Canada’s Top 40 Research Hospitals – Saint John Regional Hospital

Canada’s Top 40 Research Hospitals – Saint John Regional Hospital

Incorporating novel research into everyday clinical practice to improve patient care within NB – that’s the goal of Dr. Kavish Chandra, Director of Research in Emergency Medicine in Saint John, NB. The Emergency Department at Saint John Regional Hospital has been a leader in research – from medical student projects to nationally recognized trials –  research is an integral part of the department and the hospital.

 

Interested in what projects are ongoing that are changing how we practice medicine? Check out our Research Projects.

Continue Reading

Congratulations Dr. Melanie Johnston – Resident Research Award Winner

Congratulations to our own Dr. Melanie Johnston, a second year resident in the FMEM Program here in Saint John. Dr. Johnston was the recipient of The Dr. Douglas E. Sinclair Award in Emergency Medicine Research for her research project entitled “- Impact of shift Trial on Overnight Patient Flow at the Saint John Regional Emergency Department.” This award is presented by the Dalhousie Department of Emergency Medicine to the most significant research project presentation at the annual Emergency Medicine Research Day.

It is judged on the following criteria: background and research methodology, overall presentation, critical appraisal and appropriateness to emergency medicine and clinical practice.

Congratulations Dr. Johnston!

Continue Reading

Congratulations to Dr. Rob Dunfield – CAEP Resident Research Award Winner!

CAEP 2021 Resident Research Award Winner – Dr. Rob Dunfield

A big congratulations goes out to our very own resident researcher, Dr. Rob Dunfield! Dr. Dunfield is a second year resident in the FMEM Program here in Saint John. He is one of seven residents recognized nationally for their excellent research abstract submissions to the annual CAEP conference. Dr. Dunfield’s research project is a secondary study from the SHOC-ED group and is entitled:  “Does IVC Ultrasound independently predict fluid status in spontaneously breathing, undifferentiated hypotensive patients? SHOC-IVC”.

Congratulations again, Dr. Dunfield!

Continue Reading

In case you missed it – Spring 2020

Some non-COVID emergency updates selected from UptoDate and local research

 

Paul Atkinson, May 2020

 

You can go low(er): MAP target for older adults with septic shock

Previous studies in older adults with septic shock suggest that a mean arterial pressure (MAP) lower than the traditional target of ≥65 mmHg may have a mortality benefit. In an unblinded, randomized trial of 2600 older patients with vasodilatory shock (septic shock in 80 percent), 90-day mortality was 41 percent for individuals who received vasopressors at a MAP target of 60 to 65 mmHg (“permissive hypotension,” mean achieved MAP 67 mmHg) compared with 44 percent for patients who received usual care (mean achieved MAP 73 mmHg), although this difference was not significant. Adjusted analysis suggested a significant mortality benefit for the lower MAP target. Adverse outcomes, including acute kidney injury and supraventricular arrhythmias, were similar in both groups. These findings support the safety of a lower MAP target in older patients with septic shock but are inconclusive regarding a mortality benefit. We continue to support a target MAP within a range of 60 to 70 mmHg that is individualized for such patients.

Lamontagne F, Richards-Belle A, Thomas K, et al. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA 2020.


 

Shock first – then epi: Updated guidelines for cardiopulmonary resuscitation

An update of the guidelines for cardiopulmonary resuscitation (CPR) recently published by the International Liaison Committee on Resuscitation and American Heart Association includes no major changes in treatment recommendations for adults . The committee writes that either bag mask ventilation or an advanced airway strategy may be used during CPR for adult cardiac arrest, but that a supraglottic airway is preferred in circumstances when clinicians choose an advanced strategy but successful tracheal intubation may be difficult. For nonshockable rhythms, the committee recommends that epinephrine be given as soon as feasible during CPR, while for shockable rhythms epinephrine is given after initial defibrillation attempts are found to be unsuccessful. Recommendations against the use of vasopressin remain in place

Soar J, Maconochie I, Wyckoff MH, et al. 2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2019; 140:e826.


 

Take a hike: Exercise Prescription in the Emergency Department can Lead to Behavioral Change in Patients

 

The provision of exercise prescriptions to ED patients was shown to be feasible in a New Brunswick study. The reported improvement seen in patients receiving the intervention and the increase in reported exercise in both groups suggests that exercise prescription for ED patients may be beneficial.

 

Milne F, Leech-Porter K, Atkinson P, et al. (February 21, 2020) Combatting Sedentary Lifestyles: Can Exercise Prescription in the Emergency Department Lead to Behavioral Change in Patients? . Cureus 12(2): e7071. doi:10.7759/cureus.7071


 

Cooling is hot again? Temperature management following cardiac arrest from nonshockable rhythm

Targeted temperature management (TTM) has been found to improve outcomes following cardiac arrest, but few studies have examined its effectiveness in the subpopulation of patients with a nonshockable rhythm. In an international, multicenter, randomized trial of nearly 600 patients treated in an intensive care unit following resuscitation from cardiac arrest with nonshockable rhythm, those managed with therapeutic hypothermia (goal temperature 33°C) had a better neurologic outcome at 90 days compared with those managed with TTM (goal temperature 37°C) . There were no differences in mortality or adverse outcomes between groups. Temperature management is an important intervention for all adults recovering from cardiac arrest.

Lascarrou JB, Merdji H, Le Gouge A, et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med 2019; 381:2327.


 

Risky business: Adjusted D-dimer for patients at low risk for pulmonary embolism

In a prospective study of over 1300 patients with suspected pulmonary embolus (PE), no individuals developed symptomatic venous thromboembolism when a protocol that used D-dimer adjusted for clinical probability by Wells score was used (D-dimer <1000 ng/mL for low probability and <500 ng/mL for moderate probability) . The need for computed tomographic pulmonary angiographic imaging was reduced by an estimated 17 percent had the traditional D-dimer cut off of <500 ng/mL been used. Results from this study may not be generalizable to patients with moderate pretest probability, inpatients, or populations with low prevalence of PE. Although high-sensitivity D-dimer testing is preferred, protocols that use D-dimer levels adjusted for pretest probability may be an alternative to unadjusted D-dimer in patients with a low pretest probability for PE.

Kearon C, de Wit K, Parpia S, et al. Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med 2019; 381:2125.


 

Choice remains: Antiseizure drugs for convulsive status epilepticus

There have been few high-quality data to guide the choice among antiseizure drugs that can be given intravenously for the initial treatment of convulsive status epilepticus after administering a benzodiazepine. The randomized, blinded ESETT trial enrolled nearly 400 children and adults with convulsive status epilepticus refractory to benzodiazepine treatment and showed that fosphenytoin, valproate, and levetiracetam had similar efficacy. Each drug resulted in seizure cessation and an improved level of consciousness within 60 minutes in approximately 50 percent of patients. These findings support our recommendation to give a benzodiazepine as the first agent, followed by either fosphenytoin, valproate, or levetiracetam as the second agent, for the initial treatment of generalized convulsive status epilepticus.

Kapur J, Elm J, Chamberlain JM, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med 2019; 381:2103.


 

Are they safe? Intimate Partner Violence Documentation and Awareness in an Urban Emergency Department

 

A New Brunswick study on intimate partner violence suggests that current intimate partner violence documentation tools are not being properly utilized. Low rates of intimate partner violence documentation in high-risk patients and a lack of education among the ED staff indicate that there is a need to improve current practices. In order to improve the identification of this important problem, appropriate training and education about intimate partner violence/domestic violence are required as this will definitely instill awareness among the ED staff about available community resources for victims.

 

Vonkeman J, Atkinson P, Fraser J, et al. (December 28, 2019) Intimate Partner Violence Documentation and Awareness in an Urban Emergency Department. Cureus 11(12): e6493. doi:10.7759/cureus.6493


 

Bigger is still badder: Surgery versus conservative treatment for cerebellar hemorrhage

Current guidelines recommend surgical evacuation for cerebellar hemorrhages >3 cm in diameter. Although there are no randomized trials to guide treatment, this practice is supported by a recent meta-analysis of individual patient data from four observational studies matching 152 patients who had surgical hematoma evacuation with 152 patients who had conservative treatment . In the adjusted analysis, surgical hematoma evacuation was associated with improved survival at three months (78 versus 61 percent) yet similar rates of a favorable functional outcome. However, in the subgroup with a hematoma volume ≥15 cm3 (a comparable size to >3 cm diameter), a favorable functional outcome was more likely with hematoma evacuation. Limitations of the study include retrospective design, lack of randomization, and small sample size for subgroup analyses.

Kuramatsu JB, Biffi A, Gerner ST, et al. Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage. JAMA 2019; 322:1392.


 

No kidding: CSF analysis in well-appearing young febrile infants with UTIs

The need to perform a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis in otherwise low-risk, well-appearing febrile infants with urinary tract infections (UTIs) has been questioned. In a systematic review and meta-analysis of nearly 3900 infants 29 to 90 days of age (20 observational studies), the pooled prevalence of bacterial meningitis in those infants with UTIs was 0.25 percent. Sterile CSF pleocytosis was variably reported (in up to 29 percent of patients with UTIs), leading to unnecessary additional antibiotic coverage for suspected meningitis pending culture results. These findings support avoiding lumbar puncture in otherwise low-risk, well-appearing febrile young infants 29 to 90 days of age with UTIs.

Nugent J, Childers M, Singh-Miller N, et al. Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Pediatr 2019; 212:102.


 

Mini-ECMO: 2019 AHA update on pediatric advanced life support

The 2019 American Heart Association focused update on pediatric advanced life support provides evidence review and treatment recommendations for the use of extracorporeal membrane oxygenation (ECMO) with CPR (ECPR) and targeted temperature management after resuscitation. According to the update, use of ECPR in settings with existing ECMO protocols, expertise, and equipment may be beneficial for selected patients for whom conventional CPR is ineffective after in-hospital cardiac arrest. In addition, for infants and children who remain comatose after resuscitation from in- or out-of-hospital cardiac arrest, it is reasonable to provide five days of normothermia (temperature 36 to 37.5°C), or to provide two days of therapeutic hypothermia (targeted temperature range 32 to 34°C) followed by three days of continuous normothermia.

Duff JP, Topjian AA, Berg MD, et al. 2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2020; 145.


 

Wait a minute (or 10): Opioid analgesia and adverse events during procedural sedation in children

In children undergoing moderate to severely painful procedures, intravenous opioids (eg, fentanyl or morphine) are frequently used for pain control prior to sedation. In a prospective, multicenter observational study of almost 6,300 children undergoing sedation for painful procedures (primarily fracture reductions) in the emergency department, opioid administration prior to the procedure versus no opioid analgesia was associated with an increased risk of oxygen desaturation (9 versus 4 percent), vomiting (7 versus 5 percent), and need for positive pressure ventilation (1.5 versus 0.9 percent). These risks were greatest when opioid analgesia was administered closer to the time of sedation. These findings confirm the increased risk for adverse events during procedural sedation for children who also receive intravenous opioids for pain control; clinicians should anticipate and be prepared to handle these adverse events and, when possible, avoid opioid administration just prior to sedation.

Bhatt M, Cheng W, Roback MG, et al. Impact of Timing of Preprocedural Opioids on Adverse Events in Procedural Sedation. Acad Emerg Med 2020; 27:217.

 


Download pdf here

Continue Reading

SJRHEM @Halifax CAEP 2019

Congratulations to all our researchers presenting at CAEP Halifax 2019. This year we have had a total of 12 research abstracts accepted for either oral or poster presentations, 5 invited presentations, 3 panel discussions, 5 track chairs, and 1 national award! We are also involved in many administrative, academic and research committee meetings across the conference.


2019 CAEP Abstracts Links for Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick

Previous SJRHEM @ CAEP


Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

P. Atkinson, M. Peach, S. Hunter, A. Kanji, L. Taylor, D. Lewis, J. Milne, L. Diegelmann, H. Lamprecht, M. Stander, D. Lussier, C. Pham, R. Henneberry, M. Howlett, J. Mekwan, B. Ramrattan, J. Middleton, D. van Hoving, L. Richardson, G. Stoica, J. French

https://doi.org/10.1017/cem.2019.65


Does point-of-care ultrasonography change actual care delivered by shock subcategory in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHoC-ED investigators

P. Atkinson, S. Hunter, M. Peach, L. Taylor, A. Kanji, D. Lewis, J. Milne, L. Diegelmann, H. Lamprecht, M. Stander, D. Lussier, C. Pham, R. Henneberry, M. Howlett, J. Mekwan, B. Ramrattan, J. Middleton, D. Van Hoving, L. Richardson, G. Stoica, J. French

https://doi.org/10.1017/cem.2019.111


Diagnostic accuracy of point of care ultrasound in undifferentiated hypotension presenting to the emergency department: a systematic review

L. Richardson, O. Loubani, P. Atkinson

https://doi.org/10.1017/cem.2019.140

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/CAEP-2019-Systematic-Review-Poster-Trial-2-PA.pdf” title=”CAEP 2019 Systematic Review Poster Trial 2 PA”]


Does specialist referral influence emergency department return rate for patients with renal colic? A retrospective cohort study

A. Kanji, P. Atkinson, P. Massaro, R. Pawsey, T. Whelan

https://doi.org/10.1017/cem.2019.260

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/Does-Disposition-Influence-ED-Return-in-Renal-Colic-AK-PA.pdf” title=”Does Disposition Influence ED Return in Renal Colic- AK PA”]


Introduction of an ECPR protocol to paramedics in Atlantic Canada; a pilot knowledge translation project

C. Rouse, J. Mekwan, P. Atkinson, J. Fraser, J. Gould, D. Rollo, J. Middleton, T. Pishe, M. Howlett, J. Legare, S. Chanyi, M. Tutschka, A. Hassan, S. Lutchmedial

https://doi.org/10.1017/cem.2019.302

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/COLIN-caep-2019-pdf.pdf” title=”COLIN caep 2019 pdf”]


The Devil may not be in the detail – training first-responders to administer publicly available epinephrine – microskills checklists have low inter-observer reliability

R. Dunfield, J. Riley, C. Vaillancourt, J. Fraser, J. Woodland, J. French, P. Atkinson

https://doi.org/10.1017/cem.2019.228

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/CAEP-2019_POSTER_Final_RJD_RIM-PA.pdf” title=”CAEP 2019_POSTER_Final_RJD_RIM PA”]


How to get your departmental web content to work for you: one department’s experience with free open access medical education

K. Chandra, D. Lewis, P. Atkinson

https://doi.org/10.1017/cem.2019.209

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/KC-FOAMed_CAEP19-002.pdf” title=”KC FOAMed_CAEP19 (002)”]


Management of first trimester bleeding in the emergency department

R. Amiro, R. Clouston, J. French, P. Atkinson

https://doi.org/10.1017/cem.2019.197

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/Poster-Presentation-Renee-Amiro-CAEP-PA.pdf” title=”Poster Presentation Renee Amiro CAEP PA”]


Obtaining consensus on optimal management and follow-up of patients presenting to the emergency department with early pregnancy complications – a modified Delphi study

A. Cornelis, R. Clouston, P. Atkinson

https://doi.org/10.1017/cem.2019.215

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/Allyson-C-early-preg-caep-2019-PA.pdf” title=”Allyson C early preg caep 2019 PA”]


Emergency department staff perceived need and preferred methods for communication skills training

M. Howlett, M. Mostofa, J. Talbot, J. Fraser, P. Atkinson

https://doi.org/10.1017/cem.2019.256

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/Howlett-caep-2019-jf.pdf” title=”Howlett caep 2019 jf”]


Designing team success – an engineering approach to capture team procedural steps to develop microskills for interprofessional skills education

R. Hanlon, J. French, P. Atkinson, J. Fraser, S. Benjamin, J. Poon

https://doi.org/10.1017/cem.2019.253

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/Hanlon-Prototyping-caep-2019-new-PA.pdf” title=”Hanlon Prototyping caep 2019 – new PA”]

[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/Hanlon-Mico-skills-caep-2019-new-PA.pdf” title=”Hanlon Mico-skills caep 2019 – new PA”]



[pdf-embedder url=”https://sjrhem.ca/wp-content/uploads/2019/05/CAEP-19-Emergency-Medicine-Poster-Final.pdf” title=”CAEP 19 Emergency Medicine Poster Final”]

Continue Reading

SHoC Network – Sonography in Hypotension and Cardiac-Arrest

The Sonography in Hypotension and Cardiac-Arrest (SHoC) Network is an international group of clinicians and researchers committed to advancing the evidence around the use of Point of Care Ultrasound (PoCUS) in critically ill patients.

The group evolved from a research network established by the International Federation for Emergency Medicine (IFEM) Ultrasound Interest Group, involving several PoCUS leaders from several international emergency medicine organizations.

The SHoC Network has been instrumental in initiating several research projects, as well as producing clinical guidelines. Further details are shown below.

Publications

The SHoC-ED study 2018 (SHoC-ED1) Link  Download

The SHoC systematic review of PoCUS in cardiac arrest Link  Download

The IFEM SHoC Consensus guidelines Link  Download

The SHoC-ED3 study – PoCUS vs No PoCUS in cardiac arrest Link  Download

The SHoC-ED-ECG study – does ECG predict cardiac activity? Link  Download

The initial SHoC study – clinical basis for protocol development Link  Download

 

Current Projects

The SHoC-ED2 study – PoCUS and ECG in cardiac arrest

The SHoC systematic review of PoCUS in hypotension

 

IFEM Documents and links

SHoC Guidelines link

IFEM PoCUS curriculum link

 

Network members and contributors include:

Paul Atkinson (Chair; 1,2,3),
David Lewis (1,2,3),
James Milne (4), 
Hein Lamprecht (5),
Jacqueline Fraser (1),
James French (1,2,3),
 
Laura Diegelmann (5,6),  
Chau Pham (7),
Melanie Stander (5),
David Lussier (7),
Ryan Henneberry (8),  
Michael Howlett (1,2,3),
Jay Mekwan (1,2,3),
Brian Ramrattan (1,2,3) ,
Joanna Middleton (1,2,3),
Niel van Hoving (5),  
Mandy Peach (1),
Luke Taylor (1),  
Tara Dahn (8),
Sean Hurley (8),
K. MacSween (8),
Lucas Richardson (8),  
George Stoica (9),
Samuel Hunter (10),
Paul Olszynski (11),
Nicole Beckett (12),
Elizabeth Lalande (13),
Talia Burwash-Brennan (14), K. Burns (15),
Michael Lambert (15),
Bob Jarman (16),
Jim Connolly (16),
Ankona Banerjee(1),
Michael Woo (14),
Beatrice Hoffmann (17),
Brett Nelson (18),
Vicki Noble (19)
 
1.     Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada
2.     Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
3.     Emergency Medicine, Memorial University, NL, Canada
4.     Family Medicine, Fraser Health Authority, Vancouver, BC, Canada
5.     Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
6.    Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, USA
7.    Department of Emergency Medicine, University of Manitoba, Health Sciences Centre, Winnipeg, Manitoba, Canada
8.     Department of Emergency Medicine, Dalhousie University, QEII, Halifax, Nova Scotia, Canada
9.    Research Services, Horizon Health Network, Saint John Regional
Hospital, Saint John, New Brunswick, Canada
10. Faculty of Science, University of Ottawa, Ottawa, Ontario, Canada
11. Department of Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada
12. Department of Internal Medicine, Dalhousie University, Saint John
Regional Hospital, Saint John, New Brunswick, Canada
13. Department of Emergency Medicine, Université Laval, Québec, Québec, Canada
14. Department of Emergency Medicine, University of Ottawa, Canada
15. Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
16. Department of Emergency Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
17. Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, USA
18. Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, USA
19. Department of Emergency Medicine, Case Western Reserve University, University Hospital Cleveland Medical Center, USA
Continue Reading

A Crushing Case – Compartment Syndrome

A Crushing Case – Compartment Syndrome

Resident Clinical Pearl (RCP) March 2019

Mark McGraw– PGY1 FMEM Dalhousie University, Saint John NB

Reviewed and edited by Renee Amiro and Dr. David Lewis.


Case Part 1

Its early afternoon during your ortho call shift and you get a call from emerge staff saying that they have two patients coming with potentially significant injuries when a piece of equipment rolled over during transport. EMS has informed them that one has a broken ankle. When you arrive to the ED he tells you they are just getting the patient’s pain under control and ordering x-rays.

You head to the room to see the patient, a large burly 35 y/o with an obviously deformed R ankle. His exam is otherwise unremarkable at this time, he has good cap refill to the toes, sensation to the web space, dorsum/plantar and medial/lateral surfaces of the foot is intact and he is able to move his toes. On palpation his lower leg compartments are firm but not hard. An x-ray is done at bedside and shows a Weber Type B fracture of the fibula. His pain seems to be increasing as you speak with him and he has no significant past medical history. He tells you he was loading a piece of equipment when it got away from them and rolled over his leg pinning him momentarily, so he was hanging off a piece of equipment by the leg. Your exam is limited by pain and you ask the nurse if she can give the patient some more pain medication and you’ll return as soon as you see the other patient.


Clinical Pearl: Compartment Syndrome

Compartment Syndrome occurs when the pressure within a muscle compartment exceeds the pressure needed to adequately perfuse tissue. It is considered a true orthopedic emergency and delays in diagnosis and treatment can result in the loss of a patient’s life or limb

Anatomy/Pathophysiology

-Muscle compartments are bound by bone or fascia, two restrictive tissues that create a relatively fixed volume compartment with a very limited ability to compensate for any increase in fluid volume.

-When a traumatic or pathological process results in increased fluid within a muscle compartment the pressure within the compartment increases. This increase in pressure results in reduced arteriovenous pressure gradient (reduced arterial pressure and increased venous pressure) that impairs tissue perfusion within the compartment.

  • As the pressure rises within the compartment capillary flow declines resulting in an enhanced local blood vessel permeability which further increases compartment pressures. If pressures continue to rise tissue ischemia and necrosis will develop.
  • Time for tissue necrosis to occur will vary from patient to patient it can occur in as little as 3 hours and most literature suggests that a fasciotomy must be performed within 4 hours of the onset of ACS to prevent irreversible damage.2

 

 

Signs and Symptoms

Compartment syndrome is a true orthopedic emergency and early recognition of its clinical signs is critical in preventing irreversible tissue damage, rhabdomyolysis, and limb loss.

  1. Pain out of proportion
  2. Pain with passive stretch
  3. Paresthesia
  4. Pain at rest
  5. Paresis

 

  • Severe pain out of proportion to the examination and pain with passive stretching are the first symptoms of ACS to occur. While the early signs are 97% specific for ACS they are only 19% sensitive in the absence of other findings.

  • The combination of pain with passive stretch, paresthesia, and pain with rest has been reported to be 93% sensitive and if paresis is present the sensitivity increases to 98%1. Unfortunately, paraesthesia and paresis are late findings of ACS and delaying the diagnosis until they are present can result in unacceptable delays in treatment. Once a motor nerve deficit has occurred patients will rarely recover function after fasciotomy.

Diagnosis 1

  • Normal compartment pressures are between 8 and 10mmHg in adults and 10-15mmHg in children.
  • 30mmHg is diagnostic for compartment syndrome and should prompt an orthopedic referral when combined with clinical symptoms of compartment syndrome.
  • An alternative is to calculate a differential compartment pressure for an individual patient as factors such as hypertension, peripheral vascular disease and patient medication can cause a large variance in individuals compartment pressures.
  • Differential compartment pressure is calculated by the diastolic blood pressure minus the intra-compartmental pressure if this is under 20mHg then fasciotomy is indicated.
  • If the patient is alert and able to elevate the affected limb, serial examinations over a two-hour period may prevent unnecessary fasciotomies. This should be done in consultation with your orthopedic colleagues.

 

Measuring compartment pressures

Devise: dedicated compartment manometer (Stryker Intra-Compartmental Pressure Monitor) or by using IV tubing and an ART line transducer attached to a long needle.

Who is most at risk of developing compartment syndrome?

  1. Fractures represent 70% of all cases5.
  2. Fractures of the tibial diaphysis account for 40% of all cases in North America.
  3. Open fractures of the tibia are still high risk for compartment syndrome because the opening is insufficient to relieve the compartment pressure associated with the fracture.6

Management of potential compartment syndrome in the ED

  1. Supplemental oxygen if indicated
  2. Remove all cast material, clothing or wraps around the limb
  3. Elevate the limb to the level of the hear
  4. Apply ice to the affected limb if the compartment syndrome is secondary to trauma.
  5. Definitive treatment is a surgical fasciotomy.

 

Case Part 2

You return to see the patient and nursing staff tell you they are unable to get the patients pain under control despite significant amounts of narcotics.

The examination of the lower leg is repeated and the compartments of the leg feel the same however the patient is unable to move his toe. He reports significant pain on passive flexion and extension of the great toe. You call your staff to inform her of the change in the patient and that you are concerned about compartment syndrome and she requests compartment pressure measurements using the Stryker Kit. The senior resident performs the compartment pressure measurements with you and you record pressures of 14, 14 and 25mmHg.

In discussion with the staff you decide to leave the leg on a posterior slab unwrapped, at the level of the heart, and with ice applied 20 on 20 off and perform serial examinations. The serial examinations are unremarkable and the patients pain becomes manageable. The patient is brought to the OR approximately 5 hours later for ORIF of his distal fibula. Compartment pressures are repeated in the OR and were 12, 10, 32 mmHg. An ORIF is performed and you perform serially examinations on the patient q1h overnight. The patient is discharged the following day


Case Follow Up

The patient had significant leg pain on discharge and subsequently presented to the ED on POD#7 for significant leg swelling. Ultrasound was performed to rule out DVT and the patient was discharged for follow up in clinic. He did not go on to develop any further complications.


 

Bottom Line

Compartment syndrome is an important not to miss diagnosis. It should be considered in any hard to control limb pain, especially when associated with fracture.


 

References

  1. 1.Duckworth, A. D., & McQueen, M. M. (2017). The Diagnosis of Acute Compartment Syndrome: A Critical Analysis Review. JBJS Reviews, 5(12), e1. https://doi.org/10.2106/JBJS.RVW.17.00016
  2. Long, B., Koyfman, A., & Rdms, M. G. (2019). Clinical Review. Journal of Emergency Medicine, (December 2018), 1–12. https://doi.org/10.1016/j.jemermed.2018.12.021
  3. McQueen, M. M., & Court-Brown, C. M. (1996). Compartment monitoring in tibial fractures. The pressure threshold for decompression. The Journal of Bone and Joint Surgery. British Volume, 78(1), 99–104.
  4. McQueen, M. M., Duckworth, A. D., Aitken, S. A., Sharma, R. A., & Court-Brown, C. M. (2015). Predictors of Compartment Syndrome After Tibial Fracture. Journal of Orthopaedic Trauma, 29(10), 451–455. https://doi.org/10.1097/BOT.0000000000000347
  5. Stella, M., Santolini, E., Sanguineti, F., Felli, L., Vicenti, G., Bizzoca, D., & Santolini, F. (2019). Aetiology of trauma-related acute compartment syndrome of the leg : A systematic review. Injury, (2018). https://doi.org/10.1016/j.injury.2019.01.047
  6. Strohm, P. C., & Su, N. P. (2004). Acute compartment syndrome of the limb, 1221–1227. https://doi.org/10.1016/j.injury.2004.04.009
Continue Reading

SJRHEM @Calgary CAEP 2018

Congratulations to all our researchers presenting at CAEP Calgary 2018. This year we have had a total of 13 research abstracts accepted for either oral or poster presentation, 2 invited presentations and 1 track chair. We are also involved in a number of administrative, academic and research committee meetings across the conference.


Last years presentations (CAEP Whistler 2017) can be viewed here


Q-Code Link to this page

 

 

 

 

 

 


Download (PDF, 144KB)

 


 

Training first-responders to administer anaphylaxis publicly available epinephrine – a randomized study – Presenter – Robert Dunfield

Download (PDF, 1.08MB)

 


 

Emergency Critical Care Ultrasound (ECCU) paramedical course: A novel curriculum for training paramedics in ultrasound – Presenter – David Lewis

Download (PDF, 702KB)

 


 

Critical Dynamics Study of Burnout in Emergency Department Health Professionals in New Brunswick: Revisiting  5 years later – Presenter – Felix Zhou

Download (PDF, 585KB)

 


 

Do electrocardiogram rhythm findings predict cardiac activity during cardiac arrest? A SHoC series study. – Presenter – Paul Atkinson

Oral Research Presentation – Track 5 – Sunday May 27th 15:50hrs

 


 

Introduction of extracorporeal cardiopulmonary resuscitation (ECPR) into emergency care: a feasibility study – Presenter – Derek Rollo

Download (PDF, 673KB)

 


 

Combatting sedentary lifestyles; can exercise prescriptions in the Emergency Department lead to a behavioural change in patients? – Presenter – David Lewis

Download (PDF, 803KB)

 


 

Development of a predictive model for hospital admissions by utilizing frequencies of specific CEDIS presenting complaints – Presenter – David Lewis

Oral Research Presentation – Track 4 – Wednesday May 30th 12:45hrs

Admission Prediction


 

Changes in situational awareness of emergency teams in simulated trauma cases using an RSI checklist – Presenter – James French

Download (PDF, 937KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of surgical cricothyrotomy with 3-D printed surgical airway trainers – Presenter – James French

Download (PDF, 3.9MB)

 


 

How aware is safe enough? Situational Awareness is higher in safer teams doing simulated emergency airway cases – Presenter – James French

Download (PDF, 760KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of direct intubation with a bougie and airway manikins – James French

Download (PDF, 3.83MB)

 


 

Lung ultrasound – Presenter – Paul Atkinson

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

 


Design is Devine – Presenter – James French

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

Continue Reading

Congratulations @sjrhem resident researchers

Congratulations to Dr Mandy Peach, PGY2 in the EM/FM program, on her success in receiving the Doug Sinclair Top Resident Research Award at the Dalhousie University Emergency Medicine Research Day 2018 and also Top Project at the Dalhousie Saint John FM/EM Project/Research Day 2018. Mandy presented her research on Sonography in Hypotension (SHoC-ED) diagnoses and shock categories.

Well done Derek Rollo and Luke Taylor for their joint runners up position. Derek presented his work on the ECPR/ED-ECMO feasibility study, and Luke presented on Sonography in Hypotension (SHoC-ED) resuscitation markers.

 

Continue Reading

Pre-hospital Airway Management – the bottom line

Study review of recent Airway World Webinar.

Reviewed by David Lewis and Jay Mekwan

The study: Retrospective Data Review conducted in Australia investigating rates of successful RSI by intensive care paramedics.

Rationale: Controversial whether RSI should be completed pre-hospital as unsuccessful attempts can result in patient complications.

Results: First pass success rate of 89.4% with low rates of complications – hypoxia (1.3%) and hypotension (5.2%).

Bottom line:  Appropriately trained air transport paramedics can perform RSI pre-hospital with high levels of success.

 

The study: Retrospective review of a global database tracking critical care transport program. Looked at first pass success attempts at tracheal intubation in the field

Rationale: Critical care transport teams are the first point of critical care contact for acutely unwell patients. Tracheal intubation can be a lifesaving intervention performed while transporting to a tertiary care center.

Results: First attempt intubation success was higher in adult focused critical care transport paramedics, regardless of the age of the patient (>86%).

Bottom Line: Experience may be a significant factor for intubation success. Experienced intubators have better success rates in all patient age groups.

 

The study: Retrospective chart review of air medical patient records where cricothyrotomy was performed to assess frequency, success and technique.

Rationale: When all other airway maneuvers fail, cricothyrotomy is a potentially lifesaving skill.

The results: Performance of cricothyrotomy is rare (<1% of over 22,000 patients), but when performed had 100% success rate.

Bottom Line: Although a rarely performed skill, Helicopter Emergency Medicine Service providers can successfully perform cricothyrotomy when needed.

 

The study: Multicenter randomized clinical trial comparing outcomes in patients who were either intubated or bagged following out of hospital cardiorespiratory arrest.

Rationale: Bag mask ventilation is an easier clinical technique to perform during CPR and previously reported as superior than intubation in terms of survival. Neurological outcomes at 28 days post arrest had not been reported.

Results: No difference in rates of survival or neurological at 28 days between bagged or intubated patients. Bag mask ventilation was associated with higher regurgitation rates and, in general, were more difficult airways to manage.

Bottom line: We don’t know if bag mask ventilation or intubation is superior. More research needed.

This post was copyedited by Mandy Peach

Continue Reading

Great ideas and making things better

I heard Dr. Dylan Blacquiere speaking on the radio while driving home after one of those busy D2 shifts on Friday, and it really cheered me up to hear him describe how we all in Saint John are leading the way in managing acute stroke care. http://www.cbc.ca/player/play/1152508483846
From EMS, through Emergency Medicine, diagnostic and intervention radiology, internal medicine and neurology, Saint John Regional Hospital (probably more appropriately Saint John University Hospital) provides a world class service for stroke patients in New Brunswick.
This got me thinking about many of the other innovations and ideas that we continue to push forward locally, especially relating to emergency medicine, and how important it is not to let ourselves become disillusioned by busy shifts, perceived administrative inertia, perceived injustices, crowding and many of the negatives we face, and will likely continue to face for sometime.
To name but a few, we can be proud of the integrated STEMI program we have from EMS to Cath Lab, the Point of Care Ultrasound program that leads in this nationally and beyond, the new Trauma Team leadership program, the patient wellness initiatives such as the photography competition corridor that make things just a little brighter for patients, the regionally dominant and growing simulation program, the regional and local nursing education programs, the nationally unique and hugely popular 3 year EM residency program, the impact of our faculty on medical education at DMNB, the leading clinical care provided by a certified faculty of emergency physicians, our website, our multidisciplinary M&M and quality programs, many of the research initiatives underway including development of an ECMO/ECPR program with the NB Heart Centre, improving detection of domestic violence, innovations around tackling crowding, preventing staff burnout, better radiology requesting, encouraging exercise prescriptions, and much more.
I was particularly impressed how Dylan explained the integrative approach that was required to improve stroke care, and how that was achieved here. There are many other areas that we can also improve, innovate and lead in. Every day we see ways to make things better.
I hope that at this point in our department’s journey, we can continue to make the changes that matter, for patients, our departmental staff, physicians, nurses and support staff alike.
I encourage all of us to think of one area we can improve, to plan for change and for us all to support each other to achieve those improvements. Some of our residents are embarking on very interesting projects, such as designing early pregnancy clinic frameworks, models to improve performance under stress, and simulating EMS ECPR algorithms – all new innovations, not just chart reviews of what we are already doing. I encourage us all to support them, and others with these projects, and to begin to create innovation priorities for the department.
Continue Reading

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.

 

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

 

 

Continue Reading