The new Surviving Sepsis Campaign Guidelines are out in Critical Care Medicine. The biggest change is the change in the definition of sepsis, which now uses the language of Sepsis 3.0, introduced in 2016. Other significant changes include dropping protocolized care (ex: early goal directed therapy), and recommending against combination antibiotic therapy (double coverage) for a single pathogen [1,2].
Bonus discussion on new validation study of qSOFA
Opal SM, Rubenfeld GD, Poll T Van Der, Vincent J, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2016;315(8):801–10.
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med [Internet] 2017;1.
Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis. Jama [Internet] 2016;315(8):762.
Freund Y, LeMachatti N, Krastinova E.Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients W.ith Suspected Infection Presenting to the Emergency Department. JAMA. 2017;317(3):267-268.
This iteration of sepsis discarded systemic inflammatory response syndrome (SIRS), noting it’s poor discriminatory ability. Further, these authors sought to define sepsis as a dysregulated response to infection, not just a normal response to infection (i.e. fever and tachycardia are normal responses to infection and therefore are, alone, not evidence of sepsis).
The quick SOFA score (qSOFA) also came out in hopes it “provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcomes.” It is not part of the sepsis definition but may help in identifying those that will die or have a 3 day ICU stay. Studies looking at the performance of qSOFA applied retrospectively to data sets have not been promising [1,2].
Traditional Approach to TMJ dislocation and Syringe Technique from Core EM
We delve into core content on dental injuries using Rosen’s Emergency Medicine (8th edition) Chapter 70 “Oral Emergencies” and Tintinalli’s Emergency Medicine (8th edition) Chapter 245 “Oral and Dental Emergencies” as a guide.
A 19-year-old man presents to the Emergency Department with an avulsed tooth. He struck his mouth on the back of another player’s head while playing basketball. He arrives thirty minutes after the injury with his right maxillary central incisor in a bag of cold milk. Which of the following is the most appropriate management?
A. Discharge home with next day dental follow up
B. Fill the alveolar socket with eugenol oil
C. Reimplant the avulsed tooth
D. Scrub the tooth with normal saline
C. Reimplant the avulsed tooth (B) is the most appropriate next step. Avulsed permanent teeth should be reimplanted as soon as possible, ideally within 30 minutes of the injury. For every minute that the tooth is out of its socket, there is a 1% chance of reimplantation failure. If the tooth is not able to be reimplanted immediately, it should be stored in an appropriate medium. Cold milk is preferable to sterile water or saliva as it has magnesium and calcium. Hank’s solution, a neutral cell culture medium, is ideal. Once the tooth is reimplanted, the tooth should be stabilized until dental follow up is arranged. Avulsed primary teeth should not be reimplanted.
A 25 year-old man presents after falling face forward off his bike. He sustained an abrasion inside his upper lip and complains of a broken front tooth. He brought the fractured fragment with him. On examination, the bony structures of the jaw are non-tender. There is no malocclusion. Tooth #8 has a fracture and in the center of the exposed area is a small pink dot. What is the most appropriate plan for this patient?
A. Dental follow-up within the next 24 hours
B. Irrigation of the tooth
C. Placement of the tooth fragment in Hank’s solution
D. Viscous lidocaine for pain control
A. This patient has a dental fracture with exposed pulp. This is a dental emergency requiring dental follow-up within the next 24 hours. The most superficial dental fractures involve only the enamel on the surface and treatment is mostly cosmetic and aimed at dulling any sharp edges. Fractures that expose dentin will have an ivory-yellow appearance. In younger patients, there is less dentin relative to the pulp and treatment is aimed at protecting any pulp contamination with placement of a calcium-hydroxide dressing. Younger patients need more urgent follow-up with a dentist. The most significant dental fractures involve the pulp as in this clinical scenario. The tooth should be gently wiped clean with gauze and inspected for a drop of blood or pink blush which represents pulp exposures. The area is usually exquisitely painful. Timely follow-up (within 24 hours) is required for evaluation and possible root canal and extraction of the pulp. If dental follow-up will be delayed, the tooth should be covered with moist cotton and sealed with dry foil or a temporary commercial sealant. In order to clean the tooth, a clean gauze should be used to wipe off the surface, not irrigation of the tooth (B) as the patient will be extremely sensitive to that and all efforts should be maintained to avoid pulp contamination. Hank’s solution (C) is a physiologic solution in which an avulsed tooth may be placed while waiting for reimplantation into the socket. There is no role in a partial tooth fracture. Viscous lidocaine (D) is not an appropriate analgesic for a dental fracture. Oral analgesics or dental block should be provided for pain control.
Gorchynski J, Karabidian E, Sanchez M. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department. The Journal of emergency medicine. 47(6):676-81. 2014. [pubmed]
Caputo ND, Raja A, Shields C, Menke N. Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures? The Journal of emergency medicine. 45(1):8-12. 2013. [pubmed]
A 63-year-old man presents with left arm pain after a fall. His X-ray is shown below. What structure is commonly injured with this fracture?
A. Axillary nerve
B. Median nerve
C. Radial nerve
D. Ulnar nerve
C. Radial nerve injury is the most common nerve injury seen after humeral shaft fractures. These fractures usually occur from a direct blow to the arm and can be seen in falls and motor vehicle collisions. Patients present with severe pain, arm swelling and decreased range of motion. The arm can be shortened or rotated in a complete fracture depending on the location of the fracture. A complete neurovascular exam should be performed as with all fractures and dislocations. The radial nerve may be injured during humeral fracture in up to 20% of patients. The injury is usually a neuropraxia and resolves spontaneously in most patients. However, this recovery can take months. Humeral fractures rarely need specific reduction maneuvers for treatment. They should be placed in a sugar tong splint and placed in a sling. Gravity alone is typically successful in fracture reduction. The axillary nerve (A) may be injured during glenohumeral dislocations. The median nerve (B) may be injured during posterior elbow dislocations. Anterior elbow dislocations can be associated with ulnar nerve injury (D).
A 3-year-old girl was walking on the sidewalk with her mom when she fell onto the street. In a panicked state, her mom picked up the little girl by her arm. Immediately after, the little girl refused to move her right arm complaining that it hurt. In the emergency room, the girl is holding her right arm in a flexed, pronated, and adducted position. There is no crepitus, swelling or point tenderness along the entire right arm or clavicle. Which of the following is the next step in management of this patient?
A. Actively supinate and flex the elbow while applying pressure over the radial head
B. Consult orthopedics for casting
C. Obtain an ultrasound
D. Perform a skeletal survey
A. This child has “nursemaid’s elbow” that is due to subluxation of the annularligament rather than dislocation of the radial head. The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. It occurs in toddlers due to traction via pulling on a pronated and extended arm. The child immediately refuses to the move the arm and often cradles the affected arm. Parents often give a history of a young child with no history of trauma who suddenly refuses to use an arm. The diagnosis is clinical and imaging studies are generally not needed. If reduction is unsuccessful after 2–3 attempts then imaging studies may be warranted. Treatment is manual reduction via supination and flexion or hyperpronation. A palpable click may be felt and the child usually regains immediate movement of the arm and relief of discomfort. A skeletal survey (D) should be obtained in all cases of suspected child abuse to assess for fractures in multiple stages of healing. Child abuse should be on the differential in all pediatric orthopedic cases. Consulting orthopedics for casting (B) is not necessary as this is a dislocation injury. Ultrasonography (C) has been used as a noninvasive modality to assess for annular ligamentous injury and displacement of the radial head from the capitellum. It has also been used to assess progress of treatment for patients with recurrent subluxations, however it is not the first-line diagnostic nor treatment option.
We review a talk by Dr. Sara Gray from SMACC (Social Media and Critical Care) conference in June 2016, Resuscitative hysterotomy, which is the new name for perimortem c-section . In this talk she challenges the “4 minute” rule: if resuscitative efforts following maternal circulatory arrest are unsuccessful, cesarean delivery should be commenced at 4 minutes and completed by 5 minutes to optimize fetal outcome.
We delve into core content on pregnancy emergencies using Rosen’s Emergency Medicine (8th edition) Chapter 98and Tintinalli’s Emergency Medicine (8th edition) Chapter 178 as a guide.
Nausea and vomiting are very common in pregnancy, but few patients have hyperemesis gravidarum (~2%). Hyperemesis gravidarum is characterized by severe nausea and vomiting with starvation ketosis and significant weight loss and dehydration [2,3].
A 22-year-old woman presents complaining of vaginal bleeding and cramping for the last 4 hours. She is known to be 14-weeks pregnant. Her cervical os is dilated to 4 cm and she is actively bleeding. Pelvic ultrasound shows the gestational sac in the lower uterine segment near the cervix. Which of the following is the most likely diagnosis?
A. Complete abortion
B. Inevitable abortion
C. Missed abortion
D. Septic abortion
The patient is experiencing an inevitable abortion, which is characterized by an open cervical os and a gestational sac at the opening of the uterus on ultrasound. The case should be discussed with the patient’s obstetrician as the patient may ultimately require dilatation and curettage if all the products of conception (POC) do not pass spontaneously or the bleeding is not controlled. A complete abortion (A) occurs when the patient has passed all POC have passed. On examination, the cervix is closed and the uterus is firm and nontender. A missed abortion (C) occurs when a pregnant patient fails to pass the products of conception greater than two months after fetal demise. The pregnancy test will be negative, however ultrasound will show retained POC. A septic abortion (D) occurs when the patient develops foul-smelling discharge, vaginal bleeding, uterine tenderness and peritoneal signs following a spontaneous or induced abortion.
What is the most common cause of bleeding in the primigravid woman?
Rose CH, Faksh A, Traynor KD, Cabrera D, Arendt KW, Brost BC. Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy. American journal of obstetrics and gynecology. 213(5):653-6, 653.e1. 2015. [pubmed]
Heaton, H. “Chapter 98: Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy.” Tintinalli’s Emergency Medicine: A Comprehensive Review. 8th edition
“Chapter 178: Acute Complications of Pregnancy.” Rosen’s Emergency Medicine
The PESIT study in the New England Journal of Medicine stirred up controversy in the FOAM world earlier in October 2016. In this episode we cover the following posts on this article on pulmonary embolism in syncope:
An 83-year-old is being evaluated in the emergency department after an episode of syncope. The woman was preparing dinner when she felt her heart start to race. The next thing she remembers is waking up on the floor. She experienced a similar episode about three weeks ago. She has never had anything like this before. Her past medical history is remarkable for hypertension, hyperlipidemia and hypothyroidism. Her medications include lisinopril, atorvastatin and levothyroxine. On physical exam her blood pressure is 142/83, heart rate 76/min, and respiration rate 13/min. Cardiac auscultation reveals no murmur. The remainder of her physical exam is normal. Electrocardiogram reveals normal sinus rhythm with left axis deviation. No cardiac rhythm abnormalities are detected. What is the most likely etiology of this patient’s syncope?
A. Aortic stenosis
B. Cardiac dysrhythmia
C. Orthostatic hypotension
B. Cardiac dysrhythmia is the most likely cause of this woman’s syncope. Cardiac dysrhythmias are a common cause of syncope in the elderly population. It is characterized by a brief or absent prodrome and palpitations immediately preceding the event. Several episodes over a short period of time in someone with no history of syncope suggest a dysrhythmia. Given this patient’s short prodrome, palpitations and history of a previous similar event makes a cardiac dysrhythmia the most likely etiology.
Aortic stenosis (A) is unlikely the cause of her syncope. Aortic stenosis is associated with a crescendo-decrescendo systolic ejection murmur. Syncope related to aortic stenosis typically occurs during exertion and is associated with very severe disease. This patient’s syncopal episode occurred while stationary. Additionally, she has no systemic symptoms of aortic stenosis.Vasovagal (D) is the most common cause of syncope in the general population. It is usually triggered by provoking factors such a blood draw or an intense emotion. Prodromal symptoms include feeling warm, sweating, nausea, and pallor. This woman does not report any of these symptoms. Orthostatic hypotension (C) causes syncope upon assuming an upright position from supine or sitting. It is often caused by hypovolemia, medications or autonomic nervous system disorders. This woman was standing while preparing dinner making orthostatic hypotension unlikely.
An 18-year-old woman presents after having a syncopal episode. She is complaining of a 2-day history of lower abdominal pain and vaginal spotting. Her BP is 86/42, HR is 128, RR is 18 breaths, and oxygen saturation is 99% on room air. She is drowsy, but answers questions appropriately. What is the most appropriate next step in management?
A. Establish large-bore IV access and administer an IV fluid bolus
B. Initiate rapid sequence induction and orotracheal intubation
C. Perform a bedside urine pregnancy testing
D. Perform an ultrasound of the abdomen to assess for free fluid
A. The patient is hypotensive and tachycardic. She is suffering from hypovolemic shock secondary to a ruptured ectopic pregnancy. Therefore she requires immediate intravenous access and volume resuscitation with Lactated Ringer’s or normal saline. Emergency Department management of unstable patients includes rapid assessment of the ABC’s (Airway, Breathing, Circulation). This patient is phonating, has a respiratory rate of 18 breaths per minute and an oxygen saturation of 99% on room air. There is no concern that her airway or breathing is in immediate jeopardy, therefore she would not require immediate rapid sequence induction and orotracheal intubation (B). Although a bedside pregnancy test (C) and abdominal ultrasound (D) would help make a diagnosis of ruptured ectopic pregnancy, the next step would be to resuscitate the patient.
De Lorenzo RA. “Syncope.” Chapter 15. Rosen’s Emergency Medicine (8 ed). pp 131-145
Chapter 52. Tintinalli’s Emergency Medicine: A Comprehensive Review (8 ed).
Serrano LA, Hess EP, Bellolio MF et al. Accuracy and Quality of Clinical Decision Rules for Syncope in the Emergency Department: A Systematic Review and Meta-analysis. Annals of Emergency Medicine. 56(4):362-373.e1. 2010.
We are in Las Vegas at ACEP 2016 thanks to Annals of Emergency Medicine and ACEPnow and discuss high yield and cutting edge lectures each day.
Dr. Megan Osborn – Bell’s Palsy or Stroke?
Traditional teaching: we can differentiate Bell’s palsy (lower motor neuron) from a stroke (upper motor neuron by assessing forehead involvement. If the patient can wrinkle their forehead? Think stroke. Dr. Megan Osborn tackled the question: does this actually work all the time in her talk in the New Speakers Forum.
Llor C, Moragas A, Bayona C. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ (Clinical research ed.). 347:f5762. 2013. [pubmed]
Smith et al. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub4.22895922
Dobson R. Cough medicines’ effect is mainly placebo. BMJ. 2006 Jan 7; 332(7532): 8. PMCID: PMC1325161
Cohen et al. Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics; originally published online August 6, 2012; PMID:22869830
Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Annals of emergency medicine. 64(5):526-532.e1. 2014. [pubmed]
Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. The Cochrane database of systematic reviews. 2015. [pubmed]
Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 68(1):1-9.e1. 2016. [pubmed]
Friedman BW, Dym AA, Davitt M. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 314(15):1572-80. 2015. [pubmed]
Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. The Cochrane database of systematic reviews. 4:CD007400. 2016. [pubmed]
We are in Las Vegas at ACEP 2016 and discuss high yield or cutting edge lectures each day.
Dr. Anne Daul – Emergency Care of the Transgender Patient
Most emergency medicine physicians and trainees lack training in caring for LGBTQ patients, let alone transgender patients . Many members of the LGBTQ community may have delays in medical care including 21% of transgender patients in a Canadian survey. Also, according to a 2010 task force, 19% of transgender patients report being denied care in some way .
Here is a video from SMACC Dublin from Thom O’Neill on caring for LGBT youth
2% of active shooter events take place in the health care setting.
Plan of Action in Active Shooter Scenario: AVOID DENY DEFEND TREAT
Avoid – stay away from the shooter.
Deny – deny them access to you or the area. Lock doors, block pathways, turn off the lights, make it more difficult for them.
Defend -.if necessary, defend yourself.
Treat – once you are safe, and the scene is safe, treat and care for your patients.
Dr. Kevin Klaur – Lawsuits
Documentation and discharge instructions repeatedly come up in lawsuits.
Documentation: If you document after the fact, particularly if there was a bad outcome – be straightforward that you are documenting after the fact. Do not document as though you do now know the outcome
Discharge – lawsuits often come up because discharge instructions or documentation were not sufficient. Klauer argues that it is not sufficient to state “patient improved, discharged home.” He urges us to document a repeat exam or show HOW they are improved.
Dr. Klauer also gave some general pearls on lawsuits – high numbers for orthopedics/missed fractures and administration of RhoGham. An additional pearl he gave was for cauda equina.
These patients often have small post void residuals because it’s a neurogenic problem, not a mechanical obstruction. Thus, if a patient has other features and has a post void residual of 100 cc, it’s not necessarily not cauda equina.
One ACEP16 lecturer talked about magnesium use in alcohol withdrawal – probably not ready for prime time, Cochrane agrees .
Moll J, Krieger P, Moreno-Walton L. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 21(5):608-11. 2014. [pubmed]
Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of emergency medicine. 63(6):713-20.e1. 2014. [pubmed]
Eyes track movement in a non-voluntary way and results in pursuit, sacchade. Vision is at least 20/200 if they can do this
Stick out your hand as if to shake theirs
Often a habit to reflexively reach out
Have the patient touch their index fingers together in front of them.
This is a test of proprioception so if they are unable to do this, they either have a problem with proprioception or are faking.
Visual Field or Possible Neglect
Hold a pen horizontally in front of the patient's face and ask them to point to midline.
If the patient points off of midline, this suggests a visual field deficit
We previously reviewed eye trauma in this podcast. In this episode, we review ophthalmology basics using Tiintinalli’s Emergency Medicine Chapter 241.
When doing the pupillary exam, it is important to assess for an afferent pupillary defect (APD). Ophthalmologists will want “there is or is NOT an APD” when you consult them for essentially any reason. Normal pupils constrict when the light is shown in either pupil (direct and consensual constriction). To assess for an APD, perform the “swinging light test.”
A 72-year-old man presents with a painful red eye and visual loss worsening over the last 24 hours. He recently had cataract surgery. Examination of the eye reveals the image above. Which of the following is the most likely?
D. Vitreous hemorrhage
A. Endophthalmitis is an infection involving the anterior, posterior and vitreous chambers of the eye. It results from trauma (blunt globe rupture, penetrating injury, foreign bodies) and alsoiatrogenically after ocular surgery like cataract repair. Patients complain of severe pain in the eye and visual impairment or loss. Examination of the eye reveals decreased visual acuity, injected conjunctiva, chemosis and haziness of the infected chambers. Infections are treated with both systemic and intraocular antibiotics.
A hyphema (B) is blood in the anterior chamber usually caused by trauma. When the patient is in an upright position, blood will layer along the inferior aspect of the anterior chamber. As the hyphema increases in size, it elevates intraocular pressure. In some cases admission is warranted for patients with large hyphemas (>50%), decreased vision, sickle cell disease and elevated intraocular pressure. Treatment is aimed at decreasing pressure with topical (beta-blocker, alpha agonist or carbonic anhydrase inhibitors) and systemic therapy (carbonic anhydrase inhibitor, mannitol). Uveitis (C) occurs after blunt trauma in which the iris and ciliary body are inflamed causing ciliary spasm. Patients complain of significant photophobia with significant eye pain. Examination of the eye reveals perilimbal conjunctival injection (also called ciliary flush) and a small, poorly dilating pupil. Photophobia occurs with light shone on both the affected and unaffected eye. On slit lamp, cells (white and red) and flare (protein) are noted in the anterior chamber. Treatment is with a topical cycloplegic agent to minimize spasm. Vitreous hemorrhage (D) occurs as a result of injuries to the retina, uveal tract and their associated vascular structures. Common associated conditions include diabetic retinopathy, retinal vein occlusion and trauma. Patients complain of decreased visual acuity and floaters. The condition is not typically painful. Diagnosis is made with ocular ultrasound showing blood products in the posterior chamber.
What is a dependent pocket of pus seen in the anterior chamber called?
A 51-year-old man walks into a movie theater and experiences acute onset of right eye pain associated with nausea, vomiting, and cloudy vision. Which of the following is expected during the ophthalmologic exam?
A. Cherry-red spot in the macular area
B. Deep anterior chamber
C. Intraocular pressure >21 mm Hg
D. Miotic pupil
The patient has acute angle-closure glaucoma. This condition results in optic nerve damage from increased intraocular pressure. In patients with a narrow anterior chamber angle, reduced illumination (like entering a dark movie theater) causes mydriasis. Subsequently, folds of the peripheral iris can block the angle, which prevents aqueous humor outflow. This leads to a rapid elevation of intraocular pressure causing ocular pain, a hazy cornea, ciliary flush, a firm globe, and optic nerve damage if the pressure is not promptly relieved. An intraocular pressure >21 mm Hg is considered elevated. Pressures can elevate quickly to >60 mm Hg. The higher the pressure, the quicker damage occurs to the optic nerve and the poorer the prognosis. The diagnosis is often delayed due to the associated symptoms of nausea, vomiting, and abdominal pain. Treatment involves reducing aqueous humor production with IV acetazolamide, topical beta-blockers (timolol), and topical alpha-agonists (apraclonidine). Topical miotic agents (pilocarpine) are used to reverse the angle closure. Topical steroidshelp to reduce inflammation. Hyperosmotic agents (mannitol, glycerol) can also be administered for further reduction in intraocular pressure.
The funduscopic finding of a pale retina with a cherry-red spot in the macular area (A) is consistent with central retinal artery occlusion. This condition is associated with sudden unilateral vision loss that is painless. It is caused by a thrombotic plaque or embolus of the central retinal artery. A deep anterior chamber (B) is protective against acute angle-closure glaucoma. Individuals with a narrow chamber are at increased risk. The pupil in acute angle-closure glaucoma is most commonly fixed and mid-dilated, rather than miotic (D). Miotic pupils are associated with opiate use, cholinergic toxicity, and pontine strokes.