A two-month-old male presents with his mother to the emergency department with two tightly wound hairs around his fourth and fifth toes. He is visibly upset and crying excessively. His mother says that his toes looked like this when he woke up this morning. He is otherwise well and has had his two-month immunizations.
His toes look like this:
Hair tourniquet syndrome
Definition – a tightly wound hair, thread, rubber band that is wrapped around an appendage and causes impaired blood flow.
Why this is bad – the constriction causes edema which restricts venous blood flow causes more edema which then impedes arterial blood flow and that can cause ischemia and if left undetected could cause amputation.
Most common appendages involved – Toes, external genitalia, fingers
Most common presenting symptom – excessively crying young child or swollen appendage found by mom or dad.
Management
Goal is to remove the restricting band ASAP!
Remember to treat pain! Using emla gel on the digit prior to any manipulation and use other analgesics as you deem appropriate. Remember the use of sugar for pain management in babies.
In all management types- ensure you have gotten all of the hair and have released the constricted band completely.
Try and unwind the hair!
Works best if caught early
You can use a cutting suture needle to try and get underneath the hair and release it.
Depilatory Cream
Apply Nair to the affected toe and allow 2-8 minutes to see if the hair dissolves.
Should not be used on open wounds and can cause skin irritation.
Does not dissolve cotton, polyester or rayon threads.
Dorsal Slit Procedure (for digits)
Do a slit on the dorsal surface along the long axis of the digit through the area of constriction down to the bone to ensure release of tourniquet.
Lateral aspect contains nerves and blood vessels and should be avoided. You may cut the tendon doing a dorsal slit along the long axis- but you won’t affect function of the digit.
Ensure that the patient has close follow up to ensure healing and complete resolution of the tourniquet.
The bottom line
Think of this diagnosis and LOOK for it in a young child brought to the ED with “excessive crying”
Ensure adequate pain management prior any invasive removal of the tourniquet.
Move quickly down the list to the dorsal slit procedure (for digit) if deeply embedded hair with significant edema or tissue compromise.
Lumbar punctures (LPs) are an essential emergency physician skill. Indications including assessing for serious causes of headaches such as meningitis and subarachnoid hemorrhage.
Various limitations to successful lumbar puncture include a large body habitus, arthritic spines, and altered spinal anatomy. Furthermore, this leads to increased procedural risks (failed attempts, pain, hematoma formation, infection and traumatic tap leading to difficult CSF interpretation)
Traditional lumbar puncture
The traditional way to perform a LP is using surface landmarks. The superior iliac crests are identified and a line is drawn across the back to connect them. This helps in identifying L3/L4 space. This is deemed a safe place for LP as the spinal cord ends above this.
PoCUS guided lumbar puncture
Ultrasound has become a common tool used in the emergency department for assessment of patients and to assist in certain procedures. Lumbar puncture is one procedure where ultrasound has potential to increase success.1,2
The evidence
Meta-analysis of PoCUS guided LPs in the ED with adult and pediatric patients showed improved success rates (NNT 11) and fewer traumatic taps (NNT 6), less pain and less time to obtaining a CSF sample.4
Similar studies in neonates and infants showed reduced LP failure and traumatic taps in the PoCUS guided LP group.5
The procedure
The goal of the LP is to place a needle into the subarachnoid space where the CSF can be sampled. At the safe level, LP needle moves in-between the caudal equina.
Adapted from Tintinalli’s Emergency Medicine : A Comprehensive Study Guide, 8th ed.
Landmark based LP (briefly)
Place the patient in the lateral decubitus or seated position, allowing them to curve their spine and open the space between adjacent spinous processes
Identify the superior iliac spines and connect a line between the two iliac spines across the back (this should intersect the L4 spinous process).
LP can be safely performed in the L3/4 or L4/5 interspaces. During the procedure, the needle is directed towards the patient’s umbilicus.
PoCUS guided LP2,3,6
Identify the midline
Position patient either sitting with a curved lumbar spine or laying down in a lateral decubitus position with back perfectly perpendicular to the table and not angled at all. Using either a linear or curvilinear probe (curvilinear is recommended for obese patients), in the transverse plane start at the sacrum which will appear as a bright white line.
Move the transducer towards the patient’s head while maintaining a transverse orientation. A space will appear followed by a smaller bright curved line with posterior shadowing, this is the L5 spinous process.
Center the spinous process in your screen, and mark the location with a surgical marking pen.
Continue moving the transverse transducer cephalad, you will see the interspaces (lack of spinous process and the accompanying shadow and possibly evidence of the articular processes which appear as bat ears).
Connect each mark identifying the spinous processes—this marks the midline of the spine
Identify the interspaces
Turn the transducer into the saggital plane with the indicator towards the patient’s feet (to line up the patient’s head with the view on the screen).
Place transducer along the spinal line you marked, starting at the top, and identify the spinous processes and the interspaces.
Place the interspace in the center of the transducer and mark with a line. Move caudally, identifying the remaining interspaces.
Connect these lines to your spinal line. Where they intersect are the ideal locations for needle entry.
The bottom line
Ultrasound is a tool being utilized more often in clinical practice, including in the emergency department. Research shows that its use in obtaining lumbar punctures has potential benefits, including more success in obtaining a CSF sample and less traumatic taps, with minimal harms or downsides to use of the ultrasound.
Ladde JG. 2011. Central nervous system procedures and devices. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydula RK, Meckler GD, editors. Tintinalli’s emergency medicine: Acomprehensive study guide. 7th ed. China: McGraw-Hill Companies, Inc. p 1178-1180.
Millington SJ, Restrepo MS, Koenig S. 2018. Better with ultrasound: Lumbar puncture. Chest 2018. 154(5): 1223-1229.
Ladde JG. 2020. Central nervous system procedures and devices. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH, editors. Tintinalli’s emergency medicine: A comprehensive study guide. 9th ed. New York, NY: McGraw-Hill: http://accessmedicine.mhmedical.com.ezproxy.library.dal.ca/content.aspx?bookid=2353§ionid=221017819. Accessed November 17,2019.
Gottlieb M, Holladay D, Peksa GD. 2018. Ultrasound-assisted lumbar punctures: A systematic review and meta-analysis. Acad Emerg Med. 2019 Jan. 26(1). 85-96.
Olowoyeye A, Fadahunsi O, Okudo J, Opaneye O, Okwundu C. 2019. Ultrasound imaging versus palpation method for diagnostic lumbar puncture in neonates and infants: A systematic review and meta-analysis. BMJ Pediatrics Open. 2019 Mar. 3(1):e000412.
Jarman B, Hoffman B, Al-Githami M, Hardin J, Skoromovsky E, Durham S, et al. Ultrasound and procedures. In: Atkinson P, Bowra J, Harris T, Jarman B, Lewis D, editors. Point of Care Ultrasound for Emergency Medicine and Resuscitation. 1st ed. United Kingdom: Oxford University press; 2019. p. 198-199.
It’s a quiet night in RAZ and you pick up your next chart- a 68 year old Ms. Iris Snellen has come in with new onset, painless, monocular vision loss. You pick up the ophthalmoscope to perform fundoscopy, and despite your best attempts, like many ED physicians before you, you see nothing helpful. So instead you pick up your investigative tool of choice, the ultrasound probe, and begin your ocular POCUS exam…
Anatomy and pathophysiology
The retina is composed of multiple layers of neurons that allow for the human eye to convert light energy (photons) into images within the occipital brain. The retina sits on top of the vascular choroid which provides blood flow.
Fundoscopy allows for visualization of the following structures:
Optic disc
The macula (central, high-resolution, color vision)
The fovea (sits centrally in the macula and provides sharp, central vision)
PoCUS is adjunctive test to assess for vision-threatening and common conditions impacting the eye such as retinal detachment (RD), posterior vitreous detachment (VD) and vitreous hemorrhage (VH).
A normal eye should allow you to visualize the following structures:
https://www.nuemblog.com/ocular
In retinal detachment, the retina is separated from the choroid either through formation of a hole in the retina, peeling away from the choroid if attached to the vitreous humour or through edematous infiltration between the two layers. Separation results in rapid ischemia and death of photoreceptors with subsequent vision-loss.
Posterior vitreous detachment is common and occurs secondary liquification of the gel-like vitreous body.
Vitreous hemorrhage can occur secondary trauma, spontaneous retinal tears or vitreous detachment or any cause of retinal neovasculiarzation such as in diabetes.
Retinal detachment and the DDx
When assessing your pt, a retinal detachment should be at the top of your list of diagnoses to rule out given that prompt recognition and referral to ophthalmology may be a vision-saving intervention.
On history she may describe the following features of RD:
Floaters: may appear as spiderwebs, a large spot that comes and goes that may ‘look like a big fly’ or a showering of many small black dots.
Painless monocular vision loss: may present as a ‘curtain descending’ across her vision and/or visual field loss.
Flashes: may be easier to see at night or in a dark room (consider turning off the lights in the exam room)
Assess for risk factors for retinal detachment:
Myopia (near-sightedness): Major risk factor!
Cataract surgery
Family history of retinal detachment
Diabetes
Glaucoma
Old age
History of posterior vitreous detachment
Physical exam:
Assess for changes in visual acuity
Assess for loss of visual fields
Fundoscopy may reveal advanced detachments however, early detachments are often not visible with direct fundoscopy. Advanced detachments may reveal absence of a red reflex and a billowing retinal flap.
Ultrasound!
Your DDx may include:
Posterior vitreous detachment
Vitreous hemorrhage
Ocular migraine
CRAO/CRVO
Amaurosis fugax
(see below for distinguishing features of the DDx)
The PoCUS assessment
Most ED physicians feel more comfortable with their ultrasonography skills over their fundoscopy skills. PoCUS is a fast, portable and radiation-free approach to assessing patients for potential vision-threatening pathology such as retinal detachment. While ultrasonography should not replace ophthalmologic assessment and fundoscopy, it can be used as an additional tool to support your primary diagnosis.
Most recently, Lanham, et al., published a prospective diagnostic study involving 225 patients and 75 ED providers that found POCUS was 96.9% sensitive and 88.1% specific for the diagnosis of retinal detachment1. While studies have varied in whether sensitivity was better than specificity or vice versa, ultimately each study has shown that when trained, emergency providers are quite good at identifying RD by US2,3. In addition to RD, Lanham, et al further found ED providers did well at identifying vitreous hemorrhage (sens 81.9%, sp 82.3%) and vitreous detachment (sens 42.5%, sp 96%).
Get the PoCUS Scan:
Place a tegaderm over the eye to protect it from US gel which may be painful. You may consider using topical freezing drops to limit irritation.
Use the linear probe and scan through the eye until you are able to visualize the optic nerve, the hypoechoic structure at the back of the eye
Have the patient look side to side/up and down as this will accentuate movement of retinal or vitreous pathology.
Retinal detachment: Bright echogenic line that appears to have separated from the posterior eye/choroid and remains tethered to the optic nerve.
Posterior vitreous detachment: Bright echogenic line separated from posterior eye/choroid that is detached from the optic nerve.
Posterior vitreous hemorrhage: Vitreous shows fluid collection with variable echogenicity and ‘washing machine’ appearance.
Lahham S, et al. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA Netw Open. Published online April 12, 20192(4):e192162. doi:10.1001/jamanetworkopen.2019.2162
Kim, D., et al. Test Characteristics of Point-of-care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department. Academic Emergency Medicine. 2019;26[1]:16; http://bit.ly/2TEFutH
Vrablik ME, et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta‐analysis. Ann Emerg Med 2015; 65( 199–203): e1.
Mr. JG, a 34 year old male snowboarder, presents to your busy emergency department after a snowboarding accident. He suffered a fall onto his left outstretched hand after hitting a jump that was approximately one foot high. Radiograph shows a closed distal radius fracture with significant dorsal angulation.
Figure courtesy of Dr Pir Abdul Ahad Aziz, Radiopaedia.org, rID: 47908
Tonight is a busy shift and you’re working in a resource-limited department with very few staff. In speaking with the patient, he’s nervous about the prospect of procedural sedation and would prefer to not be “put to sleep to fix [his] wrist”. Luckily, your department recently purchased an ultrasound machine and the patient consents to a hematoma block prior to reduction.
What is a hematoma?
Following the initial impact that causes a fracture, the initial stage of bone healing involves a hematoma formation. In simple terms, a hematoma is a large blood clot that collects at the fracture site. Hematomas are rich in vascular supply and are the site of eventual soft callus formation; they’re the result of bony blood supply being disrupted at the site of the defect
Stages in Fracture Repair. The healing of a bone fracture follows a series of progressive steps: (a) A fracture hematoma forms. (b) Internal and external calli form. (c) Cartilage of the calli is replaced by trabecular bone. (d) Remodeling occurs.1
Hematoma blocks as an alternative to procedural sedation?
Compared to procedural sedation, hematoma blocks can be done safely when procedural sedation is not an option or is contraindicated. They also offer an alternative option for analgesia when an emergency department is busy and resources are lacking to safely perform procedural sedation.2
Procedural sedation requires a period of recovery after the procedure, hematoma blocks do not necessitate traditional post procedural recovery.3
Evidence that suggests post-procedure analgesia is similar in hematoma block patients compared to patients who undergo procedural sedation.4
Hematoma blocks are a form of local anaesthesia that can be used when reducing simple, closed distal long bone fractures, like the distal radius fracture in this case. They can also be performed to provide analgesia for nondisplaced fractures.2
Prior to the advent of bedside ultrasound, hematoma blocks were dependent on external anatomy landmarking, using “step-off” site of the bony deformity as the landmark for injection. This can be difficult, however, in fractures where swelling, habitus, or deformity can distort the anatomy of the hematoma.2 This is where ultrasound plays a role in identifying the deformity and therefore improves the precision of hematoma injection.
Contraindications to hematoma block include allergy to the anaesthetic being used, if the fracture is open, if there is cellulitis overlying the site of the fracture, and/or if there is a neurovascular deficit on exam of the affected limb.5
Performing a hematoma block under US guidance
Mr. JG requires reduction of his distal radius fracture. Due to his uneasiness with procedural sedation, combined with the busy and resource-strained nature of your emergency department, a hematoma block under ultrasound guidance is performed.
Gain informed consent: The initial step in performing a hematoma block is similar to all medical procedures in that the patient undergoing the procedure should be informed of the risks associated with hematoma blocks and fracture reduction. These include, although rare, compartment syndrome, local anesthetic toxicity, acute carpal tunnel syndrome, and temporary paralysis of the upper limb6. Remember that maximum dose of lidocaine without epinephrine is 5mg/kg.
Reassess the neurovascular integrity of the limb: Prior to injecting the hematoma block, ensure you have confirmed neurovascular integrity of that limb.
Grab the supplies you’ll need: The following list is limited to the supplies needed for your hematoma block and does not include the supplies needed for fracture reduction and casting.
Ultrasound machine with a linear transducer probe
Tegaderm transparent film
Sterile lubricating jelly
Sterile skin marker
Sterile gloves
Chlorhexidine swabs x 3
16G Needle (for drawing up analgesia)
20G or 22G Needle (for injecting analgesia)
10mL syringe
1% lidocaine (approximately 10mL)
Landmark the hematoma using point of care ultrasound: Trace the bone’s cortex on the dorsal aspect of the forearm from the proximal aspect of the fracture towards the fracture site until you reach an interruption in the cortex of the radius (see below). Mark that site with your marker for injection.
Left: Sagittal image of left radius outlining an interruption in the radial cortex at the site of the hematoma. Right: Same image, edited to identify anatomy.8 Edited by Robert Dunfield PGY1-Dalhousie
Clean the site and prepare other materials: Clean the site with chlorhexidine swabs x 3. Allow it to dry while you prepare the remainder of your equipment. Draw up your 10mL of 1% lidocaine with the 16G needle and then change the needle to your 20 or 22G needle. A longer needle may be needed to reach the site of the hematoma.
Prepare your transducer: Clean your linear transducer and then put on your sterile gloves. With the help of an assistant apply the sterile tegaderm film to the liner transducer and place sterile lubricating jelly on the probe.
Insert needle under US guidance: Using the probe to visualize the site of the hematoma, simultaneously begin to insert the needle in a caudal fashion toward the hematoma, visualizing the needle in the long axis. Use the ultrasound image to follow the needle’s insertion.
Injection of hematoma block under ultrasound guidance.6 Modified by Robert Dunfield PGY1-Dalhousie
Inject the lidocaine: Inject 10mL of 1% lidocaine into the hematoma.
Give time for analgesia to take effect: Allow 5 to 10 minutes of time to allow the analgesia to take full effect, then reassess neurovascular integrity.
Proceed with the reduction.
Added note:It’s possible for distal radius fractures to have an associated ulnar styloid fracture, which will require repeating the same steps as described above, only at the side of the ulnar fracture.
Summary:
Hematoma blocks under ultrasound guidance can be done on certain distal long bone fractures that lack any contraindications
Use the ultrasound probe to trace the bone’s cortex and identify the site of the hematoma, then insert the needle into the hematoma under the guidance of your linear transducer.
Confirm needle placement into the hematoma by aspiration and inject 10mL of 1% lidocaine into the hematoma.
Allow 5 to 10 minutes of analgesia onset before reducing the fracture.
Remember to reassess the limb’s neurovascular integrity before and after the procedure.
Fathi M, Moezzi M, Abbasi S, Farsi D, Zare MA, Hafezimoghadam P. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial. Emerg Med J. 2015;32:474-477.
Reichman EF. Emergency Medicine Procedures. Second Edition. 2013:Chapter 125 Hematoma Blocks.
Dr. Kavish Chandra presents rounds on Free Open Access Medical Education (FOAM) and how to make it work for you
How to get FOAM to work for you
“If you want to know how we practiced medicine 5 years ago, read a textbook. If you want to know how we practiced medicine 2 years ago, read a journal. If you want to know how we practice medicine now, go to a (good) conference. If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM. — from International EM Education Efforts & E-Learning by Joe Lex 2012
Definition
FOAM (free open access medical education) is a collection of resources, a global community and an ethos for anyone, anywhere and anytime.
Globally, there has been an exponential increase in the number of active emergency medicine and critical care websites, blogs and podcasts.
We also have our own online journal channel at Cureus.com. Articles are submitted by local as well as international authors, and reviewed by peers and finally approved by local channel editors
The practical guide (adapted from Thoma et al. (2014)
Then within the program, search blogs and website by name or URL. The programs above generally search your created list and populate a “to read list” with direct links and the option to defer until you have more time
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
Have patient blow their nose to clear all clots
Visualize nasal cavity and oropharynx now and with each reassessment for source of bleeding. Don’t forget to wear mask and use a headlamp
Soak cotton balls or pledgets in lidocaine with epinephrine and 500mg of tranexamic acid
Pack nose with soaked cotton and replace clamp for 10 mins
2. Cauterize
Remove clamp and packing
Area should be well blanched and anesthetized
Visualize plexus and cauterize proximal to bleeding area for 10 sec max AND never both sides of septum (higher risk of septal perforation)
If successful and bleeding ceases on reassessment, apply surgicel wrapped around a small piece of surgifoam to create a “dissolvable sandwich”and discharge home
Reassess in 10 mins, visualizing oropharynx for continued bleeding
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.
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.
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 line: Amoxicillin 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.
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.
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.
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
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.
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.
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.
Lalonde D. 2016. Wide awake hand surgery, CRC Press, Taylor & Francis Group. Boca Raton, FL.
Lalonde DH. 2010. “Hole-in-one” local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 126: 1642-1644.
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.
Lewis SR, Price A, Walker KJ, McGrattan K, Smith AF. 2015. Ultrasound guidance for upper and lower limb blocks. The Cochrane Library.
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
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
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.
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:
A deep breath
Wire cutters (or if not, heavy metal scissors)
Hemostat or needle driver
The steps:
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.
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.
In some instances, there may be heavy elastics vertically as well, pull and cut those as well.
Proceed with the resuscitation as deemed necessary (airway access or allowing the patient to vomit)
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)
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.
Trauma to the upper extremity can result in injury to the various components of the elbow joint and associated anatomical structures. Important neurovascular structures associated with the elbow joint are the brachial artery, radial artery, ulnar artery, median, radial, and ulnar nerve¹. Elbow injuries causing fracture increase the likelihood of neurovascular damage. If fractures are missed, this may result in further damage and complications including prolonged functional limitations to the joint, nerve damage causing distal functional decline, and potential vascular compromise to the limb more distal to the injury.
Tintinalli’s Comprehensive Guide to Emergency Medicine.2
Functionally, the elbow has two primary movements: flexion/extension, and supination/pronation¹.
Fractures at the elbow may occur at the distal humerus (supracondylar, epicondylar, condylar, trochlea, and capitellum fractures), the proximal ulna (coronoid process, olecranon fractures), and the proximal radius (radial head fractures)¹. Of these, radial head fractures are the most common. Common mechanisms for these injuries include falling on an outstretched hand and direct blows to the elbow.
How do I know if my patient requires an X-ray for their elbow pain?
There is a rule for that! The elbow extension rule!
Simply stated: If a patient with an elbow injury is able to fully extend their elbow, they are unlikely to have a fracture and do not require imaging³.
The “how to”:
Provide analgesia to patients
Have patient seated with supinated arms
Have patient flex shoulder to 90 degrees
Ask patient to fully extend elbow to either the point of locking or the same level of extension as contralateral side
Of course, no rule is perfect, and the patient should be reassessed later if the following occur
Can no longer fully straighten elbow
Pain is getting worse
Cannot use their arm as previous
The patient should have imaging at the current visit if:
Patient is unreliable for follow up
If olecranon fracture is possible
The evidence³
Of 1740 patients presenting within 72 hours of traumatic elbow injury, 31% had a fracture³. In adults with the ability to fully extend their elbow following trauma, there was a 2% chance they had a fracture. In adults unable to fully extend their elbow following trauma, there was a 48% chance they had a fracture.
In children able to fully extend their elbow following trauma, there was a 4% chance they have a fracture, and in children unable to fully extend their elbow following trauma, there was a 43% chance they had a fracture³.
Bottom Line: Patients presenting with elbow trauma and an inability to extend their elbow fully require radiography. Those able to fully extend their elbow do not require imaging unless follow up is unreliable, an olecranon fracture is suspected. Caution should be exercised with assessment in children.
Addendum:
Consider adding PoCUS to your clinical assessment of elbow injuries. Elbow joint effusions are very easily visualized. The presence of a joint effusion in a patient with elbow pain following trauma is a significant finding and warrants further investigation with radiography. Some studies have shown PoCUS to be more sensitive than x-ray in diagnosing occult elbow fractures.
(1) Appleboam, A., Reuben, AD., Benger, JR., Beech, F., Dutson, J., Haig, S., Lloyd, G. (2008). Elbow extension test to rule out elbow fracture: Multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. British Medical Journal, 337:a2428.
(2) Tintinalli, JE. (2016). Cardiogenic Shock (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 1816-1817). New York: McGraw-Hill.
(3) Sheehan, SE., Dyer, GS., Sodickson, AD., Ketankumar, IP., Khurana, B. (2013). Traumatic elbow injuries: What the orthopedic surgeon wants to know. Radiographics, 33(3), 869-884.
A two-month-old male presents with his mother to the emergency department with two tightly wound hairs around his fourth and fifth toes. He is visibly upset and crying excessively. His mother says that his toes looked like this when he woke up this morning. He is otherwise well and has had his two-month immunizations.
