Are you concerned about ED Crowding? After a busy shift do you ever “..dream it’s over”? Do you work in a “Crowded House”?
Come to the Crowded House Track at CAEP19 on May 26th 1pm. International and Canadian experts present their experience and we discuss possible solutions.
Including Dr. Taj Hassan (President Royal College of Emergency Medicine UK), Dr. Alecs Chochinov (President CAEP), Dr. Judy Morris and Dr. David Lewis.
Join in the debate – “are redirection strategies better than accommodation strategies” – should we invest all our energy in redirection to alternative services or should we accept that we can’t stem the tide and bring all these services under one roof?
Register for CAEP19 – CAEP By The Ocean. https://caepconference.ca/registration/
SJRHEM is massively involved in this Maritimes Emergency Medicine Conference. EMS tracks, Pediatrics, Trauma, Crowding. Special rates for Nurses, Paramedics, Residents etc. https://caepconference.ca/registration/
A 90-year-old female
presented to the emergency department after a fall. Her vitals were stable and
a chest x-ray demonstrated three posterior rib fractures. She was keen to be
managed at home and had the necessary supports in place. She was discharged
with a prescription for analgesics and instructions to return to the ED if her
condition changed.
4 days later, the same
patient returned to the emergency department with shortness of breath and
increased work of breathing. Auscultation revealed decreased air entry on the
left. A pneumothorax was at the top of the differential.
PoCUS for Pneumothorax
Lung ultrasound has been found to be more sensitive than chest x-ray for detecting pneumothorax.1 To begin scanning, it is best to have the patient in a supine or semi-recumbent position. The high frequency linear array transducer provides excellent near-field imaging and may be used to better appreciate Lung Sliding, however both the phased array or curvilinear probe may also be used. The probe should be positioned in the longitudinal orientation, with the marker towards the patient’s head, on the anterior chest. Scanning through various rib spaces on both sides completes the exam.
In a normal healthy
lung, the visceral and parietal pleura slide against each other creating a
distinct shimmering effect known as Lung Sliding. The presence of Lung Sliding
rules out pneumothorax with nearly 100% sensitivity in the area directly under
the probe.2*
Lung sliding
Absent lung sliding
Comet-tails are
another normal feature of a healthy lung. This is an artifact caused by the
reverberation between the parietal and visceral pleura. Comet-tails are seen as
bright, vertical lines that fade quickly. The detection of comet tails allows
you to rule-out pneumothorax.3
The Seashore Sign is a
normal finding in M-mode of a healthy lung. The sliding of the parietal and
visceral pleura creates a sand like pattern directly deep to the pleural line.
In a pneumothorax, there is air between the parietal and visceral pleura and
thus the ultrasound beam is scattered deep to the parietal pleura. In this
case, an artifact known as the Barcode Sign may be seen where a reflection of
the chest wall is seen below the parietal pleura.5*
The most specific finding
of pneumothorax is the Lung Point Sign. This is the point where the visceral
pleura begins to separate from the parietal pleura indicating the boundary of
the pneumothorax. Although pathognomonic for pneumothorax it is not always
present – the sensitivity is 66%.4
Lung Point
In summary
PoCUS for pneumothorax
can be performed quickly at the bedside and is more sensitive than chest x-ray.
Look for the absence of Lung Sliding, the absence of Comet-tails and try to
locate the Lung Point Sign.
A 20-year-old African male presented to the emergency department with black, tarry stool for the past two days. He appeared hemodynamically stable. He was treated for peptic ulcer disease (PUD) due to Helicobacter pylori infection eight months ago after an episode of severe hemorrhage. His medications included ferrous sulfate and Pepto-Bismol. He did not have a primary care provider.
What diagnoses
should be considered?
90% of melena is due to upper gastrointestinal (GI) hemorrhage proximal to the ligament of Treitz, but the pharynx and small bowel may sometimes be involved.2 Major causes of upper GI bleeding include PUD, varices, Mallory-Weiss tear, or neoplasms.1 Life-threatening hemorrhage, varices, ulcerations, arteriovenous malformations, and malignancy must also be considered.1
It is important to distinguish between dark stool from blood, known as melena, and dark stool from other causes, such as iron or bismuth. Liquid consistency, shininess, and foul smell are distinct features of melena. 5
What questions
should this patient be asked?
Symptoms can help determine the severity and etiology.1 Upper abdominal pain is common with peptic ulcer. Dysphagia combined with weight loss and early satiety is characteristic of malignancy. Significant coughing or retching may lead to Mallory-Weiss tear.2
Comorbidities and prior episodes of upper GI bleeding should be asked. History of liver disease and alcoholism are associated with variceal hemorrhage. Abdominal aortic aneurysm is associated with an aortoenteric fistula. A history of H. pylori infection and NSAID use are risk factors for PUD.2
The use of NSAIDs, antiplatelets, or anticoagulants must be identified. Medications that can induce pill esophagitis (i.e. bisphosphonates) also need to be identified. Bismuth and iron can both lead to harmless darkening of the stool.2
Are any
investigations required?
Physical exam begins with an assessment of the patient’s hemodynamic stability.2 Signs of any co-morbidities should be noted. Laboratory tests should include complete blood count, liver function tests, and serum electrolytes. The hemoglobin level may be unchanged from baseline for the first 24 hours.1
Is fecal occult blood test required?
The FOBT has only been validated for use in asymptomatic patients for colorectal cancer (CRC) screening.5 For symptomatic (i.e. melena) patients with high pre-test probability of GI bleeding, the FOBT has a high false positive rate.5
Foods with peroxidase
activity (i.e. red meat), vitamin C, antiplatelets and anticoagulants can influence
the FOBT results,5
therefore dietary and medication restriction for
three days is needed.3 Therefore,
the FOBT is unsuitable for emergency rooms despite common use in this setting
as a point-of-care (POC) test.3 The newer immunochemical FOBTs do
not require dietary restriction and have shown improved accuracy as POC testing
for CRC, but its accuracy in evaluating black-coloured stools remains unclear.3,
7
There is speculation that FOBT may be used for patients with dark stools on iron supplementation.3 However, melena is usually well-characterized by its liquid consistency, shininess, and foul smell. Importantly, the FOBT has never been validated for such use to distinguish between melena and other causes of dark stool.3, 5
How should
this patient be managed?
A hemodynamically stable patient should be promptly categorized according to rebleeding and mortality risk, using the Glasgow Blatchford Score (GBS) or Rockall Score. They are validated tools based on information such as the patient’s blood pressure, hemoglobin level, and co-morbidities.4, 6
Although pre-endoscopic empiric therapy with PPI is recommended for all patients, this is based on the excellent safety profile of PPIs rather than evidence regarding their efficacy.4 Histamine-2 receptor antagonists are ineffective as preendoscopic therapy.4, 6
Endoscopy within the first 24 hours of presentation is recommended for suspected GI bleeding,1,4 although patients with very low GBS Score (i.e. zero) are unlikely to benefit.5
Generally, all patients with upper GI bleeding require gastroenterology consult. In cases where endoscopy is not suitable, surgical consultation is needed.2
Case revisited
Physical exam and lab results were
unremarkable except low hemoglobin, which yielded a total GBS Score of 2 for
this patient. Since this is considered high risk1, gastroenterology
was consulted. The patient was given an infusion of IV PPI.
Although the patient is on iron and bismuth, he had been on these medications for many months, and, given his history of severe hemorrhage due to PUD without a family physician to provide follow-up care, it was deemed appropriate to investigate further.
References
1.
Kim B, Li B, Engel A, Samra J, Clarke S, Norton I et al. Diagnosis of
gastrointestinal bleeding: A practical guide for clinicians. World Journal of
Gastrointestinal Pathophysiology. 2014;5(4):467.
2.
Cappell M, Friedel D. Initial Management of Acute Upper Gastrointestinal
Bleeding: From Initial Evaluation up to Gastrointestinal Endoscopy. Medical
Clinics of North America. 2008;92(3):491-509.
3.
Ip S, Sokoro A, Buchel A, Wirtzfeld D, Konrad G, Fatoye T et al. Use of Fecal
Occult Blood Test in Hospitalized Patients: Survey of Physicians Practicing in
a Large Central Canadian Health Region and Canadian Gastroenterologists.
Canadian Journal of Gastroenterology. 2013;27(12):711-716.
4.
Barkun A, Fallone C, Chiba N, Fishman M, Flook N, Martin J et al. A Canadian
Clinical Practice Algorithm for the Management of Patients with Non-Variceal
Upper Gastrointestinal Bleeding. Canadian Journal of Gastroenterology.
2004;18(10):605-609.
5.
Narula N, Ulic D, Al-Dabbagh R, Ibrahim A, Mansour M, Balion C et al. Fecal
Occult Blood Testing as a Diagnostic Test in Symptomatic Patients is not
Useful: A Retrospective Chart Review. Canadian Journal of Gastroenterology and
Hepatology. 2014;28(8):421-426.
6.
Barkun A. International Consensus Recommendations on the Management of Patients
With Nonvariceal Upper Gastrointestinal Bleeding. Annals of Internal Medicine. 2010;152(2):101.
7.
Huddy JR, Ni MZ,
Markar SR, Hanna GB. Point-of-care testing in the diagnosis of gastrointestinal
cancers: Current technology and future directions. World Journal of
Gastroenterology. 2015;21(14):4111.
Conversion disorder – remember = diagnosis of exclusion. Consider admission for urgent workup for patients with neurological findings and no definitive diagnosis. Or good documentation if thought to be functional disorder.
CT reports – important to document details of Diagnostic Imaging report (verbal, system or dictated). Be aware of old reports on dictation system and make sure report is the appropriate one.
Vision loss – acute vision loss needs to be seen ASAP for assessment. Don’t need room 27 (eye room) for all eye cases. Emergent ophthalmology cases can be initially assessed in any room.
Supracondylar Fractures – remove ice packs etc to have a good look at all Ortho injuries during triage assessment, even when brought in by EMS. Assess for limb deformity, skin tenting and especially neuro-vascular compromise. These patients should be urgently assessed and appropriately managed including analgesia, splinting and emergent reduction if indicated. Don’t need to wait for room 10 ( Fracture Procedure Room) for emergent Ortho cases.
Learning Points:
Scanning Dysarthria
Scanning dysarthria (scanning speech, explosive speech) is a stuttering dysarthria found in cerebellar disorders. Spoken words are broken up into separate syllables, often separated by a noticeable pause, and spoken with varying force. The sentence “Walking is good exercise”, for example, might be pronounced as “Walk (pause) ing is good ex (pause) er (pause) cise”. Additionally, stress may be placed on unusual syllables. Charcot’s neurological triad suggestive of multiple sclerosis has it has one of the three classic symptoms.
Corneal hydrops is the acute onset of corneal edema due to a break in Descemet membrane. This condition may be seen in individuals with advanced keratoconus or other forms of corneal ectasia. More here
Keratoconus is a disorder in which the cornea assumes an irregular conical shape. Acute hydrops is a well-known complication, occurring in approximately 3% of patients with keratoconus. Hydrops occurs after rupture of the posterior cornea leads to an influx of aqueous humor into the cornea, resulting in edema. Corneal edema typically resolves in 6 to 10 weeks; therefore, hydrops is usually not an indication for emergency corneal transplantation. Infectious causes of corneal opacification and visual loss, such as bacterial, viral, or fungal keratitis, must be ruled out as the cause of acute visual loss.
Seidel Test
The test used to reveal ocular leaks from the cornea, sclera or conjunctiva following injury or surgery and sometimes disease is called Seidel test.
Dr. Mekwan presents Rounds on the topic of ‘Whole Body CT’ vs Selective CT for Trauma. This presentation includes case scenarios and a review of the literature.
Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month
Major points of interest:
A) TXA – “When did this MVA actually happen?”
Only 75% of cases receiving TXA are
receiving it within 3 hours of injury. And only ½ of theses cases are having the
drip started.
CRASH study found patients receiving TXA after 3 hours do not benefit.
B)
Bleeding on warfarin
If emergent reversal of anti-coagulation
from warfarin is needed, vitamin K (5-10mg) should be given IV (not PO), along with PCC.
C) Trauma transfers from outside of our region in the post TTL era..
Consultants accepting transfers from other regions through NB trauma
line may request that patient stop in ED first for evaluation/imaging prior to
transfer to floor or ICE.
The consultant should make every effort to evaluate their patient on arrival to ED
Expectation is that TCP and/or consultant clearly delineate their plan
with ED charge MD.
E) Matthew 4:1:1 “Man shall
not live by [RBCs] alone”
I might not have gotten that one quite right, but the MTP policy follows a 4:1:1 rule – after 4th unit of PRBCs, give a unit of platelets and FFP.
F) This guy is bleeding all over my triage room!
Patients occasionally “self-present” to triage with significant injuries
or a history of a high energy MOI. The most efficient way to mobilize resources
is to have the triage RN call a “Trauma CODE”.
G) Analgesia in pediatric population
Pain management in pediatric population is
often challenging. If IV access is delayed consider alternative routes –
intranasal fentanyl 1.5 ug/kg using MAD (mucosal atomizing device).
H) May the hoses R.I.P.
Chest tube sizes 36 F and 345F are now no
longer being stocked on chest tube cart.
I)
Post-intubation sedation
Post intubation sedation and analgesia can
be challenging. Key is to avoid starting medications that could potentially
drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.
Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of
continued agitation.
What are you looking for on the ECG of the patient with syncope?
Quick review of frequently pimped question on shift!
Two approaches – One using systematic ECG analysis, the other a mnemonic.
ECG Analysis (1)
Standard format of rate, rhythm, axis, and segments (PR, QRS, QT, ST).
Method of calculating heart rate (2)
Rate: Simple — Is the patient going too fast or too slow? *Remember this easy way to check:
Rhythm: Look at leads II, VI and aVR for P waves.
Ask yourself:
Are they upright in II/VI and inverted in aVR?
Does a QRS follow every P and a P before every QRS?
If so likely sinus rhythm.
In the setting of syncope we are looking to see if there is any signs of heart block – a P wave not conducted to a QRS, especially being sure not to miss a Mobitz type II block.
Axis: Axis comes in to play when looking for more extensive conduction disease. Is there axis deviation along with a change in your PR and BBB indicating something like a trifasicular block?
Segments:
PR interval— is it looooong (heart block) or short (reentrant)?
Long has already been discussed in looking for signs of heart block, but a short PR may be indicative of Wolf-Parkinson-White or Lown-Ganong-Levine syndromes.
WPW – look for short PR and delta wave
LGL – short PR but no delta wave due to its conduction being very close to or even through the AV node and not through an accessory pathway.
QRS Morphology analyzing this for signs of Brugada, HOCM, WPW, ARVD, pericardial effusion, and BBB.
ECG findings of Brugada (3)
Type 1: Coved ST segment elevation with T wav inversion Type 2: Saddleback ST segment elevation and upright T waves Type 3: either above without the ST elevation
QT interval — is it looooong (R on T) or short (VT/VF risk)?
Long is >450 men, 470 women
Short < 330ms – tall peaked T waves no ST segment Pearl for long – should be less than half the RR interval. —>
Normal relationship of R-R and QT interval (4)
ST segment — think MI or PE (rare causes of syncope but need to be considered)
MI – elevations or depressions
A — Aortic stenosis
Go back to patient and listen! B — Brugada C — Corrected QT D — Delta wave E — Epsilon wave as in Arrhythmogenic Right Ventricular Dysplasia (ARVD)
Epsilon: Small positive deflection (‘blip’) buried in the end of the QRS complex (6)
F — Fluid filled heart
Pericardial effusion, electrical alternans, low voltage throughout G — Giant PE H — Hypertrophy
LVH in someone who shouldn’t have it I — Intervals
PR, QRS, QT I — Ischemia
Looking for a Basic ECG Guide? See our Med Student Pearl Here:
Joe Cocker and Randy Newman had an altercation while debating who recorded the best version of “You can leave your hat on”. Randy won (mainly because he is still alive), but unfortunately he sustained a nasty head injury in the process. You deduce that he does not require a CT head but he’s got a 7 cm lac over his scalp. What should you do next?
Review of scalp anatomy:
The scalp is divided into 5 layers, which can conveniently be recalled using the mnemonic, SCALP:
Skin
Ref 1
dense Connective tissue
Aponeurosis
Loose connective tissue
Periosteum
Recall that the dense connective tissue layer is richly vascularized. The tight adhesion of these vessels to the connective tissue inhibits effective vasoconstriction, hence the profuse bleeding often seen with scalp wounds.
The loose connective tissue layer = the DANGER ZONEwhen lacerated. This layer contains the emissary veins, which connect with the intracranial venous sinuses. Consequently, lacerations reaching this layer are high risk for spreading infection to the meninges
Examining the laceration:
Ref 2
Prior to choosing the most appropriate closure technique, the wound should be cleaned and cleared of debris and the depth of the wound should be determined.
Superficial wounds: generally do not gape and have not gone beyond the aponeurosis. Adherence to the aponeurosis should prevent the wound edges from separating.
Deep wounds: gape widely due to laceration of the aponeurosis in the coronal plane. Tension secondary to the occipitofrontalis muscles will pull the wound open in opposite directions.
Ref 2
(A) Scalp laceration that extends through the aponeurosis
(B) CT showing an associated skull fracture
Choosing a closure technique:
A. The HAT technique: Hair Apposition Technique
What it is: A fast and simple technique for superficial laceration closure whereby the physician twists hair on either side of the laceration together and seals the twist with a drop of glue for primary closure. Various advantages, as described below, including no need for follow up suture or staple removal.
When to use it: Consider using HAT for linear, superficial lacerations, <10 cm that have achieved appropriate hemostasis (assuming the patient has hair!).
The evidence for HAT: An RCT based out of Singapore, comparing suturing (n=93) to HAT (n=96) for scalp lacerations <10 cm found HAT to be equally acceptable if not superior to suturing. Patients were more satisfied (100% vs 75%), had less scarring (6.3% vs 20.4%), fewer complications (7.3% vs 21.5%), lower pain scores (2 vs 4), shorter procedure times (5 vs 15 min) and less wound breakdown (0% vs 4.3%) (Ref 4)
A follow up study by the same group assessing cost-effectiveness of HAT compared to suturing found a cost savings of $28.50 USD (95% CI $16.30 to $43.40) in favor of HAT when taking into consideration materials, staff time, need for removal appointments and treatment of complications (Ref 5)
A retrospective observational study comparing HAT (n=37) to suturing (n=48) and stapling (n=49) also found HAT to be superior to both suturing and stapling due to increased patient satisfaction at days 7 and 15, reduced pain, lower cosmetic issues and complication rates (Ref 6)
How to do HAT (see diagram):
Choose 4-5 strands of hair in a bundle on either side of laceration
Cross the strands
Make a single twist to appose the wound edges
Secure with a single drop of glue
Advise patient that the glue will eventually come off on its on and no formal removal is required.
Cautions with HAT: avoid getting glue into the wound as it may result in wide scarring with a bald spot (Ref 3)
B. Wound Staples
If the HAT technique is not an option (no glue, bald, etc) and the lac is superficial (above the aponeurosis), staples are preferred over suturing due to Ref 3:
Sutures are appropriate for deep, gaping wounds or those requiring immediate hemostasis.
Suture is required for lacerations through the aponeurosis to reduce spread of infection, hematoma formation and increased scarring. Furthermore, inadequate repair of the aponeurosis may result in asymmetric contraction of the frontalis muscle (Ref 3)
Final thoughts post-closure:
White petroleum ointment is as effective as antibiotic ointment in post-procedural care (Ref 7). Furthermore, the next time you consider handing out bacitracin (or polysporin), recall that it was declared ‘contact allergen of the year for 2003’ by the American Contact Dermatitis Society. Bacitracin is among the top ten allergens in the US causing allergic contact dermatitis (Ref 8).
Wetting the wound as early as 12 hrs post-repair does not increase the risk of infection (Ref 7). Consider delaying wetting in the case of HAT.
Bottom line:
For superficial lacerations, <10 cm with adequate hemostatic control, the hair apposition technique is a fast, cost-effective method of wound closure with high patient satisfaction, reduced pain and lower complications compared to suturing and staples.
Lacerations through the aponeurosis require suturing to reduce rates of complications.
Consider use of petroleum jelly over antibiotic containing ointments such as polysporin.
4 Ong ME. “A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).” Annals of Emergency Medicine. July 2002. 40:1. 19-26.
5 Ong ME. “Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations.” Annals of Emergency Medicine. 2005 Sept; 46(3):237-42.
6 Ozturk D. “A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations.” World J Emerg Surg. 2013; 8:27.
7 Forsch, R. “Essentials of skin laceration repair.” American Family Physician.