Resident Clinical Pearl – PoCUS Triage Shoulder Dislocation

Resident Clinical Pearl – POCUS in Shoulder Dislocation

Luke Richardson, PGY 3 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

A 24 year old male rugby player presents to the emergency department with left sided shoulder pain.  He reports being hit in the middle of the game followed by a pop to his shoulder.  Since that time he has had ongoing pain and limited movement.  His vitals are normal but he appears uncomfortable.  He shows no signs of neurological or vascular injury.  History and physical exam is otherwise benign.

 

Dislocated shoulder is suspected, but is there a way to quickly diagnose prior to x-ray and therefore expedite administration of pre-procedural analgesia and preparation of procedural team and room?

 

POCUS: Shoulder Background

The shoulder is a ball-in-socket joint with a large range of motion and has a high risk of dislocation due to its shallow joint depth and limited tendinous support inferiorly.   Most commonly, the shoulder will dislocate with the humeral head anterior to the glenohumeral rim due to an superiorly placed force upon the humeral head.  Posterior dislocations are less common and commonly due to higher mechanism of injuries such as seizure or electrical shock.

 

Diagnosis of shoulder dislocation is commonly made by x-ray but this method has its downsides including time to diagnosis and increased radiation exposure.  An important consideration is the use of POCUS during shoulder reduction.  This technique allows for real time confirmation and potentially avoids the need for repeat sedation if failed reduction discovered by a trip to the x-ray department.  A recent prospective observational study of 73 patients in the emergency department revealed an accuracy of 100% sensitivity and specificity for shoulder dislocation and relocation (reference 1).   Finally, considering there is increased risk of neuro-vascular complications with time to relocation; a decrease in duration to diagnosis could potentially improve patient care.

 

 

POCUS: Shoulder Technique

Get patient to sit up to allow availability to the posterior portion of the patient shoulder.

Support the patients elbow while positioning the shoulder in adduction and internal rotation.

Using the curvilinear probe, landmark just inferior to the scapular spine and follow it laterally until you find the glenoid (G) and humeral head (HH) (Shol1).

Shol 1

You should find the humeral head (HH) as a circular structure lateral to the glenoid fossa (G) if in joint. Note the Glenoid labrum (L).

To confirm, you can internally and externally rotate the arm and visualize the humeral head freely moving within the glenoid (Shol2/Shol4) (reference 2). Note the overlying deltoid (most superficial) and the infraspinatus tendon that becomes more apparent during internal rotation.

Shol2

Shol4

If the shoulder is anteriorly dislocated you will see the humeral head displaced inferiorly (Shol5/Shol6) (reference 2,3)

If the shoulder is posteriorly dislocated you will see the humeral head more superficial than expected (Shol5) (reference 2,3)

 

Shol5

Shol6

 

Conclusion:

POCUS is an easily available and non-invasive tool in the emergency department.  It can be used in cases such as this to improve patient flow, decrease time to diagnosis, and confirm reduction.

 

Reference:

  1. Abbasi, S., Molaie, H., Hafezimoghadam, P., Amin Zare, M., Abbasi, M., Rezai, M., Farsi, D. Diagnostic accuracy of ultrasonogrpahic examination in the management of shoulder dislocation in the emergency department. Annals of Emergency Medicine. Volume 62:2. August, 2013, pg. 170-175.
  2. Tin, J., Simmons, C., Ditkowsky, J., Alerhand, S., Singh,M., US Probe: ultrasound for shoulder dislocation and reduction. EMDocs http://www.emdocs.net/us-probe-ultrasound-for-shoulder-dislocation-and-reduction/ January 18, 2018.
  3. Rich, C., Wu, S., Ye, T., Liebmann, O. Pocus: shoulder dislocation. Brown Emergency Medicine. http://brownemblog.com/blog-1/2016/11/30/pocus-shoulder-dislocation. November 30th, 2016.
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

UPDATE

 

Now open for applications/booking – Only a few places still available

 

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.

Includes:

  • 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. 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

 

There are only 2 places left on the 2 day Advanced Apps ECCU 2 course, however we still have good availability for the 1 day conference workshop

Continue Reading

Resident Clinical Pearl – Infectious flexor tenosynovitis

“Don’t pull my finger!” – a case of flexor tenosynovitis.

Resident Clinical Pearl (RCP) – July 2018

Mandy Peach – FMEM PGY3, Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

You are working a rural ED and a 70 yo male presents with an injury to his right hand about one week ago. He has no known past medical history, is widowed and lives alone. He has no family doctor; a family member made him come in.

In triage he denies any major discomfort in the finger, and has taken nothing for pain. However he has noticed it is increasing in size, becoming more red and even black in places.

Vital signs show he is hypertensive, but otherwise afebrile with a normal heart rate.

You walk into the room to do the assessment and immediately your eyes are drawn to his hand:


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHOA.

As you get further history it turns out the injury was a rusty nail to the digit – it just keeps getting better.

You are worried about an infectious flexor tenosynovitis – a can’t miss diagnosis. This is when purulent fluid collects between the visceral and parietal layers of the flexor tendon1. This infection can rapidly spread through the deep fascial spaces. Direct inoculation, like this penetrating injury, is the most common cause1.

4 clinical signs of tenosynovitis – Kanavel’s signs

  • ‘sausage digit’ – uniform, fusiform swelling
  • Digit is held in flexion as the position of comfort
  • Pain with passive extension
  • Tenderness along the tendon sheath

Figure 1: Sketchy Medicine – Flexor Tenosynovitis http://sketchymedicine.com/2012/10/flexor-tenosynovitis-kanavels-signs/

 

As you can imagine this guy had all 4 signs – slam dunk diagnosis, with a little gangrene at the tip to boot. But the diagnosis isn’t always clear cut, and some of these are late signs of infectious flexor tenosynovitis. Patients may present earlier in the course of illness, so what can we use to help diagnose this condition? PoCUS of course!

Place a high frequency linear probe at the wrist crease where you should visualize flexor tendons overlying carpel bones.

Figure 2: Normal flexor tendons (yellow) and carpel bones in transverse plane1

In infectious flexor tenosynovitis you would see anechoic edema and debris in the flexor tendon sheath, and potentially thickening of the synovial sheath. You can assess in both longitudinal and transverse planes.

Figure 3: Transverse (A) and Longitudinal (B) images showing edema in flexor tendon sheath1.

 

Treatment:

So the most common bug that causes these infections is Staphylococcus, however they can be polymicrobial2. Broad spectrum coverage is required – think ceftriaxone or pip tazo. If there is concern for MRSA than vancomycin would be indicated.

But let’s remind ourselves – he had exposure to a rusty nail – you must cover Pseudomonas as well.

We chose ceftriaxone and ciprofloxacin, administered a tetanus (he never had one before) and urgently contacted plastics. He stayed overnight in the rural ED and was transferred out the next morning for OR. Unfortunately, he did have up having the digit amputated but he recovered well.

 

Take home message: Flexor tenosynovitis is a surgical emergency – examine for Kanavel’s signs. Ultrasound can be helpful in confirming diagnosis in the right clinical context. Cover with broad spectrum antibiotics, consider MRSA or Pseudomonas coverage if indicated. Urgent plastics referral needed.

 

References:

  1. Padrez, KP., Bress, J., Johnson, B., Nagdev, A. (2015). Bedside ultrasound Identification of Infectious Flexor Tenosynovitis in the Emergency Department. West J Emerg Med; 16(2): 260-262.
  2. Flexor Tenosynovitis (Karavel’s signs). Sketchy Medicine. Retrieved from http://sketchymedicine.com/2012/10/flexor-tenosynovitis-kanavels-signs/ June 12, 2018.
  3. Tintinalli, JE. (2016). Flexor Tenosynovitis (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (page 1922). New York: McGraw-Hill.

 

 

Continue Reading

Resident Clinical Pearl – Simplifying pharyngitis management

Simplifying pharyngitis management

Resident Clinical Pearl (RCP) – June 2018

Allyson Cornelis FMEM PGY1, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

The majority of pharyngitis cases are caused by viruses. For those attributed to bacterial sources, throat culture is the gold standard for confirmation and group A streptococcus is the main bacterial agent involved¹. For pharyngitis believed to be bacterial in nature, antibiotics are prescribed to reduce the risk of developing rheumatic fever, the duration of symptoms, and transmission to others. For cases where antibiotics are prescribed, the first line medication is penicillin, due to the low resistance of group A streptococcal bacteria to this group of medications. Commonly recommended regimens include:

Penicillin V

Pediatrics

  • 40 mg/kg/day (divided BID or TID) to a max of 750 mg x 10 days
  • 250 mg BID

Adults

  • 300mgTID x 10days or
  • 600mgBID x 10days or
  • 500mgBID x 10days

Amoxicillin

Pediatrics

  • 40 mg/kg/day (divided BID or TID) x 10 days to maximum of 1000 mg/day

Adults

  • 500 mg BID x 10 days

 

An alternative treatment regimen
Common antibiotic regimens require multiple doses per day. This can be difficult for compliance purposes, especially in pediatric patients who may not like to take medications due to the taste and where difficulty with administration of doses at school may be a concern. Recommendations in recent years have included an alternate dosing schedule which allows for a single dose of antibiotic daily for patients. Possible advantages of this approach are improved compliance due to single daily dosing as well as reduced cost for patients and their families. The recommendation is 50 mg/kg once daily to a maximum of 1000mg for 10 days and is appropriate for children > 3 years old and adults.

 

Bottom lineAmoxicillin 50 mg/kg once daily (max 1000 mg daily) is an acceptable alternative to multiple daily doses of penicillin or amoxicillin for treatment of Group-A streptococcal pharyngitis infections.

 

References:

1. Caglar D, Kwun R, Schuh A. Mouth and throat disorders in infants and children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, editors. Tininalli’s emergency medicine 8th ed. New York: McGraw- Hill; 2016

2. Rx files [Internet]. Pharyngitis: Management considerations; 2017 Mar [cited 2018 May 21]. Available from: http://www.rxfiles.ca/rxfiles/uploads/documents/ABX-Pharyngitis.pdf

3. CDC.gov [Internet]. Group A Streptococcal Disease: Pharyngitis; 2017 Sep 16 [cited 2018 May 21]. Availbale from: https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

4. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Circulation. 2009 March. 119: 1541-1551.

5. Shulman ST, Bisno AL, Cleg HW, Gerber MA, Kaplan E, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the infectious diseases society of America. Clin Infec Dis. 2012 Nov; 55(10): e86-e102. Available from: https://academic.oup.com/cid/article/55/10/e86/321183

6. Andrews M, Condren M. Once-daily amoxicillin for pharyngitis. J Pediatr Pharmacol Ther. 2010 Oct-Dec. 15(4): 244-248.

 

This post was copyedited by Kavish Chandra @kavishpchandra

Continue Reading

EM Reflections – June 2018

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

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Button Battery Ingestions

Acetaminophen Overdose / Poisoning – Delayed Presentation

Transient Ischemic Attack (TIA) – Follow-Up


 

Button Battery Ingestions

Button Battery Ingestion

 

Take Home Points:

  • Button battery ingestions are can potentially be very serious. Necrosis, perforation and erosion into vessels can occur in as little as 2 hours
  • ALL nasal and esophageal button batteries should be removed within 2 hours of presentation to minimize mucosal damage
  • Consider button battery ingestion in children presenting with dysphagia, refusal to eat and hematemesis
  • Co-ingestion of a button battery with a magnet requires emergency removal regardless of where it is in the GI system
  • Early GI consult is advised

The management algorithm form National Capital Poison Center covers all eventualities! (Click to enlarge)

 


 

Acetaminophen Overdose / Poisoning – Delayed Presentation

Take Home Points:

  • N-acetylcystine (NAC) is a safe and effective antidote. Time to NAC is crucial to protect the liver from significant toxicity.
  • Stated timing and dose are often unreliable and this needs to be taken into consideration.
  • NAC is almost 100% effective if administered within 8hrs of ingestion.
  • If time of ingestion is known for certain to be < 4hrs ago – draw blood for level at 4hrs post ingestion and use nomogram to determine who to treat.
  • If time of ingestion is known for certain to be < 8hrs ago – draw blood for level immediately and use nomogram to determine who to treat (provide result can be obtained within 8 hrs – otherwise start NAC pending result)
  • If time of ingestion is known for certain to be > 8hrs and < 24hrsCommence NAC and draw blood for level immediately and use nomogram to determine whether to continue NAC.
  • If time of ingestion is > 24hrs or unknown or ingestion is staggered – Commence NAC and draw blood for level immediately – Consult toxicology for advice – Only if level is undetectable and AST is normal then NAC can be discontinued, otherwise continue NAC and consult.

View the SJRHEM Acetaminophen Poisoning post here (includes Nomograms and NAC dosing):

New Acetaminophen Poisoning Guidelines from the Royal College of EM

See also this useful NEJM Review Article

For Children, this guideline is useful.

  • Presenting between 4-24 hours (Time of ingestion is known)- use nomogram to determine who to treat.


 

  • Presenting after 24 hours or time of ingestion unknown or ingestion spans > 24hrs

From: UpToDate

 


 

Transient Ischemic Attack (TIA) – Admit or Follow-Up

Take Home Points:

  • All TIA patients need an ECG and baseline labs (CSBP recommended labs)
  • Very High Risk TIA Patients (see below) should have a CT/CTA (or MRI/MRA) immediately
  • High Risk TIA Patients (see below) should have a CT/CTA (or MRI/MRA) within 24hrs
  • All TIAs should be followed up in a specialist TIA Clinic
  • TIA’s + large artery stenosis – candidate for early revascularization (the sooner it is done the better the prognosis)

 

Full Canadian Stroke Best Practice Guideline can be viewed here

 

UpToDate: These results suggest that CEA is likely to be of greatest benefit if performed within two weeks of the last neurologic event in patients with ≥70 percent carotid stenosis. For patients with 50 to 69 percent stenosis, CEA may only have benefit if performed within two weeks of the last event.

 

Continue Reading

Trauma Reflections – June 2018

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

 


 

Major points of interest:

 

A)  Should that be bubbling like that?

Chest tube placement is a critical procedure in managing trauma patients – successful placement can be challenging, complications are common. Post-procedural imaging and check of chest drain system should determine adequate positioning/effectiveness. Check for fluctuation (tidaling) of fluid level in water seal chamber.

 

B)   Nice intubation…but why is his BP now70?

Post intubation sedation and analgesia infusions are superior to push dosing, but should be titrated up slowly to effect. Avoid starting medications that could potentially drop blood pressure at very high infusion rates – yo-yoing BP is not good for damaged neurons.

See attached NB consensus statement for suggested medications and dosages.

FINAL Consensus statement – RSI+ – July 2018

C)  Crystalloid choice in burns

(Warmed) Ringer’s lactate is the preferred crystalloid for initial management of burns patients. And probably all trauma patients for that matter.

 

D)  TTA log sheets – numbers are only slightly better

Ensure qualifying traumas have activations, and TTA log sheets are filled out. Don’t forget transfers should have activations as well.

When services are known to be required for transfer patients (intubated, critical ortho injuries etc.) call a level A activation – consultants should meet patient with you.

Remember, ED length of stay < 4hours is significantly higher with trauma activations (60% vs. 30%), so it is to our advantage to identify these patients immediately on arrival.

 

E) Propofol infusions in pediatric population

This in still a no-no in patients < 18 yo. Single doses for procedure is fine, but for maintaining sedation choose something else.

 

F)  “Moving all limbs”..

..is NOT an acceptable documentation of exam findings in a patient with suspected neurologic injury. Thorough exam to detect any deficits is needed for neurologic baseline and for comparison later. Dermatome level of sensory dysfunction, key muscle group strength (0-5 scale) and anal sphincter tone should all be recorded, with time of exam.

 

G)  We don’t talk anymore..

There should be TTL to TTL handover at shift change if the trauma patient still resides in our ED. Even if consultants are involved.

Continue Reading

Medical Student Clinical Pearl – PoCUS and Clavicle Fractures

Using PoCUS to diagnose clavicular fractures

Medical Student Pearl – May 2018

Danielle Rioux – Med III Class of 2019, Dalhousie Medicine New Brunswick 

Reviewed by Dr. Mandy Peach and Dr. David Lewis

Case: A 70 year-old man presented to the emergency department with pain in his left shoulder and clavicular region following a skiing accident. He slipped and fell on his left lateral shoulder while he was on skis at the ski hill. He has visible swelling in his left shoulder and clavicular region, and was not able to move his left arm.

On exam: The patient was in no sign of distress. He was standing and holding his left arm adducted close to his body, supporting his left arm with his right hand. There was swelling and ecchymosis in the left clavicle, mid-shaft region, with focal tenderness. On palpation, there was crepitation, tenderness, swelling, and warmth in this region. He was unable to move his left shoulder due to pain. His neurovascular exam on his left arm was normal. Auscultation of his lungs revealed normal air-entry, bilaterally and no adventitious sounds.

Point of Care Ultrasound (PoCUS): We used a linear, high-frequency transducer and placed it in the longitudinal plane on the normal right clavicle (see Image 1.), and the fractured left clavicle (see Image 2.). Image 3 shows the fractured clavicle in the transverse plane.

 

Image 1. PoCUS of normal right clavicle along the long axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).

 

 

Clip 1. PoCUS of normal right clavicle along the short axis of the clavicle. The transducer is moving from the lateral to medial, note the visible hyperechoic curved superficial cortex and the subclavian vessels at the end of the clip. 

 

Image 2. PoCUS of normal right clavicle along the short axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).

 

 

Image 3. PoCUS of a fracture in the left clavicle along the long axis of the clavicle

 

 

Clip 2. PoCUS of a fracture of the left clavicle, viewed in the long axis of the clavicle. Compare this view with image 1.

 

 

 

Clip 3. PoCUS of a fracture in the left clavicle viewed in the short axis of the clavicle. Compare this view with Clip 1. Note the fracture through the visible cortex and the displacement that becomes apparent halfway through the clip.

 

Radiographic findings: Radiographic findings of the left clavicle reveal a mid-shaft spiral clavicular fracture.  (Image 4).

Image 4. Radiographic image of fractured left clavicle.

 

Take home point: Research has shown that Ultrasonography is a sensitive diagnostic tool in the evaluation of fractures (Chapman & Black, 2003; Eckert et al., 2014; Chen et al., 2016).

This case provides an example of how PoCUS can be used to diagnose clavicle fractures in the emergency department. In a rural or office setting where radiography is not always available, PoCUS can be used to triage patients efficiently into groups of those with a fracture and those with a low likelihood of a fracture. This would enable more efficient medical referrals while improving cost-effectiveness and patient care.

 

References:

Chapman, D. & Black, K. 2003. Diagnostic musculoskeletal ultrasound for emergency physicians. Ultrasound, 25(10):60

Eckert, K., Janssen, N., Ackermann, O., Schweiger, B., Radeloff, E. & Liedgens, P. 2014 Ultrasound diagnosis of supracondylar fractures in children. Eur J Trauma Emerg Surg., 40:159–168

Chen, K.C., Chor-Ming, A., Chong, C.F. & Wang, T.L. 2016. An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department, Journal of Intensive Care, 4:55

 

This post was copyedited by Dr. Mandy Peach

 

 

Continue Reading

SJRHEM @Calgary CAEP 2018

Congratulations to all our researchers presenting at CAEP Calgary 2018. This year we have had a total of 13 research abstracts accepted for either oral or poster presentation, 2 invited presentations and 1 track chair. We are also involved in a number of administrative, academic and research committee meetings across the conference.


Last years presentations (CAEP Whistler 2017) can be viewed here


Q-Code Link to this page

 

 

 

 

 

 


Download (PDF, 144KB)

 


 

Training first-responders to administer anaphylaxis publicly available epinephrine – a randomized study – Presenter – Robert Dunfield

Download (PDF, 1.08MB)

 


 

Emergency Critical Care Ultrasound (ECCU) paramedical course: A novel curriculum for training paramedics in ultrasound – Presenter – David Lewis

Download (PDF, 702KB)

 


 

Critical Dynamics Study of Burnout in Emergency Department Health Professionals in New Brunswick: Revisiting  5 years later – Presenter – Felix Zhou

Download (PDF, 585KB)

 


 

Do electrocardiogram rhythm findings predict cardiac activity during cardiac arrest? A SHoC series study. – Presenter – Paul Atkinson

Oral Research Presentation – Track 5 – Sunday May 27th 15:50hrs

 


 

Introduction of extracorporeal cardiopulmonary resuscitation (ECPR) into emergency care: a feasibility study – Presenter – Derek Rollo

Download (PDF, 673KB)

 


 

Combatting sedentary lifestyles; can exercise prescriptions in the Emergency Department lead to a behavioural change in patients? – Presenter – David Lewis

Download (PDF, 803KB)

 


 

Development of a predictive model for hospital admissions by utilizing frequencies of specific CEDIS presenting complaints – Presenter – David Lewis

Oral Research Presentation – Track 4 – Wednesday May 30th 12:45hrs

Admission Prediction


 

Changes in situational awareness of emergency teams in simulated trauma cases using an RSI checklist – Presenter – James French

Download (PDF, 937KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of surgical cricothyrotomy with 3-D printed surgical airway trainers – Presenter – James French

Download (PDF, 3.9MB)

 


 

How aware is safe enough? Situational Awareness is higher in safer teams doing simulated emergency airway cases – Presenter – James French

Download (PDF, 760KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of direct intubation with a bougie and airway manikins – James French

Download (PDF, 3.83MB)

 


 

Lung ultrasound – Presenter – Paul Atkinson

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

 


Design is Devine – Presenter – James French

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

Continue Reading

Congratulations @sjrhem resident researchers

Congratulations to Dr Mandy Peach, PGY2 in the EM/FM program, on her success in receiving the Doug Sinclair Top Resident Research Award at the Dalhousie University Emergency Medicine Research Day 2018 and also Top Project at the Dalhousie Saint John FM/EM Project/Research Day 2018. Mandy presented her research on Sonography in Hypotension (SHoC-ED) diagnoses and shock categories.

Well done Derek Rollo and Luke Taylor for their joint runners up position. Derek presented his work on the ECPR/ED-ECMO feasibility study, and Luke presented on Sonography in Hypotension (SHoC-ED) resuscitation markers.

 

Continue Reading

ED Rounds – Oncologic Emergencies and Emerging Treatments

ED Rounds – May 2018

Dr. Paul Frankish

 

Take Home Points

  1. In patients on Immunotherapy for cancer beware of diarrhea or dyspnea, as it may represent an autoimmune side effect.

  2. LMWH is the treatment of choice for the duration of Malignancy associated PE.

  3. SVC obstruction is “sneaky” and new dyspnea is far more common than facial swelling.

 

Immunotherapy

 

 

 

 


Febrile Neutropenia

A single oral temperature >38.3 deg C

or

A sustained oral temperature >38 deg C

with

An absolute neutrophil count (ANC) less than 500 cells per microliter (0.5 x 109/L)

 

*Far and away one of the most common oncologic presentations to the ED

*70% hematologic and 30% solid organ malignancies

*Treatment Timelines (as per IDSA):

1.STAT CBC within 10 minutes

2.Broad empiric antibiotics within 60 minutes

 

History

1.Diagnosis

2.Date and type of last Chemo

3.Use of G-CSF

4.Use of antimicrobials

5.History of prior infection

6.PMH/surgical history

7.Medications/Allergies

 

Exam

1.Mental Status

2.Volume Status

3.Oral Mucosa

4.Skin/Catheter Sites

5.Respiratory

6.Cardiovascular

7.Abdomen

 

Treatment

*Imipenem 500 mg IV Q6H or

*Pip/Tazo 3.375 gram IV Q6H or

*Cipro 400 mg IV and Vanco 1 gram IV Q12H if penicillin allergic

*Consider adding Vanco to monotherapy if:

1.IV Catheter Infection

2.Gram positive organism not yet identified

3.MRSA Colonization

4.Hypotension/Shock

 


SVC Obstruction

*Subacute SVCO results in milder symptoms like facial swelling, cough, dyspnea, facial redness, dilated superficial veins.

*Acute SVCO is more severe and can result in altered LOC, increased ICP, airway obstruction.

*Test of choice is a contrast enhanced CT chest

 

 

Treatment

1.Elevate HOB

2.Dexamethasone 10 mg IV

3.Symptom control

4.Airway management if indicated

5.Urgent Radiation Oncology Consult

6.If known Small Cell Lung Cancer, then worth a call to Medical Oncology

 

 


 

Pulmonary Embolus

*New dyspnea of unknown etiology in patient with active malignancy is a PE until proven otherwise

*Alternate explanations for new dyspnea are pericardial effusion, SVCO, lung tumor burden, anemia.

*Preferred treatment is LMWH indefinitely

 

Investigation of choice is CTPA

 

ECG may show S1QT3 – But don’t rely on this sign

PoCUS may also be helpful for initial triage of acute dyspneic patient – look for dilated RV and IVC

 

Treatment

*Dalteparin 200 units/kg sc for 1 month

then

*Dalteparin 150 untis/kg sc thereafter

*Main evidence for LMWH over warfarin comes from CLOT trial

*50% reduction in recurrent VTE with LMWH vs. warfarin

*Presumed to be because of poor tolerance of PO meds in patients with cancer nauseated from chemo

*May not be relevant in era of modern anti-emetics and anticoagulants, data pending

 


 

Epidural Spinal Cord Compression

1.Back pain (90% of cases)

2.Motor weakness

3.Sensory impairment

4.Autonomic dysfunction

5.Perianal numbness

6.Conus medullaris syndrome

 

Investigations and Treatment

*Dexamethasone 10-20 mg IV immediately if SCC is suspected

*MRI is preferred (generally T/L spine)

*Radiation Oncology if previously diagnosed malignancy

*Neurosurgery if new diagnosis of malignancy

 


 

 

 


SJRH Oncology Services – On Call Consults

 

 

 


Full Presentation

 

Download (PDF, 43.05MB)

Continue Reading

EM Reflections – April 2018

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

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

 

Ondansetron (Zofran) and QTi

Globe Rupture

Ovarian Torsion

 


 

Ondansetron (Zofran) and QTi

  • Ondansetron prolongs QTi in a dose-dependent manner
  • Patient is most at risk for an arrhythmia when peak serum levels are reached
    • Largest difference in QTi was found at 15 minutes (IV), but has seen to persist up to 120 min in heart failure patients.
  • Arrhythmia after a single dose is EXCEEDINGLY RARE
    • No reports of arrhythmia after a single dose of oral ondansetron.
    • Consider ECG monitoring (or use another anti-emetic agent) in patients who are receiving IV ondansetron with other arrhythmogenic factors such as QTi prolonging agents or electrolyte abnormalities

Ondansetron and QTc Prolongation: Clinical Significance in the ED

 


 

Globe Rupture

  • When should you suspect?
    • Mechanism – severe blunt, penetrating, metal-on-metal
  • Signs of open globe include:
    • penetrating lid injury,
    • bullous subconjunctival hemorrhage
    • shallow anterior chamber
    • blood in the anterior chamber (hyphema),
    • peaked pupil
    • iris disinsertion (iridodialysis)
    • lens dislocation, and
    • vitreous hemorrhage. Loss of red reflex can indicate vitreous hemorrhage or retinal detachment.

The EyeRounds.org website has some useful tutorials.

 

Management 

  • Stop Examination
  • NO PATCH – Use Eyes Shield
  • Consult Ophthalmology immediately
  • NPO, Tetanus, IV Antibiotics, analgesia and antiemetics

Download (PDF, 181KB)

 


 

Ovarian Torsion

  • Uptodate:  It is one of the most common gynecologic emergencies and may affect females of all ages
  • Most common ages 20-50 years
  • Acute onset pain with adnexal mass
  • As size of mass increases, risk of torsion increases
    • #1 RF is ovarian mass >5 cm
    • benign > malignant
  • Increased risk during pregnancy, fertility treatments
  • U/S test of choice, although normal doppler does not rule out torsion
  • CT not diagnostic, although if you had a CT that didn’t show an ovarian mass of >5cm, unlikely it was torsion…
  • 86-95% of patients with torsion have a mass (exception – pediatric population – more likely to have torsion with normal ovaries)
  • Pediatric patients – early surgical detorsion more likely to be successful
  • >36 hours – non-viable

A useful recent review can be viewed here

CoreEM provides another useful summary (as well as a huge amount of other EM Topics)

Continue Reading