Resident Clinical Pearl: Arterial bleeding

Approach to Arterial Bleeding in the Upper Extremity

Resident Clinical Pearl (RCP) – November 2018

Tara DahnCCFP-EM PGY3, Dalhousie University, Halifax NS

Reviewed by Dr. David Lewis

This post was copyedited by Dr. Mandy Peach

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

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

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

Approach to arterial bleeding in upper extremity

Life over limb

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

 

Determine if arterial bleeding/injury exists

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

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

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

Consider vessel injured

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

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

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

Examine distal extremity well.

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

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

Explore wound carefully

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

Control bleeding definitively

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

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

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

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

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

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

 

Approach for our case

Life over limb

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

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

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

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

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

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

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

 

References:

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

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

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

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

Life in the Fast Lane: Extremity arterial injury

Tinntinalli’s Emergency Medicine

 

This post was copyedited by Dr. Mandy Peach

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Improving the economy, and our health with one simple action – reading.

Improving the health and the wealth of the population can seem like a complex, almost impossible, task for governments. It may therefore seem somewhat surprising that a single inexpensive intervention could make a major impact on both. Believe it or not, the number of hours a child reads when young could significantly impact their health and wealth later in life, and also improve the economy.

Indeed, it seems that simply by ensuring kids read more before they start school, and most certainly in the early years at school, the economy and the lives of citizens could be impacted significantly for the better. How so?

In New Brunswick (NB), our students preform reasonably well on reading and mathematics when compared to other countries. NB reading scores for 15 year olds (PISA 2016) are just above the OECD average of 493 points at 505. However, they lag behind the rest of Canada, where the average score was 527 points. A similar pattern is seen with GDP, with New Brunswick showing a GDP per capita of CAN$45,187 (US$35,375) in 2016, compared with Canada at CAN$56,129 (US$43,938), and international rates as high as US$102,831 in Luxembourg (World Bank 2016).

Research from many countries has shown that the best predictor of future education achievement and life success regardless of socio-economic background is reading ability. And what is the best predictor of Grade 2 reading levels? That would be how much a child has read up to that age (Simplicity 2018). Not what they have read, just the total reading hours.

So the number of hours a child spends reading in their early years predicts their reading ability (learning to read), which in turn helps them read to learn through their school years. This in turn is associated with better earnings and better GDP per capita, which in turn is associated with improved health outcomes (Swift 2011).

So, if you want your child to be healthy, wealthy and wise, perhaps getting early to bed every day is important, but not before they have spent some time reading!

Let’s get our children reading early, and reading more!

 

 

 

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“Double double” yellow lines for improved road safety!

When it comes to reducing road deaths and injuries in New Brunswick, perhaps we should be inspired by Voltaire to avoid letting “the perfect be the enemy of the good.” Most serious collisions on our roads result from a combination of problems with road conditions, human factors, technology, and chance. While public safety campaigns and legislation try to affect many of the human factors by highlighting the dangers of distracted driving, intoxication (a subject for another day), and speed; and car manufacturers continue to improve vehicle safety; there is strong evidence that as a society, through improved regulations, we can also save lives by simple changes to road conditions and layout.

According to the world report on road traffic injury prevention, the Dutch policy of sustainable safety divides roads into one of three types according to their function, and then sets speed limits and driving conditions accordingly. These categories are Flow Roads; Distributor Roads; and Residential Roads. For Residential Roads, the needs of non-motorized users take priority, with the use of sidewalks, cycle lanes, crosswalks and slow speed limits. Distributor Roads carry traffic to and from large urban districts, and give equal importance to motorized and non-motorized local traffic, but separate users wherever possible, with variable speed limits. Flow Roads, or arterial roads and highways, are designed to allow through-traffic to go from the place of departure to the destination without interruption. Speed limits are higher, and there should be complete separation of traffic streams. It is on this last point that we in New Brunswick often fail.

While we are fortunate to have many kilometres of twinned highways, we also have several medium volume undivided Arterial Highways such as routes 7 and 11, to name two. And this is where we should consider Voltaire’s observation. We cannot afford to twin all our arterial roads, however we can afford to modify high-risk areas to minimize the chances of major collisions occurring.

If roads did not exist, and we were to ask an engineer to design a safe road for two-way traffic, how likely is it that they would deliberately place oncoming traffic,a mixture of family vehicles and large commercial trucks, heading towards each other at combined speeds of over 200kph separated only by a thin yellow line, encouraging, in places, faster traffic to move into the apposing lane, directly facing oncoming traffic, to pass slower vehicles? Unlikely! So now that we know better, with strong evidence to back up what is essentially good common sense, can we not introduce some simple low cost measures to improve safety?

 

We saw how the government acted quickly to enact “Ellen’s Law” legislating a minimum passing distance of one metre for cars passing cyclists. Should we not consider similar principles for oncoming traffic – perhaps widening the central yellow line to a one metre wide “painted barrier” on fast arterial roads? Kind of like a “double double” yellow line! The addition of central rumble strips to such a widened median, and the erection of central median barriers in high risk areas, with safe passing zones, are all much lower cost interventions than twinning every kilometer of our road network – the perfect solution that will never happen, yet the idea of which stops us implementing other solutions that could save lives. Let’s stop the perfect becoming the enemy of the good when it comes to road safety.

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Is CT-defined obstruction a predictor of urological intervention in emergency department patients presenting with renal colic?

Larger proximal ureteral stones with severe pain, rather than ureteral obstruction, are associated with urological intervention [excerpt]

…According to the latest Canadian Urological Association guidelines for management of ureteral stones, patients presenting with ureteral stones <5 mm could be managed conservatively, provided that they don’t have infectious symptoms, intolerable pain, or a threat to renal function.1 When urological intervention is contemplated, the decision-making process takes into account patient- related factors (intolerable pain, infectious complications, impending renal failure, coagulopathies and renal anomalies including solitary kidney); and stone-related factors (stone size, location, density, and skin-to-stone distance). However, signs of ureteral obstruction on computed tomography (CT) are not part of the guidelines.

In their study, Massaro et al performed a retrospective review of 195 patients presenting with ureteral stones at a tertiary Canadian centre [@SJRHEM] between 2011 and 2013.2 Forty-two per- cent of the patients presenting with ureteral stones underwent urological intervention, including cystoscopy with retrograde pyelography, placement of ureteric stent, shockwave lithotrip- sy, and/or ureteroscopic laser lithotripsy. A radiologist and a urologist independently reviewed all CT scans for prede ned criteria of ureteral obstruction (no obstruction, partial, or com- plete obstruction) based on degree of hydronephrosis, hydro- ureter, nephromegaly, and perinephric stranding. In addition, the authors examined other potential predictors for interven- tion, including patient demographics, stone size and location, amount of analgesics used, signs and symptoms of infection, serum creatinine, cumulative intravenous uid administered, and the prescription of medical expulsive therapy.

Not surprisingly, the authors found that stone size and location, in addition to cumulative opioid dose, were independent predictors for urological intervention. In fact, every mm increase in stone size increased the likelihood of intervention 2.2 times (odds ratio [OR] 2.17; 95%  [CI] 1.67‒2.85). The OR exceeded unity for stones larger than 4.5 mm, indicating higher likelihood of urological intervention for stones larger than 4.5 mm. Similarly, proximal stones were 4.7 times more likely to require intervention than distal stones (OR 0.21; 95% CI 0.09‒0.49). Finally, every 10 mg increase in morphine administered was associated with a 30% increase in the odds of intervention (OR 1.30; 95% CI 1.07‒1.58). However, degree of obstruction was not an independent predictor of intervention for ureteral stones (OR 1.757; 95% CI 0.899‒3.436). Finally, none of the variables predicted 30-day return to the emergency department (ED). This could be explained by the very low number of returns to the ED in both groups.

Despite its retrospective nature, this study con rms previ- ous studies that ureteral stone size (>4.5 mm), proximal loca- tion, and intractable pain requiring higher doses of opioids are associated with urological intervention. Furthermore, the degree of ureteral obstruction on CT scans did not pre- dict intervention. While CT scan ndings of hydronephrosis, hydroureter, nephromegaly, and perinephric stranding are helpful in diagnosing ureteral stones, they are not helpful in guiding the decision-making process for intervention.

Sero Andonian, MD, MSc, FRCSC, FACS; Associate Professor of Urology, McGill University, Montreal, QC, Canada

Cite as: Can Urol Assoc J 2017;11(3-4):93. http://dx.doi.org/10.5489/cuaj.4511

References

  1. Ordon M, Andonian S, Blew B, et al. CUA guideline: Management of ureteral calculi. Can Urol Assoc J 2015;9(11-12):E837-51. https://doi.org/10.5489/cuaj.3483
  2. Massaro PA, Kanji A, Atkinson P, et al. Is computed tomography-de ned obstruction a predictor of urological intervention in emergency department patients presenting with renal colic? Can Urol Assoc J 2017;11(3-4):88-92. http://dx.doi.org/10.5489/cuaj.4143

Read the @SJRHEM paper here…

Download (PDF, 268KB)

 

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“Bypass in a box” – Team ECMO takes first prize at Dragons’ Den Event

April 2017 – Team ECMO, lead by Drs. Paul Atkinson, Michael Howlett, Mark Tutschka, Jay Mekwan, and Mr. Bill O’Reilly, and representing Emergency Medicine, ICU and the NB Heart Centre, has been awarded the first prize of $75,000 to fund the initial phases of their proposed ECPR project. The team hopes to research the feasibility of introducing Extracorporeal CPR (“bypass in a box”) at the Saint John Regional Hospital.

https://www.telegraphjournal.com/greater-saint-john/story/100172219/dragons-den-saint-john-hopsital

 

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SHoC blog from @CanadiEM

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

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

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

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

References

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

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

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

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

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

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

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

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

Sonography in Hypotension and Cardiac Arrest: The SHoC Consensus Statement

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

CAEP Definition of an Emergency Physician

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

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

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

CAEP Statement on the Importance of Emergency Medicine Certification in Canada

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

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

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

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

 

Read more from CAEP here.

 

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Allscripts (i3) Documents Filter

New Documents Filter for New Physicians All new physicians getting access to Allscripts will have a new filter available to them by default on their documents tab that pulls in just physician documents to make it easier to find those key documents (such as Operative Records, Discharge Summaries, etc).

For existing physicians, here is how to create a filter to help you to find Physician documents:

Download (PDF, 227KB)

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Congratulations to Dr. Luke Taylor – CAEP 2017 Resident Research Abstract Award

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

Congratulations to Dr. Luke Taylor and the rest of the team involved in the SHoC-ED1 research project. Luke’s research abstract has been selected by the Canadian Association of Emergency Medicine (CAEP) to win a CAEP2017 Resident Research Abstract Award. The announcement will be made in June at CAEP2017 in Whistler, BC.

 

On behalf of the CAEP Research Committee, I am pleased to congratulate you on winning a CAEP 2017 Resident Research Abstract Award, for your abstract titled “Does point of care ultrasound improve resuscitation markers in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 1) Study; an international randomized controlled trial.” Dr. Jeff Parry, CAEP Research Committee Chair.

Dr. Luke Taylor follows in the footsteps of Dr Kyle McGivery and Nicole Beckett who both won awards at CAEP 2016 in Quebec City.

Registration is now open for CAEP 2017 

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