RCP – Simplifying pharyngitis management

Simplifying pharyngitis management

Resident Clinical Pearl (RCP) – June 2018

Allyson Cornelis FMEM PGY1, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

The majority of pharyngitis cases are caused by viruses. For those attributed to bacterial sources, throat culture is the gold standard for confirmation and group A streptococcus is the main bacterial agent involved¹. For pharyngitis believed to be bacterial in nature, antibiotics are prescribed to reduce the risk of developing rheumatic fever, the duration of symptoms, and transmission to others. For cases where antibiotics are prescribed, the first line medication is penicillin, due to the low resistance of group A streptococcal bacteria to this group of medications. Commonly recommended regimens include:

Penicillin V

Pediatrics

  • 40 mg/kg/day (divided BID or TID) to a max of 750 mg x 10 days
  • 250 mg BID

Adults

  • 300mgTID x 10days or
  • 600mgBID x 10days or
  • 500mgBID x 10days

Amoxicillin

Pediatrics

  • 40 mg/kg/day (divided BID or TID) x 10 days to maximum of 1000 mg/day

Adults

  • 500 mg BID x 10 days

 

An alternative treatment regimen
Common antibiotic regimens require multiple doses per day. This can be difficult for compliance purposes, especially in pediatric patients who may not like to take medications due to the taste and where difficulty with administration of doses at school may be a concern. Recommendations in recent years have included an alternate dosing schedule which allows for a single dose of antibiotic daily for patients. Possible advantages of this approach are improved compliance due to single daily dosing as well as reduced cost for patients and their families. The recommendation is 50 mg/kg once daily to a maximum of 1000mg for 10 days and is appropriate for children > 3 years old and adults.

 

Bottom lineAmoxicillin 50 mg/kg once daily (max 1000 mg daily) is an acceptable alternative to multiple daily doses of penicillin or amoxicillin for treatment of Group-A streptococcal pharyngitis infections.

 

References:

1. Caglar D, Kwun R, Schuh A. Mouth and throat disorders in infants and children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, editors. Tininalli’s emergency medicine 8th ed. New York: McGraw- Hill; 2016

2. Rx files [Internet]. Pharyngitis: Management considerations; 2017 Mar [cited 2018 May 21]. Available from: http://www.rxfiles.ca/rxfiles/uploads/documents/ABX-Pharyngitis.pdf

3. CDC.gov [Internet]. Group A Streptococcal Disease: Pharyngitis; 2017 Sep 16 [cited 2018 May 21]. Availbale from: https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

4. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Circulation. 2009 March. 119: 1541-1551.

5. Shulman ST, Bisno AL, Cleg HW, Gerber MA, Kaplan E, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the infectious diseases society of America. Clin Infec Dis. 2012 Nov; 55(10): e86-e102. Available from: https://academic.oup.com/cid/article/55/10/e86/321183

6. Andrews M, Condren M. Once-daily amoxicillin for pharyngitis. J Pediatr Pharmacol Ther. 2010 Oct-Dec. 15(4): 244-248.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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SJRHEM @Calgary CAEP 2018

Congratulations to all our researchers presenting at CAEP Calgary 2018. This year we have had a total of 13 research abstracts accepted for either oral or poster presentation, 2 invited presentations and 1 track chair. We are also involved in a number of administrative, academic and research committee meetings across the conference.


Last years presentations (CAEP Whistler 2017) can be viewed here


Q-Code Link to this page

 

 

 

 

 

 


Download (PDF, 144KB)

 


 

Training first-responders to administer anaphylaxis publicly available epinephrine – a randomized study – Presenter – Robert Dunfield

Download (PDF, 1.08MB)

 


 

Emergency Critical Care Ultrasound (ECCU) paramedical course: A novel curriculum for training paramedics in ultrasound – Presenter – David Lewis

Download (PDF, 702KB)

 


 

Critical Dynamics Study of Burnout in Emergency Department Health Professionals in New Brunswick: Revisiting  5 years later – Presenter – Felix Zhou

Download (PDF, 585KB)

 


 

Do electrocardiogram rhythm findings predict cardiac activity during cardiac arrest? A SHoC series study. – Presenter – Paul Atkinson

Oral Research Presentation – Track 5 – Sunday May 27th 15:50hrs

 


 

Introduction of extracorporeal cardiopulmonary resuscitation (ECPR) into emergency care: a feasibility study – Presenter – Derek Rollo

Download (PDF, 673KB)

 


 

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

Download (PDF, 803KB)

 


 

Development of a predictive model for hospital admissions by utilizing frequencies of specific CEDIS presenting complaints – Presenter – David Lewis

Oral Research Presentation – Track 4 – Wednesday May 30th 12:45hrs

Admission Prediction


 

Changes in situational awareness of emergency teams in simulated trauma cases using an RSI checklist – Presenter – James French

Download (PDF, 937KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of surgical cricothyrotomy with 3-D printed surgical airway trainers – Presenter – James French

Download (PDF, 3.9MB)

 


 

How aware is safe enough? Situational Awareness is higher in safer teams doing simulated emergency airway cases – Presenter – James French

Download (PDF, 760KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of direct intubation with a bougie and airway manikins – James French

Download (PDF, 3.83MB)

 


 

Lung ultrasound – Presenter – Paul Atkinson

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

 


Design is Devine – Presenter – James French

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

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Congratulations @sjrhem resident researchers

Congratulations to Dr Mandy Peach, PGY2 in the EM/FM program, on her success in receiving the Doug Sinclair Top Resident Research Award at the Dalhousie University Emergency Medicine Research Day 2018 and also Top Project at the Dalhousie Saint John FM/EM Project/Research Day 2018. Mandy presented her research on Sonography in Hypotension (SHoC-ED) diagnoses and shock categories.

Well done Derek Rollo and Luke Taylor for their joint runners up position. Derek presented his work on the ECPR/ED-ECMO feasibility study, and Luke presented on Sonography in Hypotension (SHoC-ED) resuscitation markers.

 

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Congratulations to Dr. Kavish Chandra!

Congratulations to Dr. Kavish Chandra – recipient of the Iype/Wilfred Resident Award!

Dr. Chandra, a PGY3 in the Integrated Family Medicine/Emergency Medicine program, was one of 3 recipients of the prestigious Iype/Wilfred award. This is awarded annually by the New Brunswick Medical Society to residents who have demonstrated outstanding achievements during their residency training in New Brunswick. Recipients are recognized as being leaders in research and professionalism, and who do so while showing compassion and caring towards patients and colleagues.

This award will be presented to Dr. Chandra at the Celebration of Medicine ceremony hosted by the New Brunswick Medical Society on May 26, 2018.

Congratulations, Dr. Chandra!

Far right: Dr. Chandra in a simulation training session

 

This post was copy edited by Mandy Peach

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RCP – Regional anesthesia of the hand

Regional anesthesia of the hand: ultrasound-guided vs tumescent anesthesia

Resident Clinical Pearl (RCP) – February 2018

Sean Hurley Emergency Medicine PGY1 (FRCPC), Dalhousie University, Halifax, Nova Scotia

Reviewed by Dr. David Lewis

 

The goal of this resident clinical pearl is to discuss two different methods of achieving complete anesthesia of the hand. Hopefully, by the end of this article, you will have the knowledge to perform both methods in the emergency department. The first method is ultrasound (US)-guided nerve blocks of the ulnar, median, and radial nerves. The second method is the “tumescent anaesthesia” approach used by many hand surgeons around the world for wide-awake hand surgery, including local, local anesthetic guru and plastic surgeon, Dr. Donald Lalonde who provided many of the clinical pearls in this article.

 

Method 1:  Ultrasound-guided nerve block

In a recent article by Amini et al. (2016), 84% of 121 emergency medicine residency programs surveyed in the United States reported that US-guided nerve blocks are performed at their institution. Of the 16 different nerve blocks reported, forearm blocks were the most commonly performed (74%) (Table 1). The main indications for nerve blocks are outlined in Table 2 1.

Table 1 and 2 from Amini et al., 2016 1

 

Three major nerves, median, ulnar, and radial, provide sensory innervation of the hand (Figure 1). Each nerve needs to be blocked in a simple straightforward approach, which was shown to to be quick, safe and effective. After a 1-hour training session, residents, fellows, and staff emergency physicians had 100% success rate with no rescue anesthesia on 11 hand pathology patients presenting to the ED. The blocks were performed in a median time of 9 minutes with no complications 2.

 

Figure 1. Cutaenous innervation of the hand. https://www.nysora.com/wrist-block

 

Figure 2. Indications for different nerve blocks of the hand http://highlandultrasound.com/forearm-blocks/

 

Radial Nerve: Palpate the radial artery in the volar aspect of distal forearm then place the US probe over the artery in a transverse orientation. Move the probe proximally until you clearly identify the radial nerve (Figure 3), which is located at the radial aspect of the radial artery. Insert your needle using an in-line approach (Figure 4). Inject 5-10cc of 1% lidocaine with epinephrine until you can clearly see the nerve bathed in lidocaine.

Pearl: The radial nerve is often difficult to visualize in the forearm. The radial nerve is more easily visualized above the elbow along the spiral groove of the humerus. Place the probe in a transverse orientation along the lateral aspect of the humerus between the brachioradialis and brachialis muscles. This block is more proximal and will require longer time to peak anesthesia.

 

Ulnar nerve: Use the exact same 2-step approach but on the ulnar side of the forearm. The ulnar nerve is located at the ulnar aspect of the ulnar artery (Figure 3).

 

Median nerve: The median nerve lies between the palmaris longus and the flexor carpi radialis. Position the probe in the transverse plane over this location. Insert your needle from either side using an in-plane or out-of-plane approach

 

Pearl: the median nerve and the many tendons of the distal forearm can be difficult to distinguish. You can identify the nerve by tilting the probe, which causes the tendons to disappear, as the US waves are no longer reflected back to probe, while the median nerve fibers still reflect waves back to the probe. Alternatively, you can slide the probe proximally where the tendons transition to muscle fibers, allowing the median nerve to be easily distinguishable.

Pearl: The palmar cutaneous branch of the median nerve that supplies the thenar eminence branches off before the carpal tunnel. Make sure you move the probe proximally before blocking the nerve so you don’t miss this important sensory branch.

Pearl: The more local anesthetic, the better! Some resources recommend 3-5cc of 1% lidocaine per nerve. Why not use 10cc or more for each nerve? You will still be safely under 7mg/kg limit.

 

Figure 3. Ultrasound identification of the ulnar nerve (left), median nerve (middle), and radial nerve (right). (Figure from Liebemann et al, 2006) 2.

 

Figure 4. Ultrasound guided ulnar nerve block using an in-plane technique (Figure from Sohoni et al., 2016) 3.

 

Please see link to excellent descriptions and videos of ulnar, radial, and median US-guided nerve blocks in the ED. www.highlandultrasound.com/forearm-blocks/

 

Method 2: Tumescent anesthesia

Tumescent means “Swollen”. In relation to local anaesthesia, Dr. Lalonde provides the following definition in his textbook Wide-Awake Hand Surgery: “Injecting a large enough volume of local anesthetic that you can see it plump up the skin and feel its slightly firm consistency with your finger through the skin” 4. The tumescent anesthesia approach has been described in depth for a variety of hand surgeries 4-6.

Using a 10cc syringe, aim for the space directly between the median and ulnar nerve (figure 5 and Video 1).  As you puncture the skin, Inject 3-5cc in the subcutaneous space. This is critical to block superficial nerves in this region, including the palmar cutaneous branch of the median nerve. Then, move your needle >3-4mm deeper through the superficial fascia in the forearm compartment where the median and ulnar nerves reside. Inject the remainder of your 10cc syringe into this space. With a single poke, the ulnar and median nerve distributions should be completely anesthetized.

Now, all that remain are the superficial branches of radial nerves and the posterior interosseus nerve. The superficial branches of radial nerve lie over the anatomical snuffbox. Insert your needle within 1cm of your previously anesthetized skin and blow local anesthesia into the subcutaneous space as you slowly move your needle towards the radial aspect of the wrist until you have a tumescent area of local anesthesia over the snuffbox. For the PIN, which is primarily a motor branch of radial nerve but has some sensory contribution, palpate the distal radial ulnar joint  of the dorsal aspect of the wrist. The PIN runs along the interosseous membrane so the needle needs to pass through the deep fascia of the forearm. Inject another 5cc of lidocaine in this location.

 

Figure 5. Tumescent anesthesia of the median and ulnar nerve 5.

 

Video 1. Tumescent anesthesia of the hand (courtesy of S. Hurley).

 

Which approach is better?

No studies have directly compared the two approaches discussed in this article. A recent Cochrane review article reviewed compared US-guided vs. anatomical landmark technique vs. trans-arterial vs. peripheral nerve stimulation for lower and upper limb blocks by trained anaesthetists. They found US-guided had greater success rates, less conversions to general anesthetic, lower rates of parathesias and vascular puncture 7.

A recent small randomized control trial compared US-guided nerve blocks of the forearm to anatomical landmark-based technique and found 14 of 18 ultrasound-guided forearm blocks were successful, as opposed to 10 of 18 for the anatomical technique 3.

Pearl: The tumescent anesthesia technique blocks both smaller and larger nerves of the hand and will likely achieve faster anesthesia compared to nerve blocks of the ulnar, median, and radial nerve.  Expect up to an hour for the large nerve blocks to take full effect.

 

Conclusions

Both methods, US-Guided nerve blocks and tumescent anesthesia are safe, effective, and relatively easy options to achieve complete anesthesia of the hand. For both techniques, remember basic principles for minimizing pain during injection of local anaesthesia to optimize patient comfort and satisfaction 4-6.

 

References

  1. Amini R, Kartchner JZ, Nagdev A, Adhikari S. 2016. Ultrasound‐Guided nerve blocks in emergency medicine practice. Journal of Ultrasound in Medicine 35: 731-736.
  2. Liebmann O, Price D, Mills C, et al. 2006. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med 48: 558-562.
  3. Sohoni A, Nagdev A, Takhar S, Stone M. 2016. Forearm ultrasound-guided nerve blocks vs landmark-based wrist blocks for hand anesthesia in healthy volunteers. Am J Emerg Med 34: 730-734.
  4. Lalonde D. 2016. Wide awake hand surgery, CRC Press, Taylor & Francis Group. Boca Raton, FL.
  5. Lalonde DH. 2010. “Hole-in-one” local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 126: 1642-1644.
  6. Farhangkhoee H, Lalonde J, Lalonde DH. 2012. Teaching medical students and residents how to inject local anesthesia almost painlessly. Can J Plast Surg 20: 169-172.
  7. Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. 2015. Ultrasound guidance for upper and lower limb blocks. The Cochrane Library.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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RCP – Pediatric syncope: an investigative dilemma?

Pediatric syncope: an investigative dilemma??

Resident Clinical Pearl (RCP) – February 2018

Kalen Leech-Porter R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

The case

A 16 year old girl comes in by ambulance, after fainting while singing at church on a Sunday morning.  Her vitals are: HR 90, RR 16, Temp 36.5, BP 92/64. O2 Sat 99% on RA.  On arrival she is alert and looks well.  She explains that she stood up to sing, felt lightheaded and then, soon after, lost consciousness.  The paramedic lets you know witnesses say she turned ashen grey and sweaty, and was out for about 2 minutes.  She had some ‘seizure like activity for 10 seconds’ with a few twitches in different parts of her body.  The patient states she was fully recovered within a few minutes.  Family history is unremarkable, with no sudden early deaths.  Physical examination is also unremarkable.  The nurse rolls in an ECG machine to check her rhythm.

What investigations does she require?

 

Why It Matters?

Pediatric syncope is very common in the emergency setting, accounting for ~1 % of pediatric emergency visits.   Between 15 and 50% of children will have at least one syncopal event in their childhood (peaking in adolescence).  – It’s a common problem!

 

The problem?

Historically, working up pediatric syncope has varied widely.  ECG use has been routine and some centers have regularly ordered bloodwork, CTs and even EEGs.  This onslaught of testing has led to increased hospital costs, stressful false positives for patients and has not improved patient outcomes.  Plus, reading pediatric ECGs can be challenging – see the end of this pearl.

 

A potential solution

In 2017, the Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association published a position statement on an approach to pediatric syncope¹  Full Article – click here

A thorough history and physical can be sufficient in low risk patients – no investigations are required for many pediatric syncope presentations. 

Red flags

  • Lack of Prodrome: warm/clammy sensation, lightheaded ness, visual changes. Having a prodrome is the most important factor in benign syncope
  • Midexertional syncope; however post exertional syncope (having an opportunity to stop) is typically benign
  • Chest Pain preceding the event
  • Prolonged loss of consciousness
  • Family history of cardiovascular disease/sudden death
  • Syncope triggered by loud noise
  • New medications (QT prolonging drugs)
  • Abnormal physical exam – pathologic murmur, sternotomy scar, neurologic deficits

 Red herrings

  • Pallor is common in vasovagal events
  • Palpitations are common in vasovagal events (although evidence around this not robust)
  • Involuntary movement is also common in vasovagal syncope. Benign movements can be a muscle twitch to violent jerks of the whole body

 

Investigative Algorithm

Figure 1. Pediatric syncope investigative algorithm, adapted from Sanatani et al. (2017)

 

The Evidence

To create this position statement, the Canadian Cardiovascular Society (CCS) performed a literature review of 4307 references, ultimately including 231 articles for full-text review.

Most of the studies referred to in the article are retrospective reviews. Therefore, recommendations in the position statement were mostly graded as ‘Strong recommendation, low level of evidence’. I found the most compelling evidence against routine ECG was the statement: “The ECG was the only indicator of cardiac disease in 5 of 480 patients (1%) and causality could not be determined”.¹  However, they did not list a reference for this statement and I’m not sure what study they drew this conclusion from.  I do feel they make a compelling case against over investigation, but as in many areas of medicine, the evidence could be more robust.

 

Pediatric ECGs – how to interpret?

The nurse hands you the ECG, what features are worrisome on a pediatric ECG?

See following chart from the CCS¹

Figure 2. Pediatric ECG findings in syncope, adapted from Sanatani et al. (2017)

In summary, red light features should prompt an emergent cardiology referral. Yellow light features should prompt a non-urgent cardiology referral while green light features are normal variants and require no further work up.

 

Case Resolution

There were no red flags, arguably she requires no investigations, not even an ECG.   Of course, clinical acumen trumps guidelines, but at least you will be CCS endorsed if you chose to not do any further investigations.

 

References

  1. Sanatani, V. Chau, A. Fournier, A. Dixon, R. Blondin, R. Sheldon. Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association Position Statement on the Approach to Syncope in the Pediatric Patient. Canadian Journal of Cardiology. 2017; 33: 189-198.

 

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Great ideas and making things better

I heard Dr. Dylan Blacquiere speaking on the radio while driving home after one of those busy D2 shifts on Friday, and it really cheered me up to hear him describe how we all in Saint John are leading the way in managing acute stroke care. http://www.cbc.ca/player/play/1152508483846
From EMS, through Emergency Medicine, diagnostic and intervention radiology, internal medicine and neurology, Saint John Regional Hospital (probably more appropriately Saint John University Hospital) provides a world class service for stroke patients in New Brunswick.
This got me thinking about many of the other innovations and ideas that we continue to push forward locally, especially relating to emergency medicine, and how important it is not to let ourselves become disillusioned by busy shifts, perceived administrative inertia, perceived injustices, crowding and many of the negatives we face, and will likely continue to face for sometime.
To name but a few, we can be proud of the integrated STEMI program we have from EMS to Cath Lab, the Point of Care Ultrasound program that leads in this nationally and beyond, the new Trauma Team leadership program, the patient wellness initiatives such as the photography competition corridor that make things just a little brighter for patients, the regionally dominant and growing simulation program, the regional and local nursing education programs, the nationally unique and hugely popular 3 year EM residency program, the impact of our faculty on medical education at DMNB, the leading clinical care provided by a certified faculty of emergency physicians, our website, our multidisciplinary M&M and quality programs, many of the research initiatives underway including development of an ECMO/ECPR program with the NB Heart Centre, improving detection of domestic violence, innovations around tackling crowding, preventing staff burnout, better radiology requesting, encouraging exercise prescriptions, and much more.
I was particularly impressed how Dylan explained the integrative approach that was required to improve stroke care, and how that was achieved here. There are many other areas that we can also improve, innovate and lead in. Every day we see ways to make things better.
I hope that at this point in our department’s journey, we can continue to make the changes that matter, for patients, our departmental staff, physicians, nurses and support staff alike.
I encourage all of us to think of one area we can improve, to plan for change and for us all to support each other to achieve those improvements. Some of our residents are embarking on very interesting projects, such as designing early pregnancy clinic frameworks, models to improve performance under stress, and simulating EMS ECPR algorithms – all new innovations, not just chart reviews of what we are already doing. I encourage us all to support them, and others with these projects, and to begin to create innovation priorities for the department.
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New – Dal SJRHEM PoCUS Fellowship/Elective

The Dalhousie University (DU) Emergency Point of Care Ultrasound Elective and Fellowship Program at Saint John Regional Hospital (SJRH) with an optional up to 1 month placement in Pediatric PoCUS at the IWK Health Centre Pediatric Emergency Department

 

There are four primary components to the mini-fellowship and fellowship programs:

 

  1. Clinical: optimizing image acquisition and interpretation skills for both core and advanced emergency and point of care ultrasound applications
  2. Education: developing lecturing and teaching skills by developing an emergency ultrasound lecture portfolio and contributing to the program’s educational mission. Acquiring expertise at bedside ultrasound teaching and assessment.
  3. Administration: understanding the critical components required to run an emergency ultrasound program, set up and deliver educational events/courses and how to best utilize information technologies for image archiving, database management, and quality assurance.
  4. Research: understanding the state of emergency ultrasound research by participating in ultrasound journal club activities and developing an independent research project from its inception to publication.

 

For more information click here

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RCP – Wired shut: cutting jaw wires in an emergency

Wired shut: cutting jaw wires in an emergency

Resident Clinical Pearl (RCP) – January 2018

Kavish Chandra R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. Awdesh Chandra

 

It’s 0300 and you are on a solo night shift when a couple are rushed into the resuscitation bay by the triage nurse. The woman says that the man had his jaw “wired shut” three weeks ago and began retching an hour ago. Your suspicions are confirmed when you look at his mouth and see the image below:

Figure 1. Arch bars (green arrows) are used for mandibular fixation, adapted from Jones and Read (2006).

 

As your patient is being placed on cardiac and oxygen monitoring, you can see they are agitated and hypoxic. You ask yourself, how can I get access to their oropharynx and begin my resuscitation?

 

Background

Arch bars and intermaxillary fixation are placed after mandibular fractures. In Figure 1, the arch bars, horizontal bars indicated by the green arrow, are fixated by circumferential wires around the teeth.1 In order to fixate the mandible and maxilla, fixation wires (vertical wires indicated by the red arrow seen in Figure 2) bring together and upper and lower arch bars, effectively eliminating mouth opening.1

Figure 2. Intermaxillary fixation wires, vertical wires indicated by the red arrows. Adapted from Jones and Read (2006).

 

While it is standard procedure for dentists and oral surgeons to provide patients with wire cutters and instructions following intermaxillary fixation for emergencies, this may not be readily available in the emergency department when needed the most.

 

The materials required:

  1. A deep breath
  2. Wire cutters (or if not, heavy metal scissors)
  3. Hemostat or needle driver

 

The steps:

  1. Identify and cut the vertical fixation wire on one side of the twist as seen in Figure 2. This is similar to cutting a single interrupted suture.
  2. Pull on the twist with a hemostat or needle driver and pull the wire out. There are generally 2-4 fixation wires per each side that require cutting in order to open the mouth.
  3. In some instances, there may be heavy elastics vertically as well, pull and cut those as well.
  4. Proceed with the resuscitation as deemed necessary (airway access or allowing the patient to vomit)
  5. The dentist or oral surgeon can re-fixate the wires non-urgently after the emergency has passed

 

See the following links on how arch bars and intermaxillary fixating wires are placed (to get an understanding of where to cut to release the mandible)

  1. https://www.youtube.com/watch?v=RGp46yHoVag&feature=youtu.be (minute 14 and on for application of intermaxillary fixation wires)
  2. https://emcrit.org/racc/airway-decisions/

 

Pearl: consider having wire cutters as part of your difficult airway cart or kit

 

Bottom Line: intermaxillary fixation can pose a serious threat to a patient needing to vomit or one that requires emergency airway access. Be prepared to cut the right wires in order allow mouth opening.

 

References

(1) Jones TR, Read L. Emergent separation of arch bars. J Emerg Med 2006; 35(2):205-206.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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RCP – Elb-‘ow’! Does my patient with an elbow injury require an x-ray?

Elb-‘ow’! Does my patient with an elbow injury require an x-ray?

Resident Clinical Pearl (RCP) – December 2017

Allyson Cornelis R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Why should you care?

Trauma to the upper extremity can result in injury to the various components of the elbow joint and associated anatomical structures. Important neurovascular structures associated with the elbow joint are the brachial artery, radial artery, ulnar artery, median, radial, and ulnar nerve¹. Elbow injuries causing fracture increase the likelihood of neurovascular damage. If fractures are missed, this may result in further damage and complications including prolonged functional limitations to the joint, nerve damage causing distal functional decline, and potential vascular compromise to the limb more distal to the injury.

Tintinalli’s Comprehensive Guide to Emergency Medicine.2

Functionally, the elbow has two primary movements: flexion/extension, and supination/pronation¹.

Fractures at the elbow may occur at the distal humerus (supracondylar, epicondylar, condylar, trochlea, and capitellum fractures), the proximal ulna (coronoid process, olecranon fractures), and the proximal radius (radial head fractures)¹. Of these, radial head fractures are the most common. Common mechanisms for these injuries include falling on an outstretched hand and direct blows to the elbow.

 

How do I know if my patient requires an X-ray for their elbow pain?

There is a rule for that! The elbow extension rule!

Simply stated: If a patient with an elbow injury is able to fully extend their elbow, they are unlikely to have a fracture and do not require imaging³.

The “how to”:

  1. Provide analgesia to patients
  2. Have patient seated with supinated arms
  3. Have patient flex shoulder to 90 degrees
  4. Ask patient to fully extend elbow to either the point of locking or the same level of extension as contralateral side

Of course, no rule is perfect, and the patient should be reassessed later if the following occur

  • Can no longer fully straighten elbow
  • Pain is getting worse
  • Cannot use their arm as previous

The patient should have imaging at the current visit if:

  • Patient is unreliable for follow up
  • If olecranon fracture is possible

 

The evidence³

Of 1740 patients presenting within 72 hours of traumatic elbow injury, 31% had a fracture³. In adults with the ability to fully extend their elbow following trauma, there was a 2% chance they had a fracture. In adults unable to fully extend their elbow following trauma, there was a 48% chance they had a fracture.

In children able to fully extend their elbow following trauma, there was a 4% chance they have a fracture, and in children unable to fully extend their elbow following trauma, there was a 43% chance they had a fracture³.

 

Bottom LinePatients presenting with elbow trauma and an inability to extend their elbow fully require radiography. Those able to fully extend their elbow do not require imaging unless follow up is unreliable, an olecranon fracture is suspected. Caution should be exercised with assessment in children.

 


Addendum: 

Consider adding PoCUS to your clinical assessment of elbow injuries. Elbow joint effusions are very easily visualized. The presence of a joint effusion in a patient with elbow pain following trauma is a significant finding and warrants further investigation with radiography. Some studies have shown PoCUS to be more sensitive than x-ray in diagnosing occult elbow fractures.

 

Download (PDF, 2.87MB)

 


References

(1) Appleboam, A., Reuben, AD., Benger, JR., Beech, F., Dutson, J., Haig, S., Lloyd, G. (2008). Elbow extension test to rule out elbow fracture: Multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. British Medical Journal, 337:a2428.

(2) Tintinalli, JE. (2016). Cardiogenic Shock (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 1816-1817). New York: McGraw-Hill.

(3) Sheehan, SE., Dyer, GS., Sodickson, AD., Ketankumar, IP., Khurana, B. (2013). Traumatic elbow injuries: What the orthopedic surgeon wants to know. Radiographics, 33(3), 869-884.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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RCP – Animal Bites

Animal Bites

Resident Clinical Pearl (RCP) – November 2017

Renée Amiro, R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Mr. Stark brings in his 8-year-old adopted son, Jon Snow, to the emergency room on Christmas day. Jon had just received a puppy, Ghost, as a Christmas present that morning. Jon, who knows nothing (about raising puppies), was playing too rough with the pup and got a bite on his right hand.

How do we appropriately manage this animal bite in the emergency room?

Management

When a patient presents to the ED with an animal bite, the factors in management that need to be addressed are:

  1. How to properly care for the wound
  2. Is antibiotic prophylaxis needed?
  3. Does the wound require closure with sutures?
  4. When does a bite require surgical consultation?
  5. When should you worry about tetanus and rabies?

 

Caring for the wound

Managing an animal bite has much of the same principles of usual good wound care

  1. Control hemorrhage
  2. Preform a neurovascular assessment
  3. Clean the wound meticulously. This is very important in animal and human bites. To reduce the number of bacteria, the wound should be flushed with copious amounts of saline or water

Local anesthetic should be used to reduce pain and facilitate cleaning. The wound should also be inspected for foreign bodies. Bites overlying joints should be put through their entire range of motion (bone, tendon or joint capsule involvement). If you suspect a foreign body but can’t see it, get an x-ray.

Pearl: for puncture wounds (cats are the biggest perpetrators), the same principles of wound care apply except superficially irrigate wounds and do not use high pressure

 

Is antibiotic prophylaxis needed?

Most bites to not require prophylactic antibiotics. There are some high-risk wounds that do. Those include:

  1. Deep puncture wounds (think cats)
  2. Associated crush injury
  3. Injury in areas overlying venous or lymphatic compromise
  4. Primary closure of the wound
  5. Wounds on hands, genitals or overlying joints
  6. Host factors: immunocompromised, diabetes

Table of prophylactic antibiotic choices. Duration of therapy depends on the antibiotic choice.

Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

Does the wound requires closure with sutures

Generally, no, especially if cats are the perpetrators. But if cosmetic concerns arise, wounds should meet all the following criteria before primary closure:

  1. Clinically uninfected
  2. < 12 hrs old (<24 hrs on the face)
  3. NOT located on the hand or the foot

The wound should NOT be closed primarily if the following criteria are met:

  1. Crush injuries
  2. Hand and foot wounds
  3. Deep puncture wounds
  4. Cat or human wounds
  5. Immunocompromised host
  6. >12 hrs old

 

When does a bite require surgical consultation?

If the injury results in complex facial wounds, neurovascular compromise, osteomyelitis or joint infection or deep wounds that penetrate underlying structures (joint, bone, tendon), get a surgical consultation.

That being said, consider consultation with any deep wound on the hand.

 

When do I worry about tetanus and rabies prophylaxis?

When considering tetanus prophylaxis, the decision to intervene is the same in non-bite wounds.

   Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

For rabies, post-exposure prophylaxis is generally not needed in patients with a dog or cat bite as long as the animal is not showing signs of rabies: dysphagia, abnormal behaviour, paralysis, seizures and ataxia.

Ellis and Ellis. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

Bottom Line: Animal bites, like other wounds, require regular wound care with a focus on meticulous cleaning. Cat bites usually need prophylactic antibiotics, dogs usually do not. All immunocompromised hosts get prophylactic antibiotics

 

References

  1. Baddour, L. and Sexton, D. Soft tissue infections due to dog and cat bites. Retrieved from https://www.uptodate.com/contents/soft-tissue-infections-due-to-dog-and-cat-bites. Accessed August 1, 2017.
  2. Callaham, M. Controversies in antibiotic choices for bite wounds. Ann Emerg Med 1988; 17:1321.
  3. Ellis, R. and Ellis, C. Am Fam Physician. 2014 Aug 15;90(4):239-243.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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SJRHEM Journal Club Report Oct 2017

SJRHEM Journal Club Report Oct 2017

Allyson Cornelis, R1 iFMEM

Hosted by Dr Andrew Lohoar


Abstract:

Idarucizumab for Dabigatran Reversal — Full Cohort Analysis

Charles V. Pollack, Jr., M.D., Paul A. Reilly, Ph.D., Joanne van Ryn, Ph.D., John W. Eikelboom, M.B., B.S., Stephan Glund, Ph.D., Richard A. Bernstein, M.D., Ph.D., Robert Dubiel, Pharm.D., Menno V. Huisman, M.D., Ph.D., Elaine M. Hylek, M.D., Chak-Wah Kam, M.D., Pieter W. Kamphuisen, M.D., Ph.D., Jörg Kreuzer, M.D., Jerrold H. Levy, M.D., Gordon Royle, M.D., Frank W. Sellke, M.D., Joachim Stangier, Ph.D., Thorsten Steiner, M.D., Peter Verhamme, M.D., Bushi Wang, Ph.D., Laura Young, M.D., and Jeffrey I. Weitz, M.D.

N Engl J Med 2017; 377:431-441August 3, 2017DOI: 10.1056/NEJMoa1707278

 

BACKGROUND
Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran.

METHODS
We performed a multicenter, prospective, open-label study to determine whether 5 g of intravenous idarucizumab would be able to reverse the anticoagulant effect of dabigatran in patients who had uncontrolled bleeding (group A) or were about to undergo an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the diluted thrombin time or ecarin clotting time. Secondary end points included the restoration of hemostasis and safety measures.

RESULTS
A total of 503 patients were enrolled: 301 in group A, and 202 in group B. The median maximum percentage reversal of dabigatran was 100% (95% confidence interval, 100 to 100), on the basis of either the diluted thrombin time or the ecarin clotting time. In group A, 137 patients (45.5%) presented with gastrointestinal bleeding and 98 (32.6%) presented with intracranial hemorrhage; among the patients who could be assessed, the median time to the cessation of bleeding was 2.5 hours. In group B, the median time to the initiation of the intended procedure was 1.6 hours; periprocedural hemostasis was assessed as normal in 93.4% of the patients, mildly abnormal in 5.1%, and moderately abnormal in 1.5%. At 90 days, thrombotic events had occurred in 6.3% of the patients in group A and in 7.4% in group B, and the mortality rate was 18.8% and 18.9%, respectively. There were no serious adverse safety signals.

CONCLUSIONS
In emergency situations, idarucizumab rapidly, durably, and safely reversed the anticoagulant effect of dabigatran. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.)

 

http://www.nejm.org/doi/full/10.1056/NEJMoa1707278

 


SJRHEM Journal Club Report

 

Download (PDF, 89KB)

 

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