SHoC blog from @CanadiEM

Social media site @CanadiEM recently featured the @CJEMonline @IFEM2 #SHoC Consensus Protocol, featuring authors from @SJRHEM among others.

So why do we need another ultrasound protocol in emergency medicine? RUSHing from the original FAST scan, playing the ACES, FOCUSing on the CAUSE and meeting our FATE, it may seem SHoCking that many of these scanning protocols are not based on disease incidence or data on their impact, but rather on expert opinion. The Sonography in Hypotension (SHoC) protocols were developed by an international group of critical care and emergency physicians, using a Delphi consensus process, based upon the actual incidence of sonographic pathology detected in previously published international prospective studies [Milne; Gaspari]. The protocols are formulated to help the clinician utilize ultrasound to confirm or exclude common causes, and guides them to consider core, supplementary and additional views, depending upon the likely cause specific to the case.

Why would I take the time to scan the aorta of a 22 year old female with hypotension, when looking for pelvic free fluid might be more appropriate? Why would I not look for lung sliding, or B lines in a breathless shocked patient? Consideration of the shock category by addressing the “4 Fs” (fluid, form, function, and filling) will provide a sense of the best initial therapy and should help guide other investigations. Differentiating cardiogenic shock (a poorly contracting, enlarged heart, widespread lung B lines, and an engorged IVC) in an elderly hypotensive breathless patient, from sepsis (a vigorously contracting, normally sized or small heart, focal or no B lines, and an empty IVC) will change the initial resuscitation plan dramatically. Differentiating cardiac tamponade from tension pneumothorax in apparent obstructive shock or cardiac arrest will lead to dramatically differing interventions.

SHoC guides the clinician towards the more likely positive findings found in hypotensive patients and during cardiac arrest, while providing flexibility to tailor other windows to the questions the clinician needs to answer. One side does not fit all. That is hardly SHoCing news. Prospective validation of ultrasound protocols is necessary, and I look forward to future analysis of the effectiveness of these protocols.

References

Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an inter- national consensus conference. J Trauma 1999;46:466-72.

Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography. 2010 Dec 31;23(12):1225-30.

Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: cardiac arrest ultra-sound exam – a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206

Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26:87–91

Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in Shock in the evaluation of the critically lll. Emerg Med Clin North Am 2010;28:29 – 56

Jensen MB, Sloth E, Larsen KM, Schmidt MB: Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol. 2004, 21: 700-707.

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Dec 31;109:33-9.

Milne J, Atkinson P, Lewis D, et al. (April 08, 2016) Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol. Cureus 8(4): e564. doi:10.7759/cureus.564

Sonography in Hypotension and Cardiac Arrest: The SHoC Consensus Statement

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CAEP Definition of an Emergency Physician and the Importance of Emergency Medicine Certification

CAEP Definition of an Emergency Physician

An emergency physician is a physician who is engaged in the practice of emergency medicine and demonstrates the specific set of required competencies that define this field of medical practice. The accepted route to demonstration of competence in medicine in Canada is through certification by a recognized certifying body.*

CAEP recognizes that historically many of its members are physicians who have practiced emergency medicine without formal training and certification. Many have been, and continue to be key contributors to developing emergency medicine and staffing emergency departments in Canada. CAEP acknowledges the contributions of these valued physicians and recognizes them as emergency physicians. It is CAEP’s vision going forward that physicians entering emergency practise will demonstrate their competencies by obtaining certification.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency Physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

CAEP Statement on the Importance of Emergency Medicine Certification in Canada

It is CAEP’s vision, that by 2020 all emergency physicians in Canada will be certified in emergency medicine by a recognized certifying body.*

Toward that vision, provincial governments and Faculties of Medicine must urgently allocate resources to increase the numbers of emergency medicine postgraduate positions in recognized training programs so the Colleges are able to address the gap in human resources and training. Furthermore, physicians who have historically practiced emergency medicine without certification must be supported in their efforts to become certified. CAEP is committed to facilitate this process by cataloguing and nationally coordinating practice- and practitioner-friendly educational continuing professional development programs designed to assist non-certified physicians to be successful in their efforts.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

We have also published on this topic, highlighting the need for more resident positions in New Brunswick and PEI. Read our paper here.

 

Read more from CAEP here.

 

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EM Reflections – February 2017

Thanks to Dr. Joanna Middleton for her summary

Edited by Dr David Lewis

Top tips from this month’s rounds:


Imaging for Bone Mets

Plain radiographs are not very sensitive for detecting bone metastases. Metastases to bone become apparent on radiographs only after the loss of more than 50% of the bone mineral content at the site of disease. The diagnostic utility of plain films of the skull, spine, and pelvis is limited by superposition effects. In these areas, the sensitivity of plain films for bone metastases is only in the range of 44–50%.

Reproduced from:Imaging of bone metastasis: An update – World Journal of Radiology

Further resources – Diagnostic Imaging of Bone Metasteses

 


Imaging for Thoracolumbar Spine Trauma

Plain radiography is not sensitive for thoracolumbar spine trauma – Trauma of the spine and spinal cord: imaging strategies – European Spine Journal (Full Text)

We have a guideline for imaging Thoracolumbar trauma. Click image below for larger version.

Any of: High energy mechanism, Inability to ambulate, extremity paresthesia, bladder/bowel deficit, saddle anesthesia – mandates CT

 


Cervical Spine Precautions

Not all trauma patients transferred by EMS require cervical spine precautions. New Brunswick EMS have guidelines (click image for full size):

 


 

Rapid Sequence Intubation – Paralysis with Rocuronium

The recommended dose of Rocuronium for RSI is 1.2 – 1.5mg/kg (not 0.6mg/kg as stated in many drug references)

Rocuronium can be rapidly reversed by Suggamadex (and it’s reversal is quicker than waiting for Sux to wear off)

Excellent RSI reference article from LIFL – Rapid Sequence Intubation (RSI)

 

Rocuronium vs. Succinylcholine from reuben strayer on Vimeo.


Graded Assertiveness vs Advocacy

 

A reminder that we all have a responsibility to ‘speak-up’ and challenge when we see an issue. There are a number of described methodologies (see below), however the key factor is acting on your concern, don’t be that person who watches an unfolding series of errors and think ‘I wish I had said something earlier’….

As the person being challenged – be grateful that someone has had the courage to ‘speak-up’ and potentially save your ass!

 

Graded Assertiveness

More from LIFL here – Speaking Up


 

AMI – STEMI – Early Diagnosis and Reperfusion significantly impacts Mortality

We shouldn’t need reminding that early diagnosis of STEMI via history and ECG significantly impacts mortality. Dynamic ECG changes must be recognised and reperfusion strategies initiated as soon as possible.

Delayed reperfusion increases mortality.

 

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RCP – Save your Thumbs: Extra-oral reduction of anterior mandibular dislocations

Save your Thumbs: Extra-oral reduction of anterior mandibular dislocations

Resident Clinical Pearl (RCP) – February 2017

Kavish Chandra, PGY2 iFMEM, Dalhousie University, Saint John, New Brunswick

@kavishpchandra

 

Reviewed by Dr. Paul Frankish and Dr. David Lewis

 

Mandibular dislocations can be atraumatic or traumatic. The atraumatic variety can occur after extreme mouth opening from yawning, laughing or vomiting and can cause severe pain, difficulty swallowing and malocclusion of the jaw (1).Anterior mandibular dislocations are the most common form of atraumatic dislocations and can be bilateral or unilateral. In this injury, the temporal mandibular joint (TMJ) dislocates in front of the articular eminence and muscular spasm traps the mandible in that position (2).(Fig. 1A and B)

 

Figure 1A: TMJ and coronoid (black arrow) in normal resting position. Figure 1B: TMJ dislocates anteriorly and the coronoid (black arrow) is palpable just below the zygoma. Adapted from Chen et al. 2007.

 

Various reduction techniques are described and predominantly involve intra-oral manipulation, often with the use of procedural sedation (Fig. 2) (1). With the intra-oral technique, there is a risk of the mandible snapping shut on the operator’s fingers as well as the risk of a failed reduction and risks of procedural sedation.

 

Figure 2: Intra-oral TMJ reduction with thumb on molars and pressure is applied downwards and backwards. Adapted from Tintinalli’s Emergency Medicine.

 

 

The Question: is there an effective extra-oral reduction technique for anterior mandibular dislocations?

 

Chen et al. (2007) published a case series describing a rapid and effective extra-oral reduction method for anterior mandibular dislocations(2). Furthermore, their technique does not require any procedural sedation and analgesia, thereby minimizing risks to the patient and freeing up valuable ED resources.

 

Figure 3: With your fingers, pull the mandible forward (large arrow) while using the ipsilateral zygoma as fulcrum (little arrow). This further dislocates the TMJ anteriorly and facilitates contralateral TMJ reduction. See Figure 4 to perform the concurrent contralateral TMJ reduction. Adapted from Chen et al. 2007.

 

Figure 4: On the opposite side, place your thumb just above the palpable coronoid process and apply persistent pressure to push the coronoid and TMJ back (big and little arrow). Figure 3 and 4 are reversed to facilitate TMJ reduction on contralateral side. Adapted from Chen et al. 2007.

 


Why not watch this technique in action:

 

 

 


References

  1. Tintinalli, JE. (2016). Eye, ear, nose, throat and oral disorders. (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 1590-1591). New York: McGraw-Hill.
  2. Chen Y, Chen C, Lin C, Chen Y. A safe and effective way for reduction of temporomandibular joint dislocation. Ann Plast Surg. 2007;58(1):105-108. [PubMed]
  3. https://www.aliem.com/2016/trick-of-the-trade-extra-oral-technique-for-reduction-of-anterior-mandible-dislocation/

 


 

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Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

PURPOSE:

To assess and address dehydration and initiate treatment to prevent further clinical decline in children >6m with vomiting +/- diarrhea triaged CTAS 3,4,5


The hydration guidelines will be implemented in Triage level 3, 4 and 5 children who are greater than 6 months old presenting with a history of vomiting and/ or diarrhea with no abdominal pain other than expected cramping.

See the Guideline Here

 

 

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IFEM Consensus Statement – SHoC – PoCUS use in Undifferentiated Hypotension and Cardiac Arrest

International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest.

Paul Atkinson, MB, MA*†; Justin Bowra, MB‡§; James Milne, MD¶; David Lewis, MB*†; Mike Lambert, MD**; Bob Jarman, MB, MSc†††‡‡; Vicki E. Noble, MD§§¶¶; Hein Lamprecht, MB***; Tim Harris, BM†††‡‡‡; Jim Connolly, MB†† on behalf of the International Federation of Emergency Medicine Sonography in Hypotension and Cardiac Arrest working group: Romolo Gaspari, MD, PhD; Ross Kessler, MD; Christopher Raio, MD; Paul Sierzenski, MD; Beatrice Hoffmann, MD; Chau Pham, MD; Michael Woo, MD; Paul Olszynski, MD; Ryan Henneberry, MD; Oron Frenkel, MD; Jordan Chenkin, MD; Greg Hall, MD; Louise Rang, MD; Maxime Valois, MD; Chuck Wurster, MD; Mark Tutschka, MD; Rob Arntfield, MD; Jason Fischer, MD; Mark Tessaro, MD; J. Scott Bomann, DO; Adrian Goudie, MB; Gaby Blecher, MB; Andrée Salter, MB; Michael Rose, MB; Adam Bystrzycki, MB; Shailesh Dass, MB; Owen Doran, MB; Ruth Large, MB; Hugo Poncia, MB; Alistair Murray, MB; Jan Sadewasser, MD

Canadian Journal of Emergency Medicine (CJEM) 

The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest.

The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol.

Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend CoreSupplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the “4 F” approach: fluidformfunctionfilling. An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.

Download (PDF, 1.2MB)

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Resident Clinical Pearl – No Bullus Paediatric DKA

No Bullus Paediatric DKA

Resident Clinical Pearl – December 2016

Luke Taylor, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

An altered 2yr old female child presents to your Emergency Department with a BP of 80/50 and a ++high point-of-care blood glucose…….anxiety provoking for all concerned right?

With a presentation like this, the best thing to do according to the House of God…is to “check your own pulse.”  Hopefully after reading this RCP you won’t need to and please don’t waste time recognising that this is severe DKA and this child needs appropriate emergency management.

Key Point – DO NOT BOLUS Fluid and DO NOT BOLUS Insulin

Paediatric DKA (P-DKA) was deemed by a TREKK (TRanslating Emergency Knowledge for Kids) Needs Assessment to be to be an area in which general EDs wished to improve management. A lack of awareness that optimum P-DKA management is different from that of adult DKA was a major driver. In particular, recognition that P-DKA can be complicated by cerebral edema in up to 1.5% of cases.

Management

Is the child in Decompensated Shock? Systolic BP less than (70+(2*age in yrs) for a child >1yr.

If Decompensated? = Bolus 5-10cc/kg over 1-2hrs and reassess after each bolus

 

If not Decompensated? = Correct slowly

Max fluid = 2x maintenance of Normal Saline

Time: Calculate to correct fluid deficit over 48hrs, most are 4-8% dehydrated in moderate DKA

**DKA develops over days (most of the time), therefore slow correction**

Fluid alone, over first 1-2hrs, then Fluid + insulin infusion at 0.05-0.1U/kg/hr

 

Cerebral Edema (CE)

Risk factors:

  • <5yrs old
  • new onset DM
  • ++acidosis
  • longer duration of symptoms
  • severe dehydration

Symptoms of CE:

**Generally 3-12hrs after initiation of therapy

  • headache
  • vomiting
  • confusion
  • GCS<15
  • irritability

Treatment of CE:

  • ABCs
  • restrict IV fluid to maintenance
  • elevate head of bed
  • Mannitol (0.5-1gm/kg IV over 20min) and/or 3% NaCl (5-10ml/kg IV over 30min)

Bottom line

Always:

Use paediatric specific protocol

Like this: http://sjrhem.ca/guideline/dka-pediatrics/

or http://www.bcchildrens.ca/endocrinology-diabetes-site/documents/dkaprt.pdf

And: contact local paediatric diabetes specialist

DO NOT: BOLUS


References

EM Cases Paediatric DKA: https://emergencymedicinecases.com/pediatric-dka/ (Great podcast!)

Lifeinthefastlane DKA: http://lifeinthefastlane.com/ebm-diabetic-ketoacidosis/

Diabetes Ther. 2010 Dec; 1(2): 103–120. The management of diabetic ketoacidosis in children – Arlan L. Rosenbloom

TREKK: http://trekk.ca/

Download (PDF, 280KB)

 

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In case you missed it, 2016…

Don’t touch – from colon to screen.

Am J Infect Control. 2016 Mar 1;44(3):358-60.

Gerba et al. compared the occurrence of opportunistic bacterial pathogens on the surfaces of computer touch screens used in hospitals and grocery stores. Clostridium difficile and vancomycin-resistant Enterococcus were isolated on touch screens in hospitals and in MRSA in grocery stores. Enteric bacteria were more common on grocery store touch screens than on hospital computer touch screens. So don’t snack while you shop over the holidays. The keywords say everything…

Clostridium difficile; Coliforms; Computer touch screen; Methicillin-resistant Staphylococcus aureus; Vancomycin-resistant enterococcus

 

It hurts, it’s tender, but it’s not appy!

J Pediatr Gastroenterol Nutr. 2016 Mar;62(3):399-402.

Siawash at al. remind us about anterior cutaneous nerve entrapment syndrome (ACNES), a frequently overlooked condition causing abdominal pain. They carried out a cross-sectional cohort in a population 10 to 18 years of age consulting a pediatric outpatient department with new-onset AP during a 2 years’ time period. History, physical examination, diagnosis, and success of treatment were obtained in patients who were diagnosed as having ACNES. Twelve of 95 adolescents were found to be experiencing ACNES. Carnett sign was positive at the lateral border of the rectus abdominus muscle in all 12. Altered skin sensation was present in 11 of 12 patients with ACNES. Six weeks after treatment (1-3 injections, n = 5; neurectomy, n = 7), pain was absent in 11 patients.

BUT WHAT IS CARNETT’S SIGN? Have them tense the abdominal wall (by pulling their legs or head off the bed) and if the pain gets worse or stays the same- it is not intra abdominal.

 

Is there a good REASON to stop CPR?

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T, et al. Resuscitation. 2016;109:33-9.

Some clinicians use a lack of cardiac activity on ultrasound as a reason to terminate resuscitation efforts. We at the Saint John Regional Hospital Emergency Department (ED) participated in this prospective observational study at 20 EDs across North America. We assessed the association between cardiac activity on point of care ultrasound (PoCUS) during advanced cardiac life support (ACLS) and survival to hospital discharge in patients with pulseless electrical activity (PEA) or asystole. Of 793 patients with out-of-hospital cardiac arrest enrolled, 26% had ROSC, 14% survived to hospital admission, and 1.6% survived to discharge. Among 530 patients without cardiac activity on PoCUS, only 0.6% survived to discharge (compared with 3.8% of those with cardiac activity).

There is always an argument that the association between dismal survival and lack of cardiac activity is just a self-fulfilling prophecy, if absence of cardiac activity led to early termination of salvageable resuscitations. In this study, resuscitation had to continue until at least 2 scans were completed. So, unless there are very special circumstances, such as significant hypothermia, or post defibrillation, it seems safe to terminate resuscitation for most patients with asystole on ECG and without cardiac activity on ultrasound.

 

 

SIRS, I’m not sure what you mean? The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810.

Singer et al. lay out the new definitions for sepsis and septic shock. SIRS is out. Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Quantify as a SOFA score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L  in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In emergency department, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following: quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. These updated definitions and clinical criteria should replace previous definitions, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.

 

NSAIDs and Lasix – best of friends.

Eur J Intern Med. 2015 Nov;26(9):685-90.

Ungprasert and co. look at the association between exacerbation of heart failure (HF) and use of non-steroidal anti-inflammatory drugs (NSAIDs). Their systematic review and meta-analysis looked at six studies where the use of conventional NSAIDs was associated with a significantly higher risk of development of exacerbation of HF. The excess risk was approximately 40% for conventional NSAIDs and celecoxib.

 

Dispelling the nice or naughty myth: retrospective observational study of Santa Claus

BMJ 2016; 355

Park et al. report their attempt to determine which factors influence whether Santa Claus will visit children in hospital on Christmas Day. They carried out an observational study in paediatric wards in the UK. They discovered that Santa Claus visited most of the paediatric wards in all four countries: 89% in England, 100% in Northern Ireland, 93% in Scotland, and 92% in Wales. The odds of him not visiting, however, were significantly higher for paediatric wards in areas of higher socioeconomic deprivation in England (odds ratio 1.31 (95% confidence interval 1.04 to 1.71) in England, 1.23 (1.00 to 1.54) in the UK). In contrast, there was no correlation with school absenteeism, conviction rates, or distance to the North Pole. The results of this study dispel the traditional belief that Santa Claus rewards children based on how nice or naughty they have been in the previous year. Santa Claus is less likely to visit children in hospitals in the most deprived areas. Potential solutions include a review of Santa’s contract or employment of local Santas in poorly represented regions. Clearly Santa likes everyone in Northern Ireland too! Merry Christmas and happy holidays!

 

PA Dec 2016

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Resident Clinical Pearl – A New Focus for PoCUS

A New Focus for PoCUS

Elective Resident Clinical Pearl – December 2016

Heather Flemming, PGY4 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

A 70 year old female presents to the emergency department with central abdominal pain and one episode of vomiting.  Her vital signs are stable, but she appears uncomfortable.

You bring the ultrasound machine to the bedside to assess her abdominal aorta. Your exam is challenged by the presence of bowel gas, causing scattering of your ultrasound beam, but is ultimately negative for an abdominal aortic aneurysm. You note that the patient has a midline scar, which she states is from a remote hysterectomy. With increased suspicion for bowel obstruction, you move the curvilinear probe across the abdomen and generate the following images: (Video Below)

The images demonstrate dilated loops of bowel and alternating peristalsis (a ‘to and fro movements’ of bowel contents). This confirms your suspicion for a small bowel obstruction (SBO).

 

Discussion:

Bedside ultrasound is a useful tool in evaluating any patient with abdominal pain, and has shown to be more sensitive and more specific than abdominal xray in diagnosing SBO1. Additional advantages of ultrasound include lack of radiation to the patient, bedside availability and potential to improve ED flow2. Treatments, such as nasogastric tube insertion, and early consultation to general surgery can be expedited by rapid identification. In individuals with recurrent sub-acute SBO, PoCUS may become the investigation of choice, reducing radiation exposure for this group of patients.

 

Pearls for performing a bedside ultrasound for SBO:

Multiple regions of the abdomen should be assessed, including the epigastrium, bilateral colic gutters, and suprapubic regions2. (Image 2).

Image 2 (overlapping survey of all quadrants)

 

Typical SBO ultrasound finding include:

  • ≥3 bowel loops dilated >25mm (Measurements taken at 90° to bowel wall)
  • Transition point – dilated peristalsing small bowel visualized adjacent to non-peristalsing collapsed bowel
  • Increased intraluminal fluid
  • Abnormal peristalsis: Hyperdynamic, alternating or absent peristalsis
  • Abdominal free fluid may also be present

 

Credit: ACEP.org

 

References

  1. Jang, Timothy B. Schindler, Danielle. Kaji, Amy H. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J 2011 28:676-678.
  2. Chao, Gharahbaghian. Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? https://www.acep.org/content.aspx?id=100218
  1. http://www.emdocs.net/ultrasound-small-bowel-obstruction/
  1. A video on Ultrasound in Small Bowel Obstruction by the Academy of Emergency Ultrasound can be found here: https://vimeo.com/69551555
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RSI Drugs

RSI Drugs Summary

Dr James French

 


  • REDUCE THE DOSE OF INDUCTION AGENTS IN HYPOTENSION or when Pulse Rate is greater than Systolic Blood Pressure.
  • INCREASE THE DOSE OF PARALYZING AGENTS IN HYPOTENSION.

 

Give the sedative first, followed by a flush, followed by the parlaying agent, followed by a small fluid bolus.

 


KETAMINE

Ketamine is a dissociating sedative that that can also be used in lower doses for procedural sedation ( i.v. 0.5 – 1.0mg/kg) and as a powerful analgesic (i.v. 0.3mg/Kg). When used for RSI the dose is 2.0 mg/Kg and is halved to 1.0 mg/kg in hypotension or a raised shock index (i.e. if the pulse is greater than the systolic blood pressure) . Ketamine causes hypertension, tachycardia and vomiting as its main side effects. When used for procedural sedation Ketamine causes less respiratory depression than other sedatives. Patients can misperceive stimuli during sedation and recovery and become agitated; this is called “emergence”.

Ketamine is available as 10mg/ml concentration for IV use and a 50 mg/ml concentration for IM use only – confusing the concentration being used can cause cardiac arrest. The 10mg/ml concentration is used neat for analgesia, sedation and RSI in adult patients.

 


 

ETOMIDATE

Etomidate is a sedative. It has no analgesic effect.

Etomidate’s chief side effect is hypotension, hypoventilation and adrenal suppression. When used for RSI iv the dose is 0.3. In hypotension or is the pulse rate us greater than the systolic blood pressure the dose of per Kg is halved from 0.3 to 0.15 mg/kg to prevent post induction hemodynamic instability.

Etomidate can cause a myoclonic jerk which are a single gross limb movements. It has a rapid onset of 45 seconds.

Etomidate is short acting – The sedation effect lasts about 5 minutes.

Etomidate is usually dispensed as a white liquid in a single 10ml ampoule, which has a concentration of 2mg/ml.

 


 

SUCCINYCHOLINE

Succinylcholine is a depolarizing muscle relaxant that acts on acetylcholine receptors. It works by binding non-competitively to the muscular acetylcholine receptor. This causes muscular relaxation by “burning out” the neuromuscular mechanism. This activation of the neuromuscular junction causes fasiculations.

Succinylcholine also acts on the acetylcholine receptors on the heart causing bradycardia as its primary side effect, particularly when giving a second dose. 5 mcg/kg of Atropine is therefor given before the second dose of Succinylcholine and in children under one year of age (who are more prone to bradycardia).

Succinylcholine works rapidly, with optimal relaxation in the jaw produced 10 seconds after fasciculations finish in the face.

The paralyzing effect wears off after about 6 – 9 minutes.

Succinylcholine provides no analgesic or sedative effect so it is essential that analgesia and sedation are given after anesthesia.

Succinylcholine is given neat. is a clear liquid and is supplied in one concentration of 20 mg/ml in a glass ampoule containing 100mg.

Succinylcholine dose in adults is 1.5 mg kg. The dose can be increased in severe shock to 2.0 mg/kg and in children. Do not “underdose” the paralyzing drugs so round up when doing drug calculations. Especially do not practice “ampoule based medicine” when using paralyzing agents in emergency situations.

Succinylcholine cannot be given to anybody with acute or chronic neuromuscular disease.

 


 

ROCURONIUM

Rocuronium is a non-depolarizing muscle relaxant. It does not activate the acetylcholine receptor but blocks the bodies own neurotransmitter. It therefore does not cause fasciculations.

Rocuronium also blocks the action of acetylcholine on the heart causing tachycardia as its primary side effect.

Rocuronium is fast onset proving intubating conditions in 60 seconds when given in the correct dose – it is essential that this period is timed after administration.

Rocuronium is long acting providing muscular parlays for about 45 minutes. It provides no analgesic or sedative effect so it is essential that analgesia and sedation are given after anesthesia.

Rocuronium is given as 1.5mg/kg, which is a dose increase, so does not need to be adjusted in severe hypotension.

Rocuronium is given neat and is supplied as a colourless liquid of 10 mg/ml concentration.

 


Lessons from Case Review and the Literature.

 

  1. REDUCE THE DOSE OF INDUCTION AGENTS IN HYPOTENSION.
  2. INCREASE THE DOSE OF PARALYZING AGENTS IN HYPOTENSION.
  3. Give the sedative first, followed by a flush, followed by the parlaying agent, followed by a small fluid bolus.
  4. Time from the moment the drugs are given to prevent the intubator from making the first attempt too early.
  5. When pushing the drugs make sure the IV line is blocked off to prevent the drugs from being pushed back into the giving set.
  6. Use IV access on the opposite side of the blood pressure cuff.
  7. Always follow RSI drugs with analgesia first after the tube is secured.
  8. Give the RSI drugs rapidly, fast IV push, sedative first, then the paralysing agent followed by a large flush or fluid bolus.
  9. Do not paralyze the hypoxic patient until every attempt to restore hypoxia has been corrected.
  10. Resuscitate the circulation with haemorrhage control and blood products, or fluid and vasopressors prior to RSI.

 

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Antivirals for Influenza – Ontario Guidelines

Helpful guidelines published by Ontario Health

What are antiviral medications for influenza?

Antiviral medications are recommended to treat and prevent influenza. Amantadine is an older antiviral medication that is no longer used. Drugs currently used in Canada are oseltamivir (Tamiflu®) which is an oral medication, and zanamavir (Relenza®) which is an inhaled medication. Oseltamivir and zanamivir are neuraminidase inhibitors which work by blocking the exit of the influenza virus from respiratory cells and therefore prevent further replication of the virus. Because antiviral medications prevent further replication of the virus, when used for treatment, they should be taken as soon as possible, ideally within 48 hours of symptom onset.

What are the recommendations for the use of influenza antiviral medications?

Influenza antiviral medications are recommended for:

  • Treatment of moderate, progressive, severe or complicated influenza, such as individuals who are hospitalized with influenza-like illness;
  • Treatment of those at high risk for complications of influenza, such as children less than 5 years of age, adults 65 years of age and over, and those with underlying medical conditions
  • Treatment and prevention in influenza outbreaks in institutional settings

Download (PDF, 678KB)

 

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Poison Management Manual – BC Drug and Poison Information Centre

We now have access (one user license) to the Poison Management Manual from the British Columbia Drug and Poison Information Centre.

The username and password is listed on the link on the Skyline library page (and in the Notes App on the ED iPADS).  Please remember to logoff as we only are permitted one user at a time.  You will also have access to the newsletters.

There is a link icon on the ED iPADS.

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