CAEP 2019 – Crowded House?

CAEP 2019, Halifax, May 26-29, 2019

CAEP By The Ocean – Crowding Track – May 26th 1pm


Are you concerned about ED Crowding? After a busy shift do you ever “..dream it’s over”? Do you work in a “Crowded House”?



Come to the Crowded House Track at CAEP19 on May 26th 1pm. International and Canadian experts present their experience and we discuss possible solutions.

Including Dr. Taj Hassan (President Royal College of Emergency Medicine UK), Dr. Alecs Chochinov (President CAEP), Dr. Judy Morris and Dr. David Lewis.

Join in the debate – “are redirection strategies better than accommodation strategies” – should we invest all our energy in redirection to alternative services or should we accept that we can’t stem the tide and bring all these services under one roof?


Register for CAEP19 – CAEP By The Ocean. https://caepconference.ca/registration/

Crowded House – Don’t Dream It’s Over

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What’s the word? Insertion of Word catheter for Bartholin’s cysts

Resident Clinical Pearl (RCP) February 2019

Renee AmiroPGY3 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis. Copyedited by Dr. Mandy Peach

Bartholin gland are located in the vulva and are a common cause of vulvar masses.
The normal function of the Bartholin gland is to secret mucus to lubricate the vagina. These ducts can get blocked and cause fluid accumulation can cause a cyst or abscess.

Anatomy of the vagina (2)
Identifying a bartholin gland cyst (3)

Treatment:
The mainstay of management is incision and drainage with insertion of a ward catheter. The ward catheter allows the cyst to continue to drain and allow re-epithelization of the Bartholin gland allowing the duct to stay patent in future.

Indications:
Presence of an uncomplicated Bartholin’s cyst.

Contraindications:
Latex allergy – the ward catheter is made with latex.

Materials:
Alcohol swabs or other solution to clean the area.
Sterile gloves
Local anesthetic
Scalpel with an 11 blade
Gauze (+++)
Haemostat to breakup loculations
Culture swab
Ward Catheter
Syringe filled with H2O to fill the ward catheter.

Procedure

  1. Sterilize area with sterilizing solution.
  2. Inject local anesthetic in to the area that you are going to stab for the incision ~1-3cc.
  3. Stab the cyst or abscess. Make the incision about 5mm big and 1.5cm deep. Too big an incision could cause the ward catheter to fall out.
  4. Drain the cyst/abscess and breakup any loculations with the haemostat.
  5. Place the ward catheter into the incision and inflate with 2-3cc of water.
  6. Tuck the end of the ward catheter in to the vagina to minimize discomfort.
Technique for insertion of word catheter (4)

Follow up:
Pelvic rest for the duration of the time the ward catheter is in place.
Sitz baths and mild analgesia (Tylenol/Advil)

Duration of ward catheter placement is on average four weeks.

If the ward catheter falls out prior to the tract being re-epithelialized or the cyst or abscess remains the patient may need another placement of the ward catheter or follow up marsupialization procedure (obstetrics). If the area looks well healed, the ward catheter can be kept out.

Role of antibiotics:
In uncomplicated skin abscesses there has been no benefit shown from antibiotic treatment. Using an antibiotic without and I and D will not heal the Bartholin glad cyst.

Antibiotics indicated in:
High risk of complicated infection – surrounding cellulitis, pregnancy, immunocompromised.
Culture positive MRSA
Signs of systemic infection

Bottom Line:

  1. Ward catheter placement is essential if you are going to drain a Bartholin’s abscess. If you don’t the patient may loose patency of the duct which could have long term consequences such as dyspareunia.
  2. Antibiotics alone will not cure a Bartholin’s abscess. Only indicated in limited situations.

References

  1. Uptodate: Bartholin gland masses: Diagnosis and Management https://www.uptodate.com/contents/bartholin-gland-masses-diagnosis-and-management?search=bartholin%20cyst&source=search_result&selectedTitle=1~10&usage_type=default&display_rank=1
  2. Bartholin Gland Cysts: https://www.health.harvard.edu/a_to_z/bartholins-gland-cyst-a-to-z
  3. Bartholin Gland Cysts: https://www.merckmanuals.com/en-ca/home/women-s-health-issues/noncancerous-gynecologic-abnormalities/bartholin-gland-cysts
  4. Bartholin Gland Abscess or Cyst Incision and Drainage: https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=683&sectionid=45343783

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PoCUS – Pneumothorax

Medical Student Clinical Pearl

Vlad Kovalik
MD Candidate, 2019
Dalhousie University Faculty of Medicine

Reviewed and Edited by Dr. David Lewis


A 90-year-old female presented to the emergency department after a fall. Her vitals were stable and a chest x-ray demonstrated three posterior rib fractures. She was keen to be managed at home and had the necessary supports in place. She was discharged with a prescription for analgesics and instructions to return to the ED if her condition changed.

4 days later, the same patient returned to the emergency department with shortness of breath and increased work of breathing. Auscultation revealed decreased air entry on the left. A pneumothorax was at the top of the differential.

PoCUS for Pneumothorax

Lung ultrasound has been found to be more sensitive than chest x-ray for detecting pneumothorax.1 To begin scanning, it is best to have the patient in a supine or semi-recumbent position. The high frequency linear array transducer provides excellent near-field imaging and may be used to better appreciate Lung Sliding, however both the phased array or curvilinear probe may also be used. The probe should be positioned in the longitudinal orientation, with the marker towards the patient’s head, on the anterior chest. Scanning through various rib spaces on both sides completes the exam.

In a normal healthy lung, the visceral and parietal pleura slide against each other creating a distinct shimmering effect known as Lung Sliding. The presence of Lung Sliding rules out pneumothorax with nearly 100% sensitivity in the area directly under the probe.2 *

Lung sliding


Absent lung sliding

Comet-tails are another normal feature of a healthy lung. This is an artifact caused by the reverberation between the parietal and visceral pleura. Comet-tails are seen as bright, vertical lines that fade quickly. The detection of comet tails allows you to rule-out pneumothorax.3

The Seashore Sign is a normal finding in M-mode of a healthy lung. The sliding of the parietal and visceral pleura creates a sand like pattern directly deep to the pleural line. In a pneumothorax, there is air between the parietal and visceral pleura and thus the ultrasound beam is scattered deep to the parietal pleura. In this case, an artifact known as the Barcode Sign may be seen where a reflection of the chest wall is seen below the parietal pleura.5 *

The most specific finding of pneumothorax is the Lung Point Sign. This is the point where the visceral pleura begins to separate from the parietal pleura indicating the boundary of the pneumothorax. Although pathognomonic for pneumothorax it is not always present – the sensitivity is 66%.4

Lung Point

In summary

PoCUS for pneumothorax can be performed quickly at the bedside and is more sensitive than chest x-ray. Look for the absence of Lung Sliding, the absence of Comet-tails and try to locate the Lung Point Sign.

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Decisions: A 20-year-old male with dark stool

Medical Student Clinical Pearl – January 2019

Lucy Eum – Med I Class of 2021, Dalhousie Medicine New Brunswick 

Reviewed and Edited by Dr. David Lewis


Case

A 20-year-old African male presented to the emergency department with black, tarry stool for the past two days. He appeared hemodynamically stable. He was treated for peptic ulcer disease (PUD) due to Helicobacter pylori infection eight months ago after an episode of severe hemorrhage. His medications included ferrous sulfate and Pepto-Bismol. He did not have a primary care provider.

What diagnoses should be considered?

90% of melena is due to upper gastrointestinal (GI) hemorrhage proximal to the ligament of Treitz, but the pharynx and small bowel may sometimes be involved.2 Major causes of upper GI bleeding include PUD, varices, Mallory-Weiss tear, or neoplasms.1 Life-threatening hemorrhage, varices, ulcerations, arteriovenous malformations, and malignancy must also be considered.1

It is important to distinguish between dark stool from blood, known as melena, and dark stool from other causes, such as iron or bismuth. Liquid consistency, shininess, and foul smell are distinct features of melena. 5

What questions should this patient be asked?

Symptoms can help determine the severity and etiology.1 Upper abdominal pain is common with peptic ulcer. Dysphagia combined with weight loss and early satiety is characteristic of malignancy. Significant coughing or retching may lead to Mallory-Weiss tear.2

Comorbidities and prior episodes of upper GI bleeding should be asked. History of liver disease and alcoholism are associated with variceal hemorrhage. Abdominal aortic aneurysm is associated with an aortoenteric fistula. A history of H. pylori infection and NSAID use are risk factors for PUD.2

The use of NSAIDs, antiplatelets, or anticoagulants must be identified. Medications that can induce pill esophagitis (i.e. bisphosphonates) also need to be identified. Bismuth and iron can both lead to harmless darkening of the stool.2

Are any investigations required?

Physical exam begins with an assessment of the patient’s hemodynamic stability.2 Signs of any co-morbidities should be noted. Laboratory tests should include complete blood count, liver function tests, and serum electrolytes. The hemoglobin level may be unchanged from baseline for the first 24 hours.1

Is fecal occult blood test required?

The FOBT has only been validated for use in asymptomatic patients for colorectal cancer (CRC) screening.5 For symptomatic (i.e. melena) patients with high pre-test probability of GI bleeding, the FOBT has a high false positive rate.5

Foods with peroxidase activity (i.e. red meat), vitamin C, antiplatelets and anticoagulants can influence the FOBT results,5 therefore dietary and medication restriction for three days is needed.3 Therefore, the FOBT is unsuitable for emergency rooms despite common use in this setting as a point-of-care (POC) test.3 The newer immunochemical FOBTs do not require dietary restriction and have shown improved accuracy as POC testing for CRC, but its accuracy in evaluating black-coloured stools remains unclear.3, 7

There is speculation that FOBT may be used for patients with dark stools on iron supplementation.3 However, melena is usually well-characterized by its liquid consistency, shininess, and foul smell. Importantly, the FOBT has never been validated for such use to distinguish between melena and other causes of dark stool.3, 5

How should this patient be managed?

A hemodynamically stable patient should be promptly categorized according to rebleeding and mortality risk, using the Glasgow Blatchford Score (GBS) or Rockall Score. They are validated tools based on information such as the patient’s blood pressure, hemoglobin level, and co-morbidities.4, 6

Although pre-endoscopic empiric therapy with PPI is recommended for all patients, this is based on the excellent safety profile of PPIs rather than evidence regarding their efficacy.4 Histamine-2 receptor antagonists are ineffective as preendoscopic therapy.4, 6

Endoscopy within the first 24 hours of presentation is recommended for suspected GI bleeding,1,4 although patients with very low GBS Score (i.e. zero) are unlikely to benefit.5

Generally, all patients with upper GI bleeding require gastroenterology consult. In cases where endoscopy is not suitable, surgical consultation is needed.2

Case revisited

Physical exam and lab results were unremarkable except low hemoglobin, which yielded a total GBS Score of 2 for this patient. Since this is considered high risk1, gastroenterology was consulted. The patient was given an infusion of IV PPI.

Although the patient is on iron and bismuth, he had been on these medications for many months, and, given his history of severe hemorrhage due to PUD without a family physician to provide follow-up care, it was deemed appropriate to investigate further.


References

1. Kim B, Li B, Engel A, Samra J, Clarke S, Norton I et al. Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World Journal of Gastrointestinal Pathophysiology. 2014;5(4):467.

2. Cappell M, Friedel D. Initial Management of Acute Upper Gastrointestinal Bleeding: From Initial Evaluation up to Gastrointestinal Endoscopy. Medical Clinics of North America. 2008;92(3):491-509.

3. Ip S, Sokoro A, Buchel A, Wirtzfeld D, Konrad G, Fatoye T et al. Use of Fecal Occult Blood Test in Hospitalized Patients: Survey of Physicians Practicing in a Large Central Canadian Health Region and Canadian Gastroenterologists. Canadian Journal of Gastroenterology. 2013;27(12):711-716.

4. Barkun A, Fallone C, Chiba N, Fishman M, Flook N, Martin J et al. A Canadian Clinical Practice Algorithm for the Management of Patients with Non-Variceal Upper Gastrointestinal Bleeding. Canadian Journal of Gastroenterology. 2004;18(10):605-609.

5. Narula N, Ulic D, Al-Dabbagh R, Ibrahim A, Mansour M, Balion C et al. Fecal Occult Blood Testing as a Diagnostic Test in Symptomatic Patients is not Useful: A Retrospective Chart Review. Canadian Journal of Gastroenterology and Hepatology. 2014;28(8):421-426.

6. Barkun A. International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding. Annals of Internal Medicine. 2010;152(2):101.

7. Huddy JR, Ni MZ, Markar SR, Hanna GB. Point-of-care testing in the diagnosis of gastrointestinal cancers: Current technology and future directions. World Journal of Gastroenterology. 2015;21(14):4111.

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EM Reflections – January 2019

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

Edited by Dr David Lewis 


Top tips from this month’s rounds:

  1. Conversion disorder – remember = diagnosis of exclusion.  Consider admission for urgent workup for patients with neurological findings and no definitive diagnosis.  Or good documentation if thought to be functional disorder.
  2. CT reports – important to document details of Diagnostic Imaging report (verbal, system or dictated).  Be aware of old reports on dictation system and make sure report is the appropriate one.
  3. Vision loss – acute vision loss needs to be seen ASAP for assessment.  Don’t need room 27 (eye room) for all eye cases. Emergent ophthalmology cases can be initially assessed in any room.
  4. Supracondylar Fractures – remove ice packs etc to have a good look at all Ortho injuries during triage assessment, even when brought in by EMS.  Assess for limb deformity, skin tenting and especially neuro-vascular compromise. These patients should be urgently assessed and appropriately managed including analgesia, splinting and emergent reduction if indicated. Don’t need to wait for room 10 ( Fracture Procedure Room) for emergent Ortho cases.

Learning Points:

Scanning Dysarthria

Scanning dysarthria (scanning speech, explosive speech) is a stuttering dysarthria found in cerebellar disorders. Spoken words are broken up into separate syllables, often separated by a noticeable pause, and spoken with varying force. The sentence “Walking is good exercise”, for example, might be pronounced as “Walk (pause) ing is good ex (pause) er (pause) cise”. Additionally, stress may be placed on unusual syllables. Charcot’s neurological triad suggestive of multiple sclerosis has it has one of the three classic symptoms.

https://library.med.utah.edu/neurologicexam/cases/html_case03/feedback/FB_dysarthria.html


Corneal Hydrops

Corneal hydrops is the acute onset of corneal edema due to a break in Descemet membrane. This condition may be seen in individuals with advanced keratoconus or other forms of corneal ectasia. More here

Keratoconus is a disorder in which the cornea assumes an irregular conical shape. Acute hydrops is a well-known complication, occurring in approximately 3% of patients with keratoconus. Hydrops occurs after rupture of the posterior cornea leads to an influx of aqueous humor into the cornea, resulting in edema. Corneal edema typically resolves in 6 to 10 weeks; therefore, hydrops is usually not an indication for emergency corneal transplantation. Infectious causes of corneal opacification and visual loss, such as bacterial, viral, or fungal keratitis, must be ruled out as the cause of acute visual loss.


Seidel Test

The test used to reveal ocular leaks from the cornea, sclera or conjunctiva following injury or surgery and sometimes disease is called Seidel test.

http://eyewiki.aao.org/Seidel_Test

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Managing Shocks – not shock…

ED Rounds – Jan 2019

Andrew Lohoar


Dr. Lohoar presents rounds on the topic of ‘Electrical Injuries’ including electrocution, lightening strike and Taser injuries.



X2 Darts have a double barb, X26 Darts come in extra long ‘winter coat’ and standard ‘summer’ varieties.



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Trauma Reflections – December 2018

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


Major points of interest:

A)  TXA – “When did this MVA actually happen?”

Only 75% of cases receiving TXA are receiving it within 3 hours of injury. And only ½ of theses cases are having the drip started.

CRASH study found patients receiving TXA after 3 hours do not benefit.

B)   Bleeding on warfarin

If emergent reversal of anti-coagulation from warfarin is needed, vitamin K (5-10mg) should be given IV (not PO), along with PCC.

C)  Trauma transfers from outside of our region in the post TTL era..

Consultants accepting transfers from other regions through NB trauma line may request that patient stop in ED first for evaluation/imaging prior to transfer to floor or ICE.

The consultant should make every effort to evaluate their patient on arrival to ED  

Expectation is that TCP and/or consultant clearly delineate their plan with ED charge MD.   

E) Matthew 4:1:1  “Man shall not live by [RBCs] alone”

I might not have gotten that one quite right, but the MTP policy follows a 4:1:1 rule – after 4th unit of PRBCs, give a unit of platelets and FFP.

F) This guy is bleeding all over my triage room!

Patients occasionally “self-present” to triage with significant injuries or a history of a high energy MOI. The most efficient way to mobilize resources is to have the triage RN call a “Trauma CODE”.   

G)  Analgesia in pediatric population

Pain management in pediatric population is often challenging. If IV access is delayed consider alternative routes – intranasal fentanyl 1.5 ug/kg using MAD (mucosal atomizing device).

H)  May the hoses R.I.P.

Chest tube sizes 36 F and 345F are now no longer being stocked on chest tube cart.

I)     Post-intubation sedation

Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.

Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.

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