Episode 65 – Contrast-Induced Nephropathy and Genitourinary Trauma

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We cover Free Open Access Medical Education (FOAM) on Contrast-Induced Nephropathy (CIN).  A large retrospective study by Hinson and colleagues in Annals of Emergency Medicine, reignited enthusiasm in the FOAM world about the questionable entity (and clinical significance) of CIN. The data on CIN is somewhat difficult to parse out as the data consists entirely of retrospective cohort and case-control studies. The highest risk of CIN seems to come from large volume contrast procedures such as percutaneous coronary angiography. Studies looking at the risk of CIN after contrast-enhanced CT scan have been less conclusive.

The American College of Radiology (ACR) Manual on Contrast Induced Nephropathy

CIN

This Emergency Medicine Literature of Note post covers the AMACING  trial, which looks at intravenous fluid administration (0.9% NaCl) versus usual care in patients “at risk” for CIN undergoing contrast-enhanced CT scan.   The study found a difference of -0.1% (95% CI -2.25 to 2.06), which was below the non-inferiority margin. Prior literature shows similar results, with no clear-cut efficacy from prevention strategies for CIN.

This post by Dr. Joel Topf (nephrologist @kidneyboy) on the Precious Bodily Fluids blog discusses a nephrologist’s take on CIN.

EM topics post on fluids in CIN.

Core Content

We then delve into core content on genitourinary trauma using Rosen’s Chapter 47 and Tintinalli’s Chapter265 as a guide.

Screen Shot 2017-02-28 at 1.43.40 PM Screen Shot 2017-02-28 at 1.44.33 PM

 Rosh Review Emergency Board Review Questions

An 18-year-old man involved in a motor vehicle collision is transferred from a rural facility after being diagnosed with a pelvic fracture. After your initial assessment and stabilization, a secondary survey is performed. On examination, he is noted to have blood at his urethral meatus as well as a scrotal hematoma. Which of the following is the most appropriate next step?

A. Retrograde cystogram

B. Retrograde urethrogram

C. Suprapubic catheter placement

D. Transurethral urinary catheter placement

Answer

B. The patient should undergo a retrograde urethrogram to rule out an underlying urethral injury. In patients with a pelvic fracture and signs of urethral injury, a retrograde urethrogram should be performed in the supine position prior to urethral instrumentation. If a partial disruption is identified, one attempt to place a 12- or 14-French Foley or coude catheter can be made. If unsuccessful or a complete tear is diagnosed, then a suprapubic catheter will need to be placed. Pelvic fractures with displacement of the pubic symphysis can cause laceration or avulsion of the prostatic urethra. The three classic findings of urethral injury include blood at the urethral meatus, a high-riding prostate and a scrotal or perineal hematoma. Failure to recognize a urethral injury can lead to urethral stricture formation and urinary incontinence.

Urethral manipulation can convert a partial urethral tear to a complete tear, therefore transurethral urinary catheter placement (D) should be avoided until urethral integrity is known. Suprapubic catheter placement (C) may ultimately be necessary if complete urethral injury is diagnosed, however in this case a retrograde urethrogram should be performed prior to proceeding with suprapubic placement. The patient may also have a bladder injury and may require a retrograde cystogram (A), however urethral integrity must be evaluated by a retrograde urethrogram prior to performing a cystogram

A 29-year-old man presents to the ED after a MVC. A pelvic fracture is identified on radiography. His vital signs are stable. The decision is made to place a Foley catheter, but blood is noted at the urethral meatus. Which of the following is an appropriate next step?

A. Consult a urologist

B. Obtain a CT scan to evaluate for urethral injury

C. Perform a retrograde urethrogram

D. Place a condom catheter

Answer

C. Perform a retrograde urethrogram. In general, a Foley catheter should not be placed in the setting of suspected urethral injury. In such cases, it is recommended that further testing be performed to evaluate for urethral injury. A retrograde urethrogram should be performed. If there is no contrast extravasation, then a Foley catheter can safely be inserted.  A urologist should be consulted (A) if a urethral injury is confirmed by the retrograde urethrogram. A CT scan (B) is a poor study to identify urethral injuries. A condom catheter (D) does not allow for accurate urine output measurements and may delay identification of a urethral injury.

References:

  1. Hinson JS, Ehmann MR, Fine DM, et al. Risk of Acute Kidney Injury After Intravenous Contrast Media Administration. Ann Emerg Med. 2017
  2. ACR Manual on Contrast Media.  v10.2. 2016. p33-40
  3. “Genitourinary System.”  Rosen’s Emergency Medicine, 8th ed. Chapter 47, 479-499.e1
  4. “Genitourinary Trauma.” Tintinalli’s Emergency Medicine: A Comprehensive Review.  8th ed.  Chapter 265

Episode 64 – Lumbar Puncture and Central Nervous System Infections

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Ultrasound is gaining popularity in assisting lumbar punctures (LPs). We review this technique as well as Free Open Access Medical Education (FOAM) from the following sites:  5 Min SonoSinai EM, and PEM pearls from ALiEM.

US guided LP

  • This technique is likely most helpful in difficult patients. A recent study demonstrated 27% absolute increase in first attempt success using ultrasound in infants <6 months old undergoing LP; however, the success rate in both arms was abysmal with only 57% success rate in the ultrasound arm.
  • Core Content

We then delve into core content on meningitis, encephalitis, and antiNMDA receptor encephalitis using Rosen’s Chapter 109 and Tintinalli’s Chapters 117 and 174 as a guide.

 Rosh Review Emergency Board Review Questions

A 40-year-old man with HIV presents with two weeks of progressive headache, malaise, and fever. On examination, he has mild nuchal rigidity, confusion, and a temperature of 38.2oC. Cerebrospinal fluid analysis shows a white blood cell count 360 cells/mL with a monocyte predominance, glucose 28 mg/dL, and protein 220 mg/dL. What is the treatment of choice?

A. Acyclovir

B. Amphotericin B

C. Ceftriaxone

D. Vancomycin

Answer

B. Amphotericin B . Cryptococcal meningoencephalitis is an opportunistic infection that occurs primarily in patients with advanced AIDS, although it can be seen in immunocompromised transplant patients as well. The majority of HIV-related cases occur when the CD4 count is < 100 cells/mm3. Patients present with progressive headache, nausea, malaise, and fever over the course of 1 – 2 weeks. Examination findings are typical for meningitis and include altered mental status, photophobia, and fever. Meningismus is less commonly seen. Presentations can be subtle and a high index of suspicion is needed for diagnosis. A CT scan of the brain is indicated if there are signs of increased intracranial pressure or focal neurologic deficits. Lumbar puncture should be performed with careful measurement of the opening pressure. Cerebrospinal fluid will show a mildly elevated white blood cell count with a monocyte predominance, decreased glucose, and mildly elevated protein. However, in some cases the cerebrospinal fluid will only show minor, if any, abnormalities. Cryptococcal antigen testing of the CSF is nearly 100% sensitive and specific. India ink staining will show budding organisms. Treatment of choice is intravenous amphotericin B in addition to oral flucytosine for 14 days followed by an 8 week course of oral fluconazole.  Acyclovir (A) is used in the treatment of herpes meningoencephalitis. Ceftriaxone (C) and vancomycin (D) are indicated in the treatment of bacterial meningitis.

A previously healthy 18-year-old woman presents to the emergency department with complaints of fever, headache, and neck stiffness. She is accompanied by her sister, who expresses concern because the patient seems suddenly confused and cannot remember what she did yesterday. After you administer empiric intravenous antibiotics, which of the following is the next best step?

A. Chest X-ray

B. Complete blood count with differential

C. Lumbar puncture

D. Urinalysis

Answer
C.  Lumbar puncture.  Meningitis is an inflammation of the tissues surrounding the brain and spinal cord (meninges) and may be of infectious (bacterial, viral, or fungal) and various other etiologies. The classic clinical manifestations include nuchal rigidity, fever and altered mental status. Patients often present with headache as well. All patients with suspected meningitis should have lumbar puncture (LP) to evaluate the cerebrospinal fluid (CSF) unless this procedure is contraindicated. There are no absolute contraindications to LP. Relative contraindications include patients with evidence of increased intracranial pressure, thrombocytopenia, bleeding diathesis or spinal epidural abscess. Acute bacterial meningitis is a medical emergency and left untreated or treated late is almost universally fatal. Treatment involves addressing systemic complications and initiating empiric antibiotic therapy as soon as possible.

Up to half of patients with pneumococcal meningitis may have evidence of pneumonia on chest X-ray (A), but this is not part of the initial workup of patients with suspected meningitis. Complete blood count with differential (B) is often ordered in the workup for bacterial meningitis and generally shows increased white blood cell count, but is not as important to order initially as an LP. Urinalysis (D) is generally not a helpful test in the diagnosis of meningitis and therefore not recommended in the workup for patients with suspected bacterial meningitis.

References:

  1. Attia J, Hatala R, Cook DJ, Wong JG. The rational clinical examination. Does this adult patient have acute meningitis?. JAMA. 1999;282(2):175-81.
  2. Nakao JH, Jafri FN, Shah K, Newman DH. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014;32(1):24-8.
  3. Neal JT, Kaplan SL, Woodford AL, Desai K, Zorc JJ, Chen AE. The Effect of Bedside Ultrasonographic Skin Marking on Infant Lumbar Puncture Success: A Randomized Controlled Trial. Ann Emerg Med. 2016.

Episode 63 – Bradycardia

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Emergent transvenous pacing is a crucial skill for emergency physicians.  It may be daunting due to the pacing box and various catheters. We have found that  routinely rehearsing the procedure, reviewing where pacing equipment is in our departments, and where

In this episode we review the following videos:

  • Practical Pointers for Pacemaker Placement by Dr. Jason Nomura
  • Transvenous pacing video by Dr. Al Sachetti
  • Pacing 101 (Transcutaneous is Just Stupid) by Dr. Joe Bellezo on the Ultrasound Podcast
    • This podcast lays down the argument that transcutaneous pacing is stupid.  Transcutaneous pacing is difficult – patients are diaphoretic, capture rates may be 40%, and it takes a significant amount of energy. Further, it hurts.
      • However, in our opinion, there may be a role.  In this talk, Dr. Bellezo quotes a 1981 study, in which emergent pacers were placed in “6 minutes.”  Review of this study finds that this was actually 6 minutes, 45 seconds (closer to 7 minutes) [1].  This likely does not reflect the majority of emergency providers experience, certainly not ours, where the range is more often 15-30 minutes for the procedure.  Thus, transcutaneous pacing may be a temporizing measure as one locates the ultrasound, gathers the supplies, and prepares for transvenous pacing in the unstable patient.

transvenous pacing

pacing

Core Content

We delve into core content on bradycardias and heart blocks using Rosen’s Emergency Medicine (8th edition) Chapter 79 “Dysrthymias” and Tintinalli’s Emergency Medicine (8th edition) Chapter 18  “Cardiac Rhythm Disturbances” as a guide.

bradycardias

bradycardia

 Rosh Review Emergency Board Review Questions

Question 1a.

A 71-year-old woman presents after a fall at home. Her electrocardiogram is shown below.

content_ecg_-3rd_degree_heart_block

Answer

Third Degree Heart block.

Question 2.

A. Administration of epinephrine

B. Defibrillation

C. Observation

  • D. Placement of transcutaneous pacer pads
Answer

D. The patient has third degree heart block. In third degree atrioventricular (AV) block, also known as complete heart block, there is no conduction through the AV node, and an escape pacemaker is responsible for the ventricular rate. On electrocardiogram, P waves occur at regular intervals, and QRS complexes occur at regular intervals, but there is no association between the P waves and QRS complexes. When the block occurs in the AV node, a junctional escape pacemaker takes over with a rate of 40-60 beats/minute, and the QRS complex is narrow. If the block occurs at the infranodal level, a ventricular escape pacemaker paces at a rate of 40 beats/minute or less. Infranodal blocks results in a wide QRS complex. Patients with third degree heart block require cardiac pacing, as the slow escape rhythm is rarely adequate to maintain cardiac output and tissue perfusion. Transcutaneous pacing should be initiated while arrangements for transvenous pacing are made. Third degree blocks are commonly associated with cardiac ischemia or infarction. A nodal third degree block (narrow QRS complex) is a complication of acute inferior wall myocardial infarction, and may last for several days. Extensive acute anterior wall infarction is associated with infranodal third degree blocks (wide complex QRS), indicating damage to the infranodal conduction system. When a third degree heart block is seen with acute myocardial infarction, mortality is increased.

Administration of epinephrine (A) is incorrect. Defibrillation (B) the treatment for cardiac arrest from ventricular fibrillation or pulseless ventricular tachycardia.  Observation (C) is incorrect since the patient’s slow heart rate is likely not adequate to maintain cardiac output.

Question 3.

A 56-year-man presents to the ED with right arm pain and some chest discomfort. The day prior to arrival, he tried using heavier weights at the gym. He has a history of hypertension, hyperlipidemia, and COPD. In the ED, his vital signs are BP 136/90, HR 60, RR 16, and oxygen saturation 97% on room air. His rhythm strip is seen below. Which is the most appropriate management for this rhythm?

content_ecg_-_second_degree_heart_block_type_ii

A. Aspirin

B. Cardioversion

C. Observation

D. Temporary pacing

Answer

D. This ECG demonstrates type II second-degree heart block. Second-degree heart block is defined by one or more impulses not reaching the ventricles and is classified as type I and type II. Type II second-degree heart block, also known as Mobitz II, is caused by an infranodal conduction abnormality, most commonly in the bundle of His or the purkinje fibers. ECG findings demonstrate random dropped QRS complexes without any changes in the PR interval. Type II second-degree heart block carries a worse prognosis than type I second-degree heart block and necessitates treatment. Unlike type I, atropine has no effect on the His-Purkinje system and may worsen conduction. Temporary pacing is critical in this case because this rhythm can devolve to complete heart block. In the ED, transcutaneous or transvenous pacing should be instituted if the patient is symptomatic and there should be immediate consultation with a cardiologist. Patients with Mobitz II in the setting of an acute myocardial infarction should be treated with temporary pacing and revascularization; following revascularization most conduction abnormalities will improve or resolve and will not require permanent pacing.

Question 4.

A man who presents with syncope is placed on the cardiac monitor. On the monitor you note a repeating trend of 6 P waves, 5 of which are followed by a narrow QRS complex and 1 of which is not followed by a QRS complex. The PR interval during this trend progressively increases. Which of the following is the most likely diagnosis?

A. First-degree AV block

B. Third-degree AV block

C. Type I second-degree AV block

D. Type II second-degree AV block

Answer

C. A key distinction between first-degree and second-degree heart block is that in first-degree block the P wave is always followed by a QRS complex. In other words, the ratio of P waves to QRS complexes is 1:1, or, the electrical signal from the atria always passes to the ventricles. In second-degree AV block, the electrical impulse sometimes gets to the ventricles. There are two main types of second-degree AV block. In Mobitz type I, or Wenckebach, second-degree block, there is a progressive beat-to-beat lengthening of the PR interval until a P wave does not conduct through the AV node. The absent conduction and resultant “missing” QRS complex is called a “dropped” QRS, which represents an absent beat of ventricular contraction. First-degree AV block (A) has a 1:1 ratio of P waves to QRS complexes. Mobitz type II second-degree heart block (D) is characterized by a nonconducted P wave which is not preceded by progressive PR interval prolongation. AV dissociation, or third-degree AV block (B), occurs when none of the P waves conduct through the AV node. This complete AV block occurs with separate atrial and ventricular rates. There is no discrete correlation or trend between P waves and QRS complexes.

References:

  1. Lang R, David D, Klein HO, et al. The use of the balloon-tipped floating catheter in temporary transvenous cardiac pacing. Pacing Clin Electrophysiol. 1981;4(5):491-6.
  2. Roberts J and Hedges J. “Emergency Cardiac Pacing.” Roberts and Hedges’ Clinical Procedures in Emergency Medicine

Suviving Sepsis Campaign Guidelines 2017

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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

Screen Shot 2017-01-19 at 4.02.07 PM

References:

  1. 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.
  2. 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.
  3. Keh D, Trips E, Marx G, et al. Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial. JAMA. 2016;316(17):1775-1785.
  4. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis. Jama [Internet] 2016;315(8):762.
  5. 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.

Roundup: Favorite Literature of 2016

(iTUNES OR LISTEN HERE)

Article highlights of 2016

Sepsis 3.0

Singer M, Deutschman CS, Seymour CW, et al: The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).

  • 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).

Sepsis 3.0

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].

Back Up Head Elevated Intubation

Khandelwal et al. Head-elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesthesia and Analgesia. Apr 2016.

back up head elevated intubation

Ketorolac Dose

Motov, S, Yasavolian, M, Likourezos, A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department. .Ann Emerg Med. 2016 Dec 16.

ketorolac

Pulmonary Embolism in Syncope 

Prandoni et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope.   N Engl J Med 2016; 375:1524-1531. This trial is probably one of the most over-reacted to trials of 2016.  News outlets, both by lay media and for health professionals overstated the claims of this trial.

image

What the trial actually did…

PESIT

Out of Hospital Cardiac Arrest Prognostication

Jabre et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation.   Intern Med. 2016 Dec 6;165(11):770-778

OHCA

ALTE (Apparent Life Threatening Event) is out, replaced with a new definition and classification, BRUE (Brief Resolved Unexplained Event).

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B et al. Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.  Pediatrics. 2016

Screen Shot 2016-05-04 at 9.33.37 AM

References:

  1. Churpek MM, Snyder A, Han X et al. qSOFA, SIRS, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients Outside the ICU. Am J Respir Crit Care Med. 2016. [article]
  2. Brabrand M, Havshøj U, Graham CA. Validation of the qSOFA score for identification of septic patients: A retrospective study. European Journal of Internal Medicine. 36:e35-e36. 2016. [article]

Episode 62 – Dental Emergencies

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We review a trick of the trade from Academic Life in Emergency medicine for temporomandibular joint (TMJ) dislocation, the extra-oral reduction.

TMJ dislocation reduction

Traditional Approach to TMJ dislocation and Syringe Technique from Core EM

Core Content

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.

dental infections

dental trauma

mandible fracture

 Rosh Review Emergency Board Review Questions

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

Answer

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

Answer

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.

References

  1. 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]
  2. 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]
  3. Neiner J, Free R, Caldito G, Moore-Medlin T, Nathan CA. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofacial trauma & reconstruction. 9(2):121-4. 2016. [pubmed]

Episode 61 – The Elbow

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We review a podcast from Dr. Tim Horeczko’s Pediatric Emergency Playbook on elbow injuries.

critoe

Core Content

We delve into core content on other elbow adjacent injuries using Rosen’s Emergency Medicine (8th edition) Chapter  and Tintinalli’s Emergency Medicine (8th edition) Chapter  as a guide.

Elbow Trauma

olecranon bursitis

 Rosh Review Emergency Board Review Questions

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

Answer

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

Answer

A. This child has “nursemaid’s elbow” that is due to subluxation of the annular ligament 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.

Episode 60 – Resuscitative Hysterotomy + First Trimester Emergencies

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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 [1]. 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. 

resuscitative hysterotomy

Core Content

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.

first trimester bleeding

septic abortion

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].

first trimester vomiting

uti in pregnancy

 Rosh Review Emergency Board Review Questions

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

Answer

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?
 

Threatened abortion

References:

  1. 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]
  2. Heaton, H. “Chapter 98: Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy.” Tintinalli’s Emergency Medicine: A Comprehensive Review. 8th edition
  3. “Chapter 178: Acute Complications of Pregnancy.”  Rosen’s Emergency Medicine

Episode 59 – Syncope (and the PESIT study)

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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:

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Core Content

We delve into core content on syncope usingRosen’s Emergency Medicine (8th edition) and Tintinalli’s Emergency Medicine (8th edition) Chapter 52

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 Rosh Review Emergency Board Review Questions

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

D. Vasovagal

Answer

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

Answer

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.

References

  1. De Lorenzo RA. “Syncope.” Chapter 15. Rosen’s Emergency Medicine (8 ed). pp 131-145
  2. Chapter 52. Tintinalli’s Emergency Medicine: A Comprehensive Review (8 ed).
  3. 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.
PlayPlay

Bell’s Palsy and Burns

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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.

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Dr. Toree McGowan – Burns

Check out this podcast for more on burns

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  1. Sherman SC, Thompson TM, Thompson TT. Pontine hemorrhage presenting as an isolated facial nerve palsy. Annals of emergency medicine. 46(1):64-6. 2005. [pubmed]
  2. AAN Bell’s Palsy Guideline Update
  3. Fahimi J, Navi BB, Kamel H. Potential Misdiagnoses of Bell’s Palsy in the Emergency Department. Annals of Emergency Medicine. 63(4):428-434. 2014. [article]
  4. Madhok VB, Gagyor I, Daly F. Corticosteroids for Bell’s palsy (idiopathic facial paralysis). The Cochrane database of systematic reviews. 7:CD001942. 2016. [pubmed]
  5. Gagyor I, Madhok VB, Daly F. Antiviral treatment for Bell’s palsy (idiopathic facial paralysis). The Cochrane database of systematic reviews. 2015. [pubmed]
  6. Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. The Cochrane database of systematic reviews. 2008. [pubmed]
  7. Ringh M, Rosenqvist M, Hollenberg J et al. Mobile-Phone Dispatch of Laypersons for CPR in Out-of-Hospital Cardiac Arrest. N Engl J Med. 372(24):2316-2325. 2015. [article]