Episode 38 – The Nose

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

The FOAM realm has teamed with interest in a randomized trial in the ICU by Semler et al, the FELLOW trial. This trial randomized ICU patients undergoing intubation to receive 15L NC during intubation or usual care. The study found no difference in the primary outcome of the study, the difference between the mean lowest oxygen saturations between the two groups – 92% (IQR 84-99%) in the usual care vs 90% (IQR 80-96%) in the apneic arm (p=0.16). Critiques of this study can be found below:

Concerns echoed by these sources include the clinical importance of the primary outcome (not patient oriented) and that the study may have been underpowered to detect a true difference.

Statistical power – the chance that an experiment will result in a statistically significant. Three main things influence statistical power:

  • The size of the difference you’re looking to find, the smaller the difference, the more numbers one will need.
  • The p value you’re looking to find to label it a “real” effect (although p values themselves may be overrated). A p value of <0.05 will need fewer numbers than a p value of <0.001
  • The frequency of the outcome into consideration. The more infrequent the outcome, the harder it will be able pick up in a small sample.

Also, oxygen saturation, a continuous variable, was appropriately analyzed by non-parametric (non normal distribution) means. Non-parametric means often have less power to detect a difference (aren’t as powerful).  The FELLOW study was powered using parametric means, which is common practice (fewer programs can perform this) but may have also contributed to the studying having insufficient power to achieve the primary outcome.

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Core Content – Epistaxis and Sinusitis

Tintinalli (7e) Chapter 239, “Epistaxis, Nasal Fractures, and Rhinosinusitis.” Rosen’s  (8e) Chapter 75, “Upper Respiratory Infection.”, “Otolaryngology”

Epistaxis

Causes:

  • Traumatic: trauma, digital (nose picking), foreign body, sinus infection, nasogastric tube
  • Environment: dry, cold air, oxygen
  • Inhalants: inhaled steroids/medications, cocaine
  • Coagulopathy: iatrogenic (warfarin, aspirin, platelet inhibitors, etc), familial (hemophilia, von Willebrand’s disease)
  • Vascular abnormalities: aneurysm, AVM, neoplasm

Location: Anterior bleeds most common (Kiesselbach’s plexus). Posterior bleeds (sphenopalantine or carotid artery branches) more dangerous.

Treatment: (note: TXA is not in Rosen’s or Tintinalli, see Zahed and colleagues)

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Sinusitis

Symptoms:  mucopurulent nasal discharge,congestion, facial pain or pressure.  Generally last 7-10 days and often viral.   Diagnosis is predominantly clinical and does not routinely require CT scan [3]

Treatment: typically supportive care as most cases are self-limiting [2].  American Academy of Allergy Asthma Immunology Choosing Wisely : “Antibiotics usually do not help sinus problems, Antibiotics cost money. Antibiotics have risks” [4]. Despite these recommendations, provider still routinely prescribe antibiotics inappropriately [5].

Antibiotics (amoxicillin-clavulanate) recommended if:

  • Symptoms persist 10+ days
  • Severe symptoms >3-4 days or get worse after initial symptoms
    • Severe: Temperature 102F or more + purulent nasal discharge or facial pain [2]

Generously Donated Rosh Review Questions 

1.An 18-month-old girl presents to urgent care with profuse mucoid nasal discharge and cough. She has had nasal discharge for the past 2 weeks with no improvement from using a humidifier. She has also had fever for the past four days, with a Tmax of 103°F. She has not been able to attend daycare for the past week due to the fever and persistent symptoms. [polldaddy poll=9196746]

2. A 42-year-old man presents with facial pain. He reports pain over his cheeks and forehead with associated fever for the last 24 hours. On inspection of his nasal passages you not inflamed turbinates with green discharge. He is tender over palpation of the frontal and maxillary sinuses. [polldaddy poll=9196749]

Answers.

1.C. Acute sinusitis is a common illness of childhood, characterized by fever, cough, purulent nasal discharge, and nasal congestion. The most common cause of sinusitis is viral, which is best treated with supportive care. Acute bacterial sinusitis often follows a case of viral sinusitis. In young children, sinusitis may be present in the ethmoidal sinuses. The maxillary sinuses are present at birth, but are not pneumatized until 4 years of age. The sphenoid sinuses are present by age 5, and the frontal sinuses begin development at age 7-8. Due to this child’s persistent symptoms for more than 10-14 days, fever of greater than 102°F, and purulent nasal discharge for more than 3 consecutive days, the most likely diagnosis is acute bacterial sinusitis. The most common bacterial pathogens are Streptococcus pneumoniae (30%), nontypable Haemophilus influenzae (20%), and Moraxella catarrhalis (20%). Less common causes include other strains of streptococci, Staphylococcus aureus, and anaerobic bacteria. Initial treatment consists of low dose amoxicillin, which covers the most common bacterial pathogens. However, some children are at risk for resistant strains of bacterial pathogens, such as children in daycare, those less than 2 years of age, and those who have received antibiotics in the preceding 1-3 months. These children should be given amoxicillin-clavulanate with high dose amoxicillin. Children who fail initial therapy should also be escalated to high dose amoxicillin-clavulanate.Azithromycin (A) is an alternative antibiotic that can be used to treat sinusitis in older children. It would not be the first line therapy in this young child. Ceftriaxone (B) should be used in frontal sinusitis, complicated sinusitis (such as periorbital or orbital cellulitis) or in the setting of intracranial complications (such as epidural abscess, meningitis, or cavernous sinus thrombosis). Low dose amoxicillin (D) is the first line therapy in uncomplicated sinusitis, when the child does not have risk factors for resistant bacterial pathogens.

2. C. This patient has rhinosinusitis. Viral upper respiratory infections and allergic rhinitis are the most common causes of acute rhinosinusitis. Additional risk factors are ciliary immobility or dysfunction, structural abnormalities, immunocompromise, Patients with viral sinusitis are at risk of developing bacterial sinusitis as a consequence of the viral infection. Clinically patients with acute rhonisinusitis develop mucopurulent nasal discharge, facial or sinus pain, and nasal congestion. Symptoms of acute sinusitis typically progress over the first several days and spontaneously resolve after 7 to 10 days. It is difficult to distinguish clinically between viral and bacterial infection in the first several days of illness and antibiotic therapy is not recommended at this time. Management focuses on symptomatic treatment with pain management and decongestant therapy. Antihistamines may provide some benefit for patients with allergic rhinosinusitis. Decongestant therapy is available topically with agents like oxymetazoline. Systemic therapy includes pseudoephedrine. Saline nasal irrigation is beneficial for all forms of acute rhinosinusitis. Topical and systemic steroids are no longer recommended for acute sinusitis.A CT scan of the sinuses (A) is not necessary in this patient. Imaging is indicated when there are concerns for complications of cellulitis (e.g. cavernous sinus thrombosis, abscesses, orbital involvement) or invasive fungal infections. ENT consultation (B) is not necessary for uncomplicated cellulitis. A prescription for amoxicillin/clavulanic acid (D) is not indicated in the first several days of illness because of the likelihood this is viral. Without improvement after symptomatic therapy or progression to chronic sinusitis antibiotics are indicated.

References:

1.Semler MW, Janz DR, Lentz RJ, et al. Randomized Trial of Apneic Oxygenation during Endotracheal Intubation of the Critically Ill. Am J Respir Crit Care Med. 2015:rccm.201507–1294OC.

2. Chow AW, Benninger MS, Brook I et al. Executive Summary: IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clinical Infectious Diseases. 54(8):1041-1045. 2012

3. “Ten Things Physicians and Patients Should Question.” American Academy of Allergy, Asthma, and Immunology. Released April 4, 2012

4. “Treating Sinusitis.” Choosing Wisely. April 2012.

5. Sharp AL, Klau MH, Keschner JD et al. “Low-Value Care for Acute Sinusitis Encounters: Who’s Choosing Wisely?” Am J Manag Care. 2015;21(7):479-485

Episode 37 – Lacerations

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

We cover a trick of the trade from Dr. Brian Lin, posted on the Academic Life in Emergency Medicine (ALiEM site) on hemostasis in finger tip avulsions. Dr. Lin also has his own excellent FOAM site on all things laceration – LacerationRepair.com.

We also cover FOAM on dogma of wound care from Dr. Ken Milne’s The Skeptic’s Guide to Emergency Medicine, Episode #63

Core Content – Wounds and Laceration Care

Tintinalli (7e) Chapter 44, “Wound Preparation.” Rosen’s  (8e) Chapter 59, “Wound Management Principles.”

Laceration Care:

  • Use gloves, they don’t have to be sterile [1].
  • Anesthetize (lidocaine with epinephrine is just fine).
  • Irrigate copiously. It’s estimated that one needs ~60 mL/centimeter of wound or at least 200 mL.
    • You can irrigate with water or saline. Potable tap water is fine [2,3]
  • For a cornucopia of laceration techniques visit LacerationRepair.com
  • No clear “golden period” for laceration repair [4-6]. Rosen’s and Tintinalli recommend using clinical judgment as a guide.

Risks for Infection:

  • Diabetes
  • Length of laceration (>5 cm)
  • Location of the wound
  • Degree of contamination [6]

Age of wound when approximated (i.e. “golden period”) has not been found to be an independent risk factor). Rosen’s sites use of epinephrine as a risk but only cites a paper by Barker et al from 1982 in which tetracaine/epinephrine/cocaine was applied to wounds inflicted by researchers that were inoculated by s. aureus.

Prophylactic antibiotics:

Screen Shot 2015-11-15 at 5.34.59 PM

Generously Donated Rosh Review Questions 

Question 1.  An 18-year-old woman presents with a laceration to her face from a dog bite that occurred 24 hours ago. The patient owns the dog. Examination reveals a 4 cm laceration to the left cheek with no signs of infection. [polldaddy poll=9180209]

Question 2A 30-year-old man presents with a 2 cm linear laceration through his right eyebrow that he sustained after hitting his head on the kitchen cabinet. You determine that the wound will require repair with sutures. [polldaddy poll=9180210]

Answers

  1. Mammal bites to any part of the body should be copiously irrigated and explored followed by an assessment for primary closure. In this patient, primary closure is recommended as the laceration is on the face. Canine bites often involve laceration as well as crush injury to tissue depending on the size of dog. The presence of a crush injury may make primary wound repair difficult. Additionally, devascularization of the tissue may make primary closure contraindicated as the risk of infection increases. Classically, it was taught that lacerations sustained from dog bites should be irrigated, given antibiotics and not primarily repaired because of these risks. However, more recent literature has shown that the risk of infection was no different for primary closure versus healing by secondary intention. Additionally, if the laceration is to a cosmetic area like the face, primary repair should be attempted. As with any laceration, tetanus status should be updated. Copious irrigation and wound exploration is central to good wound care. Exploration should pay particular attention to the presence of foreign bodies especially teeth, which may break off during the bite. Antibiotics (A & C) are not routinely needed for dog bites despite classic teaching. Antibiotics should be reserved for patients with signs of infection, multiple comorbidities or large wounds with gross contamination. If antibiotics are given, they should primarily cover Staphylococcus and Streptococcus species, as these are the predominant organisms in the canine oral cavity. Eikenella and Pasturella are less commonly responsible for infections. Irrigation and antibiotics alone (A) would be indicated for dog bites that are grossly infected or have large defects that cannot be primarily closed. Wound closure and antibiotics without irrigation (D) is also contraindicated as copious irrigation is central to proper wound management.
  2. A pair of clean, non-sterile gloves can be worn by the physician (and any assistants) during laceration repair. The use of sterile gloves has not been proven to be associated with lower infection rates and is not required. Wounds must be prepped prior to closure. This generally involves cleaning and draping the wound, providing local or regional anesthesia, copious irrigation and exploring the wound to evaluate the integrity underlying structures and identify any foreign bodies. The skin surrounding a wound should be cleansed with either 10% povidone-iodine (C) or chlorhexidine gluconate solution. In general, these commercially available antiseptics should not be used for wound irrigation, as they can be toxic to the tissues. Irrigation should then follow with copious amounts of tap water or saline (at least 250 mL). This is best achieved with a large volume syringe attached to an 18-gauge needle or another commercially available irrigation device that achieves adequate pressure for irrigation. Alternatively, patients can irrigate at the sink if the laceration is in area that allows for this. Shaving of hair been shown to increase the risk of infection and should generally be avoided. It is best to apply a small amount of petroleum- or water-based lubricant to the hair to keep it out of the wound. Alternatively, hair can be clipped with scissors when necessary. Eyebrows (B) in particular should not be shaved as they provide anatomic landmarks that aid in wound approximation and removal results in poor short- and long-term cosmetic effect. In general, non-complex facial wounds are closed with nonabsorbable suture material, such as nylon or polypropylene. Most commonly this will be done with 6-0 suture, as it provides the best cosmetic effect. The use of 3-0 (D) and 4-0 suture is reserved for repair of fascia or wounds that are under high stress, such as those that overly major joints or involve the scalp.

References:

  1. Perelman VS, Francis GJ, Rutledge T, et al. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Annals of emergency medicine. 43(3):362-70. 2004
  2. Fernandez R, Griffiths R. Water for wound cleansing. The Cochrane database of systematic reviews. 2:CD003861. 2012.
  3. Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ open. 3(1):. 2013.
  4. American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with penetrating extremity trauma. Annals of emergency medicine. 33(5):612-36. 1999. [pubmed] **A past policy, no current clinical policy
  5. Zehtabchi S, Tan A, Yadav K, Badawy A, Lucchesi M. The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury. 43(11):1793-8. 2012.
  6. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emergency medicine journal : EMJ. 31(2):96-100. 2014.
PlayPlay

Episode 37 – Lacerations

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

We cover a trick of the trade from Dr. Brian Lin, posted on the Academic Life in Emergency Medicine (ALiEM site) on hemostasis in finger tip avulsions. Dr. Lin also has his own excellent FOAM site on all things laceration – LacerationRepair.com.

We also cover FOAM on dogma of wound care from Dr. Ken Milne’s The Skeptic’s Guide to Emergency Medicine, Episode #63

Core Content – Wounds and Laceration Care

Tintinalli (7e) Chapter 44, “Wound Preparation.” Rosen’s  (8e) Chapter 59, “Wound Management Principles.”

Laceration Care:

  • Use gloves, they don’t have to be sterile [1].
  • Anesthetize (lidocaine with epinephrine is just fine).
  • Irrigate copiously. It’s estimated that one needs ~60 mL/centimeter of wound or at least 200 mL.
    • You can irrigate with water or saline. Potable tap water is fine [2,3]
  • For a cornucopia of laceration techniques visit LacerationRepair.com
  • No clear “golden period” for laceration repair [4-6]. Rosen’s and Tintinalli recommend using clinical judgment as a guide.

Risks for Infection:

  • Diabetes
  • Length of laceration (>5 cm)
  • Location of the wound
  • Degree of contamination [6]

Age of wound when approximated (i.e. “golden period”) has not been found to be an independent risk factor). Rosen’s sites use of epinephrine as a risk but only cites a paper by Barker et al from 1982 in which tetracaine/epinephrine/cocaine was applied to wounds inflicted by researchers that were inoculated by s. aureus.

Prophylactic antibiotics:

Screen Shot 2015-11-15 at 5.34.59 PM

Generously Donated Rosh Review Questions 

Question 1.  An 18-year-old woman presents with a laceration to her face from a dog bite that occurred 24 hours ago. The patient owns the dog. Examination reveals a 4 cm laceration to the left cheek with no signs of infection. [polldaddy poll=9180209]

Question 2A 30-year-old man presents with a 2 cm linear laceration through his right eyebrow that he sustained after hitting his head on the kitchen cabinet. You determine that the wound will require repair with sutures. [polldaddy poll=9180210]

Answers

  1. Mammal bites to any part of the body should be copiously irrigated and explored followed by an assessment for primary closure. In this patient, primary closure is recommended as the laceration is on the face. Canine bites often involve laceration as well as crush injury to tissue depending on the size of dog. The presence of a crush injury may make primary wound repair difficult. Additionally, devascularization of the tissue may make primary closure contraindicated as the risk of infection increases. Classically, it was taught that lacerations sustained from dog bites should be irrigated, given antibiotics and not primarily repaired because of these risks. However, more recent literature has shown that the risk of infection was no different for primary closure versus healing by secondary intention. Additionally, if the laceration is to a cosmetic area like the face, primary repair should be attempted. As with any laceration, tetanus status should be updated. Copious irrigation and wound exploration is central to good wound care. Exploration should pay particular attention to the presence of foreign bodies especially teeth, which may break off during the bite. Antibiotics (A & C) are not routinely needed for dog bites despite classic teaching. Antibiotics should be reserved for patients with signs of infection, multiple comorbidities or large wounds with gross contamination. If antibiotics are given, they should primarily cover Staphylococcus and Streptococcus species, as these are the predominant organisms in the canine oral cavity. Eikenella and Pasturella are less commonly responsible for infections. Irrigation and antibiotics alone (A) would be indicated for dog bites that are grossly infected or have large defects that cannot be primarily closed. Wound closure and antibiotics without irrigation (D) is also contraindicated as copious irrigation is central to proper wound management.
  2. A pair of clean, non-sterile gloves can be worn by the physician (and any assistants) during laceration repair. The use of sterile gloves has not been proven to be associated with lower infection rates and is not required. Wounds must be prepped prior to closure. This generally involves cleaning and draping the wound, providing local or regional anesthesia, copious irrigation and exploring the wound to evaluate the integrity underlying structures and identify any foreign bodies. The skin surrounding a wound should be cleansed with either 10% povidone-iodine (C) or chlorhexidine gluconate solution. In general, these commercially available antiseptics should not be used for wound irrigation, as they can be toxic to the tissues. Irrigation should then follow with copious amounts of tap water or saline (at least 250 mL). This is best achieved with a large volume syringe attached to an 18-gauge needle or another commercially available irrigation device that achieves adequate pressure for irrigation. Alternatively, patients can irrigate at the sink if the laceration is in area that allows for this. Shaving of hair been shown to increase the risk of infection and should generally be avoided. It is best to apply a small amount of petroleum- or water-based lubricant to the hair to keep it out of the wound. Alternatively, hair can be clipped with scissors when necessary. Eyebrows (B) in particular should not be shaved as they provide anatomic landmarks that aid in wound approximation and removal results in poor short- and long-term cosmetic effect. In general, non-complex facial wounds are closed with nonabsorbable suture material, such as nylon or polypropylene. Most commonly this will be done with 6-0 suture, as it provides the best cosmetic effect. The use of 3-0 (D) and 4-0 suture is reserved for repair of fascia or wounds that are under high stress, such as those that overly major joints or involve the scalp.

References:

  1. Perelman VS, Francis GJ, Rutledge T, et al. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Annals of emergency medicine. 43(3):362-70. 2004
  2. Fernandez R, Griffiths R. Water for wound cleansing. The Cochrane database of systematic reviews. 2:CD003861. 2012.
  3. Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ open. 3(1):. 2013.
  4. American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with penetrating extremity trauma. Annals of emergency medicine. 33(5):612-36. 1999. [pubmed] **A past policy, no current clinical policy
  5. Zehtabchi S, Tan A, Yadav K, Badawy A, Lucchesi M. The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury. 43(11):1793-8. 2012.
  6. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emergency medicine journal : EMJ. 31(2):96-100. 2014.
PlayPlay