EM Reflections – December 2017

Thanks to Dr Joanna Middleton for leading the discussion this month and providing these tips and references.

Edited by Dr David Lewis 

 

Top tips from this month’s rounds:

Incomprehensible Patient – Delirium or Aphasia?

Pediatric Trauma

CME QUIZ

 

Take Home Points

  • Sudden onset language impairment should be assumed to be aphasia until proven otherwise
  • Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
  • Aphasic patients will be able to perform non-verbal tasks normally
  • If in doubt involve telestroke / neurology early
  • Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.
  • The injuries sustained by children in chest trauma are frequently different from adults
  • Signs of shock in pediatric trauma can be subtle
  • Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
  • Elevated Tropinin or abnormal ECG suggest blunt cardiac injury

 


Incomprehensible Patient – Delirium or Aphasia?

Both can present with disorders of speech and language, however it is important to rapidly distinguish aphasia due to it’s association with stroke and the benefits of early thrombolysis.

Delirium, also known as acute confusional state, is an organically caused decline from a previously baseline level of mental function. It often has a fluctuating course, attentional deficits, and disorganization of behaviour including speech and language.

Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Aphasia is always due to injury to the brain, most commonly from a stroke, but also trauma, tumour or infection.

 

The first tip here is to figure out how to describe the features of a patient’s language. How is the patient’s language produced and understood?

Are the words clearly enunciated (favoring aphasia) or slurred (favoring delirium)?

Is the patient’s speech grammatically correct (delirium) or lacking in appropriate syntax (aphasia)?

Is the patient’s prosody—or pattern of speech—fluent (delirium) or irregular (aphasia)?

Can the patient understand spoken language (delirium) or is there a major difficulty with following simple verbal/written commands (aphasia)?

Naming and repetition should also be assessed as part of any neurologic examination, but impairment in these modalities is not as useful in distinguishing delirium from aphasia.

The motor evaluation of inattention in a delirious patient involves testing for asterixis, either with arms and wrists fully extended or having the patient squeeze the fingers of the examiner (the “milk maid’s sign”). A delirious patient will struggle with these tasks, the extended hands may flap or the fingers may intermittently lose their grip. The aphasic patient, in contrast, may not have trouble with this.

Speak of the devil: Aphasia vs. delirium

 

Global Aphasia

  • Severe impairment of production, comprehension and repetition of language
  • Usually large CVA of left MCA
  • Usually associated with extensive perisylvian injury affecting both Broca’s and Wernicke’s areas
  • Usually accompanied by right hemiparesis and often a right visual field deficit (in right handed pt)
  • Patients with global aphasia can be shown to perform normally on nonverbal tasks such as picture matching, demonstrating they are not suffering from confusion or dementia

 

Stroke Thrombolysis – Indications and Contraindications Reminder

Patient Selection for Thrombolytic Therapy in AIS:

Inclusion criteria: Patients  >18 years of age with symptoms of AIS and a measurable neurological deficit with time of onset <4.5 h.

Exclusion criteria:

A. History

  • History of intracranial hemorrhage
  • Stroke, serious head injury or spinal trauma in the preceding 3 months
  • Recent major surgery, such as cardiac, thoracic, abdominal, or orthopedic in previous 14 days
  • Arterial puncture at a non-compressible site in the previous 7 days
  • Any other condition that could increase the risk of hemorrhage after rt-PA administration

B. Clinical

  • Symptoms suggestive of subarachnoid hemorrhage
  • Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd’s paralysis or focal neurological signs due to severe hypo- or hyperglycemia
  • Hypertension refractory to antihypertensives such that target blood pressure <185/110 cannot be achieved
  • Suspected endocarditis

C. Laboratory

  • Blood glucose concentration below 2.7 mmol/L or above 22.2 mmol/L
  • Elevated activated partial-thromboplastin time (aPTT)
  • International Normalized Ratio (INR) greater than 1.7
  • Platelet count <100 x 109/L
  • Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated insensitive global coagulation tests (aPTT for dabigatran, INR for rivaroxaban) or a quantitative test of drug activity (Hemoclot® for dabigatran, specific anti-factor Xa activity assays for rivaroxaban, apixaban and edoxaban). In this situation, endovascular treatment (thrombectomy) should be considered if patient eligible.

D. CT or MRI Findings

  • Any hemorrhage on brain CT or MRI
  • CT showing early signs of extensive infarction (hypodensity more 1/3 of cerebral hemisphere), or a score of less than 5 on the Alberta Stroke Program Early CT Score [ASPECTS], or MRI showing an infarct volume greater than 150 cc on diffusion-weighted imaging.

Relative contraindications for rt-PA therapy in AIS include the following:

  • Recent myocardial infarction with suspected pericarditis
  • Rapidly improving stroke symptoms
  • Pregnancy or post-partum period
  • Recent GI or urinary tract hemorrhage (within 21 days)

From Thrombosis Canada

Take Home Points

  • Sudden onset language impairment should be assumed to be aphasia until proven otherwise
  • Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
  • Aphasic patients will be able to perform non-verbal tasks normally
  • If in doubt involve telestroke / neurology early
  • Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.

 


Pediatric Trauma

Some specific issues particular to pediatric trauma are highlighted:

Pediatric Chest Trauma

Children have compliant chests and thus sustain musculoskeletal thoracic injuries far less frequently (5% of traumas). However, due to this elasticity, the most common injury is a pulmonary contusion.

PITFALLS

Don’t expect traditional adult injury findings: Absence of chest tenderness, crepitus and flail chests does not preclude injury.

Bendy ribs – injury to internal organs with little external evidence

Lung contusions ~50% of chest trauma

Force transmitted to lung parenchyma – lung lacerations much less common <2%

 

Pediatric Abdominal Trauma

Beware: 20-30% of pediatric trauma patients with a “normal” abdominal exam will have significant abdominal injuries on imaging.

Any polytrauma patient with hemodynamic instability should be considered to have a serious abdominal injury until proven otherwise. Tachycardia primary reflex for kids in response to hypovolemia and it may be the only sign of shock.

HIGH RISK – Indications for CT

• History that suggests severe intra-abdominal injury e.g abrupt acceleration/deceleration, pedestrian vs vehicle, handlebar injury, fall from horse etc

• Concerning physical – tenderness, peritoneal signs, seatbelt sign or other bruising

• AST >200 or ALT >125

• Decreasing Hb or Hct

• Gross hematuria

• Positive FAST

PECARN 

The Pediatric Emergency Care Applied Research Network (PECARN) network derived a clinical prediction rule to identify children (median age, 11 years) with acute blunt torso trauma at very low risk for having intra-abdominal injuries (IAIs) that require acute intervention.

The prediction rule consisted of (in descending order of importance)

  • no evidence of abdominal wall trauma or seat belt sign
  • Glasgow Coma Scale score greater than 13
  • no abdominal tenderness
  • no evidence of thoracic wall trauma
  • no complaints of abdominal pain
  • no decreased breath sounds
  • no vomiting

The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15).

Holmes JF et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med 2013 Feb 4; [e-pub ahead of print]. (http://dx.doi.org/10.1016/j.annemergmed.2012.11.009)

 

Blunt Cardiac Injury

Largest pediatric case series of BCI – 184 patients – 95% had simple cardiac contusions. https://www.ncbi.nlm.nih.gov/pubmed/8577001

The clinical presentation of blunt cardiac injury varies. Mild injuries may present without objective findings, while some patients may have minor dysrhythmias.

A normal ECG and troponin I during the first 8 hours of hospital stay rules out blunt cardiac injury, and the negative predictive value of combining these 2 simple tests was 100%. https://www.ncbi.nlm.nih.gov/pubmed/12544898

 

Click image to link to full article

 

Traumatic Tricuspid Injuries

Location, location, location

RV posterior to sternum – blunt force elevates pressures resulting in rupture of chordae, papillary muscle injury or tear of leaflet

Most frequent associated injury:  pulmonary contusion

“The presence of a transient right bundle branch block in the setting of myocardial contusion is a described, but under-recognized occurrence.”

“Although an rsr’ in the right precordial leads may be normal in children, it’s combination with an abnormal frontal axis (“bifasicular block”) is always abnormal and suggest injury to the RV”

 

Episode 95 Pediatric Trauma

Take Home Points

  • The injuries sustained by children in chest trauma are frequently different from adults
  • Signs of shock in pediatric trauma can be subtle
  • Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
  • Elevated Tropinin or abnormal ECG suggest blunt cardiac injury

 


CME QUIZ

EM Reflections - Dec 17 - CME Quiz

EM Reflections – Dec 17 – CME Quiz

Continue Reading

EM Reflections – November 2017

Thanks to Dr Paul Page for leading the discussion this month

Edited by Dr David Lewis 

Top tips from this month’s rounds:

  1. Managing violent behaviour in the Emergency Department

  2. Early CT can miss delayed onset subdural hematoma after head trauma

  3. Posterior shoulder dislocation can be missed if not specifically ruled out

  4. CME QUIZ

 


Managing violent behaviour in the Emergency Department

Workplace violence is unfortunately a common problem for Emergency Department staff.

Violence in the ED Reaches a Crisis Point

Not only is the environment high risk for exacerbating behavioural extremes but there are also a wide range of medical and psychiatric conditions that may present with violence and aggression.

Causes and associations with violence and aggressive behaviour in the ED:

Medical

  • Hypoxia
  • Hypoglycemia
  • Hypothermia
  • Metabolic
    • Pancreatitis, hepatic encephalopathy, hyponatremia, etc
  • Sepsis
    • UTI, meningitis, encephalitis, pneumonia, etc
  • Toxic
    • Alcohol, drugs, etc
  • Seizure, post ictal
  • Stroke
  • Dementia
  • Brain tumour
  • Head injury

Psychiatric

  • Schizophrenia
  • Bipolar
  • Panic disorder, antisocial personality disorder, mood disorder, etc

Environment

  • Overcrowding
  • Police custody, gang violence, etc

 

Excellent article on managing behavioural emergencies in the emergency dept from LitFL:

Behavioural Emergencies

 

Restraint

The CMPA provides medicolegal guidance on the use of restraint:

When there’s a possibility that patients may harm themselves or others, physical or chemical restraint may be required.

When using restraints physicians should consider the following risk management measures, which are based on the experts’ opinions in the analyzed CMPA cases:

  • Attempt to de-escalate the situation using other methods.
  • Obtain an adequate history, including medications and co-morbidities.
  • Conduct an appropriate physical examination.
  • Explain the plan for the use of restraints calmly and clearly to patients or substitute decision-makers.
  • Document the rationale for using restraints and use the least restrictive means necessary.
  • Ensure clear and readily available policies and procedures for monitoring restrained patients and ensure appropriate training of staff.
  • Adhere to applicable regulations, laws, and accreditation standards.

 

The National Institute of Clinical Excellence (NICE UK) provides guidance on the use of rapid tranquillisation:

Download (PDF, 62KB)

 

More Information and lInks:

Horizon Health Work Place Violence Prevention Policy: HHN-SA-012

ACEP – Emergency Department Violence Fact Sheet

Augusta University – Violence in ED Manual – violenceinedmanual

 


Reliability of Early CT in Head Injury

Modern CT is highly sensitive in the diagnosis of traumatic brain injury, including subdural and epidural hematoma following head trauma.

 

 

The medical literature contains reports of false negative early CT following minor head injury, however in this review, they were rare (3 adverse outcomes in 65,000 cases), hence their recommendation:

 

The strongest scientific evidence available at this time would suggest that a CT strategy is a safe way to triage patients for admission.

http://emj.bmj.com/content/22/2/103

Case reports of delayed diagnosis of subdural / epidural hematoma following normal CT scan 

http://www.sciencedirect.com/science/article/pii/S0196064494701156

http://thejns.org/doi/abs/10.3171/jns.1985.63.1.0030

 

In patients who present, following head trauma, with persistent symptoms despite initially normal head CT, repeat imaging with MRI is recommended.

Symptoms of subdural hematoma

  • slurred speech.
  • loss of consciousness or coma.
  • seizures.
  • numbness.
  • severe headaches.
  • weakness.
  • visual problems.

 

 


Posterior shoulder dislocation can be missed if not specifically ruled out

 

Posterior shoulder dislocation is less common than anterior dislocation. It is a commonly missed diagnosis in the Emergency Department. It can occur following trauma and should be specifically considered following seizure / electric shock.

The patient present with shoulder pain and reduced range of movement. The shoulder / arm is adducted and internally rotated.

A single AP shoulder radiograph is unreliable, but may show the ‘lightbulb sign’. The axillary lateral is usually diagnostic but may be not be possible due to pain.

Posterior shoulder dislocation should be considered in all patients where the axillary lateral was impossible to perform due to pain and immobility. A scapular Y view should be performed

 

AP Shoulder – Lightbulb sign – posterior dislocation – due to internally rotated humeral head

 

AP Shoulder – posterior dislocation (more subtle appearance) – malalignment of joint line

 

 

Axillary view – posterior dislocation

 

Scapular Y view – posterior dislocation

 

Point of Care Ultrasound

Ultrasound can be very useful for diagnosing shoulder dislocation and can be performed quickly prior to formal radiography. The transducer is placed in a transverse orientation, posteriorly, just below the scapular spine. Move laterally to the joint.

 

 

 

 

In comparison to radiography, US had a sensitivity of 100.0%, specificity of 80.0%, positive predictive value of 98.7%, and negative predictive value of 100.0% in diagnosis of shoulder dislocation. The specificity of US in diagnosis of proper reduction of the joint, was estimated to be 98.7% with a negative predictive value of 100.0%. US took a significantly less time than radiography to be performed (p < 0.001).

http://www.sciencedirect.com/science/article/pii/S2452247317300791

 

 



 

CME QUIZ

EM Reflections - Nov 17 - CME Quiz

EM Reflections – Nov 17 – CME Quiz

 

Continue Reading

RCP – Animal Bites

Animal Bites

Resident Clinical Pearl (RCP) – November 2017

Renée Amiro, R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Mr. Stark brings in his 8-year-old adopted son, Jon Snow, to the emergency room on Christmas day. Jon had just received a puppy, Ghost, as a Christmas present that morning. Jon, who knows nothing (about raising puppies), was playing too rough with the pup and got a bite on his right hand.

How do we appropriately manage this animal bite in the emergency room?

Management

When a patient presents to the ED with an animal bite, the factors in management that need to be addressed are:

  1. How to properly care for the wound
  2. Is antibiotic prophylaxis needed?
  3. Does the wound require closure with sutures?
  4. When does a bite require surgical consultation?
  5. When should you worry about tetanus and rabies?

 

Caring for the wound

Managing an animal bite has much of the same principles of usual good wound care

  1. Control hemorrhage
  2. Preform a neurovascular assessment
  3. Clean the wound meticulously. This is very important in animal and human bites. To reduce the number of bacteria, the wound should be flushed with copious amounts of saline or water

Local anesthetic should be used to reduce pain and facilitate cleaning. The wound should also be inspected for foreign bodies. Bites overlying joints should be put through their entire range of motion (bone, tendon or joint capsule involvement). If you suspect a foreign body but can’t see it, get an x-ray.

Pearl: for puncture wounds (cats are the biggest perpetrators), the same principles of wound care apply except superficially irrigate wounds and do not use high pressure

 

Is antibiotic prophylaxis needed?

Most bites to not require prophylactic antibiotics. There are some high-risk wounds that do. Those include:

  1. Deep puncture wounds (think cats)
  2. Associated crush injury
  3. Injury in areas overlying venous or lymphatic compromise
  4. Primary closure of the wound
  5. Wounds on hands, genitals or overlying joints
  6. Host factors: immunocompromised, diabetes

Table of prophylactic antibiotic choices. Duration of therapy depends on the antibiotic choice.

Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

Does the wound requires closure with sutures

Generally, no, especially if cats are the perpetrators. But if cosmetic concerns arise, wounds should meet all the following criteria before primary closure:

  1. Clinically uninfected
  2. < 12 hrs old (<24 hrs on the face)
  3. NOT located on the hand or the foot

The wound should NOT be closed primarily if the following criteria are met:

  1. Crush injuries
  2. Hand and foot wounds
  3. Deep puncture wounds
  4. Cat or human wounds
  5. Immunocompromised host
  6. >12 hrs old

 

When does a bite require surgical consultation?

If the injury results in complex facial wounds, neurovascular compromise, osteomyelitis or joint infection or deep wounds that penetrate underlying structures (joint, bone, tendon), get a surgical consultation.

That being said, consider consultation with any deep wound on the hand.

 

When do I worry about tetanus and rabies prophylaxis?

When considering tetanus prophylaxis, the decision to intervene is the same in non-bite wounds.

   Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

For rabies, post-exposure prophylaxis is generally not needed in patients with a dog or cat bite as long as the animal is not showing signs of rabies: dysphagia, abnormal behaviour, paralysis, seizures and ataxia.

Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

Bottom Line: Animal bites, like other wounds, require regular wound care with a focus on meticulous cleaning. Cat bites usually need prophylactic antibiotics, dogs usually do not. All immunocompromised hosts get prophylactic antibiotics

 

References

  1. Baddour, L. and Sexton, D. Soft tissue infections due to dog and cat bites. Retrieved from https://www.uptodate.com/contents/soft-tissue-infections-due-to-dog-and-cat-bites. Accessed August 1, 2017.
  2. Callaham, M. Controversies in antibiotic choices for bite wounds. Ann Emerg Med 1988; 17:1321.
  3. Ellis, R. and Ellis, C. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

This post was copyedited by Kavish Chandra @kavishpchandra

Continue Reading

New SJRHEM Dalhousie Course – Debriefing Skills for Simulation – The Basics

New SJRHEM Dalhousie Course – Debriefing Skills for Simulation – The Basics

When Is It?

8th-9th February 2018

Who is this for?

If you are interested in using simulation for education in healthcare, then this is for you! We aim to give you the basic skills needed to start debriefing in your own institution. This is a practical course with lots of opportunities to debrief.

 

 

Download (PDF, 260KB)

 

 

Continue Reading

RCP – Dental Block, ER Doc

Another Solution for Dental Pain when “NSAIDs do nothing for me Doc!

Resident Clinical Pearl (RCP) – Guest Resident Edition

Peter Leighton,  R3 FMEM 2+1, Dalhousie University, Halifax

Reviewed by Dr. David Lewis

 

Dental pain is a common problem encountered in the Emergency Department (ED), yet physicians in the ED often have no to little education regarding management of dental pain. Depending on where you read, dental pain complaints account for 1-5% of emergency department visits. A common approach consists of looking for infection and providing a prescription for antibiotics and NSAIDs along with recommendation to follow up with a dentist. Although, there is good evidence for NSAIDs in dental pain, some patients find that it does not help enough with their pain or they have contraindications to NSAIDs. This often leads to the prescription of opioids for dental pain. Given the recent opioid crisis in Canada, there has been a search for other forms of management of toothache/dental pain in the ED. Insert the dental block! It’s fast, easy, and provides good pain relief, while providing a chance for patients to book an appointment to see their dentist the following day. There has been some evidence that this method achieves good pain control for the patient and may help lower opioid prescriptions in the ED for dental pain.

There are essentially 2 blocks you will need to know:

  • The Inferior Alveolar Nerve Block (Mandibular teeth)
  • Supraperiosteal Infiltrations (Maxillary teeth)

Indications

  • Dental abscess
  • Toothache
  • Pulpitis
  • Root impaction
  • Dry socket
  • Post-extraction pain
  • Trauma – lacerations, fractures

Contraindications

  • Allergy to local anesthetic
  • Distortion of landmark
  • Uncooperative patient
  • Injecting through infected tissue – may cause bacteremia
  • Cardiac congenital abnormalities and mechanical valves – require prophylaxis for endocarditis
  • Coagulopathy

What you will need

  • Syringe
  • Needle – 25-27 gauge and 1.5 inch
  • Lidocaine with epinephrine (max dose 7 mg/kg)
  • Bupivicaine +/- epinephrine (max dose 2 mg/kg)
  • Non-sterile gloves
  • Suction and light source may be required

 

The combination of Lidocaine and Bupivicaine allow the mix of immediate analgesia from the Lidocaine and prolonged duration of action by the Bupivicaine. The addition of Epinephine will also increase duration of effect. This combination should provide approximately 8 or more hours of anesthetic effect.

 

Technique:

Supraperiosteal Infiltration

Pull out patient’s cheek laterally to have a good view of the patient’s tooth and gingiva. Insert needle into the mucobuccal fold just above the apex of the tooth to be anesthetized. Keep the needle parallel to the tooth and insert it a few millimeters until needle tip is above the apex of the tooth. If bone is contracted, withdraw 1-2mm and aspirate. If no blood is aspirated then inject 1-2 ml of anesthetic. If blood is aspirated then withdraw and reposition.

 

From: www.ebmedicine.net – click here for full article

 


 

Inferior Alveolar Nerve Block

Place your thumb in the coronoid (mandibular) notch of the patient and extend the patient’s cheek out laterally so you can see the patient’s pterygomandibular raphe. Place your syringe in the opposite corner of the mouth and with your needle at the middle level of the raphe, aim just lateral to the raphe. Insert your needle approx. 2-2.5cm until you hit bone. Pull back a millimeter and aspirate twice. If any blood on aspiration, withdraw and reposition more laterally. If no blood with aspiration then inject 1-2ml of anesthetic.

 

From: Jason Kim’s Blog – click here for full article

 

 

From: www.ebmedicine.net – click here for full article

 


 

Videos:

Please see the dentistry videos below to review anatomical landmarks of both techniques:

 

Supraperiosteal technique

 

Inferior Alveolar Block

 


 

References

 

  1. Complications, diagnosis, and treatment of odontogenic infections [Internet]; c2017 [cited 2017 November 10]. Available from: https://www.uptodate.com/contents/complications-diagnosis-and-treatment-of-odontogenic-infections?source=search_result&search=dental%20pain&selectedTitle=1~150.
  2. Fixing Faces Painlessly: Facial Anesthesia In Emergency Medicine [Internet]; c2017 [cited 2017 November 12]. Available from: https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=207&seg_id=4229
  3. Fox TR, Li J, Stevens S, Tippie T. A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine 2013;62(3):237-40.
  4. IA with a Short Needle [Internet]; c2015 [cited 2017 November 10]. Available from: https://www.youtube.com/watch?v=1Mf3f0XmsqI.
  5. 5. Local Infiltration [Internet]; c2014 [cited 2015 November 10]. Available from: https://www.youtube.com/watch?v=Y2NSuxd7j_g.
  6. How I learned to love dental blocks [Internet]; c2014 [cited 2017 November 10]. Available from: http://www.clinicaladvisor.com/the-waiting-room/dental-blocks-useful-in-emergency-medicine/article/382951/.
  7. M2E Too! Mellick’s Multimedia EduBlog [Internet]; c2014 [cited 2017 November 10]. Available from: http://journals.lww.com/em-news/blog/M2E/pages/post.aspx?PostID=32.
  8. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice. J Am Dent Assoc 2013 Aug;144(8):898-908.
  9. Okunseri C, Dionne RA, Gordon SM, Okunseri E, Szabo A. Prescription of opioid analgesics for nontraumatic dental conditions in emergency departments. Drug Alcohol Depend 2015 Nov 1;156:261-6.
  10. Patel NA, Afshar S. Addressing the high rate of opioid prescriptions for dental pain in the emergency department. Am J Emerg Med 2017 Jul 3.
  11. Oral Nerve Block [Internet]; c2016 [cited 2017 November 10]. Available from: https://emedicine.medscape.com/article/82850-overview#a1.
  12. Dental Pain in the ED: Big Solution in a Small Package [Internet]; c2005 [cited 2017 November 10]. Available from: http://journals.lww.com/em-news/Fulltext/2005/06000/Dental_Pain_in_the_ED__Big_Solution_in_a_Small.12.aspx.

 

 

Continue Reading

SJRHEM Journal Club Report Oct 2017

SJRHEM Journal Club Report Oct 2017

Allyson Cornelis, R1 iFMEM

Hosted by Dr Andrew Lohoar


Abstract:

Idarucizumab for Dabigatran Reversal — Full Cohort Analysis

Charles V. Pollack, Jr., M.D., Paul A. Reilly, Ph.D., Joanne van Ryn, Ph.D., John W. Eikelboom, M.B., B.S., Stephan Glund, Ph.D., Richard A. Bernstein, M.D., Ph.D., Robert Dubiel, Pharm.D., Menno V. Huisman, M.D., Ph.D., Elaine M. Hylek, M.D., Chak-Wah Kam, M.D., Pieter W. Kamphuisen, M.D., Ph.D., Jörg Kreuzer, M.D., Jerrold H. Levy, M.D., Gordon Royle, M.D., Frank W. Sellke, M.D., Joachim Stangier, Ph.D., Thorsten Steiner, M.D., Peter Verhamme, M.D., Bushi Wang, Ph.D., Laura Young, M.D., and Jeffrey I. Weitz, M.D.

N Engl J Med 2017; 377:431-441August 3, 2017DOI: 10.1056/NEJMoa1707278

 

BACKGROUND
Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran.

METHODS
We performed a multicenter, prospective, open-label study to determine whether 5 g of intravenous idarucizumab would be able to reverse the anticoagulant effect of dabigatran in patients who had uncontrolled bleeding (group A) or were about to undergo an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the diluted thrombin time or ecarin clotting time. Secondary end points included the restoration of hemostasis and safety measures.

RESULTS
A total of 503 patients were enrolled: 301 in group A, and 202 in group B. The median maximum percentage reversal of dabigatran was 100% (95% confidence interval, 100 to 100), on the basis of either the diluted thrombin time or the ecarin clotting time. In group A, 137 patients (45.5%) presented with gastrointestinal bleeding and 98 (32.6%) presented with intracranial hemorrhage; among the patients who could be assessed, the median time to the cessation of bleeding was 2.5 hours. In group B, the median time to the initiation of the intended procedure was 1.6 hours; periprocedural hemostasis was assessed as normal in 93.4% of the patients, mildly abnormal in 5.1%, and moderately abnormal in 1.5%. At 90 days, thrombotic events had occurred in 6.3% of the patients in group A and in 7.4% in group B, and the mortality rate was 18.8% and 18.9%, respectively. There were no serious adverse safety signals.

CONCLUSIONS
In emergency situations, idarucizumab rapidly, durably, and safely reversed the anticoagulant effect of dabigatran. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.)

 

http://www.nejm.org/doi/full/10.1056/NEJMoa1707278

 


SJRHEM Journal Club Report

 

Download (PDF, 89KB)

 

Continue Reading

EM Reflections – October 2017

Thanks to Dr Joanna Middleton for leading the discussion this month

Edited by Dr David Lewis

Top tips from this month’s rounds:

  1. Imaging reports can underestimate the clinical impact of an incidental finding

  2. Neuro ICU in the Emergency Department?

 


Imaging reports can underestimate the clinical impact of an incidental finding

Not all benign conditions have a benign outcome. A CT report will occasionally underestimate the clinical impact of an incidental finding. Its always worth reviewing the images yourself.

For example – a report might read – “No acute bleed or infarct, incidental finding of frontal bone fibrous dysplasia” –  may sound innocuous and unrelated to the patient’s headache, until you review the scans yourself:

 

Fibrous dysplasia is a benign condition which can present with new craniofacial asymmetry. Whilst the condition itself may be benign, the location and speed of growth can result in symptoms, especially headache and even cranial nerve compression.

Clinical Guidelines for managing craniofacial fibrous dysplasia

 


Neuro ICU in the Emergency Department?

 

Management of Intracranial Hemorrhage in the Emergency Department can be complex. The diagnosis is usually straightforward with CT (providing it has been considered as a possibility – subarachnoid hemorrhage can present with syncope alone) and the broad category of bleed determined by the history, patient age, CT appearance, etc.

ED Management will depend on the category of bleed (Primary ICH, Subdural, Epidural, Traumatic SAH, Spontaneous SAH).

From ALIEM.com, click here for the full article

 

Initial management of intracranial hemorrhage can be simplified / summarized as follows:

Airway – ET Intubation if GCS < 9

Breathing – Ventilate if GCS < 9 (SaO2 >94%, ETCO2 35-45 mmHg)

Circulation

  1. Stop the bleeding
    1. Neurosurgery (see here for indications)
    2. Reverse anticoagulation
    3. ?Tranexamic acid
  2. Maintain an adequate cerebral perfusion pressure (CPP) to ensure adequate tissue oxygenation
    1. CPP = Mean Arterial Pressure (MAP) – Intracranial Pressure (ICP)
      1. Seems simple enough? – ensure the patient’s blood pressure is high enough to overcome the ICP
    2. However, the optimal CPP following acute brain injury is not known (general consensus suggest 50-70 mmHg)
      1. In the normal brain CPP is maintained by autoregualtion
      2. Autoregulation is less effective after brain injury
      3. If the CPP is too low brain hypoxia occurs
      4. If the CPP is too high there may be a risk of hematoma expansion
    3. However, it’s not easy to measure the ICP
      1. Methods of non-invasive ICP estimation:
        1. Level of consciousness
        2. Papilledema
        3. CT appearances
        4. Transcranial doppler
        5. Sonographic Optic Nerve Sheath Diameter
        6. Lots of others
        7. None of these are perfect
      2. Invasive ICP measurement
        1. External Ventricular Drain – Neurosurgical procedure
        2. Setting up the EVD and measuring ICP requires experienced nursing staff (see below)
    4. Even measuring the MAP is not without its own problems in the ED
      1. MAP = (Systolic BP + 2(Diastolic BP))/3
      2. However non invasive measurement of MAP (based on SBP and DBP peripheral sphygmomanometry) is not accurate.
      3. An accurate measurement of MAP requires invasive monitoring via an arterial line.
    5. Assuming that we are able to accurately measure ICP and MAP, there is then the question of how to adjust these values reliably via therapeutic interventions.
      1. ICP Management (Normal = 0-15, Goal < 20)
        1. Patient position, head up
        2. Sedation and paralysis, if patient aggitated
        3. Mannitol – potential risk of acute kidney failure in prolonged use
        4. Hyperventilation – will also reduce cerebral blood flow – so PaCO2 no lower than 35 mmHg
        5. CSF Drainage : 
        6. Hypothermia
      2. MAP Management
        1. IV Fluid (crystalloid vs colloid?)
        2. Diuretics / Antihypertensives vs Inotropes
        3. A very detailed guide to blood pressure management in stroke can be viewed here: BP-Stroke


I suspect that most emergency physicians/nurses are wondering whether this level of care falls within their remit. In most hospitals the answer will be NO, these cases are stabilised and managed in an Intensive Care Unit. However, there are occasions when this level of care is required prior to transfer to another unit/hospital, in which case it is likely that the care will be directed by the local neurosurgeon / neurointensivist and the receiving specialists.


EVD Drainage System and ICP Monitoring

 

Suggest ICP Protocol from Vancouver General ICU

Download (PDF, 110KB)

 


 

CME QUIZ

 

ED Reflections - CME Quiz - Oct 2017

ED Reflections – CME Quiz – Oct 2017

 


 


Click Print, PDF or Email to save a record of this CME

Continue Reading

RCP – the “Easy IJ”

The “easy IJ”, a quick solution for difficult intravenous access?

Resident Clinical Pearl (RCP) – September 2017

Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

The importance of intravenous (IV) access is something seared in the mind of every practicing emergency department physician. Over the years, central intravenous access for difficult IV access has been obviated by the intraosseous drill and line. Furthermore, we just see and do less central IV lines. The likely reasons for this are that running vasopressors in peripheral intravenous (IV) lines is becoming more accepted as well as the increased time associated with placing a fully sterile central line (draping, etc.) as well as the risks of the over-the-wire procedure (infection, deep vein thrombosis, cardiac arrhythmias).

Enter the internal jugular vein catheterization using a peripheral IV catheter1, which is placed under a limited sterile environment. Is the 5 minutes to establish access that “easy” when peripheral access and external jugular catheterization has failed?

The materials required:

  1. US machine with high-frequency linear transducer probe
  2. Chlorhexidine swab
  3. 4.8-cm, 18-gauge single lumen catheter
  4. Two bio-occlusive adherent dressings
  5. Sterile ultrasound jelly
  6. A loop catheter extension
  7. A saline flush

Figure 1. Visual diagram of required materials for the “easy IJ”, adapted from Moayedi et al. (2016).

 

The steps:

  • Place your patient in the Trendelenburg position or instruct them to perform a Valsalva maneuver
  • The needle is inserted into the skin at approximately 45 degrees
  • Ultrasound is used to confirm real-time placement out of plane, followed by in-plane visualization to see the catheter in the vessel lumen
  • See this video for a demonstration: https://www.youtube.com/watch?v=FjSmbUWXznY

 

 

 

What does the evidence say2?

  • When studied in stable emergency department patients when peripheral or external jugular venous access was unsuccessful, the success rate of this procedure was 88% (95% CI 79-94)
  • The mean time to procedure completion was 4.4 minutes (3.8-4.9)
  • In 83 access attempts, there were no cases of pneumothorax, infection or arterial puncture
  • There was a 14% loss of IV patency immediately after insertion
  • Painful? Don’t forget, these lines were placed without local anesthesia; however, the mean pain score was 3.9 out of 10 (3.4-4.5)

Practical considerations:

So will this technique change your practice? A few things to be aware of:

  • In obese patients, the target vessel will be inherently more difficult to visualize, as well as the catheter length in this study may not be long enough to ensure patency. The median BMI in the Moayedi et al. (2016) study was 27
  • Operator skill: the vast majority of lines were placed by clinicians experienced in ultrasound guided line placement. Success and time to placement may be increased as experience decreases
  • Will more definitive access be required? The catheters placed in this study were largely only used for 24 hours. This would certainly be more than sufficient during the treatment of an ED patient, but usage time increases, infection rates will likely increase
  • Will this line achieve the infusion rate you need? See this article on infusion rates of various IV catheters

 

The bottom line: the “easy IJ” is a rapid, effective and safe alternative to establish IV access in stable patients in whom peripheral and external jugular venous attempts have failed.

 

References

(1) Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The ultrasound-guided “peripheral IJ”: internal jugular vein catheterization using a standard intravenous catheter. J Emerg Med 2013 Jan;44(1):150-154.

(2) Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. J Emerg Med 2016 Dec;51(6):636-642.

 

 

Continue Reading

“At work, at home”

As I began a new role with WorkSafeNB, alongside ongoing work in Emergency Care, I thought that perhaps it was timely to reflect on some of the best ways that we can all improve our health and the health of our patients, whether at work, or at home. Too often, we equate our health with how we feel, what pills we take, or how often we see a nurse or doctor. We all have a much greater influence and control over the quiet processes underpinning our physical and mental health than we are aware of.

How can we, as a society, achieve mindfulness that while some parts of our bodies (neurons) are as old as we are, others (skin, lungs, liver and even our heart) are replaced over time, cell by cell? That the food we eat is not just fuel for our bodies, but also supplies the building blocks – the replacement parts for our organs? To consider that when we drink that bottle of sugary pop to wash down the nachos or pizza, we should not be surprised if the body we build, over time, reflects those choices. If we sit all day, every day, and then suddenly need to run to catch a bus, or climb a flight of stairs, is it surprising that our leg muscles cry out in protest, and our heart pounds to alert us to its stress?

I believe that 2017 is as good a year as any for us as a society, and as individuals, to make some changes, so that in 2018, 2028 and beyond, we have a little bit more health, and a little less “health care” in our lives. How does that relate to work? Let’s look at a few scenarios: working, being unemployed, disability, going back to work and time spent at home.

Working: In general, going to work is good for us. Working is the most common way to make a living and attain financial independence. We know that long spells without work are harmful to physical and mental health. Earning enough money to eat well, to afford leisure, to reduce stress around meeting payments is likely to benefit our health. Work also meets many psychosocial needs including identity and providing a purpose in life.

However, many jobs pose both physical and psychological hazards that can risk health. These might include the dangers associated with construction, operating machinery or performing repetitive tasks, or may simply be the amount of sitting down at work. People who sit for prolonged periods of time have a higher risk of dying from all causes — even those who exercise regularly.

Unemployment: There is a strong association between not working and being in poor health. Unemployed people die earlier, have more physical and mental health issues, and use medical resources more frequently.

Disability: Injured and ill workers need the time and medical interventions provided to them by workers’ compensation, or other insurance, to recover from their injury or illness. However, they too will suffer the ill effects of being off work for extended periods of time.

Going back to work: For the most part, the negative effects of not working can be reversed by going back to work. Disabled and sick individuals should be encouraged and supported to return to some form of work as soon as possible, when their health condition permits. Again, this helps to promote recovery and rehabilitation; leads to better physical and mental health outcomes; improves their economic position and improves quality of life overall.

At home: Many of the factors that influence health in the workplace also apply at home and in all other settings. Better food, less sitting, more exercise, more relaxation, and active community engagement all improve our health and wellbeing.

We all know these things to be true. Physicians and politicians talk about educating the public. And yet rates of obesity, diabetes, high blood pressure, mental health issues and many other chronic illnesses continue to increase. So, while we must continue to promote healthy choices, it is clear that education and information are not very effective without systemic change.

Over the past century, major health improvements and increased life expectancy came about because of clean water and rapid declines in infectious disease, including immunization policy, as well as broad economic growth, rising living standards, and improved nutritional status. Much of this change has been at a societal level, rather than individual – in other words, ordinary people didn’t really need to make any special effort to benefit from these things. More recent smaller gains have resulted from advances in treatment of cardiovascular disease and control of its risk factors, such as smoking.

Frieden’s “Health Impact Pyramid” clearly shows that if we want to improve health, the most effective and straightforward means is through improving socio-economic factors. However, the next level of action is challenging. “Changing the context to make individuals’ default decisions healthy” may sound to some a little too much like the “nanny state” or “big brother.” But does true independent individual choice exist? We tend to eat similar foods to those around us – think of the difference you notice when you travel to another culture. The milk we drink, the bread we eat – as individuals, we do not control the ingredients. We have similar habits to those around us – think social media, cars we drive, holidays we celebrate. These choices all contain elements that are beyond our control, yet they influence our health every day. Individual choices will move in a healthier direction when government, industry and community leadership come together to establish a healthier environment.

I will sign off with my suggested prescriptions for 2017. These are all achievable, without a major amount of effort, at minimal cost, but with major potential benefit:

Prescription for Workers:

Engage in your job. Remain as physically active as possible at work – stand rather than sit, for periods of time; use the stairs rather than the elevator. Eat well – pack a salad for lunch; don’t bring unhealthy sugary snacks to work. Take regular breaks, each day, each week, and use your vacation to renew body and mind. Safety – always take full safety precautions; never operate dangerous machinery when fatigued, distracted or intoxicated; report any dangers you discover.

Prescription for Employers:

Engage your workers. Provide opportunity for physical activity. Facilitate options for healthy eating. Schedule workers appropriately, allowing adequate rest periods. Provide support for stressed, sick, or injured workers. And of course, always provide a safe work environment, cultivating a safety culture where workers are comfortable discussing dangers and precautions.

Prescription for Decision Makers (Government, Healthcare Providers, Industry, etc.):

Continue to work towards full employment. Promote exercise, and make it easier for all to exercise safely – with walking paths, cycle lanes and paths, safe crosswalks. Encourage a better general diet – create incentives for healthy choices. Encourage and incentivize the healthcare sector to make cost effective choices for treatment and investigation. Prioritize health and prevention of disease when making policy decisions – factor in long term investment and cost savings over short term gains. Help create a healthy, safe culture for all.

Prescription for All of us at Home:

Let’s think about what food we buy – we are likely to eat it! We are what we eat (and drink) – it is not just fuel. Don’t drink sugary beverages – they will damage our livers and increase our chance of diabetes and obesity. Don’t smoke – it kills – and help is available to stop. Stand up, walk around, then walk some more. There are 24 hours in a day – why not spend at least half an hour exercising? Spend some time with friends and family, and spend some time alone, thinking.

Here’s to a healthier 2017, at work, and at home.

Dr. Paul Atkinson MB MA FRCPC
Professor and Research Program Director
Emergency Medicine
Dalhousie University
Saint John Regional Hospital
Saint John, NB E2L 4L2Chair, Department of Emergency Medicine Research Committee,
Dalhousie University in New Brunswick

Chief Medical Officer, WorkSafeNB

Senior Editor, Canadian Journal of Emergency Medicine

paul.atkinson@dal.ca

@Eccucourse

Dr Paul Atkinson

 

For original article in OPUS MD and French version see below.

Download (PDF, 205KB)

Continue Reading