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)

The Awful Facet of Compare and Contrast Essay Subjects

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Trach Management Algorithms/Videos

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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

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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.

“Knot in my Throat”

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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.

Cervical seatbelt sign and CTA

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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 BCVI adapted from Biffl et al[10] (with permission)
Screening Criteria for BCVIInjury mechanism

  • Severe cervical hyperextension/rotation or hyperflexion, particularly if associated with
    • Displaced midface or complex mandibular fracture
    • Closed head injury consistent with diffuse axonal injury
  • Near hanging resulting in anoxic brain injury Physical signs
  • Seat belt abrasion or other soft tissue injury of the anterior neck resulting in significant swelling or altered mental status

Fracture in proximity to internal carotid or vertebral artery

  • Basilar skull fracture involving the carotid canal
  • Cervical vertebral body fracture
Denver Modification of Screening Criteria for BCVI adapted from Cothren et al[51] (with permission)
Denver Modification of Screening CriteriaSigns/symptoms of BCVI

  • Arterial hemorrhage
  • Cervical bruit
  • Expanding cervical hematoma
  • Focal neurological deficit
  • Neurologic examination incongruous with CAT scan findings
  • Ischemic stroke on secondary CAT scan

Risk factors for BCVI

  • High-energy transfer mechanism with
    • Lefort II or III fracture
    • Cervical spine fracture patterns: subluxation, fractures extending into the transverse foramen, fractures of C1-C3
    • Basilar skull fracture with carotid canal involvement
    • Diffuse axonal injury with GCS =6
    • Near hanging with anoxic brain injury

Decreased Survival with Intubation During Cardiac Arrest

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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

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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?

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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.