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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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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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.

 

Continue Reading

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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