RCP – Regional anesthesia of the hand

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

Resident Clinical Pearl (RCP) – February 2018

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

Reviewed by Dr. David Lewis


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


Method 1:  Ultrasound-guided nerve block

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

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


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


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


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


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

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


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


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


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

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

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


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


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


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


Method 2: Tumescent anesthesia

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

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

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


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


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


Which approach is better?

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

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

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



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



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


This post was copyedited by Kavish Chandra @kavishpchandra

Continue Reading

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

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

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

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

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

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

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

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




Continue Reading

Fall ECCU Fest 2018 – PoCUS Conference Workshop and ECCU2 Course

September 27th – 28th 2018

The Algonquin Resort in St. Andrews by-the-Sea, New Brunswick, Canada


Atlantic Canada’s top PoCUS event


Now open for applications/booking



The ECCU Conference is being held in conjunction with the ECCU2 Advanced Applications Course in order to provide those attending the course and other delegates with an opportunity to access an update in the hottest clinical PoCUS topics. The focus will be on presenting the best emerging evidence, strategies for developing a local PoCUS program and developing competencies.


  • International PoCUS experts
  • Clinical PoCUS hot topics and updates
  • Top PoCUS research
  • IP2 Diagnostic stream lectures

Conference delegates will have access to the Diagnostic stream lectures of the ECCU2 Advanced Applications Course, which will include an Gallbladder, Renal, DVT and Ocular

Invited Faculty – 2018

Dr. Hein Lamprecht – South Africa – (ECCU Fest 2018) – PoCUS Educator Extraordinaire – IFEM – WinFocus

Dr. Darryl Wood – UK/South Africa – (ECCU Fest 2018) – PoCUS bushcraft on the frontline

Dr. Peter Croft – USA – (ECCU Fest 2018) – New England PoCUS disrupter –past MGH PoCUS Fellow

Dr. David Mackenzie – USA – (ECCU Fest 2018) – Canadian New Englander, PoCUS innovator – past MGH PoCUS Fellow


Also our top Dalhousie Faculty of PoCUS Experts



Open for applications and booking: More Information Here

Continue Reading

EM Reflections – February 2018

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

Edited by Dr David Lewis 



Top tips from this month’s rounds:

Pleuritic Chest Pain – Don’t forget the Abdomen

Headache – Not always Migraine

Epistaxis – Posterior Bleed



Pleuritic Chest Pain – Don’t forget the Abdomen

The commonest causes of pleuritic chest pain (pleurisy) presenting to the ED include:

  • Pulmonary embolus
  • Pneumonia
  • Pericarditis
  • Myocardial infarct
  • Pneumothorax

Once these have been ruled out consider the following differential diagnosis:

ref: American Family Physician (May 2007)


Another differential to consider is:

Perforated peptic ulcer

This can result in localized sub-diaphragmatic peritonitis that can result in pleuritic chest pain



  • If a CT Chest has been performed – look for free air under the diaphragm
  • Always document an abdominal exam when assessing a patient with pleuritic chest pain
  • Although radiologists are highly skilled, like any physician, they are not infallible. Conservative estimates suggest an error rate of 4%. See this excellent article: The Epidemiology of Error in Radiology and Strategies for Error Reduction
  • Wherever possible physicians should always review the images from CT and X-Ray prior to reading the formal radiology report.

Arrows depicting free air on erect CXR – note the double stomach bubble sign on the left

Free air seen on lower slice of CT Chest. Easily mistaken for bowel



Headache – Not always migraine

The commonest cause of headache presenting to the ED is migraine

The features of migraine headache are well documented in this article – The diagnosis and treatment of chronic migraine


The differential diagnosis for patients presenting with headache is large. This excellent website (https://ddxof.com/) provides algorithms to help consider the differential diagnosis in the cardinal EM presentations.

From: DDxof.com


Another differential to consider is:


Sub-acute onset anemia secondary to chronic blood loss e.g menorrhagia, chronic GI bleed, etc can present with fatigue, visual disturbance and headache.


  • Patients who present to ED with a new headache (no previous hx of primary headache syndrome or change in symptoms) should have baseline investigations including CBC and Glucose.
  • Always review the paramedic and triage notes for supplementary information and the presence of additional symptoms that may broaden or narrow the differential.
  • Patient ethnicity and skin colour may mask the presence of anemia.





Epistaxis – Posterior Bleed

Posterior epistaxis is a difficult condition to manage and is associated with a number of acute and serious complications. In this study, 3.7% required intubation.

The #FOAM Blog post provides an excellent outline to the management of posterior epistaxis – EMDocs.net

The Emergency Department Management of Posterior Epistaxis


Posterior Nasal Packing – video




  • All cases of major bleeding, including epistaxis should be initially managed in the highest acuity areas of the ED. Patients can then be rapidly stepped down and relocated to lower acuity areas if determined to be lower risk after initial assessment.
  • Consider using a suction device to aid intubation in cases of massive obscuring oro/naso-pharynx haemorrhage.

PulmCrit: Large-bore suction for intubation: strategies & devices





EM Reflections - Feb 18 - CME Quiz

EM Reflections – Nov 17 – CME Quiz

Continue Reading

ED Rounds – Sexual Assault and the SJRH SANE Program

Sexually Assault and the SJRH SANE Program

ED Rounds Presentation by Dr. Robin Clouston and Maureen Hanlon RN, SANE Co-ordinator

The Sexually Assaulted Patient – Evaluation & Management in the Emergency Department

Dr. Robin Clouston

Download (PPTX, 479KB)


The Saint John SANE Program

Maureen Hanlon RN, SANE Co-ordinator

Download (PPTX, 189KB)

Continue Reading

RCP – Pediatric syncope: an investigative dilemma?

Pediatric syncope: an investigative dilemma??

Resident Clinical Pearl (RCP) – February 2018

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

Reviewed by Dr. David Lewis


The case

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

What investigations does she require?


Why It Matters?

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


The problem?

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


A potential solution

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

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

Red flags

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

 Red herrings

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


Investigative Algorithm

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


The Evidence

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

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


Pediatric ECGs – how to interpret?

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

See following chart from the CCS¹

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

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


Case Resolution

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



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



This post was copyedited by Kavish Chandra @kavishpchandra

Continue Reading

Great ideas and making things better

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

New – Dal SJRHEM PoCUS Fellowship/Elective

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


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


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


For more information click here

Continue Reading

EM Reflections – January 2018

Thanks to Dr Joanna Middleton for leading the discussion this month and providing these tips and references.

Edited by Dr David Lewis 


  1. Occult Fractures of the Upper Limb

  2. Door to Needle/Balloon Times

  3. Mycotic Aneurysms

  4. CME Quiz

Occult Fractures of the Upper Limb

In patients (particularly the elderly)who present with upper limb pain following a fall or other trauma, be careful not to miss an occult fracture. Localization may be impaired by dementia, acute confusion or other soft tissue injuries. Commonly missed fractures of the upper limb include:

  • Clavicle fracture
  • Supracondylar fracture
  • Radial Head/Neck fracture
  • Buckle fractures of the radius/ulna
  • Scaphoid fracture
  • Carpal dislocation
  • Any impacted fracture

Impacted fractures of the humeral neck may still allow some shoulder joint movement. Pain can be referred to the elbow (just as some hip injuries have pain referred to the knee).

When a fracture is strongly suspected ensure that the entire bone is included in the radiograph. If localization is impaired consider obtaining radiographs of the entire limb, starting with the most symptomatic area. Also follow the old mantra – “include the joint above and below” when ordering radiographs for suspected fracture.

Commonly missed fractures in the ED

Misses and Errors in Upper Limb Trauma Radiographs


Strategies to reduce door to ballon time

Delays in door to balloon time for the treatment of STEMI have been shown to increase mortality.



JACC 2006 Click on here for full text


BMJ 2009 – Click here for full text


This evidence has led to an international effort to establish strategies that can reduce door to balloon times

This rural program in the USA published their strategy for reducing door to ballon times below 90mins over a 4 year period. https://www.sciencedirect.com/science/article/pii/S0735109710043810. Their strategies included the following:

• Community hospital physicians visited by interventional cardiologist with recommendations to:

∘ Perform ECG within 10 min of arrival for chest pain patients

∘ Communicate with PCI center physicians via dedicated STEMI hotline

∘ Treat and triage patients without consulting with primary physicians

∘ Give aspirin 325 mg chewed, metoprolol 5 mg IV × 3 when not contraindicated, heparin 70 U/kg bolus without infusion, sublingual nitroglycerin or optional topical nitropaste without routine intravenous infusion, and clopidogrel 600 mg PO

∘ Eliminate intravenous infusions of heparin and nitroglycerin.

• Nurse coordinator hired to oversee program and communicate with emergency department personnel at all referring hospitals.

• Recommendations for medications listed above were formally endorsed for all STEMI patients.

• Formal next-day feedback provided to referring hospitals, including diagnostic and treatment intervals and patient outcomes.

• Quarterly “report cards” issued to each referring hospital emergency department.

• PCI hospital emergency physicians directly activated the interventional team (instead of discussing it first with the interventional cardiologist on call).

• A group page was implemented for simultaneous notification of all members of the interventional team and catheterization laboratory staff of an incoming STEMI patient.
ECG = electrocardiogram; IV = intravenous; PCI = percutaneous coronary intervention; PO = by mouth; STEMI = ST-segment elevation myocardial infarction.


However recent commentaries have highlighted the pitfall of this metric


The Challenges and Pitfalls of Door-to-Balloon Time as a Performance Metric



and further evidence has shown no improvement in mortality despite reducing door to balloon times. However, it should be noted that these centres were already achieving < 90 min.


This may be a result of multiple confounding factors:

total ischemic time may be a more important clinical variable than door-to-balloon time

it has been suggested that the association between door-to-balloon time and mortality may be affected by an “immigration bias” – healthier patients are likely to have shorter door-to-balloon times than are sicker patients with more complex conditions, for whom treatment may be delayed because of the time needed for medical stabilization


Whilst strategies to ever reduce door to balloon times may not be the correct focus to reduce overall mortality, it is clear that the presence of significant delays (>90mins) is associated with increased mortality.


Mycotic Aneurysms

Any kind of infected aneurysm, regardless of its pathogenesis. Such aneurysms may result from bacteremia and embolization of infectious material, which cause superinfection of a diseased and roughened atherosclerotic surface.


Aneurysmal degeneration of the arterial wall as a result of infection that may be due to bacteremia or septic embolization 

  • Symptoms:  pulsatile mass, bruit, fever
  • Risk Factors:  arterial injury, infection, atherosclerosis, IV drug use
  • #1 cause = staph, #2 = salmonella

Download (PDF, 1.14MB)




EM Reflections - Jan 18 - CME Quiz

EM Reflections – Jan 18 – CME Quiz

Continue Reading

RCP – Wired shut: cutting jaw wires in an emergency

Wired shut: cutting jaw wires in an emergency

Resident Clinical Pearl (RCP) – January 2018

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

Reviewed by Dr. Awdesh Chandra


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

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


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



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

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


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


The materials required:

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


The steps:

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


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

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


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


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



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


This post was copyedited by Kavish Chandra @kavishpchandra

Continue Reading

In Situ Simulation Report

Thanks to Dr. James French for this informative post

Report from In-Situ Sim SJRHEM December 2017

The Case:

Mr. Jeffs is a 60year old male with 1 hour of chest pain, he brings himself to the ED, is triaged and bought in to trauma. Past medical history, hypertension. Medications, Perindopril 4mg with no allergies. He presents with an Acute Myocardial Infarction and then goes into cardiac arrest (which was always going to happen) requiring ACLS. After ROSC he requires intubation, thrombolysis and ongoing critical care…..

Discussion Points

When the “shizzel” hits that fan it’s really hard to use closed loop communication but especially important.
When patients get worse rapidly (cardiac arrest is pretty “rapidly”) then by definition they will need lots of safety critical procedures and medicines administering rapidly. This will also be associated by an immediate adrenal response by many of the people in the room (I’m sure even our most experienced physicians would admit to feeling it when people get really sick). Teams who are adrenalized will suffer a certain amount of tunnel vision and auditory exclusion i.e. they won’t be able to see or hear things as well. Closed loop communication is designed for people working under these conditions to address these challenges. The person making the request gets an answer from the person they are speaking to, and most importantly gets the order repeated back to them. Close the loop to prevent the poop! Watch the video for a comical example of closed loop communication! https://emergencypedia.com/2014/11/13/8227/

Being Adaptable

Emerg Teams are highly adaptable. This case required a nurse to do an ECG as there was no ECG tech available. Well done!


Resuscitation and dose adjusting in Rapid Sequence of Anesthesia:

The induction or sedative dose should be reduced in the following circumstances:

  1. When there is hypotension
  2. When the pulse is greater than the systolic blood pressure.
  3. If there is significant comorbidity.
  4. Severe metabolic impairment from DKA, overdose, sepsis or prolonged seizure activity.

Please see the table below for examples.

The patient should also be resuscitated to a point that is appropriate for the case before the administration of drugs. In a shocked trauma patient this could be the administration of blood and splinting limb fractures. In a patient with septic shock this could be giving a fluid bolus and starting vasopressors. For More information on RSI in really sick people see this site. https://emcrit.org/racc/hop-mnemonic/


Continue Reading

Medical Student Clinical Pearl – Urinary Tract Infections

Urinary Tract Infections

Rob Hanlon, Med 1

Dalhousie Medicine New Brunswick, Class of 2021

Reviewed by: Dr David Lewis



Urinary tract infections (UTIs) are common in both the inpatient and outpatient settings. As such, it is important to understand the etiology, pathogenesis, and treatment of such infections. This post will focus primarily on uncomplicated UTIs, bacteriology and pathogenesis, treatment options with consideration for drug resistance.

Types of UTIs: 

The term UTI encompasses different infections. These include asymptomatic bacteriuria, acute uncomplicated cystitis, recurrent cystitis, complicated UTI, catheter-associated asymptomatic bacteriuria, catheter-associated UTI, prostatitis, and pyelonephritis. 1 There are two broad classifications: uncomplicated and complicated.

Uncomplicated UTIs refer to infections occurring in individuals with normal urinary tracts; meaning they have no structural or neurological issues, such as neurogenic bladder. These are differentiated into lower (bladder and urethra) and upper (ureters and kidneys) urinary tract infections; cystitis and pyelonephritis respectively. 2 Typical symptoms of cystitis include dysuria, urinary frequency and urgency, suprapubic pain, and hematuria. Symptoms of pyelonephritis include fever, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting. 3

Risk factors of uncomplicated UTIs include being female (proximity of urethral opening to anus), frequent sexual intercourse, history of recurrent UTIs, use of spermicide-coated condoms, diaphragms, obesity, and diabetes. 3 Menopause also increases the risk for UTIs as the decrease in estrogen causes the walls of the urinary tract to thin, which decreases resistances to bacteria. 4 Uncomplicated UTIs do occur in men; albeit, less frequently than women. Risk factors in men include anal intercourse (fecal bacteria), lack of circumcision, and benign prostatic hyperplasia. 5


Complicated UTIs refer to infections that are typically more severe and difficult to treat. This type of infection can be seen in people with structural abnormalities impairing the flow of urine, catheter use or other foreign bodies, renal transplantation, and kidney/bladder dysfunction.4


Bacteriology and Pathogenicity:


It is important to note that recently the urinary tract has been found to be colonized by a normal microbiome, similar in concept to the gut and vaginal lumens. The urinary tract has traditionally been thought to be a sterile lumen. Changes in the bacterial make-up may contribute to a disease state in the urinary tract.6 There is more research needed to fully appreciate how changes to the normal bacteria contribute to disease and specifically to UTIs. There is ongoing research to determine how the microorganisms become pathological and if the normal flora can be a source of a pathological process.6 There is research indicating possible alternative treatments such as probiotics and dietary modifications that can impact urinary tract diseases.6 The impact of antibiotics on the normal urinary tract bacteria is also a current research topic.6 Clinically, the presence of UTI symptoms would indicate that there is a pathological process present and, when indicated, antibiotics as first-line treatments are still recommended.

There are two mechanism by which bacteria enter the urinary tract, these are ascending infections and haematogenous infections. The ascending mechanism occurs when perineal/fecal bacteria enter the urethra and travel up towards the bladder/kidneys. The haematogenous route occurs when bacteria from the blood enter the kidneys.7


Bacteria causing UTIs are termed uropathogens. The common UTI causing organisms are gram negative Klebsiella spp., Escherichia coli, and Proteus spp., and gram positive Enterococci spp. and Staphylococcus saprophyticus. E. coli being the most common uropathogen; seen in 80% of cases. More opportunistic organisms can be isolated in complicated UTIs, such as Pseudomonas spp. and fungal Candida spp.4 8


Uropathogenic E. coli (UPEC) strains contain virulence factors that allow them to colonize the urinary tract. Fimbriae are filamentous cell surface extensions that allow the bacteria to adhere to the uroepithelium and promote invasion into the tissue. Other surface molecules include flagella that allow the bacteria to mobilize up the urinary tract. 9 UPEC also produce toxins such as haemolysin, which damage epithelial cells and induce inflammatory responses (causing UTI symptoms). Factors allowing adherence of UPEC to uroepitehlium are paramount, as urine could wash away the bacteria. Other virulence factors allow the bacteria to thrive and grow. 7


Klebsiella spp. and Proteus spp. are other gram negative uropathogens that also produce fimbriae. Klebsiella produce polysaccharide capsules that prevent host defense phagocytosis.7  It also produces an enzyme called urease, produced by Proteus spp. as well, which hydrolyzes urea into ammonia and CO2. The bacteria use ammonia as a source of nitrogen for metabolism. The enzymatic process also increases the pH of the urinary tract and leads to the formation of renal stones. 10



Pseudomonas aeruginosa is a gram-negative commonly associated with nosocomial acquired UTIs, especially when catheters are in place. Its major virulence factor is the production of biofilms, which protect it from host defenses and many antimicrobials. 7 Staphylococcus saprophyticus is a gram-positive bacterium that also produces biofilms, as well as a specific epithelial adhesion protein called lipoteichoic acid. 11


Although some of these uropathogens have similar virulence mechanisms, it is important to understand the different types of pathogens and their virulence factors because different antimicrobials target specific parts of the bacteria and the bacteria can be resistant to specific treatment options.


Treatment with Consideration for Antimicrobial Resistance

Multiple factors must be considered when choosing treatment options for UTIs in order to determine the risk of increased drug resistance. Patients are considered to be at a higher risk of drug resistance if, within the last three months, they have been found to have a multidrug resistant strain in their urine, they have been admitted to a hospital or other care facility, used broad-spectrum antibiotics, or have a travel history to areas known for resistant strains. 3


For low risk patients, treatments for uncomplicated cystitis include nitrofurantoin, trimethoprim-sulfamethoxazole, and fosfomycin. Choosing which drug depends on the individual’s allergies, local rates of resistance, and availability. If the patient has used one of these drugs within the last three months, the remaining two drugs are possible options. 3 If first-line treatments are not an option, then an oral beta-lactam, such as amoxicillin-clavulanate is appropriate. If allergic to this, then a fluoroquinolone such as ciprofloxacin can be used.3


Table 1: Drugs and dosages for empiric treatment of uncomplicated cystitis. 3



For higher risk patients, a urine culture and antimicrobial susceptibility testing should be ordered. First-line treatments (see above) can be used as empiric treatments until test results are obtained. However, if the patient is unable to take these treatments, test results should be obtained prior initiating treatment. 3


For complicated UTIs, such as catheter infections, treatment depends on the severity of the illness. Urine culture and susceptibility testing should be performed. In the case of a catheter infection, it should be removed and a sample from the catheter should be cultured. 12 If the catheterized patient requires treatment prior to obtaining test results, treatment should cover gram-negative bacilli. Third-generation cephalosporins can be used in this case. Critically ill patients should be put on broad spectrum antibiotics such as carbapenems and vancomycin, in order to cover pseudomonas and methicillin-resistant Staphylococcus aureus infections respectively. 13

Local (New Brunswick, Canada) Information on Antimicrobial Treatment of UTIs can be found here:

NB Antibiotic Guidelines and Resources



This is not an exhaustive description of infection types, treatments, or resistance mechanisms. This post focused on uncomplicated UTIs and their treatments because they are commonly seen in the clinical setting. An in-depth patient history is crucial for understanding the possible causes of a UTI and for developing a differential diagnosis. These should be included alongside test results when evaluating treatment options.





  1. Kalpana Gupta, Larissa Grigoryan, Barbara Trautner. Urinary tract infection. Annals of Internal Medicine. 2017;167(7). https://search.proquest.com/docview/1975585404.
  2. Ana L Flores-Mireles, Jennifer N Walker, Michael Caparon, Scott J Hultgren. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nature Reviews. Microbiology. 2015;13(5):269. http://www.ncbi.nlm.nih.gov/pubmed/25853778. doi: 10.1038/nrmicro3432.
  3. Hooton T, Gupta K. Acute uncomplicated cystitis in women. Retrieved from: https://www.uptodate.com/contents/acute-uncomplicated-cystitis-in-women?source=see_link. Updated 2017.
  4. Harvey S. Urinary tract infection. University of Maryland. Retrieved from: http://www.umm.edu/health/medical/reports/articles/urinary-tract-infection. Updated 2012.
  5. Hooton T. Acute uncomplicated cystitis in men. Retrieved from: https://www.uptodate.com/contents/acute-uncomplicated-cystitis-in-men?source=see_link. Updated 2017.
  6. Aragón IM, Herrera-Imbroda B, Queipo-Ortuño MI, et al. The urinary tract microbiome in health and disease. European Urology Focus. 2016. doi: 10.1016/j.euf.2016.11.001.
  7. Walsh C, Collyns T. The pathophysiology of urinary tract infections. Surgery (Oxford). https://www.sciencedirect.com/science/article/pii/S0263931917300716. doi: 10.1016/j.mpsur.2017.03.007.
  8. Beyene G, Tsegaye W. Bacterial uropathogens in urinary tract infection and antibiotic susceptibility pattern in jimma university specialized hospital, southwest ethiopia. Ethiopian journal of health sciences. 2011;21(2):141. http://www.ncbi.nlm.nih.gov/pubmed/22434993. doi: 10.4314/ejhs.v21i2.69055.
  9. Bien J, Sokolova O, Bozko P. Role of uropathogenic escherichia coli virulence factors in development of urinary tract infection and kidney damage. International journal of nephrology. 2012;2012:681473. http://www.ncbi.nlm.nih.gov/pubmed/22506110. doi: 10.1155/2012/681473.
  10. Schaffer JN, Pearson MM. Proteus mirabilis and urinary tract infections. Microbiology spectrum. 2015;3(5). http://www.ncbi.nlm.nih.gov/pubmed/26542036.
  11. Raul Raz, Raul Colodner, Calvin M. Kunin. Who are you: Staphylococcus saprophyticus? Clinical Infectious Diseases. 2005;40(6):896-898. http://www.jstor.org/stable/4463165. doi: 10.1086/428353.
  12. Fekete T. Catheter-associated urinary tract infection. Retrieved from: https://www.uptodate.com/contents/catheter-associated-urinary-tract-infection-in-adults?source=see_link#H123172989. Updated 2016.
  13. Hooton T, Gupta K. Acute complicated urinary tract infection (including pyelonephritis) in adults. Retrieved from: https://www.uptodate.com/contents/acute-complicated-urinary-tract-infection-including-pyelonephritis-in-adults?source=see_link#H12414288. Updated 2017.
Continue Reading