AUGMENTATION MANEUVERS FOR HEART MURMURS

A patient presents with a systolic murmur. The differential is wide.  Let’s use augmentation maneuvers to narrow the differential diagnosis.

 

Inspiration – Inspiration was found to increase right-sided heart murmurs with 100% sensitivity and 88% specificity (Lembo, NEJM, 1988).

 

Transient arterial occlusion by blood pressure cuff inflation increases the regurgitant murmurs of aortic regurgitation, mitral regurgitation, and ventricular septal defect.  Hand grip is sometimes taught for this purpose, but to the extent that it represents exercise, it can increase flow murmurs as well.

 

Most of the skills in auscultation come from a combination of knowledge and experience.  A good website for learning basic heart sound pathologies is easyauscultation.com

LOOK, LISTEN, AND FEEL: PHYSICAL DIAGNOSIS OF PULMONARY HYPERTENSION

Pulmonary hypertension is known for being difficult to diagnose, but there are some physical signs that may offer a clue:

  1. Giant A waves in the jugular venous pulse.
  2. Loud P2
  3. a parasternal heave at the left lower sternal border

1) Giant A waves in the jugular venous pulse can be a sign of pulmonary hypertension.  The A stands for atrial systole, and is present just before the carotid impulse.  Paul Wood, a famous cardiologist and teacher from the 20th century, recorded in 1957 a 20 minute video introducing this topic.  http://catalogue.wellcome.ac.uk/record=b1666332~S3 (accessed July 26, 2011).  Jugular waveform analysis is somewhat of a lost art, being ignored in most modern studies, despite the fact that in Dr. Wood’s cases the sign is easily discerned.  To my knowledge the sensitivity is not known.

2) A loud P2 in some cases can be discerned at the bedside in the emergency department.  Physiologic splitting happens on inspiration, and A2 (aortic sound) comes first, followed by P2 (pulmonic sound). A loud P2 is thought to be 38%-57% sensitive for pulmonary hypertension(Pilatis 2000, Sompradeekul 2010).  Audio samples are encouraged, and an example is found at http://www.easyauscultation.com/cases.aspx?CourseCaseOrder=5&CourseID=24 (accessed July 26, 2011).  This is best heard with the diaphragm in the pulmonic area with the patient leaning forward.

3) A parasternal heave is recognized by placing the palm on the patient’s parasternal area, with the elbow locked.  An impulse upward is considered a heave.  It was estimated as having 38% sensitivity for pulmonary hypertension (Pilatis 2000).

Historical signs of physical diagnosis sometimes are sometimes ignored for low sensitivity. However, these signs present with varying degrees of intensity, and certainly it behooves us to be prepared so that we can recognize those presentations that are discernible.

Take home points:

Physical signs of pulmonary hypertension include giant A waves, a loud P2,  and a parasternal heave.

THE BURN EXAM IS A MICROVASCULAR EXAM

A patient presents with extensive burns to the left hand.  None of the fingers have circumferential burns, but both volar and dorsal aspects do have larger territories affected, with extensive skin sloughing.  How do we use bedside physical examination to guide prognosis and treatment?

The physical examination of burns is essentially a microcirculatory examination for signs of viability.  We are evaluating the viability of the dermis, because this is the organ thath will help mediate wound healing.  It has a plexus of vessels and nerves, so the burn examination assesses neurological and circulatory function of the dermis.

First degree burns are easily defined.  Everything is viable.  It hurts and it is red or pink with normal blanching, which is a sign of increased blood flow.  Every aspect of neurological sensation is normal.  Furthermore, the skin is intact, without blistering.

Third degree burns are, sadly, also quite clear.  The dermis is dead.  The skin is white and leathery.  Sensation to light touch is absent. There are no signs of viability, whether of sensation or of circulation.  Skin that is red but does not blanch means the blood is extravascular, and this is consistent with a third degree burn.  The patient will generally need skin grafting, except for some very small burns <1cm.

Second degree burns, also called partial thickness burns, pose more subtle complexity, and an astute physical examination is needed.  We differentiate superficial partial thickness from deep partial thickness burns.

Superficial partial thickness burns basically just mean first degree viability, but there is some blistering.  The stratum corneum was breached, which separates as a thin blister.  If the tissue beneath has good signs of circulation then this is a superficial partial thickness burn. Signs of good circulation include a healthy pink appearance, normal capillary refill, and normal sensation.  The prognostic importance of a superficial partial thickness burn is that the stratum corneum defense layer has been breached, and topical antibiotics will be needed when the blister breaks.

Deep partial thickness burns mean there are signs of both life and death. On neurological examination, sensation might be present but subjectively diminished.  On circulatory examination, areas are white, but areas are also pink or red and blanch on pressure.   The prognostic importance of a deep partial thickness burn is that prolonged healing is expected and skin grafting may be needed.

The examination changes with time

Because of the intermediate zone of stasis, the classification of the injury may require repeat examination in 1-2 days.  In a full thickness burn, the zone of coagulation looks dead and is dead.  But the intermediate zone of stasis is red, blanches with pressure on day 1, but stops blanching or turns white on day 2 or 3.  Only on day 2 or 3 can we confirm that this is a deep partial thickness burn.  Clues that this might turn out to be the case include early petechiae, a sign that the vessel integrity is compromised.

Additionally, a first degree burn on day 1 might blister by day 2, and then reveal a second degree burn.  Interval follow-up is indicated in all burns where there is any doubt.

Back to the case:

At the bedside, you take a closer look and find areas of pallid appearance, and areas of blanching red.  Sensation is intact and normal.  There are signs of death, and signs of life.  This is a deep partial thickness burn.  Because it affects a critical area (the hand), the patient requires transfer to a burn center.

Take home points:

-repeat examination in 1-2 days is required to reliably classify a burn

-Skin uniformly alive: first degree or superficial partial thickness, excellent prognosis

-Skin uniformly dead: 3rd degree, generally requires skin grafting

-Skin has mix of circulatory/neurologic life and death: deep partial thickness burn, may need skin grafting if wound not expected to heal within 3 weeks


NEONATAL INTUBATION: POSITION FOR AN ANTERIOR AIRWAY

Case: No time, no visible larynx

You are seeing a patient in the hallway when suddenly a mother rushes in with a pallid blue lifeless infant. The nurses start CPR and bag mask ventilation as you grab a Miller blade and 4.0 tube. Your first look is all secretions. After using the adult Yankauer suction you clear that out fast and look again….esophagus. You pull back but still the larynx is nowhere to be seen. What do you do next?

Neonatal airway is a difficult airway

Success rates for pediatric emergency airway, as published, are limited. Pediatric senior residents had a 40% success rate, 47% with more experience, and 68% for fellows.(Leone 2005) Among emergency physicians, success on first attempt was 60%.(Sagarin 2002) This is markedly different from adults, where success rates are commonly well above 90%. Why is it so low? Can we prevent this?

Kids are little adults? Sniffing position

I have heard dozens of lectures on how kids are anatomically different, so we make interventions to address that. Then at the bedside I see that taken to extremes. An example is the idea that they have big heads so we need a towel behind the shoulders, and pretty soon intubation is being performed with distorted anatomy. Infants need the sniffing position just like adults. Richard Levitan recommends aligning the ear canal to the sternum as a more universal standard that applies to children, adults, and the obese. A ramp of towels behind both the shoulders and head can achieve good sniffing position.

Secretions

I have had cases where the respiratory therapist hands me the floppy small endotracheal suction. That usually doesn’t work. Use the adult Yankauer suction, and get those secretions out.

Back to the case

In this case you place towels behind the head and neck, extend the head slightly, and suction with Yankauer. Your next look is all tongue, but a gentle sweep to the left shows the arytenoids and you pass the tube just anteriorly. Capnography turns yellow through 6 tidal breaths, confirming success. You proceed with resuscitation.

Take home points:

-Neonates, like adults, need the sniffing position

-Neonatal secretions, like adult secretions, are best removed with Yankauer suction

PHYSICAL DIAGNOSIS OF KNEE EFFUSION

Anatomy of the Articular Capsule

A middle aged man presents with right knee pain and swelling.  You are concerned it might be gout and would like to tap the joint.  Is there an effusion?

There is an insufficient evidence base on this topic, but a review of the classic teachings on joint effusion is helpful.

  1. Inspection – Assess the medial and lateral peripatellar dimples, comparing to the contralateral knee. Loss of a dimple can happen with as little as 10mL of joint effusion.  This is best assessed in slight flexion (perhaps 15-20 degrees).  The knee with an effusion is often spontaneously in this position anyway, with the patient unable to hold extreme ranges of motion.
  2. Wave sign – milk the fluid to one side or the other, quickly compress it, and feel for an impulse on the opposite side.  This tends to work better if the joint fluid is thick.
  3. Ballottement – milk the fluid to the center and then tap on the patella.  You will feel a clunk with 10-15 mL of fluid.
  4. Suprapatellar space – palpate the lateral and medial suprapatellar spaces.  A large effusion (>60mL) will fill this area.  Remember that the purpose of the articular capsule of the knee is to allow extreme degrees of flexion.  This happens through redundant synovial lining of the suprapatellar bursa which slides to lubricate the lining between the joint and patella even through extreme ranges of motion.  The articularis genu muscle retracts this back during extension.  The reason this is important is that if you elevate the knee when examining it, all the fluid might track up into this large suprapatellar cavity.  So keep the knee dependent, and in slight (15-20 degrees) flexion during the examination.  This also is why we aim upward during arthrocentesis.  There is nothing inferiorly, all the capacity of the joint capsule is superiorly oriented.

Finally, the purpose of the physical examination isn’t to give you the answer, though it is nice when it does.  It just has to raise or lower your probability of disease enough to justify or eliminate the need for further testing.  Use ultrasound for confirmation if needed.

PHYSICAL DIAGNOSIS OF PEDIATRIC CHF

A 4 week old presents with respiratory distress.  Could this be congenital heart disease?

Today most cases of congenital heart disease are picked up in screening either in utero or shortly after birth.  However, we as emergency physicians will continue to see cases that are initially unrecognized.  Here is a reminder of some pediatric-pertinent findings of congenital heart disease.

  1. Cyanosis – this is only present when desaturated hemoglobin levels are above 3-5 g/dl.  A pulse oximeter will be needed to identify most patients with oxygen desaturation.  Place the oxygen probe on the right upper extremity, which is proximal to any possible aortic coarctation.  If hypoxemia is found, see if it corrects with 100% oxygen, called the hyperoxia test.  If it does not, this indicates intracardiac shunting.
  2. Hepatomegaly – infants develop hepatomegaly from venous congestion rather than peripheral edema.  Don’t forget to palpate for the liver.  Inch inward during exhalation and feel for the liver edge on inhalation.
  3. Point of maximal impulse – The normal location is the left 4th intercostal space, mid-clavicular line.  Infants have thin chest walls so this does actually provide valuable information.  The PMI may be displaced to the left or right, and it can be enlarged.  Visualization alone often provides this information.
  4. Precordial activity – a hyperactive precordium suggests volume overload.
  5. Auscultation – Listen individually to S1, systole, S2, and diastole.  Isolate each sound in your mind.  That can help you decide whether a murmur is holosytolic or ejection. If you are trying to exclude congenital heart disease, listen for physiologic splitting of S2.  Most congenital heart defects disrupt this process.

NEURO EXAM TEMPLATE – comprehensive

Neuro template

Here is a neurological examination template with parenthetical explanations. This can be a helpful reminder.

Mental status:

General: alert, attentive, affect nl

Memory: nl repitition, short-term recall, remote memory (3 presidents)

Language: receptive and expressive language intact

Visuospatial: normal clock-drawing

Motor:

Shoulder abduction (C5 – deltoid/supraspinatus) 5/5

Shoulder adduction 5/5

Elbow flexion (C5/C6 -biceps brachii – musculocutaneous nerve) 5/5

Elbow extension (C7 -triceps -radial nerve)  5/5

Wrist flexion (C7 – FCR/FCU – median/ulnar) 5/5

Wrist extension (C6 – ECR/ECU – radial nerve) 5/5

Finger adduction (T1-interossei-ulnar) 5/5

Thumb radial abduction (C7 – APL – radial nerve) 5/5

Thumb opposition (C8/T1 -opponens pollicis – median nerve) 5/5

Hip flexion (L1/L2 – iliopsoas muscle) 5/5

Hip extension (L5/S1 – gluteus maximus muscle) 5/5

Knee flexion (L5/S1 -hamstrings -sciatic nerve) 5/5

Knee extension (L3/L4 -quadriceps femoris muscle -femoral nerve) 5/5

Ankle dorsiflexion (L4/L5 -tibialis anterior muscle -deep peroneal nerve) 5/5

Ankle plantarflexion (S1 – gastrocnemius muscle -tibial nerve) 5/5

Ankle eversion (L5/S1 -peroneus longus/brevis – superficial peroneal nerve) 5/5

Ankle inversion (L4/L5 -tibialis posterior muscle – tibial nerve) 5/5

Extensor hallucis longus (L4/L5 – EHL/EDLs – deep peroneal nerve) 5/5

Flexor hallucis longus (S1 – FHL, FDLs – tibial nerve)  5/5

Sensory:

Lateral spinothalamic – pinprick, temperature nl

Dorsal columns – proprioception nl

Cortical – graphesthesia nl, proprioception nl

Reflexes:

Biceps, triceps, brachioradialis, patellar, achilles nl and symmetric

Babinski nl

Cranial nerves:

ii – vision intact

iii,iv, vi – eomi

v – facial sensation symmetrical

vii – facial movement symmetrical

viii – audition intact

ix/x – oropharyngeal motor function nl

xi – shoulder shrug symmetrical

xii – tongue motor function nl

Coordination

gait normal

finger to nose testing nl

heel to shin testing nl