EM Reflections – January 2020

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


Discussion Topics

  1. Esophageal Perforation

  2. Neonatal Status Epilepticus


Esophageal Perforation – Boerhaave syndrome

A spontaneous perforation of the esophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure (eg, severe straining or vomiting) otherwise known as Effort Rupture.

Difficult diagnosis in first few hours due to nonspecific early symptoms. But, delayed diagnosis results in significant mortality. Diagnosis and surgery within 24 hours carries a 75% survival rate but drops to approximately 50% after a 24-hour delay and approximately 10% after 48 hours.

25 to 45 percent of patients have no clear history of vomiting, and those that do are often confusing with pain sometimes preceding vomiting due to coexisting pathologies e.g gastroenteritis, gastritis, pancreatitis etc.

Clinical manifestations — The clinical features of Boerhaave syndrome depend upon the location of the perforation (cervical, intrathoracic, or intra-abdominal), the degree of leakage, and the time elapsed since the injury occurred. Patients with Boerhaave syndrome often present with excruciating retrosternal chest pain due to an intrathoracic esophageal perforation. Although a history of severe retching and vomiting preceding the onset of pain has classically been associated with Boerhaave syndrome, approximately 25 to 45 percent of patients have no history of vomiting. Patients may have crepitus on palpation of the chest wall due to subcutaneous emphysema. In patients with mediastinal emphysema, mediastinal crackling with each heartbeat may be heard on auscultation especially if the patient is in the left lateral decubitus position (Hamman’s sign). However, these signs require at least an hour to develop after an esophageal perforation and even then are present in only a small proportion of patients. Within hours of the perforation, patients can develop odynophagia, dyspnea, and sepsis and have fever, tachypnea, tachycardia, cyanosis, and hypotension on physical examination. A pleural effusion may also be detected.

Patients with cervical perforations can present with neck pain, dysphagia or dysphonia.  Patients may have tenderness to palpation of the sternocleidomastoid muscle and crepitation due to the presence of cervical subcutaneous emphysema.

Patients with an intra-abdominal perforation often report epigastric pain that may radiate to the shoulder. Patients may also report back pain and an inability to lie supine or present with an acute (surgical) abdomen. As with intrathoracic perforation, sepsis may rapidly develop within hours of presentation.

Laboratory findings — Laboratory evaluation may reveal a leukocytosis. While not part of the diagnostic workup for an esophageal perforation, pleural fluid collected during thoracentesis may contain undigested food, have a pH less than 6, or have an elevated salivary amylase level.

UptoDate

 

Chest X-ray  showing a pneumomediastinum (closed arrows) and silhouette sign over the right heart border (open arrow).

Case Presentation 1

Case Presentation 2

 

Take Home

  • The diagnosis of Boerhaave syndrome should be suspected in patients with severe chest, neck, or upper abdominal pain after an episode of severe retching and vomiting or other causes of increased intrathoracic pressure and the presence of subcutaneous emphysema (crepitus) on physical exam.
  • While thoracic and cervical radiography can be supportive of the diagnosis, the diagnosis is established by contrast esophagram or computed tomography (CT) scan
  • Delayed diagnosis is associated with high mortality
  • Radiological signs develop over time, repeat imaging is often useful when considering this diagnosis

 

Neonatal Status Epilepticus

When an altered few-day-old baby is brought into the ED, other than requesting immediate pediatric support, opening PediStat on you phone and trying to keep calm – consider the causes of altered LOC in pediatrics – Think VITAMINS:

V – Vascular (e.g. arteriovenous malformation, systemic vasculitis)

I – Infection (e.g. meningoencephalitis, overwhelming alternate source of sepsis)

T – Toxins (e.g. environmental, medications, contaminated breast milk)

A – Accident/abuse (e.g. non-accidental trauma, sequelae of previous trauma)

M – Metabolic (e.g. hypoglycemia, DKA, thyroid disorders)

I – Intussusception (e.g. the somnolent variant of intussusception, with lethargy)

N – Neoplasm (e.g. sludge phenomenon, secondary sepsis, hypoglycemia from supply-demand mismatch)

S – Seizure (e.g. seizure and its variable presentation, especially subclinical status epilepticus)

 

Altered Mental Status in Children

 

What elements are highly suggestive of true seizures?

  1. Lateralized tongue biting (high specificity)
  2. Flickering eyelids, deviation of gaze
  3. Dilated pupils with a blank stare
  4. Lip smacking
  5. Increased heart rate and blood pressure, desaturations in pulse oximetry during event

Management of Pediatric Seizures


Newborn Resuscitation

 


Elemental EM: Pediatric Intubation

 

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Trauma Reflections – December 2019

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


 

Major points of interest:

 

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

In the past year, for cases qualifying for trauma team activation, Trauma Codes were called 80% of time.

If a Trauma Code was called, trauma note use increased to 90% and time to disposition to an ICE setting was significantly decreased.

Please review the attached updated SIMPLIFIED activation criteria.

 

B) End of year AWARDS –  the “Crashys”

  1. ‘Crashy’ for the Busiest TTL of the Year with 17 cases …

P “I don’t see weak and dizzy patients” P

 

  1. ‘Crashy’ for the Most Trauma Intubations of the Year with 7 …

C “If he’s not move’n, I’m a tube’n” A

 

  1. ‘Crashy’ for the Most Trauma Chest Tubes of the Year with 3 …

T “Fetch me my scalpel” W

 

        Congratulations to all   (Sorry, there is no monetary gift associated with these awards!)     

 

C) Head injury, combative and on methadone – this should be easy..

Not really. 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. Under-dosing analgesic is often the reason adequate sedation is a struggle. Bolus, then increase infusion. Repeat.

 

D) End-tidal CO2 is an important vital sign

Especially in intubated patients.

 

E) Pediatric head injury transfer for imaging

Reassessing these patients on arrival, prior to CT, may influence management.

If there has been worsening in clinical condition, neurosurgery can be pre-alerted.

If there has been complete resolution of symptoms, CT scan may be deemed unnecessary.

 

F) “Clearing C-spine” can’t be done remotely..

CT C-spine is not 100% sensitive for ruling out injury. If radiologist reports there is no significant abnormality seen, it is a CLINICIAN”S responsibility to examine the neck before removing c-collar. If there is discrepancy (elevated pain, tenderness or neurologic symptoms/signs) or inability to cooperate with exam, leave the collar in place.

Make it known c-spine has not been cleared.

 

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

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

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

 

H) ‘Shock’ dosing of sedatives

Hypotension is not good for damaged neurons.

Shocked patients should have 1/2 dose of induction agents during RSI.

RSI Drugs

ADULT Rapid Sequence Intubation and Post-Intubation Analgesia and Sedation for Major Trauma Patients – NB Trauma

 

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EM Reflections – September 2019

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


Discussion Topics

  1. Refractory Hypotension / Sepsis – ‘ringing the changes

  2. Hypertensive Urgency / Emergency – “I was sent to the ER by the pharmacy checkout assistant

  3. Investigation Reports / Systems / Adverse Events


Refractory Hypotension / Sepsis

 

This interesting historical perspective from NPR makes an interesting read on the origins of Normal Saline

As it turns out, normal saline isn’t very normal at all. The average sodium level in a healthy patient is about 140 (as measured in something called milliequivalents per liter). For chloride, it’s about 100. But the concentration of both sodium and chloride in normal saline is 154. That’s pretty abnormal—especially the chloride.

Sidney Ringer (click for biography)

 

 “Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline.” Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adultsN Engl J Med. 2018;378:829-839.

Data Suggests Lactated Ringer’s Is Better than Normal Saline – ACEP Now

PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation

Take Home

  • Re-consider cause of hypotension in patients not responding to IV fluid resuscitation.
  • High mortality for elderly patients presenting to ED with hypotension.
  • Early switch to Ringers Lactate for IV fluids if needed for large volume resuscitation in sepsis.
  • If a British doc asks for Hartman’s, use Ringer’s… it’s the same.

 


 

Hypertensive Urgency / Emergency

Although elevated blood pressures can be alarming to the patient, hypertensive urgency usually develops over days to weeks. In this setting, it is not necessary to lower blood pressure acutely. A rapid decrease in blood pressure can actually cause symptomatic hypotension, resulting in hypoperfusion to the brain

RxFiles.ca summary pdf

How should I manage patients who present with a hypertensive urgency — i.e. BP > 180/120 mm Hg without impending or progressive end-organ damage (e.g. patient with headache, shortness or breath or epistaxis)?

  • For patients with hypertensive urgencies
    • Optimize (or restart) their current treatment regimens
    • Consider oral short-acting agents (e.g. captopril, labetalol, clonidine)
    • Do not treat aggressively with intravenous drugs or oral loading
    • Ensure that the patient has a follow-up appointment within a few days

How should I manage patients who present with a hypertensive emergency — i.e. BP > 180/120 mm Hg and impending or progressive end-organ damage (e.g. neurologic, cardiovascular, eclampsia)?

  • Reduce BP immediately with intravenous drugs, and monitor BP continuously in an intensive care setting.
  • Consider using the following drugs:
    • Vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, nitroglycerin, enalaprilat, hydralazine
    • Adrenergic blockers: labetalol, esmolol, phentolamine
  • Do not use short-acting nifedipine (lowers BP fast enough to provoke ischemia).
  • Aim for 25% reduction of the mean arterial blood pressure within minutes to 1 hour o Then if the patient is stable, reduce BP to 160/100-110 mm Hg over 2-6 hours and normalize within 24-48 hours.
  • Exceptions include stroke (unless BP is lowered to allow thrombolytic agents to be used) and dissecting aortic aneurysm (target systolic BP is < 100 mm Hg if possible).

from GAC Guidelines

Episode 40: Asymptomatic Hypertension

 

Take Home

  • Most patients with elevated BP (greater than 180/110) that are asymptomatic can safely follow up with Family Doctor.
  • True hypertensive emergencies are infrequent.
  • If mild symptoms consider starting antihypertensives in ED if unsure about follow up.
  • No good evidence that starting in antihypertensives ED for patients that can access their Family Doctor within next few days improves outcomes.

 


 

Radiology Reports / Systems / Adverse Events

 

Failure to follow up on radiology studies has become a frequent claim against both EPs and radiologists, according to Darien Cohen, MD, JD, an attending physician at Presence Resurrection Medical Center and clinical assistant professor in the Department of Emergency Medicine at University of Illinois, both in Chicago.

  • ED policies should ensure that all radiology alerts are available in a single location, and it must be clear who is responsible for follow-up.
  • Follow-up must be clearly documented in the medical record.
  • Any incidental finding mentioned on the radiology report should be communicated to the patient, and this communication must be clearly documented in the medical record.

 

Adverse Events Related to Emergency Department Care: A Systematic Review

A greater proportion of AE were preventable among the discharged population (71.4%; n = 15) than among the admitted population (40.9%; n = 9). Among discharged patients, management issues (47.6%; n = 10), diagnostic issues (33.3%; n = 7), and unsafe dispositions decisions (19%; n = 4) were the most common causes of AE

 

Safeguards in the system of care are like slices of cheese with holes representing possible failure points. See the Swiss Cheese Model at CMPA.ca

 

WTBS 9 – EM Quality Assurance Part One: Improving Follow up from the ED

 

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ADULT Rapid Sequence Intubation and Post-Intubation Analgesia and Sedation for Major Trauma Patients – NB Trauma

Consensus Statement:

ADULT Rapid Sequence Intubation and Post-Intubation

Analgesia and Sedation for Major Trauma Patients

NB Trauma Program – July 2018

Background:

  • Major trauma patients frequently require advanced airway control.
  • Endotracheal intubation is the preferred advanced airway intervention in major trauma patients.
  • Intubated trauma patients also need significant post-intubation pharmacological support.
  • Specifically, these patients require analgesia and sedation. This is particularly true when transfer to another facility is required, during which ICU level support is not available unless transfer occurs via Air Ambulance.
  • In New Brunswick, there is significant variation in the approach to both advanced airway control and post-intubation analgesia and sedation practices for major trauma patients.
  • Physicians in smaller centres in particular have asked for standardized, evidence-based guidance for both Rapid Sequence Intubation (RSI) and post-intubation pharmacological support in preparation for (and during) ground-based interfacility transfer.
  • Rapid Sequence Intubation (RSI) is a method to achieve airway control that involves rapid administration of sedative and paralytic agents, followed by endotracheal intubation.
  • The purpose of RSI is to affect a state of unconsciousness and neuromuscular blockade, allowing for increased first pass success of endotracheal intubation.
  • Post-intubation analgesia and sedation is a method of controlling pain, agitation and medically induced amnesia for major trauma patients.

 

Consensus Statements:

 

  • A provincially standardized, evidence-based guideline for Rapid Sequence Intubation should be available in all NB Trauma Centres (Appendix A).
  • Similarly, a provincially standardized, evidence-based guideline for Post-Intubation Analgesia and Sedation should be available in the Emergency Department of all NB Trauma Centres (Appendix B).
  • In addition to standardized, evidence-based guidelines, a provincially standardized equipment layout is recommended to optimize the preparation for RSI (Appendix C).
  • Ambulance New Brunswick should ensure consistency with the provincially standardized guidelines for RSI and Post-Intubation Sedation and Analgesia in procedures for Ambulance New Brunswick’s Air Medical Crew.
  • RSI should not be considered or applied for trauma patients who are in cardiac arrest or who are apneic.
  • RSI should not be considered in patients with a predicted difficult airway.
  • RSI should be considered for all trauma patients meeting the following:
    • GCS < 8, quickly deteriorating GCS or loss of airway protection
    • Facial trauma with poor airway control
    • Burns with suspected inhalation injury
    • Respiratory failure
    • Hypoxia
    • Persistent or uncompensated shock (reduction of respiratory efforts)
    • Agitation with possible injury to self or others
    • Potential for eventual respiratory compromise
    • Possible respiratory and/or neurological deterioration during prolonged transport
    • Transport in a confined space with limited resources
  • In addition to the above, RSI Guidelines should include
    • Assessment of the possibility of a difficult intubation
    • Troubleshooting
    • Immediate reference to post-intubation analgesia and sedation
  • In addition to standardized, evidence-based guidelines, a provincially standardized pre-induction checklist is recommended to optimize the preparation for RSI (Appendix D)

 


 

Download (PDF, 885KB)

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EM Reflections – June 2019 – Part 2

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

Edited by Dr David Lewis 


Discussion Topics

  1. When is a pregnancy not a pregnancy? (see part 1)
  2. Caustic Ingestions (see part 1)
  3. Transient Ischemic Attack – ED Questions

 

Transient Ischemic Attack – ED Questions

 

Transient Ischemic Attack (TIA): A brief episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, with clinical symptoms and without imaging evidence of acute infarction. Transient ischemic attack and minor stroke are the mildest form of acute ischemic stroke in a continuum that cannot be differentiated by symptom duration alone, but the former typically resolves within one hour.

https://www.strokebestpractices.ca/

 

Dual Anti-Platelet Therapy (DAPT)?

Patients who present within 48 hours of a suspected transient ischemic attack are at the highest risk for recurrent stroke

Uptodate – DAPT for high-risk TIA, defined as an ABCD2 score of ≥4

For CVA – ASA only unless already on ASA, then DAPT.  For minor CVA/TIA – DAPT


Hold Birth Control?


 

Admission?

Of all ischemic strokes during the 30 days after a first TIA, 42 percent occurred within the first 24 hours.

 


Stroke Assessment Pocket Cards

Saskatchewan TIA Referral Pathway

Saskatchewan TIA Patient Information Leaflet

 

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EM Reflections – June 2019 – Part 1

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

Edited by Dr David Lewis 


Discussion Topics

  1. When is a pregnancy not a pregnancy?
  2. Caustic Ingestions
  3. Transient Ischemic Attack – Emergency Medicine (see part 2)

When is a pregnancy not a pregnancy?

Molar Pregnancy

Hydatidiform mole (molar pregnancy) is a relatively rare complication of fertilization with an incidence in the United States of 0.63 to 1.1 per 1000 pregnancies, although rates vary geographically. It is included in the spectrum of gestational trophoblastic diseases and is comprised of both complete molar pregnancies (CM) and partial molar pregnancies (PM).

The most well characterized risk factor for CM is extreme of maternal age. Maternal ages less than 20 or greater than 40 years have been associated with relative risks for CM as high as 10- and 11-fold greater respectively. Other potential risk factors include oral contraceptive use, maternal type A or AB blood groups, maternal smoking, and maternal alcohol abuse.

Molar pregnancy typically presents in the first trimester and may be associated with a wide array of findings, including vaginal bleeding (most common), uterine size larger than expected according to pregnancy date (CM), uterine size smaller than expected according to pregnancy date (PM), excessive beta-human chorionic gonadotropin (β-hcg) levels, anemia, hyperemesis gravidum, theca lutein cysts, pre-eclampsia, and respiratory distress.Studies comparing modern clinical presentations of CM with historical presentations have demonstrated a significant reduction in many of the classic presenting signs and symptoms such as vaginal bleeding and excessive uterine size. This reduction is attributed to early detection by transvaginal ultrasound and increasingly sensitive β-hcg assays. Numerous studies evaluating the efficacy of ultrasound in detecting molar pregnancy demonstrate a 57–95 percent sensitivity for the detection of CM compared to only 18–49 percent sensitivity for PM.

More here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791738/

PoCUS – Normal Early Pregnancy

Arrow = Yolk sac (YS) within Gestational sac (GS), note the hyperechoic decidual reaction surrounding GS, Arrow head = Fetal Pole

PoCUS – Molar Pregnancy

 

PoCUS SIgns:

  • enlarged uterus
  • may be seen as an intrauterine mass with cystic spaces without any associated fetal parts
    • the multiple cystic structures classically give a “snow storm” or “bunch of grapes” type appearance.
  • may be difficult to diagnose in the first trimester 6
    • may appear similar to a normal pregnancy or as an empty gestational sac
    • <50% are diagnosed in the first trimester
  • More on Radiopedia.org

Useful post from County EM blog- click here

 


Caustic Ingestions

 

 

Hydrochloric Acid – pH 1-2

Dangerous if pH <2 or >11.5-12

For alkaline – higher percent, shorter time to burn – 10%NaOH – 1 min of contact to produce deep burn, 30% within seconds

 

Acid – painful to swallow so usually less volume, bad taste so more gagging/laryngeal injury, more aqueous so less esophageal injury, pylorospasm prevents entry into duodenum producing stagnation and prominent antrum injury.  Food is protective.  Acid ingestion typically produces a superficial coagulation necrosis that thromboses the underlying mucosal blood vessels and consolidates the connective tissue, thereby forming a protective eschar.  In enough amount – perforation.

Alkali – burns esophagus more, neutralized in stomach.  Liquefaction necrosis.

Management

Decontamination: Activated charcoal / GI decontamination / neutralisation procedures are contraindicated

Obtaining meaningful info from endoscopy after treatment with charcoal is very difficult

If asymptomatic – observe, trial of oral intake at 4 hours after exposure, earlier if low suspicion or likely benign ingestion after discussion with Poisons Centre

Symptomatic patients or those with a significant ingestion

(high-concentration acid or alkali or high volume [>200 ml] of a low-concentration acid or alkali)

Upper GI endoscopy should be performed early (3 to 48 hrs) and preferably during the first 24 hrs after ingestion to evaluate extent of esophageal and gastric damage and guide management.  Endoscopy is contraindicated in patients who have evidence of GI perforation. (Ingestion of >60 mL of concentrated HCl leads to severe injury to the GI tract with necrosis and perforation, rapid onset of MODS and is usually fatal – endoscopy within 24 hours (unless asymptomatic at 4 hours)

Complications – 1/3 develop strictures – directly related to depth/severity of injury, years later

 


 

TAKE HOME POINTS

  1. PV Bleed, Hyperemesis, PoCUS = bunch Grapes or Snowstorm – consider Molar Pregnancy
  2. Don’t use Activated Charcoal for Caustic Ingestions
  3. Discuss Caustic Ingestions with Poisons Centre
  4. Consider early endoscopy
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Trauma Reflections – February 2019

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

 

Another highly informative and brilliantly written summary by Dr. Lohoar:


 

Major points of interest:

A) Are we still calling ‘Trauma Codes’ in post TTL era?

Yes. Call away. Activation rates for cases that qualify continue to hover around 80%. Patient care is always improved with a coordinated team approach – triggered by calling a trauma code overhead. Activation criteria are as follows:

B) Should RN Trauma notes continue to be used?

Yes. Folder box on counter in room #19 has trauma activation packages – one stop shopping for all documents needed. “SJRH ED Trauma Process Checklist” is in package and is a very useful prompt (see below). Put on a sticker, get into character.

C) Are you feeling lucky?

Symptomatic head injured patients seen in peripheral centers, with concern enough for an emergent CT head request should come by ambulance not car.

 

D)  What did this guy eat for supper?

Pizza and beer, and lots of it.

Ducanto suction catheters are available on all airway carts. They are much more efficient at decontaminating airways soiled with semi-solid material when compared to Yankauer suction catheters

 

E) Boom, ET tube is in – high five – I am going for coffee..

Not so fast Slick, there is more work to be done.

 

1/ Check for ET tube placement, check for cuff leaks

2/ 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. Reassess frequently. Inadequate analgesia is often the cause of continued agitation. See attached guidelines from NB trauma – page 5 in particular

3/ NG or OG tubes should be placed and position checked as well

F)   Transfers “just for imaging”

Calls from other facilities for imaging should be screened for potential trauma patients. Care is often substandard if we are not aware of these patients, and they are being managed remotely by MDs in other facilities (playing phone tag with a radiologist).

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EM Reflections – May 2019

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 


 

Discussion Topics

  1. Measles – Refresher
  2. Posterior Stroke – Beware of Mimics
  3. Missed Fracture – Distracting Injuries

 

Measles – Refresher

Measles has for many years been an infrequent diagnosis in our population. However falling herd immunity is resulting in cases presenting to Canadian ED’s.

Measles signs and symptoms appear around 10 to 14 days after exposure to the virus.

  • Fever
  • Dry cough
  • Runny nose
  • Sore throat
  • Conjunctivitis

 

Measles causes a red, blotchy (erythematous maculopapular) rash that usually appears first on the face and behind the ears, then spreads downward to the chest and back and finally to the feet. Koplick’s spots can appear 1-2 days before the rash. The rash appearance can be variable, discrete maculopapular or merging erythematous.

 

Visit emDocs.net for this great refresher on EMin5 – Measles

EM in 5: Measles


 

Posterior Stroke – Beware of Mimics

Stroke Mimics

  • Acute peripheral vestibular dysfunction (Don’t forget the HINTS exam)
  • Basilar migraine
  • Intracranial hemorrhage
  • SAH
  • Brain Tumour
  • Toxic or metabolic disturbances
  • Neuroinflammatory or chronic infectious disorders

Note that it is possible to be influenced by past experience with mimics, resulting in falsely diagnosing a mimic in the presence of a stroke.

Stroke Chameleons

Stroke chameleons are disorders that look like other disorders but are actually stroke syndromes

  • Bilateral thalamic ischaemia is such a disorder and may cause reduced consciousness level or a global amnesic syndrome
  • Bilateral occipital stroke may present as confusion or delirium
  • Infarcts limited to the medial vermis in medial posterior inferior cerebellar artery (PICA) territory usually cause a vertiginous syndrome that resembles peripheral vestibulopathy

A very useful BMJ review article on Posterior Stroke can be accessed here.

Be cautious of migraine diagnosis with history that is different to typical migraine presentation. Multiple visits should raise concerns. Importance of thorough neuro exam to find possible deficits that would raise suspicion for more serious pathology. In posterior stroke, special attention should be given to examining the visual fields.

 

Imaging in Stroke and TIA

See Rounds Presentation by Dr. Dylan Blacquiere (Neurologist)

Imaging Recommendations. Dr Jake Swan (Radiologist)

After meeting with Dr. Blacquiere and the ER Department regarding stroke management and SAH management, I’m recommending the following based on new literature and evolving management in “high risk” patients.

1) High risk TIA patients, such as those who had a profound motor / speech deficit that is resolving should have a CTA carotid / COW as well as their standard CT head.

2) SAH patients should have CT done prior to LP due to false positive LP rates.  If there is any question about vascular malformation / aneurysm, follow with a CTA. The CTA isn’t necessary for every headache patient, etc, just those with a positive bleed on the unenhanced CT.

 

The evidence is summarised in this recent paper – Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery


 

Missed Fracture – Distracting Injuries

Standard ATLS teaching, but this error still occurs……

Ensure a complete secondary survey is completed in all patients presenting with history of trauma.

Read the StatPearl Article and then do the MCQ test here

 

Trauma! Initial Assessment and Management

 

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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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