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.​

Please share your thoughts about Dr. Mellick's posts.


Monday, July 2, 2018

The fascial planes in the upper and lower extremities play an important role in function and form, but they also make the extremities vulnerable to compartment syndrome. Emergency physicians are quite comfortable evaluating and diagnosing compartment syndrome: severe unrelenting pain, pain with passive motion of the muscle groups involved, and possibly paresthesias and pallor. The first patient I saw with this condition was at the Tripler Army Medical Center in Hawaii. A sailor dangling his legs over the dock presented after his leg was crushed between the dock and a battleship that suddenly shifted its position. I still remember the patient in the trauma room screaming in severe pain.

During my two years as an FBI doctor in the training academy at Quantico, I became quite familiar with chronic and acute exertional compartment syndrome. Agents-in-training and older police officers in physical fitness training would often present with this condition. Severe pain would typically develop in the anterior compartment while they were running and could usually be relieved with rest. Some had this condition chronically, and worked around and through it. Surgical release of the compartment was eventually the outcome for most of these cases.​

Compartment syndrome of the hand is another rare condition that can have devastating consequences. Several decades ago, a colleague of mine in Columbus, OH, accidentally impaled her hand with a recently used large central line needle. The wound became infected, and she ended up receiving emergent fasciotomies of her hand. More recently, I saw a patient who presented late after a fall from a ladder that crushed his hand under his body. This patient presented with unrelenting pain despite the fasciotomies of the hand done a week or two earlier. He had run out of his pain medications several days prior to his presentation. Only healthy doses of parenteral opiates and intermittent infusions of low-dose ketamine seemed to bring him relief.

Watch a video showing a patient with late-presentation compartment syndrome. His hand was crushed after a fall from a ladder.​

A rarer presentation of lower extremity compartment syndrome, the spontaneous compartment syndrome, presented on at least two occasions recently. One patient was an older colleague. He colleague and the other patient shown in the video had spontaneous onset of severe pain in the distribution of the anterior leg compartment. Shortly following the onset of this pain, both developed a foot drop of the involved extremity. The inciting event for the compartment syndrome almost assuredly had to be a vascular event, but other cases of spontaneous compartment syndrome have been associated with diabetes mellitus, ruptured peroneus muscles, and exertional activity. These two cases of spontaneous anterior compartment syndrome did not require fasciotomy, and were followed up by the appropriate services.

Compartmental pressure measurements with the Stryker instrument has been the recommendation until recently. Remember the Stryker? Yes, that tool that always seemed to be missing when you or your consultant needed it. Now we have a much better and more disposable tool: the Compass device by Centurion. This disposable pressure gauge efficiently and effectively measures compartment pressure. A training video showing emergency medicine residents learning to use this device by measuring artificially elevated compartmental pressures of oranges demonstrates how easy this tool is to use. (Below.)

 mellick orange compartment.jpg

Watch a video showing how to use the Compass device for compartment syndrome and how to practice using it on an orange.​

Compartment syndrome has classic causes and clinical presentations. Crush injuries, infections within the fascial space, and muscle damage during extreme overexertion can cause compartment syndrome. Intermittent exercise-induced compartment syndrome and spontaneous compartment syndrome of the lower extremity are less common presentations that are at risk of misdiagnosis.

Watch this video showing a man with compartment syndrome in his foot.​

Friday, June 1, 2018

Alcoholism has been treated with disulfiram (Antabuse) ever since the drug received FDA approval in 1951. Disulfiram is one of a number of medications that produces unwanted side effects caused by the accumulation of acetaldehyde when taken with alcohol.

The story behind the discovery of disulfiram is typical of serendipitous observations. A physician noted in 1937 that workers in the rubber industry exposed to disulfiram developed a reaction after drinking alcohol. Several decades later, two Danish researchers evaluating disulfiram as an antihelminthic developed symptoms after attending a cocktail party. (Medscape, Jan. 6, 2016; http://bit.ly/2HsHfnu.)

These observations led to the clinical application of disulfiram in treating alcoholism. Cyanamide (carbimide), certain anti-infectives such as cephalosporins, nitroimidazoles (e.g., metronidazole), furazolidone, and dermatological medications such as tacrolimus and pimecrolimus are also associated with this effect. The toxic effects of acetaldehyde accumulation associated with disulfiram are actually the aversive effect desired to discourage further alcohol intake. Facial flushing, nausea, vomiting, tachycardia, and hypotension are toxic side effects seen with acetaldehyde accumulation.

Early on there were hard-learned lessons when high doses were used, and severe or fatal reactions occurred. Subsequently, lower and safer doses were used, and a marked reduction in life-threatening side effects were noted. Disulfiram is currently used less often as a first-line agent, but patients still present to the ED occasionally with a severe disulfiram reaction.

The video demonstrates such a patient who presented with severe hypotension, nausea, vomiting, and flushing. Reactions may occur several days after treatment has ended, as this patient showed. She had stopped taking disulfiram several days before her alcohol consumption occurred. The most prominent associated findings in our patient were hypotension and flushing. The hypotension was treated with and responded to intravenous fluids and pulse dose boluses of epinephrine. We also review the preparation and application of pulse doses of intravenous epinephrine in this video.

Usually the blood pressure drop associated with the disulfiram-alcohol reaction is only moderate, but severe life-threatening arterial hypotension and shock can occur. (Am J Med Sci 2007;333[1]:53; J Pharmacovigilance 2014;2:145; http://bit.ly/2JqzniX.) Myocardial infarctions and acute strokes have also been reported. (J Pharmacovigilance 2014;2:145; http://bit.ly/2JqzniX; Folia Med (Plovdiv) 2010;52[3]:70.) Epinephrine or norepinephrine are the pressor agents of choice for hypotension, but fomepizole, an alcohol dehydrogenase inhibitor, may also be an effective treatment. (J Pharmacovigilance 2014;2:145; http://bit.ly/2JqzniX.)

Despite its known limitations, disulfiram treatment is still considered a valuable option for treating alcohol dependence, and more recently, has shown potential benefit in treating other presentations. These include treating those with co-morbid alcohol dependence and post-traumatic stress disorder, those with co-morbid cocaine and alcohol dependence, and those with cocaine dependence alone. (CNS Neurol Disord Drug Targets 2010;9[1]:5.)

Be on the lookout for patients who may present with serious side effects such as refractory hypotension and its associated ischemic complications.​

mellick Antabuse.jpg

Watch a video showing the treatment of a patient with a disulfiram (Antabuse) reaction.​

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Monday, April 30, 2018

The hair or thread tourniquet syndrome is a relatively rare condition that has evaded me in the emergency department for several decades, until past year when three cases showed up over six months. This condition has been around for as long as there has been hair or thread and body appendages. In fact, this condition may have first been described in the 1600s. (J Pediatr Adolesc Gynecol 2005;18[3]:155.)

The etiology of this condition seems almost unbelievable. How in the world does a hair get wrapped repeatedly and tightly around an appendage of the body? Some authors expressed the need to consider nonaccidental etiologies more frequently. Stranger things, however, have happened in emergency medicine (e.g., the urinary catheter tying itself in a knot in the bladder of a patient). (APSP J Case Rep 2011;2[3]:21; J Clin Ultrasound 2009;37[6]:360.)

The risks of strangulation and autoamputation of the involved appendage are very real. This condition does not respect age, gender, or appendage. Hair tourniquets of the penis, clitoris, labia minora, teeth, uvula, fingers, toes, and even the larger extremities have been reported in the young and the elderly. They are, however, much more common in infants and young children than they are in adolescents or adults. In fact, a fascinating temporal association has been made between hair tourniquets and the mother's postnatal telogen effluvium, which causes significant maternal hair loss months after the infant's delivery. Consequently, we include hair tourniquets in that long checklist of potential issues afflicting the inconsolable infant. Corneal abrasions and colic may be much more common, but it makes perfect sense to examine all of the infant's appendages for a hair tourniquet.

I have been shocked by how rapidly these hair tourniquets burrow into the chubby subcutaneous tissues, making examination and quick removal nearly impossible. Hair has significant tensile strength, stretches when it's wet, and can be inadvertently tightened when an unsuspecting parent starts tugging on the exposed end of the hair. Furthermore, it can act like a garrote and cut through the soft skin of the infant while becoming increasingly inaccessible. When the health care provider begins to tease out the hair with a needle or forceps, bleeding quickly begins, making visualization even more difficult. Timely removal of the tourniquets is critical to preventing complications. The removal technique can be manual, chemical, or surgical.

Manual removal entails simply finding the free end of the hair or thread and unwinding it. This is often easier said than done. It can also involve using a blunt object such as forceps or an ear wax speculum, pushing it underneath the constricting material, lifting the tourniquet, and then cutting it and removing it. Chemical removal involves the use of depilatory agents that chemically break down hair protein. I have never used this technique, and some have reported that it can be a slow process. The failure rate will be high if the hair is already deeply buried. Most emergency departments don't plan ahead for hair tourniquets by stockpiling depilatory agents.

Surgical removal is sometimes necessary when presentation is late or the hair has rapidly burrowed deep into the subcutaneous tissue, preventing easy access for manual removal or lessening the potential effectiveness of depilatory agents. The surgical technique often requires anesthesia of the appendage, followed by a limited but relatively deep incision to ensure that the hair or thread has been released. In fact, the phrase "cut to the bone" is used on fingers and toes. A no. 11 scalpel blade is inserted at locations that avoid neurovascular bundles, and one goes all the way to the bone before withdrawing the blade. The incision on the penis or clitoris is made to the underlying fascia while being careful not to lacerate the three penile corpora bodies, the urethra, or the dorsal penile nerves. Incisions at the four and eight o'clock positions are recommended.​

Potential complications of the procedure can be trauma to the skin, bleeding, and infection, as well as injury of underlying neurovascular bundles. Contact dermatitis or skin irritation may occur if a depilatory cream is used. Assessment of tetanus immunization status is also recommended. Finally, close follow-up the next day is recommended to assess for continued improvement and absence of ischemia signs or infection.

mellick hair tourniquet.jpg

This child had a hair tourniquet deeply embedded in his pinkie.mellick photo 2 with video.JPG

Watch the removal of a hair tourniquet from a child's toe.

Monday, April 2, 2018

Many types and etiologies of headache and facial pain afflict our patients, and sorting through them can be a challenge. Craniofacial experts themselves, in fact, do not attempt to remember the subtle differences between the various conditions causing craniofacial pain, but instead refer to the third edition of the International Classification of Headache Disorders (ICHD-3). (https://www.ichd-3.org/.)

The ICHD-3 can help the clinician manage patients presenting with headache as their chief complaint. An international panel of headache experts oversee the classification, which is currently published in a beta format so mistakes can be identified and corrected.

Therapeutic management varies significantly depending on the actual type of headache, and a more precise diagnosis makes a difference in treatment success. Gaining maximal diagnostic competence improves our therapeutic accuracy and affects the lives of our patients.

This important classification currently has three main sections: primary headaches, secondary headaches, and painful cranial neuropathies, other facial pains, and other headaches. A primary headache has no other etiology, and includes migraines, tension headaches, and the lesser-known headaches such as the paroxysmal hemicrania, hemicrania continua, cluster headache, short-lasting unilateral neuralgiform headaches, and primary stabbing, primary thunderclap, nummular, hypnic, and new daily persistent headaches.

A secondary headache comes from another underlying condition or emergency. The differentiation between primary and secondary headaches is critical. Primary headaches are classified as migraines, tension headaches, trigeminal autonomic cephalalgias, and other primary headache disorders. Each of these taxonomies are subclassified. Secondary headaches are the head and face pain etiologies that cause emergency physicians the most angst. Headaches caused by life-threatening conditions such as ruptured aneurysms and subarachnoid hemorrhages, subdural hematomas, cerebrovascular accidents, venous sinus thrombosis, and brain tumors are just a few of the secondary headache etiologies that can masquerade as primary headaches and trip up even seasoned EPs.

A 9-year-old boy crashed his motor bike and had a concussion, forehead contusion, and broken nose. A month later, he was still experiencing pain in his forehead, but rather than go right to CT or MRI, Dr. Mellick injected some bupivacaine for suspected post-traumatic supratrochlear neuralgia. The child's mother reported that his pain never returned.​

Another major challenge is the complexity of the subclassifications of primary and secondary headaches as well as the painful cranial neuropathies and other facial pains and headaches. Without a reference tool such as the ICHD-3, the average clinician will rarely be able to make the diagnosis of the less common causes of craniofacial pain.

Secondary Headaches

-Headache attributed to trauma or head or neck injury

-Headache attributed to cranial or cervical vascular disorder

-Headache attributed to nonvascular intracranial disorder

-Headache attributed to a substance or its withdrawal

-Headache attributed to infection

-Headache attributed to disorder of homeostasis

-Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure

-Headache attributed to psychiatric disorder

The third section of the ICHD-3 provides the diagnostic criteria for cranial neuropathies, other facial pains, and other headaches. This section outlines conditions such as trigeminal neuralgia, occipital neuralgia, optic neuritis, nine other lesser-known neuropathies and headaches without a clear-cut etiology or not fitting specific diagnostic criteria for any other headache diagnosis. Having access to the current diagnostic criteria for these uncommon and diagnostically challenging conditions is a huge potential help to the average clinician.

Painful Cranial Neuropathies and Other Facial Pains

-Trigeminal neuralgia

-Glossopharyngeal neuralgia

-Nervus intermedius (facial nerve) neuralgia

-Occipital neuralgia

-Optic neuritis

-Headache attributed to ischemic ocular motor nerve palsy

-Tolosa-Hunt syndrome

-Paratrigeminal oculosympathetic (Raeder's) syndrome

-Recurrent painful ophthalmoplegic neuropathy

-Burning mouth syndrome

-Persistent idiopathic facial pain

-Central neuropathic pain

Headaches can be caused by life-threatening conditions such as aneurysms, like this patient who experienced a posterior communicating artery aneurysm and was taken for emergent aneurysm coiling.​

Wednesday, February 28, 2018

I was a practicing pediatrician before I did a residency in emergency medicine. One of the most common and sometimes most stressful decisions parents had to make in the neonatal nursery was whether to circumcise their newborn son. I have to admit that the hullabaloo about the foreskin has always intrigued me. The American Academy of Pediatrics has gone back and forth over the years on the topic of circumcision and its benefits, but the current evidence clearly establishes a benefit from this procedure (Pediatrics 2012;130[3]:e756) that is performed approximately 1.4 million times each year in the United States. (Mayo Clin Proc 2014;89[5]:677.)

The morning chore of the pediatric interns rotating through the nursery was to line up male infants and perform circumcisions. We became quite proficient and could have the foreskin fixed up with a device called the Plastibell in minutes. In fact, I vaguely remember several procedural speed competitions (by others, of course) called "Circ-Offs."​

It's almost unbelievable, but the removal or non-removal of a small piece of skin from the head of the penis has actually been the focus of medical and social attention for hundreds of years. A Google search for "circumcision" produces about 11 million results in 0.58 seconds, and a PubMed search for "male circumcision" shows 6,155 published articles. Circumcision has been around for a long time. A sixth dynasty (2345-2181 BCE) Egyptian tomb has artwork showing the practice of circumcision. (See image.)

Sixth dynasty Egyptian tomb artwork showing the practice of circumcision.​ Credit: GoShows/Flickr.

The removal of the foreskin also has strong religious implications. God reportedly told Moses that this was to be done on all Israeli newborn baby boys as a sign that they were to be a nation set apart by God. And the Apostle Paul, a former rabbi who followed Jesus, debated at length that circumcision was no longer mandatory for salvation because the law had been fulfilled. I remember my father, a small-town preacher, teaching the biblical perspective of circumcision. As a preadolescent man, I was highly embarrassed when first learning about this surgical procedure. During a church service, I leaned over and whispered to my mother the innocent question, "What is circumcision, Mom?" Her answer mortified and perplexed me. Why in the world would we be talking about this in church? Honestly, I still don't completely get it.

Clearly there are medical benefits to the procedure. Circumcision has been clearly demonstrated to reduce male urinary tract infections, decrease transmission of the human immunodeficiency virus, and significantly reduce penile cancer and human papilloma virus infections. There is also an associated reduction in the risk of cervical cancer among women with circumcised partners. Foreskin inflammation is also reduced following male infant circumcision. (Saudi Med J 2016;37[9]:941.)​

Uncircumcised boys and men are at increased risk of balanitis, posthitis, and balanoposthitis. Phimosis and paraphimosis are unique problems to the uncircumcised man. Phimosis is an inability to retract the prepuce or foreskin. It is actually divided into physiologic and pathologic forms because the foreskin normally cannot be retracted in the newborn. Only after a period of nocturnal erections does the foreskin stretch sufficiently to be retracted. Premature retraction during cleaning can result in penile injury and strangulation due to paraphimosis. Pathologic phimosis also occurs in adults, and is a truly nonretractable foreskin secondary to scarring of the distal prepuce, infection, and inflammation. (See video of a patient with balanoposthitis and phimosis.)


Watch a video of a patient with phimosis.

Circumcision has its own issues and associated complications. (JAMA Pediatr 2014;168[7]:625.) Accidental traumatic amputation of the glans, infections, hemorrhagic shock due to hereditary bleeding disorders, and excessive skin removal have been just a few of the adverse events reported in the literature. Meatal stenosis caused by diaper irritation and penile glans inflammation is also a known risk for circumcised males. (See video of a patient with meatal stenosis.)​

Watch a video of a young patient with meatal stenosis.

Iatrogenic complications have also occurred in ritual circumcisions performed by rabbis. During a ceremony known as a bris, a circumcision practitioner or mohel excises the foreskin from the infant's penis, and cleanses the wound by using his mouth to suck the blood from the incision. Unfortunately, this technique has occasionally and not unexpectedly resulted in transferring the herpes virus to the baby, and fatal infectious outcomes have occurred. (http://abcn.ws/1QRjm52.) A literature review published in 2015 found 30 cases of ritual circumcision-associated HSV infections between 1988 and 2012. (J Pediatric Infect Dis Soc 2015;4[2]:126.)​