Skin and Soft Tissue Infections: A PoCUS Guided Approach

Medical Student Clinical Pearl – November 2020

 

Robert Hanlon

@roberthanlon12

Year: 4
DMNB Class of 2021
 

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual

 


Case Report

A 25yr old male presents with a 3 day history of a red swollen foot following an insect bite. He has no past medical history. On examination there is some erythema and swelling on the dorsum of the left foot. Palpation is very tender.

You are aware of recommended guidelines that advise I&D for purulent infections and decide to proceed with the procedure. Despite trying to freeze the area with lidocaine, the procedure is still painful and no pus is drained. You point to the minimal serosanguinous exudate and sheepishly suggest to the patient that the I&D was successful and that a course of antibiotics will resolve this issue.


Skin and Soft Tissue Infections: A POCUS Guided Approach

Skin and soft tissue infections (SSTIs) have a variety of potential causes, ranging in severity from mild infections like cellulitis to abscess all the way to life-threatening causes like necrotizing fasciitis.1 SSTIs are commonly encountered in the emergency department, with cellulitis and abscesses being the two most common.2 It is important to be able to recognize SSTIs and provide appropriate treatment. Abscesses require invasive management, whereas cellulitis is treated with systemic therapies; therefore, it is important to be able distinguish the different between the two types. Doing so can be difficult because of the hidden nature of abscesses. However, ultrasound can be a useful tool in establishing the presence of an abscess. This article is a review of the clinical approach and treatment for SSTIs, focusing on cellulitis and abscesses, as well as the use of ultrasound in helping to establish the diagnosis.


Approach

Clinical suspicion is the initial step in the diagnosis of SSTIs. These infections have multiple causes; therefore, obtaining a detailed history is crucial. Information about immunocompromised state, place of residence, travel, any recent trauma or surgery, previous antimicrobial use, lifestyle, hobbies, and animal bites is essential to developing an adequate differential diagnosis.3

A good understanding of the normal skin flora and common infectious organisms is key to assessing SSTIs. The most commons organisms implicated in SSTIs are Staphylococcus aureus and Streptococcus species.4-6 Methicillin resistant S. aureus (MRSA) being an important strain that has increased in prevalence in the past 20 years. Risk factors such as presence of abscess, intravenous drug use, previous MRSA status, antibiotics within 8 weeks, diabetes mellitus, and previous hospital admission within the last year increase the likelihood of the infection being cause by MRSA.4-6

Physical examination findings are crucial for establishing the presence of an SSTI; the typical criteria are a superficial lesion with the classic inflammatory findings of redness (rubor), swelling (tumor), warmth (calor), and pain (dolor).1,2,7 An abscess is defined as a fluctuant mass of puss localized and buried within a tissue, organ, or potential space; however, clinically it can be hard to determine to presence of this mass.2,7 Other associated signs and symptoms, such as crepitus, bullae, and hemorrhage, may be present upon diagnosis or may develop later during the course.2,7 Due to overlapping clinical presentations of the different SSTIs, it can be difficult to differentiate between them.


Cellulitis – No Abscess
Cellulitis – Possible Abscess
Abscess
Early Abscess

Assessment with POCUS:

Due to the similarities between different SSTI cutaneous findings and their different treatments, it is important to establish if there is an abscess present. It was common, before the introduction of ultrasound, to perform a blind needle aspiration of the infected area in order to determine the presence/absence of an abscess.8,9 However, this subjects that patient to the risks of an invasive procedure as well as pain. On the other hand, treating infection with empiric antibiotics in the presence of an unknown abscess delays drainage and allows for potential worsening of the infection.8,9

A study by Tayal et al. demonstrated that the use of ultrasound was beneficial in patients who had both low and high pretest probability for needing incision and drainage. In patients suspected of having simple cellulitis (low pretest), ultrasound was used to change management in over half of participants; establishing the need for drainage due to imaging of a fluid collection. The opposite was true in the patients suspected of having an abscess (high pretest); the study found that ultrasound was able to determine that more than half of this group did not need drainage, because of the absence of a fluid collection on imaging.10 Other studies have had similar findings, but the percent change in management was slightly lower.11

A study by Barbic et al. demonstrated that POCUS provided a rapid, non-invasive, painless, and easily repeatable test, that distinguished between abscess and cellulitis in the vast majority of cases. Their analysis concluded that POCUS had a sensitivity of 96.2% and a specificity of 82.9% in diagnosing the presence of an abscess.12 They concluded that POCUS can accurately diagnose abscess in paediatric and adult populations and is likely superior to clinical examination.12


Cobblestones

Classic finding for cellulitis (but not specific to cellulitis). There will be hyperechoic lobules of subcutaneous fat surrounded by relatively hypoechoic inflammatory fluid.13

Cobblestone – Cellulitis

Purulent Fluid Collection

Classic finding for an abscess; have a rounded shape of anechoic or hypoechoic fluid collection, and there will be surrounding areas of cobblestones from the overlying cellulitis.13 As well, there should be no color flow if doppler is applied to the area (helping to distinguish from lymph node or vessel).14

Abscess – Anechoic Collection
Possible Abscess or Lymph Node? – This is a lymph node – see below
Colour flow differentiates lymph node from abscess

Necrotizing Fasciitis

Because you do not want to miss it! Findings via ‘STAFF’; subcutaneous thickening, air, and fascial fluid.14 Note, that ultrasound does not to exclude the diagnosis. Also need clinical correlation to increase suspicion of such a serious infection.15

Necrotizing Fasciitis – STAFF

Treatment:

According to The Infectious Diseases Society of America (2014) guidelines, management of SSTIs is differentiated based on the presence/absence of purulence (i.e. abscess/fluid collection). They recommend that all purulent infections be treated with incision and drainage, with more severe infections (signs of systemic involvement) being cultured with sensitivities in order to add antibiotics to the treatment.16 Otherwise, non-purulent infections are to be treated with systemic antibiotics; the severity of the infection determining the route and choice of agent.16

Antibiotic therapy, in addition to incision and drainage of a skin abscess, is suggested for patients with any of the following:17

  • Single abscess ≥2 cm or multiple abscesses
  • Large are of surrounding cellulitis
  • Patients with immunosuppression or other comorbidities
  • Signs of systemic involvement (fever > 38°C, hypotension, or tachycardia)
  • Poor clinical response to incision and drainage alone
  • Presence of an indwelling medical device
  • High risk for adverse outcomes with endocarditis (these include a history of infective endocarditis, presence of prosthetic valve or prosthetic perivalvular material, unrepaired congenital heart defect, or valvular dysfunction in a transplanted heart)
  • High risk for transmission of aureus to others (such as in athletes or military personnel)

 

Horizon Health’s local trends recommend the following (see guideline or Spectrum app for full details)

Severity of Infection

 

 

Antibiotic

Mild

Moderate

Severe

Cephalexin 500 – 1000mg PO q6h x 5 days

ceFAZolin 2 g IV q8h x 5 days

ceFAZolin 2 g IV q8h +/- Clindamycin 900 mg IV q8h

If true beta-lactam allergy

Cefuroxime 500 mg PO BID or TID x 5 days

Clindamycin 600-900 mg IV q8h x5 days

 

If MRSA suspected

Septra 800/160 mg or 1600/320 mg PO q12h x 5 days

Vancomycin 25-30 mg/kg IV once then 15mg/kg IV q8 to q12h x 5 days

ADD Vancomycin 25-30 mg/kg IV once then 15mg/kg IV q8 to q12h

 


Some research is suggesting that POCUS can take the assessment of abscesses one step-further and impact management based on the depth and size of the fluid collection seen in imaging. Russell et al. found that abscesses less than 0.4cm below the skin surface could be effectively treated without incision and drainage.18 Another study found that patients, with skin abscesses less than or equal to 5cm in diameter, treatment with oral antibiotics in combination with incision and drainage had improved short-term outcomes compared to those patients treated with the procedure alone.18 While as mentioned above, UpToDate, suggests that antibiotics be used in single abscess greater than 2 cm in size. As well, research has found that ultrasound guided incision and drainage provides lower failure rates (less recurrent infections or multiple incisions) compared to blind incision and drainage. Likely due to better visualization of the abscess and more adequate initial drainage.19


Limitations

There are some limitations to POCUS for SSTIs: ultrasound imaging and interpretation rely on the user’s ability to obtain high-quality images in order to assess whether an abscess is present. It is important for the user to be familiar with different findings on ultrasound to guide appropriate treatment. An abscess may appear hypoechoic, hyperechoic, or anechoic (depending on tissue contents), and usually has posterior acoustic enhancement.19 Determining if it is drainable can be difficult due to this variability in imaging, and it is also quite common for early abscesses to present like cellulitis with erythema, no fluctuance, and an ultrasound that is negative for a fluid collection.20 In cases of a suspected evolving abscess, sometimes referred to as a non-ripe abscess, supportive care, including warm compresses, pain control, and close follow-up, is recommended.20 The practitioner may treat this like cellulitis; however, the patient may return with perceived failure of therapy if discharge advice does not include the possibility of of an abscess forming over time.


Abscess examples from the SJ archives


References

  1. Moffarah AS, Al Mohajer M, Hurwitz BL, Armstrong DG. Skin and Soft Tissue Infections. Microbiol Spectr. 2016 Aug;4(4). doi: 10.1128/microbiolspec.DMIH2-0014-2015.

 

  1. Martinez, N. “Skin and Soft-Tissue Infections: Itʼs More Than Just Skin Deep.” Advanced Emergency Nursing Journal, vol. 42, no. 3, 2020, pp. 196–203.

 

  1. Cieri, B., Conway, E., Sellick, J., & Mergenhagen, K. (2019). Identification of risk factors for failure in patients with skin and soft tissue infections. The American Journal of Emergency Medicine, 37(1), 48-52.

 

  1. Borgundvaag, B., Ng, W., Rowe, B., Katz, K., Farrell, Brian, Guimont, Chantal, . . . Gregson, Dan. (2013). Prevalence of methicillin-resistant Staphylococcus aureus in skin and soft tissue infections in patients presenting to Canadian emergency departments. CJEM, 15(3), 141-160.

 

  1. Esposito, S., De Simone, G., Pan, A., Brambilla, P., Gattuso, G., Mastroianni, C., . . . Savalli, F. (2019). Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry. Journal of Chemotherapy (Florence), 31(1), 9-14.

 

  1. Stenstrom, R., Grafstein, E., Romney, M., Fahimi, J., Harris, D., Hunte, G., . . . Christenson, J. (2009). Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus skin and soft tissue infection in a Canadian emergency department. CJEM, 11(5), 430-8.

 

  1. Spelman, D., Baddour, LM. (2020). Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved November 11, 2020. From: https://www.uptodate.com/contents/cellulitis-and-skin-abscess-epidemiology-microbiology-clinical-manifestations-and-diagnosis?search=abscess%20treatment&topicRef=110530&source=see_link#H2443336514

 

  1. Comer, Amanda B. “Point-of-Care Ultrasound for Skin and Soft Tissue Infections.” Advanced Emergency Nursing Journal, vol. 40, no. 4, 2018, pp. 296–303.

 

  1. Gaspari, R., Sanseverino, A., & Gleeson, T. (2019). Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Annals of Emergency Medicine, 73(1), 1-7.

 

  1. Tayal, V., Hasan, N., Norton, H., & Tomaszewski, C. (2006). The Effect of Soft‐tissue Ultrasound on the Management of Cellulitis in the Emergency Department. Academic Emergency Medicine, 13(4), 384-388.

 

  1. Alsaawi, A., Alrajhi, K., Alshehri, A., Ababtain, A., & Alsolamy, S. (2017). Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: A systematic review of the literature. European Journal of Emergency Medicine, 24(3), 162-169.

 

  1. Barbic, D., Chenkin, J., Cho, D., Jelic, T., & Scheuermeyer, F. (2017). In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open, 7(1), E013688.

 

  1. Atkinson DP, Bowra J, Harris T, Jarman B, Lewis D, editors. Point of Care Ultrasound for Emergency Medicine and Resuscitation. Oxford University Press; 2019. pp. 140, 199-200.

 

  1. Gottlieb, M., Schmitz, G., Grock, A., & Mason, J. (2018). What to Do After You Cut: Recommendations for Abscess Management in the Emergency Setting. Annals of Emergency Medicine, 71(1), 31-33.

 

  1. Castleberg, E., Jenson, N., & Dinh, V. (2014). Diagnosis of necrotizing faciitis with bedside ultrasound: The STAFF Exam. The Western Journal of Emergency Medicine, 15(1), 111-113.

 

  1. Stevens, D., Bisno, A., Chambers, H., Dellinger, E., Goldstein, E., Gorbach, S., . . . Wade, J. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 59(2), 147-159.

 

  1. Spelman, D., Baddour, LM. (2020). Cellulitis and skin abscess in adults: treatment. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved November 11, 2020. From: https://www.uptodate.com/contents/cellulitis-and-skin-abscess-in-adults-treatment?search=abscess%20treatment&topicRef=110529&source=see_link

 

  1. Russell, F., Rutz, M., Rood, L., Mcgee, J., & Sarmiento, E. (2020). Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage. The Western Journal of Emergency Medicine, 21(2), 336-342.

 

  1. Gaspari, R., Sanseverino, A., & Gleeson, T. (2019). Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Annals of Emergency Medicine, 73(1), 1-7.

 

  1. Thornton J, Hellmich T. Evaluation and Management of Abscesses in the Emergency Department. Emergency Medicine Reports. 2017 May 1;38(10).
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EM Reflections October 2020 – Spinal Cord Injury

Big thanks to Dr. Joanna Middleton for leading the discussions in October

All cases are imaginary, but highlight learning points that have been identified as potential issues during rounds.

Edited by Dr. Mandy Peach


Spinal Cord Injury

  • Recognition of various patterns of spinal cord injury
  • Reviewing EMS record can be helpful for progression of symptoms and baseline exam
  • A normal CT does not rule out spinal cord injury in a patient with neurological deficits
  • Importance of detailed neurological exam and clear communication with consultant
  • Importance of clear documentation of exam – consider using ASIA

Case

A 72 yo female presents complaining of bilateral arm weakness ongoing for 1 day. She has no other symptoms concerning for stroke. She denies any direct trauma to head or neck, but did say she was pushed from behind by a large dog and her neck ‘snapped back’ the day prior. Incidentally she says she also hasn’t urinated in over 8 hours. Her vital signs are within normal limits.


 

You are concerned about a spinal cord injury – what are the various cord syndromes? What in the history predisposes to a particular spinal cord syndrome?

4 Classification of spinal cord syndromes

This woman is elderly, likely with underlying cervical spondylosis, and has a hyperextension injury – predisposing her to a central cord syndrome. This is the most common type of incomplete spinal cord injury. Often these patients are asymptomatic from their spondylosis before the event and the mechanism of injury is usually not severe5.

Central cord syndrome involves both motor and sensory pathways and has a variable presentation. Typically one sees motor weakness in the hands and forearms with sensory preservation. Bladder dysfunction and sexual dysfunction can be seen in severe cases5. A helpful mnemonic is MUD-E6.

 

MUD-E

  • Motor loss > sensory loss
  • UE > LE
  • Distal > proximal
  • Extension type injury

 

You complete a detailed neurological exam and find she does have upper limb weakness distally. A bladder scan confirms urinary retention with 850 cc of urine in her bladder.

You decide to order a CT C -spine to assess for bony injuries. The CT scan is unremarkable.

Does this rule out a spinal cord injury in this patient?

No – normal CT does not rule out SCI in a patient with ongoing neurological deficits. In fact, in elderly patients there is often no bony injury, but the narrowed spinal canal can predispose to buckling of the ligament flava, leading to injury of the spinal cord.

You review EMS notes and nursing documentation – there are subtle differences throughout in how the exam is performed and recorded.

What is one tool that can improve your documentation in terms of accuracy and clarity?

ASIA (American Spinal Injury Association) Classification

You document your findings on ASIA, which allows for clearer communication and documentation with the attending neurosurgeon.


 

References for further reading:

4 Perron & Huff (2010). Chapter 104 Spinal Cord Disorders. Rosen’s Emergency Medicine: Concepts and Clinical Practice. pp 1389-1397. Philadephia, PA

5  Douglas, Nowak et al. (2009). Review article: Central Cord Syndrome. Journal of the American Academy of Orthopedic Surgeons. 17: 756-765

6 A boring guide to spinal cord syndromes. CanadiamEM. https://canadiem.org/a-boring-guide-to-spinal-cord-syndromes/


 

Authored and Edited by Dr. Mandy Peach

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EM Reflections October 2020 – Acute Urinary Retention

Big thanks to Dr. Joanna Middleton for leading the discussions in October

All cases are imaginary, but highlight learning points that have been identified as potential issues during rounds.

Edited by Dr. Mandy Peach


 

Acute Urinary Retention (AUR)

  • Categorized as obstructive, infectious/inflammatory, neurological, medication related
  • Physical exam should include a DRE and neurological exam
  • Investigations should include a U/A +/- C&S, creatinine, electrolytes +/- CBC
  • Consider a renal US if any renal impairment
  • PSA – defer at least 2 weeks, as acute urinary retention can cause elevation
  • Consider risk factors for post-obstructive diuresis

Case

A 60 yo male presents to the emergency department with inability to void over 8 hours, despite feeling urgency. He complains of increasing lower abdominal discomfort. He denies any infectious symptoms or new medications. He denies any back pain or recent injury. He does have a history of hesitancy and poor urine stream. He has never had a prostate exam and has no family doctor. His vital signs are within normal limits. He has a significantly distended bladder on physical exam.


Indications to insert a catheter1:

  • Inability to pass urine > 10 hours
  • Abdominal discomfort with bladder distention
  • Signs of acute kidney injury secondary to obstruction
  • Infectious cause of retention
  • Overflow incontinence

You decide to insert a urinary catheter. What else should you consider as part of your physical exam?

Consider the 4 main causes of urinary retention:

In this male patient it is pertinent to do a prostate exam to check for enlargement as well as a thorough neurological exam.

On exam you palpate a large, firm prostate. You are suspicious of prostate cancer – do you do a prostate specific antigen (PSA)?

No – acute urinary retention can transiently elevate PSA measurements up to 2 fold, this can persist for up to 2 weeks2. Defer PSA testing until after this time.

The U/A is negative for infection. The electrolytes are normal but the patient has an acute AKI with an elevated creatinine. Does this patient require renal imaging?

Consider renal imaging in any patient with AUR and abnormal renal function to assess for anatomical cause.

2 hours has passed and you reassess the patient – 1L of urine has drained upon insertion. A minimal amount has been draining since. The post-void residual is now 20 cc.

Is this patient at risk of post-obstructive diuresis?

Risk factors:

  • Abnormal electrolytes or acute creatinine elevation
  • Volume overload
  • Uremic
  • Acutely confused

Although the patient does have an abnormal creatinine, clinically he does not show signs of post-obstructive diuresis which is defined as urinary output > 200 mL for at least 2 hours after urethral catheter insertion, or > 3L in 24hrs AFTER the initial emptying of the bladder. Patients with any risk factors for post-obstructive diuresis should be observed in the ED for 4 hours.

After an appropriate observation period you discharge the patient with an urgent referral to urology given the acute presentation and abnormal prostate exam. You are sending the patient home with an indwelling catheter.

What is the optimum duration of catheter insertion? Does this patient require antibiotics?

Trials are contradictory. Some found increased likelihood of spontaneous voiding after 7 days, while an observational study found improved success if insertion was less than 3 days3.

Expert opinion from urology suggests duration of 7 days to avoid risk of re-catheterization1.

Routine antibiotics are not recommended unless the cause is thought to be infectious. However, if prostatic enlargement is thought to be the cause an alpha-blocker like tamsulosin can be beneficial1

 


 

References for further reading:

1 Ep 143 Priapism and Urinary Retention: Nuances in Management. Emergency Medicine Cases. https://emergencymedicinecases.com/priapism-urinary-retention/

2 Aliasgari, Soleimani, Moghaddam (2005).The effect of acute urinary retention on serum prostate-specific antigen level. Urology journal. Spring 2005;2(2):89-92

3 Acute Urinary Retention. Uptodate. https://www.uptodate.com/contents/acute-urinary-retention?search=post%20obstructive%20diuresis&source=search_result&selectedTitle=1~5&usage_type=default&display_rank=1#H537553020


 

Authored and Edited by Dr. Mandy Peach

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EM Reflections – September 2020

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

All cases in this series are imaginary, but highlight learning points that have been identified as potential issues during rounds

Edited by Dr David Lewis 


Discussion Topics

  1. Incomplete Abortion

    • Unstable patients require staff to staff direct communication. OBGYN staff are always in house.
    • Patients remain responsibility of EM attending staff during and after consult. Transfer of care occurs at admission.
    • Be aware of the pitfalls of handover and possible need to reassess patient depending on clinical situation
  2. Cardiac Arrest – Pulmonary Embolism

    • Be aware of bias when seen patient in low acuity area
    • Alway consider and document a ‘top 3’ differential diagnosis
    • CPR must be extended after thrombolysis for suspected / confirmed PE
    • Consider following a standardized VTE pathway

 


Incomplete Abortion

Case

A 30yr old female presents with a profuse PV bleeding. She is 7 weeks pregnant by dates. She presents with abdominal pain, palor and is hypotensive and tachycardic. During fluid resuscitation, PV exam confirms the presence of blood and clots, the os is open and contains tissue. This is removed. The bleeding appears to stop. CBC identifies a low hemoglobin. The patient is transfused. What are the potential pitfalls in the management of this case?


 

Threatened abortion

Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and closed cervix

Spontaneous abortion

Spontaneous loss of a pregnancy before 20 weeks’ gestation

 Complete abortion

Complete passage of all products of conception

 Incomplete abortion

Occurs when some, but not all, of the products of conception have passed

 Inevitable abortion

Bleeding in the presence of a dilated cervix; indicates that passage of the conceptus is unavoidable

 Septic abortion

Incomplete abortion associated with ascending infection of the endometrium, parametrium, adnexa, or peritoneum

 

First Trimester Bleeding – American Family Physician

Patient Information Leaflet

 

Management of Unstable Patients with 1st Trimester Bleeding

  • Urgent Consult to OBGYN
  • Management is similar to all unstable bleeding patients (resus room, monitors, vascular access, IV fluid +/- unmatched O neg blood, foley).
  • Investigate for DIC.
  • Tranexamic acid (1g IV) +/- oxytocin (40U by IV in 1L NS at 150cc/hour) can be given to slow bleeding before definitive management (in the OR).
  • **In an unstable patient with massive vaginal bleeding, a pelvic exam is indicated to identify a source and to look for and extract tissue found in the cervix.**
  • Any unstable patient who presents with 1st trimester bleeding and requires blood transfusion should be admitted, even if they stop bleeding in ED and the low Hb is corrected. There is potential for rebleed over next 24 hrs especially if products are retained.

Episode 23: Vaginal Bleeding in Early Pregnancy


Further Reading:

CanadiEM Frontline Primer – Early Pregnancy – First Trimester Bleeding

 

 

 


Cardiac Arrest – Pulmonary Embolism

Case

A 68 yr old male is brought into the emergency department with chest pain and shortness of breath. The patient is diaphoretic and hypotensive. They report a 5 day history of progressive leg swelling prior to these new symptoms. During the initial assessment the patients has a cardiorespiratory arrest. What is the differential diagnosis? What is the management of cardiac arrest when PE is suspected


 

A retrospective study published in Arch Intern Med  – May 2000, found that PE was found as the cause in 60 (4.8%) of 1246 cardiac arrest victims over an 8 year period.The initial rhythm diagnosis was pulseless electrical activity in 38 (63%), asystole in 19 (32%), and ventricular fibrillation in 3 (5%) of the patients. Thrombolysis resulted in significantly higher rate of ROSC, however survival to discharge was very low.

Diagnosis of PE in cases of cardiac arrest is often difficult to establish. Clinical suspicion of PE as a cause of cardiac arrest remains the key in timely diagnosis and treatment. In this study sudden dyspnea and syncope were the most suggestive reported symptoms. Deep vein thrombosis is known to be an important risk factor for PE, but clinical signs of deep vein thrombosis are rare and nonspecific. Right bundle-branch block was present in 67% of these cases, and this should induce a high suspicion for massive PE as cause of cardiac arrest. The authors recommend either transthoracic or transesophageal echocardiography be performed at the bedside in all cases to help establish the diagnosis of PE as the cause of a cardiac arrest.

 

 

Management of Cardiac Arrest in Suspected PE


  1. Commence CPR and follow the ACLS 2018 Algorithm
  2. Suspicion for PE as cause of cardiac arrest?
  3. Bedside Assessment to Increase Suspicion of PE as cause of cardiac arrest
  4. Thrombolysis
  5. VA ECMO + Interventional Radiology / Cardiovascular Surgery

1.  Commence CPR and follow the ACLS 2018 Algorithm

AHA ACLS 2018 Algorithms –  Update Highlights

2.  Suspicion for PE as cause of cardiac arrest?

  • Sudden onset dyspnoea or syncope prior to cardiac arrest
  • Right ventricular strain, new RBBB or other PE suggestive findings on ECG immediately prior to cardiac arrest
  • Initial non-shockable rhythm
  • History of immobilization prior to cardiac arrest (recent surgery, travel, injury)
  • History of thromboembolism
  • History of recent cancer diagnosis and treatment
  • Known hypercoagulation condition (e.g. Factor V Leiden)
  • No history of cardiac disease
  • Age less than 50yrs
  • Female
  • Pregnancy or Birth Control
  • Clinical signs of recent DVT (swollen leg, history of swollen/painful leg)

Improving identification of pulmonary embolism-related out-of-hospital cardiac arrest to optimize thrombolytic therapy during resuscitation

3.  Bedside Assessment to increase likelihood of PE as cause of cardiac arrest

  • Clinical exam for signs of DVT
  • Clinical assessment to exclude other reversible causes of cardiac arrest (5H’s and 5T’s)
  • DVT PoCUS
  • Transthoracic Echo PoCUS – RV dilatation, TV regurge, visible clot, dilated IVC (must not delay CPR)
  • Transesophageal Echo PoCUS – RV dilatation, TV regurge, visible clot, dilated IVC (superior images, does not interfere with CPR)

 

4.  Thrombolysis

An retrospective study published in Chest in 2019 analysed thrombolysis in PE related out-of-hospital-cardiac arrest. They found that thrombolysis was associated with increased 30 day survival but that a good neurological outcome was rare and not significantly improved. This 2019 systematic review and meta-analysis concluded that systematic thrombolysis during CPR did not improve hospital discharge rate.

Despite a weak evidence base, both the European Resuscitation Council (ERC) as well as the American Heart Association (AHA) have recommend the use of fibrinolytic therapy when PE is either known or suspected as the cause of cardiac arrest.

AHA Recommendations – in refractory cardiac arrest where PE has either been confirmed or is suspected, thrombolysis is a reasonable emergency treatment option:

  • Alteplase 50mg peripheral IV bolus
  • Option to repeat the bolus at 15 mins
  • Continue CPR for 30-60 minutes after lytic administration

EMCrit 261 – Thrombolysis during Cardiac Arrest

 

5.  VA ECMO + Interventional Radiology / Cardiovascular Surgery

Interventional and surgical procedures cannot be performed during CPR.

Several studies have concluded that ECMO can be beneficial in patients with PE related cardiac arrest

Extracorporeal membrane oxygenation in life-threatening massive pulmonary embolism

Use of extracorporeal membrane oxygenation in patients with acute high-risk pulmonary embolism: a case series with literature review

Resuscitation of prolonged cardiac arrest from massive pulmonary embolism by extracorporeal membrane oxygenation

Massive Pulmonary Embolism as a Cause of Cardiac Arrest: Navigating Unknowns in Life After Death

 

The consensus seems to be that in order to see benefit from the use of ECMO to bridge patients with massive PE / cardiac arrest a protocolized approach is required, including a standby ECMO team and predetermined pathways.

 


Further Reading

Submassive & Massive PE

 

Continue Reading

Wound Management in the ED: Absorbing the Literature – Case Study

 

A review of the principles of emergency wound management including detailed guide to suture material.

 

Medical Student Clinical Pearl – June 2020

Robert Hanlon

@roberthanlon12

Year: 4
DMNB Class of 2021

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual


 

Case Report

You are a third year clinical clerk asked to go see a patient and assess their injuries. A 28 year old female, who is sitting upright in bed and texting her friends, came into the Emergency department via ambulance with a laceration over her right forearm and wrist. EMT vital signs are as follows: BP 128/84, HR 106, RR 18, Temp 37.2, O2 Sats 99% on RA, GCS 15, and Blood glucose 6.4 mmol/L. She weighs 60 kg. The paramedics had wrapped her arm with gauze, which has a blood tinged color to it.

Crying Boy Laying Down With Injured Leg. Selective Focus On Shin.. Stock Photo, Picture And Royalty Free Image. Image 81697370.

What is your approach?


 

Emergency Wound Management

 

A – Ask yourself: is the patient stable or unstable?

  • Based on this patient’s vital signs and the fact that they seem calm and comfortable in bed, they are stable. The tachycardia noted in the vitals is likely due to pain/stress at the time collection and when taken again in the ED her heart rate is 78 and regular.
  • A critical wound (hemorrhage or arterial bleeding) will likely need immediate attention and the patient may be presenting with vital signs that suggest more instability (low BP, high HR, high RR, High Temp, low O2 Sats).
  • If the patient is stable and not exsanguinating, then a brief history and physical should be performed. 1,2 Obtain a brief history:

Arterial bleeding

 

 

B – Obtain a brief history:

Mechanism and timing of injury: The patient was carrying towels down the stairs to her pool, tripped and fell down 5 steps, landing on her right side and breaking through a glass panel on her deck. This occurred 45 minutes ago.

Potential for concurrent injuries based on mechanism: The patient denies any loss of consciousness or head trauma. Denies any pain besides the laceration and does not feel like she has broken any bones.

Functional status prior to injury: She had full range of movement and full sensation in her right arm, wrist, and hand prior to the injury.

Medical History: Patient denies any allergies, diabetes, renal disease, cardiac and vascular diseases, and no bleeding disorder. She is a healthy non-smoker, and her only medication is an OCP.

Tetanus Status: She is up-to-date with her immunizations and her last tetanus shot was 2 years ago.

 

C- Perform a Physical Exam:

Patient is a well-looking 28 year old female with no signs of distress. She is alert and oriented to person, place, and time. She has a bandage on her right forearm that has dried blood on it. She denies any numbness or tingling in her hand. There is no obvious deformity of the arm.

Remove bandage and assess wound: Patient has a 6 cm rounded laceration with the wound extending from the mid-wrist on the volar side to Lister’s tubercle on the dorsal side. It looks like you can see some tendons and muscle at the wound base, but they do not look injured. There is no sign of glass or other foreign bodies, no dead tissue, and the wound bed appears bloody. It has a slow stream of blood running out of it. The surround skin is pink and appears undamaged.

Assess for neurovascular compromise 3,4  : The wrist anatomy is complex and it is important to consider the underlying anatomy when deciding on how to test for injury. Also compare to the patients “normal” other side.

Test for motor function: patient is able to fully extend, flex, and deviate the wrist to both ulnar and radial sides. She is able to flex, extend, abduct, and adduct her thumb, and has no trouble with opposition. She has flexion at the PIP and DIP joints from D2 to D5. She is able to fully extend her fingers and perform abduction as well. Her strength is 5/5 for these movements as well.

Test for sensation: Patient has sensation to light-touch and pin-prick over her thenar eminence, distal aspect and dorsal aspect (proximal to PIP) of D2, D3, and radial half of D3 (testing for intact median nerve). As well as sensation over the radial aspect of the dorsal hand (Radial Nerve). With this injury you should not expect the ulnar nerve to be damaged, but you’re a studious clerk and testing reveals intact sensation.

Test for vascular compromise: You do not notice any pulsatile aspect to the bleeding, her skin is pink, warm, and has <3 seconds of capillary refill. You palpate strong radial pulses and are reassured that she has not injured this artery.

 

With this examination you are reassured that she has not injured any underlying structures (tendons, nerves, muscles, and vasculature). You tell the patient that despite a large cut, she is lucky that no serious damage was done.

 

D- Obtain Pain Control: Either local or regional anesthesia.

Luckily, you just finished your plastic surgery rotation and had plenty of experience drawing up local anesthetic. You also learned how to inject a wound while trying to minimize the patients pain. You were told to ALWAYS USE EPI and ALWAYS USE BICARB in your anesthetic solution.5 You draw up one 10 ml solutions (or 100mg) of Lidocaine 1% with epinephrine 1:100,000 buffered with 1 ml bicarbonate (1:10 ratio of bicarb to lidocaine). Maximum dose being 7mg/kg or 420 mg for this patient. You’re wondering if you might need more and realize that you could be getting close to the patient maximum dose; however, you remembered you could always dilute your solutions to double the amount of syringes and still have effective analgesia.5,6 You use a smaller gauge needle (27 or 30 gauge) as this helps to reduce the pain experienced by the patient.5 You let the patient sit for a while so the analgesia will be effective.

ED Rounds – EM and Hand Surgery – Dr Don Lalonde

Regional anesthesia of the hand

 

E – Irrigation and Cleansing:

You irrigation the wound with copious amounts of tap water (or saline). Again, you notice no foreign bodies or signs of infection. You position the patient lying down in bed and cleanse the skin around the wound with chlorhexidine swabs to prep the surface for wound closure.1,3,7,8

Note: Debridement of jagged, dead, or highly contaminated tissue may be necessary in order to promote wound healing and provide an optimal surface for closure and cosmetic effect.3

 

F- Wound Closure with Sutures:

When you were gathering your supplies you realized there were many options for sutures, so you decided to ask your attending. They recommended a non-absorbable either 4-0 or 5-0 Nylon suture and to use a simple interrupted technique. You closed the wound and the edges approximated well. You, your patient, attending are all happy with the result. The patient is discharged with follow-up for suture removal in 7 days.

Wound Closure Resources

 

Useful Patient Information Reference from the ACS

 


 

Suture Types: To absorb or not to absorb?

 

Typical emergency department suture choice is a monofilament non-absorbable suture, this is due to ease of handling, knot security (does not easily break), and emergency texts report a lower rate of infections.1,2,3 There is also the need for suture removal, which requires follow-up and a second look at how the wound is healing. Absorbable sutures are usually harder to handle and tying knots can be tricky due to ease of breaking, especially with smaller sized sutures. Much of the emergency texts cite an increase in rates of infection with absorbable sutures as a reason not to choose them. However, evidence suggests that there is no significant difference in rates of infections or clinical outcome.9-12 Literature does point towards higher rates of tissue reactivity (inflammation associated with placing of suture) with absorbable sutures.12 Really selection of sutures comes down to wound factors (location and tension requirements), patient factors (need for follow-up, compliance, etc.), as well as physician preference. See tables for types and recommended use.

 


 

References:

  1. Busse, Brittany, and SpringerLink. Wound Management in Urgent Care. 1st Ed. 2016.. ed. Cham: Springer International : Imprint: Springer, 2016. Web.
  2. Cydulka, Rita K. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill Education, 2018. Print.
  3. Reichman, Eric F. Reichman’s Emergency Medicine Procedures. McGraw Hill Professional, 2018.
  4. Janis, Jeffrey E. Essentials of plastic surgery. CRC Press, 2014.
  5. Strazar, A. Robert, Peter G. Leynes, and Donald H. Lalonde. “Minimizing the Pain of Local Anesthesia Injection.” Plastic and Reconstructive Surgery3 (2013): 675-84. Web.
  6. Lalonde, Donald H. ““Hole-in-One” Local Anesthesia for Wide-Awake Carpal Tunnel Surgery.”Plastic and Reconstructive Surgery 5 (2010): 1642-644. Web.
  7. Deboard, Ryan H, Dawn F Rondeau, Christopher S Kang, Alfredo Sabbaj, and John G Mcmanus. “Principles of Basic Wound Evaluation and Management in the Emergency Department.”Emergency Medicine Clinics of North America 1 (2007): 23-39. Web.
  8. Forsch, Randall T. “Essentials of Skin Laceration Repair.” American Family Physician8 (2008): 945-51. Web.
  9. Kharwadkar, N., S. Naique, and P.J.A Molitor. “Prospective Randomized Trial Comparing Absorbable and Non-absorbable Sutures in Open Carpal Tunnel Release.” Journal of Hand Surgery1 (2005): 92-95. Web.
  10. Xu, Utku, Bin, Xu, Utku, Bo, Wang, Utku, Liwei, Chen, Utku, Chunqiu, Yilmaz, Utku, Tonguç, Zheng, Utku, Wenyan, and He, Utku, Bin. “Absorbable Versus Nonabsorbable Sutures for Skin Closure: A Meta-analysis of Randomized Controlled Trials.” Annals of Plastic Surgery5 (2016): 598-606. Web.
  11. Sheik-Ali, Sharaf, and Wilfried Guets. “Absorbable vs Non Absorbable Sutures for Wound Closure. Systematic Review of Systematic Reviews.” IDEAS Working Paper Series from RePEc(2018): IDEAS Working Paper Series from RePEc, 2018. Web.
  12. deLemos, D. (2018). Closure of minor skin wounds with sutures. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved July 3rd, 2020. Source
Continue Reading

Trauma Reflections – June 2020

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


 

Major points of interest:

 

A) How are we doing with calling Trauma Codes for qualifying cases?

In the past year, for cases qualifying for trauma team activation, the rate of calling ‘Trauma Codes’ has fallen to 66%.

If a Trauma Code was called, RN trauma note use increased to 85% and time to disposition to an ICE setting was significantly decreased.

 

Please review the attached updated simplified activation criteria – notable changes are:

  • Removal of minor head injuries without signs or symptoms on anticoagulants under “D”
  • Addition of pulseless extremity under “C”


B) ECMO in trauma

MVC victim survived after being submerged x 20 minutes – CPR (with LUCAS) and then managed further with ECMO.

Key to successful outcome will be EARLY recognition of cases that may benefit and early alert/consultation with CV surgery.

Best evidence for ECMO is for re-warming severe hypothermic patients.

 


 C) Significant MOI + spine pain = CT

Obtaining spine x-rays in cases with moderate probability of bony injury inevitably leads to another trip down the long hallway to visit our diagnostic imaging colleagues (and delay to definitive diagnosis).

If your patient needs a CT, order a CT.

See attached consensus guideline.


D) Pelvic binders are not used to ‘treat’ the pelvic fracture

They are used to treat any hemodynamic instability caused by the fracture. If a patient is stable or has a pelvic fracture that is not likely causing significant bleeding, the binder can likely be loosened or removed.

A pelvic binder can exacerbate some fractures, such as lateral compression fractures. Orthopedics should be assisting with this decision.

 


E) That intubated transfer patient just waved at me!

There is a reason trauma transfers should be assessed on arrival.

Consultants are expected to attend to these patients ASAP, but timely review by emergency MD is expected to assess/treat priorities (ventilatory status, analgesia need, sedation etc.)

 


F) The patient is on warfarin…how quaint!

Do you remember when anticoagulants could be reversed? In the event you do meet a trauma patient on warfarin, early correct dosing of vitamin K and PCC may be crucial.

Review of such charts in past 2 years has our dosing all over the map.

Easy dosing regime is:

 

Vitamin K – 10mg IV and PCC – 2000IU if INR unknown,

If INR known: PCC – 3000IU if INR > 5, PCC – 2000IU if INR 3-5, PCC – 1000 if INR < 3.

 


G) Trauma checklist:

“SJRH ED Trauma Process Checklist” is in trauma note package in room 19 and is a very useful prompt (see below).


H/ High MOI Knee injuries are at risk for deterioration in department

Vascular status may change, compartment syndrome may develop.

Consider repeating physical exams, early orthopedic consultation and low threshold for CT with vascular studies.

 


I/ Where is this guy bleeding?

Maybe he isn’t. Failure to respond to resuscitation suggests continued hemorrhage or non-hemorrhagic cause for shock. With neurogenic shock, loss of sympathetic tone may cause hypotension without tachycardia or vasoconstriction.

Consideration should be made to start vasopressors in patients with spinal cord injury with persistent hypotension after attempted resuscitation and no evidence of hemorrhagic shock. Aim for a SBP of 90-100. Avoid overzealous fluid administration.

 


J/ NB Trauma Traumatic Brain Injury Consensus statement – May 2020

See attached

Download (PDF, 1.32MB)

Continue Reading

EM Reflections – June 2020

Thanks to Dr Joanna Middleton for leading the discussions this month

Edited by Dr David Lewis 


Discussion Topics

  1. Antiviral Toxicity

    • Always adjust dosing in patients with renal impairment
  2. Necrotising Fasciitis

    • Difficult clinical diagnosis
    • Should be on the differential for all soft tissue infections
    • Delayed definitive care always results in poor outcomes
  3. Epidural Abscess

    • Thorough detailed neurological examination required
    • Isolated leg weakness is rare in Stroke
    • Progressive development of symproms and mixed UMN/LMN signs suggests spinal cord compression.

 


Antiviral Toxicity

Case

A 70yr old male presents with a typical zoster rash in the left L1 dermatome. He has a past medical history of chronic renal insufficiency. He is started on Valacyclovir 1000mg TID. He represents 3 days later with hallucinations including a feeling that he was occupying a dead body. What is the differential diagnosis?


 

Varicella Zoster Encephalitis vs Valacyclovir Toxicity

VZV and antiviral toxicity can present with similar symptoms

Two main risk factors increase the risk for VZV

  • age greater than 50 years old
  • immunocompromised due to reduced T cell-mediated immunity

The main risk factor for antiviral toxicity is renal insufficiency

Differentiation

  • Timing
    • Toxicity presents within 1-3 days of starting drug (vs 1-2 weeks)

 

  • Symptoms – both can present with confusion and altered LOC
    • Encephalitis – fever, HA, seizures, more likely with Trigeminal nerve (V1) or disseminated zoster
    • Toxicity – Visual hallucinations, dysphasia, tremor/myoclonus
    • Toxicity – Cotard’s syndrome…

Cotard’s Syndrome

“le délire des négations”

(delirium of negation)

https://en.wikipedia.org/wiki/Cotard_delusion

  • Described in 1880 by neurologist Jules Cotard
    • “patient usually denies their own existence, the existence of a certain body part, or the existence of a portion of their body”
  • Seen in schizophrenia, psychosis and…
  • ….acyclovir toxicity (felt to be due to metabolite CMMB (9-carboxymethoxymethylguanine) crossing BBB)

Further Reading

Varicella Zoster Encephalitis case report and outline

Valacyclovir Toxicity case report and outline

Cotard’s Syndrome

Drug Dosing in Chronic Kidney Disease

 

 

 


Necrotising Soft Tissue Infections (NSTI)

Case

A 28yr old female presents pain, redness and swelling over the right thigh. She has a past medical history of type 2 diabetes. She is managed as an outpatient with intravenous ceftriaxone q24hrs. Her symptoms failed to respond on follow up. What is the concern now? Are there any red flags? What condition needs to be considered in patients with soft tissue infections that fail to respond to antibiotics?


NSTI first described by Hippocrates 5th century BC

“[m]any were attacked by the erysipelas all over the body when the exciting cause was a trivial accident…flesh, sinews, and bones fell away in large quantities…there were many deaths.”

 

Necrotizing fasciitis is characterized by rapid destruction of tissue, systemic toxicity, and, if not treated aggressively, gross morbidity and mortality. Early diagnosis and aggressive surgical treatment reduces risk; however, it is often difficult to diagnose NF, and sometimes patients are treated for simple cellulitis until they rapidly deteriorate.

Infection typically spreads along the muscle fascia due to its relatively poor blood supply; muscle tissue is initially spared because of its generous blood supply.

Infection requires inoculation of the pathogen into the subcutaneous tissue or via hematogenous spread.

Classification

  • Type 1 – polymicrobial – older/diabetics/EtOH/IC/PVD
  • Type 2 – monomicrobial – usually group A beta-hemolytic strep (often hematogenous) – healthy people of all ages

Early signs and symptoms of NSTI are often identical to those seen with cellulitis or abscesses potentially making the correct diagnosis difficult

‘Classic’ Signs / Symptoms

(1) the presence of bullae
(2) skin ecchymosis that precedes skin necrosis
(3) crepitus
(4) cutaneous anesthesia
(5) pain out of proportion to examination
(6) edema that extends beyond the skin erythema
(7) systemic toxicity
(8) progression of infection despite antibiotic therapy or rapid progression

First 4 are “hard” signs

  • Erythema (without sharp margins; 72 percent)
  • Edema that extends beyond the visible erythema (75 percent)
  • Severe pain (out of proportion to exam findings in some cases; 72 percent)
  • Fever (60 percent)
  • Crepitus (50 percent)
  • Skin bullae, necrosis, or ecchymosis (38 percent)

Streaking lymphangitis favours the diagnosis of cellulitis over necrotizing fasciitis

Diagnosis

  • There is no set of clinical findings, lab test results and even imaging that can definitively rule out necrotizing fasciitis
    • “Surgical exploration is the only way to establish the diagnosis of necrotizing infection”.
    • “Surgical exploration should not be delayed when there is clinical suspicion for a necrotizing infection while awaiting results of radiographic imaging other diagnostic information”
  • But what if you really aren’t sure?  Or if you get pushback?
  • CT is probably the best test – esp Type 1 (gas forming)
    • Findings – gas, fluid collections, tissue enhancement, inflammatory fascial changes
  • Finger test…
    • “After local anesthesia, make a 2-3 cm incision in the skin large enough to insert your index finger down to the deep fascia. Lack of bleeding and/or “dishwater pus” in the wound are very suggestive of NSTI. Gently probe the tissues with your finger down to the deep fascia. If the deep tissues dissect easily with minimal resistance, the finger test is + and NSTI can be ruled in.”  (emergencymedicinecases.com)
  • But what about PoCUS????

PoCUS

Diagnosis of Necrotizing Faciitis with Bedside Ultrasound: the STAFF Exam

Findings – “STAFF”

ST – subcutaneous thickening
A – air
FF – fascial fluid

Ultrasound video demonstrating Subcutaneous Thickening, Air, and Fascial Fluid (STAFF).

 

Soft tissue ultrasound findings are significantly different when compared to normal soft tissue ultrasound

Bottom Line: Limited data, but basically PoCUS is not sufficient to rule-in or rule out, but might be helpful in raising suspicion level for necrotising fasciitis for physicians who routinely scan all soft tissue infections.

 

LRINF Score

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) Score: A Tool for Distinguishing Necrotizing Fasciitis From Other Soft Tissue Infections

Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score.  2004, retrospective – score >6 negative predictive value of 96.0% and a positive predictive value of 92%.

 

A validation study looking only at patients with pathology-confirmed necrotizing fasciitis showed that a LRINEC score cutoff of 6 points for necrotizing fasciitis only had a sensitivity of 59.2% and a specificity of 83.8%, yielding a PPV of 37.9% and NPV of 92.5%. However, the study did show that severe cellulitis had a LRINEC Sscore ≥ 6 points only 16.2% of the time.  Therefore, the available evidence suggests that the LRINEC score should not be used to rule-out NSTI.

Bottom Line: Doesn’t rule-out…… or rule-in

 

Suggested Algorithm – UpToDate

 

EM Cases Review

BCE 69 Necrotizing Fasciitis

 

Further Reading

Necrotizing fasciitis – Can Fam Physician. 2009 Oct; 55(10): 981–987.

 


Epidural Abscess

Case

A 40yr old female presents with left leg weakness. She has a complex recent past medical history including recently diagnosed pneumonia, previous renal colic and type 2 diabetes. Could this be a stroke? What are the other causes of leg weakness? How does the examination differentiate UMN from LMN lesions? When considering a diagnosis of epidural abscess what investigation is required? How soon should it be performed?


Only 4% of Strokes present with isolated or predominant leg weakness. (Brain. 1994 Apr;117 ( Pt 2):347-54.
doi: 10.1093/brain/117.2.347)

Common mechanisms of weakness:

  • Upper motor neuron lesions (Stroke, Tumour, Spinal Cord Compression, etc)
  • Lower motor neuron lesions ( Neuropathy, Disc Prolapse, Spinal Cord Compression, etc)
  • Neuromuscular junction lesions (Myasthenia, etc)
  • Neuropathies (Guillain-Barre, etc)
  • Muscle (Myopathies, etc)

Full review on Muscle Weakness from the Merck Manual here

Weakness that becomes severe within minutes or less is usually caused by severe trauma or stroke; in stroke, weakness is usually unilateral and can be mild or severe. Sudden weakness, numbness, and severe pain localized to a limb are more likely caused by local arterial occlusion and limb ischemia, which can be differentiated by vascular assessment (eg, pulse, color, temperature, capillary refill, differences in Doppler-measured limb BPs). Spinal cord compression can also cause paralysis that evolves over minutes (but usually over hours or days) and is readily distinguished by incontinence and clinical findings of a discrete cord sensory and motor level.

Unilateral upper motor neuron signs (spasticity, hyperreflexia, extensor plantar response) and weakness involving an arm and a leg on the same side of the body: A contralateral hemispheric lesion, most often a stroke

Upper or lower motor neuron signs (or both) plus loss of sensation below a segmental spinal cord level and loss of bowel or bladder control (or both): A spinal cord lesion

 

Epidural Abscess

Spinal epidural abscess (SEA) is a severe pyogenic infection of the epidural space that leads to devastating neurological deficits and may be fatal. SEA is usually located in the thoracic and lumbar parts of the vertebral column and injures the spine by direct compression or local ischemia. Spinal injury may be prevented if surgical and medical interventions are implemented early. The diagnosis is difficult, because clinical symptoms are not specific and can mimic many benign conditions. The classical triad of symptoms includes back pain, fever and neurological deterioration.

Spinal Epidural Abscess: Common Symptoms of an Emergency Condition – A Case Report

 

  • 75% are a delayed diagnosis
    • Usually hematogenous spread, usually S. aureus
  • Diagnosis
    • CRP has an sensitivity of 85%, specificity of 50%
    • MRI is gold standard
    • CT with contrast 2nd choice

 

Further Reading

Spinal epidural abscess

Episode 26: Low Back Pain Emergencies

 

 

Continue Reading

EM Reflections – May 2020

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 


Discussion Topics

  1. Seizure disorder and safe discharge 

    • Consider risk factors for adverse outcome of discharge for all patients with recurrent seizure disorder
    • Use a checklist
  2. Competency and Capacity

    • Multidisciplinary consultation is paramount in deciding capacity
    • Special circumstances include vulnerable adults and pregnancy
  3. Testicular Torsion

    • Time = Testicle viability
    • Do not delay definitive management

Seizure disorder and safe discharge 

Case

A patient presents with recurrent seizures. They have a past medical history of schizophrenia and mental health delay. Following appropriate ED management with complete resolution of seizures and full recovery of the patient – what is the recommended disposition?


Seizure disorder is a common presentation to the Emergency Department. This EM Cases post provides an excellent summary for the ED approach to resolved seizures:

Ep 132 Emergency Approach to Resolved Seizures

 

ED approach to resolved seizures – Summary pdf


In this study – Ethanol withdrawal or low antiepileptic drug levels were implicated as contributing factors in 177 (49%) of patients. New‐onset seizures were thought to be present in 94 (26%) patients. Status epilepticus occurred in only 21 (6%) patients.

73% of patients were discharged.

 

 

 


Disposition

Most authors recommend admission for patients presenting with FIRST Seizure Episode. Patients with a past medical history of recurrent seizure disorder are more likely to be discharged than admitted.

However – this EBMedicine article cites an incidence of 19% seizure recurrence rate within 24 hours of presentation, which decreased to 9% if patients with alcohol related events or focal lesions on CT were excluded. They suggest, that at present, there is insufficient evidence to guide the decision to admit. They recommend this decision be tailored to the patient, taking into consideration the patient’s access to follow-up care and social risk factors (eg, alcoholism or lack of health insurance). Patients with comorbidities, including age > 60 years, known cardiovascular disease, history of cancer, or history of immunocompromise, should be considered for admission to the hospital.

 

Considerations For Safety On Discharge

Patients and their families should be counseled and instructed on basic safety measures to prevent complications (such as trauma) during seizures. For example, patients should be advised to avoid swimming or cycling following a seizure, at least until they have been reassessed by their neurologist and their antiepileptic therapy optimized, if needed. A particularly important point for seizure patients is education against driving. Although evidence remains controversial on this issue, there is general agreement that uncontrolled epileptic patients who drive are at risk for a motor vehicle crash, with potential injury or death to themselves and others. For this reason, most states do not allow these patients to drive unless they have been seizure-free on medications for 1 year. According to population survey data, 0.01% to 0.1% of all motor vehicle crashes are attributable to seizures


Competency and Capacity

Case

A young female patient with a history of polysubstance drug abuse presents with a psychotic episode. She refuses treatment. What are the competency and capacity implications? She is also pregnant. Does this change the the competency and capacity implications?


This LitFL post provides and excellent outline for Competency and Capacity in the ED:

Capacity and Competence

This article published by the RCPSC provides a useful outline from a Canadian perspective – with the following objectives.

  1. To clarify the role of decisional capacity in informed consent
  2. To discuss problems associated with decisional capacity and addiction

RCPSC – Decisional Capacity

 


 



Capacity in Pregnancy

Recommendations from the American College of Obstetricians and Gynecologists

On the basis of the principles outlined in this Committee Opinion, the American College of Obstetricians and Gynecologists (the College) makes the following recommendations:

  • Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.
  • The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable for obstetrician–gynecologists to attempt to influence patients toward a clinical decision using coercion. Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.
  • Eliciting the patient’s reasoning, lived experience, and values is critically important when engaging with a pregnant woman who refuses an intervention that the obstetrician–gynecologist judges to be medically indicated for her well-being, her fetus’s well-being, or both. Medical expertise is best applied when the physician strives to understand the context within which the patient is making her decision.
  • When working to reach a resolution with a patient who has refused medically recommended treatment, consideration should be given to the following factors: the reliability and validity of the evidence base, the severity of the prospective outcome, the degree of burden or risk placed on the patient, the extent to which the pregnant woman understands the potential gravity of the situation or the risk involved, and the degree of urgency that the case presents. Ultimately, however, the patient should be reassured that her wishes will be respected when treatment recommendations are refused.
  • Obstetrician–gynecologists are encouraged to resolve differences by using a team approach that recognizes the patient in the context of her life and beliefs and to consider seeking advice from ethics consultants when the clinician or the patient feels that this would help in conflict resolution.
  • The College opposes the use of coerced medical interventions for pregnant women, including the use of the courts to mandate medical interventions for unwilling patients. Principles of medical ethics support obstetrician–gynecologists’ refusal to participate in court-ordered interventions that violate their professional norms or their consciences. However, obstetrician–gynecologists should consider the potential legal or employment-related consequences of their refusal. Although in most cases such court orders give legal permission for but do not require obstetrician–gynecologists’ participation in forced medical interventions, obstetrician–gynecologists who find themselves in this situation should familiarize themselves with the specific circumstances of the case.
  • It is not ethically defensible to evoke conscience as a justification to attempt to coerce a patient into accepting care that she does not desire.
  • The College strongly discourages medical institutions from pursuing court-ordered interventions or taking action against obstetrician–gynecologists who refuse to perform them.
  • Resources and counseling should be made available to patients who experience an adverse outcome after refusing recommended treatment. Resources also should be established to support debriefing and counseling for health care professionals when adverse outcomes occur after a pregnant patient’s refusal of treatment.

Further Reading:

Ethically Justified Clinically Comprehensive Guidelines for the Management of the Depressed Pregnant Patient

How Do I Determine if My Patient has Decision-Making Capacity?

 


Testicular Torsion

Case

A 12 year old boy presents with scrotal discomfort in the early hours of the morning. The department is very busy and the waiting time to be seen is 4 hours. What triage category is this presenting complaint? If a diagnosis of torsion is considered, how quickly should definitive management be initiated?


Ramachandra et al. demonstrated through multivariate analysis of the factors associated with testicular salvage, that duration of symptoms of less than 6 h was a significant predictor of testicular salvage. They found that the median duration of pain was significantly longer in patients who underwent orchiectomy versus orchidopexy. Similar findings were seen with respect to time to operating room from initial presentation. They concluded that time to presentation is in fact the most important factor in determining salvageability of the testicle in testicular torsion. If surgical exploration is delayed, testicular atrophy will occur by 6 to 8 h, with necrosis ensuing within 8 to 10 h of initial presentation. Salvage rates of over 90% are seen when surgical exploration is performed within 6 h of the onset of symptoms, decreasing to 50% when symptoms last beyond 12 h. The chance of testicular salvage is less than 10%, when symptoms have been present for over 24 h

Factors influencing rate of testicular salvage in acute testicular torsion at a tertiary pediatric center.

Ramachandra P, Palazzi KL, Holmes NM, Marietti S

West J Emerg Med. 2015 Jan; 16(1):190-4.

[PubMed]

 

 

This study (Howe et al). confirmed the relationship between duration of torsion and testicle viability and also found a relationship between the degree of torsion


 

 

AAFP Review of Testicular Torsion: Diagnosis, Evaluation, and Management

 

 

 

 

 

 

Continue Reading

Lung PoCUS – Podcast

Lung PoCUS in Pediatric Emergency Medicine – Podcast

PoCUS Fellowship Clinical Pearl (RCP) May 2020

Dr. Mandy Peach (Emergency Physician and Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

 


Extract:

“My name is Mandy Peach and I am Emergency Physician at the Saint John Regional Hospital in Saint John, New Brunswick. I’m currently completing a PoCUS Fellowship and a pediatric rotation through the IWK Emergency Department in Halifax…….

What is the evidence for the use of PoCUS and diagnosing pediatric pneumonia. Well trained PoCUS Physicians can identify pneumonia with a sensitivity of 89% and a specificity of 94%, compared community-acquired pneumonia chest x-ray has a sensitivity of 69% and a specificity of 100%, if you see it great…. but what about early bacterial pneumonia and this case PoCUS has the upper hand, and if you consider consolidations behind the heart that can be visualized on PoCUS and obscured on chest x-ray – PoCUS 2  chest x-ray zero. So clearly it’s a useful tool to have when trying to differentiate between bacterial pneumonia that requires treatment and viral causes that would indicate conservative management. So how do we actually ultrasound the lungs…..the first step is to make the kid comfortable scan them in a position of comfort for example and their parents arms what the patient touch the ultrasound gel or the probe so it’s less of a scary thing maybe play their favourite music or YouTube video on the background or give them their favourite or snack do you want to choose a high frequency linear probe and scanning the longitudinal plane ……….”

 

Listen to the Podcast for some useful tips on performing and interpreting lung ultrasound in the pediatric population.

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Ear Foreign Body Removal

Ear Foreign Body Removal

Resident Clinical Pearl (RCP) May 2020

Dr. Sultan Alrobaian (PEM Fellow and Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis


Introduction

  • Most patients with ear Foreign Bodies (FB) are children, adults can also present with ear FB
  • The most common objects removed include beads, pebbles, tissue paper, small toys, popcorn kernels, and insects
  • Diagnosis is often delayed because the causative event is usually unobserved or the symptoms are nonspecific
  • Most of the patients with ear FBs were asymptomatic at presentation, other patients presented with otalgia, bleeding from the ear, otorrhea, tinnitus, hearing loss, a sense of ear fullness or symptoms of otitis media
  • Successful removal depends on several factors, including location of the foreign body, type of material and patient cooperation
  • Visualization of a foreign body on otoscopy confirms the diagnosis, the other ear and both nostrils should also be examined closely for additional foreign bodies.

Clinical Anatomy

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Equipment

  • Multiple options exist for removal of external auditory canal foreign bodies
  • Which piece of equipment to use will be influenced by the type of FB, the shape of the FB, the location of the FB and the cooperativeness of the patient

Timing

  • The type of foreign body determines the timing for removal
  • Button batteries, live insects and penetrating foreign bodies warrant urgent removal

Indications for consultation or referral to a specialist

  • Button battery
  • Potentially penetrating foreign bodies
  • Foreign body with evidence of injury to the external ear canal (EAC), tympanic membrane, middle ear, vestibular symptoms or marked pain

Technique


1 – Irrigation

  • This technique is used for small inorganic objects or insects
  • Irrigation is often better tolerated than instrumentation and does not require direct visualization
  • Contraindicated in patients with tympanostomy tubes, perforated tympanic membranes or button battery because the potential for caustic injury.
  • An angiocatheter or section of tubing from a butterfly syringe
  • Using body temperature water, retract the pinna, and squirt water superiorly in the external auditory canal, behind the FB

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2 – Instrumentation under direct visualization

  • Instrumentation can be painful and frequently warrants procedural sedation in young children or other uncooperative patients
  • General anesthesia may be required to ensure safe removal
  • Restrain if needed for safety

  • Commonly used pieces of equipment are curettes, alligator forceps, and plain forceps. Other equipment options include using a right angle hook, balloon catheter, such as a Fogarty catheter

  • Used in conjunction with the operating head of an otoscope
  • The pinna should be retracted, and the FB visualized
  • When using forceps, the FB can be grasped and removed

  • Both curettes and right angle hooks should be gently maneuvered behind the FB and rotated so the end is behind the FB, which can then be pulled out

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3 – Suction

  • This should be performed with a soft suction tipped catheter that has a thumb controlled release valve
  • Insert the suction against the FB under direct visualization and then activate the suctions and remove the FB

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4 – Cyanoacrylate

  • Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator
  • Insert it against the FB under direct visualization and hold in place until the glue dries
  • Slowly and carefully withdraw


5 – Insect removal

  • The first step is to kill the insect with mineral oil followed by lidocaine
  • Once the insect is neutralized, it can be removed by any of the above methods


SUMMARY

  • Foreign bodies of EAC frequently occur in children six years of age and younger
  • Patients with foreign bodies of the EAC are frequently asymptomatic
  • Button batteries , penetrating foreign bodies or injury to the EAC should undergo urgent removal by an otolaryngologist.
  • With adequate illumination, proper equipment, and sufficient personnel, many EAC foreign bodies can be removed

REFERENCES

1.Lotterman S, Sohal M. Ear Foreign Body Removal. [Updated 2019 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459136/

2.https://www.uptodate.com

3.Heim S W, Maughan K L. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(08):1185–1189. [PubMed] [Google Scholar]

4.Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngol. 2018;22(2):146–151. doi:10.1055/s-0037-1603922

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PoCUS in COVID

Point of Care Ultrasound (PoCUS) during the Covid-19 pandemic – Is this point of care tool more efficacious than standard imaging?

Resident Clinical Pearl (RCP) May 2020

Dr. Colin Rouse– (PGY-3  CCFP Emergency Medicine) | Dalhousie University

and Dr. Sultan Alrobaian (Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

 


Case

A 70 year of woman present to the ED with a history of fever, cough and dyspnoea. After a full clinical assessment (with appropriate PPE), Lung PoCUS is performed.


Introduction

The Covid-19 Pandemic has created the largest international public health crisis in decades. It has fundamentally changed both societal norms and health care delivery worldwide. Changes have been implemented into resuscitation protocols including ACLS to prioritise appropriate donning of personal protective equipment (PPE) and consideration of resuscitation appropriateness prior to patient contact.1 Equipment has been removed from rooms to limit cross-contamination between patients. In this Pearl we will explore why PoCUS should not be discarded as an unnecessary tool and should be strongly considered in the assessment of a potential Covid Patient.

Disclaimer: Given the novel nature of CoVid-19 there is a lack of RCT data to support the use of PoCUS. These recommendations are based solely on expert opinion and case reports until superior evidence becomes available.


Potential Benefits of PoCUS

  • Lung PoCUS has increased sensitivity compared to conventional lung X-ray for known lung pathologies such as CHF4 and Pneumonia5 with similar specificities. Given that Pneumonia is the most common complication of Covid-19 it may help diagnose this complication in patients who have a normal CXR.
  • PoCUS can be performed by the assessing physician limiting the unnecessary exposure to other health care providers such and Radiologic Technologists and other staff in the diagnostic imaging department.
  • Lung PoCUS is low cost, repeatable and available in rural settings
  • Once pneumonia is diagnosed other potential complications can be sought including VTE and cardiovascular complications.

The assessment of the potential Covid-19 patient.

First one must consider the potential risk for coronavirus transmission at each patient encounter and ensure proper PPE2 for both oneself and the PoCUS device3.


Lung Ultrasound in the potential Covid-19 Patient

Technique

  • Appropriate level PPE
  • A low-frequency (3–5 MHz) curvilinear transducer
  • Set Focus to Pleural Line and turn off machine filters (e.g THI) to maximize artifacts
  • Scanning should be completed in a 12-zone assessment6
    • 2 anterior windows
    • 2 lateral windows
    • 2 posterior windows

Findings7

Mild Disease

  • Focal Patchy B-lines in early disease/mild infection (May have normal CXR at this point)
  • Areas of normal lung

 

Moderate/Severe Disease – Findings of bilateral Pneumonitis

  • B-lines begin to coalesce (waterfall sign)
  • Thickened and irregular pleura
  • Subpleural Hypoechoic consolidation      +/- air bronchograms

 

Other Covid-19 Pearls

  • Large/Moderate Pleural Effusion rarely seen in Covid-19 (consider another diagnosis) – Small peripleural effusions are common in COVID
  • The virus has a propensity for the base of the posterior lung windows and it imperative to include these views in your assessment.


Example COVID PoCUS Videos8

Confluent B Lines and small sub pleural consolidation

 

Patchy B lines and Irregular pleura

 

Irregular pleura

 

Air Bronchogram


CT & ultrasonographic features of COVID-19 pneumonia9

It has been noted that lung abnormalities may develop before clinical manifestations and nucleic acid detection with some experts recommending early Chest CT for screening suspected patients.10 Obviously there are challenges with this recommendation mainly regarding feasibility and infection control. A group of researchers in China compared Ultrasound and CT findings in 20 patients with COVID-19. Their findings are summarized in the table below:

Their conclusion was that ultrasound has a major utility for management of COVID-19 due to its safety, repeatability, absence of radiation, low cost and point of care use. CT can be reserved for patients with a clinical question not answered by PoCUS. CT is required to assess for pneumonia that does not extend to the pleura. Scatter artifact from aerated lung obscures visualization of deep lung pathology with PoCUS. When PoCUS is sufficient it can be used to assess disease severity at presentation, track disease evolution, monitor lung recruitment maneuvers and prone positioning and guide decisions related to weaning of mechanical ventilation.


Learning Points

  • Lung PoCUS is helpful in the initial assessment of the suspected or known COVID19 Patient
  • Lung PoCUS may reveal pathology not visible on CXR
  • Lung PoCUS can provide insight into COVID19 disease severity
  • Lung PoCUS is a useful tool to track disease progression in COVID19

Lung PoCUS in COVID Deep Dive

Deep Dive Lung PoCUS – COVID 19 Pandemic

 

 


References

  1. Edelson, D. P., Sasson, C., Chan, P. S., Atkins, D. L., Aziz, K., Becker, L. B., … & Escobedo, M. (2020). Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of …. Circulation.
  2. COVID-19 – Infection Protection and Control. http://sjrhem.ca/covid-19-infection-protection-and-control/
  3. Johri, A. M., Galen, B., Kirkpatrick, J. N., Lanspa, M., Mulvagh, S., & Thamman, R. (2020). ASE Statement on Point-of-Care Ultrasound (POCUS) During the 2019 Novel Coronavirus Pandemic. Journal of the American Society of Echocardiography.
  4. Maw, A. M., Hassanin, A., Ho, P. M., McInnes, M., Moss, A., Juarez-Colunga, E., Soni, N. J., Miglioranza, M. H., Platz, E., DeSanto, K., Sertich, A. P., Salame, G., & Daugherty, S. L. (2019). Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA network open, 2(3), e190703. https://doi.org/10.1001/jamanetworkopen.2019.0703
  5. Balk, D. S., Lee, C., Schafer, J., Welwarth, J., Hardin, J., Novack, V., … & Hoffmann, B. (2018). Lung ultrasound compared to chest X‐ray for diagnosis of pediatric pneumonia: A meta‐analysis. Pediatric pulmonology, 53(8), 1130-1139.
  6. Wurster, C., Turner, J., Kim, D., Woo, M., Robichaud, L. CAEP. COVID-19 Town Hall April 15: Hot Topics in POCUS and COVID-19. https://caep.ca/covid-19-town-hall-april-15-hot-topics-in-pocus-and-covid-19/
  7. Riscinti, M. Macias, M., Scheel, T., Khalil, P., Toney, A., Thiessen, M., Kendell, J. Denver Health Ultrasound Card. http://www.thepocusatlas.com/covid19
  8. Images obtained from. Ultrasound in COVID-19. The PoCUS Atlas. http://www.thepocusatlas.com/covid19
  9. Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6
  10. National Health Commission of the people’s Republic of China. Diagnosis and treatment of novel coronavirus pneumonia (trial, the fifth version)[EB/OL]. (2020-02-05)[2020-02-06]. http://www.nhc.gov.cn/yzygj/s7653p/202002/3b09b894ac9b4204a79db5b8912d4440.shtml
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