropical and subtropical areas such as Brazil and Peru.

Even rarer diseases, tuberculosis, coccidioidomycosis, and syphilis, are associated with parinaud oculoglandular syndrome. Treating it when associated with cat scratch disease is different from that recommended for simple lymphadenopathy. The preferred regimen for any patient over age 8 is a combination of rifampin and doxycycline. For children under 8, the recommended treatment is rifampin plus azithromycin or rifampin plus trimethoprim-sulfamethoxazole.

Conjunctivitis is a relatively simple and routine pediatric diagnosis until it isn't. Acute hemorrhagic conjunctivitis, conjunctivitis-otitis syndrome, and parinaud oculoglandular syndrome are three conditions where pediatric conjunctivitis is not a simple diagnosis, and if missed, can have important clinical implications.


Watch this video of a patient with acute hemorrhagic conjunctivitis, a rare but highly contagious conjunctivitis.


This video shows a young boy with a purulent bacterial conjunctivitis, otitis media, and highly resistant, nontypeable H. Influenzae.

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Watch this video of a boy with neck and facial swelling as well as conjunctivitis, symptoms of cat scratch disease presenting with parinaud oculoglandular syndrome.

Friday, February 1, 2019

Tranexamic acid (TXA) was invented by a Japanese husband-and-wife research team in the 1960s. Years earlier, this same research team had discovered epsilon-aminocaproic acid, a derivative and an analogue of the amino acid lysine. In their search for a more potent antifibrinolytic agent, they discovered tranexamic acid, a synthetic analog of the amino acid lysine. Tranexamic acid is eight to 10 times more powerful than epsilon-aminocaproic acid.

The antifibrinolytic actions of TXA result from the binding of four or five lysine receptor sites on plasminogen. This binding prevents plasmin from binding to and degrading fibrin, preserving fibrin's matrix structure. Initially, marketing of the drug was for mild bleeding such as heavy menstrual periods and dental extractions. Currently, it is used in surgery to decrease the need for blood transfusions by decreasing bleeding and blood loss.

Relatively recently, respectability for this old drug dramatically increased when the 2011 CRASH-2 trial showed that TXA safely and dramatically reduced mortality in bleeding trauma patients. (Lancet 2010;376[9734]:23; http://bit.ly/2CoZJB4.) When treatment was initiated within three hours of injury, the risk of hemorrhage death was reduced by about one-third. Another piece of evidence for the respected stature of this inexpensive and highly cost-effective drug is its inclusion in the WHO list of essential medicines. (http://bit.ly/2CqEpLx.)

More recently, topical tranexamic acid has been used to successfully reduce bleeding in multiple surgical conditions. Successful treatment with topical applications has been reported for stomach bleeding with colostomies, gastrointestinal bleeding, uterine bleeding, and orthopedic and oral surgery, to name a few. Oral bleeding has been successfully managed in patients with hemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions. Topical application of tranexamic acid is considered safer because it is not absorbed systemically, reducing the risk of thromboembolic disease. Nevertheless, even with parenteral administration of TXA, the risk of thromboembolic disease appears relatively low.

More recently, the successful application of TXA for epistaxis has been reported. Additionally, case reports show success using TXA to manage epistaxis with rivaroxaban for hemophilia and hereditary hemorrhagic telangiectasia. Two studies by Zahed, et al., randomized patients with epistaxis to treatment with topical tranexamic acid or anterior nasal packing (ANP). (Am J Emerg Med 2013;31[9]:1389; Acad Emerg Med 2018;25[3]:261; http://bit.ly/2T0HKGQ.) They were markedly positive in favor of topical TXA (500 mg in 5 mL). Bleeding stopped remarkably sooner with TXA, and discharge from the ED was faster. Rebleeding in the ANP group was significantly greater: Rebleeding during the first 24 hours in the 2018 study was reported in five percent and 10 percent of patients in the TXA and ANP groups, respectively. (Acad Emerg Med 2018;25[3]:261; http://bit.ly/2T0HKGQ.) At one week, rebleeding had occurred in five percent of patients in the TXA group and 21 percent of those in the ANP group.

Undoubtedly, tranexamic acid can be administered topically for epistaxis in multiple ways. Dripping TXA into the nostrils with a syringe or the shortened tubing of a butterfly needle are simple and effective delivery methods. Two other possible options are demonstrated in the videos. After insertion into the nostrils, nasal tampons can be expanded with tranexamic acid or a TXA-oxymetazoline combination. TXA can also be administered topically by using an atomizer without any form of nasal packing. About 1-2 mL (100 to 200 mg of tranexamic acid) can be nebulized in the offending nostrils. This technique appears to be highly effective at widely distributing the medication throughout the nostrils.


Watch this video to see TXA administered for recurring epitaxis.

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Watch this video to see administration of oxymetazoline and TXA for a nosebleed emergency.

Monday, December 31, 2018

Some medical conditions have signs and symptoms that significantly overlap, making a diagnosis a little more difficult. Epididymitis, testicular torsion, and torsion of the testicular appendage are examples, but orbital and preseptal cellulitis are others that can cause significant diagnostic confusion.

Both conditions are more common in children than in adults, and preseptal or periorbital cellulitis is more common in children under 5. The preseptal and orbital spaces are separated by only a thin membranous septum that originates in the orbital periosteum and inserts into the tarsal plates. It is only this thin septum that stands as a barrier against progression of the preseptal infection into the orbit.

Both conditions may present with eye pain, eyelid swelling, and erythema. The occasional bee sting or mosquito bite near the eye, with its dramatic swelling of loose areolar connective tissue, can cause similar diagnostic confusion. Several years ago I had a patient with what appeared to be a localized reaction to an insect bite that subsequently turned out to an early preseptal cellulitis. On the other hand, allergic reactions that cause periorbital swelling and conjunctival chemosis are less difficult to differentiate because of the bilateral presentation.

Preseptal cellulitis once had implications that were more serious. Haemophilus influenzae type b was one of the most frequent etiologies of these infections, and it was common practice for all of these children to undergo spinal taps as part of their evaluation. The Hib vaccine dramatically reduced the frequency of infections.

The most common antibiotic recommendations for both infections still include treatment to cover Streptococcus pneumoniae and other sinusitis-associated bacteria as well as Staphylococcus aureus. Obviously, if the preseptal or periorbital cellulitis occurred after a break in the skin and the infecting organism seems most consistent with staph, then treatment with an antibiotic such as clindamycin alone may be appropriate.

Preseptal Cellulitis Pearls

  • Preseptal cellulitis is more common in younger children and is more common than orbital cellulitis.
  • Imaging is not generally indicated, but CT imaging with contrast is entirely appropriate when in doubt about the diagnosis.
  • Eye pain often occurs with periorbital cellulitis but not with eye movement. Imaging can be justified if you cannot adequately examine the eye.
  • Chemosis rarely occurs with preseptal cellulitis, but it is much more common with orbital cellulitis.
  • Direct inoculation is more common as a cause of the infection with preseptal than orbital cellulitis.
  • Treatment as an outpatient with oral antibiotics is entirely appropriate, but the most common recommendation is to treat both with an antistaphylococcal antibiotic that you would use to treat sinusitis, such as amoxicillin-clavulanate.
  • Haemophilus influenzae type b was once a formidable agent of infection that resulted in screening lumbar punctures. The Hib vaccine has dramatically reduced the incidence of this infection.
  • Outpatient treatment is usually successful.

Orbital Cellulitis Pearls

  • Orbital cellulitis is more common in children, but occurs more frequently in older children than preseptal cellulitis.
  • The ethmoid sinuses, the most common location of orbital infections, are separated from the orbit by only the paper-thin lamina papyracea.
  • The main three examination findings that confirm the diagnosis are ophthalmoplegia (and often diplopia), eye pain with movement, and proptosis.
  • Three percent to 11 percent of those with infections can have vision loss. One percent to two percent can be fatal.
  • If fever, chemosis, and leukocytosis are present, orbital cellulitis should be a strong consideration.
  • Most cases of orbital cellulitis can be treated with antibiotics alone, but surgical drainage of a subperiosteal abscess is occasionally needed.
  • CT imaging with contrast is the tool most commonly used to make the diagnosis.
  • Hospital admission for administration of parenteral antibiotics is required for this condition.
  • Use parenteral antibiotics targeting Staphylococcus and sinusitis-causing bacteria such as Streptococcus pneumoniae and Haemophilus influenzae, nontypable, such as vancomycin and ceftriaxone.
  • Treatment with metronidazole is recommended if intracranial infection is suspected.
  • The valveless superior and inferior orbital veins increase the risk of an intracranial spread of infection because they drain directly into the cavernous sinus.
  • Consider a cavernous sinus infection or other intracranial spread of infection if vision complaints and pain develop in both eyes.
  • Lateral canthotomy and cantholysis are emergently required on rare occasions.

CT imaging may at times be the only way to differentiate between preseptal and orbital cellulitis. Close follow-up is strongly recommended because of the risks associated with failure to diagnose orbital cellulitis.

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Watch this video to learn about treating orbital cellulitis.

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Watch this video to see the management of a patient with preseptal cellulitis.