EM Reflections – February 2019

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

Edited by Dr David Lewis 


Discussion Topics

  1. Can diagnostic ultrasound reliably rule out appendicitis?
  2. Do mandibular fractures need to be admitted?
  3. Can neuromuscular disorders alone result in symptoms of dyspnoea?

Can diagnostic ultrasound reliably rule out appendicitis?

  • Accuracy depends upon the skill and experience of the sonographer – when the appendix is visualized the accuracy of ultrasound is equivalent to CT – sensitivity and specificity of 91-98% and 86-92%
  • Inaccurate examinations were significantly associated with high body mass index (≥85th percentile, primarily false-negative results) 

In this case, a patient with clinically suspected appendicitis, had an ultrasound that was reported normal i.e the appendix was visualized and appeared normal. A subsequent CT confirmed the diagnosis of appendicitis.

Take Home Point: All diagnostic tests have a false negative rate. If it looks like a sock, even if the test says it isn’t, it still might be.


Do mandibular fractures need to be admitted?

  • Must assess open vs closed – open needs ABx
  • Consider MOI/associated injuries
  • Bilateral #’s – airway obstruction 
    • Posterior displacement of the tongue
    • Bleeding – tearing of the periosteum and muscles attached to the mandible – sublingual hematoma, swelling and life-threatening airway compromise
    • Edema
    • FB

Admission Criteria:

Admit (ENT, OMFS, Plastics) for:

  1. Airway compromise (e.g when lying flat)
  2. Unable to tolerate PO or secretions
  3. Inadequate pain control
  4. Open and/or unstable fractures

Useful review article here

In this case the patient was admitted to Family Medicine after discussion with other relevant specialties.

Recommended Disposition Guidelines for Trauma Patients:

Take Home Point: Mandibular fractures are usually indicative of significant force. They are usually fractured in 2 places and therefore unstable. Disposition to appropriate specialist and level of care is recommended.


Can neuromuscular disorders alone result in symptoms of dyspnoea?

Consider all the common causes of dyspnoea first

“No single abnormality is diagnostic of respiratory muscle weakness; rather, diagnosis is based on a constellation of abnormalities. The use of single tests tends to overdiagnose respiratory muscle weakness, whereas use of combinations of tests increase diagnostic accuracy.”

And interesting case report here

Take Home Point: A differential diagnosis should always include the common conditions, but also consider the rarer conditions. Online tools are available to help with rare disease diagnosis – see this article

Some online differential diagnosis tools:

http://www.findzebra.com/

https://www.isabelhealthcare.com/

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EM Reflections – December 2018

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

Edited by Dr David Lewis 

Dr. Middleton’s Tips:

  1. Lower extremity fractures that require reduction – consider posterior slab with a stirrup rather than a circumferential cast.  
  2. We have a C-arm…use it!  Sending grossly deformed bony injuries to the X-ray department for imaging can result in long delays to reduction/treatment.
  3. Handover is high risk and is a recurrent theme in EM reflections…it shouldn’t occur as a hallway conversation in passing.  Be sure to communicate what the handover physician needs to do and as the handover physician you should document completion of the task.
  4. Pelvic fractures can occur with low mechanism injuries, particularly in the elderly.  Pelvic fractures differ from hip fractures – it raises the severity of injury and should warrant a lower threshold for CT.  Pelvic fractures should have a full trauma evaluation.
  5. Episodes of hypotension in trauma patients should trigger a re-evaluation of a patient and bleeding should always be considered.
  6. Cross table lateral can help if you are unsure if the hip is out of joint.
  7. If you are taking over a sick patient in handover, be sure to document on the chart.

Tibial Shaft Fractures

High risk for compartment syndrome

Initially, all tibial shaft fractures should be stabilized with a long posterior splint with the knee in 10-15° of flexion and the ankle flexed at 90°. Admission to the hospital may also be necessary to control pain and to monitor closely for compartment syndrome.

Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application should be delayed for 3-5 days to allow early swelling to diminish. The cast should extend from the mid thigh to the metatarsal heads, with the ankle at 90° of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling

Tibial shaft fractures, even distal ones, are a different animal to ankle fractures. Forces involved in injury are much greater. There is no universally accepted classification for tibial shaft fractures. Describe the following:

  • Location (prox, middle, distal)
  • Configuration (transverse, spiral, comminuted)
  • Displacement
  • Angulation
  • Length
  • Rotation
  • Open/Closed

Ankle Classification

Type A. Fracture of the fibula distal to syndesmosis. An oblique medial malleolus fracture may also be present. 

Type B. Fracture of the fibula at the level of the syndesmosis. These fractures may be stable or unstable, based upon the presence of deltoid ligament rupture or medial malleolus fracture. 

Type C. Fracture of the fibula proximal to syndesmosis. These unstable fractures are generally associated with syndesmosis injuries, and may include medial malleolus fracture or deltoid ligament 

Full Cast vs Splint

There is little evidence favouring splint vs cast in acute lower extremity unstable fractures.  Splints are generally recommended in both reviews and textbooks, but these recommendations are not referenced. However the general consensus seems to be favouring Splint over Cast – to avoid the risk of swelling and subsequent compartment syndrome.

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Emergency clinicians have virtually abandoned the use of circumferential casts in favor of premade commercial immobilizing devices or splints made from plaster of Paris or fiberglass. The impetus for this change is primarily related to the complications occasionally associated with circumferential casts, liability issues, and ease of application brought about by new technology. In most instances, properly applied splints provide short-term immobilization equal to that of casts while allowing for continued swelling, thus reducing the risk of ischemic injury.


Acetabular Fractures vs Hip Fractures

Hip fractures are usually low impact pathological fractures and rarely associated with hemorrhage. Acetabular fracture is a PELVIC # and they bleed……

Bleeding from bone and retroperitoneal venous plexus makes up 90%, the other 10% is arterial

Patients with acetabular fractures have a high incidence of associated injuries and a full trauma assessment should be performed. 

Geriatric Acetabular Fractures

  • Often low-energy trauma in osteoporotic bone
  • 1/3 have associated injuries
  • 33% one year mortality rate
  • Judet views helpful

See this post for an approach to interpreting Pelvic X-Rays:

http://www.tamingthesru.com/blog/diagnostics/pelvic-xrays

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EM Reflections – November 2018

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

Edited by Dr David Lewis 


Top tips from this month’s rounds:

1. Severe Metabolic Acidosis

2. Ovarian Torsion

3. Acetaminophen Overdose


Severe Metabolic Acidosis with Unexplained Anion Gap

Case: Female presents with reduced LOC, found with large empty bottle of gin. Smells of alcohol. Hypothermic. VS otherwise stable.

VBG: pH – 6.89, pCO2 – 28, bicarb – 6, Lactate – 21

Anion Gap

Anion Gap = Na+ – (Cl- + HCO3-)

An elevated anion gap strongly suggests the presence of a metabolic acidosis. The normal anion gap depends on serum phosphate and serum albumin concentrations. The normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L)

MDCalc Anion Gap Calculator

Common Causes (MUDPILES):

  • Metformin, Methanol
  • Uremia
  • DKA
  • Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde
  • Iron, Isoniazid
  • Lactic acidosis
  • Ethylene glycol
  • Salicylates

Dr. Pages’s Tips: Keep toxic alcohols in the differential.  Early antibiotics for possible sepsis. Remember for sick patients to consult early to appropriate services to expedite disposition.  Sick patients take up a lot of nursing resources so also be aware of impact on nursing care and resources with these patients.


Ovarian Torsion

This is a gynae/surgical emergency, delayed diagnosis may lead to loss of ovary. Early diagnostic ultrasound is recommended.

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages.

Presents with acute onset severe lower abdominal pain, with nausea and vomiting.

Benign ovarian cyst > 5cm is the usual cause. Torsion can also occur in normal ovaries, however, particularly in premenarchal girls who have elongated infundibulopelvic ligaments 

Dr. Page’s Tips: Increased risk with large cysts but can occur without cysts as well.Time sensitive dx so need to be vigilant with assessment. When considering as dx need to get U/S arranged and gynaecology consultation. Remember we have 24 hour U/S coverage but we have to ask for the U/S.


Acetaminophen Overdose

Survival from a acetaminophen overdose is generally considered to be 100% in cases receiving NAC within 8 hours of exposure. Efficacy declines after this point. Therefore early recognition is paramount. Don’t miss the treatment window by not considering.

This post from LITFL does a great job outlining the management of Acetaminophen (Paracetamol) toxicity:

Also with have discussed Acetaminophen toxicity in EM reflections in June 2018:

and also in December 2016:

Dr. Page’s Tips: Correlate presentation with timeframe to see if adds up regarding time of OD. When patient being assessed by other services (with primary resident assessment) we need to keep in mind these are still our patients and review to make sure the plan seems appropriate.

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Trauma Reflections – October 2018

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

 


Major points of interest:

 

A)  Intubated patients should not need restraints..

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

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

 

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

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

 

C)  Trauma patients you know will require consultants

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

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

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

 

E) Managing the pediatric airway – adrenalizing for all involved

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

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

 

F) MTP

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

 

G)  Where is this patient being admitted?

Not to the hospitalist service, that is where!

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

 

H)  Chest tube types and sizes

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

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

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

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EM Reflections – September 2018

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

Edited by Dr David Lewis 

 

 


 

Top tips from this month’s rounds:

 

Pediatric Head Injury

Clonazepam Toxicity

Pediatric(< 3 months)Fever

Wide Complex Tachycardia

 


Pediatric Head Injury

  • What are the criteria for CT Head?

In a recent Lancet article (2017),  PECARN, CATCH and CHALICE were compared.

The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7–100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4–100·0; 97/98)

  • How do I use PECARN?


 

A useful review by EM Cases can be accessed here. In an update to this review they have noted recent new evidence that isolated vomiting without any other positive rule predictors may warrant observation only:

Update 2018:  A secondary analysis of the Australasian Paediatric Head Injury Rule Study demonstrated head injury with isolated vomiting (i.e. vomiting without any of clinical decision rule predictors) was uncommonly associated with TBI on CT, or the presence of clinically important TBI.  This study suggests a strategy of observation without head CT may be appropriate management.  Abstract

Vomiting alone should not instigate CT.  Risk goes up with any other Head Injury symptoms (Headache etc). These children should be observed until they are able to tolerate oral intake and the treating clinician feels comfortable that the patient is stable without additional symptoms of head injury.

This article discusses linear skull fractures. It reminds us to always consider Non-Accidental Injury in all cases of pediatric head injury, especially in the pre-mobile age group.

PoCUS may have a role to play in fine tuning risk stratification and a recent study (2018) has further evaluated diagnostic accuracy:

We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures.

  • If I don’t perform a CT, then how long should a child with a head injury be observed?

There is no definite evidence-based answer to this question. However this study suggest that 6 hrs is probably safe.

Key Points

  1. Always use a clinical decision rule to determine whether a child with head injury requires CT, Observation or can be safely discharged
  2. When using a decision rule utilize a ‘shared decision-making’ philosophy – i.e involve the parents/carers
  3. A period of observation can reduce the number of CTs performed.
  4. If observation is recommended, then allow 6hrs.
  5. Always consider non-accidental injury during your assessment of pediatric head injury.

 

 


 

Clonazepam Toxicity

  • Overdosage of clonazepam may produce somnolence, confusion, ataxia, diminished reflexes, or coma
  • Clonazepam is extensively metabolized in the liver to several metabolites
  • Clonazepam is rapidly and well absorbed from the GI tract
  • Peak blood concentrations are reached in 2 -4 hours
  • Elimination half-life … 18.7 to 39 hr

Full ToxNet entry

Treatment

Treatment is entirely supportive with IV access and fluids and maintenance of the airway and ventilation if required

Oral activated charcoal is of little value in pure benzodiazepine poisoning. It may be given to patients who have recently ingested benzodiazepines with other drugs that may benefit from decontamination

Flumazenil is rarely indicated except for iatrogenic oversedation or respiratory depression. In addition, flumazenil may cause withdrawal states and result in seizures, adrenergic stimulation, or autonomic instability in patients chronically taking benzodiazepine, or in those with ventricular dysrhythmias and seizures who are concomitantly using cocaine or tricyclic antidepressants.

Dispostion

All patients with intentional ingestion or significant ataxia, drowsiness, or respiratory depression should be observed.

Patients with severe symptoms (ie, coma, respiratory failure, or hypotension unresponsive to IV fluids) should be consulted to ICU.

Given the prolonged half-life patients strongly consider admitting patients who present with significant drowsiness or are known to have taken a large overdose.

Patients with a significant sedative drug overdose should be advised not to drive until potential interference with psychomotor performance has resolved. For significant benzodiazepine overdose, this is at least 24 hours after discharge.

Key Points

  1. Clonazepam overdose is treated with supportive measures.
  2. Clonazepam has a very long half-life. For significant drowsiness, admission should be considered to avoid potentially very long ED observation periods.

 


Pediatric (< 3 months) Fever

The management of fever in infants less than 1 month is relatively straightforward. Guidelines are generally consistent (Merck,

  • Full blood lab work-up (CBC, CRP, Cultures)
  • Urine culture
  • CXR
  • RSV, Flu nasal swabs
  • LP
  • Empiric IV Antibiotics (e.g Ampicillin 50mg/kg and Cefotaxime 50mg/kg)
  • Consult Pediatrics and Admit

Emergency Medicine Cases article can be viewed here – Episode 48 – Pediatric Fever Without A Source

*********

For infants older than 30 days and younger than 3 months the guidelines are variable:

ALiEM: Paucis Verbis: Fever without a source (29 days-3 months old)

NICE Guidelines (UK):  Fever in under 5s: assessment and initial management

MD Calc – Step-by-Step Approach Calculator 

Suggested Emergency Department Approach

  • If Sick-Appearing treat as <3 months (see above)
  • If Well- Appearing (age normal vitals):
    • Full blood lab work-up (CBC, CRP, Cultures)
    • Urine culture
    • Consider CXR
    • Consult Pediatrics (Depending on results of above will either need admission +/- antibiotics or 24hr follow-up)

Yukon Guidelines


 

Wide Complex Tachycardia

Differential Diagnosis (note: repetition is deliberate!)

  • Ventricular Tachycardia
  • Ventricular Tachycardia
  • Ventricular Tachycardia
  • SVT with aberrant conduction – lots of causes
    • Pre-existing/rate-related BBB
    • Ventricular pre-excitation (AVNRT/AVRT)
    • Dysfunction of IV conduction system (toxic, metabolic, infectious, drug related etc) – hyper K, sodium channel blockers

No ‘rule’ is specific enough to correctly identify, so treat like VT

Treatment 

  • Unstable?
    • ANY sign of end-organ dysfunction – hypotension, altered LOC, CHF/SOB, CP, diaphoretic etc
    • SHOCK
  • Stable?
    • Shock or medical management
    • Amiodarone vs procainamide, ?adenosine (see below)

Adenosine/vagal – consider in patients where uncertain of diagnosis, unlikely to be VT, no hx of CAD, young, hx of SVT

Adenosine with WPW – ContraIndicated – may induce AV block and accelerate conduction of atrial fibrillatory impulses through the bypass tract, which can lead to very rapid ventricular arrhythmias that degenerate to VF.

“Avoidance of IV beta blockers, calcium channel blockers and digoxin due to the potential for hemodynamic deterioration in patients with stable WCT, potentially resulting in hypotension, VF and cardiac arrest”. (Uptodate)

Verapamil and diltiazem are calcium channel blockers (CCBs) that should be avoided in WCTs, as cardiac arrests from hemodynamic collapse have been reported following their administration.  Not only do these agents cause negative inotropy and at times profound vasodilation, but they may also allow WCTs to degenerate into VFIB

Caveat – RRWCT (Regular Really Wide Complex Tachy)

  • One situation where you may not want to assume VT….
  • What question should you ask?
    • What is the K,
    • what is the OD?
  • Really, really wide complex tachycardia – >200 mseconds – consider tox or metabolic – try bicarb or calcium – if it narrows – not VTach.
  • Avoid procainamide and amiodarone in these patients.

 

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Trauma Reflections – August 2018

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

 


 

Major points of interest:

 

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

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

 

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

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

 

C) Who put that thing there?

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

 

D) Trauma patients you know will require consultants

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

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

 

E) Yo-yoing to DI for yet another film

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

 

F) Pregnancy tests for everybody

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

 

G) “Moving all limbs”..

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

 

H) Severe traumatic brain injury

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

 

I) Motorcycle + cocaine + EtOH + no helmet…

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

 

 

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Trauma Reflections – June 2018

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

 


 

Major points of interest:

 

A)  Should that be bubbling like that?

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

 

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

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

See attached NB consensus statement for suggested medications and dosages.

FINAL Consensus statement – RSI+ – July 2018

C)  Crystalloid choice in burns

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

 

D)  TTA log sheets – numbers are only slightly better

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

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

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

 

E) Propofol infusions in pediatric population

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

 

F)  “Moving all limbs”..

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

 

G)  We don’t talk anymore..

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

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Trauma Reflections – April 2018

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

 


 

Major points of interest:

 

A) Managing airway in severely head injured patient

Intubate GCS < 5 prior to CT scan or after? Good discussion ensued. The bottom line – with a well-placed i-gel LMA and spontaneous respirations with O2 sats of 99%, obtaining CT to rule out potentially correctable brain injury is the priority. Intubation on return to ED from DI should be done using appropriate techniques and medications to minimize surge in ICP – SEE THIS PODCAST

 

B) He is on Riveroxaban? That’s just great..

Trauma patient on NOAC/DOAC can be a challenge. Only medication with true reversal agent is dabigatran (Praxbind 5G IV). Consider Octaplex until true reversal agents for the Xa inhibitors become available. Remember TXA!

 

C) Trauma transfers from other centers

Expectation is trauma activation for all major trauma transfers, even if “direct” for a consultant.

 

D) Post intubation analgesia and sedation – “Is he hungry?”

No he isn’t! – biting the ET tube means it is time to crank up the meds. Infusions are superior to push dosing. Analgesia is often given in inadequate doses or not at all. Also consider the need for larger doses of opioids in patients on methadone.

 

E) Disposition from Emergency Department

NB Trauma Program Policy 2.4-010, which has long been approved by LMAC – commit this to memory!

“The TTL, in consultation with other inpatient services, shall determine the most appropriate service and level of care for admission, transfer or discharge.”

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EM Reflections – March 2018

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

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Abdominal Aortic Aneurysm – Size matters, but it isn’t everything

CME QUIZ

 

 


Abdominal Aortic Aneurysm – Which patients require urgent consult / transfer ?

AAA is a disease of older age. The prevalence of AAA among men aged 65 to 80 is 4 to 6 times higher than in women of the same age. The Canadian Task Force on Preventative Healthcare have recently (2017) made the following recommendations on screening:

Recommendation 1: We recommend one-time screening with ultrasound for AAA for men aged 65 to 80. (Weak recommendation; moderate quality of evidence)

Recommendation 2: We recommend not screening men older than 80 years of age for AAA. (Weak recommendation; low quality of evidence)

Recommendation 3: We recommend not screening women for AAA. (Strong recommendation; very low quality of evidence)

 

Emergency Physicians are trained to recognize the signs and symptoms of ruptured AAA (hypotension, tachycardia, pulsatile abdominal mass, back pain) and are always on the lookout for those curveball presentations e.g renal colic mimic, syncope, sciatica etc.

With the organization of centralized vascular services predominating in the majority of developed national health systems, patients with ruptured AAAs are now being transferred for specialist care. Recent evidence from the UK suggests that this practice is safe with no observed increased mortality or length of stay. and other studies have shown a benefit, with reduced mortality post service-centralization.

While there maybe benefits of centralization for patients, vascular surgeons and health economies, the initial management of the patient with AAA disease can be increasingly challenging for the Emergency Physician, especially if they are located in a peripheral hospital.

Let us consider a few scenarios:

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with severe back pain and hypotension. Point of Care Ultrasound (PoCUS) confirms the diagnosis of a 7.5cm AAA.

This scenario is relatively straightforward. The patient is judiciously resuscitated (avoiding aggressive fluid infusion), and transferred, after discussion with on-call vascular surgery, as quickly as possible directly to the receiving hospital’s vascular OR.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They are known to have a 3.7cm AAA (last surveillance scan 6 months ago). PoCUS confirms the presence of an AAA measuring approx. 3.7cm. Urinalysis is negative.

This scenario is also relatively straightforward. While the cause of the flank pain has not been determined, the risk of AAA rupture is highly improbable. For men with an AAA of 4.0 cm or smaller, it takes more than 3.5 years to have a risk of rupture greater than 1%. Given the stable vital signs, low pain score and lack of significant change in AAA size, this patient can be safely worked-up initially at the peripheral hospital pending transfer for abdominal CT if diagnosis remains unclear or symptoms change.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They have no past medical history. PoCUS confirms the presence of a new 4.7cm AAA.  

This scenario starts to become more challenging. Is the AAA leaking? Is the AAA rapidly expanding? Has PoCUS accurately measured the AAA size, Is the AAA causing the symptoms or is there another diagnosis? While this AAA is still below the elective repair size (5.5cm), the rate of growth is not know (and this is important), 4.7cm AAAs do occasionally rupture and rapidly expanding AAA’s can cause pain (the phenomena is more common in inflammatory and mycotic aetiologies). In this scenario the safest approach would be to organize transfer for an urgent CT and to arrange for Vascular Surgey consult immediately thereafter.

 

 

Salmonella aortitis may appear after a febrile gastroenteritis. The common location of primary aortitis and aneurysm formation is at the posterior wall of the suprarenal or supraceliac aorta – . 2010; 3(1): 7–15.

 

Aortitis is the all-encompassing term ascribed to inflammation of the aorta. The most common causes of aortitis are the large-vessel vasculitides including GCA and Takayasu arteritis. The majority of cases of aortitis are non-infectious, however an infectious cause must always be considered, as treatment for infectious and non-infectious aortitis is significantly different.

This article provides a detailed summary of the diagnosis and management of Aortitis

 


CME QUIZ

EM Reflections - March 2018 - CME Quiz

EM Reflections – March 2018 – CME Quiz

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EM Reflections – February 2018

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

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Pleuritic Chest Pain – Don’t forget the Abdomen

Headache – Not always Migraine

Epistaxis – Posterior Bleed

CME QUIZ

 


Pleuritic Chest Pain – Don’t forget the Abdomen

The commonest causes of pleuritic chest pain (pleurisy) presenting to the ED include:

  • Pulmonary embolus
  • Pneumonia
  • Pericarditis
  • Myocardial infarct
  • Pneumothorax

Once these have been ruled out consider the following differential diagnosis:

ref: American Family Physician (May 2007)

 

Another differential to consider is:

Perforated peptic ulcer

This can result in localized sub-diaphragmatic peritonitis that can result in pleuritic chest pain

 

Tips:

  • If a CT Chest has been performed – look for free air under the diaphragm
  • Always document an abdominal exam when assessing a patient with pleuritic chest pain
  • Although radiologists are highly skilled, like any physician, they are not infallible. Conservative estimates suggest an error rate of 4%. See this excellent article: The Epidemiology of Error in Radiology and Strategies for Error Reduction
  • Wherever possible physicians should always review the images from CT and X-Ray prior to reading the formal radiology report.

Arrows depicting free air on erect CXR – note the double stomach bubble sign on the left

Free air seen on lower slice of CT Chest. Easily mistaken for bowel

 

 


Headache – Not always migraine

The commonest cause of headache presenting to the ED is migraine

The features of migraine headache are well documented in this article – The diagnosis and treatment of chronic migraine

 

The differential diagnosis for patients presenting with headache is large. This excellent website (https://ddxof.com/) provides algorithms to help consider the differential diagnosis in the cardinal EM presentations.

From: DDxof.com

 

Another differential to consider is:

Anemia

Sub-acute onset anemia secondary to chronic blood loss e.g menorrhagia, chronic GI bleed, etc can present with fatigue, visual disturbance and headache.

Tips:

  • Patients who present to ED with a new headache (no previous hx of primary headache syndrome or change in symptoms) should have baseline investigations including CBC and Glucose.
  • Always review the paramedic and triage notes for supplementary information and the presence of additional symptoms that may broaden or narrow the differential.
  • Patient ethnicity and skin colour may mask the presence of anemia.

 

 

 

 


Epistaxis – Posterior Bleed

Posterior epistaxis is a difficult condition to manage and is associated with a number of acute and serious complications. In this study, 3.7% required intubation.

The #FOAM Blog post provides an excellent outline to the management of posterior epistaxis – EMDocs.net

The Emergency Department Management of Posterior Epistaxis

 

Posterior Nasal Packing – video

 

 

Tips:

  • All cases of major bleeding, including epistaxis should be initially managed in the highest acuity areas of the ED. Patients can then be rapidly stepped down and relocated to lower acuity areas if determined to be lower risk after initial assessment.
  • Consider using a suction device to aid intubation in cases of massive obscuring oro/naso-pharynx haemorrhage.

PulmCrit: Large-bore suction for intubation: strategies & devices

 


 

 

CME QUIZ

EM Reflections - Feb 18 - CME Quiz

EM Reflections – Nov 17 – CME Quiz

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Great ideas and making things better

I heard Dr. Dylan Blacquiere speaking on the radio while driving home after one of those busy D2 shifts on Friday, and it really cheered me up to hear him describe how we all in Saint John are leading the way in managing acute stroke care. http://www.cbc.ca/player/play/1152508483846
From EMS, through Emergency Medicine, diagnostic and intervention radiology, internal medicine and neurology, Saint John Regional Hospital (probably more appropriately Saint John University Hospital) provides a world class service for stroke patients in New Brunswick.
This got me thinking about many of the other innovations and ideas that we continue to push forward locally, especially relating to emergency medicine, and how important it is not to let ourselves become disillusioned by busy shifts, perceived administrative inertia, perceived injustices, crowding and many of the negatives we face, and will likely continue to face for sometime.
To name but a few, we can be proud of the integrated STEMI program we have from EMS to Cath Lab, the Point of Care Ultrasound program that leads in this nationally and beyond, the new Trauma Team leadership program, the patient wellness initiatives such as the photography competition corridor that make things just a little brighter for patients, the regionally dominant and growing simulation program, the regional and local nursing education programs, the nationally unique and hugely popular 3 year EM residency program, the impact of our faculty on medical education at DMNB, the leading clinical care provided by a certified faculty of emergency physicians, our website, our multidisciplinary M&M and quality programs, many of the research initiatives underway including development of an ECMO/ECPR program with the NB Heart Centre, improving detection of domestic violence, innovations around tackling crowding, preventing staff burnout, better radiology requesting, encouraging exercise prescriptions, and much more.
I was particularly impressed how Dylan explained the integrative approach that was required to improve stroke care, and how that was achieved here. There are many other areas that we can also improve, innovate and lead in. Every day we see ways to make things better.
I hope that at this point in our department’s journey, we can continue to make the changes that matter, for patients, our departmental staff, physicians, nurses and support staff alike.
I encourage all of us to think of one area we can improve, to plan for change and for us all to support each other to achieve those improvements. Some of our residents are embarking on very interesting projects, such as designing early pregnancy clinic frameworks, models to improve performance under stress, and simulating EMS ECPR algorithms – all new innovations, not just chart reviews of what we are already doing. I encourage us all to support them, and others with these projects, and to begin to create innovation priorities for the department.
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Trauma Reflections – December 2017

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

 


 

Major points of interest:

 

A) Burns – Get out your crayons……

Accurate documentation of total body surface involved is key to determination of appropriate initial fluid resuscitation. Parkland formula = 4ml Ringer’s lactate x %BSA x kg – 1⁄2 in first 8 hours. Only count 2nd and 3rd degree burns. Lund and Browder documentation sheets. Urinary output will influence adjustment of fluid rates, so careful documentation of ins/outs is important.

B) Trauma in Maine – Get me out of here!

Canadian citizens injured in the U.S. often are transferred to NB for further investigation and management. TCP does NOT coordinate these transfers. Expectation is that the TTL will communicate with the sending physician and/or receiving consultant and manage as we would any other transfer from another facility.

C) Trauma transfers from other centers

Expectation is trauma activation for all major trauma transfers, even if “direct” for a consultant.

D) Crash 3- We are recruiting….

We are recruiting to the CRASH 3 study. Please familiarize yourself with eligibility criteria – adult, TBI < 3 hours isolated TBI.

E) Pre-alert of consultants – “Call me back when he gets there…”

In cases where immediate need for surgical consultation is clear, TTL should “pre-alert” consultants with ETA. Simultaneous arrival of consultant and patient is the goal.

F) Trauma activation package

Folder box on counter in room #19 has trauma activation packages – one stop shopping for all documents needed. Please fill out ‘MD Trauma Activation Log’ for every activation.
“SJRH ED Trauma Process Checklist” is in package and is a very useful prompt. Call it overhead. Put on a sticker.

G) Documentation

Documentation is important. Consider verbalizing full physical exam during secondary survey for documentation RN to chart on page 3 of trauma notes. MD can sign these notes. This will free up space on ED chart for “higher level” documentation such as list of injuries and treatments.

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