RCP – Dental Block, ER Doc

Another Solution for Dental Pain when “NSAIDs do nothing for me Doc!

Resident Clinical Pearl (RCP) – Guest Resident Edition

Peter Leighton,  R3 FMEM 2+1, Dalhousie University, Halifax

Reviewed by Dr. David Lewis

 

Dental pain is a common problem encountered in the Emergency Department (ED), yet physicians in the ED often have no to little education regarding management of dental pain. Depending on where you read, dental pain complaints account for 1-5% of emergency department visits. A common approach consists of looking for infection and providing a prescription for antibiotics and NSAIDs along with recommendation to follow up with a dentist. Although, there is good evidence for NSAIDs in dental pain, some patients find that it does not help enough with their pain or they have contraindications to NSAIDs. This often leads to the prescription of opioids for dental pain. Given the recent opioid crisis in Canada, there has been a search for other forms of management of toothache/dental pain in the ED. Insert the dental block! It’s fast, easy, and provides good pain relief, while providing a chance for patients to book an appointment to see their dentist the following day. There has been some evidence that this method achieves good pain control for the patient and may help lower opioid prescriptions in the ED for dental pain.

There are essentially 2 blocks you will need to know:

  • The Inferior Alveolar Nerve Block (Mandibular teeth)
  • Supraperiosteal Infiltrations (Maxillary teeth)

Indications

  • Dental abscess
  • Toothache
  • Pulpitis
  • Root impaction
  • Dry socket
  • Post-extraction pain
  • Trauma – lacerations, fractures

Contraindications

  • Allergy to local anesthetic
  • Distortion of landmark
  • Uncooperative patient
  • Injecting through infected tissue – may cause bacteremia
  • Cardiac congenital abnormalities and mechanical valves – require prophylaxis for endocarditis
  • Coagulopathy

What you will need

  • Syringe
  • Needle – 25-27 gauge and 1.5 inch
  • Lidocaine with epinephrine (max dose 7 mg/kg)
  • Bupivicaine +/- epinephrine (max dose 2 mg/kg)
  • Non-sterile gloves
  • Suction and light source may be required

 

The combination of Lidocaine and Bupivicaine allow the mix of immediate analgesia from the Lidocaine and prolonged duration of action by the Bupivicaine. The addition of Epinephine will also increase duration of effect. This combination should provide approximately 8 or more hours of anesthetic effect.

 

Technique:

Supraperiosteal Infiltration

Pull out patient’s cheek laterally to have a good view of the patient’s tooth and gingiva. Insert needle into the mucobuccal fold just above the apex of the tooth to be anesthetized. Keep the needle parallel to the tooth and insert it a few millimeters until needle tip is above the apex of the tooth. If bone is contracted, withdraw 1-2mm and aspirate. If no blood is aspirated then inject 1-2 ml of anesthetic. If blood is aspirated then withdraw and reposition.

 

From: www.ebmedicine.net – click here for full article

 


 

Inferior Alveolar Nerve Block

Place your thumb in the coronoid (mandibular) notch of the patient and extend the patient’s cheek out laterally so you can see the patient’s pterygomandibular raphe. Place your syringe in the opposite corner of the mouth and with your needle at the middle level of the raphe, aim just lateral to the raphe. Insert your needle approx. 2-2.5cm until you hit bone. Pull back a millimeter and aspirate twice. If any blood on aspiration, withdraw and reposition more laterally. If no blood with aspiration then inject 1-2ml of anesthetic.

 

From: Jason Kim’s Blog – click here for full article

 

 

From: www.ebmedicine.net – click here for full article

 


 

Videos:

Please see the dentistry videos below to review anatomical landmarks of both techniques:

 

Supraperiosteal technique

 

Inferior Alveolar Block

 


 

References

 

  1. Complications, diagnosis, and treatment of odontogenic infections [Internet]; c2017 [cited 2017 November 10]. Available from: https://www.uptodate.com/contents/complications-diagnosis-and-treatment-of-odontogenic-infections?source=search_result&search=dental%20pain&selectedTitle=1~150.
  2. Fixing Faces Painlessly: Facial Anesthesia In Emergency Medicine [Internet]; c2017 [cited 2017 November 12]. Available from: https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=207&seg_id=4229
  3. Fox TR, Li J, Stevens S, Tippie T. A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine 2013;62(3):237-40.
  4. IA with a Short Needle [Internet]; c2015 [cited 2017 November 10]. Available from: https://www.youtube.com/watch?v=1Mf3f0XmsqI.
  5. 5. Local Infiltration [Internet]; c2014 [cited 2015 November 10]. Available from: https://www.youtube.com/watch?v=Y2NSuxd7j_g.
  6. How I learned to love dental blocks [Internet]; c2014 [cited 2017 November 10]. Available from: http://www.clinicaladvisor.com/the-waiting-room/dental-blocks-useful-in-emergency-medicine/article/382951/.
  7. M2E Too! Mellick’s Multimedia EduBlog [Internet]; c2014 [cited 2017 November 10]. Available from: http://journals.lww.com/em-news/blog/M2E/pages/post.aspx?PostID=32.
  8. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice. J Am Dent Assoc 2013 Aug;144(8):898-908.
  9. Okunseri C, Dionne RA, Gordon SM, Okunseri E, Szabo A. Prescription of opioid analgesics for nontraumatic dental conditions in emergency departments. Drug Alcohol Depend 2015 Nov 1;156:261-6.
  10. Patel NA, Afshar S. Addressing the high rate of opioid prescriptions for dental pain in the emergency department. Am J Emerg Med 2017 Jul 3.
  11. Oral Nerve Block [Internet]; c2016 [cited 2017 November 10]. Available from: https://emedicine.medscape.com/article/82850-overview#a1.
  12. Dental Pain in the ED: Big Solution in a Small Package [Internet]; c2005 [cited 2017 November 10]. Available from: http://journals.lww.com/em-news/Fulltext/2005/06000/Dental_Pain_in_the_ED__Big_Solution_in_a_Small.12.aspx.

 

 

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RCP – the “Easy IJ”

The “easy IJ”, a quick solution for difficult intravenous access?

Resident Clinical Pearl (RCP) – September 2017

Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

The importance of intravenous (IV) access is something seared in the mind of every practicing emergency department physician. Over the years, central intravenous access for difficult IV access has been obviated by the intraosseous drill and line. Furthermore, we just see and do less central IV lines. The likely reasons for this are that running vasopressors in peripheral intravenous (IV) lines is becoming more accepted as well as the increased time associated with placing a fully sterile central line (draping, etc.) as well as the risks of the over-the-wire procedure (infection, deep vein thrombosis, cardiac arrhythmias).

Enter the internal jugular vein catheterization using a peripheral IV catheter1, which is placed under a limited sterile environment. Is the 5 minutes to establish access that “easy” when peripheral access and external jugular catheterization has failed?

The materials required:

  1. US machine with high-frequency linear transducer probe
  2. Chlorhexidine swab
  3. 4.8-cm, 18-gauge single lumen catheter
  4. Two bio-occlusive adherent dressings
  5. Sterile ultrasound jelly
  6. A loop catheter extension
  7. A saline flush

Figure 1. Visual diagram of required materials for the “easy IJ”, adapted from Moayedi et al. (2016).

 

The steps:

  • Place your patient in the Trendelenburg position or instruct them to perform a Valsalva maneuver
  • The needle is inserted into the skin at approximately 45 degrees
  • Ultrasound is used to confirm real-time placement out of plane, followed by in-plane visualization to see the catheter in the vessel lumen
  • See this video for a demonstration: https://www.youtube.com/watch?v=FjSmbUWXznY

 

 

 

What does the evidence say2?

  • When studied in stable emergency department patients when peripheral or external jugular venous access was unsuccessful, the success rate of this procedure was 88% (95% CI 79-94)
  • The mean time to procedure completion was 4.4 minutes (3.8-4.9)
  • In 83 access attempts, there were no cases of pneumothorax, infection or arterial puncture
  • There was a 14% loss of IV patency immediately after insertion
  • Painful? Don’t forget, these lines were placed without local anesthesia; however, the mean pain score was 3.9 out of 10 (3.4-4.5)

Practical considerations:

So will this technique change your practice? A few things to be aware of:

  • In obese patients, the target vessel will be inherently more difficult to visualize, as well as the catheter length in this study may not be long enough to ensure patency. The median BMI in the Moayedi et al. (2016) study was 27
  • Operator skill: the vast majority of lines were placed by clinicians experienced in ultrasound guided line placement. Success and time to placement may be increased as experience decreases
  • Will more definitive access be required? The catheters placed in this study were largely only used for 24 hours. This would certainly be more than sufficient during the treatment of an ED patient, but usage time increases, infection rates will likely increase
  • Will this line achieve the infusion rate you need? See this article on infusion rates of various IV catheters

 

The bottom line: the “easy IJ” is a rapid, effective and safe alternative to establish IV access in stable patients in whom peripheral and external jugular venous attempts have failed.

 

References

(1) Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The ultrasound-guided “peripheral IJ”: internal jugular vein catheterization using a standard intravenous catheter. J Emerg Med 2013 Jan;44(1):150-154.

(2) Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. J Emerg Med 2016 Dec;51(6):636-642.

 

 

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RCP – Nar’ pump, mo’ problems

Nar’ pump, mo’ problems, a case on cardiogenic shock

Resident Clinical Pearl (RCP) – June 2017

Mandy Peach, R2 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed/Edited by Dr. David Lewis and Dr. Kavish Chandra

It’s 11 pm, you’re doing the overnight shift and EMS calls in to report a patient with an ETA of 3 minutes: “80 yo female, found on floor in apartment by husband after reportedly feeling unwell for 2 days. Decreased LOC but arousable and responding appropriately. BP 82/36, HR 120, RR 22, Afebrile, oxygen sat 86% on 6L nasal cannula.”

You hear the vitals, and many differentials run through your mind – PE, sepsis, hemorrhage, tamponade. Your main concerns are: this person needs more airway support and they are in shock, and when you think shock you think ‘fluids’.

EMS rolls in with your patient and she looks awful – pale, mottled extremities and drowsy. She is being re-assessed, RT is present to switch to a face mask, IV access is being established and you’re about to pound her with fluids when you are handed her ECG:

1https://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/

This lady clearly is having an inferior STEMI – there is marked ST elevation in II, III and aVF with early Q wave formation.

 

Take home point #1: In any Inferior STEMI, you must suspect RV involvement

Look for ST elevation in V1 and depression in V2, or ST elevation in lead III > lead II. If these are present – get a 15 lead ECG.1

On closer look at our patient’s ECG there is ST elevation in V1-V2 and the elevation in lead III is indeed larger than lead II. You order the 15 lead.

2 https://lifeinthefastlane.com/ecg-library/right-ventricular-infarction/

Look for ST elevation in right sided leads V3-V6, but the money is on V4R – ST elevation in this lead has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% for RV infarction2. Our patient does have RV infarction seen by ST elevation in V4R.

 

Take home point #2: RV involvement is associated with increased risk of cardiogenic shock and death with a mortality of 50% within the first 48 hours3. If there is RV involvement, giving nitroglycerin for chest pain is CONTRAINDICATED

Due to a poorly functioning RV, patients are pre-load sensitive2. If you decrease the pre-load then they have even less to pump, further worsening the hypotension.

So we have diagnosed this lady with cardiogenic shock secondary to AMI (the most common cause of cardiac related shock) and we determined she has RV involvement. We know we can’t give her nitroglycerin. Let’s reassess her status – the basic ABC’s.

Airway & Breathing – the RT has since advanced her to a non-rebreather with a sat level in the high 80’s. You suggest trying Optiflow or BiPAP as a temporizing measure – this lady is going to need to be intubated.

 

Take home point #3: Positive pressure ventilation requires a stable, cooperative patient – which is often not the case in cardiogenic shock

Positive pressure can decrease pre-load and potentially worsen hypotension3. It is a temporizing measure only. The majority will require endotracheal intubation to maintain their saturation as their work of breathing is a large expenditure of energy.

You successfully complete a RSI and the saturation improves to 94-98%.

Circulation – Repeat BP is 82/36. You complete a cardiac point-of-care-ultrasound (PoCUS) and see poor contractility, but no pericardial effusion or large clots suggesting chordae or papillary rupture. IVC is > 50% collapsible.

 

Take home point #4: On PoCUS, heart failure caused by acute ischemia will show a large RV and small LV secondary to low filling pressures, which is best seen on the apical 4 chamber view3

Your patient continues to be hypotensive – you give a small 500 cc bolus; you don’t want to overload a poorly pumping heart with fluid it can’t handle. However you anticipate that this will not be enough to improve her BP, and as she continues to be hypotensive her myocardial ischemia worsens, which subsequently worsens her pump dysfunction in a vicious cycle. She needs pressure support.

 

Take home point #5: Cardiogenic shock requires vasopressor support

If systolic BP > 90: Start with dobutamine for inotropy. Double up on agents – likely will need to add a vasoconstrictor. Dopamine is usually the next to add.

If systolic BP < 90: Can still use dobutamine, but need to add norepinephrine for vasoconstriction. Dopamine alone will worsen BP as it is a vasodilator.

3Tintinalli’s Comprehensive Guide to Emergency Medicine.

You start dobutamine and dopamine peripherally with the intention of obtaining central venous assess once stabilized.

In the meantime, cardiac labs and portable CXR are pending, you treat this patient as any other STEMI in terms of dual anti-platelet and anti-coagulation loading.

 

Take home point #6: Do not give beta blockers

Do not give beta blockers in RV infarcts as high risk of bradycardia and AV block due to ischemia of the AV nodal artery3.

You consult cardiology to activate the cath lab.

 

Take home point #7: Early revascularization in ischemic related cardiogenic shock is key

Early revascularization has a long term mortality benefit, preferably if done within 6 hours4.  Catheterization or CABG is the preferred method over thrombolytic therapy.

You consult cardiology to activate the cath lab.

Back to our patient –

This lady did go on to the cath lab and had stenting of her RCA, however her infarct likely occurred > 48 hours before presentation. Unfortunately, despite aggressive vasopressor therapy and revascularization, she coded immediately after the procedure and resuscitation attempts were unsuccessful, emphasizing the poor prognosis associated with ischemia related cardiogenic shock.

 

Bottom line for cardiogenic shock: fluid bolus 500 cc 0.9% NaCl, vasopressor support and RSI. Early revascularization is key – catheterization is preferred. Despite these interventions, the diagnosis portends a poor prognosis.

 

References

  1. Inferior STEMI – Life in the Fast Lane https://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/
  2. Right Ventricular Infarction – Life in the Fast Lane https://lifeinthefastlane.com/ecg-library/right-ventricular-infarction/
  3. Tintinalli, JE. (2016). Cardiogenic Shock (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 349-352). New York: McGraw-Hill.
  4. Cardiogenic Shock – Literature Summary – Life in the Fast Lane https://lifeinthefastlane.com/ccc/cardiogenic-shock-literature-summaries/

 

This post was copyedited by Kavish Chandra @kavishpchandra

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RCP – 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.

 


 

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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RCP – The Pregnant ED Patient – A Compendium of Pearls

The Pregnant ED Patient – A Compendium of Pearls

Resident Clinical Pearl (RCP) – April 2017

Luke Taylor, R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed/Edited by Dr. David Lewis

 

 


Many adaptations take place in the gravid female, the end goal of each being to provide optimal growth for the fetus, as well as to protect the mother from the potential risks of labour and delivery.

 

It is very important to understand these changes when assessing an unwell pregnant patient. For example, a hemorrhaging patient may not show the typical signs and symptoms of tachycardia and hypotension until much later.

 

 


Vitals:

 

BP: Blood pressure falls earlier in pregnancy with nadir in second trimester (mean ~105/60 mmHg). Third trimester BP increases and may reach pre pregnancy levels at term.

Brought on by a reduction in SVR and multiple hormonal influences not fully understood.

 

HR: CO=HRxSV. The increase in CO is attributed mainly to the increase in circulating volume (30-50% above baseline). HR increases by 15-20 beats/min over non pregnant females.

*Supine position in the gravid female can lower CO by 20-30%

 

RR: State of relative hyperventilation. NO change in RR, however there is an increase in tidal volume resulting in a 50% increase in minute ventilation. Increased O2 consumption and demand with hypersensitivity to changes in CO2.

*60-70% of women experience a sensation of dyspnea during pregnancy


 


Imaging and ECG:

 

Must ensure imaging is necessary for management and explain risks well.

** 1 rad increases the risk of childhood malignancy by 1.5-2x above baseline.

 

CXR: Minimal changes to CXR in normal pregnancy but may have; prominence of the pulmonary vasculature and elevation of the diaphragm.

 

PoCUS: FAST doesn’t perform well in pregnant patient. Small amount of physiologic free fluid in the pelvis (posterior, lower portion of uterus), all else should be considered pathologic. Physiologic hydronephrosis and hydroureter (mostly R-sided).

 

CT-A: When required to rule out PE, capable of being completed at very low rad (below teratogen cut off, CT of 1-3rad is under the teratogenic cutoff of 5-10rad = 10,000 cxr or 10x CT chest

 

ECG: Various changes occur, may include ST and T wave changes, and presence of Q waves. The heart is rotated toward the left, resulting in a 15 to 20º left axis deviation. Marked variation in chamber volumes, especially left atrial enlargement. This can lead to stretching of the cardiac conduction pathways and predisposes to alterations in cardiac rhythm.

 


Routine Laboratory Tests:

 

CBC: Physiologic Anemia – Increased retention of Na and H2O (6-8L) leading to volume expansion combined with a slightly smaller increase in red cell mass.

Leukocytosis – Due to physiologic stress from the pregnancy itself, creates a new reference range from 9000, to as high as 25000 in healthy pregnant females (often predominately neutrophils)

 

PTT: Various processes result in 20% reduction of PTT and a hypercoagulable state (also helps to protect from hemorrhage during labour).

 

Urinalysis: Very common to have 1-3+ leukocytes, presence of blood, as well as ketones on point of care testing. Not considered pathologic unless Nitrite positive.

 

Creatinine: Pre-eclamptic patients may have a creatinine in the normal range, but have a drastic reduction in GFR (40%).

 

B-HCG: Every female of childbearing years should be considered to: Be pregnant, RH-, and have an ectopic. Studies show that 7-15% of women who (in the ED) state it is “Impossible” they are pregnant, end up being. Draw a beta HCG on every women of childbearing years regardless of LMP.

 


ACLS

 

Remember, most features are the same as when resuscitating a non-pregnant patient.

Some things to remember:

 

Higher risk of aspiration – Progesterone relaxes gastroesophageal sphincters and prolongs transit times throughout the intestinal tract. = Careful bag mask ventilation, do not overdo it.

Left uterine displacement (LUD)– While patient supine to provide best chest compressions possible

Medications and Dosages– Remain the same in pregnancy, vasopressors like epinephrine should still be used despite effect on uterus perfusion

Defibrillation OK–  Fetus is not effected by defibrillation, low risk of arc if fetal monitors in place, do not delay.

Four minute rule– For patients whose uterus is at or above the umbilicus, prepare for cesarean delivery if no ROSC by 4mins. ** In a case series of 38 perimortem cesarean delivery (PMCDs), 12 of 20 women for whom maternal outcome was recorded had ROSC immediately after delivery.

Etiology:  Must continue to think broadly, however common reasons for maternal cardiac arrest are: bleeding, heart failure, amniotic fluid embolism (AFE), and sepsis. Common maternal conditions that can lead to cardiac arrest are: preeclampsia/eclampsia, cerebrovascular events, complications from anesthesia, and thrombosis/thromboembolism.

 


References

http://circ.ahajournals.org/content/132/18/1747/tab-supplemental

https://www.uptodate.com/contents/respiratory-tract-changes-during-pregnancy?source=search_result&search=pregnancy%20respiratory&selectedTitle=1~150

https://www.merckmanuals.com/en-ca/professional/gynecology-and-obstetrics/approach-to-the-pregnant-woman-and-prenatal-care/physiology-of-pregnancy

https://radiopaedia.org/cases/chest-x-ray-in-normal-pregnancy

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RCP – 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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RCP – Save your Thumbs: Extra-oral reduction of anterior mandibular dislocations

Save your Thumbs: Extra-oral reduction of anterior mandibular dislocations

Resident Clinical Pearl (RCP) – February 2017

Kavish Chandra, PGY2 iFMEM, Dalhousie University, Saint John, New Brunswick

@kavishpchandra

 

Reviewed by Dr. Paul Frankish and Dr. David Lewis

 

Mandibular dislocations can be atraumatic or traumatic. The atraumatic variety can occur after extreme mouth opening from yawning, laughing or vomiting and can cause severe pain, difficulty swallowing and malocclusion of the jaw (1).Anterior mandibular dislocations are the most common form of atraumatic dislocations and can be bilateral or unilateral. In this injury, the temporal mandibular joint (TMJ) dislocates in front of the articular eminence and muscular spasm traps the mandible in that position (2).(Fig. 1A and B)

 

Figure 1A: TMJ and coronoid (black arrow) in normal resting position. Figure 1B: TMJ dislocates anteriorly and the coronoid (black arrow) is palpable just below the zygoma. Adapted from Chen et al. 2007.

 

Various reduction techniques are described and predominantly involve intra-oral manipulation, often with the use of procedural sedation (Fig. 2) (1). With the intra-oral technique, there is a risk of the mandible snapping shut on the operator’s fingers as well as the risk of a failed reduction and risks of procedural sedation.

 

Figure 2: Intra-oral TMJ reduction with thumb on molars and pressure is applied downwards and backwards. Adapted from Tintinalli’s Emergency Medicine.

 

 

The Question: is there an effective extra-oral reduction technique for anterior mandibular dislocations?

 

Chen et al. (2007) published a case series describing a rapid and effective extra-oral reduction method for anterior mandibular dislocations(2). Furthermore, their technique does not require any procedural sedation and analgesia, thereby minimizing risks to the patient and freeing up valuable ED resources.

 

Figure 3: With your fingers, pull the mandible forward (large arrow) while using the ipsilateral zygoma as fulcrum (little arrow). This further dislocates the TMJ anteriorly and facilitates contralateral TMJ reduction. See Figure 4 to perform the concurrent contralateral TMJ reduction. Adapted from Chen et al. 2007.

 

Figure 4: On the opposite side, place your thumb just above the palpable coronoid process and apply persistent pressure to push the coronoid and TMJ back (big and little arrow). Figure 3 and 4 are reversed to facilitate TMJ reduction on contralateral side. Adapted from Chen et al. 2007.

 


Why not watch this technique in action:

 

 

 


References

  1. Tintinalli, JE. (2016). Eye, ear, nose, throat and oral disorders. (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 1590-1591). New York: McGraw-Hill.
  2. Chen Y, Chen C, Lin C, Chen Y. A safe and effective way for reduction of temporomandibular joint dislocation. Ann Plast Surg. 2007;58(1):105-108. [PubMed]
  3. https://www.aliem.com/2016/trick-of-the-trade-extra-oral-technique-for-reduction-of-anterior-mandible-dislocation/

 


 

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RCP – Awake Intubations: “Alone we can do so little, together we can do so much”

Awake Intubations: “Alone we can do so little, together we can do so much”

Resident Clinical Pearl (RCP) – January 2017

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

Reviewed by Dr. David Lewis

 

Case Example:

A healthy 60 year old man arrives at the Emergency Department (ED)3 hours after his camp caught fire.  He complains of shortness of breath and he has a hoarse voice. Vitals BP 140/90, HR 95, RR 24, Oxygen saturation 96%, afebrile.  GCS 15. You note he has facial and trunk burns. He is alert, scared but cooperative. How would you definitively manage his airway?

Picture 1.


Introduction:

RSI has gained much popularity in the ED for endotracheal intubation.  While there is good reason for this, there is still a role for awake intubation; with awake intubations the patient continues to breathe for themselves and will maintain and protect their airways.  This can be critically important in a situation where there is an anticipated difficult intubation and difficult bag mask ventilation.  The patient does have to be somewhat cooperative for awake intubation, but with proper explanation this might be the best option in a difficult situation.

Indications:

  • Predicted difficult airway anatomy (intubation AND maintaining oxygenation with BMV)
  • Variations of normal anatomy (ie Mallampati 4, obese, small mandible)
  • Pathologic distortion or obstruction: (ie burns, angioedema, stridor)
  • Predicted difficult physiology
  • Hemodynamic instability- (may still be able to do RSI- using appropriate agents and fluid bolus, but awake intubation is an option)
  • High minute volume – awake intubation will allow them to breathe at their current desired rate until intubation facilitated

Requirements:

  • Patients is awake, cooperative

Advantages of awake Intubation

  • Patient protects/maintains airways
  • Patient breathes spontaneously
  • Less risk of hypoxemia/hypercarbia with transition to positive pressure ventilation
  • May help with intubation: tissue movement/bubbles may indicate glottis opening in obscured airways

Disadvantages

  • Potentially uncomfortable
  • Requires cooperation
  • Procedure can be prolonged

 

Back to our case:

………….the hoarse voice and burns suggest airway edema.  This patient will likely both a difficult intubation and difficult to bag mask ventilate.  However, he is cooperative.  Following the AIME approach to tracheal intubation pathway (below), this patient would be a candidate for awake intubation (red arrow).

AIME approach to tracheal Intubations pathway decision making

 

Generic Approach to awake oral intubation:

  1. Supplemental O2 – consider high flow nasal prongs
  2. Prep:
    1. monitors, O2, BVM, suction, ETTs, stylet, laryngoscope, blades, drugs, alternative intubation options, rescue devices, mark cricothyroid membrane,
    2. Psychologically prepare the patient: tell them rationale and explain procedure
  3. Topical Airway Anesthesia +/- light sedation
  4. Awake intubation
  5. Confirm Tube location
  6. Additional Sedation

More Detailed:

Topical Airway Anesthesia
  1. Consider drying agent to reduce secretions and allow better working of topical anesthesia on mucous membranes: glycopyrrolate 5 micrograms/kg IV
  2. Lidocaine application -don’t add epi
    1. 5% lidocaine ointment with tongue depressor to back of tongue
    2. Gargle and swish 4% liquid lidocaine
    3. Then spray (soft palate, posterior pharynx, tonsillar pillars) as you go with either:
      1. Lidocaine 10% endotracheal spray
      2. 4% lidocaine atomizing device
    4. 4% nebulized lidocaine takes 10-12 mins but is another alternative
  3. Do not exceed toxic dose: 5 mg/kg (use less if elderly or cardiac/liver impairment)

+/- Light Sedation
  1. No sedation is reasonable
  2. Consider ketamine, or midazolam +/- fentanyl in small doses (pros and cons not discussed in this pearl)

Awake intubation using DL

Intubation may be performed with bronchoscopy, glidescope, blind nasotracheal intubation. Below is an abridged description of key points of direct laryngoscopy during awake intubation.

  1. Perform in semi-sitting or sitting position – physician may need to stand on a stool/chair
  2. Use “precision laryngoscopy”, slowly walking the blade in avoiding as many structures as possible
  3. Warn patients they will feel some pressure then compress tongue to visualize epiglottis
  4. Place blade in valleculla and perform appropriate lift to visualize cords
  5. Pass the ETT through the cords while the patient inspires

Picture 2

Post Intubation:

Don’t forget to confirm tube location, and provide sedation if the patients hemodynamics tolerate the sedation!

 

References:

Airway Management in Emergencies: Second Edition.  George Kovacs, J. Adam Law. 2011.

Picture 1

Picture 2

 

 

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Resident Clinical Pearl – No Bullus Paediatric DKA

No Bullus Paediatric DKA

Resident Clinical Pearl – December 2016

Luke Taylor, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

An altered 2yr old female child presents to your Emergency Department with a BP of 80/50 and a ++high point-of-care blood glucose…….anxiety provoking for all concerned right?

With a presentation like this, the best thing to do according to the House of God…is to “check your own pulse.”  Hopefully after reading this RCP you won’t need to and please don’t waste time recognising that this is severe DKA and this child needs appropriate emergency management.

Key Point – DO NOT BOLUS Fluid and DO NOT BOLUS Insulin

Paediatric DKA (P-DKA) was deemed by a TREKK (TRanslating Emergency Knowledge for Kids) Needs Assessment to be to be an area in which general EDs wished to improve management. A lack of awareness that optimum P-DKA management is different from that of adult DKA was a major driver. In particular, recognition that P-DKA can be complicated by cerebral edema in up to 1.5% of cases.

Management

Is the child in Decompensated Shock? Systolic BP less than (70+(2*age in yrs) for a child >1yr.

If Decompensated? = Bolus 5-10cc/kg over 1-2hrs and reassess after each bolus

 

If not Decompensated? = Correct slowly

Max fluid = 2x maintenance of Normal Saline

Time: Calculate to correct fluid deficit over 48hrs, most are 4-8% dehydrated in moderate DKA

**DKA develops over days (most of the time), therefore slow correction**

Fluid alone, over first 1-2hrs, then Fluid + insulin infusion at 0.05-0.1U/kg/hr

 

Cerebral Edema (CE)

Risk factors:

  • <5yrs old
  • new onset DM
  • ++acidosis
  • longer duration of symptoms
  • severe dehydration

Symptoms of CE:

**Generally 3-12hrs after initiation of therapy

  • headache
  • vomiting
  • confusion
  • GCS<15
  • irritability

Treatment of CE:

  • ABCs
  • restrict IV fluid to maintenance
  • elevate head of bed
  • Mannitol (0.5-1gm/kg IV over 20min) and/or 3% NaCl (5-10ml/kg IV over 30min)

Bottom line

Always:

Use paediatric specific protocol

Like this: http://sjrhem.ca/guideline/dka-pediatrics/

or http://www.bcchildrens.ca/endocrinology-diabetes-site/documents/dkaprt.pdf

And: contact local paediatric diabetes specialist

DO NOT: BOLUS


References

EM Cases Paediatric DKA: https://emergencymedicinecases.com/pediatric-dka/ (Great podcast!)

Lifeinthefastlane DKA: http://lifeinthefastlane.com/ebm-diabetic-ketoacidosis/

Diabetes Ther. 2010 Dec; 1(2): 103–120. The management of diabetic ketoacidosis in children – Arlan L. Rosenbloom

TREKK: http://trekk.ca/

Download (PDF, 280KB)

 

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Resident Clinical Pearl – A New Focus for PoCUS

A New Focus for PoCUS

Elective Resident Clinical Pearl – December 2016

Heather Flemming, PGY4 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

A 70 year old female presents to the emergency department with central abdominal pain and one episode of vomiting.  Her vital signs are stable, but she appears uncomfortable.

You bring the ultrasound machine to the bedside to assess her abdominal aorta. Your exam is challenged by the presence of bowel gas, causing scattering of your ultrasound beam, but is ultimately negative for an abdominal aortic aneurysm. You note that the patient has a midline scar, which she states is from a remote hysterectomy. With increased suspicion for bowel obstruction, you move the curvilinear probe across the abdomen and generate the following images: (Video Below)

The images demonstrate dilated loops of bowel and alternating peristalsis (a ‘to and fro movements’ of bowel contents). This confirms your suspicion for a small bowel obstruction (SBO).

 

Discussion:

Bedside ultrasound is a useful tool in evaluating any patient with abdominal pain, and has shown to be more sensitive and more specific than abdominal xray in diagnosing SBO1. Additional advantages of ultrasound include lack of radiation to the patient, bedside availability and potential to improve ED flow2. Treatments, such as nasogastric tube insertion, and early consultation to general surgery can be expedited by rapid identification. In individuals with recurrent sub-acute SBO, PoCUS may become the investigation of choice, reducing radiation exposure for this group of patients.

 

Pearls for performing a bedside ultrasound for SBO:

Multiple regions of the abdomen should be assessed, including the epigastrium, bilateral colic gutters, and suprapubic regions2. (Image 2).

Image 2 (overlapping survey of all quadrants)

 

Typical SBO ultrasound finding include:

  • ≥3 bowel loops dilated >25mm (Measurements taken at 90° to bowel wall)
  • Transition point – dilated peristalsing small bowel visualized adjacent to non-peristalsing collapsed bowel
  • Increased intraluminal fluid
  • Abnormal peristalsis: Hyperdynamic, alternating or absent peristalsis
  • Abdominal free fluid may also be present

 

Credit: ACEP.org

 

References

  1. Jang, Timothy B. Schindler, Danielle. Kaji, Amy H. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J 2011 28:676-678.
  2. Chao, Gharahbaghian. Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? https://www.acep.org/content.aspx?id=100218
  1. http://www.emdocs.net/ultrasound-small-bowel-obstruction/
  1. A video on Ultrasound in Small Bowel Obstruction by the Academy of Emergency Ultrasound can be found here: https://vimeo.com/69551555
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Resident Clinical Pearl – “Wellens ≠ well”

“Wellens ≠ well”

Resident Clinical Pearl – November 2016

Mandy Peach, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

It’s 7:30 in the morning, you are just starting your shift as a new R1 (you haven’t had coffee yet) and a 69 yo male rolls into the ED with chest pain ongoing since 2am. He has no known cardiac history (hasn’t seen a doctor in years) and is on no medications other than multivitamins. He is an active guy, doesn’t smoke or drink and has no pertinent family history.

On speaking with him he says the pain has actually subsided en route in EMS. You are passed his ECG1

picture1

Your immediate concern is to look for ST changes to determine if this guy is having a STEMI requiring immediate catheterization…but you don’t see any.

However, T-wave inversions in V1-V5 catch your eye, and they are fairly deep. Just ischemic changes?

Your staff cleverly hints – “This guy isn’t well”.

 

Wellens Syndrome

This ECG pattern is indicative of critical stenosis of the proximal LAD. It is not an acute infarction, but it is a predictor of bad things to come – namely anterior wall MI, usually within days to weeks2. Patients with this level of stenosis require more than medical management, and stress-testing them may precipitate infarction and death3.  They require catheterization.

Criteria to diagnose Wellens includes1:

  • Biphasic T waves (Type A) or deeply inverted T waves (Type B) in V2-3 (may extend to V1-6)
  • Isoelectric or minimally-elevated ST segment (< 1mm)
  • No precordial Q waves
  • Preserved precordial R wave progression
  • Recent history of angina
  • ECG pattern present in pain-free state
  • Normal or slightly elevated serum cardiac markers

The reasoning behind the T-wave pattern is as follows1:

When our patient had the chest pain at 0200 it was likely transient ischemia secondary to occlusion of the LAD. By the time he arrived to the ER the clot had spontaneously lysed and he was pain free. No ST elevation was seen, but the reperfusion of the LAD caused T wave changes – usually first biphasic (Type A) that progress to deeply inverted T waves (Type B)1:

picture1

 

But don’t be fooled – the differential for deeply inverted T waves is extensive and includes several important and potentially life-threatening conditions including1:

Pulmonary Embolism1 http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/10/ecg-wellens-syndrome-1.jpg

Brugada Syndrome1 http://i2.wp.com/lifeinthefastlane.com/wp-content/uploads/2009/09/Brugada-type-1.jpg

Hypokalemic1 http://i2.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/02/U-waves-in-hypokalaemia.jpg

 

And let’s not forget other high risk ECG presentations of chest pain that shouldn’t be missed as they involve a considerable section of the left ventricle and thus require activation of the cath lab:  http://rebelem.com/five-ecg-patterns-you-must-know/

  1. First Diagonal Branch of the LAD occlusion
  2. De Winters – proximal LAD occlusion
  3. Left Main Coronary Artery Stenosis
  4. Posterior Wall MI

 

So what happened with our guy?

The patient in this case did go on to have cardiac catheterization that same morning, most likely preventing a catastrophic MI.

 

What can you do in ED?

  1. Recognize the pattern
  2. Immediate consult to interventional cardiology
  3. Treat as unstable angina – chewable ASA and load with anti-platelet therapy in anticipation of catheterization.

 

Take away point –  Wellens ≠ well. The money isn’t always on ST changes alone, always check the T waves in V2-V3 for biphasic pattern or inversion and consider high risk ischemic ECG patterns in absence of chest pain and cardiac marker abnormalities. Poor outcomes can be prevented in these patients by consulting Cardiology and admitting for early cath.

 

 

References:

  1. http://lifeinthefastlane.com/ecg-library/wellens-syndrome/
  2. De Zwaan, C., Bar, F., Wellens, H. (1982). Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. American Heart Journal, 103 (4): 730-736.
  3. Tandy, R., Bottomy, D., Lewis, J. (1999). Wellens’ Syndome. Annals of Emergency Medicine, 33 (3): 347-351.
  4. De Zwaan, C., Bar, F., Janssen, J., Cheriex E., Dassen W., Brugada P., Penn, O., and Wellens, H. (1989). Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. American Heart Journal; 117(3): 657-65
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Resident Clinical Pearl – Superficial stab wounds: How do we know they’re superficial?

Superficial stab wounds: How do we know they’re superficial?

Resident Clinical Pearl – October 2016

Kyle McGivery, PGY3 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

Case 1:  

A 22 year old male presents with three stab wounds to his right anterior chest following an altercation.  He is alert, sitting the stretcher texting, and is hemodynamically stable.  How should this patient be managed?  When can he be safely discharged?

POCUS:   Bedside cardiac and eFAST exams should be performed immediately to r/o pericardial effusion, pneumothorax, and free fluid.  If the ultrasound is positive, arrange urgent surgical consult.  If negative, proceed with chest xray.

Wound probing:  Careful wound probing with Q-tip/sterile glove may help characterize the depth and possible intrathoracic extension of the wound.  Wound probing cannot definitively rule out penetration into thoracic cavity.  Consensus on performing this procedure is lacking, some consider there is a risk of causing a pneumothorax, although this seems unlikely if done carefully.

Monitoring and follow up imaging:  In a patient with no intrathoracic injury who remains asymptomatic, a repeat chest X-ray should be performed.  Previously a 6-hour follow up X-ray was preferred.  More recent literature suggests that shortening this period to 3 hours has no effect on outcomes.  In either case, 1-3% of patients will have clinically important findings on repeat chest X-ray.  Additionally, Berg, RJ et al. found that a 1 hour repeat X-ray did not result in fewer significant findings as compared to a 3 hour interval.

picture3

Figure 1. Anterior abdominal stab wounds


 

Case 2: 

A 24 year old male from the same altercation presents with the following injuries: see Figure 1

He has stable vitals, a normal DRE, and no sign of peritoneal irritation.  How should this patient with abdominal stab wounds be managed? 

 

Indications for immediate surgical intervention:

  • Hemodynamic instability
  • Peritonitis
  • Impalement
  • Evisceration
  • Frank blood from NG or DRE

 

For patients not meeting the above criteria, there are several options for management.

 

POCUS:  All patients with abdominal penetrating injury should have a eFAST exam performed urgently.  A positive fast requires surgical consultation.  Diagnostic peritoneal lavage may be considered but is no longer considered as part of the routine work up.

Local wound exploration (LWE):  Under sterile conditions, the wound can be inspected and possibly extended to determine if fascia has been breached.    Peritoneal violation occurs in 50-70% of abdominal stab wounds and half of these require surgical interventions.  If the fascia is intact, intra-abdominal injury is unlikely and discharge may be considered.  In order to be reliable, fascia must be visualized.  When performed by trained staff, LWE is 100% sensitive; it will allow for discharge in 25% of patients with abdominal stab wounds.

picture1

Figure 2. Local wound exploration demonstrating the anterior abdominal fascia breach

 

Imaging:  A plain film xray may reveal free air or impaled objects though a normal film does not rule out intra-abdominal injury.  The CT scan has an estimated sensitivity of 97% and specificity of 98% for identifying peritoneal violation. While routine CT is not mandatory, it should be strongly considered for upper quadrant injuries to assess for solid organ injury.  A normal CT should not preclude further work up or observation.

Observation:  Stable patients who have not had LWE should be observed for a minimum of 12 hours with serial physical exams +/- serial imaging and labs.  Surgical consultation should be considered in the event of tachycardia, hypotension, leukocytosis, or worsening pain.


 

Key Points:

  • All patients with superficial stab wounds to the chest require ultrasound to rule out pericardial effusion.

  • Repeat chest X-ray at 1-3 hours is appropriate for stable chest stab wounds; 1-3% of these will have new clinically significant findings.

  • CT scan is not 100% sensitive for evaluating intraperitoneal stab wounds; patients therefore require local wound exploration or observation for a minimum of 12 hours before discharge.


 

picture2


References:

https://www.emrap.org/episode/julyemrap/traumasurgeons

http://lifeinthefastlane.com/trauma-tribulation-02/

www.uptodate.com

http://emedicine.medscape.com/article/82869-overview?src=refgatesrc1

Berg RJ1, Inaba K, Recinos G, Barmparas G, Teixeira PG, Georgiou C, Shatz D, Rhee P, Demetriades D.  Prospective evaluation of early follow-up chest radiography after penetrating thoracic injury. (2013). Prospective evaluation of early follow-up chest radiography after penetrating thoracic injury., 37(6), 1286–1290. http://doi.org/10.1007/s00268-013-2002-0

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