Monthly Archives: May 2017

Don’t Inhale

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Had an interesting case recently while I was working at Jewish Downtown. Approximately 50s male presents in acute respiratory distress. Apparently he rented out some apartments and one of the tenants clogged one of the toilets, I didn’t have a chance to ask how.

Anyway, in an attempt to fix the problem he mixed two plumbing agents: Liquid Fire Drain Opener & some other generic drain-o liquid that he planned to use to clear the pipes. This ended up being a bad idea and a chemical reaction occurred releasing a cloud of chlorine gas. The patient inhaled this and began becoming progressively more short of breath.

While en route, EMS initially had him on a nasal cannula but transitioned him to a non-rebreather as well as a Duo-neb. At the time of his arrival to room 1 the patient was in obvious respiratory distress, diaphoretic, and anxious pulling at the non-rebreather and leads. His O2 sat was from 86%-88% on the non-rebreather with decreased breath sounds diffusely. We elected to intubate the patient with etomidate as our induction agent and rocuronium as our paralytic. After the patient was placed on the ventilator we started the patient on nebulized sodium bicarbonate.

This was something I had never done before – so I wanted to discuss chlorine gas inhalational injuries and the role of nebulized bicarb.

Chlorine gas inhalations typically occur in the setting of chemicals for cleaning an indoor pool. Chlorine gas inhalation rarely progresses to respiratory distress requiring intubation.

In 1994 the Journal of Clinical Toxicology did a two year retrospective review of 86 cases of chlorine gas inhalation and none of the patients progressed to respiratory insufficiency requiring ventilator support.  The most common symptoms are cough, chest pain, and shortness of breath and the chest xray is often unrevealing. In the study all 86 cases received nebulized sodium bicarbonate and none of the patients clinically deteriorated or acutely worsened as a result of the treatment.

While the nebulized bicarb does not reverse or work to eliminate the inhaled chlorine, it helps symptomatically with the cough and SOA. I could not find much information on the MOA or science behind the use of nebulized sodium bicarbonate but it appears to be pretty safe.

The dosing that I found is 4mL of 4% nebulized NaHCO3, and be prepared to explain this to the respiratory therapist because this is not something that they do often. Also this has to come up from pharmacy as code cart sodium bicarb is typically 7.5% so the concentrations are different.

So our patient received his nebulized bicarb once it came up from pharmacy. He was admitted to the ICU and I have not had a chance to follow up on his outcome yet. I just thought this was an interesting case and something that I had not yet encountered and figured I would share for your reading pleasures.

Always keep your differential broad

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I had a case in our department that I won’t forget for a while, and it reminded me to keep my differential broad even if the suspected diagnosis seems blatantly obvious.

 

An early 40’s female presented to our ER about 5 days after an MVC in which she was the restrained driver, where the car rolled onto its side going about 40s-50s MPH. + LOC, + airbags. Paramedics arrived on scene after a while when she was up and walking, and she refused to be taken to the ER. Over the following 5 days, she had near constant neck pain as well as a worsening headache and worsening abdominal and “rib” pain on the lower left side.

She presented to our ER in a hallway bed, where her initial HR was in the mid 80s, but BP was 80s/40s on multiple checks. O2 sat and temperature were normal. Mental status was normal, and there were no physical signs of trauma on her body. She had tenderness to the L lower and lateral ribs, as well as LUQ/LMQ abdominal tenderness, and lower midline C-spine tenderness. I quickly had her placed in a cervical collar, and brought the ultrasound to bedside a performed a FAST, which was negative (to my surprise).

I ordered fluid boluses, trauma labs, type and crossmatch, and planned to send her for a man scan, but her kidney function showed an AKI and therefore had to wait for one fluid bolus before going to the scanner. BP slowly started to trend upwards, not reaching over mid 90s systolic before she went to the scanner. Of note, she did have a slightly elevated white count in the mid-to-upper teens.

My differential? Trauma, trauma, trauma. She has to be bleeding somewhere, she may have a fractured C-spine, intracranial injury, intraabdominal injury, likely splenic laceration. My FAST just must not have picked it up. Given the history and clinical circumstance, I don’t think I was completely wrong for not having anything else on my differential for this hypotensive patient with concerning physical exam findings 5 days out from a serious car accident.

Once her man scan was done, I looked though the scans and noticed her right kidney was heterogenous with contrast enhancement with stranding around it. No fluid in her pelvis, and the rest of the man scan was entirely negative. Radiology soon called and said she had the “worst case of pyelonephritis I think I’ve ever seen”. A urine sample was finally collected after the scan resulted, which was, no longer to my surprise, infected. Upon talking to the patient, she denied any dysuria or frequency, but said her urine was “green” this morning. She never had any suprapubic pain.

That is the story of how I admitted a patient to medicine for pyelonephritis after getting a man scan and diagnosing it on CT. I don’t think I’ll be changing the top item on my differential, but I think I will keep other causes of hypotension and shock on my differential until they are ruled out in cases of delayed trauma presentation, such as this one.

ED Thoracotomy

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ED THORACOTOMY
Hey guys! Here’s the latest overview of ED thoracotomies from LITFL.com posted on March 11, 2016.  I’ve only seen 3 of these during my medical career, two of them were last week. One was my patient and the other was Jenny’s. While both didn’t survive their hospital course, my patient did regain a pulse and make it through several hours of surgery. If you haven’t encountered this scenario yet, I’m sure you aren’t alone. Still, it’s important to know not only how to perform it, but when.
Interesting articles to review:

  • #1 To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: a systematic review and meta-analysis.

    Slessor D1, Hunter S2.

    Author information

    Abstract

    STUDY OBJECTIVE:

    The role of emergency department (ED) thoracotomy after blunt trauma is controversial. The objective of this review is to determine whether patients treated with an ED thoracotomy after blunt trauma survive and whether survivors have a good neurologic outcome.

    METHODS:

    A structured search was performed with MEDLINE, EMBASE, CINAHL, and PubMed. Inclusion criteria were ED thoracotomy or out-of-hospital thoracotomy, cardiac arrest or periarrest, and blunt trauma. Outcomes assessed were mortality and neurologic result. The articles were appraised with the system designed by the Institute of Health Economics of Canada. A fixed-effects model was used to meta-analyze the data. Heterogeneity was assessed with the I(2) statistic.

    RESULTS:

    Twenty-seven articles were included in the review. All were case series. Of 1,369 patients who underwent an ED thoracotomy, 21 (1.5%) survived with a good neurologic outcome. All 21 patients had vital signs present on scene or in the ED and a maximum duration of cardiopulmonary resuscitation of 11 to 15 minutes. Thirteen studies were included in the meta-analysis. If there were either vital signs or signs of life present in the ED, the probability of a poor outcome was 99.2% (95% confidence interval 96.4% to 99.7%).

    CONCLUSION:

    There may be a role for ED thoracotomy after blunt trauma, but only in a limited group of patients. Good outcomes have been achieved for patients who had vital signs on admission and for patients who received an ED thoracotomy within 15 minutes of cardiac arrest. The proposed guideline should be used to determine which patients should be considered for an ED thoracotomy, according to level 4 evidence.

    #2 Inaba K et al. FAST Ultrasound Examination as a Predictor of outcomes After Resuscitative Thoracotomy: A Resuscitative Thoracotomy. Ann Surg 2015; 262 (3): 512 – 8. (Inaba et al. 2015)*

    • Background #1: In patients who suffer a traumatic cardiac arrest, a final salvage maneuver that is performed in the Emergency Department (ED) is a resuscitative thoracotomy (RT). There are two lines of thought about RT that are on opposite sides of the spectrum. The first line of thought is that if RT is not performed the patient is going to die anyways, so why not try it as a last ditch effort. The second line of thought is that due to the low yield in survival with RT, why expend resources and create a potential risk of harm to providers. The Focused Assessment Using Sonography for Trauma (FAST) has a high sensitivity and specificity for identifying hemopericardium and cardiac activity in a matter of seconds. Since there is really no good way to discriminate between which patients with traumatic cardiac arrest would benefit from RT, maybe adding a bedside FAST could help make this distinction.
    • This was a prospective, observational trial in 1 Trauma center in California
      • Patients undergoing RT in the ED
        • All penetrating trauma patients with absent vital signs
        • All blunt trauma patients with loss of vital signs en route or in the resuscitation bay
      • FAST performed just before or concurrently with RT
    • Bottom Line #1: ALL survivors and organ donors had visible cardiac motion on FAST. If no cardiac motion or pericardial effusion was seen on FAST, then survival was zero.

These are useful especially when you’re looking at who to perform this on. End goal is for the patient to survive the hospital course or in the case of possible organ donation.

Due to the large regional and facility variation in practice of who/when to perform this procedure, it will be very important for you to know what your facility’s policy is or your trauma team’s stance is as well.

Quick ED thoracotomy video. ..no instructional audio, so go over the steps prior to watching this. Otherwise, you may be lost. ..

Below is LITFL’s most recent post from 03/11/16:
ED Thoracotomy

Resuscitative Thoracotomy

OVERVIEW

  • resuscitative thoracotomy is a thoracotomy performed prehospital, in the emergency department or elsewhere that is an integral part of the initial resuscitation of a patient
  • an alternate term is emergency thoractomy
  • survival 4-33%
  • determinants of survival include mechanism of injury, the location of injury and the presence or absence of vital signs
  • best outcomes in:

-> penetrating chest
-> those exsaunginating from chest tube
-> isolated chest trauma
-> cardiac injuries
-> abdominal trauma that benefits from aortic clamping
-> time since loss of vitals

REQUIREMENTS

  • ETT
  • shock or arrest with a suspected correctable intrathoracic lesion
  • specific diagnosis (cardiac tamponade, penetrating cardiac lesion or aortic injury)
  • evidence of ongoing thoracic haemorrhage

INDICATIONS

Accepted

  • penetrating injury + arrest + previous signs of life
  • blunt injury + arrest + previous signs of life

Relative

  • penetrating injury + no signs of life and CPR < 15min – blunt injury + signs of life in field or during transport -> arrest 15 min
  • blunt injury + no signs of life
  • multiple blunt trauma
  • severe head injury

RESUSCITATION IN TRAUMATIC ARREST

  • 1. Intubate (reverses hypoxia)
  • 2. Insert bilateral chest drains (or thoracostomies)
  • 3. Resuscitative Thoracotomy
  • 4. Limit fluid as this worsens outcome in penetrating thoracic trauma unless haemorrhage controlled
  • 5. Limit inotropes and pressors until circulation restored (will need once defect repaired)

TECHNIQUE

Goals

  • relieve cardiac tamponade
  • perform open cardiac massage
  • occlude aorta to increase blood flow to heart and brain
  • control life threatening thoracic bleeding
  • control bronchovenous air embolism

1. Full aseptic technique*** –> This was recently an issue where the Trauma attending cited both his team and ours in Rm9 for lack of full prep –> masks, surgical gloves, gowns, etc. should be worn when performing this procedure.
2. Scalpel through skin and intercostal muscles to mid axillary line.
3. Insert heavy duty scissors into thoracostomy incisions.
4. Cut through sternum.
5. Lift up (clam shell)

-> relieve tamponade (longitudinal incision through pericardium)
-> repair cardiac wounds (non-absorbable sutures, 3.0)
-> stop massive lung or hilar bleeding with finger (partial or intermittent occlusion may be performed to avoid right heart failure)
-> identify aortic injuries (repair with 3.0 non-absorbable sutures or use finger)
-> consider aortic cross clamping at level of diaphragm (limits spinal cord ischemia)