Syncope ECG – The ABCs – Resident Clinical Pearl

ECG Interpretation in Syncope

Resident Clinical Pearl (RCP) – December 2018

Dr. Luke Taylor, FMEM PGY3 –  Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

 

What are you looking for on the ECG of the patient with syncope?

Quick review of frequently pimped question on shift!

Two approaches – One using systematic ECG analysis, the other a mnemonic.

ECG Analysis (1)

Standard format of rate, rhythm, axis, and segments (PR, QRS, QT, ST).

Method of calculating heart rate (2)

Rate: Simple — Is the patient going too fast or too slow? *Remember this easy way to check:
Rhythm: Look at leads II, VI and aVR for P waves.
Ask yourself:
Are they upright in II/VI and inverted in aVR?
Does a QRS follow every P and a P before every QRS?

If so likely sinus rhythm.

In the setting of syncope we are looking to see if there is any signs of heart block – a P wave not conducted to a QRS, especially being sure not to miss a Mobitz type II block.

Axis: Axis comes in to play when looking for more extensive conduction disease. Is there axis deviation along with a change in your PR and BBB indicating something like a trifasicular block?

Segments:

PR interval— is it looooong (heart block) or short (reentrant)?
Long has already been discussed in looking for signs of heart block, but a short PR may be indicative of Wolf-Parkinson-White or Lown-Ganong-Levine syndromes.

WPW – look for short PR and delta wave
LGL – short PR but no delta wave due to its conduction being very close to or even through the AV node and not through an accessory pathway.

QRS Morphology analyzing this for signs of Brugada, HOCM, WPW, ARVD, pericardial effusion, and BBB.

ECG findings of Brugada (3)

Type 1: Coved ST segment elevation with T wav inversion
Type 2: Saddleback ST segment elevation and upright T waves
Type 3: either above without the ST elevation

QT interval — is it looooong (R on T) or short (VT/VF risk)?
Long is >450 men, 470 women
Short < 330ms – tall peaked T waves no ST segment
Pearl for long – should be less than half the RR interval. —>

Normal relationship of R-R and QT interval (4)

 

ST segment — think MI or PE (rare causes of syncope but need to be considered)
MI – elevations or depressions

PE – Tachycardia, RV strain, T-wave inversion V1-V3, RBBB morphology, S1Q3T3

 

Mnemonic (5)

ABCDEFGHII

A — Aortic stenosis
Go back to patient and listen!
B — Brugada
C — Corrected QT
D — Delta wave
E — Epsilon wave as in Arrhythmogenic Right Ventricular Dysplasia (ARVD)

Epsilon: Small positive deflection (‘blip’) buried in the end of the QRS complex (6)

F — Fluid filled heart
Pericardial effusion, electrical alternans, low voltage throughout
G — Giant PE
H — Hypertrophy
LVH in someone who shouldn’t have it
I — Intervals
PR, QRS, QT
I — Ischemia

 


Looking for a Basic ECG Guide? See our Med Student Pearl Here:

Medical Student Clinical Pearl – Basic ECG Interpretation

 


 

References

  1. CanadiaEM – ECGs in Syncope https://canadiem.org/medical-concept-ecgs-in-syncope
  2. https://en.ecgpedia.org/wiki/Rate
  3. ECG Waves https://ecgwaves.com/brugada-syndrome-ecg-treatment-management
  4. https://www.healio.com/cardiology/learn-the-heart/case-questions/ecg-cases/question-3-5
  5. Hippo EM Education Shorts https://www.youtube.com/watch?v=raTTYV7_Asl
  6. https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy

 

This post was copyedited by Dr. Mandy Peach

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Resident Clinical Pearl – Epistaxis Management in the ED – 3 Step Method

Epistaxis Management

Resident Clinical Pearl (RCP) – December 2018

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

 

History

-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

 

Physical examination

-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.

 

Management

-Get IV access, draw CBC and coagulation profile when indicated

-Treat as unstable until proven otherwise

 

Pearls

  • Apply ice to the hard palate (popsicles, ice in the mouth) to reduce nasal blood flow up to 25%
  • TXA in patients on anti-platelets (primarily aspirin) results in faster cessation of bleeding
  • Ducanto suction in future -> SALAD technique – Ducanto-bougie intubation for large bleeds
  • Only reverse anticoagulants if absolutely necessary – “local problem, local solution”

 

Three Step Approach to Epistaxis

1. Visualize and decongest

  1. Have patient blow their nose to clear all clots
  2. Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
  3. Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
  4. Pack nose with soaked cotton and replace clamp for 10 mins

2. Cauterize

  1. Remove clamp and packing
  2. Area should be well blanched and anesthetized
  3. Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
  4. If successful and bleeding ceases on reassessment, apply surgicel wrapped around a small piece of surgifoam to create a “dissolvable sandwich”and discharge home

3. Tamponade

  1. Apply unilateral nasal packing (Rapid Rhino, Merocel, etc)
  2. Reassess in 10 mins, visualizing oropharynx for continued bleeding
  3. If stops, can discharge home with packing in place and follow up in ED or ENT clinic in 48hrs for removal. No antibiotics required in immunocompetent patients.
  4. If continues to bleed, move the patient to a higher acuity area and apply bilateral nasal packs

When to call ENT

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.

 

ED Rounds – Epistaxis

 

 

References:

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

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

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

Resident Clinical Pearl (RCP) – November 2018

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

Reviewed by Dr. David Lewis

 


Quick case!

Joe Cocker and Randy Newman had an altercation while debating who recorded the best version of “You can leave your hat on”. Randy won (mainly because he is still alive), but unfortunately he sustained a nasty head injury in the process. You deduce that he does not require a CT head but he’s got a 7 cm lac over his scalp. What should you do next?

 

Review of scalp anatomy:

The scalp is divided into 5 layers, which can conveniently be recalled using the mnemonic, SCALP:

  • Skin

    Ref 1

  • dense Connective tissue
  • Aponeurosis
  • Loose connective tissue
  • Periosteum

 

Recall that the dense connective tissue layer is richly vascularized. The tight adhesion of these vessels to the connective tissue inhibits effective vasoconstriction, hence the profuse bleeding often seen with scalp wounds.

The loose connective tissue layer = the DANGER ZONE when lacerated. This layer contains the emissary veins, which connect with the intracranial venous sinuses. Consequently, lacerations reaching this layer are high risk for spreading infection to the meninges

 

 

 

Examining the laceration:

Ref 2

Prior to choosing the most appropriate closure technique, the wound should be cleaned and cleared of debris and the depth of the wound should be determined.

  • Superficial wounds: generally do not gape and have not gone beyond the aponeurosis. Adherence to the aponeurosis should prevent the wound edges from separating.
  • Deep wounds: gape widely due to laceration of the aponeurosis in the coronal plane. Tension secondary to the occipitofrontalis muscles will pull the wound open in opposite directions.

 

Ref 2

(A) Scalp laceration that extends through the aponeurosis
(B) CT showing an associated skull fracture

 

Choosing a closure technique:

A. The HAT technique: Hair Apposition Technique

What it is: A fast and simple technique for superficial laceration closure whereby the physician twists hair on either side of the laceration together and seals the twist with a drop of glue for primary closure. Various advantages, as described below, including no need for follow up suture or staple removal.

When to use it: Consider using HAT for linear, superficial lacerations, <10 cm that have achieved appropriate hemostasis (assuming the patient has hair!).

The evidence for HAT: An RCT based out of Singapore, comparing suturing (n=93) to HAT (n=96) for scalp lacerations <10 cm found HAT to be equally acceptable if not superior to suturing. Patients were more satisfied (100% vs 75%), had less scarring (6.3% vs 20.4%), fewer complications (7.3% vs 21.5%), lower pain scores (2 vs 4), shorter procedure times (5 vs 15 min) and less wound breakdown (0% vs 4.3%) (Ref 4)

A follow up study by the same group assessing cost-effectiveness of HAT compared to suturing found a cost savings of $28.50 USD (95% CI $16.30 to $43.40) in favor of HAT when taking into consideration materials, staff time, need for removal appointments and treatment of complications (Ref 5)

A retrospective observational study comparing HAT (n=37) to suturing (n=48) and stapling (n=49) also found HAT to be superior to both suturing and stapling due to increased patient satisfaction at days 7 and 15, reduced pain, lower cosmetic issues and complication rates (Ref 6)

 

How to do HAT (see diagram):

  1. Choose 4-5 strands of hair in a bundle on either side of laceration
  2. Cross the strands
  3. Make a single twist to appose the wound edges
  4. Secure with a single drop of glue
  5. Advise patient that the glue will eventually come off on its on and no formal removal is required.

Cautions with HAT: avoid getting glue into the wound as it may result in wide scarring with a bald spot (Ref 3)

 

B. Wound Staples

If the HAT technique is not an option (no glue, bald, etc) and the lac is superficial (above the aponeurosis), staples are preferred over suturing due to Ref 3:

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

C. Wound Sutures

Sutures are appropriate for deep, gaping wounds or those requiring immediate hemostasis.

Suture is required for lacerations through the aponeurosis to reduce spread of infection, hematoma formation and increased scarring. Furthermore, inadequate repair of the aponeurosis may result in asymmetric contraction of the frontalis muscle (Ref 3)

 

 

Final thoughts post-closure:

  • White petroleum ointment is as effective as antibiotic ointment in post-procedural care (Ref 7). Furthermore, the next time you consider handing out bacitracin (or polysporin), recall that it was declared ‘contact allergen of the year for 2003’ by the American Contact Dermatitis Society. Bacitracin is among the top ten allergens in the US causing allergic contact dermatitis (Ref 8).
  • Wetting the wound as early as 12 hrs post-repair does not increase the risk of infection (Ref 7). Consider delaying wetting in the case of HAT.

Bottom line:

  • For superficial lacerations, <10 cm with adequate hemostatic control, the hair apposition technique is a fast, cost-effective method of wound closure with high patient satisfaction, reduced pain and lower complications compared to suturing and staples.
  • Lacerations through the aponeurosis require suturing to reduce rates of complications.
  • Consider use of petroleum jelly over antibiotic containing ointments such as polysporin.

 

Video

 


 

References:

 

1 Hunt, W. “The Scalp.” Teachmeanatomy.info. Last updated Oct 24, 2018. Accessed Nov 28, 2018. URL:  https://teachmeanatomy.info/head/areas/scalp/

2 Dickinson, E. Uptodate. Accessed Nov 28, 2018 URL: https://www.uptodate.com/contents/image?imageKey=EM%2F87633&topicKey=EM%2F16696&source=see_link

3 Hollander, J. “Assessment and management of scalp lacerations.” Uptodate. Updated Feb 23, 2018. Accessed Nov 28, 2018. URL: https://www.uptodate.com/contents/assessment-and-management-of-scalp-lacerations

4 Ong ME. “A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).” Annals of Emergency Medicine. July 2002. 40:1. 19-26.

5 Ong ME. “Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations.” Annals of Emergency Medicine. 2005 Sept; 46(3):237-42.

6 Ozturk D. “A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations.” World J Emerg Surg. 2013; 8:27.

7 Forsch, R. “Essentials of skin laceration repair.” American Family Physician.

8 Fraser, J. “Allergy to bacitracin.” Dermnet NZ. September 2015. Accessed on Nov 28, 2018 URL: https://www.dermnetnz.org/topics/allergy-to-bacitracin/

 


 Randy:

 

Joe:

 

 

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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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Trauma Reflections – October 2018

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

 


Major points of interest:

 

A)  Intubated patients should not need restraints..

Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.

Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.

 

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

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

 

C)  Trauma patients you know will require consultants

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

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

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

 

E) Managing the pediatric airway – adrenalizing for all involved

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

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

 

F) MTP

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

 

G)  Where is this patient being admitted?

Not to the hospitalist service, that is where!

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

 

H)  Chest tube types and sizes

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

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

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

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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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EM Reflections – October 2018

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

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

 

Trauma – Secondary Survey

DNAR Considerations 

ED Neonatal Equipment

 


Trauma – Secondary Survey

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

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

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

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

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

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

Trauma.org article on tertiary survey


DNAR Considerations 

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

CMPA – Key Concepts for End of Life Issues

  • The best interests of the patient are paramount.

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

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

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

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

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

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

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

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

Horizon Health, NB uses these accepted Canadian DNAR definitions:

 


 

ED Neonatal Equipment

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

It includes this Appendix for suggested Radiant Warmer Equipment checklist:

 

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Trauma Reflections – August 2018

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

 


 

Major points of interest:

 

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

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

 

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

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

 

C) Who put that thing there?

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

 

D) Trauma patients you know will require consultants

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

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

 

E) Yo-yoing to DI for yet another film

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

 

F) Pregnancy tests for everybody

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

 

G) “Moving all limbs”..

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

 

H) Severe traumatic brain injury

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

 

I) Motorcycle + cocaine + EtOH + no helmet…

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

 

 

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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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EM Reflections – June 2018

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

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Button Battery Ingestions

Acetaminophen Overdose / Poisoning – Delayed Presentation

Transient Ischemic Attack (TIA) – Follow-Up


 

Button Battery Ingestions

Button Battery Ingestion

 

Take Home Points:

  • Button battery ingestions are can potentially be very serious. Necrosis, perforation and erosion into vessels can occur in as little as 2 hours
  • ALL nasal and esophageal button batteries should be removed within 2 hours of presentation to minimize mucosal damage
  • Consider button battery ingestion in children presenting with dysphagia, refusal to eat and hematemesis
  • Co-ingestion of a button battery with a magnet requires emergency removal regardless of where it is in the GI system
  • Early GI consult is advised

The management algorithm form National Capital Poison Center covers all eventualities! (Click to enlarge)

 


 

Acetaminophen Overdose / Poisoning – Delayed Presentation

Take Home Points:

  • N-acetylcystine (NAC) is a safe and effective antidote. Time to NAC is crucial to protect the liver from significant toxicity.
  • Stated timing and dose are often unreliable and this needs to be taken into consideration.
  • NAC is almost 100% effective if administered within 8hrs of ingestion.
  • If time of ingestion is known for certain to be < 4hrs ago – draw blood for level at 4hrs post ingestion and use nomogram to determine who to treat.
  • If time of ingestion is known for certain to be < 8hrs ago – draw blood for level immediately and use nomogram to determine who to treat (provide result can be obtained within 8 hrs – otherwise start NAC pending result)
  • If time of ingestion is known for certain to be > 8hrs and < 24hrsCommence NAC and draw blood for level immediately and use nomogram to determine whether to continue NAC.
  • If time of ingestion is > 24hrs or unknown or ingestion is staggered – Commence NAC and draw blood for level immediately – Consult toxicology for advice – Only if level is undetectable and AST is normal then NAC can be discontinued, otherwise continue NAC and consult.

View the SJRHEM Acetaminophen Poisoning post here (includes Nomograms and NAC dosing):

New Acetaminophen Poisoning Guidelines from the Royal College of EM

See also this useful NEJM Review Article

For Children, this guideline is useful.

  • Presenting between 4-24 hours (Time of ingestion is known)- use nomogram to determine who to treat.


 

  • Presenting after 24 hours or time of ingestion unknown or ingestion spans > 24hrs

From: UpToDate

 


 

Transient Ischemic Attack (TIA) – Admit or Follow-Up

Take Home Points:

  • All TIA patients need an ECG and baseline labs (CSBP recommended labs)
  • Very High Risk TIA Patients (see below) should have a CT/CTA (or MRI/MRA) immediately
  • High Risk TIA Patients (see below) should have a CT/CTA (or MRI/MRA) within 24hrs
  • All TIAs should be followed up in a specialist TIA Clinic
  • TIA’s + large artery stenosis – candidate for early revascularization (the sooner it is done the better the prognosis)

 

Full Canadian Stroke Best Practice Guideline can be viewed here

 

UpToDate: These results suggest that CEA is likely to be of greatest benefit if performed within two weeks of the last neurologic event in patients with ≥70 percent carotid stenosis. For patients with 50 to 69 percent stenosis, CEA may only have benefit if performed within two weeks of the last event.

 

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Trauma Reflections – June 2018

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

 


 

Major points of interest:

 

A)  Should that be bubbling like that?

Chest tube placement is a critical procedure in managing trauma patients – successful placement can be challenging, complications are common. Post-procedural imaging and check of chest drain system should determine adequate positioning/effectiveness. Check for fluctuation (tidaling) of fluid level in water seal chamber.

 

B)   Nice intubation…but why is his BP now70?

Post intubation sedation and analgesia infusions are superior to push dosing, but should be titrated up slowly to effect. Avoid starting medications that could potentially drop blood pressure at very high infusion rates – yo-yoing BP is not good for damaged neurons.

See attached NB consensus statement for suggested medications and dosages.

FINAL Consensus statement – RSI+ – July 2018

C)  Crystalloid choice in burns

(Warmed) Ringer’s lactate is the preferred crystalloid for initial management of burns patients. And probably all trauma patients for that matter.

 

D)  TTA log sheets – numbers are only slightly better

Ensure qualifying traumas have activations, and TTA log sheets are filled out. Don’t forget transfers should have activations as well.

When services are known to be required for transfer patients (intubated, critical ortho injuries etc.) call a level A activation – consultants should meet patient with you.

Remember, ED length of stay < 4hours is significantly higher with trauma activations (60% vs. 30%), so it is to our advantage to identify these patients immediately on arrival.

 

E) Propofol infusions in pediatric population

This in still a no-no in patients < 18 yo. Single doses for procedure is fine, but for maintaining sedation choose something else.

 

F)  “Moving all limbs”..

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

 

G)  We don’t talk anymore..

There should be TTL to TTL handover at shift change if the trauma patient still resides in our ED. Even if consultants are involved.

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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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