Resident Clinical Pearl: Arterial bleeding

Approach to Arterial Bleeding in the Upper Extremity

Resident Clinical Pearl (RCP) – November 2018

Tara DahnCCFP-EM PGY3, Dalhousie University, Halifax NS

Reviewed by Dr. David Lewis

This post was copyedited by Dr. Mandy Peach

You are working a shift in RAZ when a pair of paramedics wheel a man on a stretcher into one of the procedure rooms. He is sitting upright and looking around but his entire left forearm and hand are wrapped in towels, which are taped tightly down. “I don’t know what’s hurt but there was a lot of blood”, he says when questioned. He had been using a reciprocating saw in his workshop.

Vital signs: T 36.5, HR 90, BP 135/90, RR 18, O2 sats 98% on RA

You ask the nurses to find a tourniquet to put around the patients arm as you start unwrapping his giant towel mitt. You get down to the skin and find a deep 1 inch transverse laceration along the radial side of the wrist. Initially there is no active bleeding, you gingerly pock the wound and …Ooops… immediately bright red pulsatile blood starts pumping out from the distal wound edge and your scrubs will need to be change before you see the next patient.

Approach to arterial bleeding in upper extremity

Life over limb

  • Get control of the bleeding and if needed focus on other more pressing injuries. Start resuscitation if needed
  • There is no bleeding in the extremity that you can’t stop with manual compression.
  • If you can’t spare a person to compress artery then consider a tourniquet. (see Table 1 on tourniquets)
  • Avoid blindly clamping as nerves are bundled with vascular structures and can be easily damaged.

 

Determine if arterial bleeding/injury exists

Look for hard or soft signs of arterial injury (See Table 2)

If hard signs of arterial injury in major vessel the patient will need operative care. Imaging is not required unless site of bleeding is not clear (and patient is stable).
If there are soft signs of arterial injury do an Arterial Pressure Index (see Box 1) to help determine if there is an underlying arterial injury.
o If API >0.9: Patient unlikely to have an arterial injury. Observe or discharge based on nature of injury/patient.
o If API < 0.9: Possible arterial injury. Patient will need further investigation, preferably by CTA.

  • API is recommended over ABI (Ankle Brachial Index) in lower extremity injuries. ABI compares lower extremity SBP to brachial SBP. Usually patients will have more atherosclerotic disease in their lower extremities, which can falsely elevate their ABI and make it harder to detect a vascular injury. The API, on the other hand, relies on the fact that the amount of atherosclerotic disease is usually symmetric between the two upper and two lower extremities.
  • API is a very good test. An API less than 0.9 has a sensitivity and specificity of 95% and 97% for major arterial injury respectively, and the negative predictive value for an API greater than 0.9 is 99% (Levy et al., 2005).

Consider vessel injured

  • A good understanding of vascular anatomy is important to identify which vessel is injured. See figures 1 and 2.

Figure 1: Upper Extremity Arteries
(https://web.duke.edu/anatomy/Lab12/Lab13_preLab.html)

Figure 2: Lower Extremity Arteries
https://anatomyclass01.us/blood-vessels-lower-limb/blood-vessels-lower-limb-arteries-in-the-lower-leg-human-anatomy-lesson

Examine distal extremity well.

  • In the excitement of pulsatile bleeding it can be easy to be tempted to skip/rush this. But with bleeding controlled remember that the extremities are much less picky about blood supply than your vital organs. You can take a few minutes to examine the distal limbs neurovascular status (blood supply, sensory and motor, tendon integrity) and should as this will be important for management decisions.
  • Arterial injuries can very often be accompanied by nerve and tendon injuries. Complete a full assessment. See Figures 3 &4 for neurologic assessment of hand.
  • Most disability following arterial injuries is not due to the actual arterial injury, but due to the accompanying nerve injury (Ekim, 2009).

Figure 3: Motor examination of the hand. 1 – Median nerve. 2- Ulnar nerve. 3- Radial nerve (Thai et al., 2015)
Figure 4: Sensory innervation of the hand and nerve locations (Thai et al., 2015)

Explore wound carefully

  • It is important to explore the wound carefully to look for other structures damaged.
  • Examine tendons and muscles by putting their accompanying joints through a full ROM to see partial lacerations that may have been pulled out of sight.

Control bleeding definitively

Proximal arterial injuries (brachial artery, proximal radial/ulnar artery)

-All brachial artery injuries will require urgent repair by vascular surgeon.
-The “golden period” is 6-8 hours before ischemia-reperfusion injury will endanger the viability of the limb (Ekim, 2009). Degree of ischemia depends on whether injury is proximal or distal to the profunda brachii (Ekim, 2009)
-Larger more proximal arteries are rarely injured alone and will nearly all have nerve/tendon/muscle injuries also requiring operative repair

Forearm/hand arterial injuries
-Many arterial injuries in/near the hand will NOT require operative repair as there are very robust collaterals in the hand with dual blood supply from the radial and ulnar arteries in most people.

-Steps to management
Manual direct digital compression: 15 minutes direct pressure without interruption will often be successful on its own.

Temporary tourniquet application and wound closure with running non-absorbable suture followed by compact compressive dressing. If vessel obviously visible may try tying off but blindly clamping/tying will likely injury neighboring structures, particularly nerves.

Operative repair may be required if bleeding cannot be controlled with above measures.
Studies have shown that in the absence of acute hand ischemia, simple ligation of a lacerated radial or ulnar artery is safe and cost effective (Johnson, M. & Johansen M.F., 1993) however some surgeons may still opt to perform a primary repair.

 

Approach for our case

Life over limb

Patient was hemodynamically stable at presentation. IV access had already been obtained by the paramedics. Bleeding was controlled with direct pressure. When visualization was required at the site of the wound a tourniquet was used.

Determine if arterial bleeding
Our patient had a clear hard sign for arterial bleeding- pulsatile blood

Consider vessel injured
Our patients pulsatile bleeding was coming from the distal edge of the wound. Leading us to conclude that it was pulsing retrograde from the palmar arch (See Figure 5 for more detailed anatomy).

Examine distal extremity well
Our patient had a completely normal sensory and motor exam of his hand as well as normal tendon function. Lucky!

Explore wound carefully
A tourniquet was needed to properly visualize and explore the wound. There were no other injured structures identified.

Control the bleeding definitively
Direct pressure for 15 minutes did not stop the bleeding. The ends of the vessel were not identified on initial wound inspection. The wound was extended a short distance (~1cm) in the direction of the bleeding but still the vessel was not identified.

Plastic surgery was consulted. They extended the wound another 3 cm distally and were able to identify the artery, which had been transected longitudinally. They concluded that it was likely the radial artery just past the superficial palmar branch. The hand was well perfused and thus the artery was ligated. The wound was irrigated well, closed and the patient was discharged with a volar slab splint and follow up.

 

References:

Ekim, H. & Tuncer, M. (2009). Management of traumatic brachial artery injuries: A report on 49 patients. Ann Saudi Med. 29(2): 105-109.

Johnson, M. & Johansen, M.F. (1993). Radial or Ulnar Artery Laceration – Repair or Ligate? Arch Surg 128(9), 971-975.

Levy, B. A., Zlowodzki, M.P., Graves, M. & Cole, P.A. (2005). Screening for extremity arterial injury with the arterial pressure index. The American Journal of Emergency Medicine, 23(5), 689-695.

Thai, J.N. et al. (2015). Evidence-based Comprehensive Approach to Forearm Arterial Laceration. Western Journal of Emergency Medicine, 16(7), 1127-1134.

Life in the Fast Lane: Extremity arterial injury

Tinntinalli’s Emergency Medicine

 

This post was copyedited by Dr. Mandy Peach

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Resident Clinical Pearl – The Acute Scrotum

What to do when the balls are in your court:

An Approach to the Acute Scrotum

Resident Clinical Pearl (RCP) – October 2018

Devin Magennis – Family Medicine, PGY2, Dalhousie University, Charlottetown PEI

Reviewed by Dr. David Lewis

 

The acute scrotum is a syndrome characterized by intense, new onset scrotal pain which can be accompanied by other symptoms such as inflammation, abdominal pain, or fever3. The incidence of acute scrotal pain is highest under the age of 153, yet it can occur at any age.  To successfully diagnosis and manage the patient with an acute scrotum it is useful to formulate a differential diagnosis using the I VINDICATE mnemonic.

Table 1- Differential diagnosis for scrotal pain organized using I VINDICATE format. The diagnoses in bold are or have the potential to be life-threatening or testicle threatening. The diagnose in Italics are common.

 

 

Review of Clinically Relevant Anatomy:

It is important to remember that during development the testicles originate in the posterior abdominal wall before migrating down into the scrotum4. Consequently, testicular pathology can present not just as scrotal pain but also as: flank pain, abdominal pain or inguinal pain2.

Once in the scrotum, the testicle sits in a vertical lie. The anterior portion of the testicle adheres to the scrotal wall via the tunica vaginalis. The tunica vaginalis is double-layered. Between these layers is a potential space for fluid to collect. Along the postero-lateral aspect of the testicle is the epididymis. It originates at the postero-superior pole, runs along the lateral aspect of the testicle down to the inferior pole4

 

Figure 1- Anatomy of the testicle. Right side of photo is anterior, left side is posterior

 

When trying to localize a patient’s symptoms it helps to divide the genital tract into segments: lower segment and the upper segment. The lower genital tract consists of the urethra. While the upper genital tract consists of the testicles, epididymis and prostate.

 

 

Testicular torsion

In a patient presenting with an acute scrotum the most important diagnosis to consider is testicular torsion1-5. Classic teaching states testicular torsion occurs in the perinatal period and during puberty. and Reported will be: sudden onset of severe unilateral testicular pain within 12 hours of presentation1. Patients will typically have had similar previous episodes, feel nauseated, may have vomited and occasionally have a history of trauma1. On inspection there will be scrotal erythema; a swollen, high-riding testicle with a horizontal lie. On palpation of the testicle it would be found to be exquisitely tender and the cremasteric reflex would be absent.

Unfortunately, testicular torsion usually does not present as described above2.  In one case series 1 in 5 patients diagnosed with testicular torsion had only abdominal pain and no scrotal pain2. While in another case series 7% of patients diagnosed with testicular torsion presented with complaints of dysuria and/or urinary frequency. Furthermore, other acute scrotal conditions have considerable overlap with the classic description of torsion2. Both epididymitis and torsion of the testicular appendage can present with sudden onset of pain2. Patients with any scrotal condition can have an absent cremasteric reflex as it is absent in 30% of the population and just to make matters more confusing, multiple case series report patients with testicular torsion still having an intact cremasteric reflex1.

 

Approach

What to ask the patient with an acute scrotum:

  • Characterize the pain
  • Location: testes, epididymis (postero-lateral aspect of testicle), upper pole of testes
  • Onset: sudden vs gradual
  • Frequency of pain
  • Radiation
  • Intensity
  • Duration
  • Events associated: trauma; dysuria, urethral discharge and urinary frequency; sexual history
  • Constitutional symptoms
  • Medical history: GU abnormalities, Recurrent UTIs, Diabetes, Alcoholism, Steroid use
  • Recent Catheterization or instrumentation of urinary tract
 

 

Physical exam for the acute scrotum

1)      Inspection:

  • Symmetry and size of testicles
  • skin erythema
  • blue dot at upper pole of testicle
  • Unilateral vein engorgement

2)      Palpation:

  • Determine site of maximal tenderness and check for masses
    • Testes
    • Epididymis
    • Upper pole of testes
    • Inguinal canal
    • McBurney’s point, Cost-vertebral angle or another abdominal or flank location

3)      Ultrasound to rule-out AAA in patients over 50

 

Management

 

The Bottom Line

  1. Testicular torsion is the one diagnosis that must be made quickly and accurately to avoid the loss of a testicle.1
  2. The classic teaching that testicular torsion can be diagnosed on history and physical exam alone is a myth. If you suspect torsion get an ultrasound and consult urology.2
  3. Torsion becomes exceedingly rare over the age of 25; however it is still possible.1
  4. Abdominal aortic aneurysm, appendicitis, nephrolithiasis and other causes of abdominal and flank pain can present as scrotal pain. Testicular torsion can present as abdominal or flank pain.2

 

References:

  1. Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular pain in children and adolescents. BMJ. 2015;350:h1563. doi: 10.1136/bmj.h1563 [doi].
  2. Mellick LB. Torsion of the testicle: It is time to stop tossing the dice. Pediatr Emerg Care. 2012;28(1):80-86. doi: 10.1097/PEC.0b013e31823f5ed9 [doi].
  3. Lorenzo L, Rogel R, Sanchez-Gonzalez JV, et al. Evaluation of adult acute scrotum in the emergency room: Clinical characteristics, diagnosis, management, and costs. Urology. 2016;94:36-41. doi: 10.1016/j.urology.2016.05.018 [doi].
  4. Drake R, Vogl AW, Mitchell AWM. Gray’s anatomy for students. Saint Louis: Elsevier; 2014. Accessed 8/11/2018 11:47:58 AM.
  5. Rottenstreich M, Glick Y, Gofrit ON. The clinical findings in young adults with acute scrotal pain. Am J Emerg Med. 2016;34(10):1931-1933. doi: S0735-6757(16)30284-4 [pii].

 

 

This post was copyedited by Dr. Mandy Peach

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Resident Clinical Pearl – Infectious flexor tenosynovitis

“Don’t pull my finger!” – a case of flexor tenosynovitis.

Resident Clinical Pearl (RCP) – July 2018

Mandy Peach – FMEM PGY3, Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

You are working a rural ED and a 70 yo male presents with an injury to his right hand about one week ago. He has no known past medical history, is widowed and lives alone. He has no family doctor; a family member made him come in.

In triage he denies any major discomfort in the finger, and has taken nothing for pain. However he has noticed it is increasing in size, becoming more red and even black in places.

Vital signs show he is hypertensive, but otherwise afebrile with a normal heart rate.

You walk into the room to do the assessment and immediately your eyes are drawn to his hand:


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHOA.

As you get further history it turns out the injury was a rusty nail to the digit – it just keeps getting better.

You are worried about an infectious flexor tenosynovitis – a can’t miss diagnosis. This is when purulent fluid collects between the visceral and parietal layers of the flexor tendon1. This infection can rapidly spread through the deep fascial spaces. Direct inoculation, like this penetrating injury, is the most common cause1.

4 clinical signs of tenosynovitis – Kanavel’s signs

  • ‘sausage digit’ – uniform, fusiform swelling
  • Digit is held in flexion as the position of comfort
  • Pain with passive extension
  • Tenderness along the tendon sheath

Figure 1: Sketchy Medicine – Flexor Tenosynovitis http://sketchymedicine.com/2012/10/flexor-tenosynovitis-kanavels-signs/

 

As you can imagine this guy had all 4 signs – slam dunk diagnosis, with a little gangrene at the tip to boot. But the diagnosis isn’t always clear cut, and some of these are late signs of infectious flexor tenosynovitis. Patients may present earlier in the course of illness, so what can we use to help diagnose this condition? PoCUS of course!

Place a high frequency linear probe at the wrist crease where you should visualize flexor tendons overlying carpel bones.

Figure 2: Normal flexor tendons (yellow) and carpel bones in transverse plane1

In infectious flexor tenosynovitis you would see anechoic edema and debris in the flexor tendon sheath, and potentially thickening of the synovial sheath. You can assess in both longitudinal and transverse planes.

Figure 3: Transverse (A) and Longitudinal (B) images showing edema in flexor tendon sheath1.

 

Treatment:

So the most common bug that causes these infections is Staphylococcus, however they can be polymicrobial2. Broad spectrum coverage is required – think ceftriaxone or pip tazo. If there is concern for MRSA than vancomycin would be indicated.

But let’s remind ourselves – he had exposure to a rusty nail – you must cover Pseudomonas as well.

We chose ceftriaxone and ciprofloxacin, administered a tetanus (he never had one before) and urgently contacted plastics. He stayed overnight in the rural ED and was transferred out the next morning for OR. Unfortunately, he did have up having the digit amputated but he recovered well.

 

Take home message: Flexor tenosynovitis is a surgical emergency – examine for Kanavel’s signs. Ultrasound can be helpful in confirming diagnosis in the right clinical context. Cover with broad spectrum antibiotics, consider MRSA or Pseudomonas coverage if indicated. Urgent plastics referral needed.

 

References:

  1. Padrez, KP., Bress, J., Johnson, B., Nagdev, A. (2015). Bedside ultrasound Identification of Infectious Flexor Tenosynovitis in the Emergency Department. West J Emerg Med; 16(2): 260-262.
  2. Flexor Tenosynovitis (Karavel’s signs). Sketchy Medicine. Retrieved from http://sketchymedicine.com/2012/10/flexor-tenosynovitis-kanavels-signs/ June 12, 2018.
  3. Tintinalli, JE. (2016). Flexor Tenosynovitis (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (page 1922). New York: McGraw-Hill.

 

 

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Medical Student Clinical Pearl – PoCUS and Clavicle Fractures

Using PoCUS to diagnose clavicular fractures

Medical Student Pearl – May 2018

Danielle Rioux – Med III Class of 2019, Dalhousie Medicine New Brunswick 

Reviewed by Dr. Mandy Peach and Dr. David Lewis

Case: A 70 year-old man presented to the emergency department with pain in his left shoulder and clavicular region following a skiing accident. He slipped and fell on his left lateral shoulder while he was on skis at the ski hill. He has visible swelling in his left shoulder and clavicular region, and was not able to move his left arm.

On exam: The patient was in no sign of distress. He was standing and holding his left arm adducted close to his body, supporting his left arm with his right hand. There was swelling and ecchymosis in the left clavicle, mid-shaft region, with focal tenderness. On palpation, there was crepitation, tenderness, swelling, and warmth in this region. He was unable to move his left shoulder due to pain. His neurovascular exam on his left arm was normal. Auscultation of his lungs revealed normal air-entry, bilaterally and no adventitious sounds.

Point of Care Ultrasound (PoCUS): We used a linear, high-frequency transducer and placed it in the longitudinal plane on the normal right clavicle (see Image 1.), and the fractured left clavicle (see Image 2.). Image 3 shows the fractured clavicle in the transverse plane.

 

Image 1. PoCUS of normal right clavicle along the long axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).

 

 

Clip 1. PoCUS of normal right clavicle along the short axis of the clavicle. The transducer is moving from the lateral to medial, note the visible hyperechoic curved superficial cortex and the subclavian vessels at the end of the clip. 

 

Image 2. PoCUS of normal right clavicle along the short axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).

 

 

Image 3. PoCUS of a fracture in the left clavicle along the long axis of the clavicle

 

 

Clip 2. PoCUS of a fracture of the left clavicle, viewed in the long axis of the clavicle. Compare this view with image 1.

 

 

 

Clip 3. PoCUS of a fracture in the left clavicle viewed in the short axis of the clavicle. Compare this view with Clip 1. Note the fracture through the visible cortex and the displacement that becomes apparent halfway through the clip.

 

Radiographic findings: Radiographic findings of the left clavicle reveal a mid-shaft spiral clavicular fracture.  (Image 4).

Image 4. Radiographic image of fractured left clavicle.

 

Take home point: Research has shown that Ultrasonography is a sensitive diagnostic tool in the evaluation of fractures (Chapman & Black, 2003; Eckert et al., 2014; Chen et al., 2016).

This case provides an example of how PoCUS can be used to diagnose clavicle fractures in the emergency department. In a rural or office setting where radiography is not always available, PoCUS can be used to triage patients efficiently into groups of those with a fracture and those with a low likelihood of a fracture. This would enable more efficient medical referrals while improving cost-effectiveness and patient care.

 

References:

Chapman, D. & Black, K. 2003. Diagnostic musculoskeletal ultrasound for emergency physicians. Ultrasound, 25(10):60

Eckert, K., Janssen, N., Ackermann, O., Schweiger, B., Radeloff, E. & Liedgens, P. 2014 Ultrasound diagnosis of supracondylar fractures in children. Eur J Trauma Emerg Surg., 40:159–168

Chen, K.C., Chor-Ming, A., Chong, C.F. & Wang, T.L. 2016. An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department, Journal of Intensive Care, 4:55

 

This post was copyedited by Dr. Mandy Peach

 

 

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Pre-hospital Airway Management – the bottom line

Study review of recent Airway World Webinar.

Reviewed by David Lewis and Jay Mekwan

The study: Retrospective Data Review conducted in Australia investigating rates of successful RSI by intensive care paramedics.

Rationale: Controversial whether RSI should be completed pre-hospital as unsuccessful attempts can result in patient complications.

Results: First pass success rate of 89.4% with low rates of complications – hypoxia (1.3%) and hypotension (5.2%).

Bottom line:  Appropriately trained air transport paramedics can perform RSI pre-hospital with high levels of success.

 

The study: Retrospective review of a global database tracking critical care transport program. Looked at first pass success attempts at tracheal intubation in the field

Rationale: Critical care transport teams are the first point of critical care contact for acutely unwell patients. Tracheal intubation can be a lifesaving intervention performed while transporting to a tertiary care center.

Results: First attempt intubation success was higher in adult focused critical care transport paramedics, regardless of the age of the patient (>86%).

Bottom Line: Experience may be a significant factor for intubation success. Experienced intubators have better success rates in all patient age groups.

 

The study: Retrospective chart review of air medical patient records where cricothyrotomy was performed to assess frequency, success and technique.

Rationale: When all other airway maneuvers fail, cricothyrotomy is a potentially lifesaving skill.

The results: Performance of cricothyrotomy is rare (<1% of over 22,000 patients), but when performed had 100% success rate.

Bottom Line: Although a rarely performed skill, Helicopter Emergency Medicine Service providers can successfully perform cricothyrotomy when needed.

 

The study: Multicenter randomized clinical trial comparing outcomes in patients who were either intubated or bagged following out of hospital cardiorespiratory arrest.

Rationale: Bag mask ventilation is an easier clinical technique to perform during CPR and previously reported as superior than intubation in terms of survival. Neurological outcomes at 28 days post arrest had not been reported.

Results: No difference in rates of survival or neurological at 28 days between bagged or intubated patients. Bag mask ventilation was associated with higher regurgitation rates and, in general, were more difficult airways to manage.

Bottom line: We don’t know if bag mask ventilation or intubation is superior. More research needed.

This post was copyedited by Mandy Peach

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Congratulations to Dr. Kavish Chandra!

Congratulations to Dr. Kavish Chandra – recipient of the Iype/Wilfred Resident Award!

Dr. Chandra, a PGY3 in the Integrated Family Medicine/Emergency Medicine program, was one of 3 recipients of the prestigious Iype/Wilfred award. This is awarded annually by the New Brunswick Medical Society to residents who have demonstrated outstanding achievements during their residency training in New Brunswick. Recipients are recognized as being leaders in research and professionalism, and who do so while showing compassion and caring towards patients and colleagues.

This award will be presented to Dr. Chandra at the Celebration of Medicine ceremony hosted by the New Brunswick Medical Society on May 26, 2018.

Congratulations, Dr. Chandra!

Far right: Dr. Chandra in a simulation training session

 

This post was copy edited by Mandy Peach

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