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New article here on screening for sex trafficking in the ED. Interesting and very practical study on screening our patients. Only takes a few questions to possibly save someone’s life.
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The Awful Facet of Compare and Contrast Essay Subjects
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Trach Management Algorithms/Videos
As a follow up to Dr. Dennison’s presentation yesterday: see this link if you’d like to watch a couple videos on replacement/troubleshooting. They go through passing a new Trach over an airway exchange catheter as well as a Bougie.
http://www.tracheostomy.org.uk/Templates/Videos.html
This link is the algorithms for both Tracheostomy and Laryngectomy: http://www.tracheostomy.org.uk/Templates/Algorithms.html
Facial Edema
This was an interesting presentation from a Peds shift.
15 y/o AAM with no significant medical history who presents with facial swelling. Patient noticed significant swelling to the left side of his face upon awakening in the morning. The swelling involved his entire left cheek, inferior lid of his left eye, upper lip and part of his right cheek. The patient denies any pain, tongue swelling, voice change, difficulty breathing or swallowing, fevers, recent ill symptoms (cough, congestion, vomiting, diarrhea), dysuria, hematuria, rectal bleeding, sore throat, ear complaints. He denies any new exposures including new medications, new soaps, detergents, animal exposures, environmental exposures, recent travel, insect bites.
PMH:none. PShx: had 4 wisdom teeth removal 1 month prior (finished antibiotics), no other recent surgeries or dental work. No EtOH, drugs. No current medications. No known allergies.
Vitals: 97.8, 90, 110/70, 18, 99 % on RA
Exam: HEENT- moderate swelling of the left buccal area, inferior lid of the left eye, upper lip. Mild swelling to the right buccal area. No erythema or palpable areas of fluctuance. No swelling surrounding the right eye. No conjunctival injection. No erythema within the ears, TMs normal. No mastoid tenderness. No lingual swelling, no erythema within the mouth or palpable areas of fluctuance. No signs of infection from previously removed wisdom teeth. No posterior oropharyngeal swelling or uvular deviation. No lymphadenopathy.
Heart- normal. Lungs- clear, no wheezing or stridor. Abdomen- normal. No CVA tenderness.
Treatment started with Benadryl for possible allergic reaction. Basic labs obtained and urine for possible nephrotic syndrome. WBC-17, otherwise normal. Urine with 200 protein, no RBC or WBC- nephrology consulted and recommended repeat POC labs as outpatient and follow-up in clinic, but no intervention at this time. Patient had mild improvement with Benadryl. Discharged home with Benadryl and steroids.
Patient re-presents 6 hours later (just came back for my shift the next day)
Facial swelling has worsened. Now involves bilateral buccal areas, bilateral lower eyelids and upper lip. No fevers, no difficulty breathing, no dysphagia. Patient had taken 1 repeat dose of Benadryl at home and had not started steroids yet. No other changes in HPI except patient mentions some bleeding from the inside of his upper lip. Upon exam, patient has some bleeding and purulent drainage from the gumline of his left central incisor. No palpable fluctuance, but able to express drainage with pressure to upper lip.
Labs obtained: WBC 17, CRP 1.6, ESR 41. UA- minimal protein. All other labs unremarkable. CT face with contrast obtained showing left central incisor periapical abscess with cortical erosion as well as extensive cellulitis of the midface. Also some concern for phlegmon within the paranasal sinus. ENT, OMFS, and finally pediatric dentistry consulted. Patient admitted for IV clindamycin, Unasyn for cellulitis and dentistry consult for possible root canal versus tooth extraction.
Bottom line: Odontogenic infections can cause orofacial infections and rarely but more importantly peripharyngeal space infections as well as jaw osteomyelitis. If concerned about deep facial infection, CT face is warranted. Treatment includes draining of pus from abscesses (either through I&D or needle aspiration) and culture as well as antibiotic therapy. Common regimens include a penicillin plus metronidazole, clindamycin, augmentin, or unasyn depending on disposition. Dentistry should be involved whether through consult or outpatient follow-up for root canal versus tooth extraction.
UofL Status Epilepticus Treatment Protocol
Labetalol Shortage
Alternatives to Labetalol- Drug currently on Shortage
“Knot in my Throat”
Recently had a patient while on a Peds EM shift with an interesting presentation. Not sure how many of us have had this case, so this should serve as a helpful reminder for management.
15yF with no significant PMHx presenting with a “knot in my throat.” Per patient report, she woke up the morning of presenting to the ED with a palpable knot. Unsure how long it had been present, but she happened to notice it that morning. Denies hx of fever, chills, changes in energy level, palpitations, shortness of breath, odonyphagia, dysphagia, changes in menstrual cycle, recent URI, changes in hair or nail quality nor irradiation to the neck. Mother was really concerned because 2 people in her family had either thyroid carcinoma or nodules removed. One was diagnosed in her 20s.
On physical exam:
General: AFVSS
HEENT: NCAT, EOMI, PERRLA, no evidence of exophthalmos
Neck: Supple, Trachea midline, R anterio-lateral neck mass – approx 1.5cm x 2cm. Firm to palpation and located anatomically near superior pole of R thyroid lobe. Moves with swallowing. No associated erythema or fluctuance. No cervical lymphadenopathy.
Lungs: CTAB,
CVS: RRR, no m/r/g. Pulses equal. No peripheral edema.
So you get labs: CBC,TSH, Free T4
All within normal limits
Beside USN revealed what appeared to a multicystic nodule in the R thyroid lobe where the patient’s palpable mass was located. So let’s get a formal USN.
Formal reveals that patient actually has multiple nodules. The largest being approx 3cm x 2cm x 2cm, and read as a colloid nodule.
Let’s recap:
We have a 15yF presenting with an asymptomatic thyroid nodule, who is euthyroid based on hx, physical exam, and labs. What’s next??
1. Discuss the case with a Pediatric Endocrinologist. Nothing acutely needs to be done; however, she should have outpatient followup with an endocrinologist to help keep surveillance of her nodules.
2. Add testing for Thyroid specific antibodies to rule out Hashimoto’s thyroiditis and other autoimmune inflammatory processes. Consider adding Anti thyroid peroxidase (Anti-TPO) and Anti-Thyroglobulin antibodies.
3. Ultrasound simply characterizes the mass that we’ve palpated. Yes, the nodule was read as a “colloid nodule,” which is fairly common regarding thyroid nodules; however, this needs to be confirmed by Cytopathology. Nuclear studies can be done but not recommended in isolation. Such studies can be helpful when determining whether a nodule is “hot” or “cold.” Simply speaking, is there increased thyroid uptake or not. CT and MRI imaging is not cost effective in the initial stages of evaluation.
4. Lastly, the best way to determine whether a nodule is benign or malignant, you have to sample the source via Fine Needle Aspiration Biopsy (FNAB). Await the cytopathology results and return to #1.
EM Cases: Occult Knee Injuries
Good 5-10 minute read with lots of pearls on Knee Injuries in the ED, their assessment, exam findings, and management.
Cervical seatbelt sign and CTA
Summary: No CTA for isolated cervical seatbelt sign.
Good blog post.
http://wueverydayebm.blogspot.com/2014/07/does-cervical-seatbelt-sign-mandate.html
Take Home:
CT-angiogram is not necessarily indicated based on the finding of a cervical seatbelt sign alone in the absence of significant hematoma, neurologic symptoms, or other traumatic injuries.
EAST Guideline:
https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury
What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI?
1. Patients presenting with any neurologic abnormality that is unexplained by a diagnosed injury should be evaluated for BCVI.
2. Blunt trauma patients presenting with epistaxis from a suspected arterial source after trauma should be evaluated for BCVI.
3. Asymptomatic patients with significant blunt head trauma as defined below are at significantly increased risk for BCVI and screening should be considered. Risk factors are as follows:
* Glasgow Coma Scale score ≤8;
* Petrous bone fracture;
* Diffuse axonal injury;
* Cervical spine fracture particularly those with (i) fracture of C1 to C3 and (ii) fracture through the foramen transversarium;
* Cervical spine fracture with subluxation or rotational component; and
* Lefort II or III facial fractures
From EAST Guideline:
An isolated cervical seat belt sign without other risk factors and normal physical examination has failed to be identified as an independent risk factor in two retrospective studies and should not be used as the sole criteria to stratify patients for screening.
References:
https://www.ncbi.nlm.nih.gov/pubmed/12013287
https://www.ncbi.nlm.nih.gov/pubmed/12013287
Alternate Screening Guidelines:
Screening Criteria for BCVIInjury mechanism
Fracture in proximity to internal carotid or vertebral artery
|
Denver Modification of Screening CriteriaSigns/symptoms of BCVI
Risk factors for BCVI
|
Decreased Survival with Intubation During Cardiac Arrest
Quick Read on something I feel like comes up a lot with our cardiac arrest patients. They don’t typically need intubated, they need good CPR. Bag or put an LMA in and stop at that. While the numbers aren’t astounding, given the differences in such a large amount of patients think these make sense.
http://www.healio.com/cardiology/arrhythmia-disorders/news/online/%7B5396b1a2-0167-4a2d-885c-0e1bc527398e%7D/findings-do-not-support-early-tracheal-intubation-for-in-hospital-cardiac-arrest-in-adults
Top Ten UTI Myths
Good 5-10 minute read on myths regarding UTI and asymptomatic bacteriuria. Hope you’ll take a look as this is a common problem in many EDs, not just ours with regards to over-diagnosis and over-treatment.
http://www.medscape.com/viewarticle/865175
Ross
Abandon the BVM?
Excellent 1 pager from Dr Levitan in the new ACEP now newspaper.
I have been trying to get the residents to implement the nasal cannula, and to a lesser extent the LMA, for years. Pearl: nasal cannula plus mandible traction opens the nasopharynx and allows oxygen to diffuse to the alveoli (due to gradient made by hemoglobin absorbing oxygen). This is apnea oxygenation, increased safe apnea time. See the pure gold article by Levitan/Weingart, apparently 4th most read annals of EM article.
Add the cannula and mandible thrust to a properly positioned patient, ear to sternal notch or even well above sternal notch, and you will be amazed how long it takes to desat. OOPS (Oxygen On, Pull the mandible, Sit the patient up.
Read this brief article a few times and change how you practice.
Level 1 Rapid Infuser & Autotransfusion
All,
Couple videos on what was covered today with Level 1 Infuser and Autotransfusion. They’re not bad, definitely get the overall setup at least. With the autotransfusion videos, there are a few small differences in their setup vs ours I think, but overall for your purposes is mostly the same. Hope this helps.
Ross
Level 1 Infuser
https://www.youtube.com/watch?v=9YIROsYE_Yo
Autotransfusion
https://www.youtube.com/watch?v=WmLs-43jaR4
Wellness Lecture
Here is the Micronutrient Wellness lecture.
How Evidence Based Are We?
Here is a pretty comical article by Dr Ioannidis. If you do not know who this is stop now and read this.
This article was just published. It is written as a report to the father of evidence based medicine, Dr David Sackett. It takes a not terribly optimistic view of the current state of medical research. He calls out industry bias, ghost authorship, and many other flaws of our system. We are very lucky to have people like Dr Ioannidis ensuring integrity to the research process.