Panel Presentations and Discussion Around Key PoCUS Papers
| Dr. Paul Atkinson |
| Dr. Michael Woo |
| Dr. Kirk Magee |
| Dr. Chau Pham |
| Dr. Ryan Henneberry |
Imagine the reality of PoCUS Artificial Intelligence…..
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/
Crowded House – Don’t Dream It’s Over
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/
Thanks to Dr. Matt Greer, Dr. Joanna Middleton, Traci Surette and Jan Murray or putting on such a well received day. The feedback was great!
More of these to come soon!
Vlad Kovalik
MD Candidate, 2019
Dalhousie University Faculty of Medicine
Reviewed and Edited by Dr. David Lewis
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.
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 *
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
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.
Lucy Eum – Med I Class of 2021, Dalhousie Medicine New Brunswick
Reviewed and Edited by Dr. David Lewis
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.
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
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
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
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
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
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.
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.
Edited by Dr David Lewis
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.
https://library.med.utah.edu/neurologicexam/cases/html_case03/feedback/FB_dysarthria.html
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.
The test used to reveal ocular leaks from the cornea, sclera or conjunctiva following injury or surgery and sometimes disease is called Seidel test.
http://eyewiki.aao.org/Seidel_Test
Dr. Lohoar presents rounds on the topic of ‘Electrical Injuries’ including electrocution, lightening strike and Taser injuries.
X2 Darts have a double barb, X26 Darts come in extra long ‘winter coat’ and standard ‘summer’ varieties.
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.
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.
If emergent reversal of anti-coagulation from warfarin is needed, vitamin K (5-10mg) should be given IV (not PO), along with PCC.
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.
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.
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”.
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).
Chest tube sizes 36 F and 345F are now no longer being stocked on chest tube cart.
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.
Dr. Luke Taylor, FMEM PGY3 – Dalhousie University, Saint John NB
Reviewed by Dr. David Lewis
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.
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
PE – Tachycardia, RV strain, T-wave inversion V1-V3, RBBB morphology, S1Q3T3
ABCDEFGHII
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
References
This post was copyedited by Dr. Mandy Peach
Devon Webster – FMEM PGY1, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. David Lewis
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?
The scalp is divided into 5 layers, which can conveniently be recalled using the mnemonic, SCALP:
Ref 1
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 ZONE when 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
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.
Ref 2
(A) Scalp laceration that extends through the aponeurosis
(B) CT showing an associated skull fracture
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)
Cautions with HAT: avoid getting glue into the wound as it may result in wide scarring with a bald spot (Ref 3)
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)
1 Hunt, W. “The Scalp.” Teachmeanatomy.info. Last updated Oct 24, 2018. Accessed Nov 28, 2018. URL: https://teachmeanatomy.info/head/areas/scalp/
2 Dickinson, E. Uptodate. Accessed Nov 28, 2018 URL: https://www.uptodate.com/contents/image?imageKey=EM%2F87633&topicKey=EM%2F16696&source=see_link
3 Hollander, J. “Assessment and management of scalp lacerations.” Uptodate. Updated Feb 23, 2018. Accessed Nov 28, 2018. URL: https://www.uptodate.com/contents/assessment-and-management-of-scalp-lacerations
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.
8 Fraser, J. “Allergy to bacitracin.” Dermnet NZ. September 2015. Accessed on Nov 28, 2018 URL: https://www.dermnetnz.org/topics/allergy-to-bacitracin/