Author Archives: David Lewis

Resident Clinical Pearl – Scalp Lacerations – “You Can Leave Your HAT On!”

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You can leave your “HAT” on: An approach to scalp lacerations and review of the hair apposition technique

Resident Clinical Pearl (RCP) – November 2018

Devon Webster – FMEM PGY1, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Quick case!

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 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

 

 

 

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):

  1. Choose 4-5 strands of hair in a bundle on either side of laceration
  2. Cross the strands
  3. Make a single twist to appose the wound edges
  4. Secure with a single drop of glue
  5. 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:

  • Rapid closure of wound edges
  • Non-circumferential wound closure avoid potential strangulation
  • No cross hatch marks
  • Less expensive

C. Wound Sutures

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.

 

Video

 

 

References:

 

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/

 

 Randy:

 

Joe:

 

 

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ECCU IP School 24th November – New Places Now Available!

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Are you finding it difficult to get your supervised scans for CPoCUS Core IP. We are here to help!

We have just been able to open up a few spaces on the ECCU IP School 24th November in Saint John, NB.

CPoCUS IP instructors will supervise up to 90 scans in this 1-day session.

Book Here Now

ECCU IP School – Application and Payment

Staff Physicians – $850

Residents – $550

 

 

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Trauma Reflections – October 2018

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Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 

Major points of interest:

 

A)  Intubated patients should not need restraints..

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.

 

B)   But what about this guy with the BP of low / really low?

Consider “vitamin K” – ketamine – can augment BP in patients who are not catecholamine depleted.

 

C)  Trauma patients you know will require consultants

When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.

Required consultants need to attend to critically injured in a timely fashion. Escalate to department head or chief of staff if there is unreasonable delay.

View the SJRHEM Trauma Page for list of definitions including Trauma Team, Activation Levels etc

 

E) Managing the pediatric airway – adrenalizing for all involved

Pediatric trauma is the pinnacle of a HALF (high acuity, low frequency) event. Team approach is key. Get out the Broselow tape.

Bradycardia with intubation attempts is not infrequent in youngest patients. Consider atropine as pre-med if  < 1 year of age or < 5 years of age and using succinylcholine.

 

F) MTP

Do not forget platelets and plasma if onto 4th unit of PRBCs – 4:1:1 ratio.

 

G)  Where is this patient being admitted?

Not to the hospitalist service, that is where!

Patients with significant injuries, but not needing immediate surgical intervention, should be admitted/observed in ICE x 24 hrs. Department head and/or chief of staff are available to assist if needed.

 

H)  Chest tube types and sizes

Pigtail catheters for traumatic pneumothorax are effective, less painful and are gaining favour as an alternative to traditional chest tubes. As for sizes, there is likely little benefit for 36F over 32 F catheters – probably time to retire these monsters from the chest tube cart.

I)     Why do bedside U/S if patient about to go to CT?

Chest scan might prompt chest tube placement prior to CT if pneumothorax is identified. Although identifying blood in the abdomen prior to CT may not change your management – it may prompt an earlier call to general surgery.

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Medical Student Clinical Pearl – Basic ECG Interpretation

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Bare Bones Basics of ECG Interpretation from a First Year Medical Student Perspective

Medical Student Clinical Pearl – October 2018

Victoria Kulesza – Med I Class of 2021, Dalhousie Medicine New Brunswick 

Reviewed and Edited by Dr. David Lewis

Physiology

Electrical Events and Corresponding Waves and Lines on a Standard ECG

Basic Interpretation

Common Arrhythmias

Summary

Suggested Resources

References

Physiology

Cardiac cells are electrically polarized in their resting state, with the inside holding a negative charge in comparison to the outside.1,3 Membrane pumps maintain this electrical polarity through the regulation of ions including potassium, sodium, chloride and calcium.1 Depolarization is the key electrical event of the heart that occurs spontaneously in some cells and is initiated by the arrival of an electrical impulse carrying positively charged ions in other cells.1 There are 3 key cells involved in the electrical and mechanical activities that occur within the heart:

 

The sequential depolarization of cells creates a wave of depolarization that transmits across the entire heart, representing a flow of electricity that can be detected by the electrodes placed on the surface of that patient’s body. The waveforms visible on the ECG represent the electrical activity of the myocardial cells, the cells making up the vast majority of the heart.1 At the end of the depolarization process, cardiac cells are repolarized through membrane pumps reversing the flow of ions. Both the depolarization and repolarization are represented as the wave forms on the ECG.1

Electrical Events and Corresponding Waves and Lines on a Standard ECG

P Wave

The heartbeat is initiated in the sinoatrial node located in the posterior wall of the right atrium.4 After the sinus node fires, the atrial myocardium is depolarized in a wave-like fashion causing the atrial contraction. This depolarization and contraction of the atrial myocardial cells results in the first P wave.1 The wave of depolarization does not immediately pass through to the ventricles, the atrioventricular node located at the floor of the right atrium, slows the conduction of the electrical impulse to allow the atria to fully complete their contraction. 1,4 The contraction of the atria forces blood from the atria through the atrio-ventricular valves, known as the tricuspid and mitral valves, into the ventricles.3

PR Interval

This interval is the time that is required for the electrical impulse to travel from the atria, through the AV node, bundle of His, bundle branches and Purkinje fibers to the point where the ventricular myocardium begins its depolarization.5 As blood flows through the AV valves the physiologic pause in electrical conduction is represented on the EKG as the flat line following the initial P wave. The ventricular conduction system is composed of 3 parts including the Bundle of His, Bundle Branches and the Terminal Purkinje Fibers.1 The ventricular depolarization is rapidly transmitted through the Bundle of His which emerges from the AV node and subsequently bifurcates into the left and right bundle branches which carry the impulse down the interventricular septum to their terminating fascicles in multiple Purkinje fibers.1,3 Once this current is delivered to the ventricular myocardium the depolarization causes ventricular contraction visible on the ECG as the QRS complex.1

PR Segment

A straight line between the end of the P wave and the start of the QRS complex reflects the time between the end of atrial depolarization and the start of ventricular depolarization.1

QRS Complex

The QRS complex consists of 3 individual waves in a normal conduction1,3:

  • Q Wave: first deflection downward
  • R Wave: first upward deflection
  • S Wave: first downward deflection subsequent to an upward deflection

A complete QRS complex represents ventricular depolarization as well as the initiation of ventricular contraction.1,3 The use of the term QRS Interval describes the duration of the QRS complex alone indicating the duration of ventricular depolarization specifically.1

ST Segment

A straight line between the end of the QRS complex and the beginning of the T wave known as the ST segment measures the time from the end of ventricular depolarization to the beginning of repolarization.1

T Wave

Following the depolarization of the myocardial cells, there is a short refractory period and subsequent recovery phase identified as the T wave on the ECG.1,3,5 This is phase of ventricular repolarization that begins after the QRS and is completed at the end of the T wave.3,5 Repolarization is a slower process than the depolarization which is illustrated by the broader nature of the T wave in comparison to the QRS.1,5

QT Interval

This interval includes the QRS complex, ST segment as well as the T wave which allows for the measurement of time between the beginning of ventricular depolarization to the end of ventricular repolarization.

 

Basic Interpretation

The most effective way to ensure clinically significant abnormalities are not missed on ECG is to develop a consistent order of analysis. One suggested order is as follows:

 

A. Determine Rate:

  1. Sinus Tachycardia = >100 BPM
  2. Sinus Bradycardia = <60 BPM
  3. Three Ways to Determine Rate:
    • Identify an R wave that falls on or near one of the heavy lines of the ECG strip, count the number of large squares between this first R wave and the beginning of the subsequent wave. Divide 300 by the number of large squares between the R waves to determine the number of cardiac cycles per minute. Counting the number of small squares between R waves and dividing 1500 by this number would identify with greater accuracy the heart rate.1
    • Identify the series of small pink indicators above the rhythm strip that identify 3 second intervals and count the number of cycles between two 3 second intervals – multiply this number by 10 to identify the number of beats per minute.1
    • In the event of an irregular heartbeat identify the number of QRS complexes and multiply this number by 6. Each started ECG paper reads at 25mm/s therefore 1 ECG represents 10 seconds of activity.2

Thaler 2015

 

B. Intervals:

Identify the length of the PR and QT Intervals as well as the width of the QRS complexes

Normal Interval Lengths5:

  1. PR = 0.12 – 0.20 sec
  2. QT = varies with overall heart rate
  3. QRS = 0.05 – 0.10 sec

 

 

 

 

 

 

 

C. Rhythm5:

  1. P waves present and normal?
  2. QRS complexes wide or narrow? General pattern – regular, regularly irregular or irregularly irregular?
    1. Wide = >0.12 sec
    2. Narrow = <0.12 sec
  3. Relationship between P waves and QRS complexes
  4. Overall rhythm regular or irregular?

 

D. Axis

  1. The ECG electrodes record the average direction of flow of electrical current within the heart.
  2. Lead I is the zero reference point, any axis lying below is deemed positive while those lying above are deemed negative.
  3. When the wave of depolarization begins, any lead that views this wave as moving towards it will record this as a positive deflection on the ECG paper.
  4. Assessment of P Wave Axis:
    • Atrial depolarization begins at the sinus node in the right atrium and follows a right to left and inferior direction. This depolarization of the right to left atria should demonstrate a positive deflection in leads aVL, I, II and aVF.
  5. Assessment of QRS Complex Axis:
    • As the wave of depolarization moves through the interventricular septum the current moves in a left to right direction. This wave may not be visible on the ECG but when apparent appears as a negative deflection in leads I, aVL (V5 and V6). As a result of the increased size of the left ventricle in comparison to the right, the remainder of the QRS complex vector of flow is directed leftward and is demonstrated as the positively deflected R wave in most left lateral and inferior leads. The aVR lead will record a deep negative deflection based on the direction of flow being away from this lead.

 

 

Common Arrhythmias1

1. Sinus Tachycardia

  • HR >100 bpm
  • Can be normal or pathologic, strenuous exercise can cause HR above 100.

 

2. Sinus Bradycardia

  • HR <60 bpm
  • Can be normal or pathologic, many well-conditioned athletes maintain a resting HR below 60.

 

3. Paroxysmal Supraventricular Tachycardia

  • HR 150-250 bpm
  • Narrow complex QRS
  • Very common, sudden onset, sudden termination.
  • Clinical Symptoms: palpitations, shortness of breath, dizziness. Possibly induced by alcohol, caffeine or extreme excitement.

 

4. Atrial Flutter

  • P waves 250-350 bpm
  • Atrial depolarization occurs so rapidly that discrete P waves are indiscernible.
  • Leads II and III demonstrate a prominent saw-tooth
  • AV node cannot handle the number of atrial impulses therefore there is an unequal number of P waves to QRS complexes – some electrical impulses from the sinus node bump into a refractory node and go no further, this is called AV Block. 2:1 block is most common while 3:1 and 4:1 are also frequently observed.
  • Clinical Symptoms: shortness of breath, angina type discomfort.

 

 

5. Atrial Fibrillation

  • AV Node may receive >500 impulses per minute
  • More common than atrial flutter, most commonly sustained arrhythmia.
  • No true P waves are discernible, AV node allows occasional impulses to pass through to the ventricles, creating an irregularly irregular ventricular rate often in the range of 120-180 bpm.
  • Clinical Symptoms: some patients experience no symptoms, others experience shortness of breath, chest pain, palpitations and dizziness.

 

6. Premature Ventricular Contractions

  • Most common ventricular arrhythmia.
  • Retrograde P wave or no P wave prior to the QRS.
  • Wide QRS of at least 0.12 seconds in majority of the leads often followed by a compensatory pause before the subsequent beat.
  • Often occur randomly and rarely require treatment unless an isolated PVC is noted in the setting of acute MI as it may trigger ventricular tachycardia or ventricular fibrillation.
  • When to worry:
    • Frequent PVCs
    • Consecutive runs, 3+ in a row
    • Multiform – demonstrating variation in the site of origin
    • Occurring on the T wave – “R-on-T” phenomenon
    • PVC in the setting of an acute MI

 

 

7. Ventricular Tachycardia

  • Rate 120-200 bpm
  • Wide complex QRS
  • A run of 3+ consecutive PVCs.
  • Prolonged ventricular tachycardia is an emergency requiring immediate treatment to prevent cardiac arrest.
  • May be uniform or polymorphic, uniform being more closely associated with healed infarctions and polymorphic waveforms more commonly associated with acute coronary events.

 

8. Ventricular Fibrillation

  • Spasmodic tracings or coarse ventricular fibrillation or fine ventricular fibrillation without any true QRS complexes.
  • Heart generates no cardiac output, CPR and defibrillation are required immediately.
  • Most common arrhythmia in adults who experience sudden death.
  • Common predisposing factors:
    • Myocardial ischemia/infarction
    • Heart failure
    • Electrolyte disturbances
    • Hypoxemia or hypercapnia
    • Hypotension or shock
    • Overdoses of stimulants especially when used in combination with others

 

 

Summary

 

 

 

 

Suggested Resources

Teaching Medicine – Rhythm Strip Interpretation Practice

ECG Guide Mobile Smartphone App

  • Available through itunes app store

The Only EKG Book You’ll Ever Need

  • PDF available online through Dalhousie Library

 

References

  1. Thaler, M. S. (2015). The Only EKG Book You’ll Ever Need (9th ed.). Lippincott, Williams & Wilkins.
  2. Andrade, J. (2013). ECG Guide [Mobile application software]. Retrieved from http://itunes.apple.com
  3. Dubin, D. (2000). Rapid interpretation of EKG’s: An interactive course (6th ed.). Tampa, Fla.: Cover Pub.
  4. McKinley, M. P., OLoughlin, V. D., Harris, R. T., & Pennefather-O’Brien, E. E. (2015). Human anatomy (4th ed.). New York, NY: McGraw-Hill Education.
  5. Khan, M. (2008). Rapid ECG interpretation (3rd ed., Contemporary cardiology (Totowa, N.J). Totowa, N.J.: Human Press.
  6. Thomas, V. (n.d.). Premature Ventricular Contractions Treatment Cape Town. Retrieved from https://cardiorhythm.co.za/premature-ventricular-contractions/
  7. https://inside.fammed.wisc.edu/medstudent/pcc/ecg/axis.html
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EM Reflections – October 2018

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Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 

 

Top tips from this month’s rounds:

 

Trauma – Secondary Survey

DNAR Considerations 

ED Neonatal Equipment

 

Trauma – Secondary Survey

The secondary survey is performed once the primary survey and resuscitation has been completed.

The secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are underway, and the normalization of vital functions has been demonstrated. When additional personnel are available, part of the secondary survey may be conducted while the other personnel attend to the primary survey. In this setting the conduction of the secondary survey should not interfere with the primary survey, which takes first priority. ATLS 9e

This means that on occasions trauma patients may be transferred to the OR or ICU before the secondary survey has been completed. The secondary survey is a thorough head to toe examination including where indicated adjunct investigations e.g limb radiographs. This assessment must be carefully performed and documented. It should not be rushed.

If there is not enough time to complete a thorough secondary survey (e.g patient transferred to OR during primary survey) then this should be communicated to the surgeon or other responsible physician (e.g ICU) and the documentation should reflect this.

We would recommend that all trauma patients admitted to the ICU undergo a repeat secondary survey assessment as part of the standard admission process. In some systems this is referred to as a Tertiary survey.

This systematic review reports a reduction missed injury rate when a tertiary survey is used as part of a trauma system.

Trauma.org article on tertiary survey

Download (PDF, 93KB)

 

DNAR Considerations 

The CMPA provides excellent guidance for clinicians considering Do Not Attempt Resuscitation orders. CMPA Website

CMPA – Key Concepts for End of Life Issues

  • The best interests of the patient are paramount.

  • The capable patient has the right to consent to or refuse medical treatment, including life-sustaining treatment.

  • Thoughtful and timely advance care planning, discussion, and documentation of a patient’s wishes and healthcare goals can help avoid misunderstandings.

  • Physicians should be familiar with any relevant laws and regulatory authority (College) policies concerning end-of-life care, and the withholding or withdrawing of life-sustaining treatment, and medical assistance in dying.

  • When considering placing a do-not-resuscitate order in the medical record, or acting upon a do-not-resuscitate order, consent from the patient or substitute decision-maker is advisable. It may also be helpful and appropriate to consult with physician colleagues and the patient’s family to determine support for the order.

  • Decisions about withholding or withdrawing life-sustaining treatment that is considered futile or not medically indicated should be discussed with the patient, or the substitute decision-maker on behalf of an incapable patient. When consensus is not achieved despite discussions with the substitute decision-maker, the family, and others such as ethics consultants, patient advocates, and spiritual advisors, it may be necessary to make an application to the court (or an administrative body) or seek intervention from the local public guardian’s office.

  • Physicians considering a request for medical assistance in dying should be familiar with the eligibility criteria set out in the Criminal Code, with applicable provincial legislation, and with applicable regulatory authority (College) guidelines.

  • Physicians should be familiar with the role of advance directives (including living wills).

  • End-of-life decisions should be carefully documented in the patient’s medical record.

Horizon Health, NB uses these accepted Canadian DNAR definitions:

 

 

ED Neonatal Equipment

Perinatal Services BC, Canada have published an excellent document – Standards for Neonatal Resuscitation

It includes this Appendix for suggested Radiant Warmer Equipment checklist:

 

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ED Rounds – Competency By Design

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ED Rounds – September 2018

Dr. Jo-Ann Talbot

 

 

Competency-based medical education (CBME) is an outcomes-based approach to the design, implementation, assessment, and evaluation of a medical education program using an organizing framework of competencies.

Competence by Design (CBD) is the Royal College’s version of CBME. It is a transformational change initiative designed to enhance CBME in residency training and specialty practice in Canada.

The first stage in residency is known as Transition to discipline. It emphasizes the orientation and assessment of new trainees. Foundations of discipline, the second stage, covers broad-based competencies that every trainee must acquire before moving on to the third stage, which is known as Core of discipline. The third stage covers more advanced, discipline-specific competencies. As part of CBD, the Royal College is also exploring moving the Royal College exam to the end of this stage.5 The fourth and final stage of residency education is known as Transition to practice. During this stage the trainee demonstrates readiness for autonomous practice

RCPSC 2016

 

Dr. Talbot’s Presentation

Competence by Design – Are You Ready?

Competency by Design Are You Ready? Dr. Jo-Ann Talbot – 2018

Click link above to view

Further Reading

CBD Cheatsheet

Download (PDF, 128KB)

Emergency Medicine – Entrustable Professional Activities 

Download (PDF, 71KB)

 

Entrustable Professional Activity Guide: Emergency Medicine

EPA-guide-emergency-medicine RCPSC 2018

Click link above to view

 

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EM Reflections – September 2018

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Thanks to Dr. Joanna Middleton for leading the discussions this month

Edited by Dr David Lewis 

 

 

 

Top tips from this month’s rounds:

 

Pediatric Head Injury

Clonazepam Toxicity

Pediatric(< 3 months)Fever

Wide Complex Tachycardia

 

Pediatric Head Injury

  • What are the criteria for CT Head?

In a recent Lancet article (2017),  PECARN, CATCH and CHALICE were compared.

The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7–100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4–100·0; 97/98)

  • How do I use PECARN?

 

A useful review by EM Cases can be accessed here. In an update to this review they have noted recent new evidence that isolated vomiting without any other positive rule predictors may warrant observation only:

Update 2018:  A secondary analysis of the Australasian Paediatric Head Injury Rule Study demonstrated head injury with isolated vomiting (i.e. vomiting without any of clinical decision rule predictors) was uncommonly associated with TBI on CT, or the presence of clinically important TBI.  This study suggests a strategy of observation without head CT may be appropriate management.  Abstract

Vomiting alone should not instigate CT.  Risk goes up with any other Head Injury symptoms (Headache etc). These children should be observed until they are able to tolerate oral intake and the treating clinician feels comfortable that the patient is stable without additional symptoms of head injury.

This article discusses linear skull fractures. It reminds us to always consider Non-Accidental Injury in all cases of pediatric head injury, especially in the pre-mobile age group.

PoCUS may have a role to play in fine tuning risk stratification and a recent study (2018) has further evaluated diagnostic accuracy:

We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures.

  • If I don’t perform a CT, then how long should a child with a head injury be observed?

There is no definite evidence-based answer to this question. However this study suggest that 6 hrs is probably safe.

Key Points

  1. Always use a clinical decision rule to determine whether a child with head injury requires CT, Observation or can be safely discharged
  2. When using a decision rule utilize a ‘shared decision-making’ philosophy – i.e involve the parents/carers
  3. A period of observation can reduce the number of CTs performed.
  4. If observation is recommended, then allow 6hrs.
  5. Always consider non-accidental injury during your assessment of pediatric head injury.

 

 

 

Clonazepam Toxicity

  • Overdosage of clonazepam may produce somnolence, confusion, ataxia, diminished reflexes, or coma
  • Clonazepam is extensively metabolized in the liver to several metabolites
  • Clonazepam is rapidly and well absorbed from the GI tract
  • Peak blood concentrations are reached in 2 -4 hours
  • Elimination half-life … 18.7 to 39 hr

Full ToxNet entry

Treatment

Treatment is entirely supportive with IV access and fluids and maintenance of the airway and ventilation if required

Oral activated charcoal is of little value in pure benzodiazepine poisoning. It may be given to patients who have recently ingested benzodiazepines with other drugs that may benefit from decontamination

Flumazenil is rarely indicated except for iatrogenic oversedation or respiratory depression. In addition, flumazenil may cause withdrawal states and result in seizures, adrenergic stimulation, or autonomic instability in patients chronically taking benzodiazepine, or in those with ventricular dysrhythmias and seizures who are concomitantly using cocaine or tricyclic antidepressants.

Dispostion

All patients with intentional ingestion or significant ataxia, drowsiness, or respiratory depression should be observed.

Patients with severe symptoms (ie, coma, respiratory failure, or hypotension unresponsive to IV fluids) should be consulted to ICU.

Given the prolonged half-life patients strongly consider admitting patients who present with significant drowsiness or are known to have taken a large overdose.

Patients with a significant sedative drug overdose should be advised not to drive until potential interference with psychomotor performance has resolved. For significant benzodiazepine overdose, this is at least 24 hours after discharge.

Key Points

  1. Clonazepam overdose is treated with supportive measures.
  2. Clonazepam has a very long half-life. For significant drowsiness, admission should be considered to avoid potentially very long ED observation periods.

 

Pediatric (< 3 months) Fever

The management of fever in infants less than 1 month is relatively straightforward. Guidelines are generally consistent (Merck,

  • Full blood lab work-up (CBC, CRP, Cultures)
  • Urine culture
  • CXR
  • RSV, Flu nasal swabs
  • LP
  • Empiric IV Antibiotics (e.g Ampicillin 50mg/kg and Cefotaxime 50mg/kg)
  • Consult Pediatrics and Admit

Emergency Medicine Cases article can be viewed here – Episode 48 – Pediatric Fever Without A Source

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For infants older than 30 days and younger than 3 months the guidelines are variable:

ALiEM: Paucis Verbis: Fever without a source (29 days-3 months old)

NICE Guidelines (UK):  Fever in under 5s: assessment and initial management

MD Calc – Step-by-Step Approach Calculator 

Suggested Emergency Department Approach

  • If Sick-Appearing treat as <3 months (see above)
  • If Well- Appearing (age normal vitals):
    • Full blood lab work-up (CBC, CRP, Cultures)
    • Urine culture
    • Consider CXR
    • Consult Pediatrics (Depending on results of above will either need admission +/- antibiotics or 24hr follow-up)

Yukon Guidelines

 

Wide Complex Tachycardia

Differential Diagnosis (note: repetition is deliberate!)

  • Ventricular Tachycardia
  • Ventricular Tachycardia
  • Ventricular Tachycardia
  • SVT with aberrant conduction – lots of causes
    • Pre-existing/rate-related BBB
    • Ventricular pre-excitation (AVNRT/AVRT)
    • Dysfunction of IV conduction system (toxic, metabolic, infectious, drug related etc) – hyper K, sodium channel blockers

No ‘rule’ is specific enough to correctly identify, so treat like VT

Treatment 

  • Unstable?
    • ANY sign of end-organ dysfunction – hypotension, altered LOC, CHF/SOB, CP, diaphoretic etc
    • SHOCK
  • Stable?
    • Shock or medical management
    • Amiodarone vs procainamide, ?adenosine (see below)

Adenosine/vagal – consider in patients where uncertain of diagnosis, unlikely to be VT, no hx of CAD, young, hx of SVT

Adenosine with WPW – ContraIndicated – may induce AV block and accelerate conduction of atrial fibrillatory impulses through the bypass tract, which can lead to very rapid ventricular arrhythmias that degenerate to VF.

“Avoidance of IV beta blockers, calcium channel blockers and digoxin due to the potential for hemodynamic deterioration in patients with stable WCT, potentially resulting in hypotension, VF and cardiac arrest”. (Uptodate)

Verapamil and diltiazem are calcium channel blockers (CCBs) that should be avoided in WCTs, as cardiac arrests from hemodynamic collapse have been reported following their administration.  Not only do these agents cause negative inotropy and at times profound vasodilation, but they may also allow WCTs to degenerate into VFIB

Caveat – RRWCT (Regular Really Wide Complex Tachy)

  • One situation where you may not want to assume VT….
  • What question should you ask?
    • What is the K,
    • what is the OD?
  • Really, really wide complex tachycardia – >200 mseconds – consider tox or metabolic – try bicarb or calcium – if it narrows – not VTach.
  • Avoid procainamide and amiodarone in these patients.

 

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Trauma Reflections – August 2018

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Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month

 

 

Major points of interest:

 

A) Blood is important stuff…so keep track of it.

Recent ATLS guidelines are suggesting switching to blood for resuscitation after one litre crystalloid bolus, not two. We will be using blood more often and it is important to keep track of amount ordered and infused. Give clear orders, document, and send any unused units back to transfusion medicine.

 

B) Analgesia/anti-emetics prior to leaving for diagnostic imaging

Moving on/off DI tables can increase pain or provoke nausea in some patients.

 

C) Who put that thing there?

If you decide to put something into your patient, such as a chest tube or ET tube, then write a procedure note, including details of placement confirmation.

 

D) Trauma patients you know will require consultants

When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.

In pediatric traumas that cannot be managed locally use the NB Trauma TCP to coordinate transfers to IWK.

 

E) Yo-yoing to DI for yet another film

“Pan-scanning” a younger patient can be a difficult decision, but if there is a high energy MOI and indication for spine imaging, CT scan is the superior imaging choice.

 

F) Pregnancy tests for everybody

Do not forget this in ‘older’ pediatric age group.

 

G) “Moving all limbs”..

..is NOT an acceptable documentation of exam findings in a patient with suspected neurologic injury. Thorough exam to detect any deficits is needed for neurologic baseline and for comparison later. Dermatome level of sensory dysfunction, key muscle group strength (0-5 scale) and anal sphincter tone should all be recorded, with time of exam.

 

H) Severe traumatic brain injury

Remember the CRASH 3 study – adult with TBI < 3hrs from time of injury.

 

I) Motorcycle + cocaine + EtOH + no helmet…

Equals an agitated head injured patient very difficult to sedate after intubation. Consider fentanyl infusion in addition to sedation infusion.

 

 

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Fall ECCU Conference Workshop – 28th September

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We still have availability for delegates wanting to attend the Fall ECCU Conference Workshop on the 28th September at the beautiful Algonquin Resort in St. Andrews, New Brunswick.

  • International PoCUS experts from South Africa, USA and Canada
  • PoCUS hot topics and updates
    • PoCUS in Rural Health
    • Why aren’t you doing THIS with PoCUS?
    • How to be a leader in PoCUS
  • Top PoCUS research
  • IP2 Diagnostic stream lectures
  • Hands-on scanning workshops

  • Choose your own workshop
    • Pediatrics, Cardiac, Lung, IVC, DVT, Gallbladder, DVT, Aorta, FAST, Obstetric
  • CPoCUS approved
  • CCFP CME approved
  • Bring the family and stay for the weekend
    • Top golf resort, whale watching, explore the islands

 

Click Here for More information and Booking

 

 

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Resident Clinical Pearl – PoCUS Triage Shoulder Dislocation

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Resident Clinical Pearl – POCUS in Shoulder Dislocation

Luke Richardson, PGY 3 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

A 24 year old male rugby player presents to the emergency department with left sided shoulder pain.  He reports being hit in the middle of the game followed by a pop to his shoulder.  Since that time he has had ongoing pain and limited movement.  His vitals are normal but he appears uncomfortable.  He shows no signs of neurological or vascular injury.  History and physical exam is otherwise benign.

 

Dislocated shoulder is suspected, but is there a way to quickly diagnose prior to x-ray and therefore expedite administration of pre-procedural analgesia and preparation of procedural team and room?

 

POCUS: Shoulder Background

The shoulder is a ball-in-socket joint with a large range of motion and has a high risk of dislocation due to its shallow joint depth and limited tendinous support inferiorly.   Most commonly, the shoulder will dislocate with the humeral head anterior to the glenohumeral rim due to an superiorly placed force upon the humeral head.  Posterior dislocations are less common and commonly due to higher mechanism of injuries such as seizure or electrical shock.

 

Diagnosis of shoulder dislocation is commonly made by x-ray but this method has its downsides including time to diagnosis and increased radiation exposure.  An important consideration is the use of POCUS during shoulder reduction.  This technique allows for real time confirmation and potentially avoids the need for repeat sedation if failed reduction discovered by a trip to the x-ray department.  A recent prospective observational study of 73 patients in the emergency department revealed an accuracy of 100% sensitivity and specificity for shoulder dislocation and relocation (reference 1).   Finally, considering there is increased risk of neuro-vascular complications with time to relocation; a decrease in duration to diagnosis could potentially improve patient care.

 

 

POCUS: Shoulder Technique

Get patient to sit up to allow availability to the posterior portion of the patient shoulder.

Support the patients elbow while positioning the shoulder in adduction and internal rotation.

Using the curvilinear probe, landmark just inferior to the scapular spine and follow it laterally until you find the glenoid (G) and humeral head (HH) (Shol1).

Shol 1

You should find the humeral head (HH) as a circular structure lateral to the glenoid fossa (G) if in joint. Note the Glenoid labrum (L).

To confirm, you can internally and externally rotate the arm and visualize the humeral head freely moving within the glenoid (Shol2/Shol4) (reference 2). Note the overlying deltoid (most superficial) and the infraspinatus tendon that becomes more apparent during internal rotation.

Shol2

Shol4

If the shoulder is anteriorly dislocated you will see the humeral head displaced inferiorly (Shol5/Shol6) (reference 2,3)

If the shoulder is posteriorly dislocated you will see the humeral head more superficial than expected (Shol5) (reference 2,3)

 

Shol5

Shol6

 

Conclusion:

POCUS is an easily available and non-invasive tool in the emergency department.  It can be used in cases such as this to improve patient flow, decrease time to diagnosis, and confirm reduction.

 

Reference:

  1. Abbasi, S., Molaie, H., Hafezimoghadam, P., Amin Zare, M., Abbasi, M., Rezai, M., Farsi, D. Diagnostic accuracy of ultrasonogrpahic examination in the management of shoulder dislocation in the emergency department. Annals of Emergency Medicine. Volume 62:2. August, 2013, pg. 170-175.
  2. Tin, J., Simmons, C., Ditkowsky, J., Alerhand, S., Singh,M., US Probe: ultrasound for shoulder dislocation and reduction. EMDocs http://www.emdocs.net/us-probe-ultrasound-for-shoulder-dislocation-and-reduction/ January 18, 2018.
  3. Rich, C., Wu, S., Ye, T., Liebmann, O. Pocus: shoulder dislocation. Brown Emergency Medicine. http://brownemblog.com/blog-1/2016/11/30/pocus-shoulder-dislocation. November 30th, 2016.
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Fall ECCU Fest 2018 – PoCUS Conference Workshop and ECCU2 Course

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September 27th – 28th 2018

The Algonquin Resort in St. Andrews by-the-Sea, New Brunswick, Canada

Atlantic Canada’s top PoCUS event

UPDATE

 

Now open for applications/booking – Only a few places still available

 

The ECCU Conference is being held in conjunction with the ECCU2 Advanced Applications Course in order to provide those attending the course and other delegates with an opportunity to access an update in the hottest clinical PoCUS topics. The focus will be on presenting the best emerging evidence, strategies for developing a local PoCUS program and developing competencies.

Includes:

  • International PoCUS experts
  • Clinical PoCUS hot topics and updates
  • Top PoCUS research
  • IP2 Diagnostic stream lectures

Conference delegates will have access to the Diagnostic stream lectures of the ECCU2 Advanced Applications Course, which will include an Gallbladder, Renal, DVT and Ocular

Invited Faculty – 2018

Dr. Hein Lamprecht – South Africa – (ECCU Fest 2018) – PoCUS Educator Extraordinaire – IFEM – WinFocus

Dr. Peter Croft – USA – (ECCU Fest 2018) – New England PoCUS disrupter –past MGH PoCUS Fellow

Dr. David Mackenzie – USA – (ECCU Fest 2018) – Canadian New Englander, PoCUS innovator – past MGH PoCUS Fellow

 

Also our top Dalhousie Faculty of PoCUS Experts

 

 

Open for applications and booking: More Information Here

 

There are only 2 places left on the 2 day Advanced Apps ECCU 2 course, however we still have good availability for the 1 day conference workshop

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