Ear Foreign Body Removal

Posted on May 30, 2020 by David Lewis

Ear Foreign Body Removal

Resident Clinical Pearl (RCP) May 2020

Dr. Sultan Alrobaian (PEM Fellow and Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

Introduction

Most patients with ear Foreign Bodies (FB) are children, adults can also present with ear FB
The most common objects removed include beads, pebbles, tissue paper, small toys, popcorn kernels, and insects
Diagnosis is often delayed because the causative event is usually unobserved or the symptoms are nonspecific
Most of the patients with ear FBs were asymptomatic at presentation, other patients presented with otalgia, bleeding from the ear, otorrhea, tinnitus, hearing loss, a sense of ear fullness or symptoms of otitis media
Successful removal depends on several factors, including location of the foreign body, type of material and patient cooperation
Visualization of a foreign body on otoscopy confirms the diagnosis, the other ear and both nostrils should also be examined closely for additional foreign bodies.

Clinical Anatomy

Equipment

Multiple options exist for removal of external auditory canal foreign bodies
Which piece of equipment to use will be influenced by the type of FB, the shape of the FB, the location of the FB and the cooperativeness of the patient

Timing

The type of foreign body determines the timing for removal
Button batteries, live insects and penetrating foreign bodies warrant urgent removal

Indications for consultation or referral to a specialist

Button battery
Potentially penetrating foreign bodies
Foreign body with evidence of injury to the external ear canal (EAC), tympanic membrane, middle ear, vestibular symptoms or marked pain

Technique

1 – Irrigation

This technique is used for small inorganic objects or insects
Irrigation is often better tolerated than instrumentation and does not require direct visualization
Contraindicated in patients with tympanostomy tubes, perforated tympanic membranes or button battery because the potential for caustic injury.
An angiocatheter or section of tubing from a butterfly syringe
Using body temperature water, retract the pinna, and squirt water superiorly in the external auditory canal, behind the FB

2 – Instrumentation under direct visualization

Instrumentation can be painful and frequently warrants procedural sedation in young children or other uncooperative patients
General anesthesia may be required to ensure safe removal
Restrain if needed for safety

Commonly used pieces of equipment are curettes, alligator forceps, and plain forceps. Other equipment options include using a right angle hook, balloon catheter, such as a Fogarty catheter

Used in conjunction with the operating head of an otoscope
The pinna should be retracted, and the FB visualized
When using forceps, the FB can be grasped and removed

Both curettes and right angle hooks should be gently maneuvered behind the FB and rotated so the end is behind the FB, which can then be pulled out

3 – Suction

This should be performed with a soft suction tipped catheter that has a thumb controlled release valve
Insert the suction against the FB under direct visualization and then activate the suctions and remove the FB

4 – Cyanoacrylate

Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator
Insert it against the FB under direct visualization and hold in place until the glue dries
Slowly and carefully withdraw

5 – Insect removal

The first step is to kill the insect with mineral oil followed by lidocaine
Once the insect is neutralized, it can be removed by any of the above methods

SUMMARY

Foreign bodies of EAC frequently occur in children six years of age and younger
Patients with foreign bodies of the EAC are frequently asymptomatic
Button batteries , penetrating foreign bodies or injury to the EAC should undergo urgent removal by an otolaryngologist.
With adequate illumination, proper equipment, and sufficient personnel, many EAC foreign bodies can be removed

REFERENCES

1.Lotterman S, Sohal M. Ear Foreign Body Removal. [Updated 2019 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459136 /

2.https://www.uptodate.com

3.Heim S W, Maughan K L. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(08):1185–1189. [PubMed] [Google Scholar]

4.Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngol. 2018;22(2):146–151. doi:10.1055/s-0037-1603922

PoCUS in COVID

Posted on May 30, 2020 by David Lewis

Point of Care Ultrasound (PoCUS) during the Covid-19 pandemic – Is this point of care tool more efficacious than standard imaging?

Resident Clinical Pearl (RCP) May 2020

Dr. Colin Rouse– (PGY-3 CCFP Emergency Medicine) | Dalhousie University

and Dr. Sultan Alrobaian (Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

Case

A 70 year of woman present to the ED with a history of fever, cough and dyspnoea. After a full clinical assessment (with appropriate PPE), Lung PoCUS is performed.

Introduction

The Covid-19 Pandemic has created the largest international public health crisis in decades. It has fundamentally changed both societal norms and health care delivery worldwide. Changes have been implemented into resuscitation protocols including ACLS to prioritise appropriate donning of personal protective equipment (PPE) and consideration of resuscitation appropriateness prior to patient contact.¹ Equipment has been removed from rooms to limit cross-contamination between patients. In this Pearl we will explore why PoCUS should not be discarded as an unnecessary tool and should be strongly considered in the assessment of a potential Covid Patient.

Disclaimer: Given the novel nature of CoVid-19 there is a lack of RCT data to support the use of PoCUS. These recommendations are based solely on expert opinion and case reports until superior evidence becomes available.

Potential Benefits of PoCUS

Lung PoCUS has increased sensitivity compared to conventional lung X-ray for known lung pathologies such as CHF⁴ and Pneumonia⁵ with similar specificities. Given that Pneumonia is the most common complication of Covid-19 it may help diagnose this complication in patients who have a normal CXR.
PoCUS can be performed by the assessing physician limiting the unnecessary exposure to other health care providers such and Radiologic Technologists and other staff in the diagnostic imaging department.
Lung PoCUS is low cost, repeatable and available in rural settings
Once pneumonia is diagnosed other potential complications can be sought including VTE and cardiovascular complications.

The assessment of the potential Covid-19 patient.

First one must consider the potential risk for coronavirus transmission at each patient encounter and ensure proper PPE² for both oneself and the PoCUS device³.

Lung Ultrasound in the potential Covid-19 Patient

Technique

Appropriate level PPE
A low-frequency (3–5 MHz) curvilinear transducer
Set Focus to Pleural Line and turn off machine filters (e.g THI) to maximize artifacts
Scanning should be completed in a 12-zone assessment⁶
- 2 anterior windows
- 2 lateral windows
- 2 posterior windows

Findings⁷

Mild Disease

Focal Patchy B-lines in early disease/mild infection (May have normal CXR at this point)
Areas of normal lung

Moderate/Severe Disease – Findings of bilateral Pneumonitis

B-lines begin to coalesce (waterfall sign)
Thickened and irregular pleura
Subpleural Hypoechoic consolidation +/- air bronchograms

Other Covid-19 Pearls

Large/Moderate Pleural Effusion rarely seen in Covid-19 (consider another diagnosis) – Small peripleural effusions are common in COVID
The virus has a propensity for the base of the posterior lung windows and it imperative to include these views in your assessment.

Example COVID PoCUS Videos⁸

Confluent B Lines and small sub pleural consolidation

Patchy B lines and Irregular pleura

Irregular pleura

Air Bronchogram

CT & ultrasonographic features of COVID-19 pneumonia⁹

It has been noted that lung abnormalities may develop before clinical manifestations and nucleic acid detection with some experts recommending early Chest CT for screening suspected patients.¹⁰ Obviously there are challenges with this recommendation mainly regarding feasibility and infection control. A group of researchers in China compared Ultrasound and CT findings in 20 patients with COVID-19. Their findings are summarized in the table below:

Their conclusion was that ultrasound has a major utility for management of COVID-19 due to its safety, repeatability, absence of radiation, low cost and point of care use. CT can be reserved for patients with a clinical question not answered by PoCUS. CT is required to assess for pneumonia that does not extend to the pleura. Scatter artifact from aerated lung obscures visualization of deep lung pathology with PoCUS. When PoCUS is sufficient it can be used to assess disease severity at presentation, track disease evolution, monitor lung recruitment maneuvers and prone positioning and guide decisions related to weaning of mechanical ventilation.

Learning Points

Lung PoCUS is helpful in the initial assessment of the suspected or known COVID19 Patient
Lung PoCUS may reveal pathology not visible on CXR
Lung PoCUS can provide insight into COVID19 disease severity
Lung PoCUS is a useful tool to track disease progression in COVID19

Lung PoCUS in COVID Deep Dive

Deep Dive Lung PoCUS – COVID 19 Pandemic

References

Edelson, D. P., Sasson, C., Chan, P. S., Atkins, D. L., Aziz, K., Becker, L. B., … & Escobedo, M. (2020). Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of …. Circulation.
COVID-19 – Infection Protection and Control. http://sjrhem.ca/covid-19-infection-protection-and-control/
Johri, A. M., Galen, B., Kirkpatrick, J. N., Lanspa, M., Mulvagh, S., & Thamman, R. (2020). ASE Statement on Point-of-Care Ultrasound (POCUS) During the 2019 Novel Coronavirus Pandemic. Journal of the American Society of Echocardiography.
Maw, A. M., Hassanin, A., Ho, P. M., McInnes, M., Moss, A., Juarez-Colunga, E., Soni, N. J., Miglioranza, M. H., Platz, E., DeSanto, K., Sertich, A. P., Salame, G., & Daugherty, S. L. (2019). Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA network open, 2(3), e190703. https://doi.org/10.1001/jamanetworkopen.2019.0703
Balk, D. S., Lee, C., Schafer, J., Welwarth, J., Hardin, J., Novack, V., … & Hoffmann, B. (2018). Lung ultrasound compared to chest X‐ray for diagnosis of pediatric pneumonia: A meta‐analysis. Pediatric pulmonology, 53(8), 1130-1139.
Wurster, C., Turner, J., Kim, D., Woo, M., Robichaud, L. CAEP. COVID-19 Town Hall April 15: Hot Topics in POCUS and COVID-19. https://caep.ca/covid-19-town-hall-april-15-hot-topics-in-pocus-and-covid-19/
Riscinti, M. Macias, M., Scheel, T., Khalil, P., Toney, A., Thiessen, M., Kendell, J. Denver Health Ultrasound Card. http://www.thepocusatlas.com/covid19
Images obtained from. Ultrasound in COVID-19. The PoCUS Atlas. http://www.thepocusatlas.com/covid19
Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6
National Health Commission of the people’s Republic of China. Diagnosis and treatment of novel coronavirus pneumonia (trial, the fifth version)[EB/OL]. (2020-02-05)[2020-02-06]. http://www.nhc.gov.cn/yzygj/s7653p/202002/3b09b894ac9b4204a79db5b8912d4440.shtml

Superficial can also be Deep – Superficial Thrombophlebitis

Posted on May 12, 2020 by David Lewis

Superficial Thrombophlebitis – an approach to diagnosis and management

Resident Clinical Pearl (RCP) May 2020

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

Reviewed by Dr. David Lewis

Case

Claude Virchow is a 59-year-old gentleman who presents to your emergency department complaining of pain to his medial right leg. 2 days ago, he bumped his knee and since then, has developed a hard, rope-like, tender swelling along the inside of his knee. On exam, you see the following image and he winces as you palpate along the indurated cord.

Figure 1 Source

In the next bed over, is a 39-year-old man presents with similar induration along his antecubital fossa bilaterally. He has a history of IVDU and was seen a week prior for the same problem. He is back as the indurated areas seem to be extending and his pain is worsening despite abstinence from injection and adherence to conservative measures. There are no signs of infection.

What are your recommendations?

What is superficial thrombophlebitis?

Thrombus formation in a superficial vein with associated inflammation of the vessel wall.
Typically involves the lower extremities with greater saphenous vein involvement in 60-80% of cases
Less commonly, affects the superficial veins of the upper extremities, neck (external jugular) or causes ‘Mondor’s syndrome,’ a superficial thrombophlebitis of the anterior chest wall.

Why does it matter?

In patients with superficial venous thrombosis (ST) >5cm in length, approximately 20% have a concomitant DVT and 4% have a PE
Some patients with ST may be candidates for anticoagulation

Anatomy review:

Lower extremity:
- Superficial venous system: primarily comprised of the greater and lesser saphenous veins (aka long and short saphenous veins)
- Deep venous system: anterior tibial, peroneal and femoral veins.
- The saphenofemoral junction (SFJ) forms the connection between the deep and superficial systems.
Upper extremity:
- Superficial: digital, metacarpal, cephalic, basilic and median veins
- Deep: radial, ulnar, brachial, axillary, subclavian veins

Figure 2 Source

Figure 3 Source

Risk Factors:

The same as VTE! E.g. malignancy, trauma, hormone therapy, etc.
Varicose veins account for up to 90% of cases of lower limb ST and risk factors for varicose veins (e.g. lack of physical activity, venous stasis) increase the risk of ST.
Risk factors suggesting concomitant DVT when ST is also present: age >60, male sex, bilateral ST, presence of systemic infection, absence of varicose veins.
Mondor’s: often associated with breast reconstruction

History & Physical:

The patient may describe a painful, erythematous, swollen, hard vein that is tender to touch.
Inquire about symptoms and looks for signs suggestive of DVT, PE or secondary infection.
Low grade fever may be present in uncomplicated ST but higher fevers and erythema extending beyond the borders of the vein suggest suppurative ST.
Ask about risk factors as per VTE though may be idiopathic.
Note that a D-Dimer is not a helpful tool for distinguishing ST from DVT

Which patients with superficial thrombophlebitis require ultrasonography?

Lower limb:
- US recommended for MOST patients
- If clinical picture is not obvious
- If suspected concomitant DVT
- ST is above the knee, especially if above mid-thigh
- ST is in the upper calf near perforating veins in the popliteal fossa
Upper limbs:
- Patients with ST of veins approaching the deep venous system (basilic, cephalic veins) that do not respond to conservative measures or have progression of their symptoms should undergo duplex US to evaluate for clot extension.
Mondor’s (anterior chest): US rarely required

Key points on ultrasound report:

For lower extremities, assess proximity to the saphenofemoral junction (SFJ) and the length of the ST. Specifically determine if ST is >5cm in length or if <3cm proximity to the SFJ.
Rule out DVT
Rule out other causes of pain (e.g. popliteal cyst, muscle mass)

Treatment:

General measures:
- Non-pharmacologic
  - Elevate extremity
  - Apply continuous, moist heat x72 hrs
  - Remove any offending solution or catheter
  - Encourage early mobility
- Pharmacologic
  - Tylenol, NSAIDs
  - Topical NSAIDs
  - Do not give antibiotics unless signs of infection.
Upper extremity ST
- Anticoagulation?
  - Limited data to guide management!
  - Some experts would suggest consideration of anticoagulation for patients with ST that are at risk for DVT (e.g. ST in veins in close proximity to deep veins).
  - May consider anticoagulation for pts with persistent symptoms despite conservative mgmt. (e.g. ongoing excessive pain and swelling) as anticoagulation is effective in alleviating symptoms, especially if ST precipitated by malignancy.
  - However, when considering treatment, important to note that PE from upper extremity ST is rare!

Mondor’s (chest well) ST
- Self-limited. Conservative management.

Lower limb ST (see algorithm below):
- ST within 3 cm of saphenofemoral junction: therapeutic dose of anticoagulation for 3 months
  - g.: rivaroxaban 15mg PO BID x3 weeks, followed by 20 mg OD, warfarin, full dose LMWH
- ST >/5cm in length but >3 cm from saphenofemoral junction: prophylactic doses of anticoagulation
  - g.: rivaroxaban 10mg PO OD, dalteparin 5,000U SC q24hrs
- ST <5cm, >3 cm from saphenofemoral junction but with severe symptoms or risk factors for extension: prophylactic doses of anticoagulant for up to 45 days
- ST <5cm, >3cm from saphenofemoral junction, no severe symptoms or risk factors: conservative treatment

Figure 4 Approach to lower limb superficial thrombophlebitis. Source: Thrombosis Canada

Disposition & Prognosis:

Patients with extensive or recurrent ST should be referred to a specialist
Isolated lower limb uncomplicated ST not affecting the great or small saphenous veins and no risk factors for DVT: organize repeat clinical examination in 7-10 days to assess for resolution or progression. If symptoms or exam worsens, order ultrasound.
Resolution of ST may take up to 2-6 weeks.

Bottom Lines:

Superficial thrombophlebitis may be associated with DVT in up to 20% of cases and PE in up to 4%.
Ultrasound should be organized for most patients with lower limb ST and for some patients with upper extremity ST (progressive symptoms and concern for extension to deep venous system)
Patients with lower limb ST within 3 cm of the saphenofemoral junction should be treated with full dose anticoagulants. Those with ST >5 cm in length but farther from the SFJ, with severe symptoms or at high risk for clot extension should be treated with lower doses of anticoagulant.
Consider anticoagulants for patients with upper extremity ST with severe persistent symptoms not responding to conservative measures to alleviate their discomfort.
Patients with uncomplicated lower limb ST should have follow up organized within 7-10 days.

References:

Chopra, V. Uptodate. Catheter-related upper extremity venous thrombosis [internet]. 2019 Nov 14. Available from: https://www.uptodate.com/contents/catheter-related-upper-extremity-venous-thrombosis?search=Catheter%20related%20upper%20extremity%20venous%20thrombosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Scovell, S. Uptodate. Phlebitis and thrombosis of the superficial lower extremity veins [internet]. 2019 Oct 3. Available from: https://www.uptodate.com/contents/phlebitis-and-thrombosis-of-the-superficial-lower-extremity-veins?search=Phlebitis%20and%20thrombosis%20of%20the%20superficial%20lower%20extremity%20veins&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Thrombosis Canada. Superficial Thrombophlebitis, Superficial Vein Thrombosis [internet]. 2019 Mar 25. Available from: https://thrombosiscanada.ca/clinicalguides/?search=superficial%20thrombophlebitis#
Thrombosis Canada. Deep Vein Thrombosis (DVT): Treatment [internet]. 2016 May 19. Available from: http://thrombosiscanada.ca/wp-content/uploads/2016/05/3_Deep-Vein-Thrombosis-Treatment-2016May19-FINAL.pdf
Mustonen, P. EBM Guidelines. Superficial venous thrombophlebitis [internet]. 2020 Mar 16. Available from: https://www.ebm-guidelines.com/ebmg/ltk.free?p_artikkeli=ebm00920
Venes, D. Taber’s Medical Dictionary. Phlebitis [Internet]. Available from: https://www.tabers.com/tabersonline/view/Tabers-Dictionary/749144/all/phlebitis.

An approach to removing hair tourniquets

Posted on May 10, 2020 by Kavish Chandra

Getting out of a hairy situation – an approach to removing hair tourniquets

Resident Clinical Pearl (RCP) May 2020

Renee Amiro – PGY3 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. Kavish Chandra

A two-month-old male presents with his mother to the emergency department with two tightly wound hairs around his fourth and fifth toes. He is visibly upset and crying excessively. His mother says that his toes looked like this when he woke up this morning. He is otherwise well and has had his two-month immunizations.

His toes look like this:

Hair tourniquet syndrome

Definition – a tightly wound hair, thread, rubber band that is wrapped around an appendage and causes impaired blood flow.

Why this is bad – the constriction causes edema which restricts venous blood flow causes more edema which then impedes arterial blood flow and that can cause ischemia and if left undetected could cause amputation.

Most common appendages involved – Toes, external genitalia, fingers

Most common presenting symptom – excessively crying young child or swollen appendage found by mom or dad.

Management

Goal is to remove the restricting band ASAP!

Remember to treat pain! Using emla gel on the digit prior to any manipulation and use other analgesics as you deem appropriate. Remember the use of sugar for pain management in babies.

In all management types- ensure you have gotten all of the hair and have released the constricted band completely.

Try and unwind the hair!

Works best if caught early
You can use a cutting suture needle to try and get underneath the hair and release it.

Depilatory Cream

Apply Nair to the affected toe and allow 2-8 minutes to see if the hair dissolves.
Should not be used on open wounds and can cause skin irritation.
Does not dissolve cotton, polyester or rayon threads.

Dorsal Slit Procedure (for digits)

Do a slit on the dorsal surface along the long axis of the digit through the area of constriction down to the bone to ensure release of tourniquet.
Lateral aspect contains nerves and blood vessels and should be avoided. You may cut the tendon doing a dorsal slit along the long axis- but you won’t affect function of the digit.
Ensure that the patient has close follow up to ensure healing and complete resolution of the tourniquet.

The bottom line

Think of this diagnosis and LOOK for it in a young child brought to the ED with “excessive crying”
Ensure adequate pain management prior any invasive removal of the tourniquet.
Move quickly down the list to the dorsal slit procedure (for digit) if deeply embedded hair with significant edema or tissue compromise.

Copyedited by Kavish Chandra

References

Lin, Michelle 2012. https://www.aliem.com/trick-of-trade-hair-tourniquet-release/

Fox, Sean 2015. https://pedemmorsels.com/hair-tourniquet/

Modified Valsalva maneuver in the treatment of SVT – REVERT Trial

Posted on February 25, 2020 by David Lewis

Falling heels over head: you make my heart skip a beat

Resident Clinical Pearl (RCP) November 2019

Patricia Marks – PGY1 (FRCPC) Dalhousie University, Halifax, NS

Reviewed by Dr David Lewis

Introduction:

Supraventricular tachycardias (SVT) is a common presentation to the emergency room, and most patients will require treatment with adenosine or electrical cardioversion, as vagal maneuvers are less than 20% of the time in clinical practice. Adenosine and electrical cardioversion both require additional hospital resources, and adenosine is poorly tolerated by patients.

The REVERT trial published in 2015 in the Lancet by Appelboam et al. proposed a modified Valsalva maneuver in the treatment of SVT. The study was a multicentre randomized control trial in England involving 433 patients with stable SVT. According to an intention to treat analysis, the authors found a 43% success rate of conversion to sinus rhythm with the modified Valsalva maneuver compared to 17% with standard Valsalva. No significant dangerous adverse effects occurred in this study.

Modified Valsalva: The How-To

Patient identification:
1. Is my patient eligible for Valsalva?
  - Stable SVT
  - Age > 18 years
  - Able to perform Valsalva
  - Able to lie flat and have legs lifted
2. Contraindications:
  - Unstable or indication for immediate cardioversion
  - Atrial fibrillation, atrial flutter, sinus tachycardia
  - Recent MI
  - Aortic stenosis
  - Glaucoma
  - Retinopathy
  - Third trimester of pregnancy
Materials
- - 10cc syringe
  - Manometer (optional)
Performing the modified Valsalva maneuver
1. Position the patient in a semi-recumbent position (45º)
2. Instruct the patient to blow into the tip of a 10cc syringe for 15 seconds. The patient should be targeting a pressure reading on the manometer of 40mmHg, or blowing hard enough to move the plunger tip*
3. Lower the patient flat and passively raise their legs to a 45º angle for 15 seconds
4. Return the patient to a semi-recumbent position for an additional 45 seconds
5. Assess the rhythm
6. Repeat x1 if unsuccessful before moving on to adenosine or electrical cardioversion (provided the patient remains stable)

*The REVERT trial used a manometer to measure 40mmHg of pressure, however Smith and Boyle have demonstrated that 40mmHg of pressure is generated when a patient is instructed to blow into a 10cc syringe until the plunger moves

Image obtained from https://www.ecgmedicaltraining.com/wp-content/uploads/2016/06/REVERT-Trial-SVT.jpg on February 21, 2020.

Watch the REVERT authors perform the maneuver:

Benefits of this method:

Easy to instruct patients; can try at home
Higher success rate than standard Valsalva
Similar ED length of stay compared to standard Valsalva
Less patients require adenosine or cardioversion

Additional considerations

No formal studies exist for pediatric patients, however a recent case report by Rayburn and Wagers did demonstrate successful conversion to sinus rhythm with this maneuver

Bottom Line

In adults with stable SVT, the modified Valsalva maneuver as published in the REVERT trial achieves a high rate of conversion to sinus rhythm with a NNT of 3.8 and without significant adverse effects. In patients without contraindications, the modified Valsalva maneuver is a low-cost and easy to teach strategy that should be trialled to convert patients in SVT prior to adenosine or electrical cardioversion.

References

Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, Lobban T, Dayer M, Vickery J, Benger J; REVERT trial collaborators. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 Oct 31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4.
Rayburn D, Wagers B. Modified Valsalva Maneuver for Pediatric Supraventricular Tachycardia. Pediatr Emerg Care. 2020 Jan;36(1):e8-e9. doi: 10.1097/PEC.0000000000002023
Smith G, Boyle MJ. The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre. Emerg Med Australas. 2009 Dec;21(6):449-54. doi: 10.1111/j.1742-6723.2009.01228.x
Smith GD, Fry MM, Taylor D, Morgans A, Cantwell K. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD009502. DOI: 10.1002/14651858.CD009502.pub3

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

Reviewed by Dr. Kavish Chandra

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