ED Rounds – Jan 2019
Dr. Kavish Chandra presents rounds on Free Open Access Medical Education (FOAM) and how to make it work for you





Please find the entire rounds presentation below
Dr. Kavish Chandra presents rounds on Free Open Access Medical Education (FOAM) and how to make it work for you
Please find the entire rounds presentation below
Luke Taylor R3 FMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. Kavish Chandra
It’s 0300 and you are on a solo night shift when a 76 year old male with blood dripping out of both nares is brought into an examining room. It looks a little more profuse than what you saw on Stranger Things last month, but you are also wondering how to best tackle this very common emergency problem
-Laterality, duration, frequency
-Estimated blood loss, presence of any clots?
-Inciting factors such as trauma or coagulopathy
-Past medical history, especially hypertension, clotting disorder, HHT
-Medications such as anticoagulants or anti-platelets
-Have patient blow nose or use suction to clear clots
-Do not try and visualize until decongestion complete
-Visualize with nasal speculum for site of bleeding. If an anterior bleed, most commonly the bleeding site will be Little’s area (Figure 1)
-See below for management if patient’s ABCs stable. If unstable be prepared to secure airway and call for help – ENT/interventional radiology
Figure 1. Nasal vascular anatomy, adapted from https://www.juniordentist.com/what-is-littles-area-or-kiesselbachs-area-and-the-arteries-in-it.html.
-Get IV access, draw CBC and coagulation profile when indicated
-Treat as unstable until proven otherwise
If bilateral nasal packing bleeding continues, assume posterior bleed and initiate resuscitation, draw labs (CBC, coagulation profile, cross-match if not already done). Reverse known coagulopathy and consult for OR or embolization.
Dr Christopher Chin and his informative talk
http://rebelem.com/topical-txa-in-epistaxis/
https://emergencymedicinecases.com/ent-emergencies/
https://lifeinthefastlane.com/epistaxis/
This post was copyedited by Kavish Chandra @kavishpchandra
Allyson Cornelis FMEM PGY1, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. David Lewis
The majority of pharyngitis cases are caused by viruses. For those attributed to bacterial sources, throat culture is the gold standard for confirmation and group A streptococcus is the main bacterial agent involved¹. For pharyngitis believed to be bacterial in nature, antibiotics are prescribed to reduce the risk of developing rheumatic fever, the duration of symptoms, and transmission to others. For cases where antibiotics are prescribed, the first line medication is penicillin, due to the low resistance of group A streptococcal bacteria to this group of medications. Commonly recommended regimens include:
Penicillin V
Pediatrics
Adults
Amoxicillin
Pediatrics
Adults
An alternative treatment regimen
Common antibiotic regimens require multiple doses per day. This can be difficult for compliance purposes, especially in pediatric patients who may not like to take medications due to the taste and where difficulty with administration of doses at school may be a concern. Recommendations in recent years have included an alternate dosing schedule which allows for a single dose of antibiotic daily for patients. Possible advantages of this approach are improved compliance due to single daily dosing as well as reduced cost for patients and their families. The recommendation is 50 mg/kg once daily to a maximum of 1000mg for 10 days and is appropriate for children > 3 years old and adults.
References:
1. Caglar D, Kwun R, Schuh A. Mouth and throat disorders in infants and children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, editors. Tininalli’s emergency medicine 8th ed. New York: McGraw- Hill; 2016
2. Rx files [Internet]. Pharyngitis: Management considerations; 2017 Mar [cited 2018 May 21]. Available from: http://www.rxfiles.ca/rxfiles/uploads/documents/ABX-Pharyngitis.pdf
3. CDC.gov [Internet]. Group A Streptococcal Disease: Pharyngitis; 2017 Sep 16 [cited 2018 May 21]. Availbale from: https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html
4. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Circulation. 2009 March. 119: 1541-1551.
5. Shulman ST, Bisno AL, Cleg HW, Gerber MA, Kaplan E, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the infectious diseases society of America. Clin Infec Dis. 2012 Nov; 55(10): e86-e102. Available from: https://academic.oup.com/cid/article/55/10/e86/321183
6. Andrews M, Condren M. Once-daily amoxicillin for pharyngitis. J Pediatr Pharmacol Ther. 2010 Oct-Dec. 15(4): 244-248.
This post was copyedited by Kavish Chandra @kavishpchandra
Sean Hurley Emergency Medicine PGY1 (FRCPC), Dalhousie University, Halifax, Nova Scotia
Reviewed by Dr. David Lewis
The goal of this resident clinical pearl is to discuss two different methods of achieving complete anesthesia of the hand. Hopefully, by the end of this article, you will have the knowledge to perform both methods in the emergency department. The first method is ultrasound (US)-guided nerve blocks of the ulnar, median, and radial nerves. The second method is the “tumescent anaesthesia” approach used by many hand surgeons around the world for wide-awake hand surgery, including local, local anesthetic guru and plastic surgeon, Dr. Donald Lalonde who provided many of the clinical pearls in this article.
In a recent article by Amini et al. (2016), 84% of 121 emergency medicine residency programs surveyed in the United States reported that US-guided nerve blocks are performed at their institution. Of the 16 different nerve blocks reported, forearm blocks were the most commonly performed (74%) (Table 1). The main indications for nerve blocks are outlined in Table 2 1.
Table 1 and 2 from Amini et al., 2016 1
Three major nerves, median, ulnar, and radial, provide sensory innervation of the hand (Figure 1). Each nerve needs to be blocked in a simple straightforward approach, which was shown to to be quick, safe and effective. After a 1-hour training session, residents, fellows, and staff emergency physicians had 100% success rate with no rescue anesthesia on 11 hand pathology patients presenting to the ED. The blocks were performed in a median time of 9 minutes with no complications 2.
Figure 1. Cutaenous innervation of the hand. https://www.nysora.com/wrist-block
Figure 2. Indications for different nerve blocks of the hand http://highlandultrasound.com/forearm-blocks/
Radial Nerve: Palpate the radial artery in the volar aspect of distal forearm then place the US probe over the artery in a transverse orientation. Move the probe proximally until you clearly identify the radial nerve (Figure 3), which is located at the radial aspect of the radial artery. Insert your needle using an in-line approach (Figure 4). Inject 5-10cc of 1% lidocaine with epinephrine until you can clearly see the nerve bathed in lidocaine.
Pearl: The radial nerve is often difficult to visualize in the forearm. The radial nerve is more easily visualized above the elbow along the spiral groove of the humerus. Place the probe in a transverse orientation along the lateral aspect of the humerus between the brachioradialis and brachialis muscles. This block is more proximal and will require longer time to peak anesthesia.
Ulnar nerve: Use the exact same 2-step approach but on the ulnar side of the forearm. The ulnar nerve is located at the ulnar aspect of the ulnar artery (Figure 3).
Median nerve: The median nerve lies between the palmaris longus and the flexor carpi radialis. Position the probe in the transverse plane over this location. Insert your needle from either side using an in-plane or out-of-plane approach
Pearl: the median nerve and the many tendons of the distal forearm can be difficult to distinguish. You can identify the nerve by tilting the probe, which causes the tendons to disappear, as the US waves are no longer reflected back to probe, while the median nerve fibers still reflect waves back to the probe. Alternatively, you can slide the probe proximally where the tendons transition to muscle fibers, allowing the median nerve to be easily distinguishable.
Pearl: The palmar cutaneous branch of the median nerve that supplies the thenar eminence branches off before the carpal tunnel. Make sure you move the probe proximally before blocking the nerve so you don’t miss this important sensory branch.
Pearl: The more local anesthetic, the better! Some resources recommend 3-5cc of 1% lidocaine per nerve. Why not use 10cc or more for each nerve? You will still be safely under 7mg/kg limit.
Figure 3. Ultrasound identification of the ulnar nerve (left), median nerve (middle), and radial nerve (right). (Figure from Liebemann et al, 2006) 2.
Figure 4. Ultrasound guided ulnar nerve block using an in-plane technique (Figure from Sohoni et al., 2016) 3.
Please see link to excellent descriptions and videos of ulnar, radial, and median US-guided nerve blocks in the ED. www.highlandultrasound.com/forearm-blocks/
Tumescent means “Swollen”. In relation to local anaesthesia, Dr. Lalonde provides the following definition in his textbook Wide-Awake Hand Surgery: “Injecting a large enough volume of local anesthetic that you can see it plump up the skin and feel its slightly firm consistency with your finger through the skin” 4. The tumescent anesthesia approach has been described in depth for a variety of hand surgeries 4-6.
Using a 10cc syringe, aim for the space directly between the median and ulnar nerve (figure 5 and Video 1). As you puncture the skin, Inject 3-5cc in the subcutaneous space. This is critical to block superficial nerves in this region, including the palmar cutaneous branch of the median nerve. Then, move your needle >3-4mm deeper through the superficial fascia in the forearm compartment where the median and ulnar nerves reside. Inject the remainder of your 10cc syringe into this space. With a single poke, the ulnar and median nerve distributions should be completely anesthetized.
Now, all that remain are the superficial branches of radial nerves and the posterior interosseus nerve. The superficial branches of radial nerve lie over the anatomical snuffbox. Insert your needle within 1cm of your previously anesthetized skin and blow local anesthesia into the subcutaneous space as you slowly move your needle towards the radial aspect of the wrist until you have a tumescent area of local anesthesia over the snuffbox. For the PIN, which is primarily a motor branch of radial nerve but has some sensory contribution, palpate the distal radial ulnar joint of the dorsal aspect of the wrist. The PIN runs along the interosseous membrane so the needle needs to pass through the deep fascia of the forearm. Inject another 5cc of lidocaine in this location.
Figure 5. Tumescent anesthesia of the median and ulnar nerve 5.
Video 1. Tumescent anesthesia of the hand (courtesy of S. Hurley).
No studies have directly compared the two approaches discussed in this article. A recent Cochrane review article reviewed compared US-guided vs. anatomical landmark technique vs. trans-arterial vs. peripheral nerve stimulation for lower and upper limb blocks by trained anaesthetists. They found US-guided had greater success rates, less conversions to general anesthetic, lower rates of parathesias and vascular puncture 7.
A recent small randomized control trial compared US-guided nerve blocks of the forearm to anatomical landmark-based technique and found 14 of 18 ultrasound-guided forearm blocks were successful, as opposed to 10 of 18 for the anatomical technique 3.
Pearl: The tumescent anesthesia technique blocks both smaller and larger nerves of the hand and will likely achieve faster anesthesia compared to nerve blocks of the ulnar, median, and radial nerve. Expect up to an hour for the large nerve blocks to take full effect.
Both methods, US-Guided nerve blocks and tumescent anesthesia are safe, effective, and relatively easy options to achieve complete anesthesia of the hand. For both techniques, remember basic principles for minimizing pain during injection of local anaesthesia to optimize patient comfort and satisfaction 4-6.
References
This post was copyedited by Kavish Chandra @kavishpchandra
Kalen Leech-Porter R3 FMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. David Lewis
A 16 year old girl comes in by ambulance, after fainting while singing at church on a Sunday morning. Her vitals are: HR 90, RR 16, Temp 36.5, BP 92/64. O2 Sat 99% on RA. On arrival she is alert and looks well. She explains that she stood up to sing, felt lightheaded and then, soon after, lost consciousness. The paramedic lets you know witnesses say she turned ashen grey and sweaty, and was out for about 2 minutes. She had some ‘seizure like activity for 10 seconds’ with a few twitches in different parts of her body. The patient states she was fully recovered within a few minutes. Family history is unremarkable, with no sudden early deaths. Physical examination is also unremarkable. The nurse rolls in an ECG machine to check her rhythm.
What investigations does she require?
Pediatric syncope is very common in the emergency setting, accounting for ~1 % of pediatric emergency visits. Between 15 and 50% of children will have at least one syncopal event in their childhood (peaking in adolescence). – It’s a common problem!
Historically, working up pediatric syncope has varied widely. ECG use has been routine and some centers have regularly ordered bloodwork, CTs and even EEGs. This onslaught of testing has led to increased hospital costs, stressful false positives for patients and has not improved patient outcomes. Plus, reading pediatric ECGs can be challenging – see the end of this pearl.
In 2017, the Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association published a position statement on an approach to pediatric syncope¹ Full Article – click here
A thorough history and physical can be sufficient in low risk patients – no investigations are required for many pediatric syncope presentations.
Red flags
Red herrings
Figure 1. Pediatric syncope investigative algorithm, adapted from Sanatani et al. (2017)
To create this position statement, the Canadian Cardiovascular Society (CCS) performed a literature review of 4307 references, ultimately including 231 articles for full-text review.
Most of the studies referred to in the article are retrospective reviews. Therefore, recommendations in the position statement were mostly graded as ‘Strong recommendation, low level of evidence’. I found the most compelling evidence against routine ECG was the statement: “The ECG was the only indicator of cardiac disease in 5 of 480 patients (1%) and causality could not be determined”.¹ However, they did not list a reference for this statement and I’m not sure what study they drew this conclusion from. I do feel they make a compelling case against over investigation, but as in many areas of medicine, the evidence could be more robust.
The nurse hands you the ECG, what features are worrisome on a pediatric ECG?
See following chart from the CCS¹
Figure 2. Pediatric ECG findings in syncope, adapted from Sanatani et al. (2017)
In summary, red light features should prompt an emergent cardiology referral. Yellow light features should prompt a non-urgent cardiology referral while green light features are normal variants and require no further work up.
There were no red flags, arguably she requires no investigations, not even an ECG. Of course, clinical acumen trumps guidelines, but at least you will be CCS endorsed if you chose to not do any further investigations.
This post was copyedited by Kavish Chandra @kavishpchandra
Kavish Chandra R3 FMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. Awdesh Chandra
It’s 0300 and you are on a solo night shift when a couple are rushed into the resuscitation bay by the triage nurse. The woman says that the man had his jaw “wired shut” three weeks ago and began retching an hour ago. Your suspicions are confirmed when you look at his mouth and see the image below:
Figure 1. Arch bars (green arrows) are used for mandibular fixation, adapted from Jones and Read (2006).
As your patient is being placed on cardiac and oxygen monitoring, you can see they are agitated and hypoxic. You ask yourself, how can I get access to their oropharynx and begin my resuscitation?
Arch bars and intermaxillary fixation are placed after mandibular fractures. In Figure 1, the arch bars, horizontal bars indicated by the green arrow, are fixated by circumferential wires around the teeth.1 In order to fixate the mandible and maxilla, fixation wires (vertical wires indicated by the red arrow seen in Figure 2) bring together and upper and lower arch bars, effectively eliminating mouth opening.1
Figure 2. Intermaxillary fixation wires, vertical wires indicated by the red arrows. Adapted from Jones and Read (2006).
While it is standard procedure for dentists and oral surgeons to provide patients with wire cutters and instructions following intermaxillary fixation for emergencies, this may not be readily available in the emergency department when needed the most.
See the following links on how arch bars and intermaxillary fixating wires are placed (to get an understanding of where to cut to release the mandible)
(1) Jones TR, Read L. Emergent separation of arch bars. J Emerg Med 2006; 35(2):205-206.
This post was copyedited by Kavish Chandra @kavishpchandra
Allyson Cornelis R1 FMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. David Lewis
Trauma to the upper extremity can result in injury to the various components of the elbow joint and associated anatomical structures. Important neurovascular structures associated with the elbow joint are the brachial artery, radial artery, ulnar artery, median, radial, and ulnar nerve¹. Elbow injuries causing fracture increase the likelihood of neurovascular damage. If fractures are missed, this may result in further damage and complications including prolonged functional limitations to the joint, nerve damage causing distal functional decline, and potential vascular compromise to the limb more distal to the injury.
Tintinalli’s Comprehensive Guide to Emergency Medicine.2
Fractures at the elbow may occur at the distal humerus (supracondylar, epicondylar, condylar, trochlea, and capitellum fractures), the proximal ulna (coronoid process, olecranon fractures), and the proximal radius (radial head fractures)¹. Of these, radial head fractures are the most common. Common mechanisms for these injuries include falling on an outstretched hand and direct blows to the elbow.
There is a rule for that! The elbow extension rule!
Simply stated: If a patient with an elbow injury is able to fully extend their elbow, they are unlikely to have a fracture and do not require imaging³.
The “how to”:
Of course, no rule is perfect, and the patient should be reassessed later if the following occur
The patient should have imaging at the current visit if:
Of 1740 patients presenting within 72 hours of traumatic elbow injury, 31% had a fracture³. In adults with the ability to fully extend their elbow following trauma, there was a 2% chance they had a fracture. In adults unable to fully extend their elbow following trauma, there was a 48% chance they had a fracture.
In children able to fully extend their elbow following trauma, there was a 4% chance they have a fracture, and in children unable to fully extend their elbow following trauma, there was a 43% chance they had a fracture³.
Consider adding PoCUS to your clinical assessment of elbow injuries. Elbow joint effusions are very easily visualized. The presence of a joint effusion in a patient with elbow pain following trauma is a significant finding and warrants further investigation with radiography. Some studies have shown PoCUS to be more sensitive than x-ray in diagnosing occult elbow fractures.
(1) Appleboam, A., Reuben, AD., Benger, JR., Beech, F., Dutson, J., Haig, S., Lloyd, G. (2008). Elbow extension test to rule out elbow fracture: Multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. British Medical Journal, 337:a2428.
(2) Tintinalli, JE. (2016). Cardiogenic Shock (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 1816-1817). New York: McGraw-Hill.
(3) Sheehan, SE., Dyer, GS., Sodickson, AD., Ketankumar, IP., Khurana, B. (2013). Traumatic elbow injuries: What the orthopedic surgeon wants to know. Radiographics, 33(3), 869-884.
This post was copyedited by Kavish Chandra @kavishpchandra
Renée Amiro, R1 FMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. David Lewis
Mr. Stark brings in his 8-year-old adopted son, Jon Snow, to the emergency room on Christmas day. Jon had just received a puppy, Ghost, as a Christmas present that morning. Jon, who knows nothing (about raising puppies), was playing too rough with the pup and got a bite on his right hand.
How do we appropriately manage this animal bite in the emergency room?
When a patient presents to the ED with an animal bite, the factors in management that need to be addressed are:
Managing an animal bite has much of the same principles of usual good wound care
Local anesthetic should be used to reduce pain and facilitate cleaning. The wound should also be inspected for foreign bodies. Bites overlying joints should be put through their entire range of motion (bone, tendon or joint capsule involvement). If you suspect a foreign body but can’t see it, get an x-ray.
Pearl: for puncture wounds (cats are the biggest perpetrators), the same principles of wound care apply except superficially irrigate wounds and do not use high pressure
Most bites to not require prophylactic antibiotics. There are some high-risk wounds that do. Those include:
Table of prophylactic antibiotic choices. Duration of therapy depends on the antibiotic choice.
Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.
Generally, no, especially if cats are the perpetrators. But if cosmetic concerns arise, wounds should meet all the following criteria before primary closure:
The wound should NOT be closed primarily if the following criteria are met:
If the injury results in complex facial wounds, neurovascular compromise, osteomyelitis or joint infection or deep wounds that penetrate underlying structures (joint, bone, tendon), get a surgical consultation.
That being said, consider consultation with any deep wound on the hand.
When considering tetanus prophylaxis, the decision to intervene is the same in non-bite wounds.
Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.
For rabies, post-exposure prophylaxis is generally not needed in patients with a dog or cat bite as long as the animal is not showing signs of rabies: dysphagia, abnormal behaviour, paralysis, seizures and ataxia.
Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.
This post was copyedited by Kavish Chandra @kavishpchandra
Welcome to SJRHEM’s newest feature, “Best of FOAM”. This is a quick curated list of the best free open access medical education the internet has to offer!
Subscribe to our twitter feed for regular updates and enjoy!
Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick
Luke Taylor, R2 FMEM, Dalhousie University, Saint John, New Brunswick
Edited by Dr Kavish Chandra – @kavishpchandra
Reviewed by Dr. David Lewis
The presentation is similar across all acute aortic syndromes (AAS)
IRAD 12 features most associated with acute aortic dissection
Pearl : When assessing a patient with chest pain (CP), think CP+ 1 (see EMCases episode 92)
These features should drastically increase your suspicion for dissection
positive calcium sign
https://radiopaedia.org/articles/tangential-calcium-sign
http://rubble.heppell.net/chestnet/t/ecgtut.htm
But don’t let POCUS delay definitive imaging when searching for an intimal flap
http://edeblog.com/2014/02/pocus-for-aortic-dissection-a-case-2/
https://emergencymedicinecases.com/aortic-dissection-em-cases-course/
http://circ.ahajournals.org/content/112/24/3802
https://lifeinthefastlane.com/collections/ebm-lecture-notes/aortic-dissection/
https://first10em.com/2017/02/07/d-dimer-aortic-dissection/
This post was copyedited by Kavish Chandra @kavishpchandra
Welcome to SJRHEM’s newest feature, “Best of FOAM”. This is a quick curated list of the best free open access medical education the internet has to offer!
Subscribe to our twitter feed for regular updates and enjoy!
Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick
Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick
Reviewed by Dr. David Lewis
The importance of intravenous (IV) access is something seared in the mind of every practicing emergency department physician. Over the years, central intravenous access for difficult IV access has been obviated by the intraosseous drill and line. Furthermore, we just see and do less central IV lines. The likely reasons for this are that running vasopressors in peripheral intravenous (IV) lines is becoming more accepted as well as the increased time associated with placing a fully sterile central line (draping, etc.) as well as the risks of the over-the-wire procedure (infection, deep vein thrombosis, cardiac arrhythmias).
Enter the internal jugular vein catheterization using a peripheral IV catheter1, which is placed under a limited sterile environment. Is the 5 minutes to establish access that “easy” when peripheral access and external jugular catheterization has failed?
Figure 1. Visual diagram of required materials for the “easy IJ”, adapted from Moayedi et al. (2016).
So will this technique change your practice? A few things to be aware of:
(1) Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The ultrasound-guided “peripheral IJ”: internal jugular vein catheterization using a standard intravenous catheter. J Emerg Med 2013 Jan;44(1):150-154.
(2) Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. J Emerg Med 2016 Dec;51(6):636-642.