Cardiovascular
Dr. Paul Keyes MD, CCFP(EM)
In this new Globe and Mail Podcast, we hear from Dr. Paul Atkinson and others who continue to provide their insights into the issues relating to increased Emergency Department wait times and expand on the widely read article “Saving Emergency Medicine: Is less more?”
You can listen to this podcast here:
Further reading and podcasts relating to Saving Emergency Medicine can be accessed here:
Med 2
DMNB Class of 2025
Reviewed by Dr D Lewis
Copy Edited by Dr. J Vonkeman
PDF Download: EMSJ Approach to Inguinal and Femoral Hernias in the ED by JShort
A 52-year-old male patient presents in the ER with a lump in their right groin. The lump protrudes when they cough and when laying on their left side, although it re-enters the abdomen on its own. You wonder if it could be a femoral or an inguinal hernia, and how to go about differentiating between the two.
A hernia is defined as an organ, or part of an organ, that protrudes through the body wall in which it is normally contained. The etiology of a hernia can be due to congenital anatomical malformations or from acquired weakening of the body wall tissues. There are various subtypes of abdominal hernias, while groin hernias consist of inguinal and femoral hernias. Throughout their lifetime, males have a 27 to 43% chance of developing a groin hernia, while females have a 3 to 6% lifetime prevalence1. Although it is much more likely that a groin hernia is inguinal in nature (they account for 96% of groin hernias), it is clinically useful to identify and distinguish between the types of groin hernias. Additionally, there are important clinical features that must not be overlooked when characterizing a groin hernia.
An important landmark in determining the hernia origin is the inguinal ligament. Inguinal hernias protrude superior to the inguinal ligament, while femoral hernias present inferior to the inguinal ligament (Figure 1). This is because femoral hernias protrude from the femoral ring, located medial to the femoral vein. As a result, in males, femoral hernias will never course into the scrotum. Femoral hernias also present more lateral than inguinal hernias and may be difficult to differentiate from lymph nodes. Although they account for only 3% of all groin hernias, 40% of femoral hernias present as urgent due to bowel strangulation or incarceration1. Females are more likely to develop femoral hernias, while males are more likely to develop inguinal hernias.
Figure 1. Groin anatomy © 2023 UpToDate7
Direct inguinal hernias originate medially, near the pubic tubercle and external inguinal ring. They protrude through Hesselbach’s triangle as a result of weakness in the floor of the inguinal canal. On exam, a bulge near the external (superficial) inguinal ring is suggestive of a direct inguinal hernia. In contrast, indirect inguinal hernias protrude near the midpoint of the inguinal ligament, at the internal (deep) inguinal ring (Figure 2). In males and females respectively, the internal inguinal ring is where the spermatic cord and round ligament exit the abdomen. A bulge in this area therefore suggests an indirect inguinal hernia. This type of hernia is the most common in all ages and sexes, accounting for approximately two thirds of all inguinal hernias2. In males, the indirect hernia often courses into the scrotum, which can be palpated if the patient strains or coughs. In contrast, it is rare for a direct hernia to course into the scrotum.
Figure 2. Anatomical comparison of direct and indirect inguinal hernias © 2020 Dr. Vaibhav Kapoor8
General considerations for investigating groin hernias include assessing the symptoms at presentation as well as any “red flag” physical findings. Patients commonly complain of dull or heavy types of discomfort when straining, which resolves when straining stops. Most groin hernias occur on the right side. Common physical findings include a bulge in the groin, which can indicate the type of hernia based on location relative to the inguinal ligament (Figure 3). However, in female or obese patients, the layers of abdominal wall may make the hernia more difficult to locate. In these cases, ultrasound or other imaging is needed to detect hernias. Clinicians should also determine if the hernia is reducible, or if the herniated bowel can be returned to the abdominal cavity when moderate pressure is applied externally.
Figure 3. Locations of femoral and inguinal hernias on examination © 2023 UpToDate7
Physical examination has a 76 to 92% sensitivity and 96% specificity for diagnosing groin hernias, although imaging may also be required1,2. Nausea, vomiting, fever, moderate-to-severe abdominal pain, localized tenderness, or bloating may indicate more sinister pathology such as bowel incarceration (when the hernia contents cannot return to the abdominal cavity), strangulation (when the blood supply to the involved bowel section is compromised) or necrosis.
Figure 5. CT images of A) femoral hernia (courtesy of Chris O’Donnell9 and B) inguinal hernia (courtesy of Erik Ranschaert10)
Uncomplicated or asymptomatic hernias in males can be monitored through watchful waiting. Surgical repair is a definitive treatment for inguinal hernias and should be considered for symptomatic or complex hernias. If repair is needed for an uncomplicated inguinal hernia, a laparoscopic repair is recommended. Watchful waiting is not recommended for femoral hernias – these patients should have a laparoscopic repair (when anatomically feasible).
Manual reduction of the hernia can be performed by following the GPS Taxis technique. Taxis is a non-invasive technique for manual reduction of incarcerated tissues in a hernia to the original compartment5. “GPS” is an acronym to remind clinicians to be gentle, be prepared, and be safe when performing taxis5. Conscious sedation with intravenous diazepam and morphine is recommended for the procedure. Consider having an anesthetist present for the procedure if the patient is frail. Provide appropriate early resuscitation by monitoring vital signs, administering oxygen therapy and establishing IV access. Place the patient in Trendelenburg position. Begin the GPS Taxis technique by palpating the fascial defect around the base of the hernia and gently manipulating hernia contents back into the abdominal cavity. Use gentle manipulation pressure over 5-10 minutes until a gurgling sound is heard (indicating successful reduction of bowel).
Taxis guided by ultrasound may increase success rates for reduction.
https://sjrhem.ca/taxis-reduction-of-inguinal-hernia/
Figure 4. Colourized clip demonstrating PoCUS assisted Taxis reduction of an inguinal hernia11
It should be noted that the major contraindication to performing GPS Taxis is bowel strangulation within the hernia. A rare but serious complication of manual reduction is reduction en masse, when a loop of bowel remains incarcerated at the neck of the hernia after manual reduction6. This can lead to early strangulation, intestinal necrosis, sepsis, organ failure and death. Femoral hernias and indirect inguinal hernias are at higher risk of reduction en masse from manual reduction attempts.
References:
Tyson Fitzherbert, DMNB Class of 2024
Reviewed by Dr. Luke Taylor and Dr. David Lewis
A 30-year-old pregnant (32 weeks) female presents to the emergency department with palpitations and chest discomfort. On ECG they are diagnosed with supraventricular tachycardia, a narrow complex arrythmia – how would you proceed?
Pregnant women have a higher incidence of cardiac arrhythmias. The exact mechanism of increased arrhythmia burden during pregnancy is unclear, but has been attributed to hemodynamic, hormonal, and autonomic changes related to pregnancy. A common arrhythmia in pregnancy is supraventricular tachycardia (SVT). SVT is a dysrhythmia originating at or above the atrioventricular (AV) node and is defined by a narrow complex (QRS < 120 milliseconds) at a rate > 100 beats per minute (bpm). The presentations of SVT in pregnancy are the same as the nonpregnant state and include symptoms of palpitations that may be associated with presyncope, syncope, dyspnea, and/or chest pain. Diagnosis is confirmed by electrocardiogram (ECG).
Figure 1: Rhythm strip demonstrating a regular, narrow-complex tachycardia, or supraventricular tachycardia (SVT).
In general, the approach to the treatment of arrhythmias in pregnancy is similar to that in the nonpregnant patient. However, due to the theoretical or known adverse effects of antiarrhythmic drugs on the fetus, antiarrhythmic drugs are often reserved for the treatment of arrhythmias associated with clinically significant symptoms or hemodynamic compromise. Below is a detailed description of the management of SVT in pregnancy.
Management:
Figure 2: Treatment algorithm for SVT in pregnancy.
General Considerations:
Case Continued:
A modified Valsalva manoeuvre is performed with resolution to sinus rhythm after 2 attempts. The patient is discharged with OBGYN follow-up.
https://sjrhem.ca/modified-valsalva-maneuver-in-the-treatment-of-svt-revert-trial/
Further Reading
References:
Dr. Nick Byers , R2 iFMEM, Dalhousie University, Saint John, New Brunswick
Reviewed/Edited by Dr. Brian Ramrattan
Case:
A 10 year old presents to the local emergency department after playing with their sibling. The child was “tackled” from behind. A history and physical exam inform you that the child has been healthy until now with a completely uneventful childhood. They are normal, healthy body habitus and laying on their right side, a pillow between their flexed left knee & hip, and straight right leg. This is the only position of comfort for the child. Neurovascular exam is normal and the child refuses to let you move the leg at all. Foot and ankle move normally. Xrays were obtained promptly. A dislocated hip was readily identified (note the arrow sign below).
Greater than 85% of traumatic pediatric hip dislocations are posterior. Male children are at a greater risk by a 4:1 ratio, and in younger patients, they often occur with minimal force, whereas older children tend to require much greater forces due to the strength of structures surrounding the joint. Fractures can be an associated injury, though it was not in this case. A general triad to consider when evaluating for posterior dislocation is an adducted, shortened, and internally rotated leg as seen below:
Treatment:
A simple dislocation should be treated with closed reduction under sedation, ideally within six hours of injury to reduce the risk of osteonecrosis of the femoral head.
Reduction techniques:
There are many reduction techniques discussed in the literature. Most involve in-line traction of the femur with abduction and external rotation as the leg lengthens, with counter-traction (or downward pressure) placed on the pelvis. This allows for the femoral head to enter the acetabulum gently.
A quick review of technique with attending staff present on shift included the following three options:
2. The Captain Morgan technique (https://www.youtube.com/watch?v=lQMWaFX-MeQ&t=6s): The physician flexes the injured hip and knee to 90o and places their foot on the stretcher at the injured hip of the patient, their knee under the patients. They then grasp the patient’s leg with one hand under the popliteal fossa and one at the ankle. With counter-traction/downward pressure on the pelvis by an assistant, the physician plantar-flexes their foot to put traction on the patient’s femur. External rotation and abduction can be applied with the lower leg as the hip is reduced.
3. The cannon technique: The stretcher is raised and the patient’s knee and hip are flexed to 90o with the popliteal fossa sitting directly over the physician’s shoulder, hands on the patient’s ankle (while facing the patients feet). An assistant stabilizes and provides downward pressure on the pelvis. The physician slowly stands up straight providing in-line traction on the femur until the hip is reduced.
Case Conclusion:
Once x-rays confirmed a posterior hip dislocation, closed reduction under sedation in the emergency department was performed by a resident and staff physician using the cannon technique. Post-reduction films and repeat neurovascular exams were normal and follow-up with orthopedics was in place before discharge home.
Post reduction film:
References:
https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations
https://www.emnote.org/emnotes/captain-morgan-hip-reduction-technique
CASTED course manual, Arun Sayal
Traumatic hip dislocation during childhood. A case report and review of the literature. American Journal of Orthopedics (Belle Mead, N.J.), 01 Sep 1996, 25(9):645-649
https://usmlepathslides.tumblr.com/post/64398003332/posterior-hip-dislocation-posterior-hip
https://posna.org/Physician-Education/Study-Guide/Hip-Dislocations-Traumatic
https://www.ochsnerjournal.org/content/18/3/242/tab-figures-data
https://coreem.net/core/hip-dislocation/
https://westjem.com/case-report/emergency-physician-reduction-of-pediatric-hip-dislocation.html
Dr. Rawan Alrashed (@rawalrashed)
PEM Physician
PoCUS Fellow
Reviewed and edited by: Dr. David Lewis
Pediatric vascular access is one of the challenging skills in the medical field especially during an emergency, different guidelines have been established to facilitate the choice of the proper IV access one of which is the miniMAGIC that was published in 2020.1 Choosing the right access is crucial for success taking in consideration the urgency of access, patient safety, infused fluid characteristic to determine the right one especially with a peripheral IV catheter failure rate of 77% in the first attempt.2 Difficult intravenous Access score (DIVA) is one of the tool that can be used to evaluate the feasibility of a peripheral IV and accordingly, the best next step for IV line insertion where Subjects with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt.3
Figure-1: DIVA score.4
Figure 2: Vascular Access Locations.5
Multiple choices are available starting from non-pharmacological distraction technique and non-nutritive sucking to the utilization of local anesthetic such as EMLA and LMX as well the needle-free lidocaine jet-injection
Patient resuscitation.
Delivering fluids, medication, Blood sampling.
Hemodynamics monitoring as well arterial blood gas.
Infection at the insertion site.
Thrombosis of the vein.
Bleeding diathesis in central line is a relative contraindication.
In IO Access, fracture on the same bone as well pathological disorder predisposing to fractures is a contraindication.
Different veins can be used for PIVC starting with dorsal veins of the hand, then the feet and then proceeding to other choices including scalp vein in infants, external jugular vein, antecubital and the great saphenous vein as in Figure-2.5
Technique:5
|
Neonate | Infant | Children | Length |
PIV | 24-26G | 22G | 20G | 2-6cm |
Midline Access | 22G | 22G | 20G | 15-30cm |
Table-1: Size of PIV catheter.
A recent RCT by Vinograd et.al. evaluated 167 children showed 85% success rate of first attempt with US guidance compared to 45% with traditional methods. Also US guidance resulted in shorter cannulation time, less redirection and fewer attempts.6
Longer catheter are preferable when using ultrasound guided insertion especially with a vein deeper then 0.5 cm to minimize the risk of dislodgment and infiltration (suggested to be longer than 2 cm). In a pilot study by Paladini, long catheter > 6 cm were associated with lower risk of failure in pediatric patients more than 10 years comparable to the short one <6 cm.8
Pitfalls:
Pitfalls:
No evidence of preferable technique in pediatrics but in adults out-of-plane proven to be superior for PIVC insertion.
https://www.coreultrasound.com/ultrasound-guided-peripheral-iv-access/
It’s considered the best alternative IV access in emergencies (peri-arrest and arrest condition) after 2 failed attempts of PIVC within 60-90 seconds, AHA recommends IO catheter as first line access in cardiac arrest. Still the outcome of out of hospital cardiac arrest and best access need more delineation.4,5
Figure-2 (on green) shows the possible site for IO insertion where the commonest one is the proximal tibial shaft about 1-2 cm from the tibial tuberosity avoiding the growth plate.
Confirmation of IO by POCUS2
Figure-3: POCUS confirmation of IO site.
Central IV Catheter (CIVC)
This an alternative longer duration route that can be utilized as an emergency line but less favorable compared to the IO during initial resuscitation. It is still considered a good choice in ill patients with difficulty of PIVC and failure of US guided peripheral access as well IO when fluid, high concentrated electrolytes and vasopressors are needed.4
The common site for insertion of non-tunneled CVC in pediatric is the internal jugular in critical care setting with higher success rate compared to femoral vein9 , but the femoral vein might be the first choice in PEM as it’s easily accessible and don’t interfere with resuscitation measures.10
Always prepare your equipment and check them, also get consent when possible before attempting a central line
Age(years) | weight (kg) | Catheter gauge | French gauge | length (cm) |
<1y | 4-8 | 24 | 3 | 5-12 |
<1y | 5-10 | 22 | 3-3.5 | 5-12 |
1-3y | 10-15 | 20 | 4 | 5-15 |
3-8y | 15-30 | 18-20 | 4-5 | 5-25 |
>8y | 30-70 | 16-20 | 5-8 | 5-30 |
Table-2: CVC sizes.4
Internal Jugular vein:
Subclavian vein:
Directly below the clavicle at the junction of the lateral one third with the medial two third directing the needle toward the sternal notch
Femoral vein:
1-2 cm below the inguinal ligament medial to the femoral artery, guide the needle toward the umbilicus
The use of ultrasound guided insertion is considered the standard of care for central line insertion. Ultrasound use reduces the number of attempts and procedure duration, increases the successful insertion rate, and reduces complications compared to the skin surface anatomic landmarks technique.9
This can facilitate visualization, increase the success rate with 95% first attempt success rate of ultrasound-guided venous punctures compared to 34% of the anatomical landmark and decrease the rate of complication that would occur with the anatomical landmark.11
Internal jugular vein:
Confirm proper placement by US as well X-Ray
R/O complication as pneumothorax, hemothorax or hematoma, mis-displacement
Artery puncture, air embolism, thoracic duct injury, arrhythmia are possible complications.
It is uncommon access in pediatric patients with the availability of IO needle, if needed the classic site is the saphenous vein which is 2 cm superior and anterior to the medial malleolus.
Resources:
Dr. Rawan Alrashed
Pediatric Emergency Physician
Dalhousie PoCUS Fellow
Dalhousie University Department of Emergency Medicine
Reviewed & Edited by Dr David Lewis (@e_med_doc)
All case histories are illustrative and not based on any individual
12 years old female, previously healthy, presented to the ED with 1 day history of abdominal pain persistent, mainly in the lower abdomen, nauseated, with loss of appetite, no vomiting, no bowel motion, low grade fever, by exam she was distress in pain with tachycardia abdominal exam showed periumbilical and RLQ tenderness. Labs requested.
Awaiting the results, thinking of differential diagnosis and best imaging study….
Would POCUS help in the diagnostic process??
In children, acute appendicitis constitutes 1-8% of the abdominal pain diagnosis and is the most common condition requiring emergency surgery. The potential for morbidity and mortality from perforation of the appendix necessitates prompt diagnosis. Although a variety of clinical scoring systems have been developed, there is still no consensus on clinical, laboratory, and imaging criteria for diagnosing appendicitis, which poses a dilemma for the emergency clinician (1). The clinical presentation of children with appendicitis varies from that of adults which makes it more difficult to diagnose it. Multiple scoring systems (Pediatric Appendicitis score, Alvarado score, Pediatric Appendicitis risk calculator) were developed and externally validated with varying degree of sensitivity and specificity (2).
The appendix is a blind-ended tubular structure that arises from the posteromedial aspect of the cecum, proximal to the ileocecal valve. The average length of the appendix varies from neonates to adults, ranging from 4.5 mm to 9.5 mm. The orientation of the appendix can be retrocecal, subcecal, preileal, retroileal, or in a pelvic site (1).
Appendicitis is a result of obstruction of the appendiceal lumen. Obstruction can occur secondary to stones, fecaliths, or other processes that inflame the lymphoid tissue.
Imaging Study |
Sensitivity |
Specificity |
US |
88% |
94% |
CT |
94% |
95% |
MRI |
96% |
96% |
(Benabbas, 2017 (2))
Cecum (C) is the most lateral structure in the RLQ, it’s a gas-fecal filled (dirty shadow) identified by following the haustra on the ascending colon caudally
Terminal ileum (TI) is a smooth wall that is fluid filled showing peristaltic movement and demonstrates valvulae conniventes.
(Ref – 9,12)
a) echogenic mucosa
b) hypoechoic muscularis mucosa
c) echogenic submucosa
d) hypoechoic muscularis propria
e) echogenic serosa
Use the LINEAR Probe (Curvilinear might be needed in large habitus people)
If appendix is not visualized use the systematic approach (suggested by Sivitiz et al)
(Ref – 3,5,8)
Retrocecal Appendix
Consider applying pressure dorsally on the patient RLQ from the back. Scan while the patient on left posterior oblique position and scan parasagittal through the right flank in a coronal plane parallel to long axis of the psoas muscle; the appendix will appear anterior to the psoas muscle.
Pelvic Appendix
Consider using curvilinear transducer. Scan deeper and use the bladder as a window
(Ref 5)
Normal Appendix |
Primary signs of Appendicitis |
Secondary signs |
Tubular blind ended structure arising from base of the Caecum |
a non compressible appendix (Target sign) |
free Fluid in the right lower quadrant |
No peristalsis |
appendix wall diameter > 3 mm |
echogenic edematous mesenteric fat stranding |
Anteroposterior diameter |
overall appendiceal diameter > 6 mm (some reported 7mm) |
appendiceal wall hyperemia (ring of fire) |
Compressible target sign |
ultrasound McBurney’s sign |
abnormal lymph nodes |
|
presence of appendicolith |
abnormal adjacent bowel, and bowel wall edema |
(Ref 4,11)
PoCUS was performed. The images strongly suggested a diagnosis of appendicitis. A consultative ultrasound was performed in Diagnostic Imaging which confirmed our findings. After surgical consultation the child had an appendectomy and discharged the next day.
1) Becker C, Kharbanda A. Acute appendicitis in pediatric patients: an evidence-based review. Pediatr Emerg Med Pract. 2019;16(9):1-20.
2) Benabbas, R., Hanna, M., Shah, J., & Sinert, R. (2017). Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis. Academic Emergency Medicine, 24(5), 523–551.
3) Swenson DW, Ayyala RS, Sams C, Lee EY. Practical Imaging Strategies for Acute Appendicitis in Children. AJR Am J Roentgenol. 2018;211(4):901-909.
4) Lawton B, Goldstein H, Davis T, Tagg A. Diagnosis of appendicitis in the paediatric emergency department: an update. Curr Opin Pediatr. 2019;31(3):312-316.
5) Berghea-Neamţu, C. T. (2019). The Ultrasonographic Exam for Acute Appendicitis at Patient’s Bed. Acta Medica Transilvanica, 24(4), 48–50.
6) Doniger SJ, Kornblith A. Point-of-Care Ultrasound Integrated Into a Staged Diagnostic Algorithm for Pediatric Appendicitis. Pediatr Emerg Care. 2018;34(2):109-115.
7) Marin JR, Abo AM, Arroyo AC, et al. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence [published correction appears in Crit Ultrasound J. 2017 Dec;9(1):3]. Crit Ultrasound J. 2016;8(1):16.
8) Sivitz AB, Cohen SG, Tejani C. Evaluation of acute appendicitis by pediatric emergency physician sonography. Ann Emerg Med. 2014;64(4):358-364.
9) “US of the GI Tract – Normal Anatomy.” The Radiology Assistant : US of the GI Tract – Normal Anatomy, https://radiologyassistant.nl/abdomen/ultrasound/lk-jg-1-1.
10) Riscinti, Matthew. “Bedside Ultrasound for Acute Appendicitis – Featuring Colorized Images.” TPA, TPA, 10 Jan. 2021, https://www.thepocusatlas.com/new-blog/appendicitis.
11) Gongidi P, Bellah RD. Ultrasound of the pediatric appendix. Pediatr Radiol. 2017;47(9):1091-1100.
12) Jeffrey RB, Wentland AL, Olcott EW. Sonography of the Cecum: Gateway to the Right Lower Quadrant. Ultrasound Q. 2018;34(3):133-140.
13) US probe: Ultrasound for small bowel obstruction. emDOCs.net – Emergency Medicine Education. (2018, March 27), http://www.emdocs.net/us-probe-ultrasound-for-small-bowel-obstruction.
14) Elikashvili I, Tay ET, Tsung JW. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med. 2014 Feb;21(2):163-70.