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
Continue Reading

Lung Ultrasound in the Evaluation of Pleural Infection

Lung Ultrasound in the Evaluation of Pleural Infection

Resident Clinical Pearl (RCP) July 2019

Yazan Ghanem PGY5 Internal Medicine, Dalhousie University

SJRHEM PoCUS Elective

 

Reviewed and edited by  Dr. David Lewis.

 


CASE: MR. WHITE

 

83 year old male with known past medical history of mild cognitive impairment (lives alone in assisted living). Two weeks prior to current presentation, he was admitted with community acquired pneumonia and discharged after 2 nights of hospital stay on oral antibiotics.

He is now presenting with 5 days history of worsening dyspnea, fever, fatigue and reduced oral intake. Vital signs are: Temperature 38.4 C; heart rate 80/min; Blood pressure 121/67; Respiratory rate 28/ minute; Oxygen saturation 90% on room air. His chest exam showed reduced air entry and dullness to percussion in the right hemithorax.

CXR:

 

Bedside POCUS:

 

Pleural fluid analysis:

•       WBC – 22,000 cells per uL

•       LDH – 1256 Units / L

•       Glc – 2.2 mmol / L

•       pH – 7.18

•       Gram Stain – Neg

 

Next steps in management?

 

A – 14 Fr pleural drain + Start IV Levofloxacin

 

B – 28 Fr pleural drain + Start Ceftriaxone / Azithromycin

 

C – 14 Fr pleural drain + Start Piperacillin – Tazobactam

 

D – Start Ceftriaxone / Azithromycin + Repeat CXR in 1 week

 

 

(See end of page for answer )

 


 

Normal Thoracic Ultrasound:

Thoracic Ultrasound is limited by bony structures (ribs and scapulae) as well as by air within lungs (poor conductor of sound waves).

With the transducer held in the longitudinal plane:

1 –     Ribs are visualized as repeating curvilinear structures with a posterior acoustic shadow.

2 –     Overlying muscle and fascia are seen as linear shadows with soft tissue with soft tissue echogenicity.

3 –     Parietal and visceral pleura is visualized as a single echogenic line no more than 2 mm in width which “slides” or “glides” beneath the ribs with respiration. Two separate lines can be seen with a high frequency transducer.

4 –     Normal aerated lung blocks progression of sound waves and is characterized by haphazard snowstorm appearance caused by reverberation artifact.

5 –     Diaphragms are bright curvilinear structures which move with respiration. Liver and spleen have a characteristic appearance below the right and left hemi diaphragms respectively.

 

 


Pleural Effusion:

Ultrasound has higher sensitivity in detecting pleural effusions than clinical examination and chest X-Ray.

On Ultrasound, pleural effusions appear as an anechoic or hypoechoic area between the visceral and parietal pleura that changes in shape with respiration. Atelectatic lung tissue appear in the far field as flapping or swaying “tongue-like” echodensities.

Ultrasound morphology:

1-     Anechoic Effusion: Totally echo-free (Could be transudative or exudative)

2-     Complex Non-septated: Echogenic appearing densities present (fibrinous debris). Always exudative.

3-     Complex Septated: Septa appear in fluid. Always exudative.

 

 


Parapneumonic Effusions and Empyema:

Ultrasound is superior to CT in demonstrating septae in the pleural space. However, CT is recommended for evaluation of complex pleuro-parenchymal disease and loculated pleural collections if drainage is planned: There is no correlation between ultrasound appearance and the presence of pus or need for surgical drainage; however, the presence of a septated appearing parapneumonic effusion correlate with poorer outcomes (longer hospital stay, longer chest tube drainage, higher likelihood for need for fibrinolytic therapy and surgical intervention.

Parapneumonic effusions appear as hyperechoic (with or without septae) on ultrasound.

 


Pulmonary Consolidation:

Pulmonary consolidation is sonographically visible in the presence of a pleural effusion that acts as an acoustic window or if directly abutting the pleura.

It appears as a wedge-shaped irregular echogenic area with air or fluid bronchograms.

 


 

Back to Mr. White

 

Next steps in management?

 

A – 14 Fr pleural drain + Start IV Levofloxacin

 

B – 28 Fr pleural drain + Start Ceftriaxone / Azithromycin

 

C –14 Fr pleural drain + Start Pipercillin- Tazobactam

 

D – Start Ceftriaxone / Azithromycin + Repeat CXR in 1 week

 

Rationale:

Complicated parapneumonic effusions should be managed with drainage and antibiotics that will treat anaerobic infection. An alternative would be a combination of Ceftriaxone and Metronidazole (No pseudomonas coverage). Levofloxacin alone does not add any anaerobic coverage. Azithromycin has poor penetration into loculated pleural collections.

 


 References

 

British Thoracic Society – Pleural Disease Guideline – 2010

https://thorax.bmj.com/content/65/8/667

 

Continue Reading

ADULT Rapid Sequence Intubation and Post-Intubation Analgesia and Sedation for Major Trauma Patients – NB Trauma

Consensus Statement:

ADULT Rapid Sequence Intubation and Post-Intubation

Analgesia and Sedation for Major Trauma Patients

NB Trauma Program – July 2018

Background:

  • Major trauma patients frequently require advanced airway control.
  • Endotracheal intubation is the preferred advanced airway intervention in major trauma patients.
  • Intubated trauma patients also need significant post-intubation pharmacological support.
  • Specifically, these patients require analgesia and sedation. This is particularly true when transfer to another facility is required, during which ICU level support is not available unless transfer occurs via Air Ambulance.
  • In New Brunswick, there is significant variation in the approach to both advanced airway control and post-intubation analgesia and sedation practices for major trauma patients.
  • Physicians in smaller centres in particular have asked for standardized, evidence-based guidance for both Rapid Sequence Intubation (RSI) and post-intubation pharmacological support in preparation for (and during) ground-based interfacility transfer.
  • Rapid Sequence Intubation (RSI) is a method to achieve airway control that involves rapid administration of sedative and paralytic agents, followed by endotracheal intubation.
  • The purpose of RSI is to affect a state of unconsciousness and neuromuscular blockade, allowing for increased first pass success of endotracheal intubation.
  • Post-intubation analgesia and sedation is a method of controlling pain, agitation and medically induced amnesia for major trauma patients.

 

Consensus Statements:

 

  • A provincially standardized, evidence-based guideline for Rapid Sequence Intubation should be available in all NB Trauma Centres (Appendix A).
  • Similarly, a provincially standardized, evidence-based guideline for Post-Intubation Analgesia and Sedation should be available in the Emergency Department of all NB Trauma Centres (Appendix B).
  • In addition to standardized, evidence-based guidelines, a provincially standardized equipment layout is recommended to optimize the preparation for RSI (Appendix C).
  • Ambulance New Brunswick should ensure consistency with the provincially standardized guidelines for RSI and Post-Intubation Sedation and Analgesia in procedures for Ambulance New Brunswick’s Air Medical Crew.
  • RSI should not be considered or applied for trauma patients who are in cardiac arrest or who are apneic.
  • RSI should not be considered in patients with a predicted difficult airway.
  • RSI should be considered for all trauma patients meeting the following:
    • GCS < 8, quickly deteriorating GCS or loss of airway protection
    • Facial trauma with poor airway control
    • Burns with suspected inhalation injury
    • Respiratory failure
    • Hypoxia
    • Persistent or uncompensated shock (reduction of respiratory efforts)
    • Agitation with possible injury to self or others
    • Potential for eventual respiratory compromise
    • Possible respiratory and/or neurological deterioration during prolonged transport
    • Transport in a confined space with limited resources
  • In addition to the above, RSI Guidelines should include
    • Assessment of the possibility of a difficult intubation
    • Troubleshooting
    • Immediate reference to post-intubation analgesia and sedation
  • In addition to standardized, evidence-based guidelines, a provincially standardized pre-induction checklist is recommended to optimize the preparation for RSI (Appendix D)

 


 

Download (PDF, 885KB)

Continue Reading

A focus on PoCUS – A reflection on the value of a PoCUS elective as a medical student

Medical Student PoCUS Elective Reflection

Nick Sajko

Class 2019 Dalhousie Medicine

@saj_ko

 

Nick Sajko, reflects on his experience after completing the SJRHEM PoCUS Elective. Nick is now a PGY1 in Emergency Medicine at the University of Alberta.


 

When my fourth and final year of medical school came around, I was at a crossroads: What did I want to do for the rest of my life? As many will attest, this question influences the choices you make in your clerkship years, especially in deciding on fourth year electives. I was ironically unfortunate in the fact that I had a broad range of interests in a system that does not always benefit those in my situation. I chose electives in Emergency Medicine, Internal Medicine, and Family Medicine – all of them providing valuable learning opportunities and a chance to hone my skills as a junior clinician. However, these “classic” or “bread and butter” electives paled in comparison to the experiences I obtained through my Point of Care Ultrasound (PoCUS) elective at SJRH – a unique elective opportunity relevant to any medical trainee.

 

It is my hope that this reflection piece will provide insight into those deciding on their elective choices and convince some of you to choose a few electives that are off the beat and path and unique. In particular, an elective in the field of PoCUS – a tool that is more useful than some may consider.

 


 

What does a PoCUS elective at SJRH entail? What can I expect?

 

My elective consisted of regularly scheduled shifts within the Emergency Department, paired with senior staff who have specialized training in PoCUS. During these shifts, I would see patients as if I was conducting a bread and butter Emergency Medicine elective, however, cases would be chosen based on the potential for ultrasound practice. This allowed me to gain a remarkable appreciation for the breadth of PoCUS applications within the primary care setting, while also allowing me to gain extremely valuable hands on time with ultrasound in a supervised setting.

 

In addition to the above, I was provided with numerous resources so as to allow for self-directed learning. One of the most valuable resources provided was the opportunity to use the SJRH EM state-of-the-art PoCUS simulator – an invaluable tool for any level of PoCUS experience. Closer to the end of this elective experience, I was offered opportunities to write PoCUS focused case-reports, as well as undergo PoCUS competency exams to solidify my skills within this setting.

The skills I learned in this elective carried forward with me into my various other electives, and provided me with a unique skill-set as a junior learner. Whether it was doing point of care ECHO in my cardiology elective, FAST scans during trauma-codes in my other Emergency Medicine electives, or assessing volume status in complex general internal medicine patients, my competency in these PoCUS applications definitely impressed both residents and staff alike during my fourth year!

 


Why is PoCUS relevant to me as a medical student wanting to specialize in: (insert hyper-specific / niche specialty here)

One question many people may have at this point is, “why would I do this if I wasn’t interested in Emergency Medicine?”. PoCUS is a constantly evolving field, with new and innovative applications being seen in clinical practice constantly. With this, PoCUS can play a huge role in many different specialties: Internal Medicine physicians use PoCUS to provide support to presumed diagnoses and perform certain procedures (such as placing central lines), while surgeons can utilize PoCUS in the examination of traumas, as well as to support diagnoses in the pre- and post-operative patient. PoCUS is steadily becoming a sought after skill in most of the medical and surgical specialties, where proficiency in its use and interpretation can set you apart from other trainees, and more importantly, add to the competency of your patient care!

The value of having this elective through the Emergency Department allows for students to test their skills in the undifferentiated patient – something that will provide learners with enhanced deduction and reasoning skills, no matter what specialty they are interested in. It also allows learners to have access to a huge pool of patients, with a wide breadth of medical problems, thus optimizing this unique elective’s value.

 


 

Is choosing a “unique”, “niche”, or “extra-focused” elective, such as PoCUS, detrimental to my CaRMS application?

Fourth year electives and CaRMS amalgamate into a cruel and unusual game – while most medical school staff and administrators will tell you that your fourth year electives are to be used to “try new things”, this is often not the reality. With the competitiveness of specialties on a constant upward trend, more and more learners choose to conduct the majority of their electives in the single specialty they are interested in. This is great for those who are certain about the field they want to practice in, but creates a predicament for those of us who want to explore a number of options before making a decision.

As I mentioned above, I was in the latter group – with interests spanning 3 different specialties, including some very competitive ones. I chose to go against the grain, so to speak, and opted to conduct a variety of electives in different specialties – including some niche electives in things such as PoCUS. Not only were these opportunities fantastic from a learning point of view, I would argue that they allowed me to stand out amongst a sea of similar applicants and provided me with a unique skill set – something that I think most programs will find enticing! But most importantly, they were fun, exciting, and allowed me to experience my fourth year of medical school the way its advertised.

For those that know their specialty of choice, I would provide the same advice – use this year to experience new things and create a unique learning identity that will set you apart from the rest.

 


 

After all the worry and panic with my elective choices, feeling like I wasn’t committed enough to one specific specialty, I ended up matching to my first-choice field and location. I think this is in large part due to the fact that I was well-rounded in my experiences and had taken the chance to explore unique learning opportunities through this fantastic elective at SJRH. The staff, the environment, and the resources that come with the PoCUS elective at SJRH EM are second to none – I am confident in saying that this elective was the most beneficial and enjoyable component to my fourth year training. Hopefully my thoughts and reflections on this experience will allow some of you to follow a similar path.

 

Nicholas Sajko, B.Sc, MD

Emergency Medicine PGY1

University of Alberta

 


 

Click here for more information on the SJRHEM PoCUS Electives and Fellowships

Continue Reading

EM Reflections – June 2019 – Part 2

Thanks to Dr. Joanna Middleton for leading the discussions this month

Edited by Dr David Lewis 


Discussion Topics

  1. When is a pregnancy not a pregnancy? (see part 1)
  2. Caustic Ingestions (see part 1)
  3. Transient Ischemic Attack – ED Questions

 

Transient Ischemic Attack – ED Questions

 

Transient Ischemic Attack (TIA): A brief episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, with clinical symptoms and without imaging evidence of acute infarction. Transient ischemic attack and minor stroke are the mildest form of acute ischemic stroke in a continuum that cannot be differentiated by symptom duration alone, but the former typically resolves within one hour.

https://www.strokebestpractices.ca/

 

Dual Anti-Platelet Therapy (DAPT)?

Patients who present within 48 hours of a suspected transient ischemic attack are at the highest risk for recurrent stroke

Uptodate – DAPT for high-risk TIA, defined as an ABCD2 score of ≥4

For CVA – ASA only unless already on ASA, then DAPT.  For minor CVA/TIA – DAPT


Hold Birth Control?


 

Admission?

Of all ischemic strokes during the 30 days after a first TIA, 42 percent occurred within the first 24 hours.

 


Stroke Assessment Pocket Cards

Saskatchewan TIA Referral Pathway

Saskatchewan TIA Patient Information Leaflet

 

Continue Reading

EM Reflections – June 2019 – Part 1

Thanks to Dr. Joanna Middleton for leading the discussions this month

Edited by Dr David Lewis 


Discussion Topics

  1. When is a pregnancy not a pregnancy?
  2. Caustic Ingestions
  3. Transient Ischemic Attack – Emergency Medicine (see part 2)

When is a pregnancy not a pregnancy?

Molar Pregnancy

Hydatidiform mole (molar pregnancy) is a relatively rare complication of fertilization with an incidence in the United States of 0.63 to 1.1 per 1000 pregnancies, although rates vary geographically. It is included in the spectrum of gestational trophoblastic diseases and is comprised of both complete molar pregnancies (CM) and partial molar pregnancies (PM).

The most well characterized risk factor for CM is extreme of maternal age. Maternal ages less than 20 or greater than 40 years have been associated with relative risks for CM as high as 10- and 11-fold greater respectively. Other potential risk factors include oral contraceptive use, maternal type A or AB blood groups, maternal smoking, and maternal alcohol abuse.

Molar pregnancy typically presents in the first trimester and may be associated with a wide array of findings, including vaginal bleeding (most common), uterine size larger than expected according to pregnancy date (CM), uterine size smaller than expected according to pregnancy date (PM), excessive beta-human chorionic gonadotropin (β-hcg) levels, anemia, hyperemesis gravidum, theca lutein cysts, pre-eclampsia, and respiratory distress.Studies comparing modern clinical presentations of CM with historical presentations have demonstrated a significant reduction in many of the classic presenting signs and symptoms such as vaginal bleeding and excessive uterine size. This reduction is attributed to early detection by transvaginal ultrasound and increasingly sensitive β-hcg assays. Numerous studies evaluating the efficacy of ultrasound in detecting molar pregnancy demonstrate a 57–95 percent sensitivity for the detection of CM compared to only 18–49 percent sensitivity for PM.

More here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791738/

PoCUS – Normal Early Pregnancy

Arrow = Yolk sac (YS) within Gestational sac (GS), note the hyperechoic decidual reaction surrounding GS, Arrow head = Fetal Pole

PoCUS – Molar Pregnancy

 

PoCUS SIgns:

  • enlarged uterus
  • may be seen as an intrauterine mass with cystic spaces without any associated fetal parts
    • the multiple cystic structures classically give a “snow storm” or “bunch of grapes” type appearance.
  • may be difficult to diagnose in the first trimester 6
    • may appear similar to a normal pregnancy or as an empty gestational sac
    • <50% are diagnosed in the first trimester
  • More on Radiopedia.org

Useful post from County EM blog- click here

 


Caustic Ingestions

 

 

Hydrochloric Acid – pH 1-2

Dangerous if pH <2 or >11.5-12

For alkaline – higher percent, shorter time to burn – 10%NaOH – 1 min of contact to produce deep burn, 30% within seconds

 

Acid – painful to swallow so usually less volume, bad taste so more gagging/laryngeal injury, more aqueous so less esophageal injury, pylorospasm prevents entry into duodenum producing stagnation and prominent antrum injury.  Food is protective.  Acid ingestion typically produces a superficial coagulation necrosis that thromboses the underlying mucosal blood vessels and consolidates the connective tissue, thereby forming a protective eschar.  In enough amount – perforation.

Alkali – burns esophagus more, neutralized in stomach.  Liquefaction necrosis.

Management

Decontamination: Activated charcoal / GI decontamination / neutralisation procedures are contraindicated

Obtaining meaningful info from endoscopy after treatment with charcoal is very difficult

If asymptomatic – observe, trial of oral intake at 4 hours after exposure, earlier if low suspicion or likely benign ingestion after discussion with Poisons Centre

Symptomatic patients or those with a significant ingestion

(high-concentration acid or alkali or high volume [>200 ml] of a low-concentration acid or alkali)

Upper GI endoscopy should be performed early (3 to 48 hrs) and preferably during the first 24 hrs after ingestion to evaluate extent of esophageal and gastric damage and guide management.  Endoscopy is contraindicated in patients who have evidence of GI perforation. (Ingestion of >60 mL of concentrated HCl leads to severe injury to the GI tract with necrosis and perforation, rapid onset of MODS and is usually fatal – endoscopy within 24 hours (unless asymptomatic at 4 hours)

Complications – 1/3 develop strictures – directly related to depth/severity of injury, years later

 


 

TAKE HOME POINTS

  1. PV Bleed, Hyperemesis, PoCUS = bunch Grapes or Snowstorm – consider Molar Pregnancy
  2. Don’t use Activated Charcoal for Caustic Ingestions
  3. Discuss Caustic Ingestions with Poisons Centre
  4. Consider early endoscopy
Continue Reading

Trauma Reflections – February 2019

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

 

Another highly informative and brilliantly written summary by Dr. Lohoar:


 

Major points of interest:

A) Are we still calling ‘Trauma Codes’ in post TTL era?

Yes. Call away. Activation rates for cases that qualify continue to hover around 80%. Patient care is always improved with a coordinated team approach – triggered by calling a trauma code overhead. Activation criteria are as follows:

B) Should RN Trauma notes continue to be used?

Yes. Folder box on counter in room #19 has trauma activation packages – one stop shopping for all documents needed. “SJRH ED Trauma Process Checklist” is in package and is a very useful prompt (see below). Put on a sticker, get into character.

C) Are you feeling lucky?

Symptomatic head injured patients seen in peripheral centers, with concern enough for an emergent CT head request should come by ambulance not car.

 

D)  What did this guy eat for supper?

Pizza and beer, and lots of it.

Ducanto suction catheters are available on all airway carts. They are much more efficient at decontaminating airways soiled with semi-solid material when compared to Yankauer suction catheters

 

E) Boom, ET tube is in – high five – I am going for coffee..

Not so fast Slick, there is more work to be done.

 

1/ Check for ET tube placement, check for cuff leaks

2/ 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. Reassess frequently. Inadequate analgesia is often the cause of continued agitation. See attached guidelines from NB trauma – page 5 in particular

3/ NG or OG tubes should be placed and position checked as well

F)   Transfers “just for imaging”

Calls from other facilities for imaging should be screened for potential trauma patients. Care is often substandard if we are not aware of these patients, and they are being managed remotely by MDs in other facilities (playing phone tag with a radiologist).

Continue Reading

It’s all in your head, literally! – Seizures versus Psychogenic Non-epileptic Seizures

It’s all in your head, literally! – Seizures versus Psychogenic Non-epileptic Seizures

Resident Clinical Pearl (RCP) May 2019

Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB

Copyedited by Renee Amiro

Reviewed by Dr. David Lewis

 


 


 

Background

When patients present with seizure like activity it can be difficult to distinguish true seizure/epilepsy from psychogenic non- epileptic seizures (PNES; also known as pseudoseizures). This task is made more difficult by the fact that 10-30% of patients with PNES can have true epilepsy as well4. The risks associated with diagnosing a psychogenic non-epileptic seizure as true seizure are mainly associated with administration of anti-epileptic drugs during both acute episodes and chronically, with the potential for associated side effects3-4,6. The most severe of these include sedation and even intubation if large enough doses are administered during an acute seizure episode. Additionally, there is added cost to both the patient and the healthcare system for continued use of medications and hospital admissions/investigations.

The underlying mechanism for PNES is believed to be psychiatric in origin, often attributed to conversion disorders, and patients are often not aware of their seizure like behaviours.


 

Risk factors for PNES include:

  1. childhood trauma
  2. PTSD
  3. depression
  4. anxiety
  5. personality disorders
  6. female gender

The challenge remains distinguishing between true seizures and PNES. There are various historical features and seizure characteristics that can assist in differentiating the two, though no one feature is confirmatory for seizure.


 

Distinguishing between PNES and true seizure3-8

Sign/symptom Seizure PNES
Eyes *open Closed, resist forced opening by examiner

 

*Fluttering

Seizure onset *abrupt Gradual
Awareness during seizure Not aware * awareness during episode
Influence of the presence of others Does not change seizure *May intensify or alleviate

 

activity may only occur/be triggered by the presence of others

Seizure activity Generalized tonic clonic

 

Synchronous

 

Stereotyped (first stiff and in extension, then develops synchronous clonic activity)

May be asynchronous, asymmetrical, waxing and waning

Thrashing/violent

Pelvic thrusting

Post ictal *Confusion May recall events during their apparent unresponsive event
head One sided Side to side head turning during event
**incontinence common occasional
***Tongue biting Common, may be severe, usually on SIDE of tongue Occasional, rare to be severe, may be on tip of tongue or the lip
Post ictal corneal reflex impaired normal
Post ictal babinksi upgoing downgoing
Hand drop test negative Positive (patient moves hand away from face)
Response to sternal rub/nail bed pressure Usually nonresponsive May stop seizing, withdraw from stimuli
****Vital signs Desaturation more likely

Ictal apnea

Ictal bradycardia

 

 

 

*represents elements found to be most useful in distinguishing PNES and ES8

** incontinence has little utility in distinguishing between PNES and true seizure5

*** lateral tongue biting was 100% specific for true seizure vs 38% sensitivity and 75% specificity for any type of tongue bite5

****prospective trial7


 

Lab Values

No lab value has proven consistently useful for confirming seizure versus PNES.

A note on Prolactin:

The American Academy of Neurology released guidelines in 2005 recommending the use of prolactin following a seizure event2.

  1. Best when drawn 10-20 minutes after the event and can be used to differentiate between PNES and true seizure
  2. If >6 hours later prolactin should be at baseline levels
  3. Cannot be used to differentiate seizure from syncope
  4. Not applicable in status epilepticus or repetitive seizures

 

Bottom Line: 

  1. Challenging to differentiate between PES and true seizure and some patients can have both!
  2. No definitive distinguishing measure but eye opening, abrupt seizure onset, and confused post-ictal state can help point toward true seizure.
  3. A normal prolactin is more helpful in ruling out seizure while an elevation is non-specific and cannot be used to confirm seizure.

 

References

  1. Abubakr A, Wambacq I. Diagnostic value of serum prolactin levels in PNES in the epilepsy monitoring unit. Neurol Clin Pract. 2016 Apr; 6(2): 116–119.
  2. Graham L. AAN releases guidelines for the use of serum prolactin assays in diagnosing epileptic seizures. Am Fam Physician. 2006. Apr; 73(7): 1284.
  3. Huff JS, Murr N. Seizure, Pseudoseizures. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441871/
  4. Mellers JDC. The approach to patients with “non-epileptic seizures.” Postgrad Med J. 2005 Aug;81(958):498-504.
  5. Nowacki T, Jirsch JD. Evaluation of the first seizure patient: Key points in the history and physical examination. 2017 Jul;49:54-63. doi: 10.1016/j.seizure.2016.12.002. Epub 2016 Dec 8.
  6. Panayiotopoulos CP. The Epilepsies: Seizures, Syndromes and Management. Oxfordshire (UK): Bladon Medical Publishing; 2005. Chapter 1, Clinical Aspects of the Diagnosis of Epileptic Seizures and Epileptic Syndromes. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2609/
  7. Pavlova M, Abdennadher M, Singh K, Katz E, Llewellyn N, Zarowsly M, et al. Advantages of respiratory monitoring during video- EEG evaluation to differentiate epileptic seizures from other events. Epilepsy Behav. 2014 Mar; 32: 142–144.
  8. Syed Tu, LaFrance WC Jr, Kahriman ES, Hasan SN, Rajasekaran V, Gulati D, et al. Can semiology predict psychogenic nonepileptic seizures? A prospective Ann Neurol.2011 Jun;69(6):997-1004
Continue Reading

SJRHEM @Halifax CAEP 2019

Congratulations to all our researchers presenting at CAEP Halifax 2019. This year we have had a total of 12 research abstracts accepted for either oral or poster presentations, 5 invited presentations, 3 panel discussions, 5 track chairs, and 1 national award! We are also involved in many administrative, academic and research committee meetings across the conference.


2019 CAEP Abstracts Links for Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick

Previous SJRHEM @ CAEP


Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

P. Atkinson, M. Peach, S. Hunter, A. Kanji, L. Taylor, D. Lewis, J. Milne, L. Diegelmann, H. Lamprecht, M. Stander, D. Lussier, C. Pham, R. Henneberry, M. Howlett, J. Mekwan, B. Ramrattan, J. Middleton, D. van Hoving, L. Richardson, G. Stoica, J. French

https://doi.org/10.1017/cem.2019.65


Does point-of-care ultrasonography change actual care delivered by shock subcategory in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

P. Atkinson, S. Hunter, M. Peach, L. Taylor, A. Kanji, D. Lewis, J. Milne, L. Diegelmann, H. Lamprecht, M. Stander, D. Lussier, C. Pham, R. Henneberry, M. Howlett, J. Mekwan, B. Ramrattan, J. Middleton, D. Van Hoving, L. Richardson, G. Stoica, J. French

https://doi.org/10.1017/cem.2019.111


Diagnostic accuracy of point of care ultrasound in undifferentiated hypotension presenting to the emergency department: a systematic review

L. Richardson, O. Loubani, P. Atkinson

https://doi.org/10.1017/cem.2019.140

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/CAEP-2019-Systematic-Review-Poster-Trial-2-PA.pdf” title=”CAEP 2019 Systematic Review Poster Trial 2 PA”]


Does specialist referral influence emergency department return rate for patients with renal colic? A retrospective cohort study

A. Kanji, P. Atkinson, P. Massaro, R. Pawsey, T. Whelan

https://doi.org/10.1017/cem.2019.260

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Does-Disposition-Influence-ED-Return-in-Renal-Colic-AK-PA.pdf” title=”Does Disposition Influence ED Return in Renal Colic- AK PA”]


Introduction of an ECPR protocol to paramedics in Atlantic Canada; a pilot knowledge translation project

C. Rouse, J. Mekwan, P. Atkinson, J. Fraser, J. Gould, D. Rollo, J. Middleton, T. Pishe, M. Howlett, J. Legare, S. Chanyi, M. Tutschka, A. Hassan, S. Lutchmedial

https://doi.org/10.1017/cem.2019.302

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/COLIN-caep-2019-pdf.pdf” title=”COLIN caep 2019 pdf”]


The Devil may not be in the detail – training first-responders to administer publicly available epinephrine – microskills checklists have low inter-observer reliability

R. Dunfield, J. Riley, C. Vaillancourt, J. Fraser, J. Woodland, J. French, P. Atkinson

https://doi.org/10.1017/cem.2019.228

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/CAEP-2019_POSTER_Final_RJD_RIM-PA.pdf” title=”CAEP 2019_POSTER_Final_RJD_RIM PA”]


How to get your departmental web content to work for you: one department’s experience with free open access medical education

K. Chandra, D. Lewis, P. Atkinson

https://doi.org/10.1017/cem.2019.209

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/KC-FOAMed_CAEP19-002.pdf” title=”KC FOAMed_CAEP19 (002)”]


Management of first trimester bleeding in the emergency department

R. Amiro, R. Clouston, J. French, P. Atkinson

https://doi.org/10.1017/cem.2019.197

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Poster-Presentation-Renee-Amiro-CAEP-PA.pdf” title=”Poster Presentation Renee Amiro CAEP PA”]


Obtaining consensus on optimal management and follow-up of patients presenting to the emergency department with early pregnancy complications – a modified Delphi study

A. Cornelis, R. Clouston, P. Atkinson

https://doi.org/10.1017/cem.2019.215

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Allyson-C-early-preg-caep-2019-PA.pdf” title=”Allyson C early preg caep 2019 PA”]


Emergency department staff perceived need and preferred methods for communication skills training

M. Howlett, M. Mostofa, J. Talbot, J. Fraser, P. Atkinson

https://doi.org/10.1017/cem.2019.256

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Howlett-caep-2019-jf.pdf” title=”Howlett caep 2019 jf”]


Designing team success – an engineering approach to capture team procedural steps to develop microskills for interprofessional skills education

R. Hanlon, J. French, P. Atkinson, J. Fraser, S. Benjamin, J. Poon

https://doi.org/10.1017/cem.2019.253

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Hanlon-Prototyping-caep-2019-new-PA.pdf” title=”Hanlon Prototyping caep 2019 – new PA”]

[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/Hanlon-Mico-skills-caep-2019-new-PA.pdf” title=”Hanlon Mico-skills caep 2019 – new PA”]



[pdf-embedder url=”http://sjrhem.ca/wp-content/uploads/2019/05/CAEP-19-Emergency-Medicine-Poster-Final.pdf” title=”CAEP 19 Emergency Medicine Poster Final”]

Continue Reading

EM Reflections – May 2019

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 


 

Discussion Topics

  1. Measles – Refresher
  2. Posterior Stroke – Beware of Mimics
  3. Missed Fracture – Distracting Injuries

 

Measles – Refresher

Measles has for many years been an infrequent diagnosis in our population. However falling herd immunity is resulting in cases presenting to Canadian ED’s.

Measles signs and symptoms appear around 10 to 14 days after exposure to the virus.

  • Fever
  • Dry cough
  • Runny nose
  • Sore throat
  • Conjunctivitis

 

Measles causes a red, blotchy (erythematous maculopapular) rash that usually appears first on the face and behind the ears, then spreads downward to the chest and back and finally to the feet. Koplick’s spots can appear 1-2 days before the rash. The rash appearance can be variable, discrete maculopapular or merging erythematous.

 

Visit emDocs.net for this great refresher on EMin5 – Measles

EM in 5: Measles


 

Posterior Stroke – Beware of Mimics

Stroke Mimics

  • Acute peripheral vestibular dysfunction (Don’t forget the HINTS exam)
  • Basilar migraine
  • Intracranial hemorrhage
  • SAH
  • Brain Tumour
  • Toxic or metabolic disturbances
  • Neuroinflammatory or chronic infectious disorders

Note that it is possible to be influenced by past experience with mimics, resulting in falsely diagnosing a mimic in the presence of a stroke.

Stroke Chameleons

Stroke chameleons are disorders that look like other disorders but are actually stroke syndromes

  • Bilateral thalamic ischaemia is such a disorder and may cause reduced consciousness level or a global amnesic syndrome
  • Bilateral occipital stroke may present as confusion or delirium
  • Infarcts limited to the medial vermis in medial posterior inferior cerebellar artery (PICA) territory usually cause a vertiginous syndrome that resembles peripheral vestibulopathy

A very useful BMJ review article on Posterior Stroke can be accessed here.

Be cautious of migraine diagnosis with history that is different to typical migraine presentation. Multiple visits should raise concerns. Importance of thorough neuro exam to find possible deficits that would raise suspicion for more serious pathology. In posterior stroke, special attention should be given to examining the visual fields.

 

Imaging in Stroke and TIA

See Rounds Presentation by Dr. Dylan Blacquiere (Neurologist)

Imaging Recommendations. Dr Jake Swan (Radiologist)

After meeting with Dr. Blacquiere and the ER Department regarding stroke management and SAH management, I’m recommending the following based on new literature and evolving management in “high risk” patients.

1) High risk TIA patients, such as those who had a profound motor / speech deficit that is resolving should have a CTA carotid / COW as well as their standard CT head.

2) SAH patients should have CT done prior to LP due to false positive LP rates.  If there is any question about vascular malformation / aneurysm, follow with a CTA. The CTA isn’t necessary for every headache patient, etc, just those with a positive bleed on the unenhanced CT.

 

The evidence is summarised in this recent paper – Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery


 

Missed Fracture – Distracting Injuries

Standard ATLS teaching, but this error still occurs……

Ensure a complete secondary survey is completed in all patients presenting with history of trauma.

Read the StatPearl Article and then do the MCQ test here

 

Trauma! Initial Assessment and Management

 

Continue Reading

PoCUS – Dilated Aortic Root

Medical Student Clinical Pearl

James Kiberd

Class 2019 Dalhousie Medicine

Reviewed and Edited by Dr. David Lewis


Case:

A 66 year-old female presented to the Emergency Department with shortness of breath and back pain. She had a known dilated aortic root, which was being followed with repeat CT scans. Given the nature of her presenting complaint, a PoCUS was performed to assess her aorta.

 

 

 

Long Axis Parasternal View:

PoCUS for Cardiac imaging has been studied in the acute care setting; focusing on the assessment for pericardial effusion, chamber size, global cardiac function, and volume status, and cardiac arrest.1

In the setting of acute aortic dissection, further evaluation is often recommended depending on the practitioner’s skill level.2 There have been case reports where ultrasound has been used to assess both Type A and Type B aortic dissections.3–5

In order to assess the aortic root, have the patient in a supine position. Either the phased array or the curvilinear probe can be used depending on examiner’s preference. The probe should be positioned with the marker towards the patient’s right shoulder on the anterior chest to the left of the patient’s lower left sternal border. By tilting the transducer between the left shoulder and right hip, long axis views are obtained at different levels with the goal of identifying four main structures; the aorta, the left atrium, and the right and left ventricles. The parasternal long axis view of our patient is shown in Figure 1, where her aortic root measured 3.83cm.

 

Figure 1: Parasternal Long Axis View of Heart: Patient’s root diameter was found to be 3.83cm.

More generally, this view can be used to assess left ventricular contractility and the presence of pericardial effusion, which were not present in this patient. She went on to have a confirmatory CT scan where her aortic root was found to be unchanged from her last scan and was 3.8 cm in diameter as assessed by PoCUS.

In Summary:

Although not rigorously studied to assess aortic root dilatation at the bedside, we present a case where PoCUS was reliable in the assessment of the aortic root. There have been other cases of aortic dissection identified by ultrasound in the emergency department setting, however confirmatory studies (either CT scan or formal echocardiography) are still recommended.


References:

  1. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: A consensus statement of the American society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-1230. doi:10.1016/j.echo.2010.10.005.
  2. Andrus P, Dean A. Focused cardiac ultrasound. Glob Heart. 2013;8(4):299-303. doi:10.1016/j.gheart.2013.12.003.
  3. Perkins AM, Liteplo A, Noble VE. Ultrasound Diagnosis of Type A Aortic Dissection. J Emerg Med. 2010;38(4):490-493. doi:10.1016/j.jemermed.2008.05.013.
  4. Bernett J, Strony R. Diagnosing acute aortic dissection with aneurysmal degeneration with point of care ultrasound. Am J Emerg Med. 2017;35(9):1384.e3-1384.e4. doi:10.1016/j.ajem.2017.05.052.
  5. Kaban J, Raio C. Emergency department diagnosis of aortic dissection by bedside transabdominal ultrasound. Acad Emerg Med. 2009;16(8):809-810. doi:10.1111/j.1553-2712.2009.00448.x.
Continue Reading

Abdominal ACNES: anterior cutaneous nerve entrapment syndrome and trigger point injections in the ED

Abdominal ACNES: anterior cutaneous nerve entrapment syndrome and trigger point injections in the ED

Resident Clinical Pearl (RCP) March 2019

Devon Webster – PGY1 FMEM Dalhousie University, Saint John NB

Reviewed and edited by Renee Amiro and  Dr. David Lewis.


 

Case:

A 32 year old woman with a history of chronic abdominal pain has been sitting in RAZ, presenting with, predictably, lower abdominal pain. She has been investigated multiple times over, with comprehensive labs, ultrasounds, pelvic exams and a previous CT, all of which have been normal. She carries with her a myriad of diagnoses; chronic abdominal and pelvic pain, IBS, fibromyalgia, depression and anxiety.

On history she reports near constant, left lower quadrant pain over the past 4 months. It is worse when sitting up and lying on her left side. The pain is sharp and she is able to localize the pain with a single fingertip. On history, you elicit no red flags for an intra-abdominal source of her pain. You ask her to lay down on the examination bed and hold your finger over the area of maximal pain. You feel no mass or abdominal wall defects. You apply light pressure, which triggers the pain, and ask her to lift her legs up. She yelps in pain, noting significant worsening to the site after tensing her abdominal muscles.

While you think of your differential for abdominal wall pain, you are highly suspicious of anterior cutaneous nerve entrapment syndrome (ACNES)…

What is ACNES?

  • Anterior cutaneous nerve entrapment syndrome (ACNES) is one of the most frequent causes of chronic abdominal wall pain and often goes undiagnosed. It is caused by entrapment of the anterior cutaneous abdominal nerves as they pass through the fibrous abdominal fascia.
  • This common condition can be treated rapidly and effectively by local trigger point injection of lidocaine and long acting steroid in the emergency department.

Pathophysiology:

  • The cutaneous branches of the sensory nerves arising from T7-T12 must make two 90* turns, traversing through channels within the abdominal fascia at the linea semilunaris (lateral border of the rectus muscles) in order to innervate the cutaneous surface of the abdomen.
  • While the neurovascular bundle should be protected from impingement by fat, it is susceptible to entrapment due to the tight passageway through the fibrous channels and sharp angulation.

Risk factors:

  • There are multiple risk factors for entrapment, and subsequent pain: tight clothing or belts, intra or extra-abdominal pressure, scarring and obesity. Pregnant women and those taking OCPs may also be at higher risk.
  • 4x more common in women, particularly those between ages 30-50 years of age.

 

 Clinical features on history:

  • Patients may describe chronic abdominal pain with maximal tenderness over a small area of the abdomen, typically <2cm
  • Pain is typically at the lateral edge of the rectus abdominis muscles and has a predilection for the right side although, the pain may be anywhere over the abdomen and may be in multiple locations.
  • Pain tends to be sharp in nature, positional and aggravated by activities that tense the abdominal muscles. Pain is generally better supine and worse when sitting or lying on the side.
  • There should be no red flags associated with the history suggestive of a more nefarious source of pain (e.g. GI bleeding, change in bowel function).

 

Physical exam:

  • Use a Q-tip to apply pressure as you move along the abdomen and try to locate the area of maximal tenderness. In most ACNES patients, you will find an area of allodynia or hyperalgesia corresponding to the area of nerve entrapment.
  • Look for a positive Carnett’s sign:
    • Ask the patient to either lift the head and shoulders or alternatively, lift their legs off of the bed while lying flat while you apply pressure over the area of pain on the abdomen.
    • Tightening of the rectus muscles should protect intra-abdominal pathology and pain will be reduced. In the case of abdominal wall pathology, including ACNES, pain will remain the same or be increased.
  • Understanding extra vs intra-abdominal pain:
    • There are 2 types of pain receptors: A-delta and C fibers.
      • A-delta: These fibers mediate sharp, sudden pain and innervate skin and muscles. Patient’s can localize this pain with a fingertip and this corresponds well with extra-abdominal wall pain, such as in ACNES
      • C fibers: Mediate dull ‘visceral’ pain that is often difficult to localize and results in pain over larger areas of the abdomen. These fibers innervate the viscera and parietal peritoneum.

 


Approach and Differential Diagnosis for Abdominal Wall Pain:

  • Look for ‘red flags’ (e.g. GI bleeding, abnormal labs, malnourished appearance) and rule out intra-abdominal sources of pain.
  • Once this has been ruled out, consider your differential for extra-abdominal wall pain which may include the following…

 

 

Diagnosis:

  • ACNES can be diagnosed on the basis of 3 criteria:

 1) Well localized abdominal pain

 2) Positive Carnett’s sign

 3) Response to trigger point injection of local anesthetic and steroid

 

 Treatment

  • Trigger point injections:
    • Act as both a source of treatment and diagnosis.
    • Provides immediate relief of symptoms to 83-91% of patients.
    • Injections can be repeated q-monthly.
    • Works through immediate anesthetization of the nerve, steroidal thinning of surrounding connective tissue and hydrodissection.
  • If the pain returns after trigger point injections, after considering other diagnoses, patient’s can be referred for chemical neurolysis (alcohol injections) or in some instances, surgical neurectomy.
  • Conservative treatment may include activity modification (e.g. avoid stomach crunches) and physical therapy

 

Technique for trigger point injections:

  1. Mark the site of maximal tenderness
  2. Inject 1-3 mL of 1% lidocaine and 1 mL of a long acting steroid using a 1.5 inch 26 gauge needle. Insert the needle until the tender area is reached (pt will let you know)
  3. Pain should resolve within 5 minutes.

 

  • US guidance may be useful for increasing the precision of the injection and can be used to visualize the passage of the nerve through the abdominal fascia.

Video guided review of ACNES:

https://www.youtube.com/watch?v=bDyX3myA0Gw&t=163s

 


References:

  1. Meyer, G, et al. “Anterior cutaneous nerve entrapment syndrome.” Uptodate. Accessed March 8, 2019. URL: https://www.uptodate.com/contents/anterior-cutaneous-nerve-entrapment-syndrome
  2. Suleiman, S, Johnston, D. “The Abdominal Wall: An Overlooked Source of Pain” American Family Physician. August 2001.
  3. Kanakarajan, S., et al. “Chronic Abdominal Wall Pain and Ultrasound-Guided Abdominal Cutaneous Nerve Infiltration: A Case Series.” Pain Medicine, volume 12, Issue 3, 1 March 2011, Pages 382-386.
Continue Reading