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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Resident Clinical Pearl – STEMI vs Pericarditis

STEMI vs Pericarditis

Resident Clinical Pearl – September 2016

Jacqueline Mackay, PGY3 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

It’s 11 pm on a busy ED shift. You have just seen a 58 year old male with chest pain. It’s been coming and going for a few days, sometimes at rest. He’s also complaining of shortness of breath and diaphoresis.

This is the ECG:

ecg

 

STEMI? or Pericarditis?

Pericarditis is inflammation of the pericardium (often following viral infection but there are many other causes) that can cause the following symptoms: chest pain (pleuritic, positional, radiating to left shoulder), tachycardia, and dyspnea. There may be an an associated pericardial friction rub or evidence of pericardial effusion (muffled heart sounds or visible on PoCUS). Widespread ST segment changes are seen on ECG due to involvement of epicardial tissue.

 

The diagnosis of acute pericarditis requires at least two of:

1.    Chest pain consistent with pericarditis

2.    Pericardial friction rub

3.    Typical ECG changes

4.    Pericardial effusion (larger than trivial)

 

There are no studies that have determined clear diagnostic criteria. One of the biggest pitfalls in the diagnosis and treatment of pericarditis is misinterpretation of the ECG. The ECG is not always a classic presentation, and it is important to look for any ECG changes that RULE-IN STEMI.

 

How to distinguish Pericarditis from STEMI on ECG:

Three questions:

1.    Is there ST depression in a lead other than aVR or V1? If YES, it’s a STEMI

2.    Is there convex up or horizontal ST elevation? If YES, it’s a STEMI

3.    Is the ST elevation in lead III greater than the ST elevation in lead II? If YES, it’s a STEMI

picture1

 

If you are able to answer NO to ALL of the above: THEN look for PR depression in MULTIPLE leads and a (usually transient) friction rub. PR depression is NOT specific for pericarditis.

 

picture1

 

Bottom Line:

ECGs can be tricky Look for ECG changes that rule-in STEMI. Think pericarditis when there is diffuse ST elevation. And if you are unsure, perform serial ECGs on any patient with chest pain!

 

References:

  1. Pericarditis vs STEMI by Amal Mattu

  2. http://lifeinthefastlane.com/ecg-library/basics/pericarditis/

  3.  LeWinter MM, et al. Clinical practice. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-6. PMID: 25517707

 

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Resident Clinical Pearl – Wide Complex Tachycardia? Check aVR!

Wide Complex Tachycardia? Check aVR!

Resident Clinical Pearl – June 2016

Robin Clouston, PGY3 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr David Lewis

 

A patient presents with an altered level of consciousness and a wide complex tachycardia on cardiac monitor. The differential is broad, including a primary cardiac dysrhythmia, electrolyte abnormality, intracranial hemorrhage and a variety of toxicities.

Here is their ECG:

Picture1

 

How can this ECG help narrow your differential?

 

When presented with an undifferentiated patient with wide complex tachycardia, remember to check aVR lead to rule in sodium channel blocker toxicity.

A variety of toxins exhibit sodium channel blockade, including:

  • Tricyclic antidepressants (TCAs) (most common)
  • Carbamazepine
  • Quinidine
  • Procainamide
  • Lidocaine
  • Amantidine
  • Cocaine
  • Diphenhydramine

 

In sodium channel blocker toxicity, including TCA overdose, there is:

  • a terminal R’ wave in aVR, of >3mm
  • an R/S ratio of >0.7

 

Practically speaking, there is an abnormally tall R’ wave in aVR. This finding is specific to sodium channel blockade and occurs due to blockade of myocardium fast sodium channels.

Picture2

 

Other findings in TCA / sodium channel blocker toxicity:

  • Wide QRS > 100ms à increased risk of seizure
  • Wide QRS > 160ms à increased risk of VT/VF
  • Prolonged QTc
  • Rightward deviation of the terminal 40 msec of QRS (difficult to measure)

 

Treatment:

Give sodium bicarbonate 100mEq amp every few minutes until QRS narrows. The sodium is the active ingredient (not the bicarb) and is used to overwhelm the sodium channels and reverse the sodium channel blockade.

 

Conclusion:

So the next time you have an undifferentiated patient with a wide complex tachycardia, be sure to check aVR and consider TCA / sodium channel blocker toxicity!

 

References:

  • http://lifeinthefastlane.com/ecg-library/basics/tca-overdose/
  • http://foamcast.org/2014/09/03/episode-13-tricyclic-antidepressants-and-sodium-channel-blockade/
  • BK Blok et al. First Aid for the Emergency Medicine Boards 3rd 2016. McGraw-Hill Education. p375-377.

 

 

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Resident Clinical Pearl – Pumping Iron! – IV Iron for Iron deficiency anemia in the ED

Pumping Iron! – IV Iron for Iron deficiency anemia in the ED

Resident Clinical Pearl – May 2016

Benoit Phelan, PGY3 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr David Lewis

 

Clinical Question

Anemia is a common finding in patients presenting to the ED. How are we currently managing anemia in our ED? When do we transfuse with packed Red Blood Cells (pRBC)? If their hemoglobin is below 70 they need to be transfused, right? Not always….

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Packed RBC transfusion can and should be avoided in patients with Iron deficiency anemia but without significant on-going blood loss, and who are hemodynamically stable, asymptomatic at rest and tolerate normal activity (absence of CP, SOB, pre-syncope, hypotension and tachycardia). Reduced exercise tolerance is not an indication to transfuse with pRBC. Packed RBC transfusions are not benign. Acute life threatening (TACO, TRALI, AHTR) and irreversible long-term consequences due to allo-immunisation may arise.

See this article for more details on the complications of blood transfusion

 

An alternative and preferable option for this population is IV Iron infusion followed by a course of PO Iron. Parenteral Iron is indicated in the setting of poor oral tolerance, poor iron absorption, rate of blood loss exceeding the rate of absorption, severe anemia (Hb<90), and time constraints (preoperative).

 

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Most patients will require 1000mg of elemental iron to replete iron stores. Relying on GI absorption alone may not be favourable in certain populations. PPI use, gastric bypass, celiac disease, and high hepcidin levels may affect iron absorption in the GI tract. The GI tract’s maximum absorption is 66mg of elemental Iron daily. Higher doses such as TID regiments will not accelerate iron store repletion and may cause poorer adherence due to GI side-effects. Alone, a single dose of IV iron will not replete iron stores completely therefore it must be followed by subsequent parenteral doses or a PO regiment. In order to optimize GI absorption patient should be advised to take Iron supplements at bedtime on an empty stomach (2h after food) with Vit C, and avoiding Calcium and magnesium as these may impair absorption. Combination therapy may increase hemoglobin by 20-50g/L over 2 to 4 weeks beginning 3 to 7days after initiation.

 

IV Iron is safe but not without risk. Serious adverse events occur in <1 in 1 million infusions (1 in 200 000 in some reports). Historically, rates were much higher due to early high molecular weight iron dextran preparations. Hypotension occurs in 1-2% of infusion. Joint ache, muscle cramp, nausea, vomiting and diarrhea may occur in <1% of infusions and normally resolves in 12 to 24 hours. IV iron should not be used or be used cautiously in the setting of acute infection/sepsis (as it may promote bacterial growth), pregnancy, atop and systemic inflammatory disease.

 

The time required for infusion can be significantly shorter than that required for pRBC transfusion. Infusion rates vary with preparation types from 15 minutes (Feraheme) to 2 hours (Venofer). Slower infusion rates are required in the presence of hypotension, age >65, severe cardiac or respiratory disease, and multiple antihypertensive agents.

Bottom Line

Pumping IV Iron is a safe alternative to pRBC for Iron deficiency anemia. Should we be using it in our ED?

 

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References

  1. Schrier S.L., Auerbach M. (2016). Treatment of iron deficiency anemia in adults. In T. W. Post (Ed.), UpToDate. Retrieved from http://www.uptodate.com/contents/treatment-of-iron-deficiency-anemia-in-adults
  2. Helman, A. (2015). IV Iron for Anemia in Emergency Medicine. In Emergency Medicine Cases. Retrieved from http://emergencymedicinecases.com/iv-iron-for-anemia-in-emergency-medicine/
  3. Wright J.M. (2016). Intravenous (IV) iron for severe iron deficiency. In Therapeutic Letter, Therapeutic Initiative, UBCm Retrieved from http://www.ti.ubc.ca/2016/02/24/97-intravenous-iv-iron-for-severe-iron-deficiency/
  4. Rampton D, Folkersen J, Fishbane S, et al. Hypersensitivity reactions to intravenous iron : guidance for risk minimization and management. 2014;99(11):1671-1676. doi:10.3324/haematol.2014.111492.
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Resident Clinical Pearl – “To choose or not to choose”: an update on the Choosing Wisely Canada campaign and emergency medicine recommendations

“To choose or not to choose”: an update on the Choosing Wisely Canada campaign and emergency medicine recommendations

Resident Clinical Pearl – April 2016

Kavish Chandra, R1 Family Medicine and Emergency Medicine, Dalhousie University

 

Reviewed by: Dr. David Lewis

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Globally, healthcare costs have increased substantially. In Canada, healthcare expenditure was predicted to reach $219 billion in 2015, amounting to 10.9% of our gross domestic product.1 Perhaps more importantly, we do not see the same increase in the quality of healthcare, with Canada ranking 10 of out 11 among developed countries.2

As physicians, our knowledge of the costs of the tests and procedures we order are poor.3 The estimated cost of a single plain film X-ray is $33.76 and a 2-region CT scan is $133.63, which does not include the radiologists interpretation.3 Couple that with the risk associated with certain tests (invasive, radiation, false negatives and positives), we overuse certain tests and subject patients to risks that provide little value to their care.

 

The solution:

The Choosing Wisely campaign was launched by the American Board of Internal Medicine in 2012.4,5 Modelled after the U.S. Choosing Wisely campaign, Choosing Wisely Canada (CWC) is a national campaign aimed to help patients and physicians critically think about medical tests, treatments and procedures that were overused and provided little benefit to patients.6 Canadian medical speciality associations were asked to identify “5 things patients and physicians should question”.

 

The Canadian Association of Emergency Physicians (CAEP) and CWC developed the emergency medicine “5 things” 7

 

  1. Don’t order CT head scans in adults and children with minor head injuries (unless positive for a head injury clinical decision rule)
  2. Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis
  3. Don’t order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags
  4. Don’t order neck radiographs in patients who have a negative examination using the Canadian C-spine rules
  5. Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses.

 

Please see the following link for a brief video of the SJRH Emergency Department Rounds presentation by Kavish Chandra

https://youtu.be/08otVwh5trA


 

Please follow the link below more information on the Choosing Wisely Canada campaign and the emergency medicine recommendations

http://www.choosingwiselycanada.org/recommendations/emergency-medicine/

 

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References

  1. Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2015. Ottawa, ON: CIHI; 2015
  2. Davis, K., Stremikis, K., Squires, D., & Schoen, K. (2014). Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally.
  3. Hale, I. (2015). Add to cart? Canadian Family Physician, 61(11), 937-9, 941-4.
  4. Medicine’s ethical responsibility for health care reform—the Top Five list. N Engl J Med. 2010;362(4):283-285.
  5. Choosing Wisely. History. http://www.choosingwisely.org/about-us/history. Accessed October 12, 2015.
  6. Choosing Wisely Canada. What is CWC. http://www.choosingwiselycanada.org/about/what-is-cwc. Accessed Oct 12, 2015.
  7. Emergency medicine (2015). Retrieved April 2, 2016, from http://www.choosingwiselycanada.org/recommendations/emergency-medicine/

 

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Resident Clinical Pearl – Severe Community Acquired Pneumonia – A Role for Corticosteroids?

Severe Community Acquired Pneumonia – A Role for Corticosteroids?

Resident Clinical Pearl – March 2016

Kalen Leech-Porter, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr Cherie-Lee Adams and Dr David Lewis

Case:

A 66 yo female presents in respiratory distress following 3 days of productive cough and fever. Fever 39.7 degrees, HR 120, RR 32, SP02 91% on100% O2 via non re-breather mask BP 85/50 on with deteriorating mental status, no urine output in the ED (CXR below)Sepsis protocol has been invoked and she is currently on IV ceftriaxone and IV azithromycin with 2L bolus of NS just finishing being bolused. As you consider RSI, you wonder is there a role for steroids in this community acquired pneumonia (CAP)?

Image 1 (radiopedia.org)

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Discussion

A recent meta-analysis (1) suggests steroids may be a useful adjunct to antibiotic therapy in patients with community-acquired pneumonia (CAP).   The meta-analysis looked at 12 different randomized control trials with a total of 1,974 patients. Hospitalized patients were found to have a decreased length of stay (1 day on average, see Figure 1) and improved time to clinical stabilization (defined by vital signs within normal limits, normal mental status and no hypoxia for 24 hours) by 1.2 days. The analysis also found a decreased risk of mechanical ventilation (5 trials, relative risk [RR] = 0.45) and acute respiratory distress syndrome (4 trials, [RR]= 0.24). In patients with severe CAP, overall mortality was reduced by 3% (RR, 0.67 [95% CI, 0.45 to 1.01].   On the surface it would appear corticosteroids are useful, particularly in severe CAP.

Figure 1

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Unfortunately, diving deeper, the results are more ambiguous than they appear. There was significant heterogeneity in the studies used; “Eligible studies reported on at least 1 of the following outcomes: duration of hospitalization, time to clinical stability, all-cause mortality, need for mechanical ventilation, need for intensive care unit (ICU) admission, or development of ARDS”; they did not all report the same end points and used different risk stratification modules. Furthermore the CI for overall mortality crossed 1, making this result of questionable reliability. When stratified into subgroups, more severe pneumonias did seem to have greater benefit from corticosteroids: (6 studies; 388 patients; RR, 0.39 [CI, 0.20 to 0.77]; P = 0%). However, this could be due to selection bias.

A previous meta-analysis (2) found no mortality benefit in most CAP but an increased incidence of hyperglycemia with steroids. This analysis did not find any benefit to adding corticosteroids but its only primary clinical outcome was overall mortality. Other outcomes such as length of stay were not examined.

Complicating conclusions of both meta-analyses was a lack of consistency in steroid prescribed; a wide range of steroids, doses and routes were used.

 

Bottom line

When excluding disease states that may be worsened by steroids (ie diabetes), Corticosteroids may be a useful adjunct for severe CAP providing modest benefit; they may reduce length of stay in hospital and may slightly reduce overall mortality. The current literature is inadequate to determine the best dose/route for steroid administration. There is insufficient data to suggest corticosteroid should be used in non-severe CAP, given the potential steroid related complications.

 

References

1. Nie W, Zhang Y, et al. Corticosteroids in the treatment of community-acquired pneumonia in adults: a meta-analysis. PLoS One 2012; 8(1):e47296

2. Siemieniuk RAC, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia. Ann Intern Med 2015;163(7):519-528.

 

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