A Peanut Problem or Pimple Popper Predicament

 A Peanut Problem or Pimple Popper Predicament – A Resident Clinical Pearl

Grace Dao PGY1

Family Medicine, Dalhousie University

Saint John, NB

Reviewed by: Dr. Chris Vaillancourt

Copyedited by: Dr. Mandy Peach

 

Case Presentation

A 30-year-old otherwise healthy female presented to the ED with concerns about an “allergic reaction” to peanut butter. She reported that she woke 30 minutes prior to her presentation in the ED with a severely swollen red and disfigured lip. Her face had looked normal upon going to bed the evening prior. Her last meal was a peanut butter sandwich, which she eats frequently without difficulty. She described having some “wheezes” and “chest tightness” to the triage RN. When seen by writer, she denied any trouble breathing. She denied any issues the night prior before going to bed. She denied any GI upset, such as cramping, nausea, vomiting or diarrhea. Besides the swollen lip, she denied noticing any other skin changes; she denied any itchy sensation. Past medical history was unremarkable; she had no history of prior allergic reaction and no known allergies. She took no medications. Review of systems was negative, besides she noted that there was pimple at the base of her nose that she had “popped” yesterday.

On exam, all vitals were within normal limits besides a HR of 110. Respiratory exam revealed no obvious stridor or increased work of breathing; there was no swelling of the tongue or uvula on inspection of the mouth, clear air entry and exit were appreciated bilaterally. A faint wheeze was appreciated bilaterally. Cardiovascular and abdominal examinations were within normal limits. A skin exam revealed a diffusely red and swollen upper lip, with skin the above the vermillion border also showing swelling and redness. Increased erythema/pus at the R nostril sill was appreciated in the area of the previously popped pimple. The lip was tender and very warm to the touch.

With 2 system involvement (lip swelling and wheezes on respiratory exam); she was treated as anaphylaxis initially and given 0.5 mg Epinephrine IM, which did not lead to any change in her symptoms. However, it would be quite unusual for an IgE mediated reaction to present this late after ingestion. A peanut allergy especially, as most of these present before age 3.

Initial bloodwork showed a normal CBC, Cr and electrolytes. CRP was elevated at 67.1. Due to no change in symptoms with anaphylaxis treatment and concerns re an infectious etiology a CT facial bones was ordered after discussion with the radiologist on call. CT report showed a broad zone of cellulitis with an evolving central abscess. ENT was consulted who reported that incision and drainage was required, and that the infection likely came from the popped pimple. They performed an incision and drainage of the abscess in the ED, took wound cultures and started empiric antibiotics, and arranged for outpatient follow-up. In discussion with the ENT, it was noted that this presentation is typical of CA-MRSA cellulitis, and, thus, antibiotics to cover MSRA were required.

Anaphylaxis

While not the outcome in this case, it is important to be familiar with the various constellation of symptoms/signs that make anaphylaxis a likely and the initial management of this “can’t miss” diagnosis, which are outlined in the included figures1,2.

Lip Cellulitis and Abscess

Interestingly, after this case, a case study of a similar presentation was found in the literature where a MRSA lip infection was initially misdiagnosed as angioedema/anaphylaxis3. The diagnosis was discovered later, after the patient was unresponsive to anaphylaxis treatment and a history of a popping a pimple on their chin the day prior was elicited. Because Methicillin-resistant Staphylococcus aureus (MRSA) soft tissue infection also has a characteristic presentation of erythema, edema, and often, areas of fluctuance it can have a similar appearance to the typical angioedema that can be found in anaphylaxis.

See Reference 3. This CT was performed after incision and drainage; thus, no abscess is appreciated

While it is important to be vigilant towards the presentation of anaphylaxis, cellulitis is another diagnosis that it important not to miss4. Like other infections, complications of cellulitis include bacteremia, endocarditis, septic arthritis, osteomyelitis, metastatic infection, sepsis and toxic shock syndrome.  In patients with suspected erysipelas or cellulitis it is important to consider the possibility of an abscess, which requires incision and drainage. Findings in keeping with a skin abscess would be a painful, erythematous, fluctuant nodule.

The central face is not the most common area to develop cellulitis; however, it is an important area to recognize cellulitis. Untreated cellulitis in this area, can lead to septic cavernous thrombosis because the veins in this region are valveless.

Other diagnoses to consider for angioedema without history consistent with IgE mediated reaction or infection:

  1. Hereditary or acquired angioedema
  2. Mast cell disorder
  3. Idiopathic angioedema

 

Bottom Line: Always consider anaphylaxis in someone with apparent lip angioedema. However, it is also important to keep infection on the differential for a swollen lip, particularly if symptoms are not responding to therapy. Asking about prior injuries/skin lesions in the previous days can help clarify likelihood of infection. Also, as a personal takeaway, I should probably stop popping pimples.

References:

  1. Sampson, H. A. , Munoz-Furlong A., Campbell, R.L., et al. (2016). Second symposium on the definition and management of anaphylaxis: Summary report: Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. J Allergy Clin Immunol 2006; 117:391. https://doi.org/10.1016/j.jaci.2005.12.1303
  2. Campbell, R.L. & Kelso, J.M. (2021). Anaphylaxis: Acute diagnosis. UpToDate. Retrieved December 30th, 2021 from : https://www.uptodate.com/contents/anaphylaxis-acute-diagnosis?search=anaphylaxis&topicRef=392&source=see_link#H1929228973
  3. Lucerna, A. R., Espinosa, J., & Darlington, A.M. (2015). Methicillin-resistant Staphylococcus Aureus Lip Infection Mimicking Angioedema. The Journal of Emergency Medicine 49 (1), 8-11 https://doi.org/10.1016/j.jemermed.2014.12.022.
  4. Spelman, D. & Baddour, L.M. (2021). Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis. UpToDate. Retrieved January 2nd, 2022 from: https://www.uptodate.com/contents/cellulitis-and-skin-abscess-epidemiology-microbiology-clinical-manifestations-and-diagnosis?search=cellulitis%20&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=2#H1368100182

Cover image from: https://www.uptodate.com/contents/an-overview-of-angioedema-clinical-features-diagnosis-and-management?search=angioedema&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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Quadriceps Tendon Rupture

Quadriceps Tendon Rupture – A Resident Clinical Pearl

Ida Szarics, PGY2

Dalhousie University

Reviewed by Dr. Paul Keyes

Copyedited by Dr. Mandy Peach

A 52 year old male presents to the ED with a right knee injury. He slipped while running, landing awkwardly on his right knee, with his foot caught behind him. He felt a “pop” and immediately had severe sharp right knee pain. He was unable to weight bear and states that his knee was swollen immediately afterwards. He denies any other injuries. He is otherwise healthy and is on no medications.

On exam, his vitals are within normal limits. There is obvious swelling of the right knee and has a palpable defect 2 cm above the patella which is extremely tender to palpation. He is unable to perform a straight leg raise. The remainder of the knee exam is non-contributory and he is neurovascularly intact.

He is clinically diagnosed with a quadriceps tendon rupture.

Above: Patients with complete quadriceps tendon ruptures will often present with a palpable defect within 2 cm above the patella. Image from: https://coreem.net/core/quadriceps-tendon-rupture/

 

Quadriceps tendon rupture: Mechanism

Quadriceps are the knee extensors, therefore rupture is most likely when the knee is flexed with simultaneous quadriceps contraction.1

-Age <40: Less common. Often occurs in athletes, particularly those who do not stretch activity, as a result of jumping and landing with the knee flexed. Patellar tendon rupture is more common in this age group

-Age >40: More common. Weaker tendons rupture more easily, so a fall onto a knee, or trying to prevent a fall onto the knees is typical.

 

Risk factors,2, 3

-Age (more common in patients >40 years of age)

-Male gender

-Type 2 Diabetes

-Renal disease

-Medications associated with tendon rupture (fluoroquinolones)

 

ABOVE: Anatomy of the muscles of the anterior thigh. Quadriceps tendon ruptures typically happen at the tendon’s insertion at the patella. Source: https://www.physio-pedia.com/Quadriceps_Tendon_Tear

 

Diagnosis

-Typically a clinical diagnosis, and is one of the “cannot miss diagnosis” in acute knee injuries.

-There is often a palpable defect ~2 cm above the patella where the tendon has been torn.

-Patients with a complete tear will be unable to perform a straight leg raise.

-Patients with a partial tear are unable to extend their knee against resistance – the ability to forcibly extend the knee against resistance is a critical part of the knee exam.

Investigations

XRays:

-May show a patella that is below expected anatomic position (patella baja). Of note, patella alta (or high-riding patella) can be a sign of patellar tendon rupture.

Ultrasound

-Can be a useful modality if diagnosis is uncertain. Often primary investigation available in the ED to supplement clinical exam findings.

MRI

-Best diagnostic modality, but cannot be obtained in the ED – this is typically a modality ordered by surgeons for surgical planning

ABOVE: Normal Knee XRay (left) and low-riding patella (right). The Insall Salvatti Index is the ratio of the patellar tendon length (red line) to the patellar length (yellow line). Normal is 0.8-1.2. Source: https://radiopaedia.org/articles/insall-salvati-ratio

 

Management

-Early surgical repair is important to maximize recovery, especially in complete tears. The distal tendon is avascular, so it will not heal well non-operatively.1

-Non-operative treatment (RICE, splinting, non-weightbearing) may be an option in partial tears or in patients with poor baseline mobility.

-Either way, orthopedic surgery should be consulted within a timely matter, usually within a week, to guide management. As time goes on difficulty of repair increases, as does probability of failed repair.  The ED physician should provide adequate analgesia as needed, immobilize the knee, and advise non-weightbearing while the patient is in the ED.

Back to our patient

Orthopedic surgery is contacted, and a plan is made to see the patient in clinic the following day to plan surgical repair. The patient’s knee is immobilized in extension, and an outpatient MRI is ordered. The patient undergoes surgical repair later that week.

References:

1Sharareh, Ben. (2021). Quadriceps Tendon Rupture. Orthobullets. https://www.orthobullets.com/knee-and-sports/3023/quadriceps-tendon-rupture

2 Von Fange, T.J., (last updated, 2021). Quadriceps Tendon and Muscle Injuries. UpToDate.

3 Nori, S., (2018) Quadriceps tendon rupture. J Family Med Prim Care. 7(1): 257–260.

 

 

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PoCUS in Early Pregnancy – a review

PoCUS in Early Pregnancy – a Resident Clinical Pearl (RCP)

Dr. Victoria Landry, R3

Integrated Family Medicine Emergency Medicine Program

Saint John, NB

Edited by Dr. Rawan AlRashed, PoCUS fellow

Copyedited by Dr. Mandy Peach

PoCUS use by the emergency physician for the diagnosis of uncomplicated intrauterine pregnancy have been proven to be affective in expiditing patient management and decreasing the length of stay in the emergency department. In a metanlaysis done by Stein et.al. emergency physiscain performed PoCUS was found to be 99.3% sensitive in ruling out ectopic pregnancy by detecting an Intauterine pregnancy (IUP). In this review, ultrasound findings in the first trimester will be highlighted.

Indication: Confirmed or suspected pregnancy with abdominal pain, vaginal bleeding, syncope, or hypotension(2)

Technique

Start with trans-abdominal ultrasound (TAUS) (1,2)

  • Use abdominal probe (deep penetration, wide field view; use “obstetrics” or “gynecology” preset)
  • Acoustic window is a full bladder (anechoic structure in the near field). Uterus is a homogenous structure beneath bladder
  • Place abdominal probe midline longitudinally/sagitally immediately superior to symphysis pubis with probe marker toward patient’s head. Adjust depth so uterus is in middle of screen. Sweep left and right till uterus disappears in each view.
  • Rotate probe 90° into transverse plane with marker toward patient’s right side. Sweep up and down till uterus disappears in each view.
  • To improve image: Turn the gain down, sweep slowly

Then Consider the use of transvaginal ultrasound (TVUS) if available, and qualified to use  (1)

  • Requires empty bladder, Patient in lithotomy position.
  • Ultrasound gel on probe, latex condom over top (ensure no air bubbles), then sterile lubricant
  • Reference mark toward ceiling (in sagittal orientation), insert 4-5cm into vagina, sweep left and right
  • Turn probe 90° C to be in coronal plane and marker to the right of the patient – sweep anterior and posterior

General principles (1)

  • follow the endometrial stripe (echogenic line within uterus) along its entire course (left to right in longitudinal view, cervix to fundus in transverse view), looking for evidence of a pregnancy
  • You are trying to rule in an intrauterine pregnancy (IUP) (as opposed to rule out an ectopic) – assume all pregnancies are ectopic until proven otherwise(2)

 

Figure 1 – Longitudinal/sagittal view (TAUS): (1)

Figure 2 – Transverse view (TAUS): (1)

Discrimination zone (βHCG levels below which you cannot see an IUP)(2, 3)

  • TVUS – βHCG 1500-2000 mlU/ml
  • TAUS – βHCG 5000-6000 mlU/ml
  • If No definite IUP (NDIUP) above these levels, strongly consider ectopic!

Findings:

Inutrauterine pregnancy

  • The “double ring sign is the earliest sign of a definitive IUP. Diagnosing an intrauterine pregnancy (IUP) requires visualization of all 3 structures inside the uterus. (1,2)
  • Decidual reaction – hyperechoic (white) line in uterus (2) represents endometrium thickening – begins around day 14 post-fertilization (1)
  • Gestational sac – anechoic (black) round area within decidual reaction, contains amniotic fluid, seen at 4-5wks (TVUS), 6wks (TAUS) (2)
  • Yolk sac +/- fetal pole within the gestational sac(2)
    • Yolk sac: circular echogenic layer, looks like a cheerio, visible when gestational sac is 10mm by TVUS (~5-6wks GA), 20mm by TAUS (~6-7wks GA) (1)
    • Fetal pole: echogenic structure; develops around the same time as yolk sac but visualized on US ~1wk later(1)

Figure 3 – Double ring sign(1)

Figure 4 – Double ring sign(4)

Figure 5 – Fetal pole(1)

Measurements

Mean sac diameter

  • Obtain sagittal view of gestational sac, measure height and length of sac using mean sac diameter calculation package, rotate probe 90º to obtain transverse view of gestational sac, measure width of sac
  • MSD (mm) + 30 = Gestational age (days)

 

Crown-rump length (CRL) = Top of skull to base of pelvis(1)

  • >5mm without visible fetal heart = unlikely to proceed to viability
  • CRL (mm) + 42 = gestational age (days)
  • The most accurate method of dating the pregnancy(3)

 

Fetal cardiac activity = proof of live IUP(1)

  • detectable ~6wks on TVUS (fetal pole is >5mm), 7-8wks on TAUS (fetal pole is >10mm) (1)
  • Normal IUP with fetal cardiac activity is reassuring!
    • absence of cardiac activity will likely result in miscarriage, presence of cardiac activity reduces risk of miscarriage (HR >100 consistent with good fetal outcome)
  • Technique(3)
    • Locate fetal pole, optimize depth, turn on M-mode (never doppler as it subjects fetus to high US energy and may be harmful)(1,2), place caliper over beating heart, measure and calculate heart rate
    • Note: must be within gestational sac, well away from uterine wall (don’t confuse with highly vascular decidual reaction)(1)
    • Normal FHR Ranges
      • 6-7wks: 100-120bpm
      • 8wks: 145-170bpm
      • 9+wks: 120-160bpm

 

Other findings and descriptions

No definitive intrauterine pregnancy (NDIUP) (2)

  • if any single criteria of IUP is missing

DDx for NDIUP(2):

  • Early normal pregnancy (βHCG below discrimination zone)
  • Threatened/spontaneous abortion
  • Anembryonic pregnancy (blighted ovum)
  • Molar pregnancy
  • Ectopic pregnancy

Threatened abortion: abnormal bleeding during pregnancy; normal IUP on US(3)

Inevitable abortion: vaginal bleeding with open os; normal IUP or product of conception (POC) near cervix on US(3)

Incomplete abortion: open os with retained POC; US shows anything from debris to embryo; abnormal uterine contents confirms dx(1)

Complete abortion: empty uterus + positive βHCG +/- closed os; same findings as for ectopic therefore requires formal US + serial βHCG(1)

Ectopic pregnancy (3)

  • NDIUP (no definitive intrauterine pregnancy) above βHCG in discriminatory zone
  • Scan adnexa for signs of ectopic
    • Tubal ring sign (thick hyperechoic ring around a tubal mass)
    • Ring of fire sign (also seen in corpus luteum cysts; high velocity flow seen on color doppler around the
    • gestational sac + fetal pole with cardiac activity outside the uterus is diagnostic of an ectopic
  • assess pouch of douglas for free fluid
  • suspicious for ectopic: ectopic mass, fluid in cul de sac, absent IUP, abnormal βHCG pattern (normally rises at least 50% in 48hr period)

Corpus luteal cyst(2,3)

  • develops due to growth, instead of normal regression, of corpus luteum
  • appears very similar to ectopic, but will move with the ovary in response to transducer manipulation instead of independent, tubal ring is thinner and less echogenic, cystic fluid is more clear and anechoic (rather than “clumpy” with echoes)
  • ovarian cyst characteristics: outside the uterus, circular, well circumscribed, do not taper to solid organs

Blighted ovum (anembryonic pregnancy)(1,2)

  • abnormally large gestational sac with no embryonic contents
    • gestational sac >20mm without yolk sac visible à suspect blighted ovum
    • >25mm without yolk sac visible à blighted ovum virtually certain (Eliminates diagnosis of ectopic)
  • Positive βHCG (higher than expected for GA)
  • Confirm with formal US

Molar pregnancy (1,3)

  • Tumor due to uncontrolled proliferation of trophoblasts (cells that surround blastocyst and later become the placenta)
  • Complete mole: no fetal/embryonic tissue; abnormally elevated βHCG >100,000 mIU/ml
  • Partial mole: may contain (abnormal) fetal structures
  • Presentation: hyperemesis, larger uterus than expected, vaginal bleeding, anemia, signs of hyperthyroidism, pregnancy-induced hypertension
  • US: appears as a “snowstorm” or “cluster of grapes” in uterus – fairly homogenous mass full of small, fluid-filled (black) holes; no detectable fetal cardiac activity
  • Needs gyne referral for surgical evacuation(2)

Pitfalls

  • Pseudogestational sac (1, 3)
    • contains no yolk sac, usually more irregularly shaped or pointy-edged than a true gestational sac, border is not as echogenic, and fluid may contain some echoes
    • Intrauterine fluid collections occur in 9-20% of ectopic pregnancies
    • Unless all 3 criteria met for double ring sign, pt requires formal US
  • Extrauterine pregnancy(1)
    • Recognize uterine tissue and always confirm bladder-uterus juxtaposition(2)
  • Interstitial and cornual ectopic pregnancies(1)
    • Rare but dangerous – tend to rupture later therefore produce more rapid hemorrhage than other ectopics
    • Myometrium around interstitial and cornual pregnancies is thin and uneven(2)
    • Measure the “myometrial mantle” (the thinnest part of myometrium around the gestational sac) – should be >5-7mm thick (thinner is concerning for cornual or interstitial ectopic pregnancy) (2)
  • Multiple pregnancies(2)
    • In multiple gestation, each fetus needs to meet the criteria for IUP
    • Heterotopic pregnancies = combined IUP and ectopic pregnancy
      • Risk is 1:30,000 in general population
      • Risk increases to 1:100 with fertility treatment (e.g. IVF)

Figure 7 – Extrauterine pregnancy(1)

Figure 8 – Normal myometrial mantle(1)

Figure 9 – Cornual ectopic pregnancy(1)

Key points(1)

  • False positive IUP can have devastating consequences
  • Any positive βHCG + no definitive IUP = presumed ectopic
    • Pt stable + no free fluid à formal US + quantitative βHCG
      • If no ectopic mass, repeat formal US and βHCG in 48hrs with consideration of patient risk of ectopic pregnancy
      • Follow up with OB to be arranged
    • Always consider other diffrerntail diagnosis for patient presentation before discharging them home.

Figure 10 – Clinical application(2)

 

References:

  1. Socransky, S., &amp; Wiss, R. (2016). Obstetrical EDE. In Essentials of point-of-care ultrasound: The EDE book (pp. 61-90). The EDE 2 Course.
  2. Long, N. (2020, March 02). VanPOCUS: 1st Trimester Obstetrics • LITFL • Ultrasound Library. Retrieved October 15, 2020, from https://litfl.com/vanpocus-1st-trimester-obstetrics/
  3. Dinh, V. (n.d.). Obstetric/OB Ultrasound Made Easy: Step-By-Step Guide. Retrieved October 15, 2020, from https://www.pocus101.com/obstetric-ob-ultrasound-made-easy-step-by-step-guide/
  4. Flores, B., Smith, T., & Joseph, J. (n.d.). OB/Gyn. Retrieved October 15, 2020, from https://www.thepocusatlas.com/obgyn-1

 

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Just the Facts: Sympathectomy for Frostbite

Just the Facts: Sympathectomy for Frostbite – A Resident Clinical Pearl

Robert J. Dunfield

PGY-3 – Integrated Family Medicine/Emergency Medicine Program

Reviewed by: Dr. Devon Webster

Copyedited by: Dr. Mandy Peach

Case:

You’re working in a rural emergency department when a 76 year old man is brought in by ambulance after being found laying in a snowbank on the side of the road, next to his parked car. The temperature outside is -20°C and it’s snowing quite heavily. As far as you can gather, the man has a history of cognitive impairment and lives alone.

You perform an appropriate initial resuscitative workup. His core temperature is warmed to 36.5°C and he is stabilized, but complains of ongoing left hand pain. You note that the man’s left hand has the following features: it is cold, throbbing, his phalanges are covered in blisters, surrounded by edema. You suspect frostbite.

Figure 1: Frostbite. [Peer-Reviewed, Web Publication] Herndon, A. Amick, A. (2021, Mar 15). Health Risks Imposed by the Beach. [NUEM Blog. Expert Commentary by Lank, P]. Retrieved from http://www.nuemblog.com/blog/health-risks-imposed-by-the-beach.

  1. What features on clinical examination distinguish first, second, third, and fourth degree frostbite? [1, 2]

In the emergency department setting, distinguishing between degrees of frostbite is not accurate and not clinically useful. Similar to burns, it is more useful in the acute setting to classify frostbite as superficial or deep to help determine prognosis. Tissue involvement can change through rewarming and progress with time. All frostbite injuries are treated with a similar approach, no matter the degree of involvement.

Classically, however, frostbite injuries have been categorized as first, second, third, or fourth degree. The following table outlines the characteristics for each of these classifications.

Clinical features indicating favourable prognosis:
* Intact sensation to pinprick
* normal skin color
* large blisters with clear fluid

Clinical features indicating poor prognosis:
* Non-blanching cyanosis
* Dark fluid-filled blisters
* Hard, non-deforming skin.

2. What treatment options are available for rewarming a peripheral frostbite injury? [1, 3, 4, 5, 6]

The treatment for frostbite requires a careful approach that starts immediately during the pre-hospital stage. These patients should:

1) be removed from the cold environment,
2) have any cold and wet clothing removed,
3) begin rewarming of affected area in circulating warm water bath (37 to 39*C)

*Avoid rewarming with dry heat, vigorous rubbing, or fire.

Once these patients have arrived to your emergency department, initial resuscitation of the whole patient should be the primary focus of treatment. Follow your ABC’s and ensure their core temperature is stabilized prior to focusing on the frostbitten limb.

 

In terms of rewarming, the traditional approach has implicated the following interventions:

1) Analgesia: thawing can be extremely painful. Administer anti-inflammatories and/or short acting opioids as needed.

2) Warm and wet immersion: immerse the frostbitten limb in circulating water/saline warmed to 37 to 39°C.

3) Fluid resuscitation: as needed, particularly if there is concern for cold diuresis in the setting of hypothermia.

4) Movement: encourage gentle movement of the affected limb as tolerated, but ensure no rubbing/friction is applied to the frostbitten area.

5) Topical aloe vera q6h: this treatment has shown to be effective in fighting the arachidonic acid cascade that promotes inflammation and prostaglandin formation, thereby reducing tissue damage in frostbite. Can be considered when available.

6) Tetanus toxoid

7) Careful wound care: this is an important aspect of ongoing management. Prior approaches to frostbite discuss the possibility of debridement of blisters and soft tissue, but this does not need to occur in the acute setting. Incision and drainage of white, cloudy blisters remains controversial.

8) Affected limb elevation

 

3. What management options exist for post-rewarming pulse deficits in frostbite? [1, 5, 6, 7]

If a hand continues to demonstrate ongoing evidence of ischemia or rewarming therapy fails to achieve reperfusion, the following management strategies are suggested:

1) If not already done, emergently consult local frostbite management expertise, such as plastic or vascular surgery.

2) Consider vascular imaging of the affected area.

3) Intravenous or intraarterial thrombolytic (Tpa 0.15 mg/kg bolus then 0.15 mg/kg over 6 hours). After Tpa is administered, start IV unfractionated heparin (2 mg/kg/min) for 24 to 72 hours. This reduces the risk of digital amputation.

4) Iloprost* IV (where available) 2 mg/kg/min, 6 hours per day for 5 days.
*Iloprost is not currently available commercially in Canada, but many Canadian physicians working in northern regions of the country are currently advocating for its increased availability. Iloprost is an arterial vasodilator, often used in pulmonary arterial hypertension.

 

4. What role does local anaesthetic play in rewarming a frostbitten hand? [8, 9]

Studies have assessed the role of regional anesthesia to create a chemical sympathectomy for patients with frostbite. Hand surgeries performed under local anaesthetic have shown to reduce sympathetic innervation of the hand, resulting in hyperemia (increased blood flow) while simultaneously providing pain control. Hyperemia is likely a result of the sympathetic blockade that results in increased blood flow and vasodilatation peripherally. This peripheral nerve block focuses on the ulnar and median nerves.

One study looked at 39 patients undergoing carpal tunnel release. It showed that a volar nerve block resulted in 74% of patients having a temperature increase of >1°C in their distal fingers following distal forearm anaesthetic block.

Concerns about finger vasoconstriction as a result of epinephrine use in anaesthetic injected at the wrist, theoretically worsening ischemia and necrosis risk in the fingers, are currently unfounded. Local anaesthetic without epinephrine comparatively will have a shorter duration of hyperemia and analgesia.

In general, there is limited research available around the use of local anaesthetic in frostbite.
No clear guidelines outlining indications and contraindications to local anaesthetic sympathectomy in the treatment of frostbite presently exist. Currently, its use as an adjunct to other routine management of acute frostbite is recommended.

5. How is a local anaesthetic sympathectomy performed in the hand? [8]

1) Materials needed:

-Aseptic cleaning wipe/solution
-10 mL syringe
-1% lidocaine with epinephrine
-18G needle (to draw up local anaesthetic)
-27G needle (to inject local anaesthetic)
-Sterile marking pen

2) Identify your landmarks: injection of the local anaesthetic should be performed between the palmaris longus and flexor carpi ulnaris tendons, just proximal to the wrist crease. Mark the area.

3) Clean the area with an antiseptic solution.

4) Inject 10 mL of 1% lidocaine to the area landmarked, subfascially. There is no need to fan the needle during this injection.

5) Continue to monitor the temperature of the involved fingers. It is possible the area near the wrist infiltrated by the local anaesthetic will blanche, but the hand and fingers distal to this area should become warmer and hyperemic.

 

  1. How long do the effects of local anaesthetic sympathectomy last? [8]

It is estimated that hyperemia will last for approximately 2 hours. Numbness may last up to 6 hours.

https://handsurgery.org/multimedia/files/preCourse/Frostbite%20treatment%20with%20blocks.pdf

 

SUMMARY AND KEY POINTS:

-Classifying frostbite in an acute setting is notoriously unreliable due to the ability of the insult to progress over time. Your approach to frostbitten patients should be consistent despite their initial tissue involvement.

-Initial management of the frostbite patient should focus on resuscitation and core rewarming.

-Removing the patient’s exposure to hypothermia and cause of frostbite, pain control, warm and wet rewarming, tetanus vaccination, topical aloe vera, wound care, considering thrombolysis, and consulting experts in frostbite management are core tenants of frostbite care.

-Consider local anaesthetic sympathectomy using distal volar wrist nerve block as an adjunctive therapy in patients with hand frostbite.

-Iloprost is currently unavailable commercially in Canada but advocacy is ongoing to increase its availability for treatment of frostbite, especially in northern areas of the country.

 

REFERENCES:

 

  1. Tintinalli, J.E., Ma, O.J., Yealy, D.M., Meckler, G. D., Stapczynski, J.S., Cline, D., Thomas, D.M. (2016). Tintinalli’s emergency medicine: A comprehensive study guide(Ninth edition.). New York: McGraw-Hill Education. Chapter 208: Cold Injuries.
  2. Comp, L. Brrr! ED Presentation, Evaluation, and Management of Cold Related Injuries. net: Practice Updates. 2018; Last updated: May 21, 2018. Accessed: June 01, 2021. Available from: http://www.emdocs.net/brrr-ed-presentation-evaluation-and-management-of-cold-related-injuries/
  3. Thomas, A. CRACKCast E139 – Frostbite. org. 2017; Last updated: December 28, 2017. Accessed: June 01, 2021. Available from: https://canadiem.org/crackcast-e139-frostbite/
  4. Handford, C., Buxton, P., Russell, K., Imray, C. E., McIntosh, S. E., Freer, L., Cochran, A., & Imray, C. H. 2014. Frostbite: a practical approach to hospital management. Extreme physiology & medicine3, 7. https://doi.org/10.1186/2046-7648-3-7
  5. Basit, H., Wallen, T.J., Dudley, C. 2021. Frostbite. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nih.gov/books/NBK536914/
  6. Poole, A., and Gauthier, J. 2016. Treatment of severe frostbite with iloprost in northern Canada. CMAJ, 188 (17-18): 1255-1258. https://doi.org/10.1503/cmaj.151252
  7. Yun, T. 2021. ‘It’s a promising result’: Made-in-Yukon treatment reducing amputations in most severe frostbite cases. CTV News: Health News. Last updated: March 3, 2021. Accessed: June 01, 2021. Available from: https://www.ctvnews.ca/health/it-s-a-promising-result-made-in-yukon-treatment-reducing-amputations-in-most-severe-frostbite-cases-1.5331820
  8. Chandran GJ, Chung B, Lalonde J, Lalonde DH. The hyperthermic effect of a distal volar forearm nerve block: a possible treatment of acute digital frostbite injuries? Plast Reconstr Surg. 2010 Sep;126(3):946-950. doi: 10.1097/PRS.0b013e3181e60400.
  9. Rakower SR, Shahgoli S, Wong SL. Doppler ultrasound and digital plethysmography to determine the need for sympathetic blockade after frostbite. J Trauma. 1978 Oct;18(10):713-8. doi: 10.1097/00005373-197810000-00006.
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A bad trip… to the ICU – A case presentation and general overview of poisonous mushroom ingestion

A bad trip… to the ICU – A Resident Clinical Pearl  on poisonous mushroom ingestion

Scott Fenwick 

PGY-1 Family Medicine, Dalhousie University

Reviewed by: Liam Walsh, Clinical Pharmacist

Copyedited by: Dr. Mandy Peach

Case Presentation:

A 43yo otherwise healthy female presents to the ED with 30 hours of intractable nausea, vomiting, diarrhea, and diffuse crampy abdominal pain. 12 hours prior to the onset of these symptoms, she had foraged six wild mushrooms, fried them with butter, and ate them with her dinner. She had used a wild mushroom reference guide and thought these “pristine white” mushrooms would be a safe steak topping.

In the ED, she was alert and oriented with a GCS of 15 and no apparent encephalopathy. Her vitals were BP 109/68, P 93, T 37, RR 16, O2 97% RA. She was retching and vomiting clear emesis, which settled some with ondansetron 8mg IV. Clinically, she looked dehydrated but otherwise not toxic. Her abdomen was soft and diffusely tender. Cardiorespiratory exams were unremarkable. There were no skin findings.

A 1L bolus of normal saline was administered. Serum laboratory studies, drawn approximately 42 hours post-ingestion returned as follows:

Urinalysis showed trace blood, ketones and protein. ECG showed normal sinus rhythm.

The marked elevation in liver enzymes and abnormal coagulation studies were concerning for hepatocellular injury and fulminant hepatic failure. The local Internal Medicine consultant was contacted, and the patient was transferred to the ICU at the nearest liver transplant center.

In consultation with pharmacy and poison control, it was determined that the most likely offending mushroom was Amanita virosa, more commonly know as a Destroying Angel.

The patient was started on NAC, activated charcoal, penicillin G, cimetidine, vitamin C, and IV silibinin (milk thistle). Consideration was given to percutaneous cholecystostomy, as the toxin can accumulate in the gallbladder, but this was not anatomically feasible at the time.
Laboratory studies peaked at 72 hours post-ingestion as follows

Vitamin K was given to lower the INR. Creatinine continued to climb and was 835 prior to initiation of hemodialysis. Liver studies slowly trended downward with ALT 9774, AST 4586, and INR 1.7 at 96-hours post-ingestion. Ultimately, liver function values returned to normal and enzymes levels continued to trend downward—making liver transplant not necessary.

Overview of Toxic Mushroom Ingestion:

Epidemiology:

According to the 2019 Annual Report of the American Association of Poison Control Centers’ National Poison Data System, more than half of toxic mushroom ingestions occur in children under the age of 6. Serious toxicity and mortality, however, is more common in foraging adults, as they are more likely to consume larger quantities of a misidentified mushroom. Data for Atlantic Canada was difficult to obtain, but the Ontario Poison Centre received 72 calls related to mushroom exposures in September 2020, generally the peak month for exposures.

Poisoning Syndromes:

Only 20% of the time is the offending mushroom correctly identified, so we often rely on the clinical presentation to identify the likely species and relevant treatment. UpToDate lists 12 different mushroom toxins and 14 unique corresponding syndromes:

  • Acute gastroenteritis (<6hrs) without liver failure
  • Delayed gastroenteritis (6-12hrs) and delayed liver failure
  • Acute gastroenteritis and delayed renal failure
  • Hallucinogenic
  • CNS depression and excitation
  • Disulfiram-like reaction
  • Cholinergic excess
  • Delayed renal failure
  • Delayed rhabdomyolysis
  • Erythromelalgia
  • Delayed encephalopathy
  • Immune-mediate hemolytic anemia
  • Shiitake dermatitis
  • Allergic bronchioalveolitis

The syndrome from this case, bolded above, is delayed liver toxicity and delayed gastroenteritis.

This syndrome follows 3 phases:

  • Phase I: Dysentery – nausea, vomiting, diarrhea (6-24hrs post-ingestion)
  • Phase II: Apparent recovery (24-36hrs post-ingestion)
  • Phase III: Fulminant hepatic and multisystem organ failure (48-96hrs post-ingestion)

Poisonous Mushrooms in New Brunswick:

The New Brunswick Museum has compiled a catalog of the mushroom species discovered in the province. One of the deadliest mushrooms in the province is the Destroying Angel. This nickname refers to a group of mushroom species under the genus Amanita. Amanita virosa is commonly found in New Brunswick and Nova Scotia. They are pristine white and often located in wooded areas or next to trees/shrubs in suburban areas. They are most prevalent in the summer and fall.

In their button stage, Destroying Angels can be confused with white mushrooms that you might buy at the grocery store. Destroying Angels produce an amatoxin—a selective inhibitor of RNA polymerase II, leading to an interruption in protein synthesis and cell death. Amatoxins are especially toxic to the GI tract, liver and kidneys.

Notably, in the NB Museum catalog, there are no reports of Amanita phalloides, aka the Death Cap, in New Brunswick. In Canada, they are more commonly found in British Columbia.

EM Approach:

History:

  1. What did they look like? Ask for photos from the patient’s phone or samples if they have them. Identification assays are available but not always useful in the acute setting.
  2. Were the mushrooms collected in a field or along/underneath trees? Many toxic mushrooms are in wooded areas.
  3. How many types of mushrooms were ingested?
  4. How long after ingestion did symptoms develop? Less than 6hrs is associated with lower risk of—but does not exclude—potentially lethal ingestion.
  5. How much was eaten? Were there multiple times of ingestion?
  6. Did others eat the mushrooms? If so, do they have similar symptoms?

Physical Exam:

  • Assess hydration status
  • Assess for encephalopathy or other signs of fulminant hepatic failure

Laboratory studies:

Treatment:

  • Ondansetron for N/V, do not use anti-diarrheal agents
  • IVF for dehydration and electrolyte abnormalities
  • If a serious ingestion cannot be excluded, patients should be admitted for 24-48hrs for observation and serial bloodwork

Evidence-based recommendations for suspected amatoxin poisoning:
o Multiple dose activated charcoal: 0.5g/kg (max 50g) q4h for 4 days post-ingestion.

o Silibinin: loading dose of 5 mg/kg IV, followed by a continuous infusion at a dose of 20 mg/kg/day for 6 days or until clinical recovery.

If IV silibinin is not available, oral milk thistle capsules (Silymarin) are an effective alternative. The initial dose is 50-100mg/kg q8h, and titrated up to 200mg/kg q8h as tolerated, with a maximum single dose of 2-3g. IV Silibinin is available only through Health Canada’s Special Access Program. Pharmacy should be contacted early to assist with this process if it’s being considered.

o Penicillin G: 300,000 to 1,000,000 units/kg/day given as a continuous IV infusion. A small amount of research shows no benefit to adding this if IV silibinin is available. If penicillin allergy, consider ceftazidime 4.5 g every 2 hours.

o NAC protocol: initial loading dose of 150 mg/kg (max 10g), next a 4-hour infusion at 12.5 mg/kg/hr, then a 16-hour infusion at 6.25 mg/kg/hr. The 16-hour dose may be repeated if significant hepatic dysfunction persists.

o Cimetidine: 300 mg IV every 8 hours until clinical improvement (evidence in animal studies only)

o Vitamin C: 3 g IV daily until clinical improvement (evidence in animal studies only)

o Dextrose for hypoglycemia

o Lactulose for hyperammonemia

o Vitamin K +/- FFP for coagulopathy

o Dialysis for AKI

o Early consultation with liver transplant center

  • Treatments for other mushroom poisoning syndromes can be found in this chart

Bottom Line:

Ask if the patient has photos of the mushrooms on their phone, or if they can describe their appearance. Call local poison control with this information.

Obtain a clear history to determine the interval between time of ingestion and time of symptom onset. Acute gastroenteritis onset (<6hrs from ingestion) is associated with favourable outcomes, and delayed gastroenteritis (usually 6-12hrs from ingestion) is more likely to have liver and/or renal failure.

Liver studies may be normal until 24-36 hours and generally peak at 72-96 hours post-ingestion.

Early treatment and consultation/transfer to a liver transplant center is imperative.

 

References:

Cover photo: https://www.deviantart.com/dreadillustrations/art/Poison-Mushrooms-774297817

Gummin, D. D., Mowry, J. B., Beuhler, M. C., Spyker, D. A., Brooks, D. E., Dibert, K. W., Rivers, L. J., Pham, N., & Ryan, M. L. (2020). 2019 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 37th Annual Report. Clinical toxicology (Philadelphia, Pa.)58(12), 1360–1541. https://doi.org/10.1080/15563650.2020.1834219

Nelson, L. S., Howland, M. A., Lewin, N. A., Smith, S. W., Goldfrank, L. R., Hoffman, R. S., & Flomenbaum, N. E. (2019). Goldfrank’s toxicologic emergencies (11th ed.). Mc Graw Hill Education.

Shannon, M. (2007). Haddad and Winchester’s clinical management of poisoning and drug overdose (4th ed.). Saunders.

NB Museum Mushroom Checklist: http://website.nbm-mnb.ca/mycologywebpages/Checklists/NBMushrooms/NBMushroomChecklist.html

Tavassoli, M., Afshari, A., Arsene, A. L., Mégarbane, B., Dumanov, J., Bastos Paoliello, M. M., Tsatsakis, A., Carvalho, F., Hashemzaei, M., Karimi, G., & Rezaee, R. (2019). Toxicological profile of Amanita virosa – A narrative review. Toxicology Reports, 6, 143–150. https://doi.org/10.1016/J.TOXREP.2019.01.002

Amanita virosa photo: https://www.tehrantimes.com/news/423947/Mushroom-poisoning-kills-18-in-Iran

White mushroom photo: https://www.stockfood.com/images/00395464-Several-button-mushrooms

Amanita phalloides photo: http://www.bccdc.ca/about/news-stories/stories/2020/death-cap-mushrooms-make-fall-appearance-in-urban-areas

 

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When you catch more than fish – Fish Hook Removal

When you catch more than fish – a Resident Clinical Pearl on Fish Hook Removal

Melanie Johnston

PGY2, FMEM Program, Dalhousie University

Reviewed & Copyedited by Dr. Mandy Peach

Introduction

Fishing is a common recreational activity in the Maritime provinces and fishhook injuries are common presentations among both recreational and commercial fishers, particularly during the warm weather months. Individuals may try to remove the fishhook themselves prior to presenting to the emergency department. While some may be successful, many will require evaluation and management in the emergency department for removal.

The majority of fishhook injuries are penetrating soft tissue injuries involving the hands, feet, or head, but can involve any body part.1 Most injuries involve superficial structures because of the forces applied to the fishing line that drive the barb parallel to the skin and keep it from penetrating deeper structures. There are four commonly used techniques to remove fishhooks, and the choice of technique will depend on the body part affected, depth of penetration, and the type of fishhook.2

Initial Evaluation

To determine the most appropriate technique for removal:

  • Determine what type of fishhook was being used (shape, size, # of hooks, location and # of barbs)
  • Perform a thorough neurovascular exam both proximal and distal to wound
  • Assess penetration depth; if difficult to assess, radiographs should be utilized for further evaluation (rule out bone and joint involvement)
  • Determine if tetanus immunization status is up to date

Figure 1: Types of fishhooks (A) Simple single barbed fishhook, (B) Multiple- barbed fishhook, (C)Treble fishhook.1

Complicated Fishhook Injuries

While the majority of fishhook cases are uncomplicated, those that require specialist referral and follow-up include:
– fishhook injuries involving the eyeball or orbit
– fishhook injuries with joint/tendon involvement
– fishhook injuries involving vital structures (carotid, radial artery, testicle, urethra)

In these cases, specialist consultations are warranted prior to fishhook extraction.1-3

Figure 2: Fishhook injury involving eye.5

Preparation for Fishhook Removal

Wound preparation: remove any additional materials attached to the fishhook (fishing line, lures, weights) using scissors/wire cutters. Surrounding skin should then be cleansed (betadine, chlorhexidine, saline irrigation).1

Pain control: Local or regional anesthesia is sufficient for most cooperative patients. If the hook is embedded in fingers or toes consider a digital block. Young children may warrant procedural sedation if uncooperative.

Tetanus prophylaxis: Status should be verified and prophylaxis given when indicated.

Four Primary Techniques for Fishhook Removal

The four primary techniques described for the removal of fishhooks are:

  • retrograde
  • string-yank
  • needle cover
  • advance and cut.1-3

The retrograde and string-yank methods generally result in the least amount of tissue trauma.

The needle cover and advance and cut techniques are generally reserved for more difficult fishhook removals.

It may take multiple techniques and attempts before a fishhook can be successfully removed. The physician should take care not to be struck by the hook on removal and eye protection should be worn.

 

Figure 3: Fishhook structure.6

 

Retrograde “Back Out” technique:

Lowest success rate. Works well for barbless/superficial embedded hooks.1

Figure 4: Retrograde technique.1

  • Apply downward pressure to the shank of the hook (helps to rotate the gook and disengage the barb)
  • Back the hook out of the skin along the path of entry
  • If any resistance/catching of the barb is experienced, should stop and consider other removal techniques

 

String-Yank Technique:

Modification of the retrograde technique. Considered to be least traumatic as it creates no new wounds.1 Generally works best on small-medium sized hooks. Cannot be performed on parts of the body that are not fixed (eg. earlobe).

Figure 5: String-Yank Technique

  • Wrap a 3-0 silk culture around the midpoint of the bend in the fishhook with the free ends of the string held tightly (can achieve a better grip wrapping the free ends around a tongue depressor or around the providers fingers)
  • Stabilize the involved skin area against a flat surface as the shank is depressed parallel against the underlying skin
  • Apply a firm quick pull parallel to the shank while continuing to exert pressure on the fishhook
  • Examine hook to ensure that the barb is intact and has been removed

Failure of this technique is most often due to non-forceful pull.

 

Needle Cover Technique:

Works well for removal of large hooks with single barbs that are superficially embedded and can be easily covered by a needle.3

Figure 6: Needle Cover Technique

  • Advance an 18 gauge (or larger) needle along the entrance wound of the fishhook
  • Direction of insertion of needle should be parallel to the shank, with the bevel pointing towards the inside of the curve of the fishhook (allows the needle to engage the barb)
  • Advance the fishhook to disengage the barb, then pull and twist so that the point of the hook enters the lumen of the needle
  • Back the fishhook out of the path of entry, moving the needle along with the fishhook

 

Advance and Cut Technique:

Almost always successful, irregardless of fishhook size. Disadvantage of this technique is additional trauma to surrounding tissue. This technique is most effective when the point of the fishhook is located near the surface of the skin.3

Figure 7: Advance and Cut technique

  • Using a needle driver (or pliers), advance the fishhook, including the entire barb, through the skin
  • Cut the advanced portion (including barb) free with pliers or other cutting tool
  • Remove the remaining portion of the fishhook back out of the original entrance wound (should be no resistance)

 

Post Fishhook Removal Wound Care
– Explore wound for possible foreign bodies (bait)
– Generally wound is left open to heal by secondary intention
– Rinse wound with normal saline irrigation post fishhook removal
– Consider application of antibiotic ointment and simple dressing
– Majority of individuals with superficial wounds do not require prophylactic antibiotics; consider in those who are immunosuppressed or who have poor wound healing (diabetics, peripheral vascular disease).

  • The most common pathogens involved in fishhook wound infections are Staph aureus, and Strep pyogenes originating from the patients’ skin flora. As such oral antibiotic coverage could include five days of: Keflex, Penicillin, Amoxicillin, Clindamycin, Septra.
    – Antibiotics for any deep wound involving tendons, cartilage, or bone
    – Discuss monitoring for signs/symptoms of infection and return for reassessment if any complications
    – Patients who receive antibiotics should be scheduled follow up evaluation in 2-3 days to assess for signs of infection

 

Bottom Line: Fishhook injuries are common emergency department presentations among both recreational and commercial fisherman. The majority of these injuries are superficial, soft tissue injuries that can be managed with one of the four techniques described above.

The initial evaluation of these patients should include a thorough neurovascular exam and assessment to determine any features that would deem the injury complicated (joint/bone involvement, orbit/eyeball involvement, vascular injury) requiring specialist consultation or further investigations (Xray).

The choice of technique utilized will vary depending on type of fishhook, location of injury, depth, and practitioner comfort. Some injuries may require multiple attempts and techniques before the hook will be successfully removed.

Post fishhook removal, the wound should be thoroughly irrigated and left to heal by secondary intention. The majority can be managed with antibiotic creams and at-home monitoring for signs of infection, but those at risk of poor wound healing can be considered for prophylactic antibiotics.

 

References:
1. Gammons, M.; Jackson, E. Fishhook Removal. Am Fam Physician. 2001 Jun 1;63(11):2231-2237. Retrieved from https://www.aafp.org/afp/2001/0601/p2231.html.

  1. Bothner, J. Fishhook removal techniques. Updated Mar 01, 2020. Retrieved from: https://www.uptodate.com/contents/fish-hook-removal-techniques?search=fishhook%20removal%20&source=search_result&selectedTitle=10~150&usage_type=default&display_rank=10#H13

  2. Riveros, T., Kim, J., Dyer, S. Trick of the Trade: Fishhook Removal Techniques. 2018, Jan 8. Retrieved from: https://www.aliem.com/trick-fishhook-removal-techniques.

  3. Cover photo: https://www.outdoorlife.com/photos/gallery/fishing/2012/04/survival-skills-how-remove-fish-hook-and-treat-injury/

  4. Inchinogolo, F. Fish-hook injuries: a risk for fisherman. Head & Face Medicine
    Volume 6, Article number: 28 (2010)

  5. Fish hook structure, retrieved from: https://en.wikipedia.org/wiki/Fish_hook
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A life threatening case of Hiccups

A life threatening case of Hiccups – A Resident Clinical Pearl

Mark McGraw, PGY3 FMEM program,  Dalhousie University Saint John

Reviewed by Dr. Luke Taylor

Copyedited by Dr. Mandy Peach

Introduction:

Its mid morning on an acute shift in the emergency department and you hear a familiar but somewhat out of place sound coming from around the corner. You look up to see the triage nurse walking in a middle-aged male patient who is hiccuping constantly. The patient looks unwell and is pale, but he is able to walk into the department without assistance. The triage nurse asks the charge doc where she should place the patient. He has had intractable hiccups for over a week and has been unable to sleep or eat anything. His chief complaint is hiccups and weakness. She notes he also has a small infected cyst on his back that is being treated with Keflex from one of the local surgeons and had a subjective fever at home. Vitals on triage were normal but she was concerned because he just didn’t look right. You suggest he take a trauma bed and state you’ll see him now based on his appearance and wonder to yourself how often a trauma bed is taken up with someone who has a chief complaint of hiccups….

A little background:

Hiccups are a bit of a physiologic anomaly and appear to have no protective effect or evolutionary purpose. Hiccups can be found early in life and are can be found as early as the second trimester of pregnancy. The incidence of hiccups in the general pediatric and adult population is unknown but its fair to say the majority of people have experienced them at some point in their lives. To most, hiccups are nothing more than a brief annoyance or embarrassing distraction but in some cases they can herald sinister pathologies.

Hiccups result from inappropriate closure of the glottis through a reflex arc that consists of the phrenic nerve, vagus nerve, and thoracic sympathetic chain. During inspiration our glottis remains patent allowing unimpeded airflow into the lungs. The hiccup reflex triggers glottis closure, typically triggered during the swallowing to prevent aspiration, about 30 milliseconds after the onset of inspiration resulting in a rush of air against a closed glottis.

The majority of problematic hiccup cases arise from stimulation, inflammation, or injury to nerves of the afferent reflex arc. Two of the most common causes of benign hiccups are gastric distension from eating a large amount of food or consuming carbonated beverages and relaxation of the glottis due to alcohol ingestion.

The differential for hiccups is broad. UpToDate lists over 50 items on its differential for persistent/intractable hiccups grouped as CNS disorders, vagus/phrenic irritation, GI disorders, thoracic disorders, CV disorders, toxic/metabolic causes, postoperative, drug induced, and psychogenic.

Hiccups under 48 hours

In patients with hiccups lasting less than 48 hours and without red flag symptoms or other warning signs it is reasonable to try physical maneuvers to stop hiccups. The goal of all these maneuvers is stimulation/irritation of the afferent reflex arc.

• Breath holding or Valsalva maneuvers (increasing hypercapnia),
• Sipping or gargling cold water (nasopharynx irritation)
• Swallowing a spoonful of dry sugar (nasopharynx irritation),
• Pulling a patient’s knees to his/her chest and having them lean forward (decrease diaphragmatic pressure)

Hiccups over 48 hours

There is little quality evidence on the treatment of hiccups. In general, if an etiology is suggested from the history and physical target treatment, i.e. using a PPI in patients with underlying GERD, should be considered.

A 2015 systematic review suggested the use of baclofen and gabapentin as first line agents in treating hiccups with metoclopramide and chlorpromazine used as second line agents. A follow up systematic review in 2017 published in the journal of emergency medicine found that only baclofen and metoclopramide had randomized control trials supporting their efficacy. Baclofen was found to be particularly effective for treatment of intractable hiccups associated with stroke.

Treatment options:

• Baclofen 5 to 10 mg PO TID,
• Gabapentin 100 to 400mg PO TID,
• Metoclopramide 10mg PO TID or QID,
• Chlorpromazine 25mg PO TID,

A recent case report published in the American Journal of Emergency Medicine (Kocak et al., 2020) demonstrated almost immediate termination of hiccups in a patient following a subdermal injection of lidocaine and thiocolchicoside into the sternocleidomastoid muscle and epigastric region.

 

 

Back to our case

Our patient settles into a bed in the trauma bay and his repeat vitals show a declining blood pressure and increasing heart rate. His only complaint at this time continues to be his persistent hiccups. Cardiac, respiratory, abdominal and CNS exams are unremarkable. When you assess the “small lump” on his back you find an area of erythema extending from the superior tip of his scapula to his L1/L2 region inferiorly with a large softball size nodule around the lateral border of his scapula. You initiate empiric therapy with pip/tazo and clindamycin and call for an urgent CT scan and surgical consult.

While prepping for the scan the patient asks about treatment for his hiccups. You decide to try metoclopramide 10mg IV, which does nothing to alleviate his hiccups. His CT scan confirms a massive abscess extending from his deltoid muscle to his obliques with infiltration into the muscle and fascia. He is taken to the OR by a team of 3 surgeons for emergent debridement of his necrotizing fasciitis. After a brief stay in the ICU he is transferred to the surgical floor where you find out his hiccups have resolved.

Summary
The next time you are working in the emergency department and a patient presents with hiccups here are a few helpful points to remember:

• Patients with hiccups lasting less than 48 hours in the absence of red flag / systemic symptoms typically do not require medical workup or treatment.
– Physical maneuvers to terminate hiccups may provide relief for patients in the ED.
• Patients with persistent hiccups over 48 hours warrant a full physical exam and laboratory studies tailored to the patient’s history as hiccups may be the initial manifestation of an underlying neoplasm, infection, or metabolic disorder.
• If no underlying etiology is found there is reasonable evidence to support empiric treatment with metoclopramide 10mg PO TID or baclofen 5 to 10mg PO TID.
• In patients with persistent hiccups secondary to another disease process empiric treatment may be a useful adjunct while the underlying cause is addressed.

 

References

Polito NB, Fellows SE. Pharmacologic Interventions for Intractable and Persistent Hiccups: A Systematic Review. J Emerg Med. 2017 Oct;53(4):540-549. doi: 10.1016/j.jemermed.2017.05.033. PMID: 29079070.
Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther. 2015 Nov;42(9):1037-50. doi: 10.1111/apt.13374. Epub 2015 Aug 25. PMID: 26307025.
Kocak AO, Akbas I, Betos Kocak M, Akgol Gur ST, Cakir Z. Intradermal injection for hiccup therapy in the Emergency Department. Am J Emerg Med. 2020 Sep;38(9):1935-1937. doi: 10.1016/j.ajem.2020.03.044. Epub 2020 Mar 25. PMID: 32245702.
Chang, F. Y., & Lu, C. L. (2012). Hiccup: mystery, nature and treatment. Journal of neurogastroenterology and motility, 18(2), 123–130. https://doi.org/10.5056/jnm.2012.18.2.123
Image of reflex arc: http://blog.clinicalmonster.com/2017/03/23/so-bored-i-hiccuped/
Marion, DW. Hiccups. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.

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Evidence of Raised Intracranial Pressure on ECG

Evidence of Raised Intracranial Pressure on ECG – A Resident Clinical Pearl

Robert Dunfield, PGY2 FMEM program,  Dalhousie University Saint John

Reviewed & Edited by Dr. Mandy Peach

Case

A 44 year old male presents to your trauma bay with progressive confusion and altered level of consciousness for the past three days. Collateral history reveals possible recent recreational methamphetamine use. No specific abnormal neurological features or findings on history and physical. A full workup is performed and investigations reveal a left frontal intracerebral hematoma with the following CT head (Figure 1) and ECG (Figure 2):

 

1. What clinical (history and physical) features suggest an elevated intracranial pressure? [4, 5]

On history, suspect an elevated intracranial pressure with:

• headaches
• vomiting
• altered mental status (ranging and alternating from drowsiness to coma)
• visual changes (blurred, diplopia, photophobia)
• history of malignancy, trauma

On examination, suspect an elevated intracranial pressure with:

Cushing triad: hypertension, bradycardia and irregular respiration. This is a sign of impending brain herniation
• pupils unequal, unreactive
• disc edema
• optic atrophy
• bulging anterior fontanelle (in infants)
• evidence of trauma

 

2. What features on ECG are in keeping with an elevated intracranial pressure? [1, 2, 6]

Elevations in ICP or brain injuries are commonly associated with the following ECG changes:

• “Cerebral” T waves: widespread giant T wave inversion
• Flat T waves
• ST elevation/depression
• QTc prolongation
• Sinus bradycardia (if seen assess for other features of Cushing triad)
• Increased U wave amplitude
• Osborn (J) waves
• Other dysrhythmias: sinus tachycardia, junctional rhythms, premature ventricular contractions, atrial fibrillation, AV blocks

ECG changes are common with elevated ICP and intracranial hemorrhage. Approximately 56% of patients with intracranial hemorrhage have associated ECG changes.

Most importantly, recognize that these ECG changes can mimic acute coronary syndromes. This is potentially dangerous as a misdiagnosis of STEMI in a patient with an intracranial bleed could lead to unnecessary thrombolytics or PCI. For this reason, keep an elevated ICP in mind when identifying the above ECG changes.

 

3. What is a cerebral T wave? [1, 5]

Cerebral T waves are deep, symmetric, inverted T-waves seen on an ECG in patients with large intracranial bleeds. They are typically widespread

 

4. What other causes, other than elevated ICP, result in inverted T waves and should be kept on your differential? [2]

When analyzing an ECG it is important to recognize other causes of inverted T waves. The differential for inverted T waves includes:

• Myocardial ischemia and infarction
• Bundle branch block
• Ventricular hypertrophy
• Pulmonary embolism
• Hypertrophic cardiomyopathy

 

5. What is the pathophysiological cause for the ECG changes associated with an elevated ICP? [3, 4]

The full pathophysiology of ECG changes related to an elevated ICP is not fully understood.

ECG changes related to an elevation in ICP are thought to be related to neurogenic cardiac injury. This is mostly due to a surge of systemic catecholamines as a result of significant sympathetic activation from the central neuroendocrine axis and activation of the adrenal glands. Additionally, any injury to the hypothalamus or insula can cause dysfunction of the autonomic nervous system and a systemic inflammatory response.

Systemic catecholamine levels can be elevated for as long as 10 days. This prolonged exposure to catecholamines as well as the systemic inflammatory response can result in cardiac injury and dysfunction.

It is also possible for the heart to suffer from “neurogenic stunned myocardium syndrome” (NSM). This is reversible myocyte damage that results in ECG changes, in addition to other cardiac effects, due an excessive release of norepinephrine. The amount of cardiac damage caused by NSM correlates with the degree of brain injury. NSM can develop within four hours of brain injury. Other causes of NSM include pheochromocytoma, near drowning, and severe emotional experiences.

 

6. What are the most common intracranial findings associated with ECG changes related to an increased ICP? [1, 3]

The most common causes of ECG changes related to an elevation in ICP involve massive intracranial hemorrhage, including subarachnoid hemorrhage (49 to 100% of cases)3 and intraparenchymal hemorrhage (57% of cases)1.

Less commonly, ECG changes are associated with massive ischemic stroke causing cerebral edema, traumatic brain injury, or less commonly cerebral metastases.

 

7. How long do ECG changes last with brain injuries related to elevated ICP, and what are the clinical implications for a finding of prolonged ECG changes? [3]

Normally, as brain injuries and elevated ICP resolve, so will ECG changes. Most ECG changes will resolve within three days but have been reported to last up to eight weeks from the etiology of the elevated ICP.

Some reports have shown that prolonged ECG changes are associated with an increased risk for ischemic neurological deficit, poor outcome, and death following a subarachnoid hemorrhage. Specifically, persistent prolonged QTc is associated with poor clinical outcomes and death, whereas recovery of QTc is associated with good clinical outcomes.

 

SUMMARY & KEY POINTS:

• Be aware of Cushing triad on clinical assessment of patients with potential elevation in ICP (sinus bradycardia, hypertension, and abnormal respiratory pattern).

• There are multiple nonspecific ECG changes associated with an elevation in ICP, including: cerebral T waves, ST elevation/depression, sinus bradycardia, increased U wave amplitude, J waves, and other dysrhythmias.

• The exact pathophysiology for the cause of elevated ICP causing ECG changes is complicated and not fully understood. It is thought to mostly be due to excess catecholamine and norepinephrine exposure, along with a dysregulated inflammatory reaction.

• Subarachnoid hemorrhage and intraparenchymal hemorrhage are the most common causes of ECG changes associated with elevated ICP.

• Be aware that ECG changes related to elevated ICP can mimic acute coronary syndrome, so keep intracranial pathologies on your differential when the above ECG changes are found.

 

Of note, the patient described in the clinical scenario was admitted to neurosurgery and observed for nearly two weeks. He recovered without operative management.

 

REFERENCES:

  1. Cadogan M. Raised Intracranial Pressure. Life in the Fast Lane 2020; Last updated: Nov. 3, 2020, Accessed: December 28, 2020. Available from: https://litfl.com/raised-intracranial-pressure-ecg-library/

  2. Gregory T and Smith M. Cardiovascular complications of brain injury, Continuing Education in Anaesthesia Critical Care & Pain. 2012; 12:2, 67–71. Available from: https://doi.org/10.1093/bjaceaccp/mkr058

  3. Levis JT. ECG Diagnosis: Deep T Wave Inversions Associated with Intracranial Hemorrhage. Perm J. 2017; 21:16, 049. doi:10.7812/TPP/16-049

  4. Pinto VL, Tadi P, Adeyinka A. Increased Intracranial Pressure. [Updated 2020 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482119/

  5. Tannenbaum L. ECG Pointers: Intracranial Hemorrhage. emDocs.net: Electrocardiography. 2018; Last updated: November 14, 2018. Accessed: December 29, 2020. Available from: http://www.emdocs.net/ecg-pointers-intracranial-hemorrhage/

  6. Yogendranathan N, Herath HM, Pahalagamage SP, Kulatunga A. Electrocardiographic changes mimicking acute coronary syndrome in a large intracranial tumour: A diagnostic dilemma. BMC Cardiovasc Disord. 2017;17(1):91. Published 2017 Apr 4. doi:10.1186/s12872-017-0525-2

 

 

 

 

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“The Mother’s Kiss”

A Tool in Nasal Foreign Body Removal in Pediatric Patients

Melanie Johnston, PGY2 iFMEM Dalhousie University Saint John

Reviewed by Dr. Mandy Peach

 

Introduction:

The highest incidence of nasal foreign bodies is in pediatric patients, ages 2-5.1 The removal of nasal foreign bodies in the emergency department can be challenging.

The most common objects removed are beads, nuts, chalk, eraser heads, pebbles, and other small objects.1,2 While most nasal foreign bodies are benign, some objects can cause severe damage and need to be urgently removed.

The diagnosis of nasal foreign may be obvious as the caregiver may have witnessed the event and present acutely. Others may have delayed presentations of weeks-months after the child develops symptoms of nasal irritation/infection from the retained foreign body. In general, organic foreign bodies (flowers, plants, bugs) tend to be more irritating to the nasal mucosa and cause symptoms much earlier.2

 

Details on history and physical exam findings that should raise suspicion of a potential nasal foreign body in a paediatric patient include:

  • Witnessed insertion of foreign body
  • Unilateral foul-smelling purulent discharge
  • Mucosal erosions/ulceration

  • Unilateral epistaxis

  • Headache focused on the same side as the foreign body
  • Nasal obstruction
  • Mouth breathing2

 

Nasal foreign bodies have the potential to dislodge posteriorly and aspirate.1 Consider aspirated FB if new wheeze/cough/shortness of breath in a child with suspected intranasal FB and be prepared for a precipitous change in the airway. 6 

 

Nasal foreign bodies are most commonly located on the floor of the nasal passage under the inferior turbinate, or superiorly  in front of the middle turbinate.2

Foreign bodies are most frequently located on the right side, due to the right handed dominance of most children.2

Figure 1. Anatomy of the nose.3

 

Examination:

Ensure good lighting to be able to visualize the canal. Place the patient in a sniffing position with caregiver assistance (they may have to firmly hold child for cooperation). Suction should be readily available for nasal discharge and to aid in visualization. Nasal speculum can be used to aid visualization of the canal. Visualization of the foreign body confirms the diagnosis.

 

Figure 2. Marble nasal foreign body in pediatric patient.4

 

ENT referral is warranted if:


– Foreign body suspected, but unable to visualize by anterior rhinoscopy
– Impacted foreign body with marked inflammation (eg button batteries)
– Penetrating foreign body
– Any foreign body that cannot be removed due to poor cooperation, bleeding, or limited instrumentation2

 

Foreign Body Removal Options:

There are a number of techniques for nasal foreign body removal in the Emergency Department: alligator forceps, suction, balloon catheters, cyanoacrylate glue.2 Depending on the patient, these methods can be technically challenging if the patient is uncooperative, and may require the use of procedural sedation. A less invasive alternative for children not willing to cooperate with manipulation in the nasal canal is the Mothers’ Kiss.

 

Mothers’ Kiss Technique:

This technique was first described in the 1960s by a general practitioner in New Jersey and uses positive pressure to mobilize the foreign body from the nasal passage.1 It is effective in approximately 60% of attempts5, and generally most effective for smooth/soft foreign bodies that totally occlude the anterior nasal cavity.2 Even when not successful, it may improve visibility of the foreign body. Theoretical risks include barotrauma to both the tympanic membranes or pneumothorax, but these complications have never been reported.5 The pressure used by the caregiver to attempt expulsion of the foreign body is equivalent to that of a sneeze, approximately 60mmHg.1 The main danger in removing a foreign body from the nose is the risk of aspiration.

Procedure:5
1) Instruct the caregiver to place their mouth over the childs’ open mouth, forming a firm seal (similar to mouth-to-mouth resuscitation).
2) Next, occlude the unaffected nostril with a finger
3) The caregiver should blow until they feel resistance (caused by the closure of the childs’ glottis), then they should deliver a short puff of air into the childs’ mouth
4) The puff of air travels through the nasopharynx, and if successful results in the expulsion of the foreign body
5) If unsuccessful, the procedure can be repeated a number of times

Figure 3: Caregiver performing “Mother’s Kiss”. Shows occlusion of unaffected nare,
with seal formed around childs’ mouth.

 

 

If the caregiver is unable to perform the procedure, the approach can be recreated with a bag-valve-mask as the positive pressure source, ensuring the mask covers only the childs’ mouth.

Figure 4: Positive Pressure Ventilation with Bag-Valve-Mask.6

 

 

For a visual review of these techniques, please refer to the following videos:

“Mother’s Kiss”

 Positive Pressure Ventilation

 

Bottom Line:

Nasal foreign bodies are a common occurrence in the paediatric population. Their removal in the Emergency Department can be challenging as the patient may be fearful and non-cooperative. While there are a number of methods for removal of nasal foreign bodies, the “Mothers’ Kiss” technique provides a relatively non-invasive alternative. It has been shown to be effective in removal of 60% of nasal foreign bodies, and is most effective if foreign bodies are smooth and located in the anterior nasal cavity. If the caregiver is unable to perform the procedure, the approach can be recreated with BVM as the positive pressure source. The risks of this technique are minimal, and even when unsuccessful, can assist in improving the visualization of the nasal foreign body.

 

References:

  1. Cook, S., Burton, M., & Glasziou, P. (2012). Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 184(17), E904–E912. https://doi.org/10.1503/cmaj.111864

  2. Isaacson, G., Ojo, A. (2020). Diagnosis and management of intranasal foreign bodies. Up to Date. Retrieved from https://www.uptodate.com/contents/diagnosis-and-management-of-intranasal-foreign-bodies.

  3. Le, P. (2020). Anatomy, Head and Neck, Nasal Concha. Retrieved from: https://www.statpearls.com/ArticleLibrary/viewarticle/32550

  4. Nose-Foreign Body Nose, Dr Vaishali Sangole. Retrieved Oct 31,2020 from: http://vaishalisangole.com/NOSE_Foreign.html

  5. Glasziou, P., Bennett, J. (2013). Mothers’ kiss for nasal foreign bodies. Australian Family Physician, 42(5): https://www.racgp.org.au/afp/2013/may/mothers-kiss/.

  6. Thoreckzo. (2017). Foreign Bodies in the Head and Neck. Pediatric Emergency Playbook. Retrieved from: https://pemplaybook.org/podcast/foreign-bodies-in-the-head-and-neck/

  7. Pretel, M. Removing object from child’s nose using the kiss technique. Youtube- retrieved from: https://www.youtube.com/watch?v=RR3SxICqdAY.

  8. Dudas, R. Nasal foreign body removal. Youtube- retrieved from: https://www.youtube.com/watch?v=PacvHiJFhNA.

 

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Fascia Iliaca Nerve Block

Hip Broke? Hip Block. Use of the fascia iliaca nerve block for analgesia in hip fractures.

Resident Clinical Pearl (RCP) July 2020

Luke Edgar, BScH MD

PGY1 Family Medicine Integrated Emergency Medicine

Dalhousie Saint John

 

Reviewed by Dr. David Lewis


Background

Hip fractures are a common and painful injury diagnosed and treated in the emergency department, with elderly patients representing the majority of cases. Advanced age, comorbidities, and increased sensitivity to side effects from systemic analgesia all pose challenges to achieving adequate pain control.1,2 Additionally, NSAID use in the elderly is frequently contraindicated due renal, cardiac, and gastrointestinal comorbidities as well as drug interactions. In elderly patients, both undertreated pain and opioid analgesia can precipitate delirium.3

Regional nerve blocks for the indication of hip and femoral neck fractures have been shown to reduce pain and need for IV opiates.1 Contraindications include infection over the injection site, patient refusal, and allergy to local anesthetic. Additionally, patients at risk for compartment syndrome (such as those with a concomitant ipsilateral tibial plateau fracture) should be selected cautiously as they may not reliably have increased pain after block.4

There are three main techniques described for regional nerve blocks to provide analgesia for hip and femoral neck fractures.1

  • Fascia Iliaca Nerve Block: Insert a needle through the fascia lata and fascia iliaca, to infiltrate dilute local anesthetic into the fascial compartment which diffuses to block the femoral, lateral femoral cutaneous, and obturator nerves.
  • Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve.
  • 3-in-1 Femoral Nerve Block: At the level of the femoral triangle, infiltrate local anesthetic around the femoral nerve while applying pressure distal to the injection site, encouraging local anesthetic to track superiorly to block the femoral, lateral femoral cutaneous, and obturator nerves.

Figure 1. Lower limb peripheral nerve sensory distribution.5 Circled in red are the nerves blocked using the fascia iliaca technique. Cutaneous distribution of the obturator nerve is not depicted but consists of a small area on the proximal medial thigh.


Technique

Table 1. Supplies and equipment for performing a fascia iliaca nerve block

Table 2. Steps to complete a fascia iliaca nerve block6

Table 3. One person technique  – Steps to complete a fascia iliaca nerve block


Figure 2. Video demonstrating the sonoanatomy of the right femoral triangle. From lateral to medial, femoral nerve, artery and vein (NAVel), labeled with yellow, red, and blue arrows, respectively.


Figure 3. Sonoanatomy of the right femoral triangle, transverse view for the fascia iliaca nerve block.


Figure 4. Sonoanatomy of the right femoral triangle demonstrating ultrasound-guided needle placement using an in-plane technique. Note two pops should be felt as the needle crossed the two fascial planes.


 

For a visual review of these steps and ultrasonographic landmarks, please see the following videos and webpage by EM Ottawa, 5 Minute Sono, and NYSORA:

EM Ottawa

5 Minute Sono

NYSORA

Ultrasound-Guided Fascia Iliaca Block


 

Complications

Serious complications of this procedure are rare, but present.

  • Local Anesthetic Systemic Toxicity (LAST) as a complication of inadvertent intravenous or intra arterial anesthetic injection.7
    1. Incidence is 8 – 30 in 100,0008
    2. Manifestations typically occur within 20 minutes of injection (although onset can be as late as >1 hr) and are primarily neurologic and cardiovascular in nature. Neurologic effects include perioral numbness, metallic taste, mental status change or anxiety, muscle twitches and visual changes, followed by loss of consciousness and seizure. Cardiovascular effects are hypertension and tachycardia followed by arrhythmias, bradycardia, hypotension and cardiac arrest.
    3. Treatment is with intravenous lipid emulsion therapy (Intralipid 20%) 1.5 mL/kg bolus followed by 0.25 mL/kg/min, Maximum total dose 12 mL/kg. Contact your poison control centre if you suspect LAST.
    4. Prior to performing a fascia iliaca block, confirm availability of intralipid within your department to be used in the event of this rare complication.
  • Femoral Nerve injury secondary to intrafascicular injection
    1. Incidence 2-30/100,0008
    2. Most symptoms of paresthesias, numbness, and weakness resolved after several months in the event of this complication8
  • Other complications include infection, nerve block failure, injury secondary to numbness/weakness of limb, and allergy to the local anesthetic.

 

Take Home Message

Femoral nerve blocks are recommended for hip and femoral fractures to reduce pain and opioid analgesia requirements. Given that poor pain control and opioid analgesia are risk factors for delirium in elderly patients, hip blocks may also reduce rates of delirium (further study required). A fascia iliaca block with 20 cc of 0.5% bupivacaine is a well described technique with very few contraindications. To reduce the risk of complications, these blocks should be completed using sterile technique under ultrasound guidance with the help of an assistant. Hip broke? Hip block.

 


 

References

  • Ritcey B, Pageau P, Woo M, Perry J. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM 2015;18(1):37-47.
  • Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fractures. J Am Geriatr Soc. 2006;54(2):270-5.
  • Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58(1):76-81.
  • Erak M, EM Ottawa Grand Rounds. Ah, that feels better! The Use of Nerve Blocks in the ED. 2016. https://emottawablog.com/2016/10/ah-that-feels-better-the-use-of-nerve-blocks-in-the-ed/. Accessed July 25, 2020.
  • Gray H. 1918. Nerve supply of the leg. Anatomy of the Human Body. Image retrieved from https://en.wikipedia.org/wiki/Nerve_supply_of_the_human_leg. Accessed July 24, 2020
  • Woo M. How to perform the Ultrasound Guided Femoral Nerve Block. EM Ottawa. 2018. https://youtu.be/_OugsPA4rxY Accessed July 25, 2020.
  • Warren L, Pak A. Local anesthetic systemic toxicity. UpToDate. 2019. uptodate.com/contents/local-anesthetic-systemic-toxicity. Accessed July 25, 2019.
  • Helman, A, Morgenstern, J, Spiegel, R, Lee, J. Regional Nerve Blocks for Hip Fractures. Emergency Medicine Cases. August, 2018. https://emergencymedicinecases.com/regional-nerve-blocks-hip-fractures/. Accessed July 25, 2020.
  • Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J of Ultrasound in Emergency Medicine 2012;43(4):692-697.

 

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Ear Foreign Body Removal

Ear Foreign Body Removal

Resident Clinical Pearl (RCP) May 2020

Dr. Sultan Alrobaian (PEM Fellow and Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis


Introduction

  • Most patients with ear Foreign Bodies (FB) are children, adults can also present with ear FB
  • The most common objects removed include beads, pebbles, tissue paper, small toys, popcorn kernels, and insects
  • Diagnosis is often delayed because the causative event is usually unobserved or the symptoms are nonspecific
  • Most of the patients with ear FBs were asymptomatic at presentation, other patients presented with otalgia, bleeding from the ear, otorrhea, tinnitus, hearing loss, a sense of ear fullness or symptoms of otitis media
  • Successful removal depends on several factors, including location of the foreign body, type of material and patient cooperation
  • Visualization of a foreign body on otoscopy confirms the diagnosis, the other ear and both nostrils should also be examined closely for additional foreign bodies.

Clinical Anatomy

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.


Equipment

  • Multiple options exist for removal of external auditory canal foreign bodies
  • Which piece of equipment to use will be influenced by the type of FB, the shape of the FB, the location of the FB and the cooperativeness of the patient

Timing

  • The type of foreign body determines the timing for removal
  • Button batteries, live insects and penetrating foreign bodies warrant urgent removal

Indications for consultation or referral to a specialist

  • Button battery
  • Potentially penetrating foreign bodies
  • Foreign body with evidence of injury to the external ear canal (EAC), tympanic membrane, middle ear, vestibular symptoms or marked pain

Technique


1 – Irrigation

  • This technique is used for small inorganic objects or insects
  • Irrigation is often better tolerated than instrumentation and does not require direct visualization
  • Contraindicated in patients with tympanostomy tubes, perforated tympanic membranes or button battery because the potential for caustic injury.
  • An angiocatheter or section of tubing from a butterfly syringe
  • Using body temperature water, retract the pinna, and squirt water superiorly in the external auditory canal, behind the FB

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.


2 – Instrumentation under direct visualization

  • Instrumentation can be painful and frequently warrants procedural sedation in young children or other uncooperative patients
  • General anesthesia may be required to ensure safe removal
  • Restrain if needed for safety

  • Commonly used pieces of equipment are curettes, alligator forceps, and plain forceps. Other equipment options include using a right angle hook, balloon catheter, such as a Fogarty catheter

  • Used in conjunction with the operating head of an otoscope
  • The pinna should be retracted, and the FB visualized
  • When using forceps, the FB can be grasped and removed

  • Both curettes and right angle hooks should be gently maneuvered behind the FB and rotated so the end is behind the FB, which can then be pulled out

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.


3 – Suction

  • This should be performed with a soft suction tipped catheter that has a thumb controlled release valve
  • Insert the suction against the FB under direct visualization and then activate the suctions and remove the FB

© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.


4 – Cyanoacrylate

  • Apply a small amount of cyanoacrylate or skin glue to the blunt end of a cotton-tipped applicator
  • Insert it against the FB under direct visualization and hold in place until the glue dries
  • Slowly and carefully withdraw


5 – Insect removal

  • The first step is to kill the insect with mineral oil followed by lidocaine
  • Once the insect is neutralized, it can be removed by any of the above methods


SUMMARY

  • Foreign bodies of EAC frequently occur in children six years of age and younger
  • Patients with foreign bodies of the EAC are frequently asymptomatic
  • Button batteries , penetrating foreign bodies or injury to the EAC should undergo urgent removal by an otolaryngologist.
  • With adequate illumination, proper equipment, and sufficient personnel, many EAC foreign bodies can be removed

REFERENCES

1.Lotterman S, Sohal M. Ear Foreign Body Removal. [Updated 2019 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459136/

2.https://www.uptodate.com

3.Heim S W, Maughan K L. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(08):1185–1189. [PubMed] [Google Scholar]

4.Awad AH, ElTaher M. ENT Foreign Bodies: An Experience. Int Arch Otorhinolaryngol. 2018;22(2):146–151. doi:10.1055/s-0037-1603922

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PoCUS in COVID

Point of Care Ultrasound (PoCUS) during the Covid-19 pandemic – Is this point of care tool more efficacious than standard imaging?

Resident Clinical Pearl (RCP) May 2020

Dr. Colin Rouse– (PGY-3  CCFP Emergency Medicine) | Dalhousie University

and Dr. Sultan Alrobaian (Dalhousie PoCUS Fellow, Saint John, NB, Canada)

Reviewed by Dr. David Lewis

 


Case

A 70 year of woman present to the ED with a history of fever, cough and dyspnoea. After a full clinical assessment (with appropriate PPE), Lung PoCUS is performed.


Introduction

The Covid-19 Pandemic has created the largest international public health crisis in decades. It has fundamentally changed both societal norms and health care delivery worldwide. Changes have been implemented into resuscitation protocols including ACLS to prioritise appropriate donning of personal protective equipment (PPE) and consideration of resuscitation appropriateness prior to patient contact.1 Equipment has been removed from rooms to limit cross-contamination between patients. In this Pearl we will explore why PoCUS should not be discarded as an unnecessary tool and should be strongly considered in the assessment of a potential Covid Patient.

Disclaimer: Given the novel nature of CoVid-19 there is a lack of RCT data to support the use of PoCUS. These recommendations are based solely on expert opinion and case reports until superior evidence becomes available.


Potential Benefits of PoCUS

  • Lung PoCUS has increased sensitivity compared to conventional lung X-ray for known lung pathologies such as CHF4 and Pneumonia5 with similar specificities. Given that Pneumonia is the most common complication of Covid-19 it may help diagnose this complication in patients who have a normal CXR.
  • PoCUS can be performed by the assessing physician limiting the unnecessary exposure to other health care providers such and Radiologic Technologists and other staff in the diagnostic imaging department.
  • Lung PoCUS is low cost, repeatable and available in rural settings
  • Once pneumonia is diagnosed other potential complications can be sought including VTE and cardiovascular complications.

The assessment of the potential Covid-19 patient.

First one must consider the potential risk for coronavirus transmission at each patient encounter and ensure proper PPE2 for both oneself and the PoCUS device3.


Lung Ultrasound in the potential Covid-19 Patient

Technique

  • Appropriate level PPE
  • A low-frequency (3–5 MHz) curvilinear transducer
  • Set Focus to Pleural Line and turn off machine filters (e.g THI) to maximize artifacts
  • Scanning should be completed in a 12-zone assessment6
    • 2 anterior windows
    • 2 lateral windows
    • 2 posterior windows

Findings7

Mild Disease

  • Focal Patchy B-lines in early disease/mild infection (May have normal CXR at this point)
  • Areas of normal lung

 

Moderate/Severe Disease – Findings of bilateral Pneumonitis

  • B-lines begin to coalesce (waterfall sign)
  • Thickened and irregular pleura
  • Subpleural Hypoechoic consolidation      +/- air bronchograms

 

Other Covid-19 Pearls

  • Large/Moderate Pleural Effusion rarely seen in Covid-19 (consider another diagnosis) – Small peripleural effusions are common in COVID
  • The virus has a propensity for the base of the posterior lung windows and it imperative to include these views in your assessment.


Example COVID PoCUS Videos8

Confluent B Lines and small sub pleural consolidation

 

Patchy B lines and Irregular pleura

 

Irregular pleura

 

Air Bronchogram


CT & ultrasonographic features of COVID-19 pneumonia9

It has been noted that lung abnormalities may develop before clinical manifestations and nucleic acid detection with some experts recommending early Chest CT for screening suspected patients.10 Obviously there are challenges with this recommendation mainly regarding feasibility and infection control. A group of researchers in China compared Ultrasound and CT findings in 20 patients with COVID-19. Their findings are summarized in the table below:

Their conclusion was that ultrasound has a major utility for management of COVID-19 due to its safety, repeatability, absence of radiation, low cost and point of care use. CT can be reserved for patients with a clinical question not answered by PoCUS. CT is required to assess for pneumonia that does not extend to the pleura. Scatter artifact from aerated lung obscures visualization of deep lung pathology with PoCUS. When PoCUS is sufficient it can be used to assess disease severity at presentation, track disease evolution, monitor lung recruitment maneuvers and prone positioning and guide decisions related to weaning of mechanical ventilation.


Learning Points

  • Lung PoCUS is helpful in the initial assessment of the suspected or known COVID19 Patient
  • Lung PoCUS may reveal pathology not visible on CXR
  • Lung PoCUS can provide insight into COVID19 disease severity
  • Lung PoCUS is a useful tool to track disease progression in COVID19

Lung PoCUS in COVID Deep Dive

Deep Dive Lung PoCUS – COVID 19 Pandemic

 

 


References

  1. Edelson, D. P., Sasson, C., Chan, P. S., Atkins, D. L., Aziz, K., Becker, L. B., … & Escobedo, M. (2020). Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of …. Circulation.
  2. COVID-19 – Infection Protection and Control. https://sjrhem.ca/covid-19-infection-protection-and-control/
  3. Johri, A. M., Galen, B., Kirkpatrick, J. N., Lanspa, M., Mulvagh, S., & Thamman, R. (2020). ASE Statement on Point-of-Care Ultrasound (POCUS) During the 2019 Novel Coronavirus Pandemic. Journal of the American Society of Echocardiography.
  4. Maw, A. M., Hassanin, A., Ho, P. M., McInnes, M., Moss, A., Juarez-Colunga, E., Soni, N. J., Miglioranza, M. H., Platz, E., DeSanto, K., Sertich, A. P., Salame, G., & Daugherty, S. L. (2019). Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA network open, 2(3), e190703. https://doi.org/10.1001/jamanetworkopen.2019.0703
  5. Balk, D. S., Lee, C., Schafer, J., Welwarth, J., Hardin, J., Novack, V., … & Hoffmann, B. (2018). Lung ultrasound compared to chest X‐ray for diagnosis of pediatric pneumonia: A meta‐analysis. Pediatric pulmonology, 53(8), 1130-1139.
  6. Wurster, C., Turner, J., Kim, D., Woo, M., Robichaud, L. CAEP. COVID-19 Town Hall April 15: Hot Topics in POCUS and COVID-19. https://caep.ca/covid-19-town-hall-april-15-hot-topics-in-pocus-and-covid-19/
  7. Riscinti, M. Macias, M., Scheel, T., Khalil, P., Toney, A., Thiessen, M., Kendell, J. Denver Health Ultrasound Card. http://www.thepocusatlas.com/covid19
  8. Images obtained from. Ultrasound in COVID-19. The PoCUS Atlas. http://www.thepocusatlas.com/covid19
  9. Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6
  10. National Health Commission of the people’s Republic of China. Diagnosis and treatment of novel coronavirus pneumonia (trial, the fifth version)[EB/OL]. (2020-02-05)[2020-02-06]. http://www.nhc.gov.cn/yzygj/s7653p/202002/3b09b894ac9b4204a79db5b8912d4440.shtml
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