Trauma Reflections – October 2018

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

 


Major points of interest:

 

A)  Intubated patients should not need restraints..

Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.

Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.

 

B)   But what about this guy with the BP of low / really low?

Consider “vitamin K” – ketamine – can augment BP in patients who are not catecholamine depleted.

 

C)  Trauma patients you know will require consultants

When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.

Required consultants need to attend to critically injured in a timely fashion. Escalate to department head or chief of staff if there is unreasonable delay.

View the SJRHEM Trauma Page for list of definitions including Trauma Team, Activation Levels etc

 

E) Managing the pediatric airway – adrenalizing for all involved

Pediatric trauma is the pinnacle of a HALF (high acuity, low frequency) event. Team approach is key. Get out the Broselow tape.

Bradycardia with intubation attempts is not infrequent in youngest patients. Consider atropine as pre-med if  < 1 year of age or < 5 years of age and using succinylcholine.

 

F) MTP

Do not forget platelets and plasma if onto 4th unit of PRBCs – 4:1:1 ratio.

 

G)  Where is this patient being admitted?

Not to the hospitalist service, that is where!

Patients with significant injuries, but not needing immediate surgical intervention, should be admitted/observed in ICE x 24 hrs. Department head and/or chief of staff are available to assist if needed.

 

H)  Chest tube types and sizes

Pigtail catheters for traumatic pneumothorax are effective, less painful and are gaining favour as an alternative to traditional chest tubes. As for sizes, there is likely little benefit for 36F over 32 F catheters – probably time to retire these monsters from the chest tube cart.

I)     Why do bedside U/S if patient about to go to CT?

Chest scan might prompt chest tube placement prior to CT if pneumothorax is identified. Although identifying blood in the abdomen prior to CT may not change your management – it may prompt an earlier call to general surgery.

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EM Reflections – October 2018

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

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

 

Trauma – Secondary Survey

DNAR Considerations 

ED Neonatal Equipment

 


Trauma – Secondary Survey

The secondary survey is performed once the primary survey and resuscitation has been completed.

The secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are underway, and the normalization of vital functions has been demonstrated. When additional personnel are available, part of the secondary survey may be conducted while the other personnel attend to the primary survey. In this setting the conduction of the secondary survey should not interfere with the primary survey, which takes first priority. ATLS 9e

This means that on occasions trauma patients may be transferred to the OR or ICU before the secondary survey has been completed. The secondary survey is a thorough head to toe examination including where indicated adjunct investigations e.g limb radiographs. This assessment must be carefully performed and documented. It should not be rushed.

If there is not enough time to complete a thorough secondary survey (e.g patient transferred to OR during primary survey) then this should be communicated to the surgeon or other responsible physician (e.g ICU) and the documentation should reflect this.

We would recommend that all trauma patients admitted to the ICU undergo a repeat secondary survey assessment as part of the standard admission process. In some systems this is referred to as a Tertiary survey.

This systematic review reports a reduction missed injury rate when a tertiary survey is used as part of a trauma system.

Trauma.org article on tertiary survey


DNAR Considerations 

The CMPA provides excellent guidance for clinicians considering Do Not Attempt Resuscitation orders. CMPA Website

CMPA – Key Concepts for End of Life Issues

  • The best interests of the patient are paramount.

  • The capable patient has the right to consent to or refuse medical treatment, including life-sustaining treatment.

  • Thoughtful and timely advance care planning, discussion, and documentation of a patient’s wishes and healthcare goals can help avoid misunderstandings.

  • Physicians should be familiar with any relevant laws and regulatory authority (College) policies concerning end-of-life care, and the withholding or withdrawing of life-sustaining treatment, and medical assistance in dying.

  • When considering placing a do-not-resuscitate order in the medical record, or acting upon a do-not-resuscitate order, consent from the patient or substitute decision-maker is advisable. It may also be helpful and appropriate to consult with physician colleagues and the patient’s family to determine support for the order.

  • Decisions about withholding or withdrawing life-sustaining treatment that is considered futile or not medically indicated should be discussed with the patient, or the substitute decision-maker on behalf of an incapable patient. When consensus is not achieved despite discussions with the substitute decision-maker, the family, and others such as ethics consultants, patient advocates, and spiritual advisors, it may be necessary to make an application to the court (or an administrative body) or seek intervention from the local public guardian’s office.

  • Physicians considering a request for medical assistance in dying should be familiar with the eligibility criteria set out in the Criminal Codewith applicable provincial legislation, and with applicable regulatory authority (College) guidelines.

  • Physicians should be familiar with the role of advance directives (including living wills).

  • End-of-life decisions should be carefully documented in the patient’s medical record.

Horizon Health, NB uses these accepted Canadian DNAR definitions:

 


 

ED Neonatal Equipment

Perinatal Services BC, Canada have published an excellent document – Standards for Neonatal Resuscitation

It includes this Appendix for suggested Radiant Warmer Equipment checklist:

 

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EM Reflections – September 2018

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

Edited by Dr David Lewis 

 

 


 

Top tips from this month’s rounds:

 

Pediatric Head Injury

Clonazepam Toxicity

Pediatric(< 3 months)Fever

Wide Complex Tachycardia

 


Pediatric Head Injury

  • What are the criteria for CT Head?

In a recent Lancet article (2017),  PECARN, CATCH and CHALICE were compared.

The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7–100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4–100·0; 97/98)

  • How do I use PECARN?


 

A useful review by EM Cases can be accessed here. In an update to this review they have noted recent new evidence that isolated vomiting without any other positive rule predictors may warrant observation only:

Update 2018:  A secondary analysis of the Australasian Paediatric Head Injury Rule Study demonstrated head injury with isolated vomiting (i.e. vomiting without any of clinical decision rule predictors) was uncommonly associated with TBI on CT, or the presence of clinically important TBI.  This study suggests a strategy of observation without head CT may be appropriate management.  Abstract

Vomiting alone should not instigate CT.  Risk goes up with any other Head Injury symptoms (Headache etc). These children should be observed until they are able to tolerate oral intake and the treating clinician feels comfortable that the patient is stable without additional symptoms of head injury.

This article discusses linear skull fractures. It reminds us to always consider Non-Accidental Injury in all cases of pediatric head injury, especially in the pre-mobile age group.

PoCUS may have a role to play in fine tuning risk stratification and a recent study (2018) has further evaluated diagnostic accuracy:

We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures.

  • If I don’t perform a CT, then how long should a child with a head injury be observed?

There is no definite evidence-based answer to this question. However this study suggest that 6 hrs is probably safe.

Key Points

  1. Always use a clinical decision rule to determine whether a child with head injury requires CT, Observation or can be safely discharged
  2. When using a decision rule utilize a ‘shared decision-making’ philosophy – i.e involve the parents/carers
  3. A period of observation can reduce the number of CTs performed.
  4. If observation is recommended, then allow 6hrs.
  5. Always consider non-accidental injury during your assessment of pediatric head injury.

 

 


 

Clonazepam Toxicity

  • Overdosage of clonazepam may produce somnolence, confusion, ataxia, diminished reflexes, or coma
  • Clonazepam is extensively metabolized in the liver to several metabolites
  • Clonazepam is rapidly and well absorbed from the GI tract
  • Peak blood concentrations are reached in 2 -4 hours
  • Elimination half-life … 18.7 to 39 hr

Full ToxNet entry

Treatment

Treatment is entirely supportive with IV access and fluids and maintenance of the airway and ventilation if required

Oral activated charcoal is of little value in pure benzodiazepine poisoning. It may be given to patients who have recently ingested benzodiazepines with other drugs that may benefit from decontamination

Flumazenil is rarely indicated except for iatrogenic oversedation or respiratory depression. In addition, flumazenil may cause withdrawal states and result in seizures, adrenergic stimulation, or autonomic instability in patients chronically taking benzodiazepine, or in those with ventricular dysrhythmias and seizures who are concomitantly using cocaine or tricyclic antidepressants.

Dispostion

All patients with intentional ingestion or significant ataxia, drowsiness, or respiratory depression should be observed.

Patients with severe symptoms (ie, coma, respiratory failure, or hypotension unresponsive to IV fluids) should be consulted to ICU.

Given the prolonged half-life patients strongly consider admitting patients who present with significant drowsiness or are known to have taken a large overdose.

Patients with a significant sedative drug overdose should be advised not to drive until potential interference with psychomotor performance has resolved. For significant benzodiazepine overdose, this is at least 24 hours after discharge.

Key Points

  1. Clonazepam overdose is treated with supportive measures.
  2. Clonazepam has a very long half-life. For significant drowsiness, admission should be considered to avoid potentially very long ED observation periods.

 


Pediatric (< 3 months) Fever

The management of fever in infants less than 1 month is relatively straightforward. Guidelines are generally consistent (Merck,

  • Full blood lab work-up (CBC, CRP, Cultures)
  • Urine culture
  • CXR
  • RSV, Flu nasal swabs
  • LP
  • Empiric IV Antibiotics (e.g Ampicillin 50mg/kg and Cefotaxime 50mg/kg)
  • Consult Pediatrics and Admit

Emergency Medicine Cases article can be viewed here – Episode 48 – Pediatric Fever Without A Source

*********

For infants older than 30 days and younger than 3 months the guidelines are variable:

ALiEM: Paucis Verbis: Fever without a source (29 days-3 months old)

NICE Guidelines (UK):  Fever in under 5s: assessment and initial management

MD Calc – Step-by-Step Approach Calculator 

Suggested Emergency Department Approach

  • If Sick-Appearing treat as <3 months (see above)
  • If Well- Appearing (age normal vitals):
    • Full blood lab work-up (CBC, CRP, Cultures)
    • Urine culture
    • Consider CXR
    • Consult Pediatrics (Depending on results of above will either need admission +/- antibiotics or 24hr follow-up)

Yukon Guidelines


 

Wide Complex Tachycardia

Differential Diagnosis (note: repetition is deliberate!)

  • Ventricular Tachycardia
  • Ventricular Tachycardia
  • Ventricular Tachycardia
  • SVT with aberrant conduction – lots of causes
    • Pre-existing/rate-related BBB
    • Ventricular pre-excitation (AVNRT/AVRT)
    • Dysfunction of IV conduction system (toxic, metabolic, infectious, drug related etc) – hyper K, sodium channel blockers

No ‘rule’ is specific enough to correctly identify, so treat like VT

Treatment 

  • Unstable?
    • ANY sign of end-organ dysfunction – hypotension, altered LOC, CHF/SOB, CP, diaphoretic etc
    • SHOCK
  • Stable?
    • Shock or medical management
    • Amiodarone vs procainamide, ?adenosine (see below)

Adenosine/vagal – consider in patients where uncertain of diagnosis, unlikely to be VT, no hx of CAD, young, hx of SVT

Adenosine with WPW – ContraIndicated – may induce AV block and accelerate conduction of atrial fibrillatory impulses through the bypass tract, which can lead to very rapid ventricular arrhythmias that degenerate to VF.

“Avoidance of IV beta blockers, calcium channel blockers and digoxin due to the potential for hemodynamic deterioration in patients with stable WCT, potentially resulting in hypotension, VF and cardiac arrest”. (Uptodate)

Verapamil and diltiazem are calcium channel blockers (CCBs) that should be avoided in WCTs, as cardiac arrests from hemodynamic collapse have been reported following their administration.  Not only do these agents cause negative inotropy and at times profound vasodilation, but they may also allow WCTs to degenerate into VFIB

Caveat – RRWCT (Regular Really Wide Complex Tachy)

  • One situation where you may not want to assume VT….
  • What question should you ask?
    • What is the K,
    • what is the OD?
  • Really, really wide complex tachycardia – >200 mseconds – consider tox or metabolic – try bicarb or calcium – if it narrows – not VTach.
  • Avoid procainamide and amiodarone in these patients.

 

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Resident Clinical Pearl – Pediatric syncope: an investigative dilemma?

Pediatric syncope: an investigative dilemma??

Resident Clinical Pearl (RCP) – February 2018

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

Reviewed by Dr. David Lewis

 

The case

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

What investigations does she require?

 

Why It Matters?

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

 

The problem?

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

 

A potential solution

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

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

Red flags

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

 Red herrings

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

 

Investigative Algorithm

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

 

The Evidence

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

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

 

Pediatric ECGs – how to interpret?

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

See following chart from the CCS¹

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

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

 

Case Resolution

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

 

References

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

 

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Resident Clinical Pearl – Suprapubic Aspiration PoCUS

Suprapubic aspiration – when the catheter doesn’t cut it.

Resident Clinical Pearl (RCP) – Guest Resident Edition

Sean Davis MD, PGY2 Family Medicine

Dalhousie University, Yarmouth, Nova Scotia

Reviewed and Edited by Dr. David Lewis

 

Urine is routinely analyzed and cultured as part of a sick child workup, as diagnosis of urinary tract infection can be difficult in pre-verbal children. They are unable to “point where it hurts”, and physical exam can be both difficult and unreliable in an irritable or obtunded infant. Urine may be collected in three ways – by “clean catch” collection, transurethral catheterization (TUC), and suprapubic aspiration (SPA). Given the inherent risk of contamination with local flora (over 25% in one cohort study)1, clean catch urine is typically useful only for ruling out UTI. TUC is more commonly performed as it does not require physician participation, but SPA remains a valid option for obtaining a urine sample for analysis and culture in children under the age of 2. It has been shown to have a significantly lower rate of contamination than TUC (1% versus 12%, respectively)1, although failure rates are higher with SPA4. Use of portable ultrasound has been shown to significantly increase the rate of success of SPA (79% US guided vs 52% blind)5.

 

RCP – The pee or not the pee: so many questions!

 

Indications:2,3

  • Labial adhesions/edema
  • Phimosis
  • Diarrhea
  • Unsuccessful urethral catheterization
  • Urethral/introital surgery
  • Urethral stricture
  • Urethral trauma
  • Urinary retention
  • Urinalysis/culture in children younger than 2 years
  • Chronic urethral/periurethral gland infection

Contraindications: 2,3

  • Genitourinary abnormalities (congenital or acquired)
  • Empty or unidentifiable bladder
  • Bladder tumor
  • Lower abdominal scarring
  • Overlying infection
  • Bleeding disorders
  • Organomegaly

Complications: 2,3

  • Gross hematuria
  • Abdominal wall cellulitis
  • Bowel perforation

Equipment: 2,3

  • Lidocaine for local anesthesia (1% or 2%, with or without epinephrine)
  • Adhesive bandaid
  • Povidone-iodine or Chlorhexidine prep
  • 25g to 27g 1” needle
  • 22g or 23g 1.5” needle
  • Sterile 5ml and 10ml syringes

Procedure (ultrasound-guided): 2,3

  • Position the patient supine in frog-leg position, using parent or caregiver to assist with immobilization.
  • Using sterile technique, identify the bladder on ultrasound; it appears as an anechoic ovoid structure just below the abdominal musculature.
    • Landmarking: midline lower abdomen, just above the pubic symphysis
  • Mark the area and sterilize; infiltrate local anesthetic into the marked area
  • Insert the needle slightly cephalad, 10-20° off perpendicular while aspirating until urine appears.
  • If the insertion is unsuccessful, do not withdraw the needle fully. Instead, pull back until the needle tip rests in the subcutaneous tissue and then redirect 10° in either direction. Do not attempt more than 3 times.
  • One sufficient urine is obtained, withdraw the needle and place a sterile dressing at the site of the insertion.

 

 

From: Performing Medical Procedures – NEJM

 

References

    1. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. Tosif S; Baker A; Oakley E; Donath S; Babl FE. J Paediatr Child Health. 2012; 48(8):659-64 (ISSN: 1440-1754). Retrieved from https://reference.medscape.com/medline/abstract/22537082 on December 10, 2017
    2. Suprapubic Aspiration. Alexander D Tapper, MD, Chirag Dave, MD, Adam J Rosh, MD, Syed Mohammad Akbar Jafri, MD. Medscape. Updated: Mar 31, 2017. Retrieved from https://emedicine.medscape.com/article/82964-overview#a4 on December 10, 2017
    3. Suprapubic Bladder Aspiration. Jennifer R. Marin, M.D., Nader Shaikh, M.D., Steven G. Docimo, M.D., Robert W. Hickey, M.D., and Alejandro Hoberman, M.D. N Engl J Med 2014; 371:e13September 4, 2014DOI: 10.1056/NEJMvcm1209888. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMvcm1209888 on December 10, 2017
    4. Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Pollack CV Jr, Pollack ES, Andrew ME. Ann Emerg Med. 1994 Feb;23(2):225-30. Retrieved December 10, 2017.
    5. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Gochman RF1, Karasic RB, Heller MB. Ann Emerg Med. 1991 Jun;20(6):631-5. Retrieved December 10, 2017.

 

Other PEM PoCUS Videos Here

 

 

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EM Reflections – December 2017

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

Edited by Dr David Lewis 

 

Top tips from this month’s rounds:

Incomprehensible Patient – Delirium or Aphasia?

Pediatric Trauma

CME QUIZ

 

Take Home Points

  • Sudden onset language impairment should be assumed to be aphasia until proven otherwise
  • Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
  • Aphasic patients will be able to perform non-verbal tasks normally
  • If in doubt involve telestroke / neurology early
  • Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.
  • The injuries sustained by children in chest trauma are frequently different from adults
  • Signs of shock in pediatric trauma can be subtle
  • Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
  • Elevated Tropinin or abnormal ECG suggest blunt cardiac injury

 


Incomprehensible Patient – Delirium or Aphasia?

Both can present with disorders of speech and language, however it is important to rapidly distinguish aphasia due to it’s association with stroke and the benefits of early thrombolysis.

Delirium, also known as acute confusional state, is an organically caused decline from a previously baseline level of mental function. It often has a fluctuating course, attentional deficits, and disorganization of behaviour including speech and language.

Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Aphasia is always due to injury to the brain, most commonly from a stroke, but also trauma, tumour or infection.

 

The first tip here is to figure out how to describe the features of a patient’s language. How is the patient’s language produced and understood?

Are the words clearly enunciated (favoring aphasia) or slurred (favoring delirium)?

Is the patient’s speech grammatically correct (delirium) or lacking in appropriate syntax (aphasia)?

Is the patient’s prosody—or pattern of speech—fluent (delirium) or irregular (aphasia)?

Can the patient understand spoken language (delirium) or is there a major difficulty with following simple verbal/written commands (aphasia)?

Naming and repetition should also be assessed as part of any neurologic examination, but impairment in these modalities is not as useful in distinguishing delirium from aphasia.

The motor evaluation of inattention in a delirious patient involves testing for asterixis, either with arms and wrists fully extended or having the patient squeeze the fingers of the examiner (the “milk maid’s sign”). A delirious patient will struggle with these tasks, the extended hands may flap or the fingers may intermittently lose their grip. The aphasic patient, in contrast, may not have trouble with this.

Speak of the devil: Aphasia vs. delirium

 

Global Aphasia

  • Severe impairment of production, comprehension and repetition of language
  • Usually large CVA of left MCA
  • Usually associated with extensive perisylvian injury affecting both Broca’s and Wernicke’s areas
  • Usually accompanied by right hemiparesis and often a right visual field deficit (in right handed pt)
  • Patients with global aphasia can be shown to perform normally on nonverbal tasks such as picture matching, demonstrating they are not suffering from confusion or dementia

 

Stroke Thrombolysis – Indications and Contraindications Reminder

Patient Selection for Thrombolytic Therapy in AIS:

Inclusion criteria: Patients  >18 years of age with symptoms of AIS and a measurable neurological deficit with time of onset <4.5 h.

Exclusion criteria:

A. History

  • History of intracranial hemorrhage
  • Stroke, serious head injury or spinal trauma in the preceding 3 months
  • Recent major surgery, such as cardiac, thoracic, abdominal, or orthopedic in previous 14 days
  • Arterial puncture at a non-compressible site in the previous 7 days
  • Any other condition that could increase the risk of hemorrhage after rt-PA administration

B. Clinical

  • Symptoms suggestive of subarachnoid hemorrhage
  • Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd’s paralysis or focal neurological signs due to severe hypo- or hyperglycemia
  • Hypertension refractory to antihypertensives such that target blood pressure <185/110 cannot be achieved
  • Suspected endocarditis

C. Laboratory

  • Blood glucose concentration below 2.7 mmol/L or above 22.2 mmol/L
  • Elevated activated partial-thromboplastin time (aPTT)
  • International Normalized Ratio (INR) greater than 1.7
  • Platelet count <100 x 109/L
  • Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated insensitive global coagulation tests (aPTT for dabigatran, INR for rivaroxaban) or a quantitative test of drug activity (Hemoclot® for dabigatran, specific anti-factor Xa activity assays for rivaroxaban, apixaban and edoxaban). In this situation, endovascular treatment (thrombectomy) should be considered if patient eligible.

D. CT or MRI Findings

  • Any hemorrhage on brain CT or MRI
  • CT showing early signs of extensive infarction (hypodensity more 1/3 of cerebral hemisphere), or a score of less than 5 on the Alberta Stroke Program Early CT Score [ASPECTS], or MRI showing an infarct volume greater than 150 cc on diffusion-weighted imaging.

Relative contraindications for rt-PA therapy in AIS include the following:

  • Recent myocardial infarction with suspected pericarditis
  • Rapidly improving stroke symptoms
  • Pregnancy or post-partum period
  • Recent GI or urinary tract hemorrhage (within 21 days)

From Thrombosis Canada

Take Home Points

  • Sudden onset language impairment should be assumed to be aphasia until proven otherwise
  • Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
  • Aphasic patients will be able to perform non-verbal tasks normally
  • If in doubt involve telestroke / neurology early
  • Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.

 


Pediatric Trauma

Some specific issues particular to pediatric trauma are highlighted:

Pediatric Chest Trauma

Children have compliant chests and thus sustain musculoskeletal thoracic injuries far less frequently (5% of traumas). However, due to this elasticity, the most common injury is a pulmonary contusion.

PITFALLS

Don’t expect traditional adult injury findings: Absence of chest tenderness, crepitus and flail chests does not preclude injury.

Bendy ribs – injury to internal organs with little external evidence

Lung contusions ~50% of chest trauma

Force transmitted to lung parenchyma – lung lacerations much less common <2%

 

Pediatric Abdominal Trauma

Beware: 20-30% of pediatric trauma patients with a “normal” abdominal exam will have significant abdominal injuries on imaging.

Any polytrauma patient with hemodynamic instability should be considered to have a serious abdominal injury until proven otherwise. Tachycardia primary reflex for kids in response to hypovolemia and it may be the only sign of shock.

HIGH RISK – Indications for CT

• History that suggests severe intra-abdominal injury e.g abrupt acceleration/deceleration, pedestrian vs vehicle, handlebar injury, fall from horse etc

• Concerning physical – tenderness, peritoneal signs, seatbelt sign or other bruising

• AST >200 or ALT >125

• Decreasing Hb or Hct

• Gross hematuria

• Positive FAST

PECARN 

The Pediatric Emergency Care Applied Research Network (PECARN) network derived a clinical prediction rule to identify children (median age, 11 years) with acute blunt torso trauma at very low risk for having intra-abdominal injuries (IAIs) that require acute intervention.

The prediction rule consisted of (in descending order of importance)

  • no evidence of abdominal wall trauma or seat belt sign
  • Glasgow Coma Scale score greater than 13
  • no abdominal tenderness
  • no evidence of thoracic wall trauma
  • no complaints of abdominal pain
  • no decreased breath sounds
  • no vomiting

The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15).

Holmes JF et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med 2013 Feb 4; [e-pub ahead of print]. (http://dx.doi.org/10.1016/j.annemergmed.2012.11.009)

 

Blunt Cardiac Injury

Largest pediatric case series of BCI – 184 patients – 95% had simple cardiac contusions. https://www.ncbi.nlm.nih.gov/pubmed/8577001

The clinical presentation of blunt cardiac injury varies. Mild injuries may present without objective findings, while some patients may have minor dysrhythmias.

A normal ECG and troponin I during the first 8 hours of hospital stay rules out blunt cardiac injury, and the negative predictive value of combining these 2 simple tests was 100%. https://www.ncbi.nlm.nih.gov/pubmed/12544898

 

Click image to link to full article

 

Traumatic Tricuspid Injuries

Location, location, location

RV posterior to sternum – blunt force elevates pressures resulting in rupture of chordae, papillary muscle injury or tear of leaflet

Most frequent associated injury:  pulmonary contusion

“The presence of a transient right bundle branch block in the setting of myocardial contusion is a described, but under-recognized occurrence.”

“Although an rsr’ in the right precordial leads may be normal in children, it’s combination with an abnormal frontal axis (“bifasicular block”) is always abnormal and suggest injury to the RV”

 

Episode 95 Pediatric Trauma

Take Home Points

  • The injuries sustained by children in chest trauma are frequently different from adults
  • Signs of shock in pediatric trauma can be subtle
  • Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
  • Elevated Tropinin or abnormal ECG suggest blunt cardiac injury

 


CME QUIZ

EM Reflections - Dec 17 - CME Quiz

EM Reflections – Dec 17 – CME Quiz

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Resident Clinical Pearl – The pee or not the pee: so many questions!

The pee or not the pee: so many questions!

Resident Clinical Pearl (RCP) – May 2017

Jacqueline MacKay, R3 FMEM, Dalhousie University, Saint John, New Brunswick

 

The case: 

A 16-month old girl with a history of fever of 39 degrees and slightly decreased oral intake for three days. She has no other symptoms of note and is a healthy, fully immunized child. Her vital signs are stable and her temperature is 37.9 after having some Advil at triage. After a careful head-to-toe examination, you note that she looks extremely well and you aren’t able identify a source for the infection.

 

Question:

Could this be a UTI? What investigations would be appropriate?

 


The overall prevalence of UTI in febrile infants age 2-24 months who have no apparent source for fever is 5%. There are some groups with higher than average risk of UTI and these groups can be identified. Additionally, the presence of another source of infection (based on clinical history and physical exam) reduces the likelihood of UTI by half.


 

Individual Risk Factors: Girls Individual Risk Factors: Boys

Caucasian race

Age < 12 months

Temperature 39 degrees or greater

Fever for 2 or more days

Absence of another source of infection

Nonblack race

Temperature 39 degrees or greater

Fever for 24 hours or more

Absence of another source of infection

 


 

In girls age 2-24 months:

  • 1 risk factor: probability of UTI 1% or less
  • 2 risk factors: probability of UTI 2% or less

 

In boys age 2-24months:

  • uncircumcised: probability of UTI exceeds 1% even in the absence of other risk factors
  • circumcised with 2 risk factors: probability of UTI 1% or less
  • circumcised with 3 risk factors: probability of UTI 2% or less

 

The probability of UTI increases with the addition of more risk factors, and some of the factors (such as fever duration) may change during the course of the illness, increasing the probability of UTI.

 

Approximately half of clinicians consider a more than 1% risk of UTI sufficient for further investigation and treatment if UTI is found, to prevent spread of infection and renal scarring.

 


 

Recommendations:

  1. If the clinician determines the febrile infant to have a low (<1%) likelihood of UTI, then clinical followup monitoring without testing is sufficient.
  2. If the clinician determines that the febrile infant is not in a low risk group (>1% risk) then there are two options: obtain a urine specimen through catheterization or suprapubic aspirate for urinalysis and culture; or to obtain a urine specimen through the most convenient means and perform a urinalysis. If the urinalysis suggests UTI (positive leukocyte esterase or nitrites, or microscopic bacteria or leukocytes), then a urine specimen should be obtained through catheterization or suprapubic aspirate.
  3. Consider SPA

RCP – Suprapubic Aspiration PoCUS

 


 

Caveats:

  1. A negative urinalysis does NOT rule out UTI with certainty in children; however it is reasonable to monitor the clinical course without initiating antibiotics.
  2. Urine from a specimen bag CANNOT be used for culture to document UTI due to high risk of contamination.

 


 

Case conclusion:

A bag specimen was obtained for urinalysis, which was negative. After discussion with the parents, no antibiotics were prescribed and close followup was available. The child’s fever resolved within 24 hours. The urine culture was also subsequently negative.

 


Reference:

American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management; Roberts KB. Urinary tract infection: Clinical practice guideline for diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128(

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ED Rounds – Oral Rehydration in Children

Pediatric Dehydration and Oral Rehydration

ED Rounds Presentation by: Dr Paul Page


 

  • Volume Depletion (hypovolemia): refers to any condition in which the effective circulating volume is reduced. It can be produced by salt and water loss (as with vomiting, diarrhea, diuretics, bleeding, or third space sequestration) or by water loss alone (as with insensible water losses or diabetes insipidus).
  • Dehydration -refers to water loss alone. The clinical manifestation of dehydration is often hypernatremia. The elevation in serum sodium concentration, and therefore serum osmolality, pulls water out of the cells into the extracellular fluid.

American Family Physician article (2009) – Diagnosis and Management of Dehydration in Children


 


SJRHEM Guideline

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

 


View/Download Full Presentation below:

Download (PDF, 817KB)

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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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Resident Clinical Pearl – To syringe or not to syringe, that is the question

To syringe or not to syringe, that is the question

Resident Clinical Pearl (RCP) – March 2017

Kalen Leech-Porter, PGY2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis and Dr. Brian Ramrattan

 

Snapshot Summary:

Problem:

  • Parents often give their children the wrong dose of medications.

Solution:

  • Provide parents a syringe to draw up medications
  • Describe the amount of medication in mL, not teaspoons or cc’s
  • Make sure to give simple instructions

 


 

Preamble:

It is well known amongst health practitioners that accurate dosing in pediatrics is extremely important; even a small miscalculation can have catastrophic results, potentially even death. We double check and triple check our calculations to make sure we prescribe the correct weight based dose. This is an excellent practice, and one we should continue to be diligent with, but if we don’t give proper instructions to parents, our calculations will be in vain: in a recent study of parents observed preparing prescriptions for their children, 84% of them made a measurement error!

The Study:

Yin HS, Parker RM, Sanders LM, et al. Liquid medication errors and dosing tools: a randomized controlled experiment. Pediatrics 2016;138(4):e20160357.

In this randomized control study, 2110 parents were assigned to 5 different groups in an outpatient office setting.  All groups got the same prescription for amoxicillin, and the parents were observed preparing the medication for their children (three times).  The groups differed in the tools provided (measuring cup, syringe, or both) and how the units were described (mls, teaspoons or both).  (See below).

 


Results:

Across all groups, 84.4% of parents made at least one measurement error (at least a 20% under/over dose).  21% of parents more than doubled the prescribed dose. The group with the fewest errors was group I: when prescriptions were only written in mLs, and only a syringe was provided.  Using the measuring cup, 43% of parents made a dosing error compared to 16% with the syringes (p<0.001).

Parents with lower health literacy and from lower socioeconomic backgrounds were more likely to make mistakes, but like those with better literacy made fewer mistakes in the syringe only group versus the groups that included cups.

 

Conclusion:

When writing out pediatric liquid prescriptions, describe the medications in terms of mL and specify that the meds should be distributed with a syringe, or provide a syringe from the hospital.  This study did not demonstrate whether having practice draw up medications reduced errors, however it seems prudent to have health care workers observe parents give a first dose in the ED if time permits.

 

 


See the SJRHEM Tylenol and Advil dosing sheets on our Patient Information Leaflet page

 


 

Reference:

Abstract/FREE Full Text

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ED Rounds – February 2015

An enjoyable and informative set of presentations by Dr Ramrattan, Dr Talbot and Dr Greer
The presentations can be downloaded and reviewed from the CPD File Store (Rounds)

Dr Brian Ramrattan – Alphabet Soup

TREKK –  Translating Emergency Knowledge for Kids
To create a national network that is a trusted source for easy access to the latest evidence, best practices, user-friendly resources and discussions in pediatric emergency care. It will be created and used by health professionals and the families they care for and its work will drive the highest quality of health care for children and families seeking emergency care in Canada.
Their mission is to deliver the highest standard of care to every child, whether they choose to seek treatment in a pediatric or general emergency department
More topics on their website
The following were presented:
Bronchiolitis, Croup, Gastroenteritis
Bronchiolitis
  • Routine CXR not supported by evidence however need to take each case on its merits. If suspect pneumonia – CXR
  • NPA or CBC does not alter management
  • High risk groups – Prems, <3/12
  • Most can be discharged
  • Steroids do not reduce LOS
  • Epinephrine may reduce admissions on day 1 but there is no long term benefit
  • Bronchodilators are not effective in bronchiolitis
  • Steroids plus Epinephrine may reduce admission rates for up to 7 days, but not recommended routinely
  • Recommended- Oxygen and Hydration
  • Admission criteria – include unable to maintain sats > 90% without O2, Not feeding, increase WOB, Resp rate > 70
Croup
  • Worse at night
  • Usually improve on way to hospital
  • Clinical diagnosis
  • Febrile, bark, tachypnea
  • Westley Croup Score – may be useful for RT to do while observing child pending discharge
  • Lateral Neck X-ray may be helpful for retropharyngeal abscess, epiglotitis
  • Recommended – Steroids +/- Epinephrine (if need rapid Rx)
Gastroenteritis
  • ORT as good as IV Rehydration
  • Anti emetics lower need for admission and IVRT
  • Not enough evidence for probiotics
  • Consider weight in kg as ORT mL per 5 mins e.g. 10kg = 10mls per 5 mins
  • Ondansetron 8-15kg – 2mg 15-30kg – 4mg
Alberta – Vomiting and Diarrhoea Pathway

 

Dr Jo-Ann Talbot – Do We Choose CPD Wisely?

We are not very good at deciding what to focus on?
Continuum from competence to expertise
Scope of Practice will impact on how we choose our CPD
Why should we have-  Practice Assessment
  • Role in Feedback in identifying areas where our competency can be improved
  • Flaws in self assessment
  • Increasing expectation of the profession
Revalidation is comming…
  • Association of Canadian Regional Colleges have guidelines
  • ACEP – Exam, PAR, Lifelong learning, Patient Feedback etc
  • UK GMC –  system
How can we Improve – Where is the Gap?
  • Perhaps chart reviews
  • Review M&Ms and complaints
  • Are there common things that we do that say if we are a safe doctor?
Needs Assessment Triangulation
  • Synthesis and integration of data from multiple sources
  • Narrow down to the most important problems
  • Assessment
    • Knowledge – e.g self assessment
    • Performance assessments – Sim, Audit, 360, Teaching
  • “How do we know if we are providing excellent care?” – Group discussion – suggested ways below
    • Informal follow up
    • CQI chart audits
    • Bounce backs
    • Procedural audits
    • External chart review
    • M&M’s
    • Trauma Charts
    • Should we get the discharge summary
    • Letters from clinics
    • But what is excellence?
      • Combination of knowledge, skill, implementation, communication
      • We are the experts in Emergency Care – we should set the standards.

 

Download (PDF, 5.91MB)

Dr Matt Greer – Turn it up to 11. LP in the Diagnosis of SAH

  • 1% Headaches = SAH
  • 14% of ED Headaches get CT (US Stats)
  • Unenhanced CT is 100% sensitive < 6hrs
  • Xantho is only useful >12hrs  but < 2weeks (this is now debated – see presentation for details)
  • Type and Location of pain has no predictability for cause
  • Do we still need to LP after CT – ( answered in the presentation)
  • No Gold standard
  • But CT plus LP had been considered standard for early studies
  • LP’s are hard to interpret
  • Unenhanced CT performed < 6hrs – 100% sensitivity
  • Need 3rd generation CT Scanner
  • Need Radiologist – who is routinely reading Head CTs
  • LP – most sensitive >12hrs  and < 2 weeks
  • Xanthochromia determined the positive result
  • But Xanthochromia may not be such a good gold standard?
  • Why  not just do CTA
  • But 2-5% have aneurysm in population
  • So which ones do you treat?
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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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