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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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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.

Tuesday, December 4, 2018

I recently met with a group from our children's hospital to standardize the hospital management of bronchiolitis according to the latest American Academy of Pediatrics guidelines. (Pediatrics 2014;134[5]:e1474; http://bit.ly/2QIGbMX.) Unfortunately, these guidelines seem to cause confusion for experienced and inexperienced emergency physicians alike.

This confusion comes from the guidelines raising unaddressed issues and new questions, most importantly not tackling important aspects of frontline clinical practice. These guidelines were developed with the best evidence currently available, and their application mostly causes confusion with our undifferentiated patients. In fact, the guidelines may potentially create unnecessary vulnerabilities in our clinical practice by minimalizing our approach to these wheezing infants. Clinical evaluations, workups, and treatments seem to be discouraged.

Diagnosis under the AAP Guidelines

  • 1a. Clinicians should diagnose bronchiolitis and assess disease severity based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 1b. Clinicians should assess risk factors for severe disease, such as age under 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency, when making decisions about the evaluation and management of children with bronchiolitis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 1c. Radiographic or laboratory studies should not be obtained routinely when clinicians diagnose bronchiolitis based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)

Treatment under the AAP Guidelines

  • 2. Clinicians should not administer albuterol (or salbutamol) to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 3. Clinicians should not administer epinephrine to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 4a. Nebulized hypertonic saline should not be administered to infants with a bronchiolitis diagnosis in the emergency department. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 4b. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis. (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings].)
  • 5. Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting. (Evidence Quality: A; Recommendation Strength: Strong Recommendation.)
  • 6a. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 6b. Clinicians may choose not to use continuous pulse oximetry for infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 7. Clinicians should not use chest physiotherapy for infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 8. Clinicians should not administer antibacterial medications to infants and children with a bronchiolitis diagnosis unless there is a concomitant bacterial infection or a strong suspicion of one. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 9. Clinicians should administer nasogastric or intravenous fluids for infants with a bronchiolitis diagnosis who cannot maintain hydration orally. (Evidence Quality: X; Recommendation Strength: Strong Recommendation.)

The Undifferentiated Patient

Wheezing patients presenting to the ED and outpatient clinic will often be undifferentiated patients in contrast to the patients admitted and treated in the hospital. This is where there seems to be a disconnect between the guidelines and the clinical practice of emergency medicine. Unfortunately, the undifferentiated febrile or afebrile patient who presents with varying degrees of respiratory distress may not have bronchiolitis.

Bronchiolitis must be distinguished from a variety of acute and chronic conditions that affect the respiratory tract. The differential to consider includes a number of life-threatening conditions. Whether or not the guidelines acknowledge it, many patients may require further testing and treatment to differentiate better the etiology of the wheezing and adventitial sounds.

Bronchiolitis Lookalikes

  • Asthma
  • Recurrent viral-triggered wheezing
  • Pneumonia
  • Chronic pulmonary disease
  • Foreign body aspiration
  • Aspiration pneumonia
  • Congenital heart disease
  • Congestive heart failure
  • Myocarditis

The Differential Diagnosis

Bronchiolitis is at best a syndrome or collection of signs and symptoms. RSV predominates, but multiple other viruses and some atypical bacteria can present with the syndrome. In fact, at least four viruses are commonly associated with wheezing in children: the respiratory syncytial virus, the rhinovirus, the human metapneumovirus, and the influenza viruses. It helps to know that coinfection with viral and bacterial pathogens such as Haemophilus influenza type b or Streptococcus pneumoniae is uncommon because of the widespread use of conjugate polysaccharide vaccines, Bordetella pertussis, Chlamydia trachomatis, or Mycoplasma pneumoniae must be included in the differential diagnosis of a lower respiratory tract infection in a young child. In fact, one of the videos below shows an infant acutely ill and co-infected with both RSV and pertussis.

The Fallacy of 'Do Less, Not More'

It is possible for seasoned providers in pediatric care to make a bronchiolitis diagnosis without further testing, but it might not be realistic to expect everyone to do the same. And it might be unrealistic to expect learners to be able to confirm the diagnosis without additional steps to differentiate the patient. (Many of my undifferentiated wheezing patients respond to nebulized albuterol and epinephrine.) Furthermore, the overall message of "do less, not more" in the current guidelines may be the predominant message heard by learners or non-pediatricians, inadvertently resulting in sicker patients not being evaluated and treated aggressively when appropriate.

The 2014 AAP guidelines seem to personify therapeutic nihilism, but more optimistic and current evidence should be incorporated into the next revision of these guidelines in 2019. It is not possible to dive deeply into the evidence, but my analysis of the current literature suggests that the following treatment options have now sufficiently matured to allow their routine application in treating the bronchiolitis syndrome:

  • Hypertonic saline (3%) nebulization (Cochrane Database Syst Rev 2017;12:CD006458)
  • Nebulized epinephrine (Cochrane Database Syst Rev 2011;[2]:CD006619 and several other studies)
  • High-flow nasal cannula (multiple studies)
  • Heliox therapy (Cochrane Database Syst Rev 2015;[9]:CD006915)

The undifferentiated patient presenting with bronchiolitis syndrome and the health care provider's experience or comfort level pose challenges that are not sufficiently addressed in the guidelines. I am convinced that there is a mismatch between ivory tower recommendations and frontline care. In fact, it is common to hear clinicians sounding like guilty schoolchildren feeling obligated to justify why they are not following these clinical guidelines. Thankfully, there is less to feel guilty about because we now have growing evidence-based treatment options for our bronchiolitis syndrome patients.

mellick bronchiolitis 1.jpg

This video shows apnea in a child infected with RSV and swine flu.

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This video shows two infants with RSV presenting to the ED.

Thursday, November 1, 2018

Pediatric patients frequently put foreign bodies into their mouths, noses, and ears. The spectrum of foreign bodies that children place into their facial orifices are impressive. Paper, vegetable matter (such as peanuts), toys, beads, metal screws, and Play-Doh are just a few examples.

The insertions are often done surreptitiously, only to be discovered days or sometimes weeks later. Occasionally, the retained foreign nasal bodies will ferment and present with a purulent, unilateral nasal drainage, accompanied by an unrelentingly repulsive odor. Sometimes an occasional cockroach wanders into the external auditory canal looking for a dark, moist cavity for sleeping or laying eggs. There appears to be a preference for the right nostrils or right external auditory canal, which correlates with a higher percentage of right-handed children.

Classic Techniques

The classic techniques for removing foreign bodies from the nose and ears include using the following:

  • Alligator forceps
  • Balloon-tipped catheters
  • Frazier suction tips
  • Ear curettes
  • Nose-blowing
  • Bulb syringe
  • Bag-valve-mask
  • Mother's breath

Tension with ENT Colleagues

An ongoing low-grade tension between otolaryngologists and emergency physicians always seems to be brewing about attempts to remove foreign bodies. It is understandable because our ENT colleagues only see our failures and our failures often slightly traumatize our patients and their orifices. If every patient with a foreign body required an otolaryngologist, however, the demand would probably outstrip the specialty's availability.

Thankfully, emergency physicians are increasingly experienced at managing these cases. And, in MacGyver fashion, we do a good job of developing our own tools for removing foreign bodies like the right-angled hook, improvised suction catheters, the application of topical skin adhesive, and the use of rare earth magnets.

Procedure Risks

Many of the classic techniques are not easily reproduced, and often fail in my hands. Besides failures, other risks include trauma-induced bleeding of the orifice's skin or mucosa, pain, perforated tympanic membranes, and unwanted displacement of the foreign body. Dislodgement may include pushing the foreign body deeper into the orifice, making access and removal even more difficult. It can also result in aspiration or ingestion of the foreign body.

My most memorable case was one where I had to remove two small screws from a child's nose with forceps. Just as I was transporting the screws across the open mouth of the crying child, I dropped both screws directly into his mouth. A subsequent x-ray demonstrated the two screws sitting safely in his stomach. Thankfully, our patient had no complications and passed the two screws uneventfully several days later.

Pain is another risk. The external auditory canal is a sensitive area containing multiple nerves that are notoriously difficult to anesthetize. Topical anesthesia has only a partial effect, and four quadrant injections for local anesthesia are difficult and painful. The nose, notorious for bleeding from the slightest trauma, can also hide foreign bodies behind and under the turbinates.

Procedure Adjuncts

Thankfully, a number of adjuncts can make removing a foreign body from the nose or ears go more smoothly, including:

  • Child life specialists
  • Atomized intranasal midazolam
  • Papoose boards or burrito sheets
  • Atomized intranasal lidocaine
  • Topical tetracaine to the external auditory canal
  • Oxymetazoline hydrochloride nasal spray
  • Ketamine procedural sedation
  • Nasal speculums
  • Otoscopes

Insects, most often cockroaches, are occasionally still moving. Besides being unnerving to the patient, insects desperately clawing during the extraction process can be uncomfortable, but several substances are reportedly excellent at humanely euthanizing cockroaches: microscope oil, 2% to 4% lidocaine, viscous lidocaine, mineral oil, EMLA cream, and ethanol.

Post-procedure Interventions

A number of interventions are often recommended following extraction. First, always check the orifice for additional foreign bodies. Many clinicians will use topical antibiotic drops for the external ear canals or a topical antibiotic ointment for the nostrils. Their reasoning is that trauma to the mucosa or skin is not uncommon after orifice instrumentation. Systemic antibiotics may be necessary to treat sinusitis from a chronically retained nasal foreign body. Pain control with ibuprofen or acetaminophen is also helpful. Post-procedure epistaxis can be treated with an oxymetazoline nasal spray. The emergency department visit may also be an appropriate time for counseling the parents on child safety.

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Watch a video of using a suction catheter to remove a bead stuck in child's nose.


Two medical students help Dr. Mellick experiment using suction to remove a hearing aid from the ear in this video.

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EPs first tried a bulb syringe, direct removal, and bag-valve-mask to remove a nasal foreign body, but sometimes you just have to call for ENT consult, as shown in this video.

Saturday, September 29, 2018

Delusional parasitosis is a rare condition, but it is more common where methamphetamine and cocaine abuse is high. It is a fascinating condition to witness; patients are convinced that their skin is infested with foreign organisms or materials despite incontrovertible evidence to the contrary.

This condition is known by numerous names—Ekbom syndrome, delusory parasitosis, psychogenic parasitosis, delusional parasitosis, delusional ectoparasitosis, formication, chronic tactile hallucinosis, dermatophobia, parasitophobia, and cocaine bugs—but delusional parasitosis and more recently delusional infestation are considered the correct nomenclature. Another term commonly used in association with this condition is Morgellons disease. Morgellons refers to cutaneous symptoms like biting, crawling, or stinging sensation, finding fibers on or under the skin, and persistent skin lesions. Formication, a medical term derived from the Latin word for ant, is the sensation that resembles small insects crawling on or under the skin.

Patients have reported infestations ranging from "bugs," parasites, worms, and mites to bacteria, fungus, living "threads," and other living organisms for the pruritus they experienced. It is not uncommon for these patients to present clothing lint, pieces of skin, or other debris contained in plastic wrap, on adhesive tape, or in matchboxes. Some authors call this the matchbox sign or the Saran wrap sign. The patients will confidently state that these containers house the parasites, but close inspection, possibly even under a microscope, consistently fails to demonstrate insects or parasites. Even entomologists and pest control professionals often find themselves consulted by these patients.

It is nearly impossible to convince these patients that they do not have infestations despite the most convincing health care provider arguments and clinical demonstrations. It is almost embarrassing as the health care provider to try to convince an obviously intact person without any obvious cognitive impairment that he is delusional.

Unfortunately, these patients can inflict significant harm to themselves from self-treatment or their insistence on medical intervention. The video below shows a patient who adamantly defended her mental health as normal, but her shaved head and skin injuries from topical cleaning solutions and picking at her skin were dramatic.

Delusional parasitosis is considered a monosymptomatic hypochondriacal psychosis, and have been associated with schizophrenia, obsessional states, bipolar disorder, depression, and anxiety disorders. Many patients with psychopathology may complain of delusional parasitosis, and its coexistence is generally considered coincidental. Secondary delusional infestation is a symptom caused by a medication or another medical illness rather than a disorder. This condition, like other isolated delusional disorders, occurs primarily in white middle-aged or older women, even though the condition has been reported in all age groups and in men.

Treatment is ideally a therapeutic alliance with the patient, discontinuing any medication or drug that may be causing the condition, and administering psychotropic medications. If stopping offending agents does not result in improvement, antipsychotic medications such as risperidone, aripiprazole, olanzapine, or quetiapine may be required. Convincing the patient to take the medication requires significant discussion and patient education. Antipsychotic drugs may be used for limited periods in secondary delusional infestation while the underlying medicine, medical, or psychiatric condition is being managed.

About five to 15 percent of reported cases represent folie à deux, where other family members adopt the delusional symptoms. I remember evaluating a 4-year-old for this condition; he presented with his entire family, including his grandmother. Even though the index patient was the child's mother who was using methamphetamines, the grandmother showed me scuff marks on the floor and described them as parasites that had fallen off their bodies.

Watch a video of a woman with delusional parasitosis whose shaved head and skin injuries were dramatic.

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