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:

2005
• 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.

2006
• 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.

2007
• 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

https://www.medscape.com/viewarticle/537538

 

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.

http://www.nejm.org/doi/full/10.1056/NEJMoa1208200

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)

 


 

CME QUIZ

EM Reflections - Jan 18 - CME Quiz

EM Reflections – Jan 18 – CME Quiz

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RCP – Elb-‘ow’! Does my patient with an elbow injury require an x-ray?

Elb-‘ow’! Does my patient with an elbow injury require an x-ray?

Resident Clinical Pearl (RCP) – December 2017

Allyson Cornelis R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Why should you care?

Trauma to the upper extremity can result in injury to the various components of the elbow joint and associated anatomical structures. Important neurovascular structures associated with the elbow joint are the brachial artery, radial artery, ulnar artery, median, radial, and ulnar nerve¹. Elbow injuries causing fracture increase the likelihood of neurovascular damage. If fractures are missed, this may result in further damage and complications including prolonged functional limitations to the joint, nerve damage causing distal functional decline, and potential vascular compromise to the limb more distal to the injury.

Tintinalli’s Comprehensive Guide to Emergency Medicine.2

Functionally, the elbow has two primary movements: flexion/extension, and supination/pronation¹.

Fractures at the elbow may occur at the distal humerus (supracondylar, epicondylar, condylar, trochlea, and capitellum fractures), the proximal ulna (coronoid process, olecranon fractures), and the proximal radius (radial head fractures)¹. Of these, radial head fractures are the most common. Common mechanisms for these injuries include falling on an outstretched hand and direct blows to the elbow.

 

How do I know if my patient requires an X-ray for their elbow pain?

There is a rule for that! The elbow extension rule!

Simply stated: If a patient with an elbow injury is able to fully extend their elbow, they are unlikely to have a fracture and do not require imaging³.

The “how to”:

  1. Provide analgesia to patients
  2. Have patient seated with supinated arms
  3. Have patient flex shoulder to 90 degrees
  4. Ask patient to fully extend elbow to either the point of locking or the same level of extension as contralateral side

Of course, no rule is perfect, and the patient should be reassessed later if the following occur

  • Can no longer fully straighten elbow
  • Pain is getting worse
  • Cannot use their arm as previous

The patient should have imaging at the current visit if:

  • Patient is unreliable for follow up
  • If olecranon fracture is possible

 

The evidence³

Of 1740 patients presenting within 72 hours of traumatic elbow injury, 31% had a fracture³. In adults with the ability to fully extend their elbow following trauma, there was a 2% chance they had a fracture. In adults unable to fully extend their elbow following trauma, there was a 48% chance they had a fracture.

In children able to fully extend their elbow following trauma, there was a 4% chance they have a fracture, and in children unable to fully extend their elbow following trauma, there was a 43% chance they had a fracture³.

 

Bottom LinePatients presenting with elbow trauma and an inability to extend their elbow fully require radiography. Those able to fully extend their elbow do not require imaging unless follow up is unreliable, an olecranon fracture is suspected. Caution should be exercised with assessment in children.

 


Addendum: 

Consider adding PoCUS to your clinical assessment of elbow injuries. Elbow joint effusions are very easily visualized. The presence of a joint effusion in a patient with elbow pain following trauma is a significant finding and warrants further investigation with radiography. Some studies have shown PoCUS to be more sensitive than x-ray in diagnosing occult elbow fractures.

 

Download (PDF, 2.87MB)

 


References

(1) Appleboam, A., Reuben, AD., Benger, JR., Beech, F., Dutson, J., Haig, S., Lloyd, G. (2008). Elbow extension test to rule out elbow fracture: Multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. British Medical Journal, 337:a2428.

(2) Tintinalli, JE. (2016). Cardiogenic Shock (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 1816-1817). New York: McGraw-Hill.

(3) Sheehan, SE., Dyer, GS., Sodickson, AD., Ketankumar, IP., Khurana, B. (2013). Traumatic elbow injuries: What the orthopedic surgeon wants to know. Radiographics, 33(3), 869-884.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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ED Rounds – Ortho Clinic Pathway

ED Rounds – Ortho Clinic Pathway

ED Rounds Presentation by Dr Paul Keyes

 


 

A personal perspective on system review and pathway re-engineering…

 


Rationalization of Process

  • —Every consult is entered by ERP into I3 and printed to accompany copy or ED chart and is placed in clinic book, with a patient sticker placed on clinic appointment sheet.
  • —Non-urgent consults are faxed to orthopedic surgeons offices for triage and cue placement with all other primary care referrals
  • —If subspecialty specific consult requested, then this is faxed to the orthopod of choice’s office. If urgent, then the orthopod on call will sort/laterally refer consult in clinic that week

Outcomes

  • —Collaborative approach ED and ortho
  • —Single process for all orthopedic referrals
  • —Identical sorting of: In ED, Clinic, Ortho office/subspecialty referrals
  • —Legible, billable consults
  • —Timely and appropriate consultations/assessments
  • —Orthopod flexibility as to site of consultation/clinic
  • —Appropriate chain of responsibility from Consult to consultant evaluation

 

Download (PDF, 3.8MB)

 

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EM Reflections – March 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:

 


Vertebral Artery Dissection – a tricky diagnosis and potentially catastrophic if missed…

 

Consider dissection in vertigo patients even without history of significant or mild trauma.

Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Dizziness, vertigo, double vision, ataxia, and dysarthria are common clinical features. Lateral medullary (Wallenberg syndrome) and cerebellar infarctions are the most common types of strokes.

Diagnosis – CT Angiography

Treatment – Antiplatelet or Anticoagulation (unless contraindications – see article below)

Cervical Artery Dissection in Stroke Study (CADISS) trial, RCT – antiplatelets versus anticoagulants in the treatment of extracranial carotid and vertebral artery dissections (VADs) = no difference found in outcomes between groups receiving antiplatelets vs anticoagulants. CADISS

Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations – (full text)

Rounds Presentation by Dr Kavish Chandra (R2 iFMEM)

Download (PDF, 755KB)


 

Limping Kids – inability to weight bear is always significant…

Need for thorough investigation of non traumatic hip pain in child unable to weight bear. Don’t get biased with previous diagnosis even if by specialists.

Don’t miss – Septic Arthritis or SCFE


From – Orthobullets.com – Hip Septic Arthritis – Pediatric – Author:

See this SJRHEM ED Rounds on Limping Kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring (and a high CRP mandates further Ix to rule out septic arthritis)
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg

 

 

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DEM Rounds – October 14th 2014

A big welcome to our nursing / nurse practitioner colleagues at todays rounds. Recent attendance at m&m’s and rounds has been increasing significantly, and a larger venue may soon be required! Just a reminder that ALL (Students, Residents, Physicians, Nurses, NPs, etc) are invited to these CPD (continuous professional development) events.

Dr Chris Vaillancourt  presented the recent update in Food Allergies

We were remind that we are frequently faced with patients and their parents requiring advice on the hot topic of food allergies and especially ‘prevention’ of food allergies

Notes from rounds:

If one parent with a food allergy the child has 30% chance of developing Atopy (atopic dermatitis, childhood Asthma, food allergy, allergic rhinitis) in that order – allergic march – developed over childhood in this order
If two parents  with food allergy = child risk = 70%

Allergen exposure in early infancy is good if its via the gut, bad if its via the skin (especially if atopic via atopic skin rash)
Due to activation of T-Helper Cells – TH1 vs TH2 = less allergies if TH1 activated via gut than TH2 vis skin

Current Strategies  – debunked
Maternal hypoallergenic food eating – false
No cat in house – false – in fact a cat in the house with new infant may be protective

Mechanism
Most kids are getting sensitised via ‘broken skin’ in first year life
Via T-Helper 2 system
Getting exposed via gut stims TH1 system  – reduced risk of allergy

Window of opportunity
For kids at risk
4-6 months window for oral sensitisation – may reduce risk of later food allergy

Other Recommendations
No evidence for using soy milk to prevent food allergy

Breast feed until 4-6months then feed them what you want

Wait fro LEAP study – big RCT looking at food allergies and due to present results in next 2 months

 

 

Dr Peter Ross  presented on Ebola. An extremely stimulating review of the current situation and state of preparedness of own own system. Much discussion was had both during and after the presentation.

It was noted that there is a Provincial plan for managing patient with suspected Ebola. This can be accessed via the Horizon Intranet (Skyline Homepage) This is updated regularly. SJRHEM has printed copies of the plan in accessible areas of the department. These should be accessed and read by all. We have already completed an in-situ simulation for a ‘potential’ ebola case this month. The report for this can be accessed in the Simulation Files  – InSitu Sessions – Oct 3rd.

PPE Training is ongoing

Dr Howlett will be posting an update to this website in the next week

Video: here

Full presentation here : 

Download (PDF, 796KB)

 

Dr David Lewis presented on limping kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg

Full presentation here: 

Download (PDF, 2.08MB)

 

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DEM Rounds – June 10th 2014

Impressive attendance at today’s Rounds. This must be reflective of the quality of the presentations, which were both informative and entertaining.

Dr Todd Way kicked us off with a timely reminder on the importance of quality ED Charting. Remember, “if its not written in the chart – it didn’t happen” – Your best defence in any legal issue or complaint are high quality, contemporaneous and legible notes in the ED chart.

We were reminded of the importance of addressing inconsistencies between other related records (triage/EMS) and our own notes “historic alternans”

More and more physicians are now subject to the “Atlantic Colleges Medical Peer Review” process – which includes a thorough review of charting practice. So, now is a good time to reflect on your ED Charting by asking yourselves the following questions:

  • The best part of my chart is_________
  • The first thing I would change about the way I chart is _______.
  • The main reason I don’t do a better job of charting is ________.
  • My ED department could better support my charting by ________.
  • If I could choose 1 thing to change in my colleagues chart it would be _________.
  • The ideal type of charting for me is _______. (Ie. EMR, T-chart, form chart, dictation, scribed, etc.)

Full presentation here:  ER Charting-Way-June 2014

 

Dr Paul Page chose the beginning of summer to remind us that, with the close proximity of the Bay of Fundy, accidental hypothermia can occur at any time of the year here in Atlantic Canada!

Accidental hypothermia is defined as a drop in core body temperature to less than 35 degrees Celsius. Measurement of core temperature is dependent on properly calibrated low reading thermometers. In an intubated patient use a thermistor transducer inserted into lower 1/3 esophagus.

Rewarming with high volumes of warm (38-42 degrees Celsius) i.v fluids. Active external and minimally invasive internal rewarming.

Consider ECMO if not responding to medical therapy or when signs of life absent.

Up to 3 defibrillations but withhold epinephrine until temp > 30 degrees Celsius

Potassium  10-12 mmol per litre is the cut-off for futility.

Immersion has a better outcome than submersion.

 

Full presentation here : Accidental Hypothermia – Page – June 2014

 

Dr Paul Keyes gave us the benefit of his many years in practice with his talk “the orthopaedic things I wish I knew in 1998…”

 

Posterior dislocation of the gleno-humeral joint is commonly missed. Patients with poor ability to communicate suffer this injury disproportionately – Epilepsy, ETOH, Electrocution.

 

Knowledge of the shoulder radiographic views and ability to interpret the axillary Y view is imperative.

 

Whatever reduction technique is used the elbow must be able to cross the midline freely to confirm the shoulder is in joint.

If you cant prove its in joint then it’s out of joint…

 

Joint aspiration  delays arthroplasty by 3-6 months, due to perceived increased risk of infection by the orthopaedic surgeon. It may be appropriate if concerned about a possible diagnosis of septic arthritis, but do consider the implications and definitely don’t stick a needle through an infected bursitis in to a sterile joint.

 

Don’t aspirate a joint post-arthroplasty until you have discussed the case with the operative surgeon/surgeon on call.

 

Hip arthroplasty can be either Total or Hemi. Total hip arthroplasty (THA) includes an acetabular component which can result in an obstruction to straightforward reduction.  THAs are more likely to be damaged by vigorous reduction attempts. Therefore discuss with operative surgeon/surgeon on call prior to any heroics.

 

Flouroscopic guided reduction will save time and face. It should be considered for all major joint reductions but in particular the elbow joint.

 

Always document vascular/nerve integrity pre and post reduction.

 

Full presentation here: ED rounds Ortho – Keyes – June 2014

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