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

ED Rounds – October 2015

This month ED Rounds were presented by Dr Mike Howlett  , Dr James French and Dr Wendy Alexander (Pediatrician SJRH).


Congestive Heart Failure – Dr Mike Howlett

Dr Howlett presented 4 cases that highlighted the differences in pathophysiology and approaches to treatment for CHF in the ED.

The definition of Congestive Heart Failure (ESC 2012 Guidelines)

a syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of cardiac structure or function

Diagnosis of CHF

The diagnosis of heart failure with reduced ejection fraction (Systolic) and Heart Failure with preserved ejection fraction (Diastolic) is summarised in the box below.

Diagnosis HF

The mortality of Diastolic and Systolic HF are similar


Dr Howlett’s full presentation can be downloaded / viewed below:

Download (PDF, 7.3MB)


How to be Awesome at Simulation – Dr James French

Dr French presented an interactive session that highlighted the important steps to designing, running and debriefing a simulation.

See our Simulation Program page for more details

Presentation to be uploaded here soon…


Pediatric Asthma – Dr Wendy Alexander

Dr Alexander presented pediatric pearls accumulated over her 25 years of practice.

See the SJRHEM Pediatric Asthma Guidelines





Continue Reading

ED Rounds – June 2015

Thanks to Dr Emily Love for preparing this useful post that summarizes the ED Rounds presentations for June 2015.

Resident Elective to South Africa.

Dr Leanne Hewitson and Dr Sarah Compeau

This was a great presentation. The girls talked about their work in several different hospitals in South Africa where they had an opportunity to assess and treat a large volume of trauma patients. In terms of some of the ways these hospitals differed from ours, there were often less resources (for example, there would be only so many suture trays for the night and they had to be careful not to use these up unnecessarily; also there were only two bags of O negative blood in the department in one of the hospitals – if they needed more they had to call a driver who would transport the blood from a facility 45 mins down the road).  

Another difference was staffing. There typically was not an attending staff on site, and they had a lot of independence in terms of diagnosing and treating their patients. they worked closely with a junior resident, a medical student and a senior physician who was not yet an attending (I can’t remember the name they assigned to this role).

Examples of hands-on opportunities: chest tube insertion, assessing and treating stab wounds and patients with multiple traumas

In terms of the discussion after the presentation, we talked about safety. In one of the cities, it was not safe to go out alone at night and was necessary to always have a route planned out so they would not get lost and end up in a dangerous area. The girls did feel  that with good planning and proper cautions the benefits of the experience outweighed the risks.  

Hands on experience: We talked about how valuable this experience was in terms of seeing a large volume of trauma patients, which we don’t see here in Canada. The girls both feel they are much more comfortable treating trauma patients here after their experience and would recommend it to other residents.

Teaching residents in other centers: Sarah and Leanne were able to both learn from house staff at the hospitals and also share some of their own skills. For example, they were able to teach ACLS protocols to the residents at one of the centers as they did not have formal  ACLS training as they did here.

Download (PDF, 7.5MB)

ST elevation in a 33 year old in RAZ

Dr Nicola Smith

This was a very interesting prevention and a good lesson to all of us on recognizing our own biases that may affect patient care.

When a 33 yo otherwise healthy female presented to RAZ with a headache, some potential biases were as follows

1- the triage note mentioned that she was quiet anxious but had settled

2-  she was in RAZ which gives the impression the patient is not acutely ill

3- it was the end of the day after a long busy day

The resident who saw this patient recognized these biases, and spent time with her to do a thorough history and physical. She was prompted to order an ECG which showed the ST elevations when the patient spoke about pain starting in her abdomen and moving up to her head and also left arm numbness.  

the patient turned out to have a pheochromocytoma. Lessons we learned about this are as follows:

1- close blood pressure and HR control are key before any surgery as there is a risk with surgery of further release of catecholamines and  a hypertensive emergency

2- these patients need close work-up for MENS syndromes

3 – there are some case studies reporting ST elevations in pheochromocytoma.

Download (PDF, 15.07MB)

Continue Reading