EM Reflections – March 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:

 


Vertebral Artery Dissection – a tricky diagnosis and potentially catastrophic if missed…

 

Consider dissection in vertigo patients even without history of significant or mild trauma.

Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Dizziness, vertigo, double vision, ataxia, and dysarthria are common clinical features. Lateral medullary (Wallenberg syndrome) and cerebellar infarctions are the most common types of strokes.

Diagnosis – CT Angiography

Treatment – Antiplatelet or Anticoagulation (unless contraindications – see article below)

Cervical Artery Dissection in Stroke Study (CADISS) trial, RCT – antiplatelets versus anticoagulants in the treatment of extracranial carotid and vertebral artery dissections (VADs) = no difference found in outcomes between groups receiving antiplatelets vs anticoagulants. CADISS

Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations – (full text)

Rounds Presentation by Dr Kavish Chandra (R2 iFMEM)

Download (PDF, 755KB)


 

Limping Kids – inability to weight bear is always significant…

Need for thorough investigation of non traumatic hip pain in child unable to weight bear. Don’t get biased with previous diagnosis even if by specialists.

Don’t miss – Septic Arthritis or SCFE


From – Orthobullets.com – Hip Septic Arthritis – Pediatric – Author:

See this SJRHEM ED Rounds on Limping Kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring (and a high CRP mandates further Ix to rule out septic arthritis)
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg

 

 

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NB Trauma – ATLS Course – April 21-23, 2017 – last few places remaining…!

The Advanced Trauma Life Support® (ATLS®) program can teach you a systematic, concise approach to the care of a trauma patient. ATLS was developed by the American College of Surgeons (ACS) Committee on Trauma (COT) and was first introduced in the US and abroad in 1980.  Its courses provide you with a safe and reliable method for immediate management of injured patients.  The course teaches you how to assess a patient’s condition, resuscitate and stabilize him or her, and determine if his or her needs exceed a facility’s capacity. Inter hospital transfer and assurance of optimal patient care during transfer is also covered.  An ATLS course provides an easy method to remember for evaluation and treatment of a trauma victim.

 

 

The NB Trauma Program invites physicians to register for this 2 ½ day course that provides physicians with a measurable, comprehensive and reproducible system of trauma assessment and critical interventions for the patient with multiple injuries.

 

Enrollment is limited and registration is first-come, first-served basis, upon receipt of full payment. A one-day Refresher course is also being offered (on Sunday) and starts at 8:00am.  These courses will be conducted in English.

 

Location:       Saint John Regional Hospital

 

Dates:

April 21, 2017              4:00pm – 9:30pm

April 22, 2017              8:00am – 6:30pm

April 23, 2017              8:00am – 3:30pm

 

Questions?    Please contact Lisa at (506) 648-5056 or Lisa.Miller-Snow@HorizonNB.ca

 


 

Download (PDF, 1.07MB)

 


Application Form:

 

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ED Rounds – Delirium in the ED

Delirium in the ED: How can we help?

Presented by: Dr Cherie-Lee Adams

 


Incidence of Delirium

  • 40% admitted patients >65yo
  • 10-20% on admission
  • 5-10% more during admission

Increased Risk of Delirium:

  • Male
  • >60yo, more prevalent >80yo
  • Hearing/visual impairment
  • Dementia
  • Depression
  • Functional dependence
  • Polypharmacy
  • Major medical/surgical illness


DSM-V Criteria

  • A) Disturbance in attention and awareness
  • B) Disturbance is ACUTE
  • C) Concurrent cognitive impairment
  • D) Not evolving dementia, nor coma
  • E) Can be explained by Hx/Px/Ix

 


 

Non – Pharmacological Approach

  • Nutritional support
  • Optimize hearing/sight
  • Maximize day/night/date/time cues
  • Minimize pain
  • Rehabilitate- ambulate, encourage self-care
  • Avoid restraints

Pharmacological Options

  • Treat only if distress/agitated/safety concern
      • don’t treat hypoactive delirium, wandering, or prophylactically
  • monotherapy
  • low dose
  • short course
  • Benzos- reserve for withdrawal
  • APs
        • Haldol 0.25-0.5mg
        • risperidone 0.25mg od-bid
        • olanzapine 1.25-2.5mg/d
        • quetiapine 12.5-50mg/d

 

Take Home Points

  • Delirium is common, esp in elderly
  • Significant morbidity/mortality associated
  • Brief screening with DTS/bCAM works
  • Intervention focus on limiting pathology, normalizing activities, minimizing drugs
  • Low dose APs for short period for agitation

 


 

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ED Rounds – Compassion Fatigue and Burnout – Dr Jenn Hannigan

Preventing Compassion Fatigue and Burnout

Presented by: Dr Jenn Hannigan MD CCFP(PM)

 

The practice of medicine is:

an art, not a trade;

a calling not a business;

a calling in which your heart will be exercised equally with your head.

-Sir William Osler


Compassion Fatigue:

  • “the cost of caring”
  • Secondary or vicarious traumatization
  • Symptoms parallel to PTSD
    • Hyperarousal (poor sleep, irritability)
    • Avoidance (“not wanting to go there”)
    • Re-experiencing (intrusive thoughts/dreams when triggered)

Burnout:

  • Emotional exhaustion
  • Reduced personal accomplishment and commitment to the profession
  • Depersonalization
    • A negative attitude towards patients
    • Personal detachment
    • Loss of ideals

 

How can we mitigate burnout:

  • Mindfulness Meditation
  • Reflective Writing
  • Adequate supervision and mentoring
  • Sustainable workload
  • Promotion of feelings of choice and control
  • Appropriate recognition and reward
  • Supportive work community
  • Promotion of fairness and justice in the workplace

 

Between stimulus and response there is a space.

In that space is our power to choose our response.

In our response lies our growth and our freedom.

  -Viktor Frankl


 

 


Getting Started with Meditation:

 


 

Download (PDF, 1.02MB)

 

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ED Rounds – Sickle Cell Anemia

Sickle Cell Disease

Presented by: Dr Paul Vanhoutte

 

As we welcome new families to New Brunswick from the Middle East and Africa, we are likely to see an increased incidence of sickle cell emergencies.  Needs assessments in Canada have shown that Emergencies Physicians outside of the major urban centres lack experience and knowledge in dealing with this disease.

 

 

Global distribution of the sickle cell gene – from: http://www.nature.com/articles/ncomms1104

Emergency Presentations

  • Acute painful episodes
  • Acute anemic crisis
  • Acute aplastic crisis
  • Acute chest syndrome
  • Infection
  • Splenic sequestration
  • Cerebrovascular events
  • Avascular necrosis
  • Renal complications
  • Hepatobiliary complications
  • Ophthalmic complications
  • Priapism

 

A recent article and podcast in EM Cases provides a great outline on  – Emergency Management of Sickle Cell Disease

 

Take Home Points

  • Treat sickle – acute painful episodes with opiate analgesia.
  • Normal vital signs do not exclude sickle – acute painful crisis.
  • High index of suspicion for associated sepsis ( meningitis, septic arthritis, osteomyelitis, pneumonia, pyelonephritis)especially if they have a fever
  • Check renal function before prescribing NSAIDS
  • Supplemental Oxygen only if hypoxic (<92%)
  • IV fluids only required if hypotensive/ hypovolemic

 

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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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EM Reflections – January 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:


1. Presenting Complaint: Abdominal Pain – Might not be due to Abdominal pathology

Keep in mind other life threatening causes of abd pain not in the abd. ( ie Aortic Dissection, PE, ACS, Pneumonia).

ECG on all pts who present with pain between chin and umbilicus.

 

 


 

2. Presenting Complaint: Back Pain – Careful with diagnosis of MSK Back Pain

Careful review of vital signs (current and recorded – including EMS). Persistent hypotension or even an episode of recorded hypotension should warrant further evaluation to rule out other more serious diagnoses (AAA, Pancreatitis, bowel perf, hemorrhage etc). (see article pdf below). PoCUS for AAA is highly sensitive and specific and should be considered in all patients >60 who present with back pain, syncope, transient hypotension etc. Although this study found that Routine Screening for Asymptomatic Abdominal Aortic Aneurysm in High-risk Patients Is Not Recommended in Emergency Departments That Are Frequently Crowded

 

Midline Abdomen, Transverse PoCUS view of the Abdominal Aorta – Spot the abnormality?

 


 

3. Can you reliably differentiate Cardiac Chest pain from Non Cardiac Chest pain by history alone?

Whilst the history is very important in the assessment of a patient with chest pain, it cannot reliably exclude Cardiac Chest Pain. Neither can examination (chest wall tenderness etc). All patients who present to ED with chest pain should have an ECG.

Link to a good article on Non Cardiac Chest Pain here.

 

 


 

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Download (PDF, 445KB)

 

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ED Rounds – Lyme Disease – Dr Paul Frankish

Lyme Disease: Update and recent controversies

Presented by Dr Paul Frankish

 

 


 Link to NB Health Lyme Disease Information


Transmission

  • Borrelia burgdorferi
  • Tick-borne spirochetal bacteria
  • Ixodes scapularis and Ixodes pacificus
  • Field mice, birds and white-tailed deer

Discovered in Lyme, Connecticut  by Dr. Burgdorfer, investigating an abnormal cluster of juvenile RA. Other common tick-borne illnesses are transmitted through the lone star tick (Amblyomma americanum) and the American dog tick (Dermacentor variabilis) that transmit ehrlichiosis and Rocky Mountain spotted fever, respectively.  The ticks serve as the vector between the animal population and humans.  Deer are the preferred host for ticks, and the tick population is highest when deer are present, but the actually pick up the Borrelia from small mammals mostly.


Identification

A) is an Argasid (soft tick, Ornithodoros turicata)

B) has a scutum, long body butshort mouth parts (dog tick, Dermacentor variabilis)

C) is Ixodes scapularis(!)

D) has a scutum, but has a short and stout body – it also has a “lone star” on its body (lone star tick, Amblyomma americanum)


Erythema Migrans Pearls

  • Often just a macule with no central clearing (20-30%)
  • Classically 1-2 weeks from time of tick bite, but anywhere from 3-30 days
  • Some patients may either not have it or notice it
  • May have multiple lesions
  • Rashes within 2 days are usually an immune reaction to tick saliva


Clinical Pearls

  • Always take clinical context into consideration
  • If IgM positive and IgG negative greater than 4 weeks since infection, likely false positive
  • Do not use the test in the setting of EM rash
  • Consider testing if all satisfied:
    • Lyme endemic area
    • Risks for exposure
    • Any features of disseminated or late disease

Testing


Prophylaxis

  • Common ED presentation
  • If attached less than 36 hrs or not Ixodes scapularis, then risk is very low
  • Criteria for prophylaxis (need all)3:
    • Ixodes scapularis
    • Attached longer than 36 hrs
    • Prophylaxis within 72 hrs of removal
    • Greater than 20% local tick infection rate
  • Single dose of Doxycycline 200 mg or 4mg/kg for children greater than 8 years old
  • Children < 8yrs
    • Not sufficient evidence to recommend any other regimes
    • A “watch and wait” approach is recommended in these cases

Full Presentation with Notes

Download (PDF, 4.33MB)


NB Health Lyme Disease Update Jan 2017

Download (PDF, 190KB)

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RCP – Awake Intubations: “Alone we can do so little, together we can do so much”

Awake Intubations: “Alone we can do so little, together we can do so much”

Resident Clinical Pearl (RCP) – January 2017

Kalen Leech-Porter, PGY2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Case Example:

A healthy 60 year old man arrives at the Emergency Department (ED)3 hours after his camp caught fire.  He complains of shortness of breath and he has a hoarse voice. Vitals BP 140/90, HR 95, RR 24, Oxygen saturation 96%, afebrile.  GCS 15. You note he has facial and trunk burns. He is alert, scared but cooperative. How would you definitively manage his airway?

Picture 1.


Introduction:

RSI has gained much popularity in the ED for endotracheal intubation.  While there is good reason for this, there is still a role for awake intubation; with awake intubations the patient continues to breathe for themselves and will maintain and protect their airways.  This can be critically important in a situation where there is an anticipated difficult intubation and difficult bag mask ventilation.  The patient does have to be somewhat cooperative for awake intubation, but with proper explanation this might be the best option in a difficult situation.

Indications:

  • Predicted difficult airway anatomy (intubation AND maintaining oxygenation with BMV)
  • Variations of normal anatomy (ie Mallampati 4, obese, small mandible)
  • Pathologic distortion or obstruction: (ie burns, angioedema, stridor)
  • Predicted difficult physiology
  • Hemodynamic instability- (may still be able to do RSI- using appropriate agents and fluid bolus, but awake intubation is an option)
  • High minute volume – awake intubation will allow them to breathe at their current desired rate until intubation facilitated

Requirements:

  • Patients is awake, cooperative

Advantages of awake Intubation

  • Patient protects/maintains airways
  • Patient breathes spontaneously
  • Less risk of hypoxemia/hypercarbia with transition to positive pressure ventilation
  • May help with intubation: tissue movement/bubbles may indicate glottis opening in obscured airways

Disadvantages

  • Potentially uncomfortable
  • Requires cooperation
  • Procedure can be prolonged

 

Back to our case:

………….the hoarse voice and burns suggest airway edema.  This patient will likely both a difficult intubation and difficult to bag mask ventilate.  However, he is cooperative.  Following the AIME approach to tracheal intubation pathway (below), this patient would be a candidate for awake intubation (red arrow).

AIME approach to tracheal Intubations pathway decision making

 

Generic Approach to awake oral intubation:

  1. Supplemental O2 – consider high flow nasal prongs
  2. Prep:
    1. monitors, O2, BVM, suction, ETTs, stylet, laryngoscope, blades, drugs, alternative intubation options, rescue devices, mark cricothyroid membrane,
    2. Psychologically prepare the patient: tell them rationale and explain procedure
  3. Topical Airway Anesthesia +/- light sedation
  4. Awake intubation
  5. Confirm Tube location
  6. Additional Sedation

More Detailed:

Topical Airway Anesthesia
  1. Consider drying agent to reduce secretions and allow better working of topical anesthesia on mucous membranes: glycopyrrolate 5 micrograms/kg IV
  2. Lidocaine application -don’t add epi
    1. 5% lidocaine ointment with tongue depressor to back of tongue
    2. Gargle and swish 4% liquid lidocaine
    3. Then spray (soft palate, posterior pharynx, tonsillar pillars) as you go with either:
      1. Lidocaine 10% endotracheal spray
      2. 4% lidocaine atomizing device
    4. 4% nebulized lidocaine takes 10-12 mins but is another alternative
  3. Do not exceed toxic dose: 5 mg/kg (use less if elderly or cardiac/liver impairment)

+/- Light Sedation
  1. No sedation is reasonable
  2. Consider ketamine, or midazolam +/- fentanyl in small doses (pros and cons not discussed in this pearl)

Awake intubation using DL

Intubation may be performed with bronchoscopy, glidescope, blind nasotracheal intubation. Below is an abridged description of key points of direct laryngoscopy during awake intubation.

  1. Perform in semi-sitting or sitting position – physician may need to stand on a stool/chair
  2. Use “precision laryngoscopy”, slowly walking the blade in avoiding as many structures as possible
  3. Warn patients they will feel some pressure then compress tongue to visualize epiglottis
  4. Place blade in valleculla and perform appropriate lift to visualize cords
  5. Pass the ETT through the cords while the patient inspires

Picture 2

Post Intubation:

Don’t forget to confirm tube location, and provide sedation if the patients hemodynamics tolerate the sedation!

 

References:

Airway Management in Emergencies: Second Edition.  George Kovacs, J. Adam Law. 2011.

Picture 1

Picture 2

 

 

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NB Trauma – Advanced Trauma Life Support Course (ATLS) – April 21st-23rd 2017

There are still a few places on the NB Trauma – ATLS Course (Saint John Regional Hospital  April 21st-23rd 2017).

The NB Trauma Program invites physicians to register for this 2 1⁄2 day course that provides physicians with a measurable, comprehensive and reproducible system of trauma assessment and critical interventions for the patient with multiple injuries.

Enrolment is limited and registration is first-come, first-served basis, upon receipt of full payment. A one-day Refresher course is also being offered (on Sunday) and starts at 8:00am. These courses will be conducted in English.

More Information:

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Posted in CPD

The 2017 SJRHEM EMR Course – Now Open for Registration

The Emergency Medicine Review (EMR) course is offered by the Saint John Regional Hospital Emergency Department to guide eligible candidates in preparation for the CCFP (EM) licensing exam.


Over the 20 interactive sessions, a CCFP(EM) lecturer will review the CFPC’s Priority Topics in Emergency Medicine: the core material covered in the exam. A practice written exam and final oral exam are offered at the end of the course. Feedback is provided throughout.

Practice Short Answer Management Problems (SAMPs) are sent for completion and self-marking one week prior to each session
Practice orals are completed by 1-2 participants while others review
Core material is presented in a case-based format with “SAMP-style”, interactive questioning

More Information Here

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