A Crushing Case – Compartment Syndrome

A Crushing Case – Compartment Syndrome

Resident Clinical Pearl (RCP) March 2019

Mark McGraw– PGY1 FMEM Dalhousie University, Saint John NB

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


Case Part 1

Its early afternoon during your ortho call shift and you get a call from emerge staff saying that they have two patients coming with potentially significant injuries when a piece of equipment rolled over during transport. EMS has informed them that one has a broken ankle. When you arrive to the ED he tells you they are just getting the patient’s pain under control and ordering x-rays.

You head to the room to see the patient, a large burly 35 y/o with an obviously deformed R ankle. His exam is otherwise unremarkable at this time, he has good cap refill to the toes, sensation to the web space, dorsum/plantar and medial/lateral surfaces of the foot is intact and he is able to move his toes. On palpation his lower leg compartments are firm but not hard. An x-ray is done at bedside and shows a Weber Type B fracture of the fibula. His pain seems to be increasing as you speak with him and he has no significant past medical history. He tells you he was loading a piece of equipment when it got away from them and rolled over his leg pinning him momentarily, so he was hanging off a piece of equipment by the leg. Your exam is limited by pain and you ask the nurse if she can give the patient some more pain medication and you’ll return as soon as you see the other patient.


Clinical Pearl: Compartment Syndrome

Compartment Syndrome occurs when the pressure within a muscle compartment exceeds the pressure needed to adequately perfuse tissue. It is considered a true orthopedic emergency and delays in diagnosis and treatment can result in the loss of a patient’s life or limb

Anatomy/Pathophysiology

-Muscle compartments are bound by bone or fascia, two restrictive tissues that create a relatively fixed volume compartment with a very limited ability to compensate for any increase in fluid volume.

-When a traumatic or pathological process results in increased fluid within a muscle compartment the pressure within the compartment increases. This increase in pressure results in reduced arteriovenous pressure gradient (reduced arterial pressure and increased venous pressure) that impairs tissue perfusion within the compartment.

  • As the pressure rises within the compartment capillary flow declines resulting in an enhanced local blood vessel permeability which further increases compartment pressures. If pressures continue to rise tissue ischemia and necrosis will develop.
  • Time for tissue necrosis to occur will vary from patient to patient it can occur in as little as 3 hours and most literature suggests that a fasciotomy must be performed within 4 hours of the onset of ACS to prevent irreversible damage.2

 

 

Signs and Symptoms

Compartment syndrome is a true orthopedic emergency and early recognition of its clinical signs is critical in preventing irreversible tissue damage, rhabdomyolysis, and limb loss.

  1. Pain out of proportion
  2. Pain with passive stretch
  3. Paresthesia
  4. Pain at rest
  5. Paresis

 

  • Severe pain out of proportion to the examination and pain with passive stretching are the first symptoms of ACS to occur. While the early signs are 97% specific for ACS they are only 19% sensitive in the absence of other findings.

  • The combination of pain with passive stretch, paresthesia, and pain with rest has been reported to be 93% sensitive and if paresis is present the sensitivity increases to 98%1. Unfortunately, paraesthesia and paresis are late findings of ACS and delaying the diagnosis until they are present can result in unacceptable delays in treatment. Once a motor nerve deficit has occurred patients will rarely recover function after fasciotomy.

Diagnosis 1

  • Normal compartment pressures are between 8 and 10mmHg in adults and 10-15mmHg in children.
  • 30mmHg is diagnostic for compartment syndrome and should prompt an orthopedic referral when combined with clinical symptoms of compartment syndrome.
  • An alternative is to calculate a differential compartment pressure for an individual patient as factors such as hypertension, peripheral vascular disease and patient medication can cause a large variance in individuals compartment pressures.
  • Differential compartment pressure is calculated by the diastolic blood pressure minus the intra-compartmental pressure if this is under 20mHg then fasciotomy is indicated.
  • If the patient is alert and able to elevate the affected limb, serial examinations over a two-hour period may prevent unnecessary fasciotomies. This should be done in consultation with your orthopedic colleagues.

 

Measuring compartment pressures

Devise: dedicated compartment manometer (Stryker Intra-Compartmental Pressure Monitor) or by using IV tubing and an ART line transducer attached to a long needle.

Who is most at risk of developing compartment syndrome?

  1. Fractures represent 70% of all cases5.
  2. Fractures of the tibial diaphysis account for 40% of all cases in North America.
  3. Open fractures of the tibia are still high risk for compartment syndrome because the opening is insufficient to relieve the compartment pressure associated with the fracture.6

Management of potential compartment syndrome in the ED

  1. Supplemental oxygen if indicated
  2. Remove all cast material, clothing or wraps around the limb
  3. Elevate the limb to the level of the hear
  4. Apply ice to the affected limb if the compartment syndrome is secondary to trauma.
  5. Definitive treatment is a surgical fasciotomy.

 

Case Part 2

You return to see the patient and nursing staff tell you they are unable to get the patients pain under control despite significant amounts of narcotics.

The examination of the lower leg is repeated and the compartments of the leg feel the same however the patient is unable to move his toe. He reports significant pain on passive flexion and extension of the great toe. You call your staff to inform her of the change in the patient and that you are concerned about compartment syndrome and she requests compartment pressure measurements using the Stryker Kit. The senior resident performs the compartment pressure measurements with you and you record pressures of 14, 14 and 25mmHg.

In discussion with the staff you decide to leave the leg on a posterior slab unwrapped, at the level of the heart, and with ice applied 20 on 20 off and perform serial examinations. The serial examinations are unremarkable and the patients pain becomes manageable. The patient is brought to the OR approximately 5 hours later for ORIF of his distal fibula. Compartment pressures are repeated in the OR and were 12, 10, 32 mmHg. An ORIF is performed and you perform serially examinations on the patient q1h overnight. The patient is discharged the following day


Case Follow Up

The patient had significant leg pain on discharge and subsequently presented to the ED on POD#7 for significant leg swelling. Ultrasound was performed to rule out DVT and the patient was discharged for follow up in clinic. He did not go on to develop any further complications.


 

Bottom Line

Compartment syndrome is an important not to miss diagnosis. It should be considered in any hard to control limb pain, especially when associated with fracture.


 

References

  1. 1.Duckworth, A. D., & McQueen, M. M. (2017). The Diagnosis of Acute Compartment Syndrome: A Critical Analysis Review. JBJS Reviews, 5(12), e1. https://doi.org/10.2106/JBJS.RVW.17.00016
  2. Long, B., Koyfman, A., & Rdms, M. G. (2019). Clinical Review. Journal of Emergency Medicine, (December 2018), 1–12. https://doi.org/10.1016/j.jemermed.2018.12.021
  3. McQueen, M. M., & Court-Brown, C. M. (1996). Compartment monitoring in tibial fractures. The pressure threshold for decompression. The Journal of Bone and Joint Surgery. British Volume, 78(1), 99–104.
  4. McQueen, M. M., Duckworth, A. D., Aitken, S. A., Sharma, R. A., & Court-Brown, C. M. (2015). Predictors of Compartment Syndrome After Tibial Fracture. Journal of Orthopaedic Trauma, 29(10), 451–455. https://doi.org/10.1097/BOT.0000000000000347
  5. Stella, M., Santolini, E., Sanguineti, F., Felli, L., Vicenti, G., Bizzoca, D., & Santolini, F. (2019). Aetiology of trauma-related acute compartment syndrome of the leg : A systematic review. Injury, (2018). https://doi.org/10.1016/j.injury.2019.01.047
  6. Strohm, P. C., & Su, N. P. (2004). Acute compartment syndrome of the limb, 1221–1227. https://doi.org/10.1016/j.injury.2004.04.009
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An approach to the unexpected pregnancy

Resident Clinical Pearl (RCP) – March 2019

Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

 

As Emergency Physicians we perform a number of pregnancy tests on women of childbearing age presenting to our care. It is an important part of our practise to screen for life threatening conditions like ectopic pregnancy and also avoid giving medications or preforming investigations that could be harmful to a fetus.

As with any medical test that we do, there are sure to be surprise results that we, or the patients, were not expecting.

A positive BHcG is not always a positive result for a patient we are treating. It is important as medical providers to handle this situation in an empathetic way and be armed with information to help the patient with this potentially life changing information.

An approach to an unexpected pregnancy result:


1. Ensure that the patient either has a support person with them, or if they wish, is alone. This is still confidential information and should be treated as such.
2. After informing the the patient of the pregnancy test result, it can be helpful to assess whether this is a wanted pregnancy. This can help you to assess what information you are going to provide her.
3. If it is an unwanted/surprise pregnancy it is helpful to inform her of her options.
      a. Continue the pregnancy to term
      b. Abortion
      c. Adoption


Since continuing with the pregnancy and adoption will be a long-term navigation and not necessarily time sensitive these discussions are better carried out in primary care / family practice. However, the options for pregnancy termination that are available in Canada and specifically New Brunswick are time sensitive.

It is crucial that patients who are considering these options be provided with accurate and timely information about their legal choice to end a pregnancy. Physicians who are unable to provide this information, for whatever reason, are expected to pass this responsibility on to a physician who can in a time sensitive manner.

Abortion options available in Canada:

 


Information for Patients considering termination of pregnancy


Surgical Abortion:
Abortion is decriminalized. There is no actual legal limit on the gestational age on which abortions can be performed.
Most intuitions in Canada have their own gestational age cut offs and the majority of abortions done in Canada are before 20wks.
The early on in the pregnancy generally the safer the procedure.

Advantages: once you’ve had the procedure it is done.
Disadvantages: you have had to have a d&c (dilation and curettage) and although relatively safe, there are always risks associated with surgical procedures.

 

Medical Abortion:
Medications used are Mifepristone and Misoprostol.
Mifepristone blocks progesterone which is a hormone responsible for maintaining a pregnancy.
Misoprostol is a medication taken up to 48 hours after the mifepristone and causes uterine contractions that empty the uterus.
The process is often described as like having a really heavy and crampy period.
Advantages: No surgical procedure, so can be done in your own home.
Disadvantages: more prolonged, may require more follow up with physicians, can’t be done past 9 weeks.

In New Brunswick: the drug can only be obtained with a prescription from a doctor who has completed the six-hour training required to prescribe it. It’s unclear how many New Brunswick doctors have the training.
You must have a valid health card and an ultrasound showing your gestational age to have the drug covered by the province.

 

Options available in New Brunswick:

Clinic 554 (Fredricton NB)
Able to self refer
Phone Number 506-261-7355
Patients can expect a 5-10-minute intake appointment over the phone.
Counselling, ultrasound and doctor’s exam are all done in the same visit as the abortion so you would only have to travel once.
Surgical are preformed up to 15wks and 6days.
Medical up to 9 weeks.
Cost between 700-850$ for surgical abortion.
Medical abortions are free.

Bathurst Chaleur Regional Hospital (Bathurst)
Able to self refer
Phone number 506-544-2133
Surgical abortions are available up to 13wks 6days.
Hospital based surgical abortions are free of charge.

Dr. Georges Dumont University Hospital Center (Moncton) – French
Able to self refer
Phone number 506-862-2770
Surgical abortions are available up to 13wks and 6days.
Hospital based surgical abortions are free of charge.


The Moncton Hospital- English
Able to self refer
Phone number 1-844- 806- 9205
Surgical abortions are available up to 13wks and 6days.
Hospital based surgical abortions are free of charge.
For options available in every province in Canada please see this list:
http://www.arcc-cdac.ca/list-abortion-clinics-canada.pdf

 

Copyedited by Dr. Mandy Peach

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Shoulder Dislocation – The Cunningham Technique

The Cunningham Technique for massaging a shoulder dislocation back into place

Resident Clinical Pearl (RCP) February 2019

Renee Amiro – PGY2 FMEM Dalhousie University, Saint John NB

Reviewed and edited by Dr. David Lewis


Case

A 53-year-old man comes in to the emergency department after having fallen at work and “hurt his shoulder”. Clinically, it is assessed as an anterior shoulder dislocation and he is sent to x-ray which confirms your diagnosis.

Traditionally, the way to reduce a dislocated shoulder involves procedural sedation and some pulling on the arm. While it may save the patient some pain, procedural sedation is not without its risks to the patient and has high staffing needs. Learning some less risky techniques for shoulder reduction can make it safer for your patient and less time intensive for you and your staff!

Anatomy

The shoulder is an inherently unstable joint. The glenoid is shallow and only a small portion of the humeral head is articulating with the glenoid in any position. The rotator cuff provides additional support to the shoulder joint.

Mechanism of Injury for an Anterior Shoulder Dislocation

Most commonly it is a blow to the abducted, externally rotated, and extended arm.

Less commonly a blow to the posterior humerus or fall on an outstretched arm.

Clinical Exam

The arm will be slightly abducted and externally rotated. It will be lost of the normal rounded appearance of the shoulder.

Examination of the axillary nerve and peripheral pulses are essential when examining a patient with an anterior shoulder dislocation before and after reduction.

Imaging

On AP radiograph  the head of the humerus will appear medial to the glenoid. On a lateral radiograph it will appear anteriorly displaced. Take care with posterior dislocations as these can appear in joint on the AP, and may only be apparent on the lateral Y view.

 

Figure 2. radiograph of an anterior shoulder dislocation.2

Don’t forget you can use PoCUS to triage shoulder injuries too:

Resident Clinical Pearl – PoCUS Triage Shoulder Dislocation

 

Based on your clinical examination and imaging, you have determined that this patient indeed has an anterior shoulder dislocation. You have decided to avoid procedural sedation if you can and attempt reduction with the Cunningham technique!

The Cunningham Technique

Step 1
  • Inform the patient of what you are going to attempt. Tell them that their cooperation is necessary for success. Try and relax the patient by getting them to do deep, slow breathing.
Step 2
  • Sit the patient up with the back straight and shoulder blades pulled back. You can use a bed or a chair, whatever is easiest and most comfortable for both you and the patient.
Step 3
  • Get the patient to support the arm and bring it in to the best position to facilitate reduction. That location is typically with the arm abducted and pointing down with the elbow flexed at 90 degrees with the forearm pointing horizontally and anteriorly.
Step 4
  • Sit opposite the patient and place your hand on their elbow in between their body and their arm. Rest their forearm and hand on your arm.
Step 5
  • Apply steady downward traction with the weight of your forearm. Keep the gentle weight on the arm through out. Should now be causing pain as this will cause the muscles to spasm.
Step 6
  • Massage the trapezius, deltoid, and biceps muscles in sequential order. Repeat this process over and over. Your thumb should be anterior with four fingers posterior as your massaging these muscles. Most times you will not get the traditional “clunk” sound so frequent reassessments are necessary to see if the shoulder has been relocated.

YouTube Video Link of Cunningham Technique

The Bottom Line

The Cunningham technique can be used as a safe, successful and less resource intensive procedure to relocate an anterior shoulder dislocation. Patient engagement and cooperation is essential in its success.


Similar Alternative to the Cunningham Technique (The Sool’s Method):


References

  1. Cunningham N. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med (Fremantle). 2003 Oct-Dec;15(5-6):521-4. PMID: 14992071.

 

  1. Sherman, S. (2018, August). Shoulder dislocation. Retrieved March 01, 2019, from UTD
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PoCUS – Pleural Effusion

Medical Student Clinical Pearl

James Kiberd

Class 2019 Dalhousie Medicine

Reviewed and Edited by Dr. David Lewis


Case: 

A 90 year-old male presented with worsening shortness of breath on exertion, crackles bilaterally at the bases on auscultation with known history of congestive heart failure. Bedside ultrasound was performed to assess for pleural effusion

Lung Views:

In order to perform ultrasound of the lungs, there are four views that are obtained (see Figure 1). Place the patient supine. The high frequency linear array transducer is often used, but either the phased array or curvilinear transducers can be used. The first views are taken at both right and left mid-clavicular lines of the anterior chest. With the marker of the transducer pointed toward the patient’s head, a minimum of 3-4 rib spaces should be identified. The next views are of the posterior-lateral chest. The patient can be supine or in the sitting position. It is these views where a pleural effusion can be identified.

Figure 1: Chest views with ultrasound. ‘A’ are anterior chest view positions and ‘B’ are posterolateral view positions

Pleural Effusion

Pleural effusion is assessed by ultrasound placing the transducer in the midaxillary line with the marker oriented toward the patient’s head. On the patient’s right side the diaphragm, the liver, and the vertebral line can be seen. On the left, the diaphragm, spleen, and vertebral line should be in view. In a patient without pleural effusion, one should not be able to visualize the lung as it is mostly air and scatters the sound produced by the transducer. However, in the presence of pleural effusion, the area above the diaphragm is filled with fluid and therefore will appear anechoic. In addition, the vertebral line will be present past the diaphragm as the fluid allows the sound waves to propagate and not scatter. This is known as the ‘spine sign’ (also known as the ‘V-line’). Finally, one is often able to see the atelectatic lung float and move with respirations in the fluid, this is known as the ‘sinusoid sign.’ These are the three criteria outlined by consensus statements in the identification of pleural effusions.1 Occasionally, the area above the diaphragm may look like spleen or liver, but this is known as ‘mirror image’ artifact and is normal.2 Figure 2 shows both the right and left views of our patient.

Figure 2: Pleural effusion showing anechoic pleural fluid, atelectatic lung, and ‘spine sign

Accuracy with Ultrasound

Ultrasound is more accurate than either chest x-ray or physical exam in the identification of small pleural effusions.3 For a chest x-ray to identify fluid there usually needs to be more than 200cc present.2 A meta-analysis found that ultrasound had a mean sensitivity of 93% (95%CI: 89-96%) and specificity of 96% (95%CI: 95-98%).4

 

Our patient went on to have a chest x-ray where he was found to have bilateral pleural effusions (see Figure 3).

Figure 3: Bilateral pleural effusions seen on chest radiography in our patient.

In Summary

Three criteria are used to identify pleural effusion on ultrasound; anechoic fluid above the diaphragm, the ability to visualize the spine above the diaphragm (‘spine sign’), and atelectatic lung moving with respirations (‘sinusoid sign’). Lung ultrasound for the detection of pleural effusion is more reliable to identify small effusions in comparison to both radiography and physical exam.


References:

  1. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. doi:10.1007/s00134-012-2513-4.
  2. Liu RB, Donroe JH, McNamara RL, Forman HP, Moore CL. The practice and implications of finding fluid during point-of-care ultrasonography: A review. JAMA Intern Med. 2017;177(12):1818-1825. doi:10.1001/jamainternmed.2017.5048.
  3. Wong CL, Holroyd-leduc J, Straus SE. CLINICIAN ’ S CORNER Does This Patient Have a Pleural Effusion ? PATIENT SCENARIO. Jama. 2010;301(3):309-317. doi:10.1001/jama.2008.937.
  4. Grimberg AI, Carlos Shigueoka DI, Nagib Atallah III Á, et al. Diagnostic accuracy of sonography for pleural effusion: systematic review Acurácia diagnóstica da ultrassonografia nos derrames pleurais: revisão sistemática
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EM Reflections – February 2019

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

Edited by Dr David Lewis 


Discussion Topics

  1. Can diagnostic ultrasound reliably rule out appendicitis?
  2. Do mandibular fractures need to be admitted?
  3. Can neuromuscular disorders alone result in symptoms of dyspnoea?

Can diagnostic ultrasound reliably rule out appendicitis?

  • Accuracy depends upon the skill and experience of the sonographer – when the appendix is visualized the accuracy of ultrasound is equivalent to CT – sensitivity and specificity of 91-98% and 86-92%
  • Inaccurate examinations were significantly associated with high body mass index (≥85th percentile, primarily false-negative results) 

In this case, a patient with clinically suspected appendicitis, had an ultrasound that was reported normal i.e the appendix was visualized and appeared normal. A subsequent CT confirmed the diagnosis of appendicitis.

Take Home Point: All diagnostic tests have a false negative rate. If it looks like a sock, even if the test says it isn’t, it still might be.


Do mandibular fractures need to be admitted?

  • Must assess open vs closed – open needs ABx
  • Consider MOI/associated injuries
  • Bilateral #’s – airway obstruction 
    • Posterior displacement of the tongue
    • Bleeding – tearing of the periosteum and muscles attached to the mandible – sublingual hematoma, swelling and life-threatening airway compromise
    • Edema
    • FB

Admission Criteria:

Admit (ENT, OMFS, Plastics) for:

  1. Airway compromise (e.g when lying flat)
  2. Unable to tolerate PO or secretions
  3. Inadequate pain control
  4. Open and/or unstable fractures

Useful review article here

In this case the patient was admitted to Family Medicine after discussion with other relevant specialties.

Recommended Disposition Guidelines for Trauma Patients:

Take Home Point: Mandibular fractures are usually indicative of significant force. They are usually fractured in 2 places and therefore unstable. Disposition to appropriate specialist and level of care is recommended.


Can neuromuscular disorders alone result in symptoms of dyspnoea?

Consider all the common causes of dyspnoea first

“No single abnormality is diagnostic of respiratory muscle weakness; rather, diagnosis is based on a constellation of abnormalities. The use of single tests tends to overdiagnose respiratory muscle weakness, whereas use of combinations of tests increase diagnostic accuracy.”

And interesting case report here

Take Home Point: A differential diagnosis should always include the common conditions, but also consider the rarer conditions. Online tools are available to help with rare disease diagnosis – see this article

Some online differential diagnosis tools:

http://www.findzebra.com/

https://www.isabelhealthcare.com/

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CAEP 2019 – Crowded House?

CAEP 2019, Halifax, May 26-29, 2019

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


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



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

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

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


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

Crowded House – Don’t Dream It’s Over

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

Resident Clinical Pearl (RCP) February 2019

Renee AmiroPGY3 FMEM Dalhousie University, Saint John NB

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

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

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

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

Indications:
Presence of an uncomplicated Bartholin’s cyst.

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

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

Procedure

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

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

Duration of ward catheter placement is on average four weeks.

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

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

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

Bottom Line:

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

References

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

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PoCUS – Pneumothorax

Medical Student Clinical Pearl

Vlad Kovalik
MD Candidate, 2019
Dalhousie University Faculty of Medicine

Reviewed and Edited by Dr. David Lewis


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

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

PoCUS for Pneumothorax

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

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

Lung sliding


Absent lung sliding

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

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

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

Lung Point

In summary

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

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

Medical Student Clinical Pearl – January 2019

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

Reviewed and Edited by Dr. David Lewis


Case

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

What diagnoses should be considered?

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

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

What questions should this patient be asked?

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

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

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

Are any investigations required?

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

Is fecal occult blood test required?

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

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

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

How should this patient be managed?

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

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

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

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

Case revisited

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

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


References

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

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

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

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

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

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

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

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