Syncope ECG – The ABCs – Resident Clinical Pearl

ECG Interpretation in Syncope

Resident Clinical Pearl (RCP) – December 2018

Dr. Luke Taylor, FMEM PGY3 –  Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

 

What are you looking for on the ECG of the patient with syncope?

Quick review of frequently pimped question on shift!

Two approaches – One using systematic ECG analysis, the other a mnemonic.

ECG Analysis (1)

Standard format of rate, rhythm, axis, and segments (PR, QRS, QT, ST).

Method of calculating heart rate (2)

Rate: Simple — Is the patient going too fast or too slow? *Remember this easy way to check:
Rhythm: Look at leads II, VI and aVR for P waves.
Ask yourself:
Are they upright in II/VI and inverted in aVR?
Does a QRS follow every P and a P before every QRS?

If so likely sinus rhythm.

In the setting of syncope we are looking to see if there is any signs of heart block – a P wave not conducted to a QRS, especially being sure not to miss a Mobitz type II block.

Axis: Axis comes in to play when looking for more extensive conduction disease. Is there axis deviation along with a change in your PR and BBB indicating something like a trifasicular block?

Segments:

PR interval— is it looooong (heart block) or short (reentrant)?
Long has already been discussed in looking for signs of heart block, but a short PR may be indicative of Wolf-Parkinson-White or Lown-Ganong-Levine syndromes.

WPW – look for short PR and delta wave
LGL – short PR but no delta wave due to its conduction being very close to or even through the AV node and not through an accessory pathway.

QRS Morphology analyzing this for signs of Brugada, HOCM, WPW, ARVD, pericardial effusion, and BBB.

ECG findings of Brugada (3)

Type 1: Coved ST segment elevation with T wav inversion
Type 2: Saddleback ST segment elevation and upright T waves
Type 3: either above without the ST elevation

QT interval — is it looooong (R on T) or short (VT/VF risk)?
Long is >450 men, 470 women
Short < 330ms – tall peaked T waves no ST segment
Pearl for long – should be less than half the RR interval. —>

Normal relationship of R-R and QT interval (4)

 

ST segment — think MI or PE (rare causes of syncope but need to be considered)
MI – elevations or depressions

PE – Tachycardia, RV strain, T-wave inversion V1-V3, RBBB morphology, S1Q3T3

 

Mnemonic (5)

ABCDEFGHII

A — Aortic stenosis
Go back to patient and listen!
B — Brugada
C — Corrected QT
D — Delta wave
E — Epsilon wave as in Arrhythmogenic Right Ventricular Dysplasia (ARVD)

Epsilon: Small positive deflection (‘blip’) buried in the end of the QRS complex (6)

F — Fluid filled heart
Pericardial effusion, electrical alternans, low voltage throughout
G — Giant PE
H — Hypertrophy
LVH in someone who shouldn’t have it
I — Intervals
PR, QRS, QT
I — Ischemia

 


Looking for a Basic ECG Guide? See our Med Student Pearl Here:

Medical Student Clinical Pearl – Basic ECG Interpretation

 


 

References

  1. CanadiaEM – ECGs in Syncope https://canadiem.org/medical-concept-ecgs-in-syncope
  2. https://en.ecgpedia.org/wiki/Rate
  3. ECG Waves https://ecgwaves.com/brugada-syndrome-ecg-treatment-management
  4. https://www.healio.com/cardiology/learn-the-heart/case-questions/ecg-cases/question-3-5
  5. Hippo EM Education Shorts https://www.youtube.com/watch?v=raTTYV7_Asl
  6. https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy

 

This post was copyedited by Dr. Mandy Peach

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Resident Clinical Pearl – Epistaxis Management in the ED – 3 Step Method

Epistaxis Management

Resident Clinical Pearl (RCP) – December 2018

Luke Taylor R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. Kavish Chandra

 

It’s 0300 and you are on a solo night shift when a 76 year old male with blood dripping out of both nares is brought into an examining room. It looks a little more profuse than what you saw on Stranger Things last month, but you are also wondering how to best tackle this very common emergency problem

 

History

-Laterality, duration, frequency

-Estimated blood loss, presence of any clots?

-Inciting factors such as trauma or coagulopathy

-Past medical history, especially hypertension, clotting disorder, HHT

-Medications such as anticoagulants or anti-platelets

 

Physical examination

-Have patient blow nose or use suction to clear clots

-Do not try and visualize until decongestion complete

-Visualize with nasal speculum for site of bleeding. If an anterior bleed, most commonly the bleeding site will be Little’s area (Figure 1)

-See below for management if patient’s ABCs stable. If unstable be prepared to secure airway and call for help – ENT/interventional radiology

 

Figure 1. Nasal vascular anatomy, adapted from https://www.juniordentist.com/what-is-littles-area-or-kiesselbachs-area-and-the-arteries-in-it.html.

 

Management

-Get IV access, draw CBC and coagulation profile when indicated

-Treat as unstable until proven otherwise

 

Pearls

  • Apply ice to the hard palate (popsicles, ice in the mouth) to reduce nasal blood flow up to 25%
  • TXA in patients on anti-platelets (primarily aspirin) results in faster cessation of bleeding
  • Ducanto suction in future -> SALAD technique – Ducanto-bougie intubation for large bleeds
  • Only reverse anticoagulants if absolutely necessary – “local problem, local solution”

 

Three Step Approach to Epistaxis

1. Visualize and decongest

  1. Have patient blow their nose to clear all clots
  2. Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
  3. Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
  4. Pack nose with soaked cotton and replace clamp for 10 mins

2. Cauterize

  1. Remove clamp and packing
  2. Area should be well blanched and anesthetized
  3. Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
  4. If successful and bleeding ceases on reassessment, apply surgicel wrapped around a small piece of surgifoam to create a “dissolvable sandwich”and discharge home

3. Tamponade

  1. Apply unilateral nasal packing (Rapid Rhino, Merocel, etc)
  2. Reassess in 10 mins, visualizing oropharynx for continued bleeding
  3. If stops, can discharge home with packing in place and follow up in ED or ENT clinic in 48hrs for removal. No antibiotics required in immunocompetent patients.
  4. If continues to bleed, move the patient to a higher acuity area and apply bilateral nasal packs

When to call ENT

If bilateral nasal packing bleeding continues, assume posterior bleed and initiate resuscitation, draw labs (CBC, coagulation profile, cross-match if not already done). Reverse known coagulopathy and consult for OR or embolization.

 

ED Rounds – Epistaxis

 

 

References:

Dr Christopher Chin and his informative talk

http://rebelem.com/topical-txa-in-epistaxis/

https://emergencymedicinecases.com/ent-emergencies/ 

https://lifeinthefastlane.com/epistaxis/

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Resident Clinical Pearl – Scalp Lacerations – “You Can Leave Your HAT On!”

You can leave your “HAT” on: An approach to scalp lacerations and review of the hair apposition technique

Resident Clinical Pearl (RCP) – November 2018

Devon Webster – FMEM PGY1, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 


Quick case!

Joe Cocker and Randy Newman had an altercation while debating who recorded the best version of “You can leave your hat on”. Randy won (mainly because he is still alive), but unfortunately he sustained a nasty head injury in the process. You deduce that he does not require a CT head but he’s got a 7 cm lac over his scalp. What should you do next?

 

Review of scalp anatomy:

The scalp is divided into 5 layers, which can conveniently be recalled using the mnemonic, SCALP:

  • Skin

    Ref 1

  • dense Connective tissue
  • Aponeurosis
  • Loose connective tissue
  • Periosteum

 

Recall that the dense connective tissue layer is richly vascularized. The tight adhesion of these vessels to the connective tissue inhibits effective vasoconstriction, hence the profuse bleeding often seen with scalp wounds.

The loose connective tissue layer = the DANGER ZONE when lacerated. This layer contains the emissary veins, which connect with the intracranial venous sinuses. Consequently, lacerations reaching this layer are high risk for spreading infection to the meninges

 

 

 

Examining the laceration:

Ref 2

Prior to choosing the most appropriate closure technique, the wound should be cleaned and cleared of debris and the depth of the wound should be determined.

  • Superficial wounds: generally do not gape and have not gone beyond the aponeurosis. Adherence to the aponeurosis should prevent the wound edges from separating.
  • Deep wounds: gape widely due to laceration of the aponeurosis in the coronal plane. Tension secondary to the occipitofrontalis muscles will pull the wound open in opposite directions.

 

Ref 2

(A) Scalp laceration that extends through the aponeurosis
(B) CT showing an associated skull fracture

 

Choosing a closure technique:

A. The HAT technique: Hair Apposition Technique

What it is: A fast and simple technique for superficial laceration closure whereby the physician twists hair on either side of the laceration together and seals the twist with a drop of glue for primary closure. Various advantages, as described below, including no need for follow up suture or staple removal.

When to use it: Consider using HAT for linear, superficial lacerations, <10 cm that have achieved appropriate hemostasis (assuming the patient has hair!).

The evidence for HAT: An RCT based out of Singapore, comparing suturing (n=93) to HAT (n=96) for scalp lacerations <10 cm found HAT to be equally acceptable if not superior to suturing. Patients were more satisfied (100% vs 75%), had less scarring (6.3% vs 20.4%), fewer complications (7.3% vs 21.5%), lower pain scores (2 vs 4), shorter procedure times (5 vs 15 min) and less wound breakdown (0% vs 4.3%) (Ref 4)

A follow up study by the same group assessing cost-effectiveness of HAT compared to suturing found a cost savings of $28.50 USD (95% CI $16.30 to $43.40) in favor of HAT when taking into consideration materials, staff time, need for removal appointments and treatment of complications (Ref 5)

A retrospective observational study comparing HAT (n=37) to suturing (n=48) and stapling (n=49) also found HAT to be superior to both suturing and stapling due to increased patient satisfaction at days 7 and 15, reduced pain, lower cosmetic issues and complication rates (Ref 6)

 

How to do HAT (see diagram):

  1. Choose 4-5 strands of hair in a bundle on either side of laceration
  2. Cross the strands
  3. Make a single twist to appose the wound edges
  4. Secure with a single drop of glue
  5. Advise patient that the glue will eventually come off on its on and no formal removal is required.

Cautions with HAT: avoid getting glue into the wound as it may result in wide scarring with a bald spot (Ref 3)

 

B. Wound Staples

If the HAT technique is not an option (no glue, bald, etc) and the lac is superficial (above the aponeurosis), staples are preferred over suturing due to Ref 3:

  • Rapid closure of wound edges
  • Non-circumferential wound closure avoid potential strangulation
  • No cross hatch marks
  • Less expensive

C. Wound Sutures

Sutures are appropriate for deep, gaping wounds or those requiring immediate hemostasis.

Suture is required for lacerations through the aponeurosis to reduce spread of infection, hematoma formation and increased scarring. Furthermore, inadequate repair of the aponeurosis may result in asymmetric contraction of the frontalis muscle (Ref 3)

 

 

Final thoughts post-closure:

  • White petroleum ointment is as effective as antibiotic ointment in post-procedural care (Ref 7). Furthermore, the next time you consider handing out bacitracin (or polysporin), recall that it was declared ‘contact allergen of the year for 2003’ by the American Contact Dermatitis Society. Bacitracin is among the top ten allergens in the US causing allergic contact dermatitis (Ref 8).
  • Wetting the wound as early as 12 hrs post-repair does not increase the risk of infection (Ref 7). Consider delaying wetting in the case of HAT.

Bottom line:

  • For superficial lacerations, <10 cm with adequate hemostatic control, the hair apposition technique is a fast, cost-effective method of wound closure with high patient satisfaction, reduced pain and lower complications compared to suturing and staples.
  • Lacerations through the aponeurosis require suturing to reduce rates of complications.
  • Consider use of petroleum jelly over antibiotic containing ointments such as polysporin.

 

Video

 


 

References:

 

1 Hunt, W. “The Scalp.” Teachmeanatomy.info. Last updated Oct 24, 2018. Accessed Nov 28, 2018. URL:  https://teachmeanatomy.info/head/areas/scalp/

2 Dickinson, E. Uptodate. Accessed Nov 28, 2018 URL: https://www.uptodate.com/contents/image?imageKey=EM%2F87633&topicKey=EM%2F16696&source=see_link

3 Hollander, J. “Assessment and management of scalp lacerations.” Uptodate. Updated Feb 23, 2018. Accessed Nov 28, 2018. URL: https://www.uptodate.com/contents/assessment-and-management-of-scalp-lacerations

4 Ong ME. “A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).” Annals of Emergency Medicine. July 2002. 40:1. 19-26.

5 Ong ME. “Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations.” Annals of Emergency Medicine. 2005 Sept; 46(3):237-42.

6 Ozturk D. “A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations.” World J Emerg Surg. 2013; 8:27.

7 Forsch, R. “Essentials of skin laceration repair.” American Family Physician.

8 Fraser, J. “Allergy to bacitracin.” Dermnet NZ. September 2015. Accessed on Nov 28, 2018 URL: https://www.dermnetnz.org/topics/allergy-to-bacitracin/

 


 Randy:

 

Joe:

 

 

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Resident Clinical Pearl: Arterial bleeding

Approach to Arterial Bleeding in the Upper Extremity

Resident Clinical Pearl (RCP) – November 2018

Tara DahnCCFP-EM PGY3, Dalhousie University, Halifax NS

Reviewed by Dr. David Lewis

This post was copyedited by Dr. Mandy Peach

You are working a shift in RAZ when a pair of paramedics wheel a man on a stretcher into one of the procedure rooms. He is sitting upright and looking around but his entire left forearm and hand are wrapped in towels, which are taped tightly down. “I don’t know what’s hurt but there was a lot of blood”, he says when questioned. He had been using a reciprocating saw in his workshop.

Vital signs: T 36.5, HR 90, BP 135/90, RR 18, O2 sats 98% on RA

You ask the nurses to find a tourniquet to put around the patients arm as you start unwrapping his giant towel mitt. You get down to the skin and find a deep 1 inch transverse laceration along the radial side of the wrist. Initially there is no active bleeding, you gingerly pock the wound and …Ooops… immediately bright red pulsatile blood starts pumping out from the distal wound edge and your scrubs will need to be change before you see the next patient.

Approach to arterial bleeding in upper extremity

Life over limb

  • Get control of the bleeding and if needed focus on other more pressing injuries. Start resuscitation if needed
  • There is no bleeding in the extremity that you can’t stop with manual compression.
  • If you can’t spare a person to compress artery then consider a tourniquet. (see Table 1 on tourniquets)
  • Avoid blindly clamping as nerves are bundled with vascular structures and can be easily damaged.

 

Determine if arterial bleeding/injury exists

Look for hard or soft signs of arterial injury (See Table 2)

If hard signs of arterial injury in major vessel the patient will need operative care. Imaging is not required unless site of bleeding is not clear (and patient is stable).
If there are soft signs of arterial injury do an Arterial Pressure Index (see Box 1) to help determine if there is an underlying arterial injury.
o If API >0.9: Patient unlikely to have an arterial injury. Observe or discharge based on nature of injury/patient.
o If API < 0.9: Possible arterial injury. Patient will need further investigation, preferably by CTA.

  • API is recommended over ABI (Ankle Brachial Index) in lower extremity injuries. ABI compares lower extremity SBP to brachial SBP. Usually patients will have more atherosclerotic disease in their lower extremities, which can falsely elevate their ABI and make it harder to detect a vascular injury. The API, on the other hand, relies on the fact that the amount of atherosclerotic disease is usually symmetric between the two upper and two lower extremities.
  • API is a very good test. An API less than 0.9 has a sensitivity and specificity of 95% and 97% for major arterial injury respectively, and the negative predictive value for an API greater than 0.9 is 99% (Levy et al., 2005).

Consider vessel injured

  • A good understanding of vascular anatomy is important to identify which vessel is injured. See figures 1 and 2.

Figure 1: Upper Extremity Arteries
(https://web.duke.edu/anatomy/Lab12/Lab13_preLab.html)

Figure 2: Lower Extremity Arteries
https://anatomyclass01.us/blood-vessels-lower-limb/blood-vessels-lower-limb-arteries-in-the-lower-leg-human-anatomy-lesson

Examine distal extremity well.

  • In the excitement of pulsatile bleeding it can be easy to be tempted to skip/rush this. But with bleeding controlled remember that the extremities are much less picky about blood supply than your vital organs. You can take a few minutes to examine the distal limbs neurovascular status (blood supply, sensory and motor, tendon integrity) and should as this will be important for management decisions.
  • Arterial injuries can very often be accompanied by nerve and tendon injuries. Complete a full assessment. See Figures 3 &4 for neurologic assessment of hand.
  • Most disability following arterial injuries is not due to the actual arterial injury, but due to the accompanying nerve injury (Ekim, 2009).

Figure 3: Motor examination of the hand. 1 – Median nerve. 2- Ulnar nerve. 3- Radial nerve (Thai et al., 2015)
Figure 4: Sensory innervation of the hand and nerve locations (Thai et al., 2015)

Explore wound carefully

  • It is important to explore the wound carefully to look for other structures damaged.
  • Examine tendons and muscles by putting their accompanying joints through a full ROM to see partial lacerations that may have been pulled out of sight.

Control bleeding definitively

Proximal arterial injuries (brachial artery, proximal radial/ulnar artery)

-All brachial artery injuries will require urgent repair by vascular surgeon.
-The “golden period” is 6-8 hours before ischemia-reperfusion injury will endanger the viability of the limb (Ekim, 2009). Degree of ischemia depends on whether injury is proximal or distal to the profunda brachii (Ekim, 2009)
-Larger more proximal arteries are rarely injured alone and will nearly all have nerve/tendon/muscle injuries also requiring operative repair

Forearm/hand arterial injuries
-Many arterial injuries in/near the hand will NOT require operative repair as there are very robust collaterals in the hand with dual blood supply from the radial and ulnar arteries in most people.

-Steps to management
Manual direct digital compression: 15 minutes direct pressure without interruption will often be successful on its own.

Temporary tourniquet application and wound closure with running non-absorbable suture followed by compact compressive dressing. If vessel obviously visible may try tying off but blindly clamping/tying will likely injury neighboring structures, particularly nerves.

Operative repair may be required if bleeding cannot be controlled with above measures.
Studies have shown that in the absence of acute hand ischemia, simple ligation of a lacerated radial or ulnar artery is safe and cost effective (Johnson, M. & Johansen M.F., 1993) however some surgeons may still opt to perform a primary repair.

 

Approach for our case

Life over limb

Patient was hemodynamically stable at presentation. IV access had already been obtained by the paramedics. Bleeding was controlled with direct pressure. When visualization was required at the site of the wound a tourniquet was used.

Determine if arterial bleeding
Our patient had a clear hard sign for arterial bleeding- pulsatile blood

Consider vessel injured
Our patients pulsatile bleeding was coming from the distal edge of the wound. Leading us to conclude that it was pulsing retrograde from the palmar arch (See Figure 5 for more detailed anatomy).

Examine distal extremity well
Our patient had a completely normal sensory and motor exam of his hand as well as normal tendon function. Lucky!

Explore wound carefully
A tourniquet was needed to properly visualize and explore the wound. There were no other injured structures identified.

Control the bleeding definitively
Direct pressure for 15 minutes did not stop the bleeding. The ends of the vessel were not identified on initial wound inspection. The wound was extended a short distance (~1cm) in the direction of the bleeding but still the vessel was not identified.

Plastic surgery was consulted. They extended the wound another 3 cm distally and were able to identify the artery, which had been transected longitudinally. They concluded that it was likely the radial artery just past the superficial palmar branch. The hand was well perfused and thus the artery was ligated. The wound was irrigated well, closed and the patient was discharged with a volar slab splint and follow up.

 

References:

Ekim, H. & Tuncer, M. (2009). Management of traumatic brachial artery injuries: A report on 49 patients. Ann Saudi Med. 29(2): 105-109.

Johnson, M. & Johansen, M.F. (1993). Radial or Ulnar Artery Laceration – Repair or Ligate? Arch Surg 128(9), 971-975.

Levy, B. A., Zlowodzki, M.P., Graves, M. & Cole, P.A. (2005). Screening for extremity arterial injury with the arterial pressure index. The American Journal of Emergency Medicine, 23(5), 689-695.

Thai, J.N. et al. (2015). Evidence-based Comprehensive Approach to Forearm Arterial Laceration. Western Journal of Emergency Medicine, 16(7), 1127-1134.

Life in the Fast Lane: Extremity arterial injury

Tinntinalli’s Emergency Medicine

 

This post was copyedited by Dr. Mandy Peach

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Resident Clinical Pearl – The Acute Scrotum

What to do when the balls are in your court:

An Approach to the Acute Scrotum

Resident Clinical Pearl (RCP) – October 2018

Devin Magennis – Family Medicine, PGY2, Dalhousie University, Charlottetown PEI

Reviewed by Dr. David Lewis

 

The acute scrotum is a syndrome characterized by intense, new onset scrotal pain which can be accompanied by other symptoms such as inflammation, abdominal pain, or fever3. The incidence of acute scrotal pain is highest under the age of 153, yet it can occur at any age.  To successfully diagnosis and manage the patient with an acute scrotum it is useful to formulate a differential diagnosis using the I VINDICATE mnemonic.

Table 1- Differential diagnosis for scrotal pain organized using I VINDICATE format. The diagnoses in bold are or have the potential to be life-threatening or testicle threatening. The diagnose in Italics are common.

 

 

Review of Clinically Relevant Anatomy:

It is important to remember that during development the testicles originate in the posterior abdominal wall before migrating down into the scrotum4. Consequently, testicular pathology can present not just as scrotal pain but also as: flank pain, abdominal pain or inguinal pain2.

Once in the scrotum, the testicle sits in a vertical lie. The anterior portion of the testicle adheres to the scrotal wall via the tunica vaginalis. The tunica vaginalis is double-layered. Between these layers is a potential space for fluid to collect. Along the postero-lateral aspect of the testicle is the epididymis. It originates at the postero-superior pole, runs along the lateral aspect of the testicle down to the inferior pole4

 

Figure 1- Anatomy of the testicle. Right side of photo is anterior, left side is posterior

 

When trying to localize a patient’s symptoms it helps to divide the genital tract into segments: lower segment and the upper segment. The lower genital tract consists of the urethra. While the upper genital tract consists of the testicles, epididymis and prostate.

 

 

Testicular torsion

In a patient presenting with an acute scrotum the most important diagnosis to consider is testicular torsion1-5. Classic teaching states testicular torsion occurs in the perinatal period and during puberty. and Reported will be: sudden onset of severe unilateral testicular pain within 12 hours of presentation1. Patients will typically have had similar previous episodes, feel nauseated, may have vomited and occasionally have a history of trauma1. On inspection there will be scrotal erythema; a swollen, high-riding testicle with a horizontal lie. On palpation of the testicle it would be found to be exquisitely tender and the cremasteric reflex would be absent.

Unfortunately, testicular torsion usually does not present as described above2.  In one case series 1 in 5 patients diagnosed with testicular torsion had only abdominal pain and no scrotal pain2. While in another case series 7% of patients diagnosed with testicular torsion presented with complaints of dysuria and/or urinary frequency. Furthermore, other acute scrotal conditions have considerable overlap with the classic description of torsion2. Both epididymitis and torsion of the testicular appendage can present with sudden onset of pain2. Patients with any scrotal condition can have an absent cremasteric reflex as it is absent in 30% of the population and just to make matters more confusing, multiple case series report patients with testicular torsion still having an intact cremasteric reflex1.

 

Approach

What to ask the patient with an acute scrotum:

  • Characterize the pain
  • Location: testes, epididymis (postero-lateral aspect of testicle), upper pole of testes
  • Onset: sudden vs gradual
  • Frequency of pain
  • Radiation
  • Intensity
  • Duration
  • Events associated: trauma; dysuria, urethral discharge and urinary frequency; sexual history
  • Constitutional symptoms
  • Medical history: GU abnormalities, Recurrent UTIs, Diabetes, Alcoholism, Steroid use
  • Recent Catheterization or instrumentation of urinary tract
 

 

Physical exam for the acute scrotum

1)      Inspection:

  • Symmetry and size of testicles
  • skin erythema
  • blue dot at upper pole of testicle
  • Unilateral vein engorgement

2)      Palpation:

  • Determine site of maximal tenderness and check for masses
    • Testes
    • Epididymis
    • Upper pole of testes
    • Inguinal canal
    • McBurney’s point, Cost-vertebral angle or another abdominal or flank location

3)      Ultrasound to rule-out AAA in patients over 50

 

Management

 

The Bottom Line

  1. Testicular torsion is the one diagnosis that must be made quickly and accurately to avoid the loss of a testicle.1
  2. The classic teaching that testicular torsion can be diagnosed on history and physical exam alone is a myth. If you suspect torsion get an ultrasound and consult urology.2
  3. Torsion becomes exceedingly rare over the age of 25; however it is still possible.1
  4. Abdominal aortic aneurysm, appendicitis, nephrolithiasis and other causes of abdominal and flank pain can present as scrotal pain. Testicular torsion can present as abdominal or flank pain.2

 

References:

  1. Jefferies MT, Cox AC, Gupta A, Proctor A. The management of acute testicular pain in children and adolescents. BMJ. 2015;350:h1563. doi: 10.1136/bmj.h1563 [doi].
  2. Mellick LB. Torsion of the testicle: It is time to stop tossing the dice. Pediatr Emerg Care. 2012;28(1):80-86. doi: 10.1097/PEC.0b013e31823f5ed9 [doi].
  3. Lorenzo L, Rogel R, Sanchez-Gonzalez JV, et al. Evaluation of adult acute scrotum in the emergency room: Clinical characteristics, diagnosis, management, and costs. Urology. 2016;94:36-41. doi: 10.1016/j.urology.2016.05.018 [doi].
  4. Drake R, Vogl AW, Mitchell AWM. Gray’s anatomy for students. Saint Louis: Elsevier; 2014. Accessed 8/11/2018 11:47:58 AM.
  5. Rottenstreich M, Glick Y, Gofrit ON. The clinical findings in young adults with acute scrotal pain. Am J Emerg Med. 2016;34(10):1931-1933. doi: S0735-6757(16)30284-4 [pii].

 

 

This post was copyedited by Dr. Mandy Peach

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Resident Clinical Pearl – PoCUS Triage Shoulder Dislocation

Resident Clinical Pearl – POCUS in Shoulder Dislocation

Luke Richardson, PGY 3 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

A 24 year old male rugby player presents to the emergency department with left sided shoulder pain.  He reports being hit in the middle of the game followed by a pop to his shoulder.  Since that time he has had ongoing pain and limited movement.  His vitals are normal but he appears uncomfortable.  He shows no signs of neurological or vascular injury.  History and physical exam is otherwise benign.

 

Dislocated shoulder is suspected, but is there a way to quickly diagnose prior to x-ray and therefore expedite administration of pre-procedural analgesia and preparation of procedural team and room?

 

POCUS: Shoulder Background

The shoulder is a ball-in-socket joint with a large range of motion and has a high risk of dislocation due to its shallow joint depth and limited tendinous support inferiorly.   Most commonly, the shoulder will dislocate with the humeral head anterior to the glenohumeral rim due to an superiorly placed force upon the humeral head.  Posterior dislocations are less common and commonly due to higher mechanism of injuries such as seizure or electrical shock.

 

Diagnosis of shoulder dislocation is commonly made by x-ray but this method has its downsides including time to diagnosis and increased radiation exposure.  An important consideration is the use of POCUS during shoulder reduction.  This technique allows for real time confirmation and potentially avoids the need for repeat sedation if failed reduction discovered by a trip to the x-ray department.  A recent prospective observational study of 73 patients in the emergency department revealed an accuracy of 100% sensitivity and specificity for shoulder dislocation and relocation (reference 1).   Finally, considering there is increased risk of neuro-vascular complications with time to relocation; a decrease in duration to diagnosis could potentially improve patient care.

 

 

POCUS: Shoulder Technique

Get patient to sit up to allow availability to the posterior portion of the patient shoulder.

Support the patients elbow while positioning the shoulder in adduction and internal rotation.

Using the curvilinear probe, landmark just inferior to the scapular spine and follow it laterally until you find the glenoid (G) and humeral head (HH) (Shol1).

Shol 1

You should find the humeral head (HH) as a circular structure lateral to the glenoid fossa (G) if in joint. Note the Glenoid labrum (L).

To confirm, you can internally and externally rotate the arm and visualize the humeral head freely moving within the glenoid (Shol2/Shol4) (reference 2). Note the overlying deltoid (most superficial) and the infraspinatus tendon that becomes more apparent during internal rotation.

Shol2

Shol4

If the shoulder is anteriorly dislocated you will see the humeral head displaced inferiorly (Shol5/Shol6) (reference 2,3)

If the shoulder is posteriorly dislocated you will see the humeral head more superficial than expected (Shol5) (reference 2,3)

 

Shol5

Shol6

 

Conclusion:

POCUS is an easily available and non-invasive tool in the emergency department.  It can be used in cases such as this to improve patient flow, decrease time to diagnosis, and confirm reduction.

 

Reference:

  1. Abbasi, S., Molaie, H., Hafezimoghadam, P., Amin Zare, M., Abbasi, M., Rezai, M., Farsi, D. Diagnostic accuracy of ultrasonogrpahic examination in the management of shoulder dislocation in the emergency department. Annals of Emergency Medicine. Volume 62:2. August, 2013, pg. 170-175.
  2. Tin, J., Simmons, C., Ditkowsky, J., Alerhand, S., Singh,M., US Probe: ultrasound for shoulder dislocation and reduction. EMDocs http://www.emdocs.net/us-probe-ultrasound-for-shoulder-dislocation-and-reduction/ January 18, 2018.
  3. Rich, C., Wu, S., Ye, T., Liebmann, O. Pocus: shoulder dislocation. Brown Emergency Medicine. http://brownemblog.com/blog-1/2016/11/30/pocus-shoulder-dislocation. November 30th, 2016.
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Resident Clinical Pearl – Infectious flexor tenosynovitis

“Don’t pull my finger!” – a case of flexor tenosynovitis.

Resident Clinical Pearl (RCP) – July 2018

Mandy Peach – FMEM PGY3, Dalhousie University, Saint John NB

Reviewed by Dr. David Lewis

You are working a rural ED and a 70 yo male presents with an injury to his right hand about one week ago. He has no known past medical history, is widowed and lives alone. He has no family doctor; a family member made him come in.

In triage he denies any major discomfort in the finger, and has taken nothing for pain. However he has noticed it is increasing in size, becoming more red and even black in places.

Vital signs show he is hypertensive, but otherwise afebrile with a normal heart rate.

You walk into the room to do the assessment and immediately your eyes are drawn to his hand:


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WHOA.

As you get further history it turns out the injury was a rusty nail to the digit – it just keeps getting better.

You are worried about an infectious flexor tenosynovitis – a can’t miss diagnosis. This is when purulent fluid collects between the visceral and parietal layers of the flexor tendon1. This infection can rapidly spread through the deep fascial spaces. Direct inoculation, like this penetrating injury, is the most common cause1.

4 clinical signs of tenosynovitis – Kanavel’s signs

  • ‘sausage digit’ – uniform, fusiform swelling
  • Digit is held in flexion as the position of comfort
  • Pain with passive extension
  • Tenderness along the tendon sheath

Figure 1: Sketchy Medicine – Flexor Tenosynovitis http://sketchymedicine.com/2012/10/flexor-tenosynovitis-kanavels-signs/

 

As you can imagine this guy had all 4 signs – slam dunk diagnosis, with a little gangrene at the tip to boot. But the diagnosis isn’t always clear cut, and some of these are late signs of infectious flexor tenosynovitis. Patients may present earlier in the course of illness, so what can we use to help diagnose this condition? PoCUS of course!

Place a high frequency linear probe at the wrist crease where you should visualize flexor tendons overlying carpel bones.

Figure 2: Normal flexor tendons (yellow) and carpel bones in transverse plane1

In infectious flexor tenosynovitis you would see anechoic edema and debris in the flexor tendon sheath, and potentially thickening of the synovial sheath. You can assess in both longitudinal and transverse planes.

Figure 3: Transverse (A) and Longitudinal (B) images showing edema in flexor tendon sheath1.

 

Treatment:

So the most common bug that causes these infections is Staphylococcus, however they can be polymicrobial2. Broad spectrum coverage is required – think ceftriaxone or pip tazo. If there is concern for MRSA than vancomycin would be indicated.

But let’s remind ourselves – he had exposure to a rusty nail – you must cover Pseudomonas as well.

We chose ceftriaxone and ciprofloxacin, administered a tetanus (he never had one before) and urgently contacted plastics. He stayed overnight in the rural ED and was transferred out the next morning for OR. Unfortunately, he did have up having the digit amputated but he recovered well.

 

Take home message: Flexor tenosynovitis is a surgical emergency – examine for Kanavel’s signs. Ultrasound can be helpful in confirming diagnosis in the right clinical context. Cover with broad spectrum antibiotics, consider MRSA or Pseudomonas coverage if indicated. Urgent plastics referral needed.

 

References:

  1. Padrez, KP., Bress, J., Johnson, B., Nagdev, A. (2015). Bedside ultrasound Identification of Infectious Flexor Tenosynovitis in the Emergency Department. West J Emerg Med; 16(2): 260-262.
  2. Flexor Tenosynovitis (Karavel’s signs). Sketchy Medicine. Retrieved from http://sketchymedicine.com/2012/10/flexor-tenosynovitis-kanavels-signs/ June 12, 2018.
  3. Tintinalli, JE. (2016). Flexor Tenosynovitis (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (page 1922). New York: McGraw-Hill.

 

 

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Resident Clinical Pearl – Simplifying pharyngitis management

Simplifying pharyngitis management

Resident Clinical Pearl (RCP) – June 2018

Allyson Cornelis FMEM PGY1, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

The majority of pharyngitis cases are caused by viruses. For those attributed to bacterial sources, throat culture is the gold standard for confirmation and group A streptococcus is the main bacterial agent involved¹. For pharyngitis believed to be bacterial in nature, antibiotics are prescribed to reduce the risk of developing rheumatic fever, the duration of symptoms, and transmission to others. For cases where antibiotics are prescribed, the first line medication is penicillin, due to the low resistance of group A streptococcal bacteria to this group of medications. Commonly recommended regimens include:

Penicillin V

Pediatrics

  • 40 mg/kg/day (divided BID or TID) to a max of 750 mg x 10 days
  • 250 mg BID

Adults

  • 300mgTID x 10days or
  • 600mgBID x 10days or
  • 500mgBID x 10days

Amoxicillin

Pediatrics

  • 40 mg/kg/day (divided BID or TID) x 10 days to maximum of 1000 mg/day

Adults

  • 500 mg BID x 10 days

 

An alternative treatment regimen
Common antibiotic regimens require multiple doses per day. This can be difficult for compliance purposes, especially in pediatric patients who may not like to take medications due to the taste and where difficulty with administration of doses at school may be a concern. Recommendations in recent years have included an alternate dosing schedule which allows for a single dose of antibiotic daily for patients. Possible advantages of this approach are improved compliance due to single daily dosing as well as reduced cost for patients and their families. The recommendation is 50 mg/kg once daily to a maximum of 1000mg for 10 days and is appropriate for children > 3 years old and adults.

 

Bottom lineAmoxicillin 50 mg/kg once daily (max 1000 mg daily) is an acceptable alternative to multiple daily doses of penicillin or amoxicillin for treatment of Group-A streptococcal pharyngitis infections.

 

References:

1. Caglar D, Kwun R, Schuh A. Mouth and throat disorders in infants and children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, editors. Tininalli’s emergency medicine 8th ed. New York: McGraw- Hill; 2016

2. Rx files [Internet]. Pharyngitis: Management considerations; 2017 Mar [cited 2018 May 21]. Available from: http://www.rxfiles.ca/rxfiles/uploads/documents/ABX-Pharyngitis.pdf

3. CDC.gov [Internet]. Group A Streptococcal Disease: Pharyngitis; 2017 Sep 16 [cited 2018 May 21]. Availbale from: https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

4. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Circulation. 2009 March. 119: 1541-1551.

5. Shulman ST, Bisno AL, Cleg HW, Gerber MA, Kaplan E, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the infectious diseases society of America. Clin Infec Dis. 2012 Nov; 55(10): e86-e102. Available from: https://academic.oup.com/cid/article/55/10/e86/321183

6. Andrews M, Condren M. Once-daily amoxicillin for pharyngitis. J Pediatr Pharmacol Ther. 2010 Oct-Dec. 15(4): 244-248.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Resident Clinical Pearl – Regional anesthesia of the hand

Regional anesthesia of the hand: ultrasound-guided vs tumescent anesthesia

Resident Clinical Pearl (RCP) – February 2018

Sean Hurley Emergency Medicine PGY1 (FRCPC), Dalhousie University, Halifax, Nova Scotia

Reviewed by Dr. David Lewis

 

The goal of this resident clinical pearl is to discuss two different methods of achieving complete anesthesia of the hand. Hopefully, by the end of this article, you will have the knowledge to perform both methods in the emergency department. The first method is ultrasound (US)-guided nerve blocks of the ulnar, median, and radial nerves. The second method is the “tumescent anaesthesia” approach used by many hand surgeons around the world for wide-awake hand surgery, including local, local anesthetic guru and plastic surgeon, Dr. Donald Lalonde who provided many of the clinical pearls in this article.

 

Method 1:  Ultrasound-guided nerve block

In a recent article by Amini et al. (2016), 84% of 121 emergency medicine residency programs surveyed in the United States reported that US-guided nerve blocks are performed at their institution. Of the 16 different nerve blocks reported, forearm blocks were the most commonly performed (74%) (Table 1). The main indications for nerve blocks are outlined in Table 2 1.

Table 1 and 2 from Amini et al., 2016 1

 

Three major nerves, median, ulnar, and radial, provide sensory innervation of the hand (Figure 1). Each nerve needs to be blocked in a simple straightforward approach, which was shown to to be quick, safe and effective. After a 1-hour training session, residents, fellows, and staff emergency physicians had 100% success rate with no rescue anesthesia on 11 hand pathology patients presenting to the ED. The blocks were performed in a median time of 9 minutes with no complications 2.

 

Figure 1. Cutaenous innervation of the hand. https://www.nysora.com/wrist-block

 

Figure 2. Indications for different nerve blocks of the hand http://highlandultrasound.com/forearm-blocks/

 

Radial Nerve: Palpate the radial artery in the volar aspect of distal forearm then place the US probe over the artery in a transverse orientation. Move the probe proximally until you clearly identify the radial nerve (Figure 3), which is located at the radial aspect of the radial artery. Insert your needle using an in-line approach (Figure 4). Inject 5-10cc of 1% lidocaine with epinephrine until you can clearly see the nerve bathed in lidocaine.

Pearl: The radial nerve is often difficult to visualize in the forearm. The radial nerve is more easily visualized above the elbow along the spiral groove of the humerus. Place the probe in a transverse orientation along the lateral aspect of the humerus between the brachioradialis and brachialis muscles. This block is more proximal and will require longer time to peak anesthesia.

 

Ulnar nerve: Use the exact same 2-step approach but on the ulnar side of the forearm. The ulnar nerve is located at the ulnar aspect of the ulnar artery (Figure 3).

 

Median nerve: The median nerve lies between the palmaris longus and the flexor carpi radialis. Position the probe in the transverse plane over this location. Insert your needle from either side using an in-plane or out-of-plane approach

 

Pearl: the median nerve and the many tendons of the distal forearm can be difficult to distinguish. You can identify the nerve by tilting the probe, which causes the tendons to disappear, as the US waves are no longer reflected back to probe, while the median nerve fibers still reflect waves back to the probe. Alternatively, you can slide the probe proximally where the tendons transition to muscle fibers, allowing the median nerve to be easily distinguishable.

Pearl: The palmar cutaneous branch of the median nerve that supplies the thenar eminence branches off before the carpal tunnel. Make sure you move the probe proximally before blocking the nerve so you don’t miss this important sensory branch.

Pearl: The more local anesthetic, the better! Some resources recommend 3-5cc of 1% lidocaine per nerve. Why not use 10cc or more for each nerve? You will still be safely under 7mg/kg limit.

 

Figure 3. Ultrasound identification of the ulnar nerve (left), median nerve (middle), and radial nerve (right). (Figure from Liebemann et al, 2006) 2.

 

Figure 4. Ultrasound guided ulnar nerve block using an in-plane technique (Figure from Sohoni et al., 2016) 3.

 

Please see link to excellent descriptions and videos of ulnar, radial, and median US-guided nerve blocks in the ED. www.highlandultrasound.com/forearm-blocks/

 

Method 2: Tumescent anesthesia

Tumescent means “Swollen”. In relation to local anaesthesia, Dr. Lalonde provides the following definition in his textbook Wide-Awake Hand Surgery: “Injecting a large enough volume of local anesthetic that you can see it plump up the skin and feel its slightly firm consistency with your finger through the skin” 4. The tumescent anesthesia approach has been described in depth for a variety of hand surgeries 4-6.

Using a 10cc syringe, aim for the space directly between the median and ulnar nerve (figure 5 and Video 1).  As you puncture the skin, Inject 3-5cc in the subcutaneous space. This is critical to block superficial nerves in this region, including the palmar cutaneous branch of the median nerve. Then, move your needle >3-4mm deeper through the superficial fascia in the forearm compartment where the median and ulnar nerves reside. Inject the remainder of your 10cc syringe into this space. With a single poke, the ulnar and median nerve distributions should be completely anesthetized.

Now, all that remain are the superficial branches of radial nerves and the posterior interosseus nerve. The superficial branches of radial nerve lie over the anatomical snuffbox. Insert your needle within 1cm of your previously anesthetized skin and blow local anesthesia into the subcutaneous space as you slowly move your needle towards the radial aspect of the wrist until you have a tumescent area of local anesthesia over the snuffbox. For the PIN, which is primarily a motor branch of radial nerve but has some sensory contribution, palpate the distal radial ulnar joint  of the dorsal aspect of the wrist. The PIN runs along the interosseous membrane so the needle needs to pass through the deep fascia of the forearm. Inject another 5cc of lidocaine in this location.

 

Figure 5. Tumescent anesthesia of the median and ulnar nerve 5.

 

Video 1. Tumescent anesthesia of the hand (courtesy of S. Hurley).

 

Which approach is better?

No studies have directly compared the two approaches discussed in this article. A recent Cochrane review article reviewed compared US-guided vs. anatomical landmark technique vs. trans-arterial vs. peripheral nerve stimulation for lower and upper limb blocks by trained anaesthetists. They found US-guided had greater success rates, less conversions to general anesthetic, lower rates of parathesias and vascular puncture 7.

A recent small randomized control trial compared US-guided nerve blocks of the forearm to anatomical landmark-based technique and found 14 of 18 ultrasound-guided forearm blocks were successful, as opposed to 10 of 18 for the anatomical technique 3.

Pearl: The tumescent anesthesia technique blocks both smaller and larger nerves of the hand and will likely achieve faster anesthesia compared to nerve blocks of the ulnar, median, and radial nerve.  Expect up to an hour for the large nerve blocks to take full effect.

 

Conclusions

Both methods, US-Guided nerve blocks and tumescent anesthesia are safe, effective, and relatively easy options to achieve complete anesthesia of the hand. For both techniques, remember basic principles for minimizing pain during injection of local anaesthesia to optimize patient comfort and satisfaction 4-6.

 

References

  1. Amini R, Kartchner JZ, Nagdev A, Adhikari S. 2016. Ultrasound‐Guided nerve blocks in emergency medicine practice. Journal of Ultrasound in Medicine 35: 731-736.
  2. Liebmann O, Price D, Mills C, et al. 2006. Feasibility of forearm ultrasonography-guided nerve blocks of the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann Emerg Med 48: 558-562.
  3. Sohoni A, Nagdev A, Takhar S, Stone M. 2016. Forearm ultrasound-guided nerve blocks vs landmark-based wrist blocks for hand anesthesia in healthy volunteers. Am J Emerg Med 34: 730-734.
  4. Lalonde D. 2016. Wide awake hand surgery, CRC Press, Taylor & Francis Group. Boca Raton, FL.
  5. Lalonde DH. 2010. “Hole-in-one” local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 126: 1642-1644.
  6. Farhangkhoee H, Lalonde J, Lalonde DH. 2012. Teaching medical students and residents how to inject local anesthesia almost painlessly. Can J Plast Surg 20: 169-172.
  7. Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. 2015. Ultrasound guidance for upper and lower limb blocks. The Cochrane Library.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Resident Clinical Pearl – Pediatric syncope: an investigative dilemma?

Pediatric syncope: an investigative dilemma??

Resident Clinical Pearl (RCP) – February 2018

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

Reviewed by Dr. David Lewis

 

The case

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

What investigations does she require?

 

Why It Matters?

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

 

The problem?

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

 

A potential solution

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

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

Red flags

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

 Red herrings

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

 

Investigative Algorithm

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

 

The Evidence

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

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

 

Pediatric ECGs – how to interpret?

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

See following chart from the CCS¹

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

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

 

Case Resolution

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

 

References

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

 

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Resident Clinical Pearl – Wired shut: cutting jaw wires in an emergency

Wired shut: cutting jaw wires in an emergency

Resident Clinical Pearl (RCP) – January 2018

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

Reviewed by Dr. Awdesh Chandra

 

It’s 0300 and you are on a solo night shift when a couple are rushed into the resuscitation bay by the triage nurse. The woman says that the man had his jaw “wired shut” three weeks ago and began retching an hour ago. Your suspicions are confirmed when you look at his mouth and see the image below:

Figure 1. Arch bars (green arrows) are used for mandibular fixation, adapted from Jones and Read (2006).

 

As your patient is being placed on cardiac and oxygen monitoring, you can see they are agitated and hypoxic. You ask yourself, how can I get access to their oropharynx and begin my resuscitation?

 

Background

Arch bars and intermaxillary fixation are placed after mandibular fractures. In Figure 1, the arch bars, horizontal bars indicated by the green arrow, are fixated by circumferential wires around the teeth.1 In order to fixate the mandible and maxilla, fixation wires (vertical wires indicated by the red arrow seen in Figure 2) bring together and upper and lower arch bars, effectively eliminating mouth opening.1

Figure 2. Intermaxillary fixation wires, vertical wires indicated by the red arrows. Adapted from Jones and Read (2006).

 

While it is standard procedure for dentists and oral surgeons to provide patients with wire cutters and instructions following intermaxillary fixation for emergencies, this may not be readily available in the emergency department when needed the most.

 

The materials required:

  1. A deep breath
  2. Wire cutters (or if not, heavy metal scissors)
  3. Hemostat or needle driver

 

The steps:

  1. Identify and cut the vertical fixation wire on one side of the twist as seen in Figure 2. This is similar to cutting a single interrupted suture.
  2. Pull on the twist with a hemostat or needle driver and pull the wire out. There are generally 2-4 fixation wires per each side that require cutting in order to open the mouth.
  3. In some instances, there may be heavy elastics vertically as well, pull and cut those as well.
  4. Proceed with the resuscitation as deemed necessary (airway access or allowing the patient to vomit)
  5. The dentist or oral surgeon can re-fixate the wires non-urgently after the emergency has passed

 

See the following links on how arch bars and intermaxillary fixating wires are placed (to get an understanding of where to cut to release the mandible)

  1. https://www.youtube.com/watch?v=RGp46yHoVag&feature=youtu.be (minute 14 and on for application of intermaxillary fixation wires)
  2. https://emcrit.org/racc/airway-decisions/

 

Pearl: consider having wire cutters as part of your difficult airway cart or kit

 

Bottom Line: intermaxillary fixation can pose a serious threat to a patient needing to vomit or one that requires emergency airway access. Be prepared to cut the right wires in order allow mouth opening.

 

References

(1) Jones TR, Read L. Emergent separation of arch bars. J Emerg Med 2006; 35(2):205-206.

 

This post was copyedited by Kavish Chandra @kavishpchandra

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Resident Clinical Pearl – Suprapubic Aspiration PoCUS

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

Resident Clinical Pearl (RCP) – Guest Resident Edition

Sean Davis MD, PGY2 Family Medicine

Dalhousie University, Yarmouth, Nova Scotia

Reviewed and Edited by Dr. David Lewis

 

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

 

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

 

Indications:2,3

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

Contraindications: 2,3

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

Complications: 2,3

  • Gross hematuria
  • Abdominal wall cellulitis
  • Bowel perforation

Equipment: 2,3

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

Procedure (ultrasound-guided): 2,3

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

 

 

From: Performing Medical Procedures – NEJM

 

References

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

 

Other PEM PoCUS Videos Here

 

 

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