COVID-19 – Saint John and New Brunswick

This post is provided as an information resource specifically for HealthCare Professionals within the Saint John Region and New Brunswick Emergency Departments

This post is updated regularly

SJRHEM COVID-19 Pages


COVID-19

New Brunswick Public Health – Link

Trauma New Brunswick Program

WorkSafe New Brunswick


Academic Activity – Dal, DMNB, Residents, News, Cancellations


Staff Wellness

 


What is COVID-19

  • A novel betacoronavirus first reported in Wuhan, China on December 31st 2019
  • Symptoms for the novel coronavirus are similar to those for influenza or other respiratory illnesses.
  • Current assumptions are that spread is via droplet and/or fomite to face
  • Infection Prevention and Control = Contact and Droplet precautions

COVID-19 – SOURCES OF INFORMATION

SJRHEM GRAND ROUNDS

 


 

How to Collect NP Swab

 

 


 

 

 

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SHoC Network – Sonography in Hypotension and Cardiac-Arrest

The Sonography in Hypotension and Cardiac-Arrest (SHoC) Network is an international group of clinicians and researchers committed to advancing the evidence around the use of Point of Care Ultrasound (PoCUS) in critically ill patients.

The group evolved from a research network established by the International Federation for Emergency Medicine (IFEM) Ultrasound Interest Group, involving several PoCUS leaders from several international emergency medicine organizations.

The SHoC Network has been instrumental in initiating several research projects, as well as producing clinical guidelines. Further details are shown below.

Publications

The SHoC-ED study 2018 (SHoC-ED1) Link  Download

The SHoC systematic review of PoCUS in cardiac arrest Link  Download

The IFEM SHoC Consensus guidelines Link  Download

The SHoC-ED3 study – PoCUS vs No PoCUS in cardiac arrest Link  Download

The SHoC-ED-ECG study – does ECG predict cardiac activity? Link  Download

The initial SHoC study – clinical basis for protocol development Link  Download

Current Projects

The SHoC-ED2 study – PoCUS and ECG in cardiac arrest

The SHoC systematic review of PoCUS in hypotension

IFEM Documents and links

SHoC Guidelines link

IFEM PoCUS curriculum link

Network members and contributors include:

Paul Atkinson (Chair; 1,2,3),
David Lewis (1,2,3),
James Milne (4), 
Hein Lamprecht (5),
Jacqueline Fraser (1),
James French (1,2,3),
Laura Diegelmann (5,6),  
Chau Pham (7),
Melanie Stander (5),
David Lussier (7),
Ryan Henneberry (8),  
Michael Howlett (1,2,3),
Jay Mekwan (1,2,3),
Brian Ramrattan (1,2,3) ,
Joanna Middleton (1,2,3),
Niel van Hoving (5),  
Mandy Peach (1),
Luke Taylor (1),  
Tara Dahn (8),
Sean Hurley (8),
K. MacSween (8),
Lucas Richardson (8),  
George Stoica (9),
Samuel Hunter (10),
Paul Olszynski (11),
Nicole Beckett (12),
Elizabeth Lalande (13),
Talia Burwash-Brennan (14), K. Burns (15),
Michael Lambert (15),
Bob Jarman (16),
Jim Connolly (16),
Ankona Banerjee(1),
Michael Woo (14),
Beatrice Hoffmann (17),
Brett Nelson (18),
Vicki Noble (19)
1.     Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada
2.     Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
3.     Emergency Medicine, Memorial University, NL, Canada
4.     Family Medicine, Fraser Health Authority, Vancouver, BC, Canada
5.     Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
6.    Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, USA
7.    Department of Emergency Medicine, University of Manitoba, Health Sciences Centre, Winnipeg, Manitoba, Canada
8.     Department of Emergency Medicine, Dalhousie University, QEII, Halifax, Nova Scotia, Canada
9.    Research Services, Horizon Health Network, Saint John Regional
Hospital, Saint John, New Brunswick, Canada
10. Faculty of Science, University of Ottawa, Ottawa, Ontario, Canada
11. Department of Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada
12. Department of Internal Medicine, Dalhousie University, Saint John
Regional Hospital, Saint John, New Brunswick, Canada
13. Department of Emergency Medicine, Université Laval, Québec, Québec, Canada
14. Department of Emergency Medicine, University of Ottawa, Canada
15. Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
16. Department of Emergency Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
17. Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, USA
18. Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, USA
19. Department of Emergency Medicine, Case Western Reserve University, University Hospital Cleveland Medical Center, USA
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“The Mother’s Kiss”

A Tool in Nasal Foreign Body Removal in Pediatric Patients

Melanie Johnston, PGY2 iFMEM Dalhousie University Saint John

Reviewed by Dr. Mandy Peach

 

Introduction:

The highest incidence of nasal foreign bodies is in pediatric patients, ages 2-5.1 The removal of nasal foreign bodies in the emergency department can be challenging.

The most common objects removed are beads, nuts, chalk, eraser heads, pebbles, and other small objects.1,2 While most nasal foreign bodies are benign, some objects can cause severe damage and need to be urgently removed.

The diagnosis of nasal foreign may be obvious as the caregiver may have witnessed the event and present acutely. Others may have delayed presentations of weeks-months after the child develops symptoms of nasal irritation/infection from the retained foreign body. In general, organic foreign bodies (flowers, plants, bugs) tend to be more irritating to the nasal mucosa and cause symptoms much earlier.2

 

Details on history and physical exam findings that should raise suspicion of a potential nasal foreign body in a paediatric patient include:

  • Witnessed insertion of foreign body
  • Unilateral foul-smelling purulent discharge
  • Mucosal erosions/ulceration

  • Unilateral epistaxis

  • Headache focused on the same side as the foreign body
  • Nasal obstruction
  • Mouth breathing2

 

Nasal foreign bodies have the potential to dislodge posteriorly and aspirate.1 Consider aspirated FB if new wheeze/cough/shortness of breath in a child with suspected intranasal FB and be prepared for a precipitous change in the airway. 6 

 

Nasal foreign bodies are most commonly located on the floor of the nasal passage under the inferior turbinate, or superiorly  in front of the middle turbinate.2

Foreign bodies are most frequently located on the right side, due to the right handed dominance of most children.2

Figure 1. Anatomy of the nose.3

 

Examination:

Ensure good lighting to be able to visualize the canal. Place the patient in a sniffing position with caregiver assistance (they may have to firmly hold child for cooperation). Suction should be readily available for nasal discharge and to aid in visualization. Nasal speculum can be used to aid visualization of the canal. Visualization of the foreign body confirms the diagnosis.

 

Figure 2. Marble nasal foreign body in pediatric patient.4

 

ENT referral is warranted if:


– Foreign body suspected, but unable to visualize by anterior rhinoscopy
– Impacted foreign body with marked inflammation (eg button batteries)
– Penetrating foreign body
– Any foreign body that cannot be removed due to poor cooperation, bleeding, or limited instrumentation2

 

Foreign Body Removal Options:

There are a number of techniques for nasal foreign body removal in the Emergency Department: alligator forceps, suction, balloon catheters, cyanoacrylate glue.2 Depending on the patient, these methods can be technically challenging if the patient is uncooperative, and may require the use of procedural sedation. A less invasive alternative for children not willing to cooperate with manipulation in the nasal canal is the Mothers’ Kiss.

 

Mothers’ Kiss Technique:

This technique was first described in the 1960s by a general practitioner in New Jersey and uses positive pressure to mobilize the foreign body from the nasal passage.1 It is effective in approximately 60% of attempts5, and generally most effective for smooth/soft foreign bodies that totally occlude the anterior nasal cavity.2 Even when not successful, it may improve visibility of the foreign body. Theoretical risks include barotrauma to both the tympanic membranes or pneumothorax, but these complications have never been reported.5 The pressure used by the caregiver to attempt expulsion of the foreign body is equivalent to that of a sneeze, approximately 60mmHg.1 The main danger in removing a foreign body from the nose is the risk of aspiration.

Procedure:5
1) Instruct the caregiver to place their mouth over the childs’ open mouth, forming a firm seal (similar to mouth-to-mouth resuscitation).
2) Next, occlude the unaffected nostril with a finger
3) The caregiver should blow until they feel resistance (caused by the closure of the childs’ glottis), then they should deliver a short puff of air into the childs’ mouth
4) The puff of air travels through the nasopharynx, and if successful results in the expulsion of the foreign body
5) If unsuccessful, the procedure can be repeated a number of times

Figure 3: Caregiver performing “Mother’s Kiss”. Shows occlusion of unaffected nare,
with seal formed around childs’ mouth.

 

 

If the caregiver is unable to perform the procedure, the approach can be recreated with a bag-valve-mask as the positive pressure source, ensuring the mask covers only the childs’ mouth.

Figure 4: Positive Pressure Ventilation with Bag-Valve-Mask.6

 

 

For a visual review of these techniques, please refer to the following videos:

“Mother’s Kiss”

 Positive Pressure Ventilation

 

Bottom Line:

Nasal foreign bodies are a common occurrence in the paediatric population. Their removal in the Emergency Department can be challenging as the patient may be fearful and non-cooperative. While there are a number of methods for removal of nasal foreign bodies, the “Mothers’ Kiss” technique provides a relatively non-invasive alternative. It has been shown to be effective in removal of 60% of nasal foreign bodies, and is most effective if foreign bodies are smooth and located in the anterior nasal cavity. If the caregiver is unable to perform the procedure, the approach can be recreated with BVM as the positive pressure source. The risks of this technique are minimal, and even when unsuccessful, can assist in improving the visualization of the nasal foreign body.

 

References:

  1. Cook, S., Burton, M., & Glasziou, P. (2012). Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(17), E904–E912. https://doi.org/10.1503/cmaj.111864

  2. Isaacson, G., Ojo, A. (2020). Diagnosis and management of intranasal foreign bodies. Up to Date. Retrieved from https://www.uptodate.com/contents/diagnosis-and-management-of-intranasal-foreign-bodies.

  3. Le, P. (2020). Anatomy, Head and Neck, Nasal Concha. Retrieved from: https://www.statpearls.com/ArticleLibrary/viewarticle/32550

  4. Nose-Foreign Body Nose, Dr Vaishali Sangole. Retrieved Oct 31,2020 from: http://vaishalisangole.com/NOSE_Foreign.html

  5. Glasziou, P., Bennett, J. (2013). Mothers’ kiss for nasal foreign bodies. Australian Family Physician, 42(5): https://www.racgp.org.au/afp/2013/may/mothers-kiss/.

  6. Thoreckzo. (2017). Foreign Bodies in the Head and Neck. Pediatric Emergency Playbook. Retrieved from: https://pemplaybook.org/podcast/foreign-bodies-in-the-head-and-neck/

  7. Pretel, M. Removing object from child’s nose using the kiss technique. Youtube- retrieved from: https://www.youtube.com/watch?v=RR3SxICqdAY.

  8. Dudas, R. Nasal foreign body removal. Youtube- retrieved from: https://www.youtube.com/watch?v=PacvHiJFhNA.

 

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Spontaneous Abortion

Medical Student Clinical Pearl

Miranda Lees, Clinical Clerk II

Dalhousie Medicine New Brunswick, Saint John

Reviewed by Dr. Mandy Peach

Case

A 21yo G3P1A1 female at 6 weeks gestation presented to the Emergency Department with an 8 hour history of vaginal bleeding and abdominal pain. The bleeding is a mixture of bright red and brown blood with no clots, and the abdominal pain is episodic cramping in her suprapubic region.

Her obstetrical history is significant for 2 prior pregnancies, the first of which was carried to term with an uncomplicated vaginal delivery, and the second of which had resulted in a spontaneous abortion at 6 weeks gestation. She is otherwise healthy. The patient noted with both prior pregnancies she had similar vaginal bleeding around 6-8 weeks gestation. She was given RhoGAM due to her Rh- blood type.

On assessment the patient appeared well with all vital signs within normal limits. On physical exam bowel sounds were present, the abdomen was tympanic to percussion, and pain on palpation was present in the patient’s suprapubic region.

 

Differential for life threatening causes of vaginal bleeding in pregnancy

<20 weeks gestation >20 weeks gestation
      ruptured ectopic pregnancy          placental abruption
       retained products of conception          placenta previa
       complication of termination          post partum hemorrhage

Other causes for vaginal bleeding to consider in pregnancy and in non-pregnant patients

Spontaneous abortion
Acute heavy menstrual bleeding
Genitourinary trauma
Uterine arteriovenous malformation
Ruptured ovarian cyst
Ovarian torsion
Pelvic Inflammatory Disease
Fibroids
Polyps
Foreign body
Coagulation disorder
Medication related
Gynecologic malignancy

 

Investigations

A βhCG was ordered to confirm pregnancy and bedside ultrasound was done to look for intrauterine pregnancy.

Transabdominal ultrasound showed the following:

The presence of a gestational sac within the uterus and a fetal heartbeat within the fetal pole confirmed a viable intrauterine pregnancy (IUP). The patient was diagnosed with threatened abortion.

 

Spontaneous Abortion-an overview

Spontaneous abortion is one of the most common complications of pregnancy, occurring in 17-22% of pregnancies2 and is defined as loss of pregnancy prior to 20 weeks gestation, occurring most often in the first trimester3. There are 3 primary causes: chromosomal abnormalities in the fetus, maternal anatomic abnormalities, and trauma.3

Risk factors for spontaneous abortion

age (below 20 and above 35)
moderate to severe bleeding (especially if passage of clots)
prior pregnancy loss
maternal comorbidities (DM, autoimmune conditions, obesity, thyroid disease)
infection (notably parvovirus, CMV and untreated syphilis)
teratogenic medications
maternal radiation exposure
maternal smoking
caffeine
alcohol use

 

Classification4

Missed abortion is characterized by an asymptomatic death of the fetus with a lack of contractions to push out the products of conception.5

Clinical presentation

Spontaneous abortion most commonly presents with vaginal bleeding and cramping, ranging from mild to severe1. However, most women with first-trimester bleeding will not undergo spontaneous abortion1. Bleeding associated with spontaneous abortion often involves passage of clots or fetal tissue, and the cramping can be constant or intermittent, often worse with passage of tissue1.

Diagnosis

Confirmation of spontaneous abortion requires pelvic ultrasound.

In patients with a prior ultrasound showing intrauterine pregnancy, diagnosis of spontaneous abortion can be made if a subsequent ultrasound shows no intrauterine pregnancy or a loss of previously-seen fetal heartbeat1.

In patients with a prior ultrasound showing intrauterine pregnancy with no fetal heartbeat, spontaneous abortion is diagnosed based on the following1:

  • A gestational sac >25mm in diameter containing no yolk sac or embryo
  • An embryo with crown rump length >7mm with no fetal cardiac activity
  • After pelvic ultrasound showing a gestational sac without a yolk sac, absence of embryo with a heartbeat in >2 weeks
  • After pelvic ultrasound showing a gestational sac with a yolk sac, absence of embryo with a heartbeat in >11 days

Case conclusion

The patient was treated with IM RhoGAM, a formal pelvic and transvaginal ultrasound was arranged for the next day, and she was discharged home. The follow-up ultrasound showed a gestational sac present in the uterus, an embryo with crown rump length of 8.1mm and the presence of a fetal heartbeat.

 

References

  1. Borhart D. Approach to the adult with vaginal bleeding in the Emergency Department. In: UptoDate, Hockberger R (Ed), UpToDate, Waltham, MA. (Accessed on October 8, 2020).
  2. Gracia C, Sammel M, Chittams J, Hummel A, Shaunik A, et al. Risk Factors for Spontaneous Abortion in Early Symptomatic First-Trimester Pregnancies. Obstetrics & Gynecology. 2005;106(5):993-999. doi 1097/01.AOG.0000183604.09922.e0.
  3. Prager, Mikes & Dalton. Pregnancy loss (miscarriage): Risk factors, etiology, clinical manisfestations, and diagnostic evaluation. In: UptoDate, Eckler (Ed), UptoDate, Waltham MA. (accessed Nov 28, 2020)
  4. Diaz. 2018. Types of Spontaneous Abortion. In: GrepMed. Image Based Medical Reference. https://www.grepmed.com/images/5425/classification-spontaneous-obstetrics-diagnosis-abortion-obgyn-types (Accessed Nov 28, 2020)
  5. Alves C, Rapp A. Spontaneous Abortion (Miscarriage) [Updated 2020 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560521/.

 

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Skin and Soft Tissue Infections: A PoCUS Guided Approach

Medical Student Clinical Pearl – November 2020

 

Robert Hanlon

@roberthanlon12

Year: 4
DMNB Class of 2021
 

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual

 


Case Report

A 25yr old male presents with a 3 day history of a red swollen foot following an insect bite. He has no past medical history. On examination there is some erythema and swelling on the dorsum of the left foot. Palpation is very tender.

You are aware of recommended guidelines that advise I&D for purulent infections and decide to proceed with the procedure. Despite trying to freeze the area with lidocaine, the procedure is still painful and no pus is drained. You point to the minimal serosanguinous exudate and sheepishly suggest to the patient that the I&D was successful and that a course of antibiotics will resolve this issue.


Skin and Soft Tissue Infections: A POCUS Guided Approach

Skin and soft tissue infections (SSTIs) have a variety of potential causes, ranging in severity from mild infections like cellulitis to abscess all the way to life-threatening causes like necrotizing fasciitis.1 SSTIs are commonly encountered in the emergency department, with cellulitis and abscesses being the two most common.2 It is important to be able to recognize SSTIs and provide appropriate treatment. Abscesses require invasive management, whereas cellulitis is treated with systemic therapies; therefore, it is important to be able distinguish the different between the two types. Doing so can be difficult because of the hidden nature of abscesses. However, ultrasound can be a useful tool in establishing the presence of an abscess. This article is a review of the clinical approach and treatment for SSTIs, focusing on cellulitis and abscesses, as well as the use of ultrasound in helping to establish the diagnosis.


Approach

Clinical suspicion is the initial step in the diagnosis of SSTIs. These infections have multiple causes; therefore, obtaining a detailed history is crucial. Information about immunocompromised state, place of residence, travel, any recent trauma or surgery, previous antimicrobial use, lifestyle, hobbies, and animal bites is essential to developing an adequate differential diagnosis.3

A good understanding of the normal skin flora and common infectious organisms is key to assessing SSTIs. The most commons organisms implicated in SSTIs are Staphylococcus aureus and Streptococcus species.4-6 Methicillin resistant S. aureus (MRSA) being an important strain that has increased in prevalence in the past 20 years. Risk factors such as presence of abscess, intravenous drug use, previous MRSA status, antibiotics within 8 weeks, diabetes mellitus, and previous hospital admission within the last year increase the likelihood of the infection being cause by MRSA.4-6

Physical examination findings are crucial for establishing the presence of an SSTI; the typical criteria are a superficial lesion with the classic inflammatory findings of redness (rubor), swelling (tumor), warmth (calor), and pain (dolor).1,2,7 An abscess is defined as a fluctuant mass of puss localized and buried within a tissue, organ, or potential space; however, clinically it can be hard to determine to presence of this mass.2,7 Other associated signs and symptoms, such as crepitus, bullae, and hemorrhage, may be present upon diagnosis or may develop later during the course.2,7 Due to overlapping clinical presentations of the different SSTIs, it can be difficult to differentiate between them.


Cellulitis – No Abscess
Cellulitis – Possible Abscess
Abscess
Early Abscess

Assessment with POCUS:

Due to the similarities between different SSTI cutaneous findings and their different treatments, it is important to establish if there is an abscess present. It was common, before the introduction of ultrasound, to perform a blind needle aspiration of the infected area in order to determine the presence/absence of an abscess.8,9 However, this subjects that patient to the risks of an invasive procedure as well as pain. On the other hand, treating infection with empiric antibiotics in the presence of an unknown abscess delays drainage and allows for potential worsening of the infection.8,9

A study by Tayal et al. demonstrated that the use of ultrasound was beneficial in patients who had both low and high pretest probability for needing incision and drainage. In patients suspected of having simple cellulitis (low pretest), ultrasound was used to change management in over half of participants; establishing the need for drainage due to imaging of a fluid collection. The opposite was true in the patients suspected of having an abscess (high pretest); the study found that ultrasound was able to determine that more than half of this group did not need drainage, because of the absence of a fluid collection on imaging.10 Other studies have had similar findings, but the percent change in management was slightly lower.11

A study by Barbic et al. demonstrated that POCUS provided a rapid, non-invasive, painless, and easily repeatable test, that distinguished between abscess and cellulitis in the vast majority of cases. Their analysis concluded that POCUS had a sensitivity of 96.2% and a specificity of 82.9% in diagnosing the presence of an abscess.12 They concluded that POCUS can accurately diagnose abscess in paediatric and adult populations and is likely superior to clinical examination.12


Cobblestones

Classic finding for cellulitis (but not specific to cellulitis). There will be hyperechoic lobules of subcutaneous fat surrounded by relatively hypoechoic inflammatory fluid.13

Cobblestone – Cellulitis

Purulent Fluid Collection

Classic finding for an abscess; have a rounded shape of anechoic or hypoechoic fluid collection, and there will be surrounding areas of cobblestones from the overlying cellulitis.13 As well, there should be no color flow if doppler is applied to the area (helping to distinguish from lymph node or vessel).14

Abscess – Anechoic Collection
Possible Abscess or Lymph Node? – This is a lymph node – see below
Colour flow differentiates lymph node from abscess

Necrotizing Fasciitis

Because you do not want to miss it! Findings via ‘STAFF’; subcutaneous thickening, air, and fascial fluid.14 Note, that ultrasound does not to exclude the diagnosis. Also need clinical correlation to increase suspicion of such a serious infection.15

Necrotizing Fasciitis – STAFF

Treatment:

According to The Infectious Diseases Society of America (2014) guidelines, management of SSTIs is differentiated based on the presence/absence of purulence (i.e. abscess/fluid collection). They recommend that all purulent infections be treated with incision and drainage, with more severe infections (signs of systemic involvement) being cultured with sensitivities in order to add antibiotics to the treatment.16 Otherwise, non-purulent infections are to be treated with systemic antibiotics; the severity of the infection determining the route and choice of agent.16

Antibiotic therapy, in addition to incision and drainage of a skin abscess, is suggested for patients with any of the following:17

  • Single abscess ≥2 cm or multiple abscesses
  • Large are of surrounding cellulitis
  • Patients with immunosuppression or other comorbidities
  • Signs of systemic involvement (fever > 38°C, hypotension, or tachycardia)
  • Poor clinical response to incision and drainage alone
  • Presence of an indwelling medical device
  • High risk for adverse outcomes with endocarditis (these include a history of infective endocarditis, presence of prosthetic valve or prosthetic perivalvular material, unrepaired congenital heart defect, or valvular dysfunction in a transplanted heart)
  • High risk for transmission of aureus to others (such as in athletes or military personnel)

 

Horizon Health’s local trends recommend the following (see guideline or Spectrum app for full details)

Severity of Infection

 

 

Antibiotic

Mild

Moderate

Severe

Cephalexin 500 – 1000mg PO q6h x 5 days

ceFAZolin 2 g IV q8h x 5 days

ceFAZolin 2 g IV q8h +/- Clindamycin 900 mg IV q8h

If true beta-lactam allergy

Cefuroxime 500 mg PO BID or TID x 5 days

Clindamycin 600-900 mg IV q8h x5 days

 

If MRSA suspected

Septra 800/160 mg or 1600/320 mg PO q12h x 5 days

Vancomycin 25-30 mg/kg IV once then 15mg/kg IV q8 to q12h x 5 days

ADD Vancomycin 25-30 mg/kg IV once then 15mg/kg IV q8 to q12h

 


Some research is suggesting that POCUS can take the assessment of abscesses one step-further and impact management based on the depth and size of the fluid collection seen in imaging. Russell et al. found that abscesses less than 0.4cm below the skin surface could be effectively treated without incision and drainage.18 Another study found that patients, with skin abscesses less than or equal to 5cm in diameter, treatment with oral antibiotics in combination with incision and drainage had improved short-term outcomes compared to those patients treated with the procedure alone.18 While as mentioned above, UpToDate, suggests that antibiotics be used in single abscess greater than 2 cm in size. As well, research has found that ultrasound guided incision and drainage provides lower failure rates (less recurrent infections or multiple incisions) compared to blind incision and drainage. Likely due to better visualization of the abscess and more adequate initial drainage.19


Limitations

There are some limitations to POCUS for SSTIs: ultrasound imaging and interpretation rely on the user’s ability to obtain high-quality images in order to assess whether an abscess is present. It is important for the user to be familiar with different findings on ultrasound to guide appropriate treatment. An abscess may appear hypoechoic, hyperechoic, or anechoic (depending on tissue contents), and usually has posterior acoustic enhancement.19 Determining if it is drainable can be difficult due to this variability in imaging, and it is also quite common for early abscesses to present like cellulitis with erythema, no fluctuance, and an ultrasound that is negative for a fluid collection.20 In cases of a suspected evolving abscess, sometimes referred to as a non-ripe abscess, supportive care, including warm compresses, pain control, and close follow-up, is recommended.20 The practitioner may treat this like cellulitis; however, the patient may return with perceived failure of therapy if discharge advice does not include the possibility of of an abscess forming over time.


Abscess examples from the SJ archives


References

  1. Moffarah AS, Al Mohajer M, Hurwitz BL, Armstrong DG. Skin and Soft Tissue Infections. Microbiol Spectr. 2016 Aug;4(4). doi: 10.1128/microbiolspec.DMIH2-0014-2015.

 

  1. Martinez, N. “Skin and Soft-Tissue Infections: Itʼs More Than Just Skin Deep.” Advanced Emergency Nursing Journal, vol. 42, no. 3, 2020, pp. 196–203.

 

  1. Cieri, B., Conway, E., Sellick, J., & Mergenhagen, K. (2019). Identification of risk factors for failure in patients with skin and soft tissue infections. The American Journal of Emergency Medicine, 37(1), 48-52.

 

  1. Borgundvaag, B., Ng, W., Rowe, B., Katz, K., Farrell, Brian, Guimont, Chantal, . . . Gregson, Dan. (2013). Prevalence of methicillin-resistant Staphylococcus aureus in skin and soft tissue infections in patients presenting to Canadian emergency departments. CJEM, 15(3), 141-160.

 

  1. Esposito, S., De Simone, G., Pan, A., Brambilla, P., Gattuso, G., Mastroianni, C., . . . Savalli, F. (2019). Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry. Journal of Chemotherapy (Florence), 31(1), 9-14.

 

  1. Stenstrom, R., Grafstein, E., Romney, M., Fahimi, J., Harris, D., Hunte, G., . . . Christenson, J. (2009). Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus skin and soft tissue infection in a Canadian emergency department. CJEM, 11(5), 430-8.

 

  1. Spelman, D., Baddour, LM. (2020). Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved November 11, 2020. From: https://www.uptodate.com/contents/cellulitis-and-skin-abscess-epidemiology-microbiology-clinical-manifestations-and-diagnosis?search=abscess%20treatment&topicRef=110530&source=see_link#H2443336514

 

  1. Comer, Amanda B. “Point-of-Care Ultrasound for Skin and Soft Tissue Infections.” Advanced Emergency Nursing Journal, vol. 40, no. 4, 2018, pp. 296–303.

 

  1. Gaspari, R., Sanseverino, A., & Gleeson, T. (2019). Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Annals of Emergency Medicine, 73(1), 1-7.

 

  1. Tayal, V., Hasan, N., Norton, H., & Tomaszewski, C. (2006). The Effect of Soft‐tissue Ultrasound on the Management of Cellulitis in the Emergency Department. Academic Emergency Medicine, 13(4), 384-388.

 

  1. Alsaawi, A., Alrajhi, K., Alshehri, A., Ababtain, A., & Alsolamy, S. (2017). Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: A systematic review of the literature. European Journal of Emergency Medicine, 24(3), 162-169.

 

  1. Barbic, D., Chenkin, J., Cho, D., Jelic, T., & Scheuermeyer, F. (2017). In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open, 7(1), E013688.

 

  1. Atkinson DP, Bowra J, Harris T, Jarman B, Lewis D, editors. Point of Care Ultrasound for Emergency Medicine and Resuscitation. Oxford University Press; 2019. pp. 140, 199-200.

 

  1. Gottlieb, M., Schmitz, G., Grock, A., & Mason, J. (2018). What to Do After You Cut: Recommendations for Abscess Management in the Emergency Setting. Annals of Emergency Medicine, 71(1), 31-33.

 

  1. Castleberg, E., Jenson, N., & Dinh, V. (2014). Diagnosis of necrotizing faciitis with bedside ultrasound: The STAFF Exam. The Western Journal of Emergency Medicine, 15(1), 111-113.

 

  1. Stevens, D., Bisno, A., Chambers, H., Dellinger, E., Goldstein, E., Gorbach, S., . . . Wade, J. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 59(2), 147-159.

 

  1. Spelman, D., Baddour, LM. (2020). Cellulitis and skin abscess in adults: treatment. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved November 11, 2020. From: https://www.uptodate.com/contents/cellulitis-and-skin-abscess-in-adults-treatment?search=abscess%20treatment&topicRef=110529&source=see_link

 

  1. Russell, F., Rutz, M., Rood, L., Mcgee, J., & Sarmiento, E. (2020). Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage. The Western Journal of Emergency Medicine, 21(2), 336-342.

 

  1. Gaspari, R., Sanseverino, A., & Gleeson, T. (2019). Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Annals of Emergency Medicine, 73(1), 1-7.

 

  1. Thornton J, Hellmich T. Evaluation and Management of Abscesses in the Emergency Department. Emergency Medicine Reports. 2017 May 1;38(10).
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CAEP Emergency Physician of the Year – Dr. David Lewis

A huge congratulations goes out to our very own Dr. David Lewis who is one of the recipients of 2020’s CAEP Emergency Physician of the Year! This is an annual award recognizing excellence in the specialty of emergency medicine and is awarded to a physician who has made outstanding contributions to the field in a number of areas including patient care, community service, healthcare administration and CAEP activities.

Dr. Lewis is an integral part of our emergency department as Assistant Clinical Departmental Head, Ultrasound Program Director, Informatics Lead and as a senior clinician. He has been actively involved with CAEP as a member of the planning committee, ultrasound committee and as Scientific Co-chair. Dr. Lewis continues to contribute to research as an editor with CJEM and as an active contributor to local projects. Last year he co-founded the PoCUS Fellowship program with the intentions of promoting the capabilities of PoCUS, and training fellows who will then carry on this knowledge in administering their own programs. Clinically, he is a seasoned member of the department with a wealth of experience and one committed to excellent patient care.

It comes as no surprise that Dr. Lewis has been awarded this honour – congratulations and SJRHEM is so happy to call you our own!

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EM Reflections October 2020 – Spinal Cord Injury

Big thanks to Dr. Joanna Middleton for leading the discussions in October

All cases are imaginary, but highlight learning points that have been identified as potential issues during rounds.

Edited by Dr. Mandy Peach


Spinal Cord Injury

  • Recognition of various patterns of spinal cord injury
  • Reviewing EMS record can be helpful for progression of symptoms and baseline exam
  • A normal CT does not rule out spinal cord injury in a patient with neurological deficits
  • Importance of detailed neurological exam and clear communication with consultant
  • Importance of clear documentation of exam – consider using ASIA

Case

A 72 yo female presents complaining of bilateral arm weakness ongoing for 1 day. She has no other symptoms concerning for stroke. She denies any direct trauma to head or neck, but did say she was pushed from behind by a large dog and her neck ‘snapped back’ the day prior. Incidentally she says she also hasn’t urinated in over 8 hours. Her vital signs are within normal limits.


 

You are concerned about a spinal cord injury – what are the various cord syndromes? What in the history predisposes to a particular spinal cord syndrome?

4 Classification of spinal cord syndromes

This woman is elderly, likely with underlying cervical spondylosis, and has a hyperextension injury – predisposing her to a central cord syndrome. This is the most common type of incomplete spinal cord injury. Often these patients are asymptomatic from their spondylosis before the event and the mechanism of injury is usually not severe5.

Central cord syndrome involves both motor and sensory pathways and has a variable presentation. Typically one sees motor weakness in the hands and forearms with sensory preservation. Bladder dysfunction and sexual dysfunction can be seen in severe cases5. A helpful mnemonic is MUD-E6.

 

MUD-E

  • Motor loss > sensory loss
  • UE > LE
  • Distal > proximal
  • Extension type injury

 

You complete a detailed neurological exam and find she does have upper limb weakness distally. A bladder scan confirms urinary retention with 850 cc of urine in her bladder.

You decide to order a CT C -spine to assess for bony injuries. The CT scan is unremarkable.

Does this rule out a spinal cord injury in this patient?

No – normal CT does not rule out SCI in a patient with ongoing neurological deficits. In fact, in elderly patients there is often no bony injury, but the narrowed spinal canal can predispose to buckling of the ligament flava, leading to injury of the spinal cord.

You review EMS notes and nursing documentation – there are subtle differences throughout in how the exam is performed and recorded.

What is one tool that can improve your documentation in terms of accuracy and clarity?

ASIA (American Spinal Injury Association) Classification

You document your findings on ASIA, which allows for clearer communication and documentation with the attending neurosurgeon.


 

References for further reading:

4 Perron & Huff (2010). Chapter 104 Spinal Cord Disorders. Rosen’s Emergency Medicine: Concepts and Clinical Practice. pp 1389-1397. Philadephia, PA

5  Douglas, Nowak et al. (2009). Review article: Central Cord Syndrome. Journal of the American Academy of Orthopedic Surgeons. 17: 756-765

6 A boring guide to spinal cord syndromes. CanadiamEM. https://canadiem.org/a-boring-guide-to-spinal-cord-syndromes/


 

Authored and Edited by Dr. Mandy Peach

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EM Reflections October 2020 – Acute Urinary Retention

Big thanks to Dr. Joanna Middleton for leading the discussions in October

All cases are imaginary, but highlight learning points that have been identified as potential issues during rounds.

Edited by Dr. Mandy Peach


 

Acute Urinary Retention (AUR)

  • Categorized as obstructive, infectious/inflammatory, neurological, medication related
  • Physical exam should include a DRE and neurological exam
  • Investigations should include a U/A +/- C&S, creatinine, electrolytes +/- CBC
  • Consider a renal US if any renal impairment
  • PSA – defer at least 2 weeks, as acute urinary retention can cause elevation
  • Consider risk factors for post-obstructive diuresis

Case

A 60 yo male presents to the emergency department with inability to void over 8 hours, despite feeling urgency. He complains of increasing lower abdominal discomfort. He denies any infectious symptoms or new medications. He denies any back pain or recent injury. He does have a history of hesitancy and poor urine stream. He has never had a prostate exam and has no family doctor. His vital signs are within normal limits. He has a significantly distended bladder on physical exam.


Indications to insert a catheter1:

  • Inability to pass urine > 10 hours
  • Abdominal discomfort with bladder distention
  • Signs of acute kidney injury secondary to obstruction
  • Infectious cause of retention
  • Overflow incontinence

You decide to insert a urinary catheter. What else should you consider as part of your physical exam?

Consider the 4 main causes of urinary retention:

In this male patient it is pertinent to do a prostate exam to check for enlargement as well as a thorough neurological exam.

On exam you palpate a large, firm prostate. You are suspicious of prostate cancer – do you do a prostate specific antigen (PSA)?

No – acute urinary retention can transiently elevate PSA measurements up to 2 fold, this can persist for up to 2 weeks2. Defer PSA testing until after this time.

The U/A is negative for infection. The electrolytes are normal but the patient has an acute AKI with an elevated creatinine. Does this patient require renal imaging?

Consider renal imaging in any patient with AUR and abnormal renal function to assess for anatomical cause.

2 hours has passed and you reassess the patient – 1L of urine has drained upon insertion. A minimal amount has been draining since. The post-void residual is now 20 cc.

Is this patient at risk of post-obstructive diuresis?

Risk factors:

  • Abnormal electrolytes or acute creatinine elevation
  • Volume overload
  • Uremic
  • Acutely confused

Although the patient does have an abnormal creatinine, clinically he does not show signs of post-obstructive diuresis which is defined as urinary output > 200 mL for at least 2 hours after urethral catheter insertion, or > 3L in 24hrs AFTER the initial emptying of the bladder. Patients with any risk factors for post-obstructive diuresis should be observed in the ED for 4 hours.

After an appropriate observation period you discharge the patient with an urgent referral to urology given the acute presentation and abnormal prostate exam. You are sending the patient home with an indwelling catheter.

What is the optimum duration of catheter insertion? Does this patient require antibiotics?

Trials are contradictory. Some found increased likelihood of spontaneous voiding after 7 days, while an observational study found improved success if insertion was less than 3 days3.

Expert opinion from urology suggests duration of 7 days to avoid risk of re-catheterization1.

Routine antibiotics are not recommended unless the cause is thought to be infectious. However, if prostatic enlargement is thought to be the cause an alpha-blocker like tamsulosin can be beneficial1

 


 

References for further reading:

1 Ep 143 Priapism and Urinary Retention: Nuances in Management. Emergency Medicine Cases. https://emergencymedicinecases.com/priapism-urinary-retention/

2 Aliasgari, Soleimani, Moghaddam (2005).The effect of acute urinary retention on serum prostate-specific antigen level. Urology journal. Spring 2005;2(2):89-92

3 Acute Urinary Retention. Uptodate. https://www.uptodate.com/contents/acute-urinary-retention?search=post%20obstructive%20diuresis&source=search_result&selectedTitle=1~5&usage_type=default&display_rank=1#H537553020


 

Authored and Edited by Dr. Mandy Peach

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Trauma Reflections – October 2020

Big thanks to Sue Benjamin for her efforts in putting these reviews together!

 

Major points of interest:

 

A) Kudos – Trauma Codes for qualifying cases has improved!

May – September 2020, for cases qualifying for trauma team activation, the rate of calling ‘Trauma Codes’ has improved to 84%. RN trauma note is 93% for the activations.

Many of the missed activations are transfers from peripheral sites

 Please review the attached updated simplified activation criteria – notable changes are:

1/ Removal of minor head injuries without signs or symptoms on anticoagulants under “D”

2/ Addition of pulseless extremity under “C”

 

B) Chest Tubes in trauma – 5 year review

Chest tubes are placed infrequently (~ 1 per month) in our departments.

Review of post procedure x-rays (thanks J ‘Mek1’) showed there was less than optimal tube positioning 60% of the time.

Tube position and function must be critically reviewed post procedure.

Chest tube discussion/demonstration with Dr Russell will take place at next Trauma case review  (January 2021)

C) Oh, that patient is just here for Plastics..

‘Distracting’ injuries are called that for a reason. It is hard to look past deformed limbs, but always perform a head to toe assessment (including FAST) to identify associated injuries to others systems.

Trauma transfers should be re-assessed by ED physician at receiving hospital, to also determine if there are any other concerning injuries that have been missed.

Trauma cases being transferred to consultants, outside of NB trauma line, should be identified by charge MD when taking report.

 

D) “Penetrating neck trauma is en route”

Those words will wake you up in a hurry.

Keys to management are early notification (pre-arrival) of consultants (ENT +/- vascular) and clear airway plans that include a ‘double set’ up for potential need for surgical airway.

 

E) What kind of monster would order a ‘Panscan’ on a child? 

One that can weigh the risks (missed injuries) vs. benefits (minimizing radiation exposure).

Panscans in pediatric patients should never be ordered routinely, but should be considered in cases with high risk for clinically significant multi-system injuries (head, spine, thorax, abdomen).

 

F) Blunt traumatic cardiac arrest

This population has a grave prognosis.

Airway management, continuous chest compressions, rapid fluid/blood resuscitation and consideration for procedural interventions (thoracostomies, pericardiocentesis) are usual steps in care.

Epinephrine has no role unless medical cause for arrest is suspected.

A more in-depth review will be topic of upcoming SJRH ED rounds.

 

G) What did this guy have for supper?

Pizza and beer, and lots of it.

Ducanto catheters – large bore suction catheters – are available on all airway carts in the top drawer. They are much more efficient at decontaminating airways soiled with semi-solid material when compared to Yankauer.

 

H) Updated Trauma checklist:

“SJRH ED Trauma Process Checklist” is in trauma note package in room 19 and is a very useful prompt (see below). K/ T- L spine Traumatic Spine Injury Guidelines also below.

Download (PDF, 98KB)

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A Case of Uveitis

Medical Student Clinical Pearl (RCP) October 2020

Ben McMullin, Clinical Clerk III

Dalhousie Medicine New Brunswick, Saint John

Reviewed by Dr. Mandy Peach

 

Case Presentation

A 40 year old female presented to the Emergency Department with a 5 day history of right sided eye pain. The pain came on insidiously and had gradually been worsening. She had gone to a walk in clinic 3 days prior to presenting to the ED, and was prescribed antibiotics. Her symptoms continued to worsen despite treatment.

In the emergency department, she denied any discharge, and claimed that her eye was not pruritic. She stated that her eye pain was photophobic, but denied any visual disturbances or changes. She did not have fever or chills.

On exam, she did not have any periorbital erythema or conjunctival injection. She did not have any discharge. Normal ocular movements were noted. Her pupils were equal and reactive to light. Her visual acuity was 20/20 in both eyes. Peripheral vision was normal bilaterally. On slit lamp exam, no foreign body or corneal abrasion was identified.

Ophthalmology was consulted emergently, and agreed to assess this patient the same day.

 

Differential Diagnosis

  • Conjunctivitis
  • Acute closed-angle glaucoma
  • Scleritis
  • Keratitis
  • Uveitis
  • Foreign body1

 

Definition

Uveitis refers to inflammation in the uvea, which is the middle portion of the eye. The uvea is made up of the iris and the ciliary body anteriorly, and the choroid posteriorly. Inflammation can be localized anteriorly, posteriorly, or can be generalized.1

Figure 1 : Anatomy of the eye. Rosenbaum, James. “Uveitis: etiology, clinical manifestations, and diagnosis” last modified August 31, 2020

Anterior uveitis can be acute or chronic, and the acute form is the most common form of uveitis. Posterior uveitis, affecting the retina and choroid, and intermediate uveitis, affecting the vitreous body, are less common.2 Uveitis can be classified by location, clinical course or side affected.

Table 1: Classification of uveitis. Muñoz-Fernández S, & Martín-Mola E. (2006). Uveitis. Best Practice & Research Clinical Rheumatology 2006; 20(3), 487-505.

 

Etiology

Approximately 30% of uveitis cases are idiopathic.1 However uveitis can be associated with many rheumatologic conditions such as spondylarthritis, juvenile idiopathic arthritis, psoriatic arthritis, as well as inflammatory bowel disease, multiple sclerosis, and sarcoidosis3. It can also arise from infectious sources such as cytomegalovirus, HSV, varicella zoster virus, lyme disease, syphilis, and tuberculosis, among others. Uveitis can also occur after trauma to the eye.1

 

Clinical Presentation

Anterior and posterior uveitis typically have different presentations.

In anterior inflammation, pain, photophobia, and redness are more commonly seen with a variation in the degree of vision loss (if any). On exam, one can see a ciliary flush where inflammation of the limbus results in redness next to the iris, but not in the periphery of the eye.

Figure 2:  Ciliary flush. https://commons.wikimedia.org/wiki/File:Ciliary-flush.jpg

Photophobia is consensual meaning shining a light in the unaffected eye causes pain in the affected eye due to pupillary constriction.7 On slit lamp examination one may see ‘cells and flare’ when looking at the anterior chamber  in the oblique view – the stereotypical ‘snowflakes in headlights’ appearance.

Figure 3: Cells and flare.http://blog.clinicalmonster.com/2017/08/22/bored-review-anterior-uveitis/cell-flare/

Precipitates or a hypopyon may also be seen.

 

Posterior inflammation is more subtle and can present with non specific vision changes such as flashers/floaters or decreased visual acuity, while pain is less frequently present.1

Visual loss is an important complication of uveitis and can be caused by cataracts, macular edema, epiretinal membrane, and glaucoma.4

 

 

Red Flags for Painful Red Eye

 The following signs and symptoms should prompt urgent referral to ophthalmology:

  • Severe eye pain
  • Vision loss or deficits
  • Loss of pupil reactivity
  • Corneal ulceration
  • Extraocular eye movement stiffness5

 

 

Management

 Uveitis is an ophthalmologic emergency which is vision threatening. Ophthalmological follow up within 24 hours is vital. Without prompt referral to an ophthalmologist for slit lamp examination and treatment, vision loss can be permanent.1

Topical corticosteroids such as prednisolone are often used in the initial management of uveitis. Immunomodulatory agents can also be used6 – both should be used in discussion with an ophthalmologist as inappropriate steroid use could lead to worsening infection or corneal ulceration7.

To help control pain from excessive constriction of the pupil, cycloplegic drops – like Homatropine (1 drop TID of 2‐5% solution) – can be used. Be aware the effects can last a few days.7

A workup for associated conditions is also reasonable, such as chest XR and serologic testing for commonly associated autoimmune and rheumatologic conditions. Screening for associated infections should also be considered.4

 

 

 References

  1. Rosenbaum, James. “Uveitis: etiology, clinical manifestations, and diagnosis” last modified August 31, 2020, https://www.uptodate.com/contents/uveitis-etiology-clinical-manifestations-and-diagnosis?search=uveitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4
  2. Muñoz-Fernández S, & Martín-Mola E. (2006). Uveitis. Best Practice & Research Clinical Rheumatology 2006; 20(3), 487-505.
  3. Brown, H. (2010). Uveitis.Gp, , 34-35. Retrieved from http://ezproxy.library.dal.ca/login?url=https://www-proquest-com.ezproxy.library.dal.ca/docview/744242835?accountid=10406
  4. Dunn, James. Uveitis. Prim Care Clin Office Pract 2015; 42: 305-323.
  5. Dunlop AL, Wells JR. Approach to red eye for primary care practitioners. Prim Care Clin Office Pract 2015; 42: 267-284.
  6. Dupre AA & Wightman JM. (2018). Red and painful eye. In R. M. Walls (Ed.), Rosen’s Emergency Medicine: Concepts and Clinical Practice (9th, pp. 169-183). Philadelphia, PA: Elsevier Inc.
  7. Emergency Medicine Cases (2010). Nontraumatic Eye Emergencies. Retrieved from https://emergencymedicinecases.com/episode-9-nontraumatic-eye-emergencies/

 

Copyedited by Dr. Mandy Peach

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EM Reflections – September 2020

Thanks to Dr. Paul Page for leading the discussions this month

All cases in this series are imaginary, but highlight learning points that have been identified as potential issues during rounds

Edited by Dr David Lewis 


Discussion Topics

  1. Incomplete Abortion

    • Unstable patients require staff to staff direct communication. OBGYN staff are always in house.
    • Patients remain responsibility of EM attending staff during and after consult. Transfer of care occurs at admission.
    • Be aware of the pitfalls of handover and possible need to reassess patient depending on clinical situation
  2. Cardiac Arrest – Pulmonary Embolism

    • Be aware of bias when seen patient in low acuity area
    • Alway consider and document a ‘top 3’ differential diagnosis
    • CPR must be extended after thrombolysis for suspected / confirmed PE
    • Consider following a standardized VTE pathway

 


Incomplete Abortion

Case

A 30yr old female presents with a profuse PV bleeding. She is 7 weeks pregnant by dates. She presents with abdominal pain, palor and is hypotensive and tachycardic. During fluid resuscitation, PV exam confirms the presence of blood and clots, the os is open and contains tissue. This is removed. The bleeding appears to stop. CBC identifies a low hemoglobin. The patient is transfused. What are the potential pitfalls in the management of this case?


 

Threatened abortion

Bleeding before 20 weeks’ gestation in the presence of an embryo with cardiac activity and closed cervix

Spontaneous abortion

Spontaneous loss of a pregnancy before 20 weeks’ gestation

 Complete abortion

Complete passage of all products of conception

 Incomplete abortion

Occurs when some, but not all, of the products of conception have passed

 Inevitable abortion

Bleeding in the presence of a dilated cervix; indicates that passage of the conceptus is unavoidable

 Septic abortion

Incomplete abortion associated with ascending infection of the endometrium, parametrium, adnexa, or peritoneum

 

First Trimester Bleeding – American Family Physician

Patient Information Leaflet

 

Management of Unstable Patients with 1st Trimester Bleeding

  • Urgent Consult to OBGYN
  • Management is similar to all unstable bleeding patients (resus room, monitors, vascular access, IV fluid +/- unmatched O neg blood, foley).
  • Investigate for DIC.
  • Tranexamic acid (1g IV) +/- oxytocin (40U by IV in 1L NS at 150cc/hour) can be given to slow bleeding before definitive management (in the OR).
  • **In an unstable patient with massive vaginal bleeding, a pelvic exam is indicated to identify a source and to look for and extract tissue found in the cervix.**
  • Any unstable patient who presents with 1st trimester bleeding and requires blood transfusion should be admitted, even if they stop bleeding in ED and the low Hb is corrected. There is potential for rebleed over next 24 hrs especially if products are retained.

Episode 23: Vaginal Bleeding in Early Pregnancy


Further Reading:

CanadiEM Frontline Primer – Early Pregnancy – First Trimester Bleeding

 

 

 


Cardiac Arrest – Pulmonary Embolism

Case

A 68 yr old male is brought into the emergency department with chest pain and shortness of breath. The patient is diaphoretic and hypotensive. They report a 5 day history of progressive leg swelling prior to these new symptoms. During the initial assessment the patients has a cardiorespiratory arrest. What is the differential diagnosis? What is the management of cardiac arrest when PE is suspected


 

A retrospective study published in Arch Intern Med  – May 2000, found that PE was found as the cause in 60 (4.8%) of 1246 cardiac arrest victims over an 8 year period.The initial rhythm diagnosis was pulseless electrical activity in 38 (63%), asystole in 19 (32%), and ventricular fibrillation in 3 (5%) of the patients. Thrombolysis resulted in significantly higher rate of ROSC, however survival to discharge was very low.

Diagnosis of PE in cases of cardiac arrest is often difficult to establish. Clinical suspicion of PE as a cause of cardiac arrest remains the key in timely diagnosis and treatment. In this study sudden dyspnea and syncope were the most suggestive reported symptoms. Deep vein thrombosis is known to be an important risk factor for PE, but clinical signs of deep vein thrombosis are rare and nonspecific. Right bundle-branch block was present in 67% of these cases, and this should induce a high suspicion for massive PE as cause of cardiac arrest. The authors recommend either transthoracic or transesophageal echocardiography be performed at the bedside in all cases to help establish the diagnosis of PE as the cause of a cardiac arrest.

 

 

Management of Cardiac Arrest in Suspected PE


  1. Commence CPR and follow the ACLS 2018 Algorithm
  2. Suspicion for PE as cause of cardiac arrest?
  3. Bedside Assessment to Increase Suspicion of PE as cause of cardiac arrest
  4. Thrombolysis
  5. VA ECMO + Interventional Radiology / Cardiovascular Surgery

1.  Commence CPR and follow the ACLS 2018 Algorithm

AHA ACLS 2018 Algorithms –  Update Highlights

2.  Suspicion for PE as cause of cardiac arrest?

  • Sudden onset dyspnoea or syncope prior to cardiac arrest
  • Right ventricular strain, new RBBB or other PE suggestive findings on ECG immediately prior to cardiac arrest
  • Initial non-shockable rhythm
  • History of immobilization prior to cardiac arrest (recent surgery, travel, injury)
  • History of thromboembolism
  • History of recent cancer diagnosis and treatment
  • Known hypercoagulation condition (e.g. Factor V Leiden)
  • No history of cardiac disease
  • Age less than 50yrs
  • Female
  • Pregnancy or Birth Control
  • Clinical signs of recent DVT (swollen leg, history of swollen/painful leg)

Improving identification of pulmonary embolism-related out-of-hospital cardiac arrest to optimize thrombolytic therapy during resuscitation

3.  Bedside Assessment to increase likelihood of PE as cause of cardiac arrest

  • Clinical exam for signs of DVT
  • Clinical assessment to exclude other reversible causes of cardiac arrest (5H’s and 5T’s)
  • DVT PoCUS
  • Transthoracic Echo PoCUS – RV dilatation, TV regurge, visible clot, dilated IVC (must not delay CPR)
  • Transesophageal Echo PoCUS – RV dilatation, TV regurge, visible clot, dilated IVC (superior images, does not interfere with CPR)

 

4.  Thrombolysis

An retrospective study published in Chest in 2019 analysed thrombolysis in PE related out-of-hospital-cardiac arrest. They found that thrombolysis was associated with increased 30 day survival but that a good neurological outcome was rare and not significantly improved. This 2019 systematic review and meta-analysis concluded that systematic thrombolysis during CPR did not improve hospital discharge rate.

Despite a weak evidence base, both the European Resuscitation Council (ERC) as well as the American Heart Association (AHA) have recommend the use of fibrinolytic therapy when PE is either known or suspected as the cause of cardiac arrest.

AHA Recommendations – in refractory cardiac arrest where PE has either been confirmed or is suspected, thrombolysis is a reasonable emergency treatment option:

  • Alteplase 50mg peripheral IV bolus
  • Option to repeat the bolus at 15 mins
  • Continue CPR for 30-60 minutes after lytic administration

EMCrit 261 – Thrombolysis during Cardiac Arrest

 

5.  VA ECMO + Interventional Radiology / Cardiovascular Surgery

Interventional and surgical procedures cannot be performed during CPR.

Several studies have concluded that ECMO can be beneficial in patients with PE related cardiac arrest

Extracorporeal membrane oxygenation in life-threatening massive pulmonary embolism

Use of extracorporeal membrane oxygenation in patients with acute high-risk pulmonary embolism: a case series with literature review

Resuscitation of prolonged cardiac arrest from massive pulmonary embolism by extracorporeal membrane oxygenation

Massive Pulmonary Embolism as a Cause of Cardiac Arrest: Navigating Unknowns in Life After Death

 

The consensus seems to be that in order to see benefit from the use of ECMO to bridge patients with massive PE / cardiac arrest a protocolized approach is required, including a standby ECMO team and predetermined pathways.

 


Further Reading

Submassive & Massive PE

 

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Fascia Iliaca Nerve Block

Hip Broke? Hip Block. Use of the fascia iliaca nerve block for analgesia in hip fractures.

Resident Clinical Pearl (RCP) July 2020

Luke Edgar, BScH MD

PGY1 Family Medicine Integrated Emergency Medicine

Dalhousie Saint John

 

Reviewed by Dr. David Lewis


Background

Hip fractures are a common and painful injury diagnosed and treated in the emergency department, with elderly patients representing the majority of cases. Advanced age, comorbidities, and increased sensitivity to side effects from systemic analgesia all pose challenges to achieving adequate pain control.1,2 Additionally, NSAID use in the elderly is frequently contraindicated due renal, cardiac, and gastrointestinal comorbidities as well as drug interactions. In elderly patients, both undertreated pain and opioid analgesia can precipitate delirium.3

Regional nerve blocks for the indication of hip and femoral neck fractures have been shown to reduce pain and need for IV opiates.1 Contraindications include infection over the injection site, patient refusal, and allergy to local anesthetic. Additionally, patients at risk for compartment syndrome (such as those with a concomitant ipsilateral tibial plateau fracture) should be selected cautiously as they may not reliably have increased pain after block.4

There are three main techniques described for regional nerve blocks to provide analgesia for hip and femoral neck fractures.1

  • Fascia Iliaca Nerve Block: Insert a needle through the fascia lata and fascia iliaca, to infiltrate dilute local anesthetic into the fascial compartment which diffuses to block the femoral, lateral femoral cutaneous, and obturator nerves.
  • Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve.
  • 3-in-1 Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve while applying pressure distal to the injection site, encouraging local anesthetic to track superiorly to block the femoral, lateral femoral cutaneous, and obturator nerves.

Figure 1. Lower limb peripheral nerve sensory distribution.5 Circled in red are the nerves blocked using the fascia iliaca technique. Cutaneous distribution of the obturator nerve is not depicted but consists of a small area on the proximal medial thigh.


Technique

Table 1. Supplies and equipment for performing a fascia iliaca nerve block

Table 2. Steps to complete a fascia iliaca nerve block6

Table 3. One person technique  – Steps to complete a fascia iliaca nerve block


Figure 2. Video demonstrating the sonoanatomy of the right femoral triangle. From lateral to medial, femoral nerve, artery and vein (NAVel), labeled with yellow, red, and blue arrows, respectively.


Figure 3. Sonoanatomy of the right femoral triangle, transverse view for the fascia iliaca nerve block.


Figure 4. Sonoanatomy of the right femoral triangle demonstrating ultrasound-guided needle placement using an in-plane technique. Note two pops should be felt as the needle crossed the two fascial planes.


 

For a visual review of these steps and ultrasonographic landmarks, please see the following videos and webpage by EM Ottawa, 5 Minute Sono, and NYSORA:

EM Ottawa

5 Minute Sono

NYSORA

Ultrasound-Guided Fascia Iliaca Block


 

Complications

Serious complications of this procedure are rare, but present.

  • Local Anesthetic Systemic Toxicity (LAST) as a complication of inadvertent intravenous or intra arterial anesthetic injection.7
    1. Incidence is 8 – 30 in 100,0008
    2. Manifestations typically occur within 20 minutes of injection (although onset can be as late as >1 hr) and are primarily neurologic and cardiovascular in nature. Neurologic effects include perioral numbness, metallic taste, mental status change or anxiety, muscle twitches and visual changes, followed by loss of consciousness and seizure. Cardiovascular effects are hypertension and tachycardia followed by arrhythmias, bradycardia, hypotension and cardiac arrest.
    3. Treatment is with intravenous lipid emulsion therapy (Intralipid 20%) 1.5 mL/kg bolus followed by 0.25 mL/kg/min, Maximum total dose 12 mL/kg. Contact your poison control centre if you suspect LAST.
    4. Prior to performing a fascia iliaca block, confirm availability of intralipid within your department to be used in the event of this rare complication.
  • Femoral Nerve injury secondary to intrafascicular injection
    1. Incidence 2-30/100,0008
    2. Most symptoms of paresthesias, numbness, and weakness resolved after several months in the event of this complication8
  • Other complications include infection, nerve block failure, injury secondary to numbness/weakness of limb, and allergy to the local anesthetic.

 

Take Home Message

Femoral nerve blocks are recommended for hip and femoral fractures to reduce pain and opioid analgesia requirements. Given that poor pain control and opioid analgesia are risk factors for delirium in elderly patients, hip blocks may also reduce rates of delirium (further study required). A fascia iliaca block with 20 cc of 0.5% bupivacaine is a well described technique with very few contraindications. To reduce the risk of complications, these blocks should be completed using sterile technique under ultrasound guidance with the help of an assistant. Hip broke? Hip block.

 


 

References

  • Ritcey B, Pageau P, Woo M, Perry J. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM 2015;18(1):37-47.
  • Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fractures. J Am Geriatr Soc. 2006;54(2):270-5.
  • Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58(1):76-81.
  • Erak M, EM Ottawa Grand Rounds. Ah, that feels better! The Use of Nerve Blocks in the ED. 2016. https://emottawablog.com/2016/10/ah-that-feels-better-the-use-of-nerve-blocks-in-the-ed/. Accessed July 25, 2020.
  • Gray H. 1918. Nerve supply of the leg. Anatomy of the Human Body. Image retrieved from https://en.wikipedia.org/wiki/Nerve_supply_of_the_human_leg. Accessed July 24, 2020
  • Woo M. How to perform the Ultrasound Guided Femoral Nerve Block. EM Ottawa. 2018. https://youtu.be/_OugsPA4rxY Accessed July 25, 2020.
  • Warren L, Pak A. Local anesthetic systemic toxicity. UpToDate. 2019. uptodate.com/contents/local-anesthetic-systemic-toxicity. Accessed July 25, 2019.
  • Helman, A, Morgenstern, J, Spiegel, R, Lee, J. Regional Nerve Blocks for Hip Fractures. Emergency Medicine Cases. August, 2018. https://emergencymedicinecases.com/regional-nerve-blocks-hip-fractures/. Accessed July 25, 2020.
  • Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J of Ultrasound in Emergency Medicine 2012;43(4):692-697.

 

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Wound Management in the ED: Absorbing the Literature – Case Study

 

A review of the principles of emergency wound management including detailed guide to suture material.

 

Medical Student Clinical Pearl – June 2020

Robert Hanlon

@roberthanlon12

Year: 4
DMNB Class of 2021

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual


 

Case Report

You are a third year clinical clerk asked to go see a patient and assess their injuries. A 28 year old female, who is sitting upright in bed and texting her friends, came into the Emergency department via ambulance with a laceration over her right forearm and wrist. EMT vital signs are as follows: BP 128/84, HR 106, RR 18, Temp 37.2, O2 Sats 99% on RA, GCS 15, and Blood glucose 6.4 mmol/L. She weighs 60 kg. The paramedics had wrapped her arm with gauze, which has a blood tinged color to it.

Crying Boy Laying Down With Injured Leg. Selective Focus On Shin.. Stock Photo, Picture And Royalty Free Image. Image 81697370.

What is your approach?


 

Emergency Wound Management

 

A – Ask yourself: is the patient stable or unstable?

  • Based on this patient’s vital signs and the fact that they seem calm and comfortable in bed, they are stable. The tachycardia noted in the vitals is likely due to pain/stress at the time collection and when taken again in the ED her heart rate is 78 and regular.
  • A critical wound (hemorrhage or arterial bleeding) will likely need immediate attention and the patient may be presenting with vital signs that suggest more instability (low BP, high HR, high RR, High Temp, low O2 Sats).
  • If the patient is stable and not exsanguinating, then a brief history and physical should be performed. 1,2 Obtain a brief history:

Arterial bleeding

 

 

B – Obtain a brief history:

Mechanism and timing of injury: The patient was carrying towels down the stairs to her pool, tripped and fell down 5 steps, landing on her right side and breaking through a glass panel on her deck. This occurred 45 minutes ago.

Potential for concurrent injuries based on mechanism: The patient denies any loss of consciousness or head trauma. Denies any pain besides the laceration and does not feel like she has broken any bones.

Functional status prior to injury: She had full range of movement and full sensation in her right arm, wrist, and hand prior to the injury.

Medical History: Patient denies any allergies, diabetes, renal disease, cardiac and vascular diseases, and no bleeding disorder. She is a healthy non-smoker, and her only medication is an OCP.

Tetanus Status: She is up-to-date with her immunizations and her last tetanus shot was 2 years ago.

 

C- Perform a Physical Exam:

Patient is a well-looking 28 year old female with no signs of distress. She is alert and oriented to person, place, and time. She has a bandage on her right forearm that has dried blood on it. She denies any numbness or tingling in her hand. There is no obvious deformity of the arm.

Remove bandage and assess wound: Patient has a 6 cm rounded laceration with the wound extending from the mid-wrist on the volar side to Lister’s tubercle on the dorsal side. It looks like you can see some tendons and muscle at the wound base, but they do not look injured. There is no sign of glass or other foreign bodies, no dead tissue, and the wound bed appears bloody. It has a slow stream of blood running out of it. The surround skin is pink and appears undamaged.

Assess for neurovascular compromise 3,4  : The wrist anatomy is complex and it is important to consider the underlying anatomy when deciding on how to test for injury. Also compare to the patients “normal” other side.

Test for motor function: patient is able to fully extend, flex, and deviate the wrist to both ulnar and radial sides. She is able to flex, extend, abduct, and adduct her thumb, and has no trouble with opposition. She has flexion at the PIP and DIP joints from D2 to D5. She is able to fully extend her fingers and perform abduction as well. Her strength is 5/5 for these movements as well.

Test for sensation: Patient has sensation to light-touch and pin-prick over her thenar eminence, distal aspect and dorsal aspect (proximal to PIP) of D2, D3, and radial half of D3 (testing for intact median nerve). As well as sensation over the radial aspect of the dorsal hand (Radial Nerve). With this injury you should not expect the ulnar nerve to be damaged, but you’re a studious clerk and testing reveals intact sensation.

Test for vascular compromise: You do not notice any pulsatile aspect to the bleeding, her skin is pink, warm, and has <3 seconds of capillary refill. You palpate strong radial pulses and are reassured that she has not injured this artery.

 

With this examination you are reassured that she has not injured any underlying structures (tendons, nerves, muscles, and vasculature). You tell the patient that despite a large cut, she is lucky that no serious damage was done.

 

D- Obtain Pain Control: Either local or regional anesthesia.

Luckily, you just finished your plastic surgery rotation and had plenty of experience drawing up local anesthetic. You also learned how to inject a wound while trying to minimize the patients pain. You were told to ALWAYS USE EPI and ALWAYS USE BICARB in your anesthetic solution.5 You draw up one 10 ml solutions (or 100mg) of Lidocaine 1% with epinephrine 1:100,000 buffered with 1 ml bicarbonate (1:10 ratio of bicarb to lidocaine). Maximum dose being 7mg/kg or 420 mg for this patient. You’re wondering if you might need more and realize that you could be getting close to the patient maximum dose; however, you remembered you could always dilute your solutions to double the amount of syringes and still have effective analgesia.5,6 You use a smaller gauge needle (27 or 30 gauge) as this helps to reduce the pain experienced by the patient.5 You let the patient sit for a while so the analgesia will be effective.

ED Rounds – EM and Hand Surgery – Dr Don Lalonde

Regional anesthesia of the hand

 

E – Irrigation and Cleansing:

You irrigation the wound with copious amounts of tap water (or saline). Again, you notice no foreign bodies or signs of infection. You position the patient lying down in bed and cleanse the skin around the wound with chlorhexidine swabs to prep the surface for wound closure.1,3,7,8

Note: Debridement of jagged, dead, or highly contaminated tissue may be necessary in order to promote wound healing and provide an optimal surface for closure and cosmetic effect.3

 

F- Wound Closure with Sutures:

When you were gathering your supplies you realized there were many options for sutures, so you decided to ask your attending. They recommended a non-absorbable either 4-0 or 5-0 Nylon suture and to use a simple interrupted technique. You closed the wound and the edges approximated well. You, your patient, attending are all happy with the result. The patient is discharged with follow-up for suture removal in 7 days.

Wound Closure Resources

 

Useful Patient Information Reference from the ACS

 


 

Suture Types: To absorb or not to absorb?

 

Typical emergency department suture choice is a monofilament non-absorbable suture, this is due to ease of handling, knot security (does not easily break), and emergency texts report a lower rate of infections.1,2,3 There is also the need for suture removal, which requires follow-up and a second look at how the wound is healing. Absorbable sutures are usually harder to handle and tying knots can be tricky due to ease of breaking, especially with smaller sized sutures. Much of the emergency texts cite an increase in rates of infection with absorbable sutures as a reason not to choose them. However, evidence suggests that there is no significant difference in rates of infections or clinical outcome.9-12 Literature does point towards higher rates of tissue reactivity (inflammation associated with placing of suture) with absorbable sutures.12 Really selection of sutures comes down to wound factors (location and tension requirements), patient factors (need for follow-up, compliance, etc.), as well as physician preference. See tables for types and recommended use.

 


 

References:

  1. Busse, Brittany, and SpringerLink. Wound Management in Urgent Care. 1st Ed. 2016.. ed. Cham: Springer International : Imprint: Springer, 2016. Web.
  2. Cydulka, Rita K. Tintinalli’s Emergency Medicine Manual. 8th ed. New York: McGraw-Hill Education, 2018. Print.
  3. Reichman, Eric F. Reichman’s Emergency Medicine Procedures. McGraw Hill Professional, 2018.
  4. Janis, Jeffrey E. Essentials of plastic surgery. CRC Press, 2014.
  5. Strazar, A. Robert, Peter G. Leynes, and Donald H. Lalonde. “Minimizing the Pain of Local Anesthesia Injection.” Plastic and Reconstructive Surgery3 (2013): 675-84. Web.
  6. Lalonde, Donald H. ““Hole-in-One” Local Anesthesia for Wide-Awake Carpal Tunnel Surgery.”Plastic and Reconstructive Surgery 5 (2010): 1642-644. Web.
  7. Deboard, Ryan H, Dawn F Rondeau, Christopher S Kang, Alfredo Sabbaj, and John G Mcmanus. “Principles of Basic Wound Evaluation and Management in the Emergency Department.”Emergency Medicine Clinics of North America 1 (2007): 23-39. Web.
  8. Forsch, Randall T. “Essentials of Skin Laceration Repair.” American Family Physician8 (2008): 945-51. Web.
  9. Kharwadkar, N., S. Naique, and P.J.A Molitor. “Prospective Randomized Trial Comparing Absorbable and Non-absorbable Sutures in Open Carpal Tunnel Release.” Journal of Hand Surgery1 (2005): 92-95. Web.
  10. Xu, Utku, Bin, Xu, Utku, Bo, Wang, Utku, Liwei, Chen, Utku, Chunqiu, Yilmaz, Utku, Tonguç, Zheng, Utku, Wenyan, and He, Utku, Bin. “Absorbable Versus Nonabsorbable Sutures for Skin Closure: A Meta-analysis of Randomized Controlled Trials.” Annals of Plastic Surgery5 (2016): 598-606. Web.
  11. Sheik-Ali, Sharaf, and Wilfried Guets. “Absorbable vs Non Absorbable Sutures for Wound Closure. Systematic Review of Systematic Reviews.” IDEAS Working Paper Series from RePEc(2018): IDEAS Working Paper Series from RePEc, 2018. Web.
  12. deLemos, D. (2018). Closure of minor skin wounds with sutures. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved July 3rd, 2020. Source
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Trauma Reflections – June 2020

Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month


 

Major points of interest:

 

A) How are we doing with calling Trauma Codes for qualifying cases?

In the past year, for cases qualifying for trauma team activation, the rate of calling ‘Trauma Codes’ has fallen to 66%.

If a Trauma Code was called, RN trauma note use increased to 85% and time to disposition to an ICE setting was significantly decreased.

 

Please review the attached updated simplified activation criteria – notable changes are:

  • Removal of minor head injuries without signs or symptoms on anticoagulants under “D”
  • Addition of pulseless extremity under “C”


B) ECMO in trauma

MVC victim survived after being submerged x 20 minutes – CPR (with LUCAS) and then managed further with ECMO.

Key to successful outcome will be EARLY recognition of cases that may benefit and early alert/consultation with CV surgery.

Best evidence for ECMO is for re-warming severe hypothermic patients.

 


 C) Significant MOI + spine pain = CT

Obtaining spine x-rays in cases with moderate probability of bony injury inevitably leads to another trip down the long hallway to visit our diagnostic imaging colleagues (and delay to definitive diagnosis).

If your patient needs a CT, order a CT.

See attached consensus guideline.


D) Pelvic binders are not used to ‘treat’ the pelvic fracture

They are used to treat any hemodynamic instability caused by the fracture. If a patient is stable or has a pelvic fracture that is not likely causing significant bleeding, the binder can likely be loosened or removed.

A pelvic binder can exacerbate some fractures, such as lateral compression fractures. Orthopedics should be assisting with this decision.

 


E) That intubated transfer patient just waved at me!

There is a reason trauma transfers should be assessed on arrival.

Consultants are expected to attend to these patients ASAP, but timely review by emergency MD is expected to assess/treat priorities (ventilatory status, analgesia need, sedation etc.)

 


F) The patient is on warfarin…how quaint!

Do you remember when anticoagulants could be reversed? In the event you do meet a trauma patient on warfarin, early correct dosing of vitamin K and PCC may be crucial.

Review of such charts in past 2 years has our dosing all over the map.

Easy dosing regime is:

 

Vitamin K – 10mg IV and PCC – 2000IU if INR unknown,

If INR known: PCC – 3000IU if INR > 5, PCC – 2000IU if INR 3-5, PCC – 1000 if INR < 3.

 


G) Trauma checklist:

“SJRH ED Trauma Process Checklist” is in trauma note package in room 19 and is a very useful prompt (see below).


H/ High MOI Knee injuries are at risk for deterioration in department

Vascular status may change, compartment syndrome may develop.

Consider repeating physical exams, early orthopedic consultation and low threshold for CT with vascular studies.

 


I/ Where is this guy bleeding?

Maybe he isn’t. Failure to respond to resuscitation suggests continued hemorrhage or non-hemorrhagic cause for shock. With neurogenic shock, loss of sympathetic tone may cause hypotension without tachycardia or vasoconstriction.

Consideration should be made to start vasopressors in patients with spinal cord injury with persistent hypotension after attempted resuscitation and no evidence of hemorrhagic shock. Aim for a SBP of 90-100. Avoid overzealous fluid administration.

 


J/ NB Trauma Traumatic Brain Injury Consensus statement – May 2020

See attached

Download (PDF, 1.32MB)

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