Category Archives: Resident

It’s all in your head, literally! – Seizures versus Psychogenic Non-epileptic Seizures

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It’s all in your head, literally! – Seizures versus Psychogenic Non-epileptic Seizures

Resident Clinical Pearl (RCP) May 2019

Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB

Copyedited by Renee Amiro

Reviewed by Dr. David Lewis

 

 

 

Background

When patients present with seizure like activity it can be difficult to distinguish true seizure/epilepsy from psychogenic non- epileptic seizures (PNES; also known as pseudoseizures). This task is made more difficult by the fact that 10-30% of patients with PNES can have true epilepsy as well4. The risks associated with diagnosing a psychogenic non-epileptic seizure as true seizure are mainly associated with administration of anti-epileptic drugs during both acute episodes and chronically, with the potential for associated side effects3-4,6. The most severe of these include sedation and even intubation if large enough doses are administered during an acute seizure episode. Additionally, there is added cost to both the patient and the healthcare system for continued use of medications and hospital admissions/investigations.

The underlying mechanism for PNES is believed to be psychiatric in origin, often attributed to conversion disorders, and patients are often not aware of their seizure like behaviours.

 

Risk factors for PNES include:

  1. childhood trauma
  2. PTSD
  3. depression
  4. anxiety
  5. personality disorders
  6. female gender

The challenge remains distinguishing between true seizures and PNES. There are various historical features and seizure characteristics that can assist in differentiating the two, though no one feature is confirmatory for seizure.

 

Distinguishing between PNES and true seizure3-8

Sign/symptom Seizure PNES
Eyes *open Closed, resist forced opening by examiner

 

*Fluttering
Seizure onset *abrupt Gradual
Awareness during seizure Not aware * awareness during episode
Influence of the presence of others Does not change seizure *May intensify or alleviate

 

activity may only occur/be triggered by the presence of others
Seizure activity Generalized tonic clonic

 

Synchronous

 

Stereotyped (first stiff and in extension, then develops synchronous clonic activity)

 May be asynchronous, asymmetrical, waxing and waning

Thrashing/violent

Pelvic thrusting
Post ictal *Confusion May recall events during their apparent unresponsive event
head One sided Side to side head turning during event
**incontinence common occasional
***Tongue biting Common, may be severe, usually on SIDE of tongue Occasional, rare to be severe, may be on tip of tongue or the lip
Post ictal corneal reflex impaired normal
Post ictal babinksi upgoing downgoing
Hand drop test negative Positive (patient moves hand away from face)
Response to sternal rub/nail bed pressure Usually nonresponsive May stop seizing, withdraw from stimuli
****Vital signs Desaturation more likely

Ictal apnea

Ictal bradycardia

  

 

 

*represents elements found to be most useful in distinguishing PNES and ES8

** incontinence has little utility in distinguishing between PNES and true seizure5

*** lateral tongue biting was 100% specific for true seizure vs 38% sensitivity and 75% specificity for any type of tongue bite5

****prospective trial7

 

Lab Values

No lab value has proven consistently useful for confirming seizure versus PNES.

A note on Prolactin:

The American Academy of Neurology released guidelines in 2005 recommending the use of prolactin following a seizure event2.

  1. Best when drawn 10-20 minutes after the event and can be used to differentiate between PNES and true seizure
  2. If >6 hours later prolactin should be at baseline levels
  3. Cannot be used to differentiate seizure from syncope
  4. Not applicable in status epilepticus or repetitive seizures

 

Bottom Line: 

  1. Challenging to differentiate between PES and true seizure and some patients can have both!
  2. No definitive distinguishing measure but eye opening, abrupt seizure onset, and confused post-ictal state can help point toward true seizure.
  3. A normal prolactin is more helpful in ruling out seizure while an elevation is non-specific and cannot be used to confirm seizure.

 

References

  1. Abubakr A, Wambacq I. Diagnostic value of serum prolactin levels in PNES in the epilepsy monitoring unit. Neurol Clin Pract. 2016 Apr; 6(2): 116–119.
  2. Graham L. AAN releases guidelines for the use of serum prolactin assays in diagnosing epileptic seizures. Am Fam Physician. 2006. Apr; 73(7): 1284.
  3. Huff JS, Murr N. Seizure, Pseudoseizures. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441871/
  4. Mellers JDC. The approach to patients with “non-epileptic seizures.” Postgrad Med J. 2005 Aug;81(958):498-504.
  5. Nowacki T, Jirsch JD. Evaluation of the first seizure patient: Key points in the history and physical examination. 2017 Jul;49:54-63. doi: 10.1016/j.seizure.2016.12.002. Epub 2016 Dec 8.
  6. Panayiotopoulos CP. The Epilepsies: Seizures, Syndromes and Management. Oxfordshire (UK): Bladon Medical Publishing; 2005. Chapter 1, Clinical Aspects of the Diagnosis of Epileptic Seizures and Epileptic Syndromes. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2609/
  7. Pavlova M, Abdennadher M, Singh K, Katz E, Llewellyn N, Zarowsly M, et al. Advantages of respiratory monitoring during video- EEG evaluation to differentiate epileptic seizures from other events. Epilepsy Behav. 2014 Mar; 32: 142–144.
  8. Syed Tu, LaFrance WC Jr, Kahriman ES, Hasan SN, Rajasekaran V, Gulati D, et al. Can semiology predict psychogenic nonepileptic seizures? A prospective Ann Neurol.2011 Jun;69(6):997-1004
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SJRHEM @Halifax CAEP 2019

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Congratulations to all our researchers presenting at CAEP Halifax 2019. This year we have had a total of 12 research abstracts accepted for either oral or poster presentations, 5 invited presentations, 3 panel discussions, 5 track chairs, and 1 national award! We are also involved in many administrative, academic and research committee meetings across the conference.

2019 CAEP Abstracts Links for Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick

Previous SJRHEM @ CAEP

Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

P. Atkinson, M. Peach, S. Hunter, A. Kanji, L. Taylor, D. Lewis, J. Milne, L. Diegelmann, H. Lamprecht, M. Stander, D. Lussier, C. Pham, R. Henneberry, M. Howlett, J. Mekwan, B. Ramrattan, J. Middleton, D. van Hoving, L. Richardson, G. Stoica, J. French

https://doi.org/10.1017/cem.2019.65

Does point-of-care ultrasonography change actual care delivered by shock subcategory in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

P. Atkinson, S. Hunter, M. Peach, L. Taylor, A. Kanji, D. Lewis, J. Milne, L. Diegelmann, H. Lamprecht, M. Stander, D. Lussier, C. Pham, R. Henneberry, M. Howlett, J. Mekwan, B. Ramrattan, J. Middleton, D. Van Hoving, L. Richardson, G. Stoica, J. French

https://doi.org/10.1017/cem.2019.111

Diagnostic accuracy of point of care ultrasound in undifferentiated hypotension presenting to the emergency department: a systematic review

L. Richardson, O. Loubani, P. Atkinson

https://doi.org/10.1017/cem.2019.140

CAEP 2019 Systematic Review Poster Trial 2 PA

Does specialist referral influence emergency department return rate for patients with renal colic? A retrospective cohort study

A. Kanji, P. Atkinson, P. Massaro, R. Pawsey, T. Whelan

https://doi.org/10.1017/cem.2019.260

Does Disposition Influence ED Return in Renal Colic- AK PA

Introduction of an ECPR protocol to paramedics in Atlantic Canada; a pilot knowledge translation project

C. Rouse, J. Mekwan, P. Atkinson, J. Fraser, J. Gould, D. Rollo, J. Middleton, T. Pishe, M. Howlett, J. Legare, S. Chanyi, M. Tutschka, A. Hassan, S. Lutchmedial

https://doi.org/10.1017/cem.2019.302

COLIN caep 2019 pdf

The Devil may not be in the detail – training first-responders to administer publicly available epinephrine – microskills checklists have low inter-observer reliability

R. Dunfield, J. Riley, C. Vaillancourt, J. Fraser, J. Woodland, J. French, P. Atkinson

https://doi.org/10.1017/cem.2019.228

CAEP 2019_POSTER_Final_RJD_RIM PA

How to get your departmental web content to work for you: one department’s experience with free open access medical education

K. Chandra, D. Lewis, P. Atkinson

https://doi.org/10.1017/cem.2019.209

KC FOAMed_CAEP19 (002)

Management of first trimester bleeding in the emergency department

R. Amiro, R. Clouston, J. French, P. Atkinson

https://doi.org/10.1017/cem.2019.197

Poster Presentation Renee Amiro CAEP PA

Obtaining consensus on optimal management and follow-up of patients presenting to the emergency department with early pregnancy complications – a modified Delphi study

A. Cornelis, R. Clouston, P. Atkinson

https://doi.org/10.1017/cem.2019.215

Allyson C early preg caep 2019 PA

Emergency department staff perceived need and preferred methods for communication skills training

M. Howlett, M. Mostofa, J. Talbot, J. Fraser, P. Atkinson

https://doi.org/10.1017/cem.2019.256

Howlett caep 2019 jf

Designing team success – an engineering approach to capture team procedural steps to develop microskills for interprofessional skills education

R. Hanlon, J. French, P. Atkinson, J. Fraser, S. Benjamin, J. Poon

https://doi.org/10.1017/cem.2019.253

Hanlon Prototyping caep 2019 - new PA
 Hanlon Mico-skills caep 2019 - new PA
CAEP 19 Emergency Medicine Poster Final
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Abdominal ACNES: anterior cutaneous nerve entrapment syndrome and trigger point injections in the ED

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Abdominal ACNES: anterior cutaneous nerve entrapment syndrome and trigger point injections in the ED

Resident Clinical Pearl (RCP) March 2019

Devon Webster – PGY1 FMEM Dalhousie University, Saint John NB

Reviewed and edited by Renee Amiro and  Dr. David Lewis.

 

Case:

A 32 year old woman with a history of chronic abdominal pain has been sitting in RAZ, presenting with, predictably, lower abdominal pain. She has been investigated multiple times over, with comprehensive labs, ultrasounds, pelvic exams and a previous CT, all of which have been normal. She carries with her a myriad of diagnoses; chronic abdominal and pelvic pain, IBS, fibromyalgia, depression and anxiety.

On history she reports near constant, left lower quadrant pain over the past 4 months. It is worse when sitting up and lying on her left side. The pain is sharp and she is able to localize the pain with a single fingertip. On history, you elicit no red flags for an intra-abdominal source of her pain. You ask her to lay down on the examination bed and hold your finger over the area of maximal pain. You feel no mass or abdominal wall defects. You apply light pressure, which triggers the pain, and ask her to lift her legs up. She yelps in pain, noting significant worsening to the site after tensing her abdominal muscles.

While you think of your differential for abdominal wall pain, you are highly suspicious of anterior cutaneous nerve entrapment syndrome (ACNES)…

What is ACNES?

  • Anterior cutaneous nerve entrapment syndrome (ACNES) is one of the most frequent causes of chronic abdominal wall pain and often goes undiagnosed. It is caused by entrapment of the anterior cutaneous abdominal nerves as they pass through the fibrous abdominal fascia.
  • This common condition can be treated rapidly and effectively by local trigger point injection of lidocaine and long acting steroid in the emergency department.

Pathophysiology:

  • The cutaneous branches of the sensory nerves arising from T7-T12 must make two 90* turns, traversing through channels within the abdominal fascia at the linea semilunaris (lateral border of the rectus muscles) in order to innervate the cutaneous surface of the abdomen.
  • While the neurovascular bundle should be protected from impingement by fat, it is susceptible to entrapment due to the tight passageway through the fibrous channels and sharp angulation.

Risk factors:

  • There are multiple risk factors for entrapment, and subsequent pain: tight clothing or belts, intra or extra-abdominal pressure, scarring and obesity. Pregnant women and those taking OCPs may also be at higher risk.
  • 4x more common in women, particularly those between ages 30-50 years of age.

 

 Clinical features on history:

  • Patients may describe chronic abdominal pain with maximal tenderness over a small area of the abdomen, typically <2cm
  • Pain is typically at the lateral edge of the rectus abdominis muscles and has a predilection for the right side although, the pain may be anywhere over the abdomen and may be in multiple locations.
  • Pain tends to be sharp in nature, positional and aggravated by activities that tense the abdominal muscles. Pain is generally better supine and worse when sitting or lying on the side.
  • There should be no red flags associated with the history suggestive of a more nefarious source of pain (e.g. GI bleeding, change in bowel function).

 

Physical exam:

  • Use a Q-tip to apply pressure as you move along the abdomen and try to locate the area of maximal tenderness. In most ACNES patients, you will find an area of allodynia or hyperalgesia corresponding to the area of nerve entrapment.
  • Look for a positive Carnett’s sign:
    • Ask the patient to either lift the head and shoulders or alternatively, lift their legs off of the bed while lying flat while you apply pressure over the area of pain on the abdomen.
    • Tightening of the rectus muscles should protect intra-abdominal pathology and pain will be reduced. In the case of abdominal wall pathology, including ACNES, pain will remain the same or be increased.
  • Understanding extra vs intra-abdominal pain:
    • There are 2 types of pain receptors: A-delta and C fibers.
      • A-delta: These fibers mediate sharp, sudden pain and innervate skin and muscles. Patient’s can localize this pain with a fingertip and this corresponds well with extra-abdominal wall pain, such as in ACNES
      • C fibers: Mediate dull ‘visceral’ pain that is often difficult to localize and results in pain over larger areas of the abdomen. These fibers innervate the viscera and parietal peritoneum.

 

Approach and Differential Diagnosis for Abdominal Wall Pain:

  • Look for ‘red flags’ (e.g. GI bleeding, abnormal labs, malnourished appearance) and rule out intra-abdominal sources of pain.
  • Once this has been ruled out, consider your differential for extra-abdominal wall pain which may include the following…

 

 

Diagnosis:

  • ACNES can be diagnosed on the basis of 3 criteria:

 1) Well localized abdominal pain

 2) Positive Carnett’s sign

 3) Response to trigger point injection of local anesthetic and steroid

 

 Treatment

  • Trigger point injections:
    • Act as both a source of treatment and diagnosis.
    • Provides immediate relief of symptoms to 83-91% of patients.
    • Injections can be repeated q-monthly.
    • Works through immediate anesthetization of the nerve, steroidal thinning of surrounding connective tissue and hydrodissection.
  • If the pain returns after trigger point injections, after considering other diagnoses, patient’s can be referred for chemical neurolysis (alcohol injections) or in some instances, surgical neurectomy.
  • Conservative treatment may include activity modification (e.g. avoid stomach crunches) and physical therapy

 

Technique for trigger point injections:

  1. Mark the site of maximal tenderness
  2. Inject 1-3 mL of 1% lidocaine and 1 mL of a long acting steroid using a 1.5 inch 26 gauge needle. Insert the needle until the tender area is reached (pt will let you know)
  3. Pain should resolve within 5 minutes.

 

  • US guidance may be useful for increasing the precision of the injection and can be used to visualize the passage of the nerve through the abdominal fascia.

Video guided review of ACNES:

https://www.youtube.com/watch?v=bDyX3myA0Gw&t=163s

 

References:

  1. Meyer, G, et al. “Anterior cutaneous nerve entrapment syndrome.” Uptodate. Accessed March 8, 2019. URL: https://www.uptodate.com/contents/anterior-cutaneous-nerve-entrapment-syndrome
  2. Suleiman, S, Johnston, D. “The Abdominal Wall: An Overlooked Source of Pain” American Family Physician. August 2001.
  3. Kanakarajan, S., et al. “Chronic Abdominal Wall Pain and Ultrasound-Guided Abdominal Cutaneous Nerve Infiltration: A Case Series.” Pain Medicine, volume 12, Issue 3, 1 March 2011, Pages 382-386.
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An approach to the unexpected pregnancy

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Resident Clinical Pearl (RCP) – March 2019

Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

 

As Emergency Physicians we perform a number of pregnancy tests on women of childbearing age presenting to our care. It is an important part of our practise to screen for life threatening conditions like ectopic pregnancy and also avoid giving medications or preforming investigations that could be harmful to a fetus.

As with any medical test that we do, there are sure to be surprise results that we, or the patients, were not expecting.

A positive BHcG is not always a positive result for a patient we are treating. It is important as medical providers to handle this situation in an empathetic way and be armed with information to help the patient with this potentially life changing information.

An approach to an unexpected pregnancy result:


1. Ensure that the patient either has a support person with them, or if they wish, is alone. This is still confidential information and should be treated as such.
2. After informing the the patient of the pregnancy test result, it can be helpful to assess whether this is a wanted pregnancy. This can help you to assess what information you are going to provide her.
3. If it is an unwanted/surprise pregnancy it is helpful to inform her of her options.
      a. Continue the pregnancy to term
      b. Abortion
      c. Adoption


Since continuing with the pregnancy and adoption will be a long-term navigation and not necessarily time sensitive these discussions are better carried out in primary care / family practice. However, the options for pregnancy termination that are available in Canada and specifically New Brunswick are time sensitive.

It is crucial that patients who are considering these options be provided with accurate and timely information about their legal choice to end a pregnancy. Physicians who are unable to provide this information, for whatever reason, are expected to pass this responsibility on to a physician who can in a time sensitive manner.

Abortion options available in Canada:

 

Information for Patients considering termination of pregnancy


Surgical Abortion:
Abortion is decriminalized. There is no actual legal limit on the gestational age on which abortions can be performed.
Most intuitions in Canada have their own gestational age cut offs and the majority of abortions done in Canada are before 20wks.
The early on in the pregnancy generally the safer the procedure.

Advantages: once you’ve had the procedure it is done.
Disadvantages: you have had to have a d&c (dilation and curettage) and although relatively safe, there are always risks associated with surgical procedures.

 

Medical Abortion:
Medications used are Mifepristone and Misoprostol.
Mifepristone blocks progesterone which is a hormone responsible for maintaining a pregnancy.
Misoprostol is a medication taken up to 48 hours after the mifepristone and causes uterine contractions that empty the uterus.
The process is often described as like having a really heavy and crampy period.
Advantages: No surgical procedure, so can be done in your own home.
Disadvantages: more prolonged, may require more follow up with physicians, can’t be done past 9 weeks.

In New Brunswick: the drug can only be obtained with a prescription from a doctor who has completed the six-hour training required to prescribe it. It’s unclear how many New Brunswick doctors have the training.
You must have a valid health card and an ultrasound showing your gestational age to have the drug covered by the province.

 

Options available in New Brunswick:

Clinic 554 (Fredricton NB)
Able to self refer
Phone Number 506-261-7355
Patients can expect a 5-10-minute intake appointment over the phone.
Counselling, ultrasound and doctor’s exam are all done in the same visit as the abortion so you would only have to travel once.
Surgical are preformed up to 15wks and 6days.
Medical up to 9 weeks.
Cost between 700-850$ for surgical abortion.
Medical abortions are free.

Bathurst Chaleur Regional Hospital (Bathurst)
Able to self refer
Phone number 506-544-2133
Surgical abortions are available up to 13wks 6days.
Hospital based surgical abortions are free of charge.

Dr. Georges Dumont University Hospital Center (Moncton) – French
Able to self refer
Phone number 506-862-2770
Surgical abortions are available up to 13wks and 6days.
Hospital based surgical abortions are free of charge.


The Moncton Hospital- English
Able to self refer
Phone number 1-844- 806- 9205
Surgical abortions are available up to 13wks and 6days.
Hospital based surgical abortions are free of charge.
For options available in every province in Canada please see this list:
http://www.arcc-cdac.ca/list-abortion-clinics-canada.pdf

 

Copyedited by Dr. Mandy Peach

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Shoulder Dislocation – The Cunningham Technique

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The Cunningham Technique for massaging a shoulder dislocation back into place

Resident Clinical Pearl (RCP) February 2019

Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB

Reviewed and edited by Dr. David Lewis. 

Case

A 53-year-old man comes in to the emergency department after having fallen at work and “hurt his shoulder”. Clinically, it is assessed as an anterior shoulder dislocation and he is sent to x-ray which confirms your diagnosis.

Traditionally, the way to reduce a dislocated shoulder involves procedural sedation and some pulling on the arm. While it may save the patient some pain, procedural sedation is not without its risks to the patient and has high staffing needs. Learning some less risky techniques for shoulder reduction can make it safer for your patient and less time intensive for you and your staff!

Anatomy

The shoulder is an inherently unstable joint. The glenoid is shallow and only a small portion of the humeral head is articulating with the glenoid in any position. The rotator cuff provides additional support to the shoulder joint.

Mechanism of Injury for an Anterior Shoulder Dislocation

Most commonly it is a blow to the abducted, externally rotated, and extended arm.

Less commonly a blow to the posterior humerus or fall on an outstretched arm.

Clinical Exam

The arm will be slightly abducted and externally rotated. It will be lost of the normal rounded appearance of the shoulder.

Examination of the axillary nerve and peripheral pulses are essential when examining a patient with an anterior shoulder dislocation before and after reduction.

Imaging

On AP radiograph  the head of the humerus will appear medial to the glenoid. On a lateral radiograph it will appear anteriorly displaced. Take care with posterior dislocations as these can appear in joint on the AP, and may only be apparent on the lateral Y view.

 

Figure 2. radiograph of an anterior shoulder dislocation.2

Don’t forget you can use PoCUS to triage shoulder injuries too:

Resident Clinical Pearl – PoCUS Triage Shoulder Dislocation

 

Based on your clinical examination and imaging, you have determined that this patient indeed has an anterior shoulder dislocation. You have decided to avoid procedural sedation if you can and attempt reduction with the Cunningham technique!

The Cunningham Technique

Step 1
  • Inform the patient of what you are going to attempt. Tell them that their cooperation is necessary for success. Try and relax the patient by getting them to do deep, slow breathing.
Step 2
  • Sit the patient up with the back straight and shoulder blades pulled back. You can use a bed or a chair, whatever is easiest and most comfortable for both you and the patient.
Step 3
  • Get the patient to support the arm and bring it in to the best position to facilitate reduction. That location is typically with the arm abducted and pointing down with the elbow flexed at 90 degrees with the forearm pointing horizontally and anteriorly.
Step 4
  • Sit opposite the patient and place your hand on their elbow in between their body and their arm. Rest their forearm and hand on your arm.
Step 5
  • Apply steady downward traction with the weight of your forearm. Keep the gentle weight on the arm through out. Should now be causing pain as this will cause the muscles to spasm.
Step 6
  • Massage the trapezius, deltoid, and biceps muscles in sequential order. Repeat this process over and over. Your thumb should be anterior with four fingers posterior as your massaging these muscles. Most times you will not get the traditional “clunk” sound so frequent reassessments are necessary to see if the shoulder has been relocated.

YouTube Video Link of Cunningham Technique

The Bottom Line

The Cunningham technique can be used as a safe, successful and less resource intensive procedure to relocate an anterior shoulder dislocation. Patient engagement and cooperation is essential in its success.

Similar Alternative to the Cunningham Technique (The Sool’s Method):

References

  1. Cunningham N. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):521-4. PMID: 14992071.

 

  1. Sherman, S. (2018, August). Shoulder dislocation. Retrieved March 01, 2019, from UTD
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CAEP 2019 – Crowded House?

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CAEP 2019, Halifax, May 26-29, 2019

CAEP By The Ocean – Crowding Track – May 26th 1pm

Are you concerned about ED Crowding? After a busy shift do you ever “..dream it’s over”? Do you work in a “Crowded House”?

Come to the Crowded House Track at CAEP19 on May 26th 1pm. International and Canadian experts present their experience and we discuss possible solutions.

Including Dr. Taj Hassan (President Royal College of Emergency Medicine UK), Dr. Alecs Chochinov (President CAEP), Dr. Judy Morris and Dr. David Lewis.

Join in the debate – “are redirection strategies better than accommodation strategies” – should we invest all our energy in redirection to alternative services or should we accept that we can’t stem the tide and bring all these services under one roof?

Register for CAEP19 – CAEP By The Ocean. https://caepconference.ca/registration/

Crowded House – Don’t Dream It’s Over

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What’s the word? Insertion of Word catheter for Bartholin’s cysts

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Resident Clinical Pearl (RCP) February 2019

Renee Amiro – PGY3 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis. Copyedited by Dr. Mandy Peach

Bartholin gland are located in the vulva and are a common cause of vulvar masses.
The normal function of the Bartholin gland is to secret mucus to lubricate the vagina. These ducts can get blocked and cause fluid accumulation can cause a cyst or abscess.

Anatomy of the vagina (2)
Identifying a bartholin gland cyst (3)

Treatment:
The mainstay of management is incision and drainage with insertion of a ward catheter. The ward catheter allows the cyst to continue to drain and allow re-epithelization of the Bartholin gland allowing the duct to stay patent in future.

Indications:
Presence of an uncomplicated Bartholin’s cyst.

Contraindications:
Latex allergy – the ward catheter is made with latex.

Materials:
Alcohol swabs or other solution to clean the area.
Sterile gloves
Local anesthetic
Scalpel with an 11 blade
Gauze (+++)
Haemostat to breakup loculations
Culture swab
Ward Catheter
Syringe filled with H2O to fill the ward catheter.

Procedure

  1. Sterilize area with sterilizing solution.
  2. Inject local anesthetic in to the area that you are going to stab for the incision ~1-3cc.
  3. Stab the cyst or abscess. Make the incision about 5mm big and 1.5cm deep. Too big an incision could cause the ward catheter to fall out.
  4. Drain the cyst/abscess and breakup any loculations with the haemostat.
  5. Place the ward catheter into the incision and inflate with 2-3cc of water.
  6. Tuck the end of the ward catheter in to the vagina to minimize discomfort.
Technique for insertion of word catheter (4)

Follow up:
Pelvic rest for the duration of the time the ward catheter is in place.
Sitz baths and mild analgesia (Tylenol/Advil)

Duration of ward catheter placement is on average four weeks.

If the ward catheter falls out prior to the tract being re-epithelialized or the cyst or abscess remains the patient may need another placement of the ward catheter or follow up marsupialization procedure (obstetrics). If the area looks well healed, the ward catheter can be kept out.

Role of antibiotics:
In uncomplicated skin abscesses there has been no benefit shown from antibiotic treatment. Using an antibiotic without and I and D will not heal the Bartholin glad cyst.

Antibiotics indicated in:
High risk of complicated infection – surrounding cellulitis, pregnancy, immunocompromised.
Culture positive MRSA
Signs of systemic infection

Bottom Line:

  1. Ward catheter placement is essential if you are going to drain a Bartholin’s abscess. If you don’t the patient may loose patency of the duct which could have long term consequences such as dyspareunia.
  2. Antibiotics alone will not cure a Bartholin’s abscess. Only indicated in limited situations.

References

  1. Uptodate: Bartholin gland masses: Diagnosis and Management https://www.uptodate.com/contents/bartholin-gland-masses-diagnosis-and-management?search=bartholin%20cyst&source=search_result&selectedTitle=1~10&usage_type=default&display_rank=1
  2. Bartholin Gland Cysts: https://www.health.harvard.edu/a_to_z/bartholins-gland-cyst-a-to-z
  3. Bartholin Gland Cysts: https://www.merckmanuals.com/en-ca/home/women-s-health-issues/noncancerous-gynecologic-abnormalities/bartholin-gland-cysts
  4. Bartholin Gland Abscess or Cyst Incision and Drainage: https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343783

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Syncope ECG – The ABCs

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ECG Interpretation in Syncope

Resident Clinical Pearl (RCP) – December 2018

Dr. Luke Taylor, FMEM PGY3 –  Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

 

What are you looking for on the ECG of the patient with syncope?

Quick review of frequently pimped question on shift!

Two approaches – One using systematic ECG analysis, the other a mnemonic.

ECG Analysis (1)

Standard format of rate, rhythm, axis, and segments (PR, QRS, QT, ST).

Method of calculating heart rate (2)

Rate: Simple — Is the patient going too fast or too slow? *Remember this easy way to check:
Rhythm: Look at leads II, VI and aVR for P waves.
Ask yourself:
Are they upright in II/VI and inverted in aVR?
Does a QRS follow every P and a P before every QRS?

If so likely sinus rhythm.

In the setting of syncope we are looking to see if there is any signs of heart block – a P wave not conducted to a QRS, especially being sure not to miss a Mobitz type II block.

Axis: Axis comes in to play when looking for more extensive conduction disease. Is there axis deviation along with a change in your PR and BBB indicating something like a trifasicular block?

Segments:

PR interval— is it looooong (heart block) or short (reentrant)?
Long has already been discussed in looking for signs of heart block, but a short PR may be indicative of Wolf-Parkinson-White or Lown-Ganong-Levine syndromes.

WPW – look for short PR and delta wave
LGL – short PR but no delta wave due to its conduction being very close to or even through the AV node and not through an accessory pathway.

QRS Morphology analyzing this for signs of Brugada, HOCM, WPW, ARVD, pericardial effusion, and BBB.

ECG findings of Brugada (3)

Type 1: Coved ST segment elevation with T wav inversion
Type 2: Saddleback ST segment elevation and upright T waves
Type 3: either above without the ST elevation

QT interval — is it looooong (R on T) or short (VT/VF risk)?
Long is >450 men, 470 women
Short < 330ms – tall peaked T waves no ST segment
Pearl for long – should be less than half the RR interval. —>

Normal relationship of R-R and QT interval (4)

 

ST segment — think MI or PE (rare causes of syncope but need to be considered)
MI – elevations or depressions

PE – Tachycardia, RV strain, T-wave inversion V1-V3, RBBB morphology, S1Q3T3

 

Mnemonic (5)

ABCDEFGHII

A — Aortic stenosis
Go back to patient and listen!
B — Brugada
C — Corrected QT
D — Delta wave
E — Epsilon wave as in Arrhythmogenic Right Ventricular Dysplasia (ARVD)

Epsilon: Small positive deflection (‘blip’) buried in the end of the QRS complex (6)

F — Fluid filled heart
Pericardial effusion, electrical alternans, low voltage throughout
G — Giant PE
H — Hypertrophy
LVH in someone who shouldn’t have it
I — Intervals
PR, QRS, QT
I — Ischemia

 

Looking for a Basic ECG Guide? See our Med Student Pearl Here:

Medical Student Clinical Pearl – Basic ECG Interpretation

 

 

References

  1. CanadiaEM – ECGs in Syncope https://canadiem.org/medical-concept-ecgs-in-syncope
  2. https://en.ecgpedia.org/wiki/Rate
  3. ECG Waves https://ecgwaves.com/brugada-syndrome-ecg-treatment-management
  4. https://www.healio.com/cardiology/learn-the-heart/case-questions/ecg-cases/question-3-5
  5. Hippo EM Education Shorts https://www.youtube.com/watch?v=raTTYV7_Asl
  6. https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy

 

This post was copyedited by Dr. Mandy Peach

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Epistaxis Management in the ED – 3 Step Method

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Epistaxis Management

Resident Clinical Pearl (RCP) – December 2018

Luke Taylor R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. Kavish Chandra

 

It’s 0300 and you are on a solo night shift when a 76 year old male with blood dripping out of both nares is brought into an examining room. It looks a little more profuse than what you saw on Stranger Things last month, but you are also wondering how to best tackle this very common emergency problem

 

History

-Laterality, duration, frequency

-Estimated blood loss, presence of any clots?

-Inciting factors such as trauma or coagulopathy

-Past medical history, especially hypertension, clotting disorder, HHT

-Medications such as anticoagulants or anti-platelets

 

Physical examination

-Have patient blow nose or use suction to clear clots

-Do not try and visualize until decongestion complete

-Visualize with nasal speculum for site of bleeding. If an anterior bleed, most commonly the bleeding site will be Little’s area (Figure 1)

-See below for management if patient’s ABCs stable. If unstable be prepared to secure airway and call for help – ENT/interventional radiology

 

Figure 1. Nasal vascular anatomy, adapted from https://www.juniordentist.com/what-is-littles-area-or-kiesselbachs-area-and-the-arteries-in-it.html.

 

Management

-Get IV access, draw CBC and coagulation profile when indicated

-Treat as unstable until proven otherwise

 

Pearls

  • Apply ice to the hard palate (popsicles, ice in the mouth) to reduce nasal blood flow up to 25%
  • TXA in patients on anti-platelets (primarily aspirin) results in faster cessation of bleeding
  • Ducanto suction in future -> SALAD technique – Ducanto-bougie intubation for large bleeds
  • Only reverse anticoagulants if absolutely necessary – “local problem, local solution”

 

Three Step Approach to Epistaxis

1. Visualize and decongest

  1. Have patient blow their nose to clear all clots
  2. Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
  3. Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
  4. Pack nose with soaked cotton and replace clamp for 10 mins

2. Cauterize

  1. Remove clamp and packing
  2. Area should be well blanched and anesthetized
  3. Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
  4. If successful and bleeding ceases on reassessment, apply surgicel wrapped around a small piece of surgifoam to create a “dissolvable sandwich”and discharge home

3. Tamponade

  1. Apply unilateral nasal packing (Rapid Rhino, Merocel, etc)
  2. Reassess in 10 mins, visualizing oropharynx for continued bleeding
  3. If stops, can discharge home with packing in place and follow up in ED or ENT clinic in 48hrs for removal. No antibiotics required in immunocompetent patients.
  4. If continues to bleed, move the patient to a higher acuity area and apply bilateral nasal packs

When to call ENT

If bilateral nasal packing bleeding continues, assume posterior bleed and initiate resuscitation, draw labs (CBC, coagulation profile, cross-match if not already done). Reverse known coagulopathy and consult for OR or embolization.

 

ED Rounds – Epistaxis

 

 

References:

Dr Christopher Chin and his informative talk

http://rebelem.com/topical-txa-in-epistaxis/

https://emergencymedicinecases.com/ent-emergencies/ 

https://lifeinthefastlane.com/epistaxis/

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Scalp Lacerations – “You Can Leave Your HAT On!”

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You can leave your “HAT” on: An approach to scalp lacerations and review of the hair apposition technique

Resident Clinical Pearl (RCP) – November 2018

Devon Webster – FMEM PGY1, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Quick case!

Joe Cocker and Randy Newman had an altercation while debating who recorded the best version of “You can leave your hat on”. Randy won (mainly because he is still alive), but unfortunately he sustained a nasty head injury in the process. You deduce that he does not require a CT head but he’s got a 7 cm lac over his scalp. What should you do next?

 

Review of scalp anatomy:

The scalp is divided into 5 layers, which can conveniently be recalled using the mnemonic, SCALP:

  • Skin

    Ref 1

  • dense Connective tissue
  • Aponeurosis
  • Loose connective tissue
  • Periosteum

 

Recall that the dense connective tissue layer is richly vascularized. The tight adhesion of these vessels to the connective tissue inhibits effective vasoconstriction, hence the profuse bleeding often seen with scalp wounds.

The loose connective tissue layer = the DANGER ZONE when lacerated. This layer contains the emissary veins, which connect with the intracranial venous sinuses. Consequently, lacerations reaching this layer are high risk for spreading infection to the meninges

 

 

 

Examining the laceration:

Ref 2

Prior to choosing the most appropriate closure technique, the wound should be cleaned and cleared of debris and the depth of the wound should be determined.

  • Superficial wounds: generally do not gape and have not gone beyond the aponeurosis. Adherence to the aponeurosis should prevent the wound edges from separating.
  • Deep wounds: gape widely due to laceration of the aponeurosis in the coronal plane. Tension secondary to the occipitofrontalis muscles will pull the wound open in opposite directions.

 

Ref 2

(A) Scalp laceration that extends through the aponeurosis
(B) CT showing an associated skull fracture

 

Choosing a closure technique:

A. The HAT technique: Hair Apposition Technique

What it is: A fast and simple technique for superficial laceration closure whereby the physician twists hair on either side of the laceration together and seals the twist with a drop of glue for primary closure. Various advantages, as described below, including no need for follow up suture or staple removal.

When to use it: Consider using HAT for linear, superficial lacerations, <10 cm that have achieved appropriate hemostasis (assuming the patient has hair!).

The evidence for HAT: An RCT based out of Singapore, comparing suturing (n=93) to HAT (n=96) for scalp lacerations <10 cm found HAT to be equally acceptable if not superior to suturing. Patients were more satisfied (100% vs 75%), had less scarring (6.3% vs 20.4%), fewer complications (7.3% vs 21.5%), lower pain scores (2 vs 4), shorter procedure times (5 vs 15 min) and less wound breakdown (0% vs 4.3%) (Ref 4)

A follow up study by the same group assessing cost-effectiveness of HAT compared to suturing found a cost savings of $28.50 USD (95% CI $16.30 to $43.40) in favor of HAT when taking into consideration materials, staff time, need for removal appointments and treatment of complications (Ref 5)

A retrospective observational study comparing HAT (n=37) to suturing (n=48) and stapling (n=49) also found HAT to be superior to both suturing and stapling due to increased patient satisfaction at days 7 and 15, reduced pain, lower cosmetic issues and complication rates (Ref 6)

 

How to do HAT (see diagram):

  1. Choose 4-5 strands of hair in a bundle on either side of laceration
  2. Cross the strands
  3. Make a single twist to appose the wound edges
  4. Secure with a single drop of glue
  5. Advise patient that the glue will eventually come off on its on and no formal removal is required.

Cautions with HAT: avoid getting glue into the wound as it may result in wide scarring with a bald spot (Ref 3)

 

B. Wound Staples

If the HAT technique is not an option (no glue, bald, etc) and the lac is superficial (above the aponeurosis), staples are preferred over suturing due to Ref 3:

  • Rapid closure of wound edges
  • Non-circumferential wound closure avoid potential strangulation
  • No cross hatch marks
  • Less expensive

C. Wound Sutures

Sutures are appropriate for deep, gaping wounds or those requiring immediate hemostasis.

Suture is required for lacerations through the aponeurosis to reduce spread of infection, hematoma formation and increased scarring. Furthermore, inadequate repair of the aponeurosis may result in asymmetric contraction of the frontalis muscle (Ref 3)

 

 

Final thoughts post-closure:

  • White petroleum ointment is as effective as antibiotic ointment in post-procedural care (Ref 7). Furthermore, the next time you consider handing out bacitracin (or polysporin), recall that it was declared ‘contact allergen of the year for 2003’ by the American Contact Dermatitis Society. Bacitracin is among the top ten allergens in the US causing allergic contact dermatitis (Ref 8).
  • Wetting the wound as early as 12 hrs post-repair does not increase the risk of infection (Ref 7). Consider delaying wetting in the case of HAT.

Bottom line:

  • For superficial lacerations, <10 cm with adequate hemostatic control, the hair apposition technique is a fast, cost-effective method of wound closure with high patient satisfaction, reduced pain and lower complications compared to suturing and staples.
  • Lacerations through the aponeurosis require suturing to reduce rates of complications.
  • Consider use of petroleum jelly over antibiotic containing ointments such as polysporin.

 

Video

 

 

References:

 

1 Hunt, W. “The Scalp.” Teachmeanatomy.info. Last updated Oct 24, 2018. Accessed Nov 28, 2018. URL:  https://teachmeanatomy.info/head/areas/scalp/

2 Dickinson, E. Uptodate. Accessed Nov 28, 2018 URL: https://www.uptodate.com/contents/image?imageKey=EM%2F87633&topicKey=EM%2F16696&source=see_link

3 Hollander, J. “Assessment and management of scalp lacerations.” Uptodate. Updated Feb 23, 2018. Accessed Nov 28, 2018. URL: https://www.uptodate.com/contents/assessment-and-management-of-scalp-lacerations

4 Ong ME. “A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).” Annals of Emergency Medicine. July 2002. 40:1. 19-26.

5 Ong ME. “Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations.” Annals of Emergency Medicine. 2005 Sept; 46(3):237-42.

6 Ozturk D. “A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations.” World J Emerg Surg. 2013; 8:27.

7 Forsch, R. “Essentials of skin laceration repair.” American Family Physician.

8 Fraser, J. “Allergy to bacitracin.” Dermnet NZ. September 2015. Accessed on Nov 28, 2018 URL: https://www.dermnetnz.org/topics/allergy-to-bacitracin/

 

 Randy:

 

Joe:

 

 

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Arterial bleeding

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Approach to Arterial Bleeding in the Upper Extremity

Resident Clinical Pearl (RCP) – November 2018

Tara Dahn – CCFP-EM PGY3, Dalhousie University, Halifax NS

Reviewed by Dr. David Lewis

This post was copyedited by Dr. Mandy Peach

You are working a shift in RAZ when a pair of paramedics wheel a man on a stretcher into one of the procedure rooms. He is sitting upright and looking around but his entire left forearm and hand are wrapped in towels, which are taped tightly down. “I don’t know what’s hurt but there was a lot of blood”, he says when questioned. He had been using a reciprocating saw in his workshop.

Vital signs: T 36.5, HR 90, BP 135/90, RR 18, O2 sats 98% on RA

You ask the nurses to find a tourniquet to put around the patients arm as you start unwrapping his giant towel mitt. You get down to the skin and find a deep 1 inch transverse laceration along the radial side of the wrist. Initially there is no active bleeding, you gingerly pock the wound and …Ooops… immediately bright red pulsatile blood starts pumping out from the distal wound edge and your scrubs will need to be change before you see the next patient.

Approach to arterial bleeding in upper extremity

Life over limb

  • Get control of the bleeding and if needed focus on other more pressing injuries. Start resuscitation if needed
  • There is no bleeding in the extremity that you can’t stop with manual compression.
  • If you can’t spare a person to compress artery then consider a tourniquet. (see Table 1 on tourniquets)
  • Avoid blindly clamping as nerves are bundled with vascular structures and can be easily damaged.

 

Determine if arterial bleeding/injury exists

Look for hard or soft signs of arterial injury (See Table 2)

If hard signs of arterial injury in major vessel the patient will need operative care. Imaging is not required unless site of bleeding is not clear (and patient is stable).
If there are soft signs of arterial injury do an Arterial Pressure Index (see Box 1) to help determine if there is an underlying arterial injury.
o If API >0.9: Patient unlikely to have an arterial injury. Observe or discharge based on nature of injury/patient.
o If API < 0.9: Possible arterial injury. Patient will need further investigation, preferably by CTA.

  • API is recommended over ABI (Ankle Brachial Index) in lower extremity injuries. ABI compares lower extremity SBP to brachial SBP. Usually patients will have more atherosclerotic disease in their lower extremities, which can falsely elevate their ABI and make it harder to detect a vascular injury. The API, on the other hand, relies on the fact that the amount of atherosclerotic disease is usually symmetric between the two upper and two lower extremities.
  • API is a very good test. An API less than 0.9 has a sensitivity and specificity of 95% and 97% for major arterial injury respectively, and the negative predictive value for an API greater than 0.9 is 99% (Levy et al., 2005).

Consider vessel injured

  • A good understanding of vascular anatomy is important to identify which vessel is injured. See figures 1 and 2.

Figure 1: Upper Extremity Arteries
(https://web.duke.edu/anatomy/Lab12/Lab13_preLab.html)

Figure 2: Lower Extremity Arteries
https://anatomyclass01.us/blood-vessels-lower-limb/blood-vessels-lower-limb-arteries-in-the-lower-leg-human-anatomy-lesson

Examine distal extremity well.

  • In the excitement of pulsatile bleeding it can be easy to be tempted to skip/rush this. But with bleeding controlled remember that the extremities are much less picky about blood supply than your vital organs. You can take a few minutes to examine the distal limbs neurovascular status (blood supply, sensory and motor, tendon integrity) and should as this will be important for management decisions.
  • Arterial injuries can very often be accompanied by nerve and tendon injuries. Complete a full assessment. See Figures 3 &4 for neurologic assessment of hand.
  • Most disability following arterial injuries is not due to the actual arterial injury, but due to the accompanying nerve injury (Ekim, 2009).

Figure 3: Motor examination of the hand. 1 – Median nerve. 2- Ulnar nerve. 3- Radial nerve (Thai et al., 2015)
Figure 4: Sensory innervation of the hand and nerve locations (Thai et al., 2015)

Explore wound carefully

  • It is important to explore the wound carefully to look for other structures damaged.
  • Examine tendons and muscles by putting their accompanying joints through a full ROM to see partial lacerations that may have been pulled out of sight.

Control bleeding definitively

Proximal arterial injuries (brachial artery, proximal radial/ulnar artery)

-All brachial artery injuries will require urgent repair by vascular surgeon.
-The “golden period” is 6-8 hours before ischemia-reperfusion injury will endanger the viability of the limb (Ekim, 2009). Degree of ischemia depends on whether injury is proximal or distal to the profunda brachii (Ekim, 2009)
-Larger more proximal arteries are rarely injured alone and will nearly all have nerve/tendon/muscle injuries also requiring operative repair

Forearm/hand arterial injuries
-Many arterial injuries in/near the hand will NOT require operative repair as there are very robust collaterals in the hand with dual blood supply from the radial and ulnar arteries in most people.

-Steps to management
Manual direct digital compression: 15 minutes direct pressure without interruption will often be successful on its own.

Temporary tourniquet application and wound closure with running non-absorbable suture followed by compact compressive dressing. If vessel obviously visible may try tying off but blindly clamping/tying will likely injury neighboring structures, particularly nerves.

Operative repair may be required if bleeding cannot be controlled with above measures.
Studies have shown that in the absence of acute hand ischemia, simple ligation of a lacerated radial or ulnar artery is safe and cost effective (Johnson, M. & Johansen M.F., 1993) however some surgeons may still opt to perform a primary repair.

 

Approach for our case

Life over limb

Patient was hemodynamically stable at presentation. IV access had already been obtained by the paramedics. Bleeding was controlled with direct pressure. When visualization was required at the site of the wound a tourniquet was used.

Determine if arterial bleeding
Our patient had a clear hard sign for arterial bleeding- pulsatile blood

Consider vessel injured
Our patients pulsatile bleeding was coming from the distal edge of the wound. Leading us to conclude that it was pulsing retrograde from the palmar arch (See Figure 5 for more detailed anatomy).

Examine distal extremity well
Our patient had a completely normal sensory and motor exam of his hand as well as normal tendon function. Lucky!

Explore wound carefully
A tourniquet was needed to properly visualize and explore the wound. There were no other injured structures identified.

Control the bleeding definitively
Direct pressure for 15 minutes did not stop the bleeding. The ends of the vessel were not identified on initial wound inspection. The wound was extended a short distance (~1cm) in the direction of the bleeding but still the vessel was not identified.

Plastic surgery was consulted. They extended the wound another 3 cm distally and were able to identify the artery, which had been transected longitudinally. They concluded that it was likely the radial artery just past the superficial palmar branch. The hand was well perfused and thus the artery was ligated. The wound was irrigated well, closed and the patient was discharged with a volar slab splint and follow up.

 

References:

Ekim, H. & Tuncer, M. (2009). Management of traumatic brachial artery injuries: A report on 49 patients. Ann Saudi Med. 29(2): 105-109.

Johnson, M. & Johansen, M.F. (1993). Radial or Ulnar Artery Laceration – Repair or Ligate? Arch Surg 128(9), 971-975.

Levy, B. A., Zlowodzki, M.P., Graves, M. & Cole, P.A. (2005). Screening for extremity arterial injury with the arterial pressure index. The American Journal of Emergency Medicine, 23(5), 689-695.

Thai, J.N. et al. (2015). Evidence-based Comprehensive Approach to Forearm Arterial Laceration. Western Journal of Emergency Medicine, 16(7), 1127-1134.

Life in the Fast Lane: Extremity arterial injury

Tinntinalli’s Emergency Medicine

 

This post was copyedited by Dr. Mandy Peach

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