EM Reflections – September 2017

Thanks to Dr Paul Page for leading the discussion

Edited by Dr David Lewis

Top tips from this month’s rounds:

  1. Non-specific Abdo pain – Appendicitis is always high on the differential 

  2. Intoxicated patients are at high risk for Head Injury

  3. Acute Heart Failure has a higher mortality than acute NSTEMI

  4. Enhancing Morbidity and Mortality Rounds Quality


Non-specific Abdo pain – Appendicitis is always high on the differential 

Does a normal white count exclude appendicitis?No – Clinicians should be wary of reliance on either elevated temperature or total WBC count as an indicator of the presence of appendicitis. The ROC curve suggests there is no value of total WBC count or temperature that has sufficient sensitivity and specificity to be of clinical value in the diagnosis of appendicitis. Acad Emerg Med. 2004 Oct;11(10):1021-7.Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis.

Does a normal CRP exclude appendicitis?No – Acad Emerg Med. 2015 Sep;22(9):1015-24. doi: 10.1111/acem.12746. Epub 2015 Aug 20. Accuracy of White Blood Cell Count and C-reactive Protein Levels Related to Duration of Symptoms in Patients Suspected of Acute Appendicitis.

 

A useful review on the diagnosis of appendicitis – JAMA. 2007 Jul 25; 298(4): 438–451. Does This Child Have Appendicitis?

 

Summary of Accuracy of Symptoms

Download (PDF, 124KB)

Summary of Accuracy of Signs

Download (PDF, 117KB)

 

 

Finally – Don’t forget Emergency Physicians can learn how to use Point of Care Ultrasound (PoCUS – ?Appendicitis) which can significantly improve diagnostic accuracy in experienced hands. Experience comes with practice.

J Med Radiat Sci. 2016 Mar; 63(1): 59–66. Published online 2016 Jan 20. doi:  10.1002/jmrs.154
Ultrasound of paediatric appendicitis and its secondary sonographic signs: providing a more meaningful finding

See SJRHEM PoCUS Quick Reference

PoCUS – Measurements and Quick Reference

 


 

Intoxicated patients are at high risk for Head Injury

Intoxicated patients with minor head injury are at significant risk for intracranial injury, with 8% of intoxicated patients in our cohort suffering clinically important intracranial injuries. The Canadian CT Head Rule and National Emergency X-Radiography Utilization Study criteria did not have adequate sensitivity for detecting clinically significant intracranial injuries in a cohort of intoxicated patients.

ACADEMIC EMERGENCY MEDICINE 2013; 20:754–760. Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

Canadian CT Head Rule not applicable to intoxicated patients (GCS<13)

Download (PDF, 76KB)

 

 

CMPA provide useful guidance on the duties expected in the management of intoxicated ED patients.

 

All intoxicated patients, even the so called ‘frequent fliers’ require a full assessment, including history (from 3rd parties if available), full examination (especially neurological), blood glucose level, neurological observations, and this assessment should be carefully documented.

 

Can we defer CT imaging for intoxicated patients presenting with possible brain injury?

This study suggests that deferring CT imaging while monitoring improving clinical status in alcohol-intoxicated patients with AMS and possible ICH is a safe ED practice. This practice follows the individual emergency physician’s comfort in waiting and will vary from one physician to another.

http://www.sciencedirect.com/science/article/pii/S0735675716306805

 

Download (PDF, 172KB)

 

 


 

Acute Heart Failure has a higher mortality than acute NSTEMI

Cardiac markers are routinely used to exclude NSTEMI in patient presenting with chest pain. However the diagnosis of acute heart failure (AHF) is mainly clinical, including CXR, ECG, PoCUS.

Ultrasound B Lines and Heart Failure

 

There is good evidence that BNP can be helpful in ruling out AHF – BMJ 2015;350:h910

Recommended Link – Emergency Medicine Cardiac Research and Education Group

Download (PDF, 1.32MB)

 

 

Emergency Treatment of Acute Congestive Heart Failure

Most recent recommendations from Canadian Cardiovascular Society (2012)

  • 1 – We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation > 90% (Strong Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places relatively higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on long-term clinical usage of supplemental oxygen without supportive data.

  • 2 – We recommend CPAP or BIPAP not be used routinely (Strong Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP might be appropriate for patients with persistent hypoxia and pulmonary edema.

  • 3 – We recommend intravenous diuretics be given as first-line therapy for patients with congestion (Strong Recommendation, Moderate-Quality Evidence).
  • 4 – We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (eg, twice daily) or as a continuous infusion (Strong Recommendation, Moderate-Quality Evidence).
  • 5 – We recommend the following intravenous vasodilators, titrated to systolic BP (SBP) > 100 mm Hg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mm Hg):
    • i

      Nitroglycerin (Strong Recommendation, Moderate-Quality Evidence);

    • ii

      Nesiritide (Weak Recommendation, High-Quality Evidence);

    • iii

      Nitroprusside (Weak Recommendation, Low-Quality Evidence).

Values and preferences. This recommendation places a high value on the relief of the symptom of dyspnea and less value on the lack of efficacy of vasodilators or diuretics to reduce hospitalization or mortality.

  • 6 – We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine, or milrinone (Strong Recommendation, High-Quality Evidence).

Values and preferences. This recommendation for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short term hemodynamic effects of inotropes.

  • 7 – We recommend continuation of chronic β-blocker therapy with AHF, unless the patient is symptomatic from hypotension or bradycardia (Strong Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places higher value on the RCT evidence of efficacy and safety to continue β-blockers, the ability of clinicians to use clinical judgement and lesser value on observational evidence for patients with AHF.

  • 8 – We recommend tolvaptan be considered for patients with symptomatic or severe hyponatremia (< 130 mmol/L) and persistent congestion despite standard therapy, to correct hyponatremia and the related symptoms (Weak Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places higher value on the correction of symptoms and complications related to hyponatremia and lesser value on the lack of efficacy of vasopressin antagonists to reduce HF-related hospitalizations or mortality.

 

Emergency Medicine Cases – Episode 4: Acute Congestive Heart Failure 

In Summary

  • AHF is a serious life-threatening condition in its own right, excluding NSTEMI does not change that. Appropriate management and disposition (almost always admission) is required.
  • Oxygen and intravenous Diuretics are the first-line  treatment
  • Nitrates are recommended in the relief of dyspnea in hemodynamically stable patients (SBP > 100 mm Hg)

 


Enhancing Morbidity and Mortality Rounds Quality

The Ottawa M&M Model

CalderMM-Rounds-Guide-2012

 

 

Continue Reading

Medical Student Clinical Pearl – Reversal of Anticoagulation in the Emergency Department

Reversal of Anticoagulation for Bleeding Complications in the ED


Tess Robart, Med 1

Dalhousie Medicine New Brunswick, Class of 2020

Reviewed by: Dr David Lewis and Liam Walsh (SJRH Pharmacy)


Clinical Question:

Emergency Departments frequently encounter patients on anticoagulant therapy. How are we currently managing anticoagulation reversal in our ED? How do we approach reversal, considering urgency in the face of major bleeding complications or prior to emergency surgery?

Background:

As result of the narrow therapeutic window of many anticoagulants, treatment presents a significant risk for life-threatening bleeds. Major bleeding involving the gastrointestinal, urinary tract, and soft tissue occurs in up to 6.5% of patients on anticoagulant therapy. The incidence of fatal bleeding is approximately 1% each year (1). Standard therapy for the control of coagulopathy related bleeding has traditionally required the use of available blood products, reversal of drug-induced anticoagulation, and recombinant activated factor VII (rFVIIa). The introduction of new direct oral anticoagulants (DOACs), dabigatran, apixaban and rivaroxaban presents the need for a new realm of antidotes and reversal agents.



Indications for Reversal:

Emergency physicians should consider reversal of anticoagulation for patients presenting with bleeding in the case of anticoagulant use, antiplatelet use, trauma, intracranial hemorrhage, stroke, and bleeding of the gastrointestinal tract, deep muscles, retro-ocular region, or joint spaces (2,3). The severity of each hemorrhage should be considered, reversing in cases of shock or if the patient requires blood transfusions because of excessive bleeding (2).

Patients should also undergo reversal of anticoagulation if urgent or emergent surgery is necessary (4).

For most medical conditions requiring anticoagulation, the target international normalized ratio (INR) is 2.0 to 3.0 (5). Notable exceptions to this rule are patients with mechanical heart valves, and antiphospholipid antibody syndrome. These patients require more intense anticoagulation, with target INR values between 2.5-3.5 (5).

The following laboratory assays should be considered, and repeated as clinically indicated (2):

  • PT/INR
  • aPTT
  • TT (thrombin time)
  • Basic Metabolic Panel
  • CBC

Initial assessment should address the following from a patient history (2):

  • How severe is the bleed, and where is it located?
  • Is the patient actively bleeding now?
  • Which agent is the patient receiving?
  • When was the last dose of anticoagulant administered?
  • Could the patient have taken an unintentional or intentional overdose of anticoagulant?
  • Does the patient have any history of renal or hepatic disease?
  • Is the patient taking other medications that would affect hemostasis?
  • Does the patient have any other comorbidities that would contribute to bleeding risk?

See this article for more details on the management of anticoagulation reversal in the face of major bleeding

It is important to note that not all coagulopathies will be anticoagulant drug induced. After all drug-induced causes have been ruled out, it is appropriate to follow previously established protocols (ie. transfusion protocol).


Table 1: Common Anticoagulants and Drug Reversal Considerations 


Table 2: Anticoagulant Reversal Agents (5)

 


Bottom Line: 

 

Anticoagulation leading to clinically significant bleeding is an issue commonly encountered in the emergency department. Therapies designed to combat and reverse anticoagulation are constantly changing in response to new anticoagulant medications. Emergency physicians must be well versed around anticoagulants commonly used, and recognize the antidotes used to treat their overuse in urgent and emergent situations.

 

 


References:

 

  1. Leissinger C.A., Blatt P.M., Hoots W.K., et al. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: A review of the literature. Am J Hematol. 2008;83:137-43.
  2. Garcia D.A., Crowther M. (2017) Management of bleeding in patients receiving direct oral anticoagulants. Retrieved from https://www.uptodate.com/contents/management-of-bleeding-in-patients-receiving-direct-oral-anticoagulants?source=search_result&search=reversal%20of%20anticoagulation&selectedTitle=1~150
  3. UC Davis Health Centre. Reversal of Anticoagulants at UCDMC. Retrieved from Reversal of Anticoagulants at UCDMC – UC Davis Health
  4. Vigue B. Bench-to-bedside review: Optimising emergency reversal of vitamin K antagonists in severe haemorrhage–from theory to practice. Crit Care. 2009;13:209.
  5. Mathew, A. E, Kumar, A. (2010) Focus On: Reversal of Anticoagulation. American College of Emergency Physicians. Retrieved from https://www.acep.org/Clinical—Practice-Management/Focus-On–Reversal-of-Anticoagulation/
  6. Brooks J.C., Noncardiogenic pulmonary edema immediately following rapid protamine administration. Ann Pharmacotherap1999;33(9):927-30.
  7. National Advisory Committee on Blood and Blood Products. Recommendations for Use of Prothrombin Complex Concentrates in Canada. May 16, 2014. http://www.nacblood.ca/resources/guidelines/PCC-Recommendations-Final-2014-05-16.pdf
Continue Reading

SHoC blog from @CanadiEM

Social media site @CanadiEM recently featured the @CJEMonline @IFEM2 #SHoC Consensus Protocol, featuring authors from @SJRHEM among others.

So why do we need another ultrasound protocol in emergency medicine? RUSHing from the original FAST scan, playing the ACES, FOCUSing on the CAUSE and meeting our FATE, it may seem SHoCking that many of these scanning protocols are not based on disease incidence or data on their impact, but rather on expert opinion. The Sonography in Hypotension (SHoC) protocols were developed by an international group of critical care and emergency physicians, using a Delphi consensus process, based upon the actual incidence of sonographic pathology detected in previously published international prospective studies [Milne; Gaspari]. The protocols are formulated to help the clinician utilize ultrasound to confirm or exclude common causes, and guides them to consider core, supplementary and additional views, depending upon the likely cause specific to the case.

Why would I take the time to scan the aorta of a 22 year old female with hypotension, when looking for pelvic free fluid might be more appropriate? Why would I not look for lung sliding, or B lines in a breathless shocked patient? Consideration of the shock category by addressing the “4 Fs” (fluid, form, function, and filling) will provide a sense of the best initial therapy and should help guide other investigations. Differentiating cardiogenic shock (a poorly contracting, enlarged heart, widespread lung B lines, and an engorged IVC) in an elderly hypotensive breathless patient, from sepsis (a vigorously contracting, normally sized or small heart, focal or no B lines, and an empty IVC) will change the initial resuscitation plan dramatically. Differentiating cardiac tamponade from tension pneumothorax in apparent obstructive shock or cardiac arrest will lead to dramatically differing interventions.

SHoC guides the clinician towards the more likely positive findings found in hypotensive patients and during cardiac arrest, while providing flexibility to tailor other windows to the questions the clinician needs to answer. One side does not fit all. That is hardly SHoCing news. Prospective validation of ultrasound protocols is necessary, and I look forward to future analysis of the effectiveness of these protocols.

References

Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an inter- national consensus conference. J Trauma 1999;46:466-72.

Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography. 2010 Dec 31;23(12):1225-30.

Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: cardiac arrest ultra-sound exam – a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206

Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26:87–91

Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in Shock in the evaluation of the critically lll. Emerg Med Clin North Am 2010;28:29 – 56

Jensen MB, Sloth E, Larsen KM, Schmidt MB: Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol. 2004, 21: 700-707.

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Dec 31;109:33-9.

Milne J, Atkinson P, Lewis D, et al. (April 08, 2016) Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol. Cureus 8(4): e564. doi:10.7759/cureus.564

Sonography in Hypotension and Cardiac Arrest: The SHoC Consensus Statement

Continue Reading

CAEP Definition of an Emergency Physician and the Importance of Emergency Medicine Certification

CAEP Definition of an Emergency Physician

An emergency physician is a physician who is engaged in the practice of emergency medicine and demonstrates the specific set of required competencies that define this field of medical practice. The accepted route to demonstration of competence in medicine in Canada is through certification by a recognized certifying body.*

CAEP recognizes that historically many of its members are physicians who have practiced emergency medicine without formal training and certification. Many have been, and continue to be key contributors to developing emergency medicine and staffing emergency departments in Canada. CAEP acknowledges the contributions of these valued physicians and recognizes them as emergency physicians. It is CAEP’s vision going forward that physicians entering emergency practise will demonstrate their competencies by obtaining certification.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency Physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

CAEP Statement on the Importance of Emergency Medicine Certification in Canada

It is CAEP’s vision, that by 2020 all emergency physicians in Canada will be certified in emergency medicine by a recognized certifying body.*

Toward that vision, provincial governments and Faculties of Medicine must urgently allocate resources to increase the numbers of emergency medicine postgraduate positions in recognized training programs so the Colleges are able to address the gap in human resources and training. Furthermore, physicians who have historically practiced emergency medicine without certification must be supported in their efforts to become certified. CAEP is committed to facilitate this process by cataloguing and nationally coordinating practice- and practitioner-friendly educational continuing professional development programs designed to assist non-certified physicians to be successful in their efforts.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

We have also published on this topic, highlighting the need for more resident positions in New Brunswick and PEI. Read our paper here.

 

Read more from CAEP here.

 

Continue Reading

SJRHEM at Interprofessional Health Research Day 2017

iHR day is a collaboration between Horizon Health – Saint John Zone, the University of New Brunswick – Saint John Campus, the New Brunswick Community College – Saint John Campus and Dalhousie Medicine New Brunswick.

The day featured oral and poster presentations by health researchers from these four institutions, an outstanding keynote speaker, and a great opportunity to discuss health research with your colleagues. More information here


SJRHEM Research had 8 research abstract accepted to this event:

 

 

Initial validation of the core components in the SHoC-Hypotension Protocol. What rates of ultrasound findings are reported in emergency department patients with undifferentiated hypotension? Results from the first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial.

Combination of easily measurable real time variables to predict ED crowding

ULTRASIM: ULtrasound in TRAuma SIMulation. Does the use of ultrasound improve diagnosis during simulated trauma scenarios?

Does point of care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? The First Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial.

Does point of care ultrasound improve resuscitation markers in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 1) Study; an international randomized controlled trial.

Combatting sedentary lifestyles; can exercise prescriptions in the Emergency Department lead to a behavioural change in patients?

Determining ED staff documentation practice, awareness, and knowledge of intimate partner violence questioning and documentation tools

To choose or not to choose: evaluating the effect of a Choosing Wisely knowledge translation initiative in rural and urban EM physicians

 

Continue Reading

Interprofessional Health Research Day 2017 – Devon McLean

ULTRASIM: ULtrasound in TRAuma SIMulation. Does the use of ultrasound improve diagnosis during simulated trauma scenarios?

Point of care ultrasound (US) is a key adjunct in the management of trauma patients, in the form of the extended focussed assessment with sonography in trauma (E-FAST) scan. This study assessed the impact of adding an edus2 ultrasound simulator on the diagnostic capabilities of resident and attending physicians participating in simulated trauma scenarios.

Download (PDF, 430KB)

Continue Reading

Interprofessional Health Research Day 2017 – Fiona Milne and Kalen Leech-Porter

Combatting sedentary lifestyles; can exercise prescriptions in the Emergency Department lead to a behavioural change in patients?

Patients with chronic diseases such as COPD, coronary artery disease, depression and anxiety are known to benefit from exercise. They also frequently visit the emergency department (ED). Despite the large therapeutic window and evidence supporting its role in disease management, there are few studies examining prescribing exercise in the ED. We asked: Is exercise prescription in the ED feasible and effective?

Download (PDF, 414KB)

Continue Reading

Interprofessional Health Research Day 2017 – Janeske Vonkeman

Determining ED staff documentation practice, awareness, and knowledge of intimate partner violence questioning and documentation tools

Domestic violence (DV) rates in smaller cities have been reported to be some of the highest in Canada. It is highly likely that emergency department staff will come across victims of intimate partner violence (IPV) in their daily practice. The purpose of this study is to better understand current practices for detecting IPV, staff awareness and knowledge surrounding IPV, available screening tools, and barriers to questioning about IPV. in the emergency department (ED). Finally, we will determine whether ED staff would be willing to implement a brief 3-question IPV screening tool, the Partner Violence Screen (PVS) in their daily practice.

 

Download (PDF, 543KB)

Continue Reading

Welcome Block 10

Dr. A. Sundaram

March 8- April 3

PGY1 Ophthalmology
“I go by Aish. I am a first year Ophthalmology resident. I am originally from Alberta and did my undergrad in medical sciences and business at University of Western Ontario. I subsequently did my medical school at University of Alberta.”


Dr. F. MacKay

March 8- April 3

PGY1 FM

“Hi there. My name is Fraser. I live across the street. I am an alumni of Dal, U of T, Holland College, and the mean streets of many a Canadian city. I am a Family Medicine Resident. For now, when not developing my Doctoring skills, I am busy training my daughters to be astronauts and/or circus acrobats.”


Dr. D. Rollo

March 8- April 3

PGY1 FM

“Born, raised and refined in Western Canada. Home grown in Okotoks AB then borrowed a degree in biochemistry from UBC in Kelowna before I finally landed on Vancouver Island to learn medicine. From West to East, quite the jump and quite the adventure!”


Clinical Clerks

Sean Casey

March 6 – March 26

3rd DMNB

 

 

 

Continue Reading

ED Rounds – Lyme Disease – Dr Paul Frankish

Lyme Disease: Update and recent controversies

Presented by Dr Paul Frankish

 

 


 Link to NB Health Lyme Disease Information


Transmission

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

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


Identification

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

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

C) is Ixodes scapularis(!)

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


Erythema Migrans Pearls

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


Clinical Pearls

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

Testing


Prophylaxis

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

Full Presentation with Notes

Download (PDF, 4.33MB)


NB Health Lyme Disease Update Jan 2017

Download (PDF, 190KB)

Continue Reading

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

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

Resident Clinical Pearl (RCP) – January 2017

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

Reviewed by Dr. David Lewis

 

Case Example:

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

Picture 1.


Introduction:

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

Indications:

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

Requirements:

  • Patients is awake, cooperative

Advantages of awake Intubation

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

Disadvantages

  • Potentially uncomfortable
  • Requires cooperation
  • Procedure can be prolonged

 

Back to our case:

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

AIME approach to tracheal Intubations pathway decision making

 

Generic Approach to awake oral intubation:

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

More Detailed:

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

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

Awake intubation using DL

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

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

Picture 2

Post Intubation:

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

 

References:

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

Picture 1

Picture 2

 

 

Continue Reading