Author Archives: David Lewis

SJRHEM Journal Club – March 2018

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DEM Journal Club Report

 

  1. Host/Presenter/Date:

    Dr. Talbot /Dr. Chandra/ March

  2. Title of paper/citation:

Sergey Motov, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: an RCT. Ann Emerg Med. 2017; 70:177-84.

  1. Research question/PICOD

Question: Does increasing the dose of intravenous Ketorolac improve analgesia in emergency department patients with a variety of pain syndromes?

Population: 240 patients, 80 allocated to each group

Adult patients (18-65) who presented to the emergency department with acute (less than 30 d) moderate to severe (intensity of 5 or greater on a standard 0-10 pain scale) flank, abdominal, musculoskeletal, or headache pain, who would routinely be treated with ketorolac by the attending emergency physician.

(Exclusion criteria: Older than 65 yrs, pregnancy or breastfeeding, active PUD, acute GI hemorrhage, history of renal or hepatic disease, allergy to NSAIDs, unstable vitals systolic BP <90 or > 180 mmHg or HR < 50 or > 150, and patients that had already received analgesic.

Intervention (1): Ketorolac 10 mg IV  (given over 1-2 minutes)

Intervention (2): Ketorolac 15 mg IV (given over 1-2 minutes)

Intervention (3):  Ketorolac 30 mg IV (given over 1-2 minutes)

Patients who still desired pain medications after 30 minutes were offered Morphine 0.1 mg/kg IV as a rescue analgesic.

Outcome:  Primary: Reduction in the numeric pain scale score at 30 minutes from medication administration

Secondary: Rates and percentage of subjects experiencing adverse events or requiring rescue analgesia.

Design: Randomized control trial

  1. Results

Ketorolac dose Pain Score

Initial

 Pain Score

30 min

 Difference
10 mg 7.73 5.13 2.6
15 mg 7.54 5.05 2.5
30 mg 7.8 4.84 3.0

 

Patients in all dosing regimens had clinically significant improvement in their pain scores after 30 min. The reduction in pain persisted through to 120 minutes.

There was no difference in the rate of rescue morphine use by group over time.

There was no difference in the common adverse effects (dizziness 18% vs 20% vs 15%, nausea 11% vs 14% vs 10%, headache 10% vs 2.5% vs 3.8%, itching 0% vs 1.3% vs 1.3%, or flushing 0% vs 1.3% vs 0%).

Other more serious side effects were not documented (gastrointestinal bleeding, renal impairment, changes in bleeding times). There are other studies that suggest that some of these adverse effects are dose related and therefore lower doses would be expected to reduce these complications.

 

 

  1. Authors conclusions

Ketorolac had similar analgesic efficacy profiles at doses of 10 mg, 15 mg and 30 mg IV for short term treatment of acute moderate to severe pain in the Emergency Department.  The results of the study provide a basis for changes in practice patterns and guidelines in the Emergency Department supporting the use of the 10 mg IV ketorolac dose.

 

  1. Discussion at Journal Club

    1. Strengths
      1. Randomized control blinded design
      2. Excellent data collection for primary outcome (99%)
  • Groups were treated the same
  1. Weakness
    1. Single center
    2. Although randomized, the patients were also only recruited between 8 am and 8 pm Monday to Friday as a convenience sample. This could lead to selection bias.
  • Although the patient, nurse, research coordinator, research fellow and the physicians were blinded to the group allocation, the pharmacist, research manager and the statistician were aware of patient allocation.

 

  1. Bottom line/suggested change to practice/actions

 

Patients presenting to the emergency department with moderate to severe pain receiving a single dose of intravenous Ketorolac had a significant reduction in pain with no difference between the dosing regimens of 10mg, 15 mg and 30 mg IV.

We recommend a change to our renal colic protocol and our ED Assessment order set to administer Ketorolac 10 mg IV instead of 30 mg IV of the treatment of a variety of conditions with moderate to severe pain. Unfortunately, the Ketorolac used in the emergency department comes in a 30 mg/ml vial. It is more efficient to draw up the full dose for each individual patient than be taking 1/3 of a ml out and possibly throwing the remainder out. Recommend asking Emergency Department pharmacist to determine if other solution strengths are available. Ketorolac could be a narcotic sparing analgesic, where in the opinion of the attending physician, appropriate patients can be given ketorolac and then reassessed at 30 minutes and rescue mediation given as required.

 

 

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EM Reflections – March 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:

Abdominal Aortic Aneurysm – Size matters, but it isn’t everything

CME QUIZ

 

 

Abdominal Aortic Aneurysm – Which patients require urgent consult / transfer ?

AAA is a disease of older age. The prevalence of AAA among men aged 65 to 80 is 4 to 6 times higher than in women of the same age. The Canadian Task Force on Preventative Healthcare have recently (2017) made the following recommendations on screening:

Recommendation 1: We recommend one-time screening with ultrasound for AAA for men aged 65 to 80. (Weak recommendation; moderate quality of evidence)

Recommendation 2: We recommend not screening men older than 80 years of age for AAA. (Weak recommendation; low quality of evidence)

Recommendation 3: We recommend not screening women for AAA. (Strong recommendation; very low quality of evidence)

 

Emergency Physicians are trained to recognize the signs and symptoms of ruptured AAA (hypotension, tachycardia, pulsatile abdominal mass, back pain) and are always on the lookout for those curveball presentations e.g renal colic mimic, syncope, sciatica etc.

With the organization of centralized vascular services predominating in the majority of developed national health systems, patients with ruptured AAAs are now being transferred for specialist care. Recent evidence from the UK suggests that this practice is safe with no observed increased mortality or length of stay. and other studies have shown a benefit, with reduced mortality post service-centralization.

While there maybe benefits of centralization for patients, vascular surgeons and health economies, the initial management of the patient with AAA disease can be increasingly challenging for the Emergency Physician, especially if they are located in a peripheral hospital.

Let us consider a few scenarios:

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with severe back pain and hypotension. Point of Care Ultrasound (PoCUS) confirms the diagnosis of a 7.5cm AAA.

This scenario is relatively straightforward. The patient is judiciously resuscitated (avoiding aggressive fluid infusion), and transferred, after discussion with on-call vascular surgery, as quickly as possible directly to the receiving hospital’s vascular OR.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They are known to have a 3.7cm AAA (last surveillance scan 6 months ago). PoCUS confirms the presence of an AAA measuring approx. 3.7cm. Urinalysis is negative.

This scenario is also relatively straightforward. While the cause of the flank pain has not been determined, the risk of AAA rupture is highly improbable. For men with an AAA of 4.0 cm or smaller, it takes more than 3.5 years to have a risk of rupture greater than 1%. Given the stable vital signs, low pain score and lack of significant change in AAA size, this patient can be safely worked-up initially at the peripheral hospital pending transfer for abdominal CT if diagnosis remains unclear or symptoms change.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They have no past medical history. PoCUS confirms the presence of a new 4.7cm AAA.  

This scenario starts to become more challenging. Is the AAA leaking? Is the AAA rapidly expanding? Has PoCUS accurately measured the AAA size, Is the AAA causing the symptoms or is there another diagnosis? While this AAA is still below the elective repair size (5.5cm), the rate of growth is not know (and this is important), 4.7cm AAAs do occasionally rupture and rapidly expanding AAA’s can cause pain (the phenomena is more common in inflammatory and mycotic aetiologies). In this scenario the safest approach would be to organize transfer for an urgent CT and to arrange for Vascular Surgey consult immediately thereafter.

 

 

Salmonella aortitis may appear after a febrile gastroenteritis. The common location of primary aortitis and aneurysm formation is at the posterior wall of the suprarenal or supraceliac aorta – . 2010; 3(1): 7–15.

 

Aortitis is the all-encompassing term ascribed to inflammation of the aorta. The most common causes of aortitis are the large-vessel vasculitides including GCA and Takayasu arteritis. The majority of cases of aortitis are non-infectious, however an infectious cause must always be considered, as treatment for infectious and non-infectious aortitis is significantly different.

This article provides a detailed summary of the diagnosis and management of Aortitis

 

CME QUIZ

EM Reflections - March 2018 - CME Quiz

EM Reflections – March 2018 – CME Quiz

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CPoCUS Independent Practitioner Certification Workshop

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 CPoCUS Independent Practitioner Certification Workshop

Halifax, Nova Scotia

June 22-24, 2018

This intensive workshop will give participants the opportunity to obtain all of the required observed scans PLUS complete the three-part examination series towards CORE Independent Practitioner certification with the Canadian Point of Care Ultrasound Society (formerly the Canadian Emergency Ultrasound Society). This includes the addition of basic lung (hemothorax and pneumothorax) certification. There will be many instructors, ultrasound machines and many models available while you are here.

A CPoCUS approved introductory ultrasound course is strongly recommended prior to taking this workshop but is not required.

Cost for this workshop: 

$4600 + GST (Space is limited so register early)

Eligible for 25 Royal College Section 3 OR 60 CCFP Cert+ credits.

Registration fees are refundable (minus a $300 processing fee) up to one month prior to course dates. After this time, full course payments are non-refundable.

The course will take place at the Best Western Plus in Dartmouth.

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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

 

Now open for applications/booking

 

 

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. Darryl Wood – UK/South Africa – (ECCU Fest 2018) – PoCUS bushcraft on the frontline

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

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EM Reflections – February 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:

Pleuritic Chest Pain – Don’t forget the Abdomen

Headache – Not always Migraine

Epistaxis – Posterior Bleed

CME QUIZ

 

Pleuritic Chest Pain – Don’t forget the Abdomen

The commonest causes of pleuritic chest pain (pleurisy) presenting to the ED include:

  • Pulmonary embolus
  • Pneumonia
  • Pericarditis
  • Myocardial infarct
  • Pneumothorax

Once these have been ruled out consider the following differential diagnosis:

ref: American Family Physician (May 2007)

 

Another differential to consider is:

Perforated peptic ulcer

This can result in localized sub-diaphragmatic peritonitis that can result in pleuritic chest pain

 

Tips:

  • If a CT Chest has been performed – look for free air under the diaphragm
  • Always document an abdominal exam when assessing a patient with pleuritic chest pain
  • Although radiologists are highly skilled, like any physician, they are not infallible. Conservative estimates suggest an error rate of 4%. See this excellent article: The Epidemiology of Error in Radiology and Strategies for Error Reduction
  • Wherever possible physicians should always review the images from CT and X-Ray prior to reading the formal radiology report.

Arrows depicting free air on erect CXR – note the double stomach bubble sign on the left

Free air seen on lower slice of CT Chest. Easily mistaken for bowel

 

 

Headache – Not always migraine

The commonest cause of headache presenting to the ED is migraine

The features of migraine headache are well documented in this article – The diagnosis and treatment of chronic migraine

 

The differential diagnosis for patients presenting with headache is large. This excellent website (https://ddxof.com/) provides algorithms to help consider the differential diagnosis in the cardinal EM presentations.

From: DDxof.com

 

Another differential to consider is:

Anemia

Sub-acute onset anemia secondary to chronic blood loss e.g menorrhagia, chronic GI bleed, etc can present with fatigue, visual disturbance and headache.

Tips:

  • Patients who present to ED with a new headache (no previous hx of primary headache syndrome or change in symptoms) should have baseline investigations including CBC and Glucose.
  • Always review the paramedic and triage notes for supplementary information and the presence of additional symptoms that may broaden or narrow the differential.
  • Patient ethnicity and skin colour may mask the presence of anemia.

 

 

 

 

Epistaxis – Posterior Bleed

Posterior epistaxis is a difficult condition to manage and is associated with a number of acute and serious complications. In this study, 3.7% required intubation.

The #FOAM Blog post provides an excellent outline to the management of posterior epistaxis – EMDocs.net

The Emergency Department Management of Posterior Epistaxis

 

Posterior Nasal Packing – video

 

 

Tips:

  • All cases of major bleeding, including epistaxis should be initially managed in the highest acuity areas of the ED. Patients can then be rapidly stepped down and relocated to lower acuity areas if determined to be lower risk after initial assessment.
  • Consider using a suction device to aid intubation in cases of massive obscuring oro/naso-pharynx haemorrhage.

PulmCrit: Large-bore suction for intubation: strategies & devices

 

 

 

CME QUIZ

EM Reflections - Feb 18 - CME Quiz

EM Reflections – Nov 17 – CME Quiz

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ED Rounds – Sexual Assault and the SJRH SANE Program

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Sexually Assault and the SJRH SANE Program

ED Rounds Presentation by Dr. Robin Clouston and Maureen Hanlon RN, SANE Co-ordinator

The Sexually Assaulted Patient – Evaluation & Management in the Emergency Department

Dr. Robin Clouston

Download (PPTX, 479KB)

 

The Saint John SANE Program

Maureen Hanlon RN, SANE Co-ordinator

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New – Dal SJRHEM PoCUS Fellowship/Elective

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The Dalhousie University (DU) Emergency Point of Care Ultrasound Elective and Fellowship Program at Saint John Regional Hospital (SJRH) with an optional up to 1 month placement in Pediatric PoCUS at the IWK Health Centre Pediatric Emergency Department

 

There are four primary components to the mini-fellowship and fellowship programs:

 

  1. Clinical: optimizing image acquisition and interpretation skills for both core and advanced emergency and point of care ultrasound applications
  2. Education: developing lecturing and teaching skills by developing an emergency ultrasound lecture portfolio and contributing to the program’s educational mission. Acquiring expertise at bedside ultrasound teaching and assessment.
  3. Administration: understanding the critical components required to run an emergency ultrasound program, set up and deliver educational events/courses and how to best utilize information technologies for image archiving, database management, and quality assurance.
  4. Research: understanding the state of emergency ultrasound research by participating in ultrasound journal club activities and developing an independent research project from its inception to publication.

 

For more information click here

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EM Reflections – January 2018

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Thanks to Dr Joanna Middleton for leading the discussion this month and providing these tips and references.

Edited by Dr David Lewis 

 

  1. Occult Fractures of the Upper Limb

  2. Door to Needle/Balloon Times

  3. Mycotic Aneurysms

  4. CME Quiz

Occult Fractures of the Upper Limb

In patients (particularly the elderly)who present with upper limb pain following a fall or other trauma, be careful not to miss an occult fracture. Localization may be impaired by dementia, acute confusion or other soft tissue injuries. Commonly missed fractures of the upper limb include:

  • Clavicle fracture
  • Supracondylar fracture
  • Radial Head/Neck fracture
  • Buckle fractures of the radius/ulna
  • Scaphoid fracture
  • Carpal dislocation
  • Any impacted fracture

Impacted fractures of the humeral neck may still allow some shoulder joint movement. Pain can be referred to the elbow (just as some hip injuries have pain referred to the knee).

When a fracture is strongly suspected ensure that the entire bone is included in the radiograph. If localization is impaired consider obtaining radiographs of the entire limb, starting with the most symptomatic area. Also follow the old mantra – “include the joint above and below” when ordering radiographs for suspected fracture.

Commonly missed fractures in the ED

Misses and Errors in Upper Limb Trauma Radiographs

 

Strategies to reduce door to ballon time

Delays in door to balloon time for the treatment of STEMI have been shown to increase mortality.

 

 

JACC 2006 Click on here for full text

 

BMJ 2009 – Click here for full text

 

This evidence has led to an international effort to establish strategies that can reduce door to balloon times

This rural program in the USA published their strategy for reducing door to ballon times below 90mins over a 4 year period. https://www.sciencedirect.com/science/article/pii/S0735109710043810. Their strategies included the following:

2005
• Community hospital physicians visited by interventional cardiologist with recommendations to:

∘ Perform ECG within 10 min of arrival for chest pain patients

∘ Communicate with PCI center physicians via dedicated STEMI hotline

∘ Treat and triage patients without consulting with primary physicians

∘ Give aspirin 325 mg chewed, metoprolol 5 mg IV × 3 when not contraindicated, heparin 70 U/kg bolus without infusion, sublingual nitroglycerin or optional topical nitropaste without routine intravenous infusion, and clopidogrel 600 mg PO

∘ Eliminate intravenous infusions of heparin and nitroglycerin.

2006
• Nurse coordinator hired to oversee program and communicate with emergency department personnel at all referring hospitals.

• Recommendations for medications listed above were formally endorsed for all STEMI patients.

• Formal next-day feedback provided to referring hospitals, including diagnostic and treatment intervals and patient outcomes.

• Quarterly “report cards” issued to each referring hospital emergency department.

2007
• PCI hospital emergency physicians directly activated the interventional team (instead of discussing it first with the interventional cardiologist on call).

• A group page was implemented for simultaneous notification of all members of the interventional team and catheterization laboratory staff of an incoming STEMI patient.
ECG = electrocardiogram; IV = intravenous; PCI = percutaneous coronary intervention; PO = by mouth; STEMI = ST-segment elevation myocardial infarction.

 

However recent commentaries have highlighted the pitfall of this metric

 

The Challenges and Pitfalls of Door-to-Balloon Time as a Performance Metric

https://www.medscape.com/viewarticle/537538

 

and further evidence has shown no improvement in mortality despite reducing door to balloon times. However, it should be noted that these centres were already achieving < 90 min.

http://www.nejm.org/doi/full/10.1056/NEJMoa1208200

This may be a result of multiple confounding factors:

total ischemic time may be a more important clinical variable than door-to-balloon time

it has been suggested that the association between door-to-balloon time and mortality may be affected by an “immigration bias” – healthier patients are likely to have shorter door-to-balloon times than are sicker patients with more complex conditions, for whom treatment may be delayed because of the time needed for medical stabilization

 

Whilst strategies to ever reduce door to balloon times may not be the correct focus to reduce overall mortality, it is clear that the presence of significant delays (>90mins) is associated with increased mortality.

 

Mycotic Aneurysms

Any kind of infected aneurysm, regardless of its pathogenesis. Such aneurysms may result from bacteremia and embolization of infectious material, which cause superinfection of a diseased and roughened atherosclerotic surface.

 

Aneurysmal degeneration of the arterial wall as a result of infection that may be due to bacteremia or septic embolization 

  • Symptoms:  pulsatile mass, bruit, fever
  • Risk Factors:  arterial injury, infection, atherosclerosis, IV drug use
  • #1 cause = staph, #2 = salmonella

Download (PDF, 1.14MB)

 

 

CME QUIZ

EM Reflections - Jan 18 - CME Quiz

EM Reflections – Jan 18 – CME Quiz

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In Situ Simulation Report

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Thanks to Dr. James French for this informative post

Report from In-Situ Sim SJRHEM December 2017

The Case:

Mr. Jeffs is a 60year old male with 1 hour of chest pain, he brings himself to the ED, is triaged and bought in to trauma. Past medical history, hypertension. Medications, Perindopril 4mg with no allergies. He presents with an Acute Myocardial Infarction and then goes into cardiac arrest (which was always going to happen) requiring ACLS. After ROSC he requires intubation, thrombolysis and ongoing critical care…..

Discussion Points

When the “shizzel” hits that fan it’s really hard to use closed loop communication but especially important.
When patients get worse rapidly (cardiac arrest is pretty “rapidly”) then by definition they will need lots of safety critical procedures and medicines administering rapidly. This will also be associated by an immediate adrenal response by many of the people in the room (I’m sure even our most experienced physicians would admit to feeling it when people get really sick). Teams who are adrenalized will suffer a certain amount of tunnel vision and auditory exclusion i.e. they won’t be able to see or hear things as well. Closed loop communication is designed for people working under these conditions to address these challenges. The person making the request gets an answer from the person they are speaking to, and most importantly gets the order repeated back to them. Close the loop to prevent the poop! Watch the video for a comical example of closed loop communication! https://emergencypedia.com/2014/11/13/8227/

Being Adaptable

Emerg Teams are highly adaptable. This case required a nurse to do an ECG as there was no ECG tech available. Well done!

 

Resuscitation and dose adjusting in Rapid Sequence of Anesthesia:

The induction or sedative dose should be reduced in the following circumstances:

  1. When there is hypotension
  2. When the pulse is greater than the systolic blood pressure.
  3. If there is significant comorbidity.
  4. Severe metabolic impairment from DKA, overdose, sepsis or prolonged seizure activity.

Please see the table below for examples.

The patient should also be resuscitated to a point that is appropriate for the case before the administration of drugs. In a shocked trauma patient this could be the administration of blood and splinting limb fractures. In a patient with septic shock this could be giving a fluid bolus and starting vasopressors. For More information on RSI in really sick people see this site. https://emcrit.org/racc/hop-mnemonic/

 

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Medical Student Clinical Pearl – Urinary Tract Infections

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Urinary Tract Infections

Rob Hanlon, Med 1

Dalhousie Medicine New Brunswick, Class of 2021

Reviewed by: Dr David Lewis

 

 

Urinary tract infections (UTIs) are common in both the inpatient and outpatient settings. As such, it is important to understand the etiology, pathogenesis, and treatment of such infections. This post will focus primarily on uncomplicated UTIs, bacteriology and pathogenesis, treatment options with consideration for drug resistance.

Types of UTIs: 

The term UTI encompasses different infections. These include asymptomatic bacteriuria, acute uncomplicated cystitis, recurrent cystitis, complicated UTI, catheter-associated asymptomatic bacteriuria, catheter-associated UTI, prostatitis, and pyelonephritis. 1 There are two broad classifications: uncomplicated and complicated.

Uncomplicated UTIs refer to infections occurring in individuals with normal urinary tracts; meaning they have no structural or neurological issues, such as neurogenic bladder. These are differentiated into lower (bladder and urethra) and upper (ureters and kidneys) urinary tract infections; cystitis and pyelonephritis respectively. 2 Typical symptoms of cystitis include dysuria, urinary frequency and urgency, suprapubic pain, and hematuria. Symptoms of pyelonephritis include fever, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting. 3

Risk factors of uncomplicated UTIs include being female (proximity of urethral opening to anus), frequent sexual intercourse, history of recurrent UTIs, use of spermicide-coated condoms, diaphragms, obesity, and diabetes. 3 Menopause also increases the risk for UTIs as the decrease in estrogen causes the walls of the urinary tract to thin, which decreases resistances to bacteria. 4 Uncomplicated UTIs do occur in men; albeit, less frequently than women. Risk factors in men include anal intercourse (fecal bacteria), lack of circumcision, and benign prostatic hyperplasia. 5

 

Complicated UTIs refer to infections that are typically more severe and difficult to treat. This type of infection can be seen in people with structural abnormalities impairing the flow of urine, catheter use or other foreign bodies, renal transplantation, and kidney/bladder dysfunction.4

 

Bacteriology and Pathogenicity:

 

It is important to note that recently the urinary tract has been found to be colonized by a normal microbiome, similar in concept to the gut and vaginal lumens. The urinary tract has traditionally been thought to be a sterile lumen. Changes in the bacterial make-up may contribute to a disease state in the urinary tract.6 There is more research needed to fully appreciate how changes to the normal bacteria contribute to disease and specifically to UTIs. There is ongoing research to determine how the microorganisms become pathological and if the normal flora can be a source of a pathological process.6 There is research indicating possible alternative treatments such as probiotics and dietary modifications that can impact urinary tract diseases.6 The impact of antibiotics on the normal urinary tract bacteria is also a current research topic.6 Clinically, the presence of UTI symptoms would indicate that there is a pathological process present and, when indicated, antibiotics as first-line treatments are still recommended.

There are two mechanism by which bacteria enter the urinary tract, these are ascending infections and haematogenous infections. The ascending mechanism occurs when perineal/fecal bacteria enter the urethra and travel up towards the bladder/kidneys. The haematogenous route occurs when bacteria from the blood enter the kidneys.7

 

Bacteria causing UTIs are termed uropathogens. The common UTI causing organisms are gram negative Klebsiella spp., Escherichia coli, and Proteus spp., and gram positive Enterococci spp. and Staphylococcus saprophyticus. E. coli being the most common uropathogen; seen in 80% of cases. More opportunistic organisms can be isolated in complicated UTIs, such as Pseudomonas spp. and fungal Candida spp.4 8

 

Uropathogenic E. coli (UPEC) strains contain virulence factors that allow them to colonize the urinary tract. Fimbriae are filamentous cell surface extensions that allow the bacteria to adhere to the uroepithelium and promote invasion into the tissue. Other surface molecules include flagella that allow the bacteria to mobilize up the urinary tract. 9 UPEC also produce toxins such as haemolysin, which damage epithelial cells and induce inflammatory responses (causing UTI symptoms). Factors allowing adherence of UPEC to uroepitehlium are paramount, as urine could wash away the bacteria. Other virulence factors allow the bacteria to thrive and grow. 7

 

Klebsiella spp. and Proteus spp. are other gram negative uropathogens that also produce fimbriae. Klebsiella produce polysaccharide capsules that prevent host defense phagocytosis.7  It also produces an enzyme called urease, produced by Proteus spp. as well, which hydrolyzes urea into ammonia and CO2. The bacteria use ammonia as a source of nitrogen for metabolism. The enzymatic process also increases the pH of the urinary tract and leads to the formation of renal stones. 10

Proteus

 

Pseudomonas aeruginosa is a gram-negative commonly associated with nosocomial acquired UTIs, especially when catheters are in place. Its major virulence factor is the production of biofilms, which protect it from host defenses and many antimicrobials. 7 Staphylococcus saprophyticus is a gram-positive bacterium that also produces biofilms, as well as a specific epithelial adhesion protein called lipoteichoic acid. 11

 

Although some of these uropathogens have similar virulence mechanisms, it is important to understand the different types of pathogens and their virulence factors because different antimicrobials target specific parts of the bacteria and the bacteria can be resistant to specific treatment options.

 

Treatment with Consideration for Antimicrobial Resistance

Multiple factors must be considered when choosing treatment options for UTIs in order to determine the risk of increased drug resistance. Patients are considered to be at a higher risk of drug resistance if, within the last three months, they have been found to have a multidrug resistant strain in their urine, they have been admitted to a hospital or other care facility, used broad-spectrum antibiotics, or have a travel history to areas known for resistant strains. 3

 

For low risk patients, treatments for uncomplicated cystitis include nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin. Choosing which drug depends on the individual’s allergies, local rates of resistance, and availability. If the patient has used one of these drugs within the last three months, the remaining two drugs are possible options. 3 If first-line treatments are not an option, then an oral beta-lactam, such as amoxicillin-clavulanate is appropriate. If allergic to this, then a fluoroquinolone such as ciprofloxacin can be used.3

 

Table 1: Drugs and dosages for empiric treatment of uncomplicated cystitis. 3

 

 

For higher risk patients, a urine culture and antimicrobial susceptibility testing should be ordered. First-line treatments (see above) can be used as empiric treatments until test results are obtained. However, if the patient is unable to take these treatments, test results should be obtained prior initiating treatment. 3

 

For complicated UTIs, such as catheter infections, treatment depends on the severity of the illness. Urine culture and susceptibility testing should be performed. In the case of a catheter infection, it should be removed and a sample from the catheter should be cultured. 12 If the catheterized patient requires treatment prior to obtaining test results, treatment should cover gram-negative bacilli. Third-generation cephalosporins can be used in this case. Critically ill patients should be put on broad spectrum antibiotics such as carbapenems and vancomycin, in order to cover pseudomonas and methicillin-resistant Staphylococcus aureus infections respectively. 13

Local (New Brunswick, Canada) Information on Antimicrobial Treatment of UTIs can be found here:

NB Antibiotic Guidelines and Resources

 

 

This is not an exhaustive description of infection types, treatments, or resistance mechanisms. This post focused on uncomplicated UTIs and their treatments because they are commonly seen in the clinical setting. An in-depth patient history is crucial for understanding the possible causes of a UTI and for developing a differential diagnosis. These should be included alongside test results when evaluating treatment options.

 

 

References:

 

  1. Kalpana Gupta, Larissa Grigoryan, Barbara Trautner. Urinary tract infection. Annals of Internal Medicine. 2017;167(7). https://search.proquest.com/docview/1975585404.
  2. Ana L Flores-Mireles, Jennifer N Walker, Michael Caparon, Scott J Hultgren. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nature Reviews. Microbiology. 2015;13(5):269. http://www.ncbi.nlm.nih.gov/pubmed/25853778. doi: 10.1038/nrmicro3432.
  3. Hooton T, Gupta K. Acute uncomplicated cystitis in women. Retrieved from: https://www.uptodate.com/contents/acute-uncomplicated-cystitis-in-women?source=see_link. Updated 2017.
  4. Harvey S. Urinary tract infection. University of Maryland. Retrieved from: http://www.umm.edu/health/medical/reports/articles/urinary-tract-infection. Updated 2012.
  5. Hooton T. Acute uncomplicated cystitis in men. Retrieved from: https://www.uptodate.com/contents/acute-uncomplicated-cystitis-in-men?source=see_link. Updated 2017.
  6. Aragón IM, Herrera-Imbroda B, Queipo-Ortuño MI, et al. The urinary tract microbiome in health and disease. European Urology Focus. 2016. doi: 10.1016/j.euf.2016.11.001.
  7. Walsh C, Collyns T. The pathophysiology of urinary tract infections. Surgery (Oxford). https://www.sciencedirect.com/science/article/pii/S0263931917300716. doi: 10.1016/j.mpsur.2017.03.007.
  8. Beyene G, Tsegaye W. Bacterial uropathogens in urinary tract infection and antibiotic susceptibility pattern in jimma university specialized hospital, southwest ethiopia. Ethiopian journal of health sciences. 2011;21(2):141. http://www.ncbi.nlm.nih.gov/pubmed/22434993. doi: 10.4314/ejhs.v21i2.69055.
  9. Bien J, Sokolova O, Bozko P. Role of uropathogenic escherichia coli virulence factors in development of urinary tract infection and kidney damage. International journal of nephrology. 2012;2012:681473. http://www.ncbi.nlm.nih.gov/pubmed/22506110. doi: 10.1155/2012/681473.
  10. Schaffer JN, Pearson MM. Proteus mirabilis and urinary tract infections. Microbiology spectrum. 2015;3(5). http://www.ncbi.nlm.nih.gov/pubmed/26542036.
  11. Raul Raz, Raul Colodner, Calvin M. Kunin. Who are you: Staphylococcus saprophyticus? Clinical Infectious Diseases. 2005;40(6):896-898. http://www.jstor.org/stable/4463165. doi: 10.1086/428353.
  12. Fekete T. Catheter-associated urinary tract infection. Retrieved from: https://www.uptodate.com/contents/catheter-associated-urinary-tract-infection-in-adults?source=see_link#H123172989. Updated 2016.
  13. Hooton T, Gupta K. Acute complicated urinary tract infection (including pyelonephritis) in adults. Retrieved from: https://www.uptodate.com/contents/acute-complicated-urinary-tract-infection-including-pyelonephritis-in-adults?source=see_link#H12414288. Updated 2017.
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RCP – Suprapubic Aspiration PoCUS

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Suprapubic aspiration – when the catheter doesn’t cut it.

Resident Clinical Pearl (RCP) – Guest Resident Edition

Sean Davis MD, PGY2 Family Medicine

Dalhousie University, Yarmouth, Nova Scotia

Reviewed and Edited by Dr. David Lewis

 

Urine is routinely analyzed and cultured as part of a sick child workup, as diagnosis of urinary tract infection can be difficult in pre-verbal children. They are unable to “point where it hurts”, and physical exam can be both difficult and unreliable in an irritable or obtunded infant. Urine may be collected in three ways – by “clean catch” collection, transurethral catheterization (TUC), and suprapubic aspiration (SPA). Given the inherent risk of contamination with local flora (over 25% in one cohort study)1, clean catch urine is typically useful only for ruling out UTI. TUC is more commonly performed as it does not require physician participation, but SPA remains a valid option for obtaining a urine sample for analysis and culture in children under the age of 2. It has been shown to have a significantly lower rate of contamination than TUC (1% versus 12%, respectively)1, although failure rates are higher with SPA4. Use of portable ultrasound has been shown to significantly increase the rate of success of SPA (79% US guided vs 52% blind)5.

 

RCP – The pee or not the pee: so many questions!

 

Indications:2,3

  • Labial adhesions/edema
  • Phimosis
  • Diarrhea
  • Unsuccessful urethral catheterization
  • Urethral/introital surgery
  • Urethral stricture
  • Urethral trauma
  • Urinary retention
  • Urinalysis/culture in children younger than 2 years
  • Chronic urethral/periurethral gland infection

Contraindications: 2,3

  • Genitourinary abnormalities (congenital or acquired)
  • Empty or unidentifiable bladder
  • Bladder tumor
  • Lower abdominal scarring
  • Overlying infection
  • Bleeding disorders
  • Organomegaly

Complications: 2,3

  • Gross hematuria
  • Abdominal wall cellulitis
  • Bowel perforation

Equipment: 2,3

  • Lidocaine for local anesthesia (1% or 2%, with or without epinephrine)
  • Adhesive bandaid
  • Povidone-iodine or Chlorhexidine prep
  • 25g to 27g 1” needle
  • 22g or 23g 1.5” needle
  • Sterile 5ml and 10ml syringes

Procedure (ultrasound-guided): 2,3

  • Position the patient supine in frog-leg position, using parent or caregiver to assist with immobilization.
  • Using sterile technique, identify the bladder on ultrasound; it appears as an anechoic ovoid structure just below the abdominal musculature.
    • Landmarking: midline lower abdomen, just above the pubic symphysis
  • Mark the area and sterilize; infiltrate local anesthetic into the marked area
  • Insert the needle slightly cephalad, 10-20° off perpendicular while aspirating until urine appears.
  • If the insertion is unsuccessful, do not withdraw the needle fully. Instead, pull back until the needle tip rests in the subcutaneous tissue and then redirect 10° in either direction. Do not attempt more than 3 times.
  • One sufficient urine is obtained, withdraw the needle and place a sterile dressing at the site of the insertion.

 

 

From: Performing Medical Procedures – NEJM

 

References

    1. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. Tosif S; Baker A; Oakley E; Donath S; Babl FE. J Paediatr Child Health. 2012; 48(8):659-64 (ISSN: 1440-1754). Retrieved from https://reference.medscape.com/medline/abstract/22537082 on December 10, 2017
    2. Suprapubic Aspiration. Alexander D Tapper, MD, Chirag Dave, MD, Adam J Rosh, MD, Syed Mohammad Akbar Jafri, MD. Medscape. Updated: Mar 31, 2017. Retrieved from https://emedicine.medscape.com/article/82964-overview#a4 on December 10, 2017
    3. Suprapubic Bladder Aspiration. Jennifer R. Marin, M.D., Nader Shaikh, M.D., Steven G. Docimo, M.D., Robert W. Hickey, M.D., and Alejandro Hoberman, M.D. N Engl J Med 2014; 371:e13September 4, 2014DOI: 10.1056/NEJMvcm1209888. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMvcm1209888 on December 10, 2017
    4. Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Pollack CV Jr, Pollack ES, Andrew ME. Ann Emerg Med. 1994 Feb;23(2):225-30. Retrieved December 10, 2017.
    5. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Gochman RF1, Karasic RB, Heller MB. Ann Emerg Med. 1991 Jun;20(6):631-5. Retrieved December 10, 2017.

 

Other PEM PoCUS Videos Here

 

 

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The 2018 Emergency Medicine Review Course

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The Emergency Medicine Review (EM Review) course is offered by the Saint John Regional Hospital Emergency Department to guide eligible candidates in preparation for the CCFP (EM) licensing exam.
Over the 19 interactive sessions, a CCFP(EM) lecturer will review the CFPC’s Priority Topics in Emergency Medicine: the core material covered in the exam. A practice written exam and final oral exam are offered at the end of the course. Feedback is provided throughout. 

The EM Review 18 Course (interactive Course) is now full. If you would like to be placed on a waiting list for the self-directed stream only, please email us at info.emreview@gmail.com

We offer two streams to the EM Review Course:

  1. Interactive Stream – Cost: $2750:
    • Access to online sessions each Tuesday evening from 7-9pm. Includes access to recorded lectures, practice SAMPs, a practice exam, and a live practice oral exam session (5 cases).
    • We have strict registration caps on this stream to allow for adequate participant involvement each week

  1. Self- Directed Stream -Cost $2000:
    • Access to all online material, including recorded lectures, practice SAMPs, practice exam, and a live practice oral exam session (5 cases). Note: this stream does not include participation in the interactive sessions each week. Instead, the recordings are available for your viewing after each session.

Weekly Overview:

  • Practice Short Answer Management Problems (SAMPs) are sent for completion and self-marking one week prior to each session
  • Practice orals are completed by 1-2 participants while others review
  • Core material is presented in a case-based format with “SAMP-style”, interactive questioning

More Information Here

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