• Pediatric Respiratory Distress (Dr. Poteh)
  • Bronchiolitis
    • <2 years (>2 years is referred to as WARI)
    • Leading cause of hospitalization in infants in the US
    • Symptoms often worsen on day 3-5 of illness and worse at night
    • Hypoxemia occurs from V/Q mismatch from mucus plugging
    • Pathophysiology à infection causes inflammation of the bronchiolar epithelium
    • Commonly causes by RSV, but also caused by other viruses and bacterial infections
    • Exam tricks:
      • Expose trunk
      • Count RR yourself for at least 30 seconds
      • Note signs of respiratory distress
      • Assess activity level (playful, fatigue, lethargic)
      • Assess hydration status (tears, saliva, capillary refill, wet diapers in 24 hours)
      • Check the ears (occasionally have coinfections)
      • Always do an abdominal examination to assess for hepatosplenomegaly
    • Management:
      • Suction! Suction! Suction!
      • CXR unnecessary unless concern for superinfection or clinical picture not consistent with typical bronchiolitis (prolonged symptoms, high fevers, persistent hypoxia) à atelectasis and peribronchial cuffing on CXR if obtained
      • Viral testing is not always necessary (exception: influenza, COVID-19, RSV <1 month causes apnea)
      • Respiratory support
      • Dexamethasone in patients <1yo with no history of wheezing did not demonstrate benefit
      • Albuterol has not been shown to benefit patients
    • Bronchiolitis Score is helpful with risk stratification
    • Discharge Criteria
      • O2 saturation >90% while awake
      • Adequate PO intake
      • Mild/moderate work of breathing
      • Reliable caretaker
      • Timely pediatrician follow-up in 1-2 days
    • Admission Criteria
      • Hypoxemia
      • Severe respiratory distress
      • Apnea
      • High-risk patients
      • Poor oral intake
      • Parents uncomfortable with discharge
    • Consider intubation if…
      • Recurrent apnea
      • Declining mental status
      • Not improving with respiratory support
  • Asthma Exacerbation    
    • Antibody binds antigen à release of histamine/leukotrienes à inflammation à bronchospasm
    • Pediatric Respiratory Assessment Measure (PRAM) is helpful for risk stratification
    • Timing of medications is key!
    • CXR is not required unless concern for complicating factors
    • Management:
      • Beta-2 agonists 
        • Albuterol à MDI vs. nebulizer
          • Always use a spacer!
          • Short vs. 1-hour long vs. continuous albuterol nebulizer
          • Discharge à take 4 puffs every 4 hours for the next 48 hours, then as needed after that
          • Remember to write for MDI with spacer if discharging with albuterol prescription
        • Terbutaline à IV vs. SQ
      • Corticosteroids à mainstay of treatment considering the pathophysiology
        • Dexamethasone
        • Prednisone/prednisolone
        • Methylprednisolone
      • Ipratropium nebulizer
        • Anticholinergic
        • Often used in conjunction with albuterol nebulizer
      • Magnesium sulfate
        • Smooth-muscle relaxer
        • Can cause smooth-muscle relaxation in the vasculature à hypotension (consider IVF bolus)
      • Epinephrine à anaphylaxis dosing
    • Admission Criteria
      • Requiring >1 1-hour long albuterol
      • Respiratory distress
      • Hypoxemia (O2 <92%)
      • Dehydration
  • Croup (laryngotracheobronchitis à upper airway)
    • Acute subglottic inflammation
      • Morbidity is greatest in 1^st year of life due to narrower subglottic airway
    • Affects children aged 6-36 months
    • Classically caused by parainfluenza virus, but also caused by many other viruses
    • Clinical presentation:
      • Barky cough
      • Inspiratory stridor (more concerning if occurring at rest)
      • Tachypnea
      • Suprasternal retractions (hypoxia, intercostal retractions, abnormal breath sounds, subcostal retractions are uncommon à croup is a disease of the upper airway, if hypoxia is present and lungs are clear to auscultation there should be high concern for impending upper airway compromise)
      • Low-grade fever
    • Management
      • Dexamethasone
      • Racemic epinephrine for resting stridor or respiratory distress (can repeat every 15-20 minutes)
      • Monitor for 3-4 hours prior to discharge if administering racemic epinephrine à admit for refractory stridor or if repeat dosing of racemic epinephrine is required
      • Consider Heliox for severe respiratory distress as it decreases turbulent flow

• Documentation Lecture (Ashley Chesman)
  • Critical Care Documentation
    • 7.2% of all ED visits reported to Medicare in 2019 were reported as critical care
    • Time at bedside, but also time spent engaged in work directly related to the patient’s care:
      • Reviewing test results and imaging studies
      • Consulting services
      • Placing orders
    • Procedures billed separately
    • Billings starts at 30 minutes à critical care time requests <30 minutes may not be compensated  
    • E/M and Critical Care Same Date of Service
      • Can now bill for E/M and Critical Care on the same date/visit
      • Documentation must support decompensation to a state requiring critical care
    • Remember to document critical care time beginning in residency!

• Subclavian Central Venous Lines (Drs. Nichols and Leavitt)
  • Contraindications
    • Overlying infection
    • Anatomic obstruction
    • Fracture of ipsilateral clavicle
    • Relative à coagulopathy (harder to compress and apply pressure to the subclavian site)
  • Complications
    • Arterial injury
    • Pneumothorax
    • Air embolism
    • Cardiac dysrhythmia
    • Infection
    • Bleeding
  • Supra- vs. Infraclavicular Subclavian Access
    • Infraclavicular
      • Utilizes short-axis ultrasound
      • Index finger on the sternal notch and thumb at the midpoint of the clavicle at the angle
      • Make contact with the clavicle and “walk-down” and pass under the clavicle vs. insert needle further laterally to avoid having to “walk-down” the clavicle
      • Ultrasound assisted technique utilizes short-axis
    • Supraclavicular
      • Well-defined landmarks (claviculo-SCM angle)
        • 1 cm superior and 1 cm lateral to the claviculo-SCM angle
        • 5-15 degrees above the coronal plane
        • Don’t advance past 3 cm
        • Ultrasound assisted technique utilizes long-axis as opposed to the short-axes
      • Shorter distance from skin to vein
      • Larger target area
      • Straighter path to the SVC
      • Less proximity to the lung
      • Fewer complications compared to infraclavicular
      • Found to be non-inferior to the infraclavicular approach

04/06/2022

• Lightning Lectures – Pulmonary Cases (Drs. Bishop and Slaven)
  • Tuberculosis
    • TB concern à NAAT + sputum cultures to assist with diagnosis (95% sensitive)
      • Negative pressure room with airborne precautions, PPE precautions for providers, HIV test if TB suspected  
    • Mycobacterium tuberculosis à aerobic rod, highly antigenic à can disseminate systemically if initial granuloma formation fails to contain the infection
    • Immunocompromised population at highest risk (2x)
    • bCG vaccine recipients all have positive TB skin tests (PPD)
    • Interferon test does not distinguish between latent and active TB
    • Active TB àINH, RIF, pyrizanimide, ethambutol x8 weeks à INH/RIF x18 weeks + B6
      • Hepatotoxicity
    • Latent TB à INH x9 months + B6
    • Must contact Public Health Department prior to discharge
  • Spontaneous Pneumothorax
    • Sudden pleuritic chest pain, increased work of breathing, hypoxia
    • DDx with examination + upright CXR
      • CT chest is very sensitive/specific but takes time to obtain
      • Consider US
    • Management:
      • Supplemental O2
      • Unstable à Decompression (treatment for tension PTX)
      • Stable, small à consider observation 4-6 hours, repeat CXR, must ensure follow-up within 24 hours à admit any recurrent or complicated PTX
      • Admit everything else and all PTX caused by comorbidities
• Inhaled Intoxicants (Dr. Eisenstat)
  • Huffing/bagging à toluene is intoxicating substance (higher in gold and silver paints)
    • Can cause NAGMA, renal tubular acidosis, hypokalemia, chronic encephalopathy
    • Sudden sniffing death syndrome à hydrocarbon (huffing) + high levels of catecholamine surge à death
      • Generally not recommended to use epinephrine/norepinephrine in patients suspected of hydrocarbon toxicity
  • Aluminum encephalopathy from black tar heroin use à basal ganglia lesions on MRI
  • High water solubility à chlorine, tear gases, ammonia (mucous membrane effects)
  • Low water solubility à phosgene, chloramine, nitrogen dioxide (delayed pulmonary edema)
  • Phosphine gas/aluminum phosphide à occurs when aluminum phosphide interacts with moisture à can expose providers during ventilation efforts/resuscitation
  • Nitrogen dioxide à silo fillers
  • Phosgene à choking agent, delayed pulmonary edema
  • Tear gases à OC spray AKA pepper spray AKA mace à capsaicin-based tear gas à causes severe burning and irritation, CS (military grade) is more potent
    • Treatment is irritation (consider Morgan lens for eye involvement)
  • Organophosphates à nerve agents àdecontamination, atropine, pralidoxime, supportive care
  • Asphyxiants à methane, propane, argon gas à sudden collapse, helper also collapses, etc.
  • Carbon monoxide à can be high in smokers (COHgb of 10) and large cities
    • Treatment is controversial à begins with O2 therapy (100% FiO2, NRBM)
    • Consider hyperbaric in COHgb levels >25 (15 in pregnant patients due to fetal Hgb affinity for CO) or signs of organ dysfunction (AMS, NSTEMI)
    • The reason for HBO therapy is to reduce long-term symptoms, which are often delayed (up to 6-8 weeks), not life-saving
  • Cyanide à combustion of nitriles in house fires à leads to unconsciousness and CV collapse à elevated lactate (>8 with ingestion, >10 in house fires) with high suspicion
    • Amyl nitrite (induces methemoglobinemia) vs. Hydroxocobalamin/Cyanokit (safer, colors urine organe/red) with levels >8 
  • Hydrogen sulfide à cellular asphyxiant similar to cyanide à rotten-egg smell in low concentrations (odorless in high concentrations), used in chemical suicide

• COPD and Asthma Cases (Dr. French)
  • COPD à titrate goal O2 to 88-92%
  • Patients need PPV
  • Antibiotics for COPD exacerbation à some evidence for reduced rate of readmission/representation
  • Remember to consider breath-stacking/auto-PEEP in MV
  • PRAM Score for asthma exacerbation à follow-up 3 hours with additional PRAM Score, can assist with disposition planning
    • PRAM >12 à marker of impending respiratory failure

• ED Management of Brain Aneurisms (Dr. Ding)
  • Unstable à repair
  • Stable à timely outpatient follow-up
  • 1/3 will die, 1/3 will be self-sufficient at discharge, 1/3 will have poor recovery
  • Surgery (clip) vs. endovascular (coiling)
    • Treatment modality depends on multiple factors à age, medical comorbidities, multiple aneurisms, location, size, symptoms
  • Which aneurisms will rupture à location (anterior communicating, posterior communicating aa. higher risk) vs. size of aneurism vs. risk factors vs. family history vs. connective tissue disease/AAA vs. stress vs. growth of aneurism  
  • Enlarging and symptomatic unruptured aneurisms should be treated
  • Before/after stent-coiling or flow diversion à DAPT
  • Consult NES for incidentally found aneurisms on imaging, both admitted and discharged
  • CTA/MRA for history of aneurism and symptoms
  • Consider SAH in post-coital headache 
  • Don’t forget about LP vs. MRI in patients suspicious for SAH with negative CT/CTA

Interesting paper here, retrospective data pulled from the NEAR registry, a big high quality airway registry.

The take home point was NO difference in desaturations during induction in the ramp vs supine position. They reported DL and VL cohorts separately. Now I like to ramp patients, especially those with low GCS or obesity. So I am going to find the issues with the paper, and try to hold strong in my beliefs.

But seriously, there are some problems. It is retrospective. The patients who were ramped were probably sicker and more obese! It turns out they are:

However, obesity and subjective impression of difficult airway were more common in the ramped cohorts (Table 1) and independently associated with postinduction hypoxemia (Tables 3 and 4).

The paper is in AEM and therefore very well done. They perform adjusted analyses to try to tease out any real effects. But you cannot infer causation with this study. They do cite one paper on ICU intubations that found no benefit and possible adverse effects of ramping. But this study did not control for … wait for it … apneic oxygenation! Remember the post this week on airway success, apneic oxygenation is awesome, do it. But at least in this paper all patients had apneic O2.

Something else left out is how long they were ramped before intubation (i wouldn’t expect 30 seconds of ramping to help), they excluded trauma patients, they didn’t talk about how ramping can prevent vomiting / aspiration, they did mention that perioperative data suggests benefit to ramping : ).

Overall this paper is worth reading and the stats get pretty thick. Maybe a journal club in the future. But we have to be very careful making practice changes or any strong assertions based on a confounded (direct quote: “we are unable to control for unmeasured confounders”) retrospective paper.

Check out this paper in the upcoming Annals of EM. Data from the Videography in Pediatric Resuscitation (VIPER) Collaborative. Not a huge number of patients (494), but a solid N for a pediatric airway paper.

Research Pearl: Never just read the abstract, at least also look at the tables and figures! Then of course when you write a paper (or even an abstract), spend tons of time on your tables and figures, they are often the most efficient way to convey your findings to the reader.

Much of their findings are of course applicable to adult airway. Some interesting stats:

– The first-attempt success rate was 67%

– Median laryngoscopy duration 35 seconds (interquartile range 25 to 40)

– Hypoxemia occurred in 15% of the patients.

– Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia.

– Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts.

***What is happening? Why do we not set up apneic oxygenation on everyone? They had two of the 18 people (11%) with apneic O2 desat, but 18% of those with no apneic O2. Of course 18 is a tiny number and we can’t draw any conclusions, but there is no reason not to throw a nasal cannula (>15L) on every patient you intubate.

Take a look at Table 1 (pasted below), impressive intubation success for EM residents.

Ok that’s probably enough for one post, check out the paper.

Aaron R. Kuzel, D.O., M.B.A

Acute Coronary Syndrome

Acute Coronary Syndrome or ACS is any condition that results in ischemia of the coronary arteries resulting in diminished perfusion of the myocardial tissue. There is a spectrum of cardiac diseases that fall into the designation of ACS including: ST-Elevation Myocardial Infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. This discussion will center around STEMIs as well as introduce some STEMI-equivalents.

Chest pain is the most common presenting symptoms for ACS. However, 20-30% of patients presenting with ACS will present with atypical symptoms. There are associated risk factors for ACS as noted in the table below.

Work-Up and Management

Patients presenting with concern for ACS should receive prompt electrocardiography (ECG) as well as CBC, chest radiograph, electrolytes, serum troponin, and PT/PTT. The 2013 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend serial ECGs in the first hour if there are concerning symptoms and the first ECG is non-diagnostic. The serial ECGs are important as approximately 15-20% of STEMIs are diagnosed on the repeat ECG. Missing a STEMI or myocardial infarction is one of the most common causes of malpractice for the emergency physician. The table below demonstrates the most common causes of losses in malpractice cases related to the cause of chest pain.

Definition of a STEMI

ST-segment elevations are noted with the red arrows. Notice that there are ST-segment elevations in three contiguous leads: II, III, and AVF. There is usually reciprocal ST-segment depression in the opposite leads associated with ST-elevation myocardial infarctions. In this case of an Inferior Myocardial Infarction, there are reciprocal ST-segment depressions in the Septal and Lateral leads. This is denoted with blue arrows.

Wellens Syndrome

Wellens Syndrome refers to angina associated with T wave inversions in the left anterior descending coronary artery or LAD most notably in leads V2 and V3. Wellens Syndrome often presents in a pain-free state, but those patients who did not undergo reperfusion therapy with Wellens Syndrome noted on the ECG fared poorly with 75% developing an anterior wall myocardial infarction due to proximal LAD occlusion. Patients diagnosed with Wellens Syndrome should proceed urgently to cardiac catheterization.

There are two types of Wellens Syndrome:

Type A is a biphasic T wave in V2 and V3 occurring in 25% of cases and Type B are deep, symmetrically inverted T-waves in V2 and V3 occurring in 75% of cases. (Picture from WikEM). In the EKG below from Life in the Fast Lane ECG Library , there are inverted T-waves in V2 and V3 consistent with Type B Wellens Syndrome.

De Winter’s T Waves

De Winter’s T waves were first identified in 2008 and account for 2% of proximal LAD occlusions making it a STEMI-equivalent requiring emergent cardiac catheterization. De Winter’s T waves are tall, peaked T waves in the precordial leads (V1-V6) with ST-segment depression at the J-point. In most cases, ST-segment elevation will be seen in lead aVR, however this is not specific.

In this figure, there are obvious peaked T waves in leads V2, V3, and V4 denoted by the red arrows indicating De Winter’s T waves. There is some ST-segment elevation in aVR consistent with this finding. A patient presenting to the emergency department with this ECG finding should go immediately to cardiac catheterization for likely LAD occlusion.

Left Bundle Branch Block with Myocardial Infarction

Previously, a new Left Bundle Branch Block (LBBB) was considered a STEMI-equivalent, however, recent literature suggests that a new LBBB does not often demonstrate increased risk of acute myocardial infarction. However, in 1996, Dr. Sgarbossa published a study of acute myocardial infarction in the presence of a LBBB with three criteria. Although the Sgarbossa criteria is not very sensitive, the findings were very specific for the finding of acute myocardial infarction.

Dr. Amal Mattu, professor of emergency medicine from the University of Maryland, separates the Sgarbossa criteria into three subsections: Category A, B, and C.

In Sgarbossa A, the QRS complex is deflected in the positive direction (up) and ST-segment elevation is also present or concordance. If this occurs in any lead in the presence of a LBBB this is a STEMI-equivalent and the patient should proceed to cardiac catheterization. In Sgarbossa B, the QRS complex is deflected in the negative direction as well as the ST-Segment depression a shown in the example above in V1. If the ST segment is depressed in V1, V2, or V3 and the QRS complex is deflected downward this is also a STEMI-equivalent indicating acute myocardial infarction in the presence of a LBBB. Finally, in Sgarbossa C if the ST segment elevation is greater than 5 mm (or 5 blocks), this may indicate a STEMI-equivalent, however this is not as specific as criteria A or B. That being said, the finding of Sgarbossa C should prompt the physician to consult Interventional Cardiology as well as consider other signs and symptoms of ischemia.

Sgarbossa A:

In the above example, there is ST elevation concordance with the QRS in the presence of a LBBB in lead aVL indicating a myocardial infarction. Notice, that this is the only lead with ST-elevation >1 mm, but the criteria indicates that concordant ST-segment elevation in any lead with a LBBB is an indication for PCI.

In this example, there is concordant ST-depression in lead V2 in the presence of a LBBB indicating the need for emergent cardiac catherization.

Conclusion:

There are many findings on ECG that could indicate either a STEMI, STEMI-equivalent, or the presence of ischemia. It is important to note that there are a multitude of other ischemic rhythms and this is a brief and limited introduction to ischemic ECGs. Ischemia can be present even in the absence of ECG changes or changes in troponin, so history and physical still remain the most important methods in physician diagnosis of myocardial infarction and ischemia.

For further reading for acute care ECGs, I recommend:

Electrocardiography in Emergency Medicine by Amal Mattu, Jeffrey Tabas, and Robert Barish

ECGs for the Emergency Physician Volume 1 and Volume 2 by Amal Mattu and William Brady

Electrocardiography in Emergency, Acute, and Critical Care by Amal Mattu Jeffrey Tabas and William Brady

References:

AHA ACA – NSTEMI ACS Guidelines 2014

de Winter R, et al. A new ECG sign of proximal LAD occlusion. NEJM. 2008; 359:2071–2073.

de Zwaan C, Bär FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 Pt 2):730-736.

Hennings JR and Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012; 30(6):994–1000.

Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med. 2000 Apr 20;342(16):1187-95.

Maloy KR, Bhat R, Davis J, et al. Sgarbossa Criteria are highly specific for acute myocardial infarction with pacemakers. West J Emerg Med. 2010;11(4):354-357. (Retrospective cohort; 57 patients)

Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffith JL, Selker HP. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000 Apr 20;342(16):1163-70.

Sgarbossa EB, Pinski SL, Barbagelata MD, et al. Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block. NEJM. 1996;334(8)

Thygesen, K et al. Fourth Universal Definition of Myocardial Infarction (2018). 2018 Nov 13;138(20):e618-e651.

Ünlüer EE et al. Red Flags in Electrocardiogram for Emergency Physicians: Remembering Wellens’ Syndrome and Upright T wave in V1. West J Emerg Med. 2012 May; 13(2): 160–162

As we know, point-of-care ultrasound has become an extremely useful tool in the ED, allowing providers to glean disposition-altering information from a quick and non-invasive bedside study.  On my ultrasound month, I helped out with a patient who presented with shortness of air for 2-3 days.  The patient was a fairly poor historian, but she reported progressive dyspnea on exertion for several weeks along with cough and orthopnea.  She had no formal diagnosis of COPD or CHF, but she had an extensive smoking history.  I was asked to perform a bedside echo to help narrow down the differentials. The images I obtained demonstrated some classic findings of right heart strain, and I felt like this would be a good opportunity to review some of them.

1. RV dilatation

In a normal heart, the LV should be fairly circular in the parasternal short axis view, and the RV will appear more crescent-shaped. Additionally, the walls surrounding the LV should move inward equally during systole. In the setting of elevated RV pressures, you can often see the interventricular septum bowing in towards the LV, creating a “D” shaped left ventricle, as seen in the clip above. Interestingly, there are different variants of the so-called “D sign”, helping to distinguish between right ventricular pressure vs. volume overload. In pressure overload, the RV presses on the septum during systole AND diastole. Conversely, in volume overload, the septal bowing is much more pronounced in diastole compared to systole. Our patient has a D-shaped LV throughout the cardiac cycle, suggesting RV pressure overload.

4. McConnell’s Sign

This finding refers to RV wall hypokinesis with apical sparing. As you can see in the video above, the apex of the RV appears to bounce up and down while the rest of the RV remains stationary. In the right clinical setting, McConnell’s sign is considered highly specific for acute pulmonary embolism. Disclaimer: this clip came from one of Dr. Nichols’s patients who was later found to have an extensive saddle embolus.

5. Lack of respiratory variation in the inferior vena cava

The normal IVC diameter is less than 1.7 cm and there is a 50% decrease in the diameter during inspiration when the RA pressure is normal (0-5 mmHg). When the inspiratory collapse is less than 50%, the RA pressure is usually between 10-15 mmHg. If there is no collapse with respirations in a spontaneously breathing patient, this suggests markedly increased RA pressure > 15 mmHg. This is usually best evaluated using M mode, measuring the diameter of the IVC during inspiration and comparing to its diameter during expiration. Our patient has an enlarged IVC with almost no collapsibility throughout the respiratory cycle.

Conclusion

If you identify any of these findings on a patient in the emergency department, you should consider common causes of RV failure and strain, such as PE, pulmonary hypertension, left heart failure, ARDS, severe tricuspid regurgitation, volume overload, etc. Our patient received a CT PE in the ED, which was negative. She was subsequently admitted to the cardiology service, where right heart catheterization found evidence of severe pre-capillary pulmonary hypertension. After a few days of monitoring, she was subsequently discharged back into the world with a prescription for diuretics and follow up in the pulmonary clinic.

Neck Trauma
Dr. McMurray

Zone 1: Clavicles to cricoid

• Highest mortality rate due to proximity to mediastinal structures

Zone 2: Cricoid cartilage to angle of mandible

• Most commonly injured
• Classically, zone II injuries undergo surgical exploration, zone I and III undergo further evaluation

Zone 3: angle of mandible to base of skull

Penetrating trauma:

• Has to penetrate the platysma which demarcates superficial from deep wounds
• Most common cause of immediate death is involvement of carotid artery

Hard signs of vascular injury:

• Hypotension
• Arterial bleeding
• Rapidly expanding hematoma
• Deficits (pulse/neuro)
• (bruit/thrill)

Hard signs of aerodigestive trauma:

Air bubbling, massive hemoptysis, respiratory distress

Soft signs

subQ air

dysphonia

dysphagia

Blunt Trauma

• Blunt vascular injury have up to 60% risk of stroke; if no operative intervention, consider ASA/Plavix/heparin etc

Denver Screening Criteria

• Used to screen for vertebral and carotid artery dissection and/or injury after blunt head/neck trauma
• CTA if 1 or more criteria present
• Reduces number of missed injuries to <5%

Strangulation

• Most common cause of death is neck vessel occlusion rather than airway obstruction
• Also can have laryngotracheal fx, C-spine injury
• If dyspnea, dysphonia, odynophagia, etc need laryngobronchoscopy
  
  

Ophthalmic Trauma
Dr. Nelson

Corneal abrasions:

• Richly innervated = very painful
• Short healing time 24-48 hours
• Common causes: mechanical trauma, foreign body, contact lenses, flash burns
• Clinical features: foreign body/gritty sensation, injection, tearing, relief with topical anesthetic, can also have photophobia and vision change
• Workup and diagnosis: eyelid exam with eversion, fluorescein exam looking for uptake
• Consider corneal ulceration in contact lens wearers
• Treatment: Removal of foreign body, PO/topical NSAIDs, abx (erythromycin in general population, fluoroquinolone drops in contact wearers for pseudomonal coverage)
• Ophtho follow up

Open globe:

• Full thickness disruption of sclera or cornea
• Clinical pictures: pain, decreased visual acuity, teardrop shaped pupil
• AVOID pressure on the eye = do NOT perform tonometry
• May have positive Seidel’s test on fluorescein exam
• CT orbit if concern for foreign body
• Management: urgent ophtho consult for repair, cover eye, elevate HOB, bed rest, tdap, abx
  • If no foreign body, IV fluoroquinolone
  • If foreign body, IV vanc+ceftaz

Eyelid Lacerations:

• Ophtho consult for repair:
  • Lid margin
  • Within 6-8mm of medial canthus
  • Lacrimal duct/sac
  • Inner surface of lid
  • If ptosis is present
  • Tarsal plate or levator palpebrae involvement
• Full thickness (through and through): high risk for ocular injury, eval for corneal lacs and globe rupture
• Partial thickness: most simple horizontal lacs can be repaired by ED physician, ends of sutures should be kept away from cornea to prevent further abrasion
• Lid margin lacerations: very small <1mm do not need repair and will heal spontaneously, if larger consult ophtho for repair
  
  

PEM Lecture-Abdominal Trauma:
Dr. Elmore

• Trauma is the most common cause of death in children from 1-18 years old in the US
• Blunt abd trauma accounts for more than 90% of childhood injuries
• It is the most unrecognized cause of fatal injuries
• Children are at greater risk due to immature skeleton and they have higher abd organ to body mass ratio
• Children are able to compensate in the face of significant blood loss
• Clinical prediction rule may rule out intraabdominal injury in blunt trauma
  • No sign of abd wall injury
  • No TTP
  • No evidence thoracic wall trauma
  • No abdominal pain
  • No decrased bowel sounds
  • No vomiting
• HDS but concern for intraabdominal injury if:
  • Hct<30
  • UA>5 RBCs
  • AST>200,ALT>125
  • Elevated lipase
  • Low systolic BP
  • Femur fx
• Spleen most commonly injured intraabdominal organ, liver second
• Pancreatic injury = classic “handlebar” injury from bike accident (also consider duodenal injury/hematoma with this mechanism)
• Hollow viscera injuries are rare, but most common causes are lap belt injuries, peds vs. auto, NAT (rapid acceleration/deceleration)
• As many as 50% of children with Chance fx have intra-abdominal injury such as duo perf, mesenteric disruption, transection of small bowel, panc injury, bladder rupture
• TEN-4 rule for NAT
  • Bruising on torso, ears, or neck of child >4 years old
  • Any bruising in an infant 4 months old or less
    
    

Small Group: Abdominal Trauma
Dr. Harmon

•   Indications for immediate lap in penetrating abdominal trauma:
  • Peritonitis (rigid abdominal wall, rebound tenderness)
  • Hemodynamic instability
  • Evisceration of abdominal contents
  • Hematemesis or gross blood per rectum
• Literature varies widely on sensitivity of CT for bowel/mesenteric injuries
• CT findings that may indicate bowel injury:
  • Stranding, bowel wall thickening, pneumoperitoneum
• Findings concerning for diaphragm injury:
  • Elevated/blurred L hemidiaphragm, bowel sounds in chest, gastric bubble/air fluid level in chest, mediastinal shift away from affected side
  • Gold standard for diagnosis of diaphragm injury is exploration in OR; cannot be ruled out by CT or CXR

 Traumacology
Dr. Senn, PharmD

• Triad of trauma: hypothermia, coagulopathy, acidosis
  
  
• TXA for trauma patients:
  • CRASH-2 trial compared TXA vs. placebo
    • In hospital mortality within 4 weeks of injury
    • Reduction in all cause mortality, greatest benefit SBP<75 and if given within 3 hours of initial injury
  • MATTERS trial 1g TXA given, greater impact on those requiring MTP
• Take-home points for TXA: consider using in adult trauma patients with severe hemorrhagic shock (SBP<90), ideally <3h from injury
  • Dosing: 1g over 10 min followed by 1g over 8h
• Trauma patients, hypocalcemia, and blood transfusion
  • Twice mortality for those with iCal <0.9
  • Calcium plays vital role in coagulopathy
  • Consider administration 1g CaCl or 3g Ca gluconate when giving 3-4 PRBCs/FFP

“Can you come see this patient in triage? Their knee is definitely dislocated.”
“Hey, doc, we’re bringing in this guy involved in an MVC, his knee was dislocated but it reduced on its own.”

It is important to be able to tell the difference between a true knee dislocation and a patellar dislocation.

Patellar Dislocation
A normally functioning patella is nestled within the trochlear groove of the distal femur. Patellar dislocations can occur either from a direct blow to the knee or from planting the ipsilateral foot and rapid change of direction/twisting, either of which can cause the patella to become displaced from the trochlear groove. Usually the patella becomes displaced laterally.

Reduction of the patellar dislocation involves extending the leg at the knee. Gentle pressure can be applied from the lateral aspect, directed medially, while extending. Post-reduction plainfilms should be obtained to evaluate for any associated fractures. If no fracture, the patient can be placed in a knee immobilizer for 7-10 days and follow up with orthopedics. Patellar dislocations are recurrent around 40% of the time.

Knee Dislocation
Knee dislocations are most commonly high mechanism injuries and have a high rate of neurovascular injury. They are rare, but it is difficult to know how many there truly are as up to 50% of them reduce spontaneously. The most common nerve injury is to the common peroneal nerve, with the popliteal artery being the most commonly affected artery. 60% of knee dislocations have associated fractures.

Treatment is emergent reduction and neurovascular examination. Presence of pulses does not exclude vascular injury. ABIs can be performed if pulses are normal. If ABI normal, may elect to observe the patient. If ABI abnormal, CTA indicated. If pulses are unequal, decreased or absent, you must ensure that the joint was reduced appropriately, and if still unable to locate pulses, immediate surgical intervention may be required.

Especially since both patellar dislocations and knee dislocations may spontaneously reduce, it is helpful to ask the patient and/or EMS about the initial appearance of the knee. A self-reduced patellar dislocation likely only requires plainfilms, while a self-reduced knee dislocation merits further evaluation for neurovascular injury.

Pelvic Trauma
Dr. Ferko

• Signs of pelvic trauma: hematuria, inability to void, abnormally positioned prostate
• Diagnosis:
• Hematuria, but severity of hematuria on UA does not equal severity of injury
  • Plainfilms to evaluate for fx near kidney/bladder/urethra
  • Retrograde urethrogram
  • Retrograde cystogram
• Retrograde urethrogram-when?
  • Male with external signs of trauma
  • Perform ideally before foley placement
  • Females-urology consult needed
  • Defer if CTA pelvis needed as it will interfere with contrast
• Retrograde urethrogram-how?
  • Patient supine
  • Obtain baseline KUB
  • 60cc syringe with 10% contrast, in last 10cc repeat KUB
  • For stretch injury/partial disruption, usually conservative management with catheter
• Retrograde cystogram
  • Fully fill bladder; inject until full and then 50cc further (usually around 400cc)

(from Journal of Urology)

Le Fort Fractures
Dr. Lehnig

• Complete or partial separation of mid face from skull
• Pterygoid involved in all
• Usually caused by blunt trauma
• LeFort I most common
• Higher velocity more likely to cause II/III
• LeFort I: palate-facial separation (think dentures)-mobility of the maxilla
• LeFort II: (nose and mouth) Nasal bridge, maxilla, lacrimal bones, orbital floor, and rim
• LeFort III: across nasal bridge, orbital walls, zygomatic arch (“floating face”)
• Endotracheal intubation preferred over nasal, prep for difficult airway
• LeFort II/III: CTA indicated
• Complications: Vascular injury (internal carotid as high as 7%), nerve injury, eye injury
• Treatment: definitive tx is surgical, ophtho consult, NES if CSF leak
• No specific guidelines on abx, many get augmentin

Prehospital Airway Management
Dr. Price

• Methods available? ET tube (oral or nasal), BVM (with OPA/NPA), supraglottic, needle cric (methods vary by state per state regulations)
• Variables to consider: patient (age, condition), provider (level, experience, training), setting (environment, distance)
• Study with 4 Key questions addressed
  • BVM vs SGA
  • BVM vs ETI
  • SGA vs ETI
  • Benefits and harms comparison based on pt type, technique, and devices
  • Methods: 1990-2020, >9000 abstracts, 99 studies
  • Results…inconclusive benefits, but harms: no difference in reported aspiration, airway trauma, regurgitation with any devices; BUT number of attempts less with SGA than ETI
  • Conclusion: current evidence does not favor more invasive airway approaches based on survival, neurologic function, ROSC, or successful airway insertion
• More research needed, may be more useful to study ventilation management as it may reveal clinically relevant differences

Oral Boards Prep
Dr. Shaw

Learning Points:

• In every patient, unless something requires emergent intervention, perform physical exam head to toe
• Remember to request repeat vitals
• Use a systematic approach
• Primary survey in trauma:
  • MARCH
    • Massive hemorrhage
    • Airway
    • Respiration
    • Circulation
    • Hypothermia/Head injury
  • Massive hemorrhage:
    • Tourniquet: place proximal to bleed, write time of placement
    • Twist tourniquet until you lose pulses in the extremity
    • 2 inches, 2 hours
    • 2 inches proximal to wound
    • On for up to 2 hours (can be left up to 6 hours, but can have neurovascular damage)
  • Airway:
    • Oxygenate
    • Ventilate (apnea)
    • Protect airway (secretions, mental status)
    • Clinical course (too agitated for CT)
  • Respiratory:
    • Rate, breath sounds, stridor, tracheal deviation, JVD
    • Needle decompression can be done either anteriorly at mid-clavicular line or laterally at anterior axillary
    • If needle decompression or chest tube for penetrating trauma, remember to place occlusive dressing over the initial injuries/wounds
  • Circulation:
    • BP, HR
    • 14G (250ml/min) and 16G (150ml/min) peripheral IVs have higher flow rate than Cordis (130ml/min)
  • Head Injury/Hypothermia:
    • GCS, pupillary exam, neuro exam
• Primary survey for every trauma patient, every time

Tumor Lysis Syndrome – Dr. Aher

typically occurs within days after chemotherapy.

Findings of: Hyperkalemia, Hyperuricemia, Hyperphosphatemia, HYPOcalcemia (2/2 phosphate binding Calcium

Dialysis indications: Potassium >6, Cr. >10, Uric Acid >10, symptomatic hypocalcemia, Phos >10, Volume overload

Methemoglobinemia – Dr. Norby-Hill

Can happen with dapsone overdose

Dissociation between SPaO2 and PaO2

Acquired cases from medications and environment, commonly dapsone, local anesthetics, nitrites, h202

50% is fatal

Features: refractory to supplemental o2, color of blood, cyanosis, respiratory depression

Tx: methylene blue (Not in G6PD or those on SSRIs as MB is MAOI), ASCORBIC ACID, EXCHANGE TRANSFUSION

Pediatric Surgical Emergencies – Dr. Robin Lund

Early blood tinged emesis – cracked nipples

Pyloric stenosis: M>F 4:1, 3 to 5 weeks, veracious eaters, NBNB projectile every feed, dehydration, malnutrition

Appy’s usually missed the younger they are

Intuss – 6 mo to 3 yo; ddx Meckels and hsp. 

Features: colicky severe, 20 min, emesis, sausage mass

NEC: sudden feeding intolerance, distention, tenderness, bilious vomiting, diarrhea, rectal bleeding

Malrotation: <1* vomiting, sick, abd distension, peritonitis.

Heme emergencies – Dr. McGee

1 single unit of donor platelets raises plts by 30k

Transfusion indications: <10k (20k if febrile or septic), <50k active bleeding, <100k CNS bleeding or neuraxial surgery

-vwb dz tx for minor bleeding is ddavp

Post transfusion purpura: alloantigen on transfused plts: t penia, purport, clinically significant bleeding. Tx IVIG

Don’t forget about HIIT if recent inpatient stint

MAHAs – non immune HA.

TMAs: microvascular hemolysis; tap, has, drug, complement, pregnancy, htn emergency

High Sensitivity Troponin – Dr. Adam Ross

6 or above reported. Anything less than 20 nl in males; <15 normal in females

>88 MI

15 or greater (change in either direction) increase is clinically significant (2 hours)

TBD if there will be poc trop in R9

Single trop undetectable with >3 hours of symptoms

Hemophilia Lecture

A is Factor VIII deficiency

B is Factor IX

Both are 

VWD: VWf “chaperones” Factor VIII and facilitates its efficacy

Emicizumab: bispecific mab. Helps factor 9 and 10 work. Subcutaneous injection prophylactically.

Meds ending in -ate are for VIII deficiency.

Transfusion Reaction – Dr. Bayers

1. TRALI vs TACO
   1. TRALI more often febrile, more often low BP
   2. TACO very consistent with CHF exacerbation, likely preceding CHF.
2. Other Transfusion Reactions on the Differential
   1. Anaphylaxis
   2. Sepsis – Transfusion Transmitted
   3. Urticaria
   4. FNHTR
   5. AHTR – usually secondary to ABO incompatibility: send Coombs, recheck T&S, DIC, Haptoglobin

If Fever and no other symptoms: stop transfusion, give antipyretic, wait 30 minutes and continue transfusion

Research Overview – Dr. Huecker

Think Do Write

Be passionate

Research Louisville September

ACEP October

CORD March

AAEM April

SAEM May

IRB submission typically takes one month

Common IRB approved research:

-human subjects research

-quality improvement

-program evaluation

Utilize Jacob

-plan stats, charts, graphs, that you want back in a timely fashion. Give him time to complete

Tuberculosis – Dr. Matthew Keller

Most common symptom is cough

8 weeks for exposure testing

2-4 weeks of treatment of active TB before non-infectious

Active TB:

Symptomatic +ppd, +qfg, abnormal cxr, +sputum or culture -> RIPE

Latent TB Isoniazid x9 months

Don’t treat CAP with quinolone (especially) if TB is on ddx

Case Follow Up: Hyperviscosity syndrome – Dr. Slaven

Hyperviscosity syndrome

Features: fever, fatigue, headache, blurred vision, dyspnea, chest pain. polycythemia, thrombocytosis.

Mgt: Give IV fluids Consider phlebotomy.

Causes of fever other than obvious: Infection/Iatrogenic, Mets, AI, Drugs, Endocrine, Clots. (IMADEClots)

Case Follow Up: Febrile Neutropenia – Dr. Ferko

ANC <500 + fever

More than 80% hematologic malignancies. Often currently receiving chemo

Blunted immune response; not necessarily SIRS

COPD places into high risk category.

To be low risk category, everything needs to look good, including transportation and likelihood to follow up

Consider using MASCC Risk score

Admit: Cover pseudomonas, not necessary to start MRSA coverage unless:

Pneumonia

Not HDS

If MRSA suspected

Catheter or skin and soft tissue infection

PECARN Pediatric Head Injury/Trauma Algorithm

Presenter: Dr. Tara Kopp, Pediatric EM

• SNOUT – sensitivity = rule out
• SPIN – specificity = rule in
• PECARN = cohort of 20+ large academic institutions that combine to produce academic research studies
• ciTBI = clinically important traumatic brain injury
• Want to have high sensitivity = screening test = rule out ciTBI and need for CT scan

PECARN Criteria:

• Age: <2 yo or >2 yo
• GCS ≤14 or signs of basilar skull fracture or signs of AMS
  • AMS = Agitation, somnolence, repetitive questioning, or slow response to verbal communication
• History of LOC or history of vomiting or severe headache or severe mechanism of injury
  • Small children = severe fall > 3 ft
  • Older children = severe fall > 5ft

Observation vs CT scan

• Observation usually 4-6 hours; may take into account time from injury
• Children with no PECARN criteria ciTBI predictors = lots of head CTs which could be avoided
• Recommend repeat physical exam prior to discharge if observation

Conclusion:

• Severe injury mechanism
  • Children with isolated severe injury mechanism are at low risk of ciTBI, and many do not require imaging.
• Scalp hematoma
  • Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to determine need for imaging in otherwise asymptomatic children.
• VP shunt
  • Children with VP shunts had higher CT use but similar rates of ciTBI compared with children w/o VP shunts. (limited sample size)

Peritonsillar abscess

Presenter: Dr. Brett Nelson

• Most common deep space infection of head and neck
• Predisposed by previous/recurrent tonsilitis or pharyngitis

Symptoms:

• Odynophagia, drooling, voice change

Evaluation:

• Edematous tonsil, pillars, or soft palate
• Uvula deviation
• Ultrasound
  • Intraoral US with endocavitary probe
  • Submandibular US with linear probe
• CT head/neck w/ contrast

Treatment:

• Needle aspiration – start near superior tonsillar pole, cut needle guard to protect
• Incision and drainage – cut scalpel guard to protect
• Antibiotics alone – Augmentin +/- Clindamycin
• “Quinsy Tonsillectomy” – performed by ENT in severe cases of airway obstruction

Disposition: Usually discharge with ENT follow-up

Sialolithiasis and Suppurative Parotitis

Presenter: Dr. Kyle Stucker

Sialolithiasis:

• Calcium carbonate or phosphate stones of salivary gland in stagnant duct
• Mechanism: Duct stasis, bacterial migrations alter salivary gland pH, altered duct electrolyte concentrations
• 80% occur in submandibular gland
• Usually 5mm; >10-15 mm = “megalith”

Diagnosis:

• Facial swelling, pain, discomfort
• Clinical – stone may be palpated
• CT scan
• Ultrasound

Treatment:

• <5 mm stone
  • Conservative
  • Outpatient therapy and analgesia
  • Gland massage
  • Sialogogues, such as lemon drops
  • Antibiotics if concern for infection
  • ENT referral
• > 5mm
  • Consider ENT consult

Suppurative Parotitis

• Duct infection or infected stone
• Evaluated with CT or US
• Collect cultures if visible purulent discharge

Treatment:

• Augmentin or clindamycin if penicillin allergy
• Admit for IV abx (Unasyn) if concern for sepsis, signs of trismus or airway compromise

Small Group Lecture: ENT Foreign Bodies

Present: Dr. Taylor Strohmaier

Ear foreign body:

• Lidocaine, mineral oil, hydrogen peroxide – anesthesia and kill insect

Removal techniques:

• Irrigation – may utilize IV catheter; contraindicated in TM perforation and button battery
• Forceps – flat or alligator, right angle tool, currette (lighted if available)
• Dermabond + Q-tip – allow glue to become tacky
• Snake pediatric NG tube/foley past to attempt to drag out

Consider otic drops if TM perforation or significant EAC trauma

• Cipro-dex drops
• Dry ear precautions

Consult ENT:

• Unable to remove FB
• Patient requires sedation

Eye foreign body:

Eye exam: EOM, pupils, visual acuity, fluorescein stain, Woods lamp, slit-lamp exam, tonometry, ultrasound, CT scan (may be helpful if concern for metallic FB)

Removal techniques: irrigation, moist Q-tip or cotton swab, 18 g needle on slit-lamp exam, eye burr

Complication of metallic FB: rust ring or corneal perforation (open globe)

• Rust rings can form within only a few hours
• Update Tdap
• Consult ophthalmology

Antibiotic:

• Moxifloxacin (Vigamox), ofloxacin, ciprofloxacin drops
  • Require pseudomonal coverage for contact len wearers
• Erythromycin ointment

Consult ophthalmology if unable to remove FB, visual deficit, concern for open globe, or rust ring

Follow-up with optho – 24-48 hrs

Nasal Foreign Body:

Removal Techniques:

• Mother’s Kiss Technique
• Suctioning
• Forceps with nasal speculum
• Dermabond on Q-tip
• Foley catheter, Fogarty catheter or Katz extractor

Complications:

• Soft tissue injury – epistaxis, septal injury/hematoma, nasopharyngeal trauma
• Barotrauma
• Displacement of FB into airway

Disposition:

• Discharge home following FB removal in uncomplicated cases
• Antibiotics if concern for infection
• ENT consult if unable to remove FB or persistent epistaxis

Here are four papers on ovarian torsion. If you suspect torsion clinically, do NOT be reassured by normal flow on USN. Only the last paper (12 years old) showed a high sensitivity of ultrasound doppler flow for torsion. The other findings matter!

Diagnostic Efficacy of Sonography for Diagnosis of Ovarian Torsion (2014)

323 subjects. The ultrasound correctly diagnosed 72.1% of ovarian torsion and missed 27.9% of them (false negatives)

Ovarian torsion: Case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department (2014)

20 cases, 20 controls. Pelvic US for ovarian torsion was 80.0% sensitive (95% CI, 58.4-91.9%) and 95.0% specific (95% CI, 76.4-99.1%) for reader 1, while 80.0% sensitive (95% CI, 58.4-91.9%) and 85.0% specific (95% CI, 64.0-95.0%) for reader 2.

Diagnosis of Ovarian Torsion: Is It Time to Forget About Doppler? (2018)

55 cases of surgically proven torsion, 48 controls. Sixty-one percent of right ovarian torsion case and 27% of left ovarian torsion cases had normal Doppler flow. Presence of ovarian cysts was significantly associated with torsion. Sensitivity of ultrasound was 70% and specificity was 87%.

Doppler studies of the ovarian venous blood flow in the diagnosis of adnexal torsion (2009)

One hundred and ninety-nine patients presented with adnexal mass and intermittent lower abdominal pain. Sensitivity and specificity of tissue edema, absence of intra-ovarian vascularity, absence of arterial flow, and absence or abnormal venous flow in the diagnosis of adnexal torsion were: 21% and 100%, 52% and 91%, 76% and 99%, and 100% and 97%, respectively. All patients with adnexal torsion had absent flow or abnormal flow pattern in the ovarian vein. In 13 patients, the only abnormality was absent or abnormal ovarian venous flow with normal gray-scale US appearance and normal arterial blood flow. Of these 13 patients, 8 (62%) had adnexal torsion or subtorsion.

TL;DR

1. Ovarian Torsion is a clinical diagnosis. Ultrasound is NOT 100% sensitive.

2. Read the USN report, Just like a cardiac cath*, normal must really mean normal. If you can’t visualize one ovary, or have normal ovarian flow but a large cyst, or have edema, etc, that is NOT a normal pelvic ultrasound.

* A cath report that has 50% blockage in 2 vessels is not “normal” or “clean”! Caths with absence of a lesion that requires PCI (stent) can still have abnormalities that are very important. Remember, the 50% coronary plaques are the most likely to be unstable and rupture.