PoCUS assisted lumbar puncture

Posted on November 19, 2019 by Kavish Chandra

PoCUS assisted lumbar puncture

Resident Clinical Pearl (RCP) November 2019

Allyson Cornelis – PGY3 FMEM Dalhousie University, Saint John NB

Lumbar punctures (LPs) are an essential emergency physician skill. Indications including assessing for serious causes of headaches such as meningitis and subarachnoid hemorrhage.

Various limitations to successful lumbar puncture include a large body habitus, arthritic spines, and altered spinal anatomy. Furthermore, this leads to increased procedural risks (failed attempts, pain, hematoma formation, infection and traumatic tap leading to difficult CSF interpretation)

Traditional lumbar puncture

The traditional way to perform a LP is using surface landmarks. The superior iliac crests are identified and a line is drawn across the back to connect them. This helps in identifying L3/L4 space. This is deemed a safe place for LP as the spinal cord ends above this.

PoCUS guided lumbar puncture

Ultrasound has become a common tool used in the emergency department for assessment of patients and to assist in certain procedures. Lumbar puncture is one procedure where ultrasound has potential to increase success.^1,2

The evidence

Meta-analysis of PoCUS guided LPs in the ED with adult and pediatric patients showed improved success rates (NNT 11) and fewer traumatic taps (NNT 6), less pain and less time to obtaining a CSF sample.⁴

Similar studies in neonates and infants showed reduced LP failure and traumatic taps in the PoCUS guided LP group.⁵

The procedure

The goal of the LP is to place a needle into the subarachnoid space where the CSF can be sampled. At the safe level, LP needle moves in-between the caudal equina.

Adapted from Tintinalli’s Emergency Medicine : A Comprehensive Study Guide, 8th ed.

Landmark based LP (briefly)

Place the patient in the lateral decubitus or seated position, allowing them to curve their spine and open the space between adjacent spinous processes

Identify the superior iliac spines and connect a line between the two iliac spines across the back (this should intersect the L4 spinous process).

LP can be safely performed in the L3/4 or L4/5 interspaces. During the procedure, the needle is directed towards the patient’s umbilicus.

PoCUS guided LP^2,3,6

Identify the midline

Position patient either sitting with a curved lumbar spine or laying down in a lateral decubitus position with back perfectly perpendicular to the table and not angled at all. Using either a linear or curvilinear probe (curvilinear is recommended for obese patients), in the transverse plane start at the sacrum which will appear as a bright white line.
Move the transducer towards the patient’s head while maintaining a transverse orientation. A space will appear followed by a smaller bright curved line with posterior shadowing, this is the L5 spinous process.

Center the spinous process in your screen, and mark the location with a surgical marking pen.

Continue moving the transverse transducer cephalad, you will see the interspaces (lack of spinous process and the accompanying shadow and possibly evidence of the articular processes which appear as bat ears).
Connect each mark identifying the spinous processes—this marks the midline of the spine

Identify the interspaces

Turn the transducer into the saggital plane with the indicator towards the patient’s feet (to line up the patient’s head with the view on the screen).

Place transducer along the spinal line you marked, starting at the top, and identify the spinous processes and the interspaces.
Place the interspace in the center of the transducer and mark with a line. Move caudally, identifying the remaining interspaces.

Connect these lines to your spinal line. Where they intersect are the ideal locations for needle entry.

The bottom line

Ultrasound is a tool being utilized more often in clinical practice, including in the emergency department. Research shows that its use in obtaining lumbar punctures has potential benefits, including more success in obtaining a CSF sample and less traumatic taps, with minimal harms or downsides to use of the ultrasound.

Copyedited by Kavish Chandra

Resources:

Ladde JG. 2011. Central nervous system procedures and devices. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydula RK, Meckler GD, editors. Tintinalli’s emergency medicine: Acomprehensive study guide. 7th ed. China: McGraw-Hill Companies, Inc. p 1178-1180.
Millington SJ, Restrepo MS, Koenig S. 2018. Better with ultrasound: Lumbar puncture. Chest 2018. 154(5): 1223-1229.
Ladde JG. 2020. Central nervous system procedures and devices. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH, editors. Tintinalli’s emergency medicine: A comprehensive study guide. 9th ed. New York, NY: McGraw-Hill: http://accessmedicine.mhmedical.com.ezproxy.library.dal.ca/content.aspx?bookid=2353&sectionid=221017819. Accessed November 17,2019.
Gottlieb M, Holladay D, Peksa GD. 2018. Ultrasound-assisted lumbar punctures: A systematic review and meta-analysis. Acad Emerg Med. 2019 Jan. 26(1). 85-96.
Olowoyeye A, Fadahunsi O, Okudo J, Opaneye O, Okwundu C. 2019. Ultrasound imaging versus palpation method for diagnostic lumbar puncture in neonates and infants: A systematic review and meta-analysis. BMJ Pediatrics Open. 2019 Mar. 3(1):e000412.
Jarman B, Hoffman B, Al-Githami M, Hardin J, Skoromovsky E, Durham S, et al. Ultrasound and procedures. In: Atkinson P, Bowra J, Harris T, Jarman B, Lewis D, editors. Point of Care Ultrasound for Emergency Medicine and Resuscitation. 1st ed. United Kingdom: Oxford University press; 2019. p. 198-199.

Color Flow Doppler to Assess Cardiac Valve Competence

Posted on November 1, 2019 by David Lewis

Color Flow Doppler to Assess Cardiac Valve Competence

Resident Clinical Pearl (RCP) April 2019

Dr. Scott Foley – CCFP-EM PGY3 Dalhousie University, Halifax NS

Reviewed by Dr. David Lewis

Background:

When colour Doppler is initiated, the machine uses the principals of the Doppler effect to determine the direction of movement of the tissues off which it is reflecting.

The Doppler effect is the change in frequency of a wave in relation to an observer who is moving relative to a wave source. It was named after the Austrian physicist Christian Doppler who first described the phenomenon in 1842. The classic example is the change in pitch of a siren heard from an ambulance as it moves towards and away from an observer.

These principles are applied to POCUS in the form of colour Doppler where direction of flow is reflected by the colour (Red = moving towards the probe, Blue = moving away from the probe), and the velocity of the flow is reflected by the intensity of the colour (brighter colour = higher velocity).
*Note: the colour does not represent venous versus arterial flow.

The use of colour Doppler ultrasound can be useful in the emergency department to determine vascular flow in peripheral vessels as well as through the heart. It is one way to determine cardiac valve competency by focusing on flow through each valve.

Obtaining Views:

To optimize valve assessment, proper views of each valve must be obtained. It is best to have the direction of the ultrasound waves be parallel to the direction of flow. External landmarks for the views used are seen below:

Mitral Valve and Tricuspid Valve: The best view for each of these is the apical 4 chamber view. If unable to obtain this view, the mitral valve can be seen in parasternal long axis as well.
Aortic Valve: The best view is the apical 5 chamber or apical 3 chamber but are challenging to obtain. Instead, the parasternal long axis is frequently used.
Pulmonic Valve: Although not commonly assessed, the parasternal short axis can be used.
Visit 5minutesono.com for video instruction on obtaining views

Parasternal long axis: MV, AV

Parasternal short axis: PV, TV

Apical 4 chamber: TV, MV

Assessing Valvular Competency:

How to examine valvular competency:

Get view and locate valve in question
Visually examine valve: opening, closing, calcification
Use colour Doppler:
1. Place colour box over valve (as targeted as possible (resize select box) to not include other valves)
2. Freeze image and scroll through images frame by frame
3. Examine for pathologic colour jets in systole and diastole
Estimating severity:
1. Grade 1 – jet noticeable just at valve
2. Grade 2 – jet extending out 1/3 of atrium/ventricle
3. Grade 3 – jet extending out 2/3 of atrium/ventricle
4. Grade 4 – jet filling entire atrium/ventricle

See video tutorial below for more

Mitral Regurgitation A4C

Tricuspid Regurgitation A4C

Aortic Stenosis PSLA

Bottom line:

Color flow Doppler on POCUS is a straightforward way to assess for valvular competency in the Emergency Department. A more detailed valvular assessment requires skill, knowledge and experience.

Useful Video Tutorials:

Mitral Regurgitation

Aortic Stenosis vs Sclerosis

Tricuspid Valve

References:

https://www.radiologycafe.com/medical-students/radiology-basics/ultrasound-overview
By Patrick J. Lynch and C. Carl Jaffe – http://www.yale.edu/imaging/echo_atlas/views/index.html, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=21448310
5minutesono.com
ECCU ShoC 2018 powerpoint, Paul Atkinson, David Lewis

Shining a light on acute vision loss: PoCUS for the retina

Posted on October 25, 2019 by Kavish Chandra

Shining a light on acute vision loss: PoCUS for retinal pathology

Resident Clinical Pearl (RCP) August 2019

Dr. Devon Webster – PGY2 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. Kavish Chandra

It’s a quiet night in RAZ and you pick up your next chart- a 68 year old Ms. Iris Snellen has come in with new onset, painless, monocular vision loss. You pick up the ophthalmoscope to perform fundoscopy, and despite your best attempts, like many ED physicians before you, you see nothing helpful. So instead you pick up your investigative tool of choice, the ultrasound probe, and begin your ocular POCUS exam…

Anatomy and pathophysiology

The retina is composed of multiple layers of neurons that allow for the human eye to convert light energy (photons) into images within the occipital brain. The retina sits on top of the vascular choroid which provides blood flow.

Fundoscopy allows for visualization of the following structures:

Optic disc
The macula (central, high-resolution, color vision)
The fovea (sits centrally in the macula and provides sharp, central vision)
The retinal artery and vein

https://stanfordmedicine25.stanford.edu/the25/fundoscopic.html

PoCUS is adjunctive test to assess for vision-threatening and common conditions impacting the eye such as retinal detachment (RD), posterior vitreous detachment (VD) and vitreous hemorrhage (VH).

A normal eye should allow you to visualize the following structures:

https://www.nuemblog.com/ocular

In retinal detachment, the retina is separated from the choroid either through formation of a hole in the retina, peeling away from the choroid if attached to the vitreous humour or through edematous infiltration between the two layers. Separation results in rapid ischemia and death of photoreceptors with subsequent vision-loss.

Posterior vitreous detachment is common and occurs secondary liquification of the gel-like vitreous body.

Vitreous hemorrhage can occur secondary trauma, spontaneous retinal tears or vitreous detachment or any cause of retinal neovasculiarzation such as in diabetes.

Retinal detachment and the DDx

When assessing your pt, a retinal detachment should be at the top of your list of diagnoses to rule out given that prompt recognition and referral to ophthalmology may be a vision-saving intervention.

On history she may describe the following features of RD:

Floaters: may appear as spiderwebs, a large spot that comes and goes that may ‘look like a big fly’ or a showering of many small black dots.
Painless monocular vision loss: may present as a ‘curtain descending’ across her vision and/or visual field loss.
Flashes: may be easier to see at night or in a dark room (consider turning off the lights in the exam room)

Assess for risk factors for retinal detachment:

Myopia (near-sightedness): Major risk factor!
Cataract surgery
Family history of retinal detachment
Diabetes
Glaucoma
Old age
History of posterior vitreous detachment

Physical exam:

Assess for changes in visual acuity
Assess for loss of visual fields
Fundoscopy may reveal advanced detachments however, early detachments are often not visible with direct fundoscopy. Advanced detachments may reveal absence of a red reflex and a billowing retinal flap.
Ultrasound!

Your DDx may include:

Posterior vitreous detachment
Vitreous hemorrhage
Ocular migraine
CRAO/CRVO
Amaurosis fugax

(see below for distinguishing features of the DDx)

The PoCUS assessment

Most ED physicians feel more comfortable with their ultrasonography skills over their fundoscopy skills. PoCUS is a fast, portable and radiation-free approach to assessing patients for potential vision-threatening pathology such as retinal detachment. While ultrasonography should not replace ophthalmologic assessment and fundoscopy, it can be used as an additional tool to support your primary diagnosis.

Most recently, Lanham, et al., published a prospective diagnostic study involving 225 patients and 75 ED providers that found POCUS was 96.9% sensitive and 88.1% specific for the diagnosis of retinal detachment¹. While studies have varied in whether sensitivity was better than specificity or vice versa, ultimately each study has shown that when trained, emergency providers are quite good at identifying RD by US^2,3. In addition to RD, Lanham, et al further found ED providers did well at identifying vitreous hemorrhage (sens 81.9%, sp 82.3%) and vitreous detachment (sens 42.5%, sp 96%).

Get the PoCUS Scan:

Place a tegaderm over the eye to protect it from US gel which may be painful. You may consider using topical freezing drops to limit irritation.
Use the linear probe and scan through the eye until you are able to visualize the optic nerve, the hypoechoic structure at the back of the eye
Have the patient look side to side/up and down as this will accentuate movement of retinal or vitreous pathology.

1. Retinal detachment: Bright echogenic line that appears to have separated from the posterior eye/choroid and remains tethered to the optic nerve.
2. Posterior vitreous detachment: Bright echogenic line separated from posterior eye/choroid that is detached from the optic nerve.
3. Posterior vitreous hemorrhage: Vitreous shows fluid collection with variable echogenicity and ‘washing machine’ appearance.

Jacobsen et al. (2016). WestJEM. 17(2)

Differential of painless visual loss

Resources:

Lahham S, et al. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA Netw Open. Published online April 12, 20192(4):e192162. doi:10.1001/jamanetworkopen.2019.2162
Kim, D., et al. Test Characteristics of Point-of-care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department. Academic Emergency Medicine. 2019;26[1]:16; http://bit.ly/2TEFutH
Vrablik ME, et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta‐analysis. Ann Emerg Med 2015; 65( 199–203): e1.
Mason, J. (Host). (2019 Jan). C3-Vision Loss-Retinal Detachment [Audio podast]. Retrieved from EMRAP: https://www.emrap.org/episode/c3visionloss/c3visionloss1 .
Arroyo, J. (Jan 2018). Retinal Detachment. Retrieved from Uptodate: https://www.uptodate.com/contents/retinal-detachment
Givre, S., et al. (Feb 2019). Amaurosis fugax (transient monocular or binocular visual loss). Retrieved from Uptodate: https://www.uptodate.com/contents/amaurosis-fugax-transient-monocular-or-binocular-visual-loss?search=painless%20monocular%20vision%20loss&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Porfiris, G. (2015). ABCs of Emergency Medicine, 14^th Edition, Chapter 23: Eye Emergencies.

Differential of painless visual loss

Posted on October 25, 2019 by Kavish Chandra

Differential for painless visual loss

Dr. Devon Webster – PGY2 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. Kavish Chandra

Ultrasound guided hematoma block for distal radius fractures

Posted on October 20, 2019 by Kavish Chandra

Ultrasound guided hematoma block for distal radius fractures

Resident Clinical Pearl (RCP) September 2019

Robert Dunfield – PGY1 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. Kavish Chandra

Mr. JG, a 34 year old male snowboarder, presents to your busy emergency department after a snowboarding accident. He suffered a fall onto his left outstretched hand after hitting a jump that was approximately one foot high. Radiograph shows a closed distal radius fracture with significant dorsal angulation.

Figure courtesy of Dr Pir Abdul Ahad Aziz, Radiopaedia.org, rID: 47908

Tonight is a busy shift and you’re working in a resource-limited department with very few staff. In speaking with the patient, he’s nervous about the prospect of procedural sedation and would prefer to not be “put to sleep to fix [his] wrist”. Luckily, your department recently purchased an ultrasound machine and the patient consents to a hematoma block prior to reduction.

What is a hematoma?

Following the initial impact that causes a fracture, the initial stage of bone healing involves a hematoma formation. In simple terms, a hematoma is a large blood clot that collects at the fracture site. Hematomas are rich in vascular supply and are the site of eventual soft callus formation; they’re the result of bony blood supply being disrupted at the site of the defect

Stages in Fracture Repair. The healing of a bone fracture follows a series of progressive steps: (a) A fracture hematoma forms. (b) Internal and external calli form. (c) Cartilage of the calli is replaced by trabecular bone. (d) Remodeling occurs.¹

Hematoma blocks as an alternative to procedural sedation?

Compared to procedural sedation, hematoma blocks can be done safely when procedural sedation is not an option or is contraindicated. They also offer an alternative option for analgesia when an emergency department is busy and resources are lacking to safely perform procedural sedation.²

Procedural sedation requires a period of recovery after the procedure, hematoma blocks do not necessitate traditional post procedural recovery.³
Evidence that suggests post-procedure analgesia is similar in hematoma block patients compared to patients who undergo procedural sedation.⁴
Hematoma blocks are a form of local anaesthesia that can be used when reducing simple, closed distal long bone fractures, like the distal radius fracture in this case. They can also be performed to provide analgesia for nondisplaced fractures.²

Prior to the advent of bedside ultrasound, hematoma blocks were dependent on external anatomy landmarking, using “step-off” site of the bony deformity as the landmark for injection. This can be difficult, however, in fractures where swelling, habitus, or deformity can distort the anatomy of the hematoma.² This is where ultrasound plays a role in identifying the deformity and therefore improves the precision of hematoma injection.

Contraindications to hematoma block include allergy to the anaesthetic being used, if the fracture is open, if there is cellulitis overlying the site of the fracture, and/or if there is a neurovascular deficit on exam of the affected limb.⁵

Performing a hematoma block under US guidance

Mr. JG requires reduction of his distal radius fracture. Due to his uneasiness with procedural sedation, combined with the busy and resource-strained nature of your emergency department, a hematoma block under ultrasound guidance is performed.

Gain informed consent: The initial step in performing a hematoma block is similar to all medical procedures in that the patient undergoing the procedure should be informed of the risks associated with hematoma blocks and fracture reduction. These include, although rare, compartment syndrome, local anesthetic toxicity, acute carpal tunnel syndrome, and temporary paralysis of the upper limb⁶. Remember that maximum dose of lidocaine without epinephrine is 5mg/kg.
Reassess the neurovascular integrity of the limb: Prior to injecting the hematoma block, ensure you have confirmed neurovascular integrity of that limb.
Grab the supplies you’ll need: The following list is limited to the supplies needed for your hematoma block and does not include the supplies needed for fracture reduction and casting.
- Ultrasound machine with a linear transducer probe
- Tegaderm transparent film
- Sterile lubricating jelly
- Sterile skin marker
- Sterile gloves
- Chlorhexidine swabs x 3
- 16G Needle (for drawing up analgesia)
- 20G or 22G Needle (for injecting analgesia)
- 10mL syringe
- 1% lidocaine (approximately 10mL)
Landmark the hematoma using point of care ultrasound: Trace the bone’s cortex on the dorsal aspect of the forearm from the proximal aspect of the fracture towards the fracture site until you reach an interruption in the cortex of the radius (see below). Mark that site with your marker for injection.

Left: Sagittal image of left radius outlining an interruption in the radial cortex at the site of the hematoma. Right: Same image, edited to identify anatomy.⁸ Edited by Robert Dunfield PGY1-Dalhousie

Clean the site and prepare other materials: Clean the site with chlorhexidine swabs x 3. Allow it to dry while you prepare the remainder of your equipment. Draw up your 10mL of 1% lidocaine with the 16G needle and then change the needle to your 20 or 22G needle. A longer needle may be needed to reach the site of the hematoma.
Prepare your transducer: Clean your linear transducer and then put on your sterile gloves. With the help of an assistant apply the sterile tegaderm film to the liner transducer and place sterile lubricating jelly on the probe.
Insert needle under US guidance: Using the probe to visualize the site of the hematoma, simultaneously begin to insert the needle in a caudal fashion toward the hematoma, visualizing the needle in the long axis. Use the ultrasound image to follow the needle’s insertion.

Injection of hematoma block under ultrasound guidance.⁶Modified by Robert Dunfield PGY1-Dalhousie

Inject the lidocaine: Inject 10mL of 1% lidocaine into the hematoma.
Give time for analgesia to take effect: Allow 5 to 10 minutes of time to allow the analgesia to take full effect, then reassess neurovascular integrity.
Proceed with the reduction.
Added note: It’s possible for distal radius fractures to have an associated ulnar styloid fracture, which will require repeating the same steps as described above, only at the side of the ulnar fracture.

Summary:

- Hematoma blocks under ultrasound guidance can be done on certain distal long bone fractures that lack any contraindications
- Use the ultrasound probe to trace the bone’s cortex and identify the site of the hematoma, then insert the needle into the hematoma under the guidance of your linear transducer.
- Confirm needle placement into the hematoma by aspiration and inject 10mL of 1% lidocaine into the hematoma.
- Allow 5 to 10 minutes of analgesia onset before reducing the fracture.
- Remember to reassess the limb’s neurovascular integrity before and after the procedure.

Copyedited by Kavish Chandra

Resources:

Rice University. Anatomy and Physiology. Chapter 6.5: Bone Repair. https://opentextbc.ca/anatomyandphysiology/chapter/6-5-fractures-bone-repair. Accessed: September 03, 2019. Last updated: unknown.
Gottlieb M and Cosby K. Ultrasound-guided hematoma block for distal radial and ulnar fractures. Journal of Emergency Medicine. 2015;48(3):310-312.
Alerhand S and Koyfman A. Ultrasound-Guided Hematoma Block. emDocs.net. http://www.emdocs.net/ultrasound-guided-hematoma-block/. Accessed: September 07, 2019. Last updated: December 21, 2014.
Fathi M, Moezzi M, Abbasi S, Farsi D, Zare MA, Hafezimoghadam P. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial. Emerg Med J. 2015;32:474-477.
Reichman EF. Emergency Medicine Procedures. Second Edition. 2013:Chapter 125 Hematoma Blocks.
Emiley P, Schreier S, Pryor P. Hematoma Blocks for Reduction of Distal Radius Fractures. Emergency Physicians Monthly. https://epmonthly.com/article/hematoma-blocks-for-reduction-of-distal-radius-fractures/. Accessed: September 14, 2019. Last updated: February 2017.
Beaty JH and Kasser JR. Rockwood and Wilkins’ Fractures in Children. Chapter 3: Pain Relief and Related Concerns in Children’s Fractures, pp61-63.
EM Cases and POCUS Toronto. POCUS Cases 4: Distal Radius Fracture. https://emergencymedicinecases.com/video/pocus-cases-4-distal-radius-fracture/. Accessed: September 14, 2019. Last updated: July 2018.

Lung Ultrasound in the Evaluation of Pleural Infection

Posted on July 31, 2019 by David Lewis

Lung Ultrasound in the Evaluation of Pleural Infection

Resident Clinical Pearl (RCP) July 2019

Yazan Ghanem – PGY5 Internal Medicine, Dalhousie University

SJRHEM PoCUS Elective

Reviewed and edited by Dr. David Lewis.

CASE: MR. WHITE

83 year old male with known past medical history of mild cognitive impairment (lives alone in assisted living). Two weeks prior to current presentation, he was admitted with community acquired pneumonia and discharged after 2 nights of hospital stay on oral antibiotics.

He is now presenting with 5 days history of worsening dyspnea, fever, fatigue and reduced oral intake. Vital signs are: Temperature 38.4 C; heart rate 80/min; Blood pressure 121/67; Respiratory rate 28/ minute; Oxygen saturation 90% on room air. His chest exam showed reduced air entry and dullness to percussion in the right hemithorax.

CXR:

Bedside POCUS:

Pleural fluid analysis:

• WBC – 22,000 cells per uL

• LDH – 1256 Units / L

• Glc – 2.2 mmol / L

• pH – 7.18

• Gram Stain – Neg

Next steps in management?

A – 14 Fr pleural drain + Start IV Levofloxacin

B – 28 Fr pleural drain + Start Ceftriaxone / Azithromycin

C – 14 Fr pleural drain + Start Piperacillin – Tazobactam

D – Start Ceftriaxone / Azithromycin + Repeat CXR in 1 week

(See end of page for answer )

Normal Thoracic Ultrasound:

Thoracic Ultrasound is limited by bony structures (ribs and scapulae) as well as by air within lungs (poor conductor of sound waves).

With the transducer held in the longitudinal plane:

1 – Ribs are visualized as repeating curvilinear structures with a posterior acoustic shadow.

2 – Overlying muscle and fascia are seen as linear shadows with soft tissue with soft tissue echogenicity.

3 – Parietal and visceral pleura is visualized as a single echogenic line no more than 2 mm in width which “slides” or “glides” beneath the ribs with respiration. Two separate lines can be seen with a high frequency transducer.

4 – Normal aerated lung blocks progression of sound waves and is characterized by haphazard snowstorm appearance caused by reverberation artifact.

5 – Diaphragms are bright curvilinear structures which move with respiration. Liver and spleen have a characteristic appearance below the right and left hemi diaphragms respectively.

Pleural Effusion:

Ultrasound has higher sensitivity in detecting pleural effusions than clinical examination and chest X-Ray.

On Ultrasound, pleural effusions appear as an anechoic or hypoechoic area between the visceral and parietal pleura that changes in shape with respiration. Atelectatic lung tissue appear in the far field as flapping or swaying “tongue-like” echodensities.

Ultrasound morphology:

1- Anechoic Effusion: Totally echo-free (Could be transudative or exudative)

2- Complex Non-septated: Echogenic appearing densities present (fibrinous debris). Always exudative.

3- Complex Septated: Septa appear in fluid. Always exudative.

Parapneumonic Effusions and Empyema:

Ultrasound is superior to CT in demonstrating septae in the pleural space. However, CT is recommended for evaluation of complex pleuro-parenchymal disease and loculated pleural collections if drainage is planned: There is no correlation between ultrasound appearance and the presence of pus or need for surgical drainage; however, the presence of a septated appearing parapneumonic effusion correlate with poorer outcomes (longer hospital stay, longer chest tube drainage, higher likelihood for need for fibrinolytic therapy and surgical intervention.

Parapneumonic effusions appear as hyperechoic (with or without septae) on ultrasound.

Pulmonary Consolidation:

Pulmonary consolidation is sonographically visible in the presence of a pleural effusion that acts as an acoustic window or if directly abutting the pleura.

It appears as a wedge-shaped irregular echogenic area with air or fluid bronchograms.

Back to Mr. White

Next steps in management?

A – 14 Fr pleural drain + Start IV Levofloxacin

B – 28 Fr pleural drain + Start Ceftriaxone / Azithromycin

C –14 Fr pleural drain + Start Pipercillin- Tazobactam

D – Start Ceftriaxone / Azithromycin + Repeat CXR in 1 week

Rationale:

Complicated parapneumonic effusions should be managed with drainage and antibiotics that will treat anaerobic infection. An alternative would be a combination of Ceftriaxone and Metronidazole (No pseudomonas coverage). Levofloxacin alone does not add any anaerobic coverage. Azithromycin has poor penetration into loculated pleural collections.

References

British Thoracic Society – Pleural Disease Guideline – 2010

https://thorax.bmj.com/content/65/8/667

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

Posted on May 22, 2019 by Renee Amiro

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

Resident Clinical Pearl (RCP) May 2019

Allyson Cornelis – 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 effects^3-4,6. 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:

childhood trauma
PTSD
depression
anxiety
personality disorders
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 seizure^3-8

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.

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

Bottom Line:

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

References

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.
Graham L. AAN releases guidelines for the use of serum prolactin assays in diagnosing epileptic seizures. Am Fam Physician. 2006. Apr; 73(7): 1284.
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/
Mellers JDC. The approach to patients with “non-epileptic seizures.” Postgrad Med J. 2005 Aug;81(958):498-504.
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.
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/
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.
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

SJRHEM @Halifax CAEP 2019

Posted on May 15, 2019 by David Lewis

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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/CAEP-2019-Systematic-Review-Poster-Trial-2-PA.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Does-Disposition-Influence-ED-Return-in-Renal-Colic-AK-PA.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/COLIN-caep-2019-pdf.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/CAEP-2019_POSTER_Final_RJD_RIM-PA.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/KC-FOAMed_CAEP19-002.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Poster-Presentation-Renee-Amiro-CAEP-PA.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Allyson-C-early-preg-caep-2019-PA.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Howlett-caep-2019-jf.pdf” title=”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

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Hanlon-Prototyping-caep-2019-new-PA.pdf” title=”Hanlon Prototyping caep 2019 – new PA”]

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Hanlon-Mico-skills-caep-2019-new-PA.pdf” title=”Hanlon Mico-skills caep 2019 – new PA”]

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/CAEP-19-Emergency-Medicine-Poster-Final.pdf” title=”CAEP 19 Emergency Medicine Poster Final”]

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

Posted on April 11, 2019 by David Lewis

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:

Mark the site of maximal tenderness
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)
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:

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
Suleiman, S, Johnston, D. “The Abdominal Wall: An Overlooked Source of Pain” American Family Physician. August 2001.
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.

An approach to the unexpected pregnancy

Posted on March 18, 2019 by Mandy Peach

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

Shoulder Dislocation – The Cunningham Technique

Posted on March 2, 2019 by David Lewis

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

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.

Sherman, S. (2018, August). Shoulder dislocation. Retrieved March 01, 2019, from UTD

CAEP 2019 – Crowded House?

Posted on February 4, 2019 by David Lewis

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?

Crowded House – Don’t Dream It’s Over