Tag Archives: Procedures

Another nose picker….

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I had a case of epistaxis the other day so I thought it would be interesting to review the management here. All of the following information can be found in Tintinalli’s, and there are also some great instructions in Roberts and Hedges. Disclaimer: this is not a complete review of epistaxis, mostly just the management. You can review the pathophysiology/epidemiology/important historical aspects/etc in your reference of choice. Here we go:

The management starts with a good physical exam. You need to figure out whether this is an anterior or posterior bleed. Posterior bleeds are much rarer, but are more difficult to control and usually bleed a lot more and require ENT assistance. The right equipment is essential.

Find a mask with a shield, a good light source, a nasal speculum, some 2×2 gauze, and some bayonet forceps. Position the patient upright and have them blow all the clots out of their nose (you might want to step back for this part). Using your equipment you’ve already laid out, look into the nose to see if you can identify the bleeding. Most cases are anterior bleeds, so you will likely see the source of bleeding (usually Kiesselbach plexus in the anterior septum). Spray some oxymetazoline or phenylephrine in the affected naris (or both if it’s not clear) to constrict the vessels. Now it’s time for direct pressure. Some hospitals have commercial devices that will do the work for you. If not, you can tape 2 tongue depressors together starting from one end and going about halfway, leaving the other end open. This can then be used to pinch the patient’s nose closed. Leave undisturbed for 15 minutes…..

Congratulations! You’ve just put a stop to most cases of epistaxis. If you’re not that lucky, it’s time to escalate. If you’ve identified the source of bleeding, you can try silver nitrate. Provide analgesia by soaking your gauze in a 1:1 mix of your vasoconstrictor and 4% Lidocaine and placing it in the anterior nose for a few minutes. Then, go back and cauterize with the silver nitrate. Avoid more than 3 attempts, and never cauterize both sides of the septum.

Still bleeding? Well, nevermind that busy ED you’re running, or the multiple ambulance crews dropping off more patients. Time to try a last ditch move before packing. You can try Gelfoam or Surgicel, or you can also try soaking some gauze in TXA and applying pressure over the site of bleeding with that. But if the patient continues to bleed, it’s probably time to pack…

Anterior nose packing can be done in multiple ways. Many EDs have the Rhino Rocket, or some other form of anterior nasal balloon. You insert these along the floor of the nasal cavity, and gently inflate with air (don’t use saline in case it ruptures). Other types of anterior packs have a sponge material which will expand inside the nose once it contacts the blood. You can also add a few mLs of saline to help it along. If the bleeding continues, you may try anterior packing the other naris. If you are unfortunate and work in an ED that does not have these devices, you will need to use strip gauze to fashion your own pack (again, great pictures in the references mentioned above).

If you’re still bleeding, it’s probably time to call for help. Continued bleeding despite the above measures suggests a posterior bleed. You can perform a posterior nasal pack while waiting for your specialist, or if you do not have ENT available. There are more commercial devices available that are longer and have an additional balloon for posterior packing. If you don’t have this available, you can use a 14 French foley catheter. Anesthetize the nose once again as before. Cut off the distal end of the foley past the balloon. Lubricate the end with Lidocaine gel, and advance along the floor of the nasal cavity, continuing until you can see it in the oropharynx. Now inflate the balloon with 7 mL of air, and retract a few centimeters to lodge it in the posterior nasopharynx.

Dispo: If anterior bleeding has been controlled, patient may be discharged with ENT followup. If packing is in place, antibiotics are controversial. Consider starting Augmentin to cover for Staph aureus and toxic shock syndrome. Posterior packs need to be admitted for further management by ENT.

Solid work! There are only 6 new ones to pick up…..

Paraspinous blocks for migraines

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Many of you have probably heard me discuss my love of paraspinous blocks for migraine headaches, and I know several of you have learned how to do them on me when I have a migraine. This seems to be one of those slightly voodoo things that I would have sworn could never work, until I tried it and had almost immediate relief when several traditional abortive therapies failed.

For those who haven’t, this is an incredibly easy procedure that takes a minimal amount of time and can give real relief in migraine patients. There is no complicated anatomy involved, no significant technique or skill level required, and is safe enough that I have talked many novices through the procedure on a patient with supervision.

To do the block, the most important part is selecting the correct patient to increase your chances of success. Technically it won’t hurt anyone to do a block on them, but I’ve quickly learned this has a near zero chance of working in patients who state only an IV cocktail of dilaudid and phenergan works for their migraines. I’ve also found minimal effects on those who are texting while under bright lights and listening to music. I have had the most success on patients that look absolutely miserable: the ones curled up into a fetal position, actively vomiting, crying, with all the lights out and begging you to do ANYTHING to make their headaches go away. These people also tend to be quite enthusiastic about a treatment that you can administer on the spot and will work within 5-10 minutes typically. For all the things we do that sometimes have fairly minimal objective evidence of relief, it makes me very happy to walk back into a room in 20 minutes and see this previously miserable patient looking completely normal, stating their headache has resolved, and being ready to discharge… all without medications from pharmacy or an IV.

I typically use bupivicaine and do not use any subcutaneous lidocaine as the youtube video attached at the end of this post shows. I draw up 3cc, planning to use 1.5cc on each side. Your landmarks will be your C6 or C7 spinous process. I typically go C7 because it is easy to find by asking patients to flex their chin to their chest, and I like to keep things easy. C7 is the most prominent spinous process at the base of the neck. Not sure if you’re at C6, C7, or T1? Even better, for this block it doesn’t really seem to matter because it still works! You’ll be injecting approximately 2cm laterally to the edge of the spinous process, give or take half a centimeter based on body size. Again, don’t get too caught up in the details- it seems to work at 1.5cm to 3cm laterally to the process. After a swipe with an alcohol prep (bonus points- you can hand the patient another alcohol prep pad to inhale for relief of their nausea and vomiting! See last week’s journal club article for more details), you’ll insert the needle (any size, but a 25g hurts less) parallel to the ground in a straight anterior tract. I insert the needle 1.5-2cm. Aspirate to make sure you aren’t in a vessel, then inject 1cc of bupivicaine deep, and the remaining .0.5cc while withdrawing your needle. Repeat on the opposite side, stick a bandaid on, and reasses in about 20 mins. If it’s going to work, most seem to start to get significant relief in about 10 mins. If unchanged in 20ish minutes, I proceed to other therapies.

When I’m in first care, I typically will take a bottle of bupivicaine and a needle/syringe into the room when I walk in for an initial evaluation. If the patient seems to be a good candidate and is agreeable, I go ahead and do the block at that time. By the time I do my charting or see the next patient, I typically have a good idea of if the patient has improved, or rather if I need to start ordering other therapies.

Quick and easy, and I have about a 60-75% success rate on patients. Pretty good considering a standard migraine patient will likely take a couple of hours to receive IVFs, meds and reassess. You can sometimes get these people dispo’d in less than 30 minutes!

I’ve attached a quick video for you visual learners

Wound prophylaxis – Should lip lacs get antibiotics (and few others)?

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During my review for 72 hour returns we had a through and through lip laceration come in that returned with a wound infection a few days later.  This prompted me to look up current recommendations as I’m pretty sure that I haven’t been giving antibiotic prophylaxis for this.

Searching literature, Tintinalli and UpToDate…… Most superficial wounds do not require prophylaxis, however, through and through lip lacerations were an area of uncertainty and debate….

Tintinalli  – “matter of provider preference.”

UptoDate – no clear clinical evidence to say that these wounds should receive antibiotic prophylaxis , however, due to the pathogens of the oral cavity, they recommend prophylaxis.

Current literature – Review article in 2008, Annals of Emergency Medicine, Mark DG et al – review of studies do not show a statistically significant benefit; however, the only double-blinded randomized control trial showed a trend toward benefit in patient’s that were compliant with therapy.

Some other stats – Rate of infection in wound treated in the ED (Tintinalli)

Head and neck 1-2%

Upper extremity 4%

Lower extremity 7%

Oral wounds – 9-27%

If giving prophylaxis then Pen VK or Clindamycin is recommended for 3-5 days.

For other oral wounds, <1cm, no need to close. Close if large gap susceptible to food getting trapped, and counsel on good oral hygiene.  Dental and OMFS usually recommend d/c with chlorhexidine gluconate oral rinse (0.12%) (Peridex) and will have patients swish and spit after meals to keep the wound from contamination with food particles.

My take away from this is strongly consider antibiotic prophylaxis with through and through oral wounds as they are higher risk for infection with oral flora; however, not an absolute must based on the current evidence.  Be sure to emphasize good oral hygiene, and as always, close follow up with good return precautions.

Other wounds to strongly consider prophylaxis due to increased risk for infection are mammalian and human bite wounds, crush injury, puncture wounds, and wounds with either fresh or salt water contamination, or patients who are immunocompromised, asplenic, advanced liver disease, associated edema (according to the IDSA).

Open fractures and wounds with joint capsule violation should receive antibiotic prophylaxis.

Reminder: Update Tetanus and simple lacerations do not need antibiotic prophylaxis.

SIH – Spontaenous Intracranial Hypotension

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Recent EMRAP podcast reminded me of a case from when I was a Medical Officer in the Navy.

One of my Marines, early twenties, with no medical problems presented for follow up in sick call after being seen in the emergency department for a headache.  Since it was the worst headache of his life, an LP was performed.  Both the LP and the CT head were negative. He was given standard headache treatment with “migraine cocktail” from what I remember, however, no significant relief.

He presented to clinic with complaint of ongoing headache that was only better if he laid completely flat with excruciating pain with sitting up.   He refused to do anything other than lay on the gurney in the treatment room.

His presentation was classic for post LP headache, however, he states that this was the same headache that he presented to the ED for the previous evening and was not changed by the LP.  He was adamant about this timeline and unchanging symptoms after LP. Physical exam was normal to include normal Neuro exam.

I subsequently called the Neurologist on call at Naval Hospital, who stated the likely diagnosis was a “spontaneous CSF leak” and recommended a blood patch.  I was quite confused as I had never heard of such and it seemed like a made up diagnosis to me at the time.   I did, however,  want to help my patient and for him to leave the clinic at some point that day.  I then called anesthesia who was agreeable to the blood patch given recent LP and current exam/symptoms.   The patch lead to resolution of his symptoms and he was able to stand up and walk without a headache.

This is the only case that I have seen, however, the recent EMRAP review leads me to believe that I might see another case while practicing Emergency Medicine.

SIH is caused by a spontaneous tear in the dura in the spine or elsewhere in the meninges and leads to intracranial hypotension from CSF leak.  Symptoms are incredibly similar to post LP headache given the pathophysiology on really differ in that CSF leak in an LP is iatrogenic and SIH is well, spontaneous.  Diagnosis can be by LP, which will demonstrate low opening pressure, or MRI of the Brain W/WO and Spine W/O which will demonstrate the leak.  The symptoms are similar regardless of the level at which the leak occurs so you may have scan the entire meninges to find it.

Treatment initially is caffeine and rest for mild-moderate headaches and lumbar blood patch for moderate-severe headaches.

Uptodate has a lengthy but throughouh algorithm for diagnosis and treatment.   If lumbar patch doesn’t work, a more targeted approach may need to be employed.

  • Take-home point – consider SIH when someone presents with post LP headache symptoms without having had one performed in the recent past.

Neonatal Airway

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I’m currently on peds anesthesia and behind on reading Annals, which worked out in my favor.  I was looking through the February 2017 issue and there’s an EM:RAP commentary about the neonatal airway.  So I figured I would give you all the highlights from that article.

  • At birth, an oxygen level of 60% is normal.  There’s a nice chart showing the oxygen saturation and how it increases after birth.
    • 1 minute- 60-65%
    • 2 minutes- 65-70%
    • 3 minutes 70-75%
    • 4 minutes 75-80%
    • 5 minutes 80-85%
    • 10 minutes 85-95%
  • Remember when doing BVM on a neonate, not to press too hard on their face.  Their nose is not stiff and they are obligate nose breathers.  So don’t close off their airway by pressing too hard.
  • Don’t worry about using a paralytic in the neonate.  You can either time passing the tube through the cords or just push it through.
  • Tube size/Blade size
    • Normally in peds we use the formula (age in yrs/4) + 4
    • For neonates, they suggest the 0-1-2-3 rule: Use a 0 straight blade in a 1-2 kg newborn with a 3.0 mm uncuffed tube
    • They also recommend resting your pinky on the cric to provide your own cric pressure since neonatal airways can be very anterior
  • How far to pass the tube
    • 1 kg neonate- 7 cm
    • 2 kg neonate- 8 cm
    • 3 kg neonate- 9 cm

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)

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.

Can you give Vasopressors through a PIV?

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I looked back and couldn’t find a post about this topic in the last year or so but forgive me if it has already been posted. I have been following R.E.B.E.L. EM for a few months now  and I would recommend it to everyone who has the time and wants quick summaries on the latest EM literature.  They have short written summaries of papers including pros/cons of the study and what they feel are the most important take away points. It was founded by Salim Rezaie with Rob Rogers, Matt Astin and Anand Swaminatham serving as editors.

Occasionally they will have a “mythbuster” post looking at common myths in the ED and the most uptodate literature available on the topic. (their latest mythbust is on “safe” glucose levels before ED discharge but I digress)

 

Back in May they reviewed the safety of vasopressors through a PIV. The topic paper was titled “A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters”

What the review found was very interesting: of 318 events, 204 results in local tissue damage, 114 were only extravasation events and 7 events involved the use of a CVC (so clearly not completely safe). Interesting, of the 204 local tissue events 85.3% involved PIV distal to the antecubital fossa and 96.8% involved administration of >4hrs.

REBEL EM’s take away points were:

In critically ill patients, with hemodynamic instability, vasopressor infusion through a proximal PIV (antecubital fossa or external jugular vein), for <4hours of duration is unlikely to result in tissue injury and will reduce the time it takes to achieve hemodynamic stability.

What I feel like this means for us is simple: If you have a crashing, hypotensive patient who needs a pressor without a CVC but good proximal PIVs, start the pressor immediately, stabilize the patient as best you can, then take the time to properly place a CVC.

Continue to monitor the PIV until it can be switch to the CVC and stop the pressor immediately if there is any suspicion for local extravasation. I am sure this will make some people nervous but I think this is better then placing a “crash line” that is less then sterile which will expose an already ill patient to infection or other complications secondary to a hastily placed CVC.

I highly recommend read their review and how they came to this conclusion along with their other posts. I have included the link to this study at the bottom.

http://rebelem.com/mythbuster-administration-of-vasopressors-through-peripheral-intravenous-access/

Delivery in the Emergency Department

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I will apologize for the wall of text in advance but I thought I to share an experience from last May that fits pretty well with the first 2 weeks of lectures this month. I think it definitely highlights the importance of  feeling comfortable with both delivery and newborn resuscitation in case they actually happen to you. I’ve also tried to point out all problems that came about but I am sure I didn’t hit them all and I am positive that I could have handled some of them better. 

It was nearly the end of a pretty typical shift at Jewish Downtown. For those of you who haven’t been there or don’t know there is zero OB coverage at Jewish. I was finishing my charts when I hear the secretary say “pregnant woman in labor” over the phone. That is a pretty unusual thing to hear at Jewish so I immediately asked the attending who was sitting closer if I heard that correctly. I also half-jokingly said I definitely wanted in on the patient if they were serious because I still needed a few more deliveries. The attending chuckles and replied that she thought the secretary was only joking because there shouldn’t be any reason for a laboring patient to come to Jewish, so I returned to my charts.

About 2 minutes later they call for a physician from the room behind the doctors area and we walk into what is in fact a laboring patient. The nurses state she seems to be contracting every 3-4 minutes but they don’t know much else at this point. While the attending checks her cervix, I grab the ultrasound and check the fetal position. She was about 8cm dilated and the best I could tell the baby was vertex but the head was so far down I gather this from the rest of the anatomy. Immediately calls start going out to the neonatologist at Kosair while we attempt to talk to the family and figure out how the patient ended up at Jewish. Here comes out first problem:

Problem 1: Neither the patient nor the family speak a word of english. Not only that but there is no translator phone in the room so the family has to be taken to another room to try to get some questions answered.

In the meantime I attempt to get a fetal heart rate to assess how the fetus is doing.

Problem 2: The only doppler is a pen style for checking pulses that doesn’t actually display a pulse number.

I go back to the ultrasound, find the heart and count the beats on the screen while a nurse counts for 15 seconds to get a FHR of about 144, which is always reassuring. In the mean time we are able to obtain some more information from the family.  

Apparently, the patient’s water broke during her office visit around 2pm (it’s now almost 11pm) and she was told to go to the hospital. For whatever reason they decided to wait and they got mixed up between Norton’s and Jewish hence our current situation. There are calls being made to Norton’s L&D informing them of the situation and transport is on the way. The neonatologist is also en route as a safety precaution in case she actually delivers here. The patient and fetus appear to be stable, and while still contracting around every 3-4 minutes she still isn’t fully dilated. I make the mistake of leaving the room assuming that the patient will soon be swept away to have her baby properly on an L&D floor. About 5 minutes later another call from the room and I walk in to see the beginning of this baby crowning.

The nurses wheel in their delivery kit as I gown and glove up. I apply a few packets of lubricant jelly, have the nurses move the patient closer to the end of the bed and attempt to create a semi-sterile field with the supplies available.

Problem 3: It’s nice and easy to set up to deliver in a room with a bed designed to deliver a baby. Unfortunately for me this situation involved a nurse/tech on each leg and the patient mostly laying flat in a bed with bag to collect fluid half hanging off the table but mostly just shoved under her bottom as best as I can with no real drainage.

Problems 4 & 5: Did I mention she didn’t speak english, also I have no idea what the word for “push” is in her language.  Also when you are on the L&D floor you have all kinds of cool toys such a tocometer to help you know when to tell the patient to push. I do not have that luxury.

I attempt to put a hand on her abdomen to feel her uterus contract so I know when to tell her to push and hope that she figures out what we want from her. Maybe it was a good thought but I have no idea, good thing she does and she is pushing every few minutes and the head is progressing it’s way out.. After a few good pushes the progress seems to slow a little bit and I start to worry a little bit that this 2 week post-dates baby may be stuck. What was that mnemonic for shoulder dystocia again? All I can remember is McRobert’s maneuver, but for anyone curious, Rosen’s has a nice one:

Help: Obstetrics, neonatology, anesthesia

Episiotomy: Generous, possibly even episioproctotomy

Legs flexed: McRoberts’ maneuver

Pressure Suprapubic pressure: shoulder pressure

Enter the vagina: Rubin’s maneuver or Wood’s maneuver

Remove posterior arm Splint, sweep, grasp, and pull to extension

Luckily, I have the nurses holding onto each leg (because this bed doesn’t have stirrups) so they flex her legs towards her as much as they can and everything continues to progress smoothly. Eventually the head is out and the rest of this baby boy delivers quickly. He is suctioned, wrapped in a warm blanket and the nurses begin assessing him. I think we put his APGAR at a 7 at 1 minute.

So I am done right? Baby is out, nothing more to see or do, lets ship them out. Right?……

Turning back to the patient I realize she seems still be bleeding a little more than I expected. It’s hard to figure out where she is bleeding from so I deliver the placenta which appears to be intact. I even sweep and massage the uterus just to be sure which seems to be contracting well.

Problem 6(?): Not really a problem because it seems her bleeding was not coming from the uterus but I have no access to the medications typically used to help control uterine bleeding after a deliver such a pitocin. Not that it matters because I didn’t know what the dose would be anyway. Just another interesting thought that I had during this whole process.

Since the placenta is whole, and seems to be firm I look for other sources of bleeding. This is when I realize the patient has a nice 2nd or 3rd degree tear (Dr Sterrett would be very disappointed I didn’t control the head well enough). I check to make sure it isn’t a 4th (thankfully it’s not), and start contemplating my next course of action. The attending asks what kind of suture I want to use to repair her tear. My only reaction was to smile and say “nothing”, followed by explaining that since the bleeding is slowing it’d probably be better to let the OB-GYNs fix her. I plan to pack her to make sure she doesn’t bleed too much in transport. 

Problem 7: No one had even seen a vaginal packing kit in the ED before, so we improvised and used some kerlex with a tail for easy removal.
By the time this had finished the neonatologist had arrived and began assessing the newborn. I think we ended up giving him apgars of 7 and 9. I started the patient on some fluids (because we didn’t have an IV when all of this started, another mistake I didn’t realize until it was all over) and within another 2 minutes transport had arrived to take the patient to Norton’s and she was actually swept away. Hopefully the OBs she finally got to didn’t think I botch the whole thing too much. Overall it was a pretty intimidating and adrenaline pumping situation. Not sure if I will ever have an experience quite like this again but if it does happen at least it will not be the first. 

Any comments, critiques, criticism or otherwise are welcome.

Emergency Escharotomy

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Case: 57 yo M who presents via EMS found with circumferential burns on bilateral lower extremities, left upper extremity, lower pelvis, and left side of chest after being trapped in a burning tent. Unknown time of incident.

VS: HR: 128, RR: 24, BP: 112/64, SpO2 96% on 4L O2

Alert, oriented x 2. SEVERELY DISTRESSED. Singed nares bilaterally. Bilateral wheezes, tachypneic. Tachycardic, RR. Abd S/NT/ND. Once again, 3rd degree burns circumferential burns from lower pelvis, extending to groin, and down to bilateral lower extremities. The 3rd degree burn covered the left side of his chest and his RUE. No pulses were palpated in his LUE or BLE. Though burned, BLE and RUE appeared blanched with poor cap refill and cool to touch. 72% estimated burn coverage total. Pt stated he was unable to feel or move bilateral lower extremities.

During the process of IV, O2, monitor, and moving the pt over. I called for pain medication, intubation meds, and got the equipment ready for intubation.

Trauma, Plastics, Urology – paged. Don’t wait to get consults on board in a case where you are preparing to do this procedure.

On physical exam, remember Wallace rule of nines (see total body surface area): 9% for each arm, 18% for each leg, 18% for the front of the torso, 18% for the back of the torso, and 9% for the head and 1% for the perineum. At the same time, think Lactated Ringers at 4 mL x kg x percentage burn = total fluids needed for replacement in initial 24hrs. First half of amount in first 8 hours with the second half over 16hrs{{Parkland}}.

But, first, intubate to secure the airway, provide pain control, and facilitate further exam. Needless to say, burns are extremely painful.. . so are escharotomies.

Trauma wedge took the RLE, and I had the LLE. In the race to get pulses back, I succeeded and was rewarded with getting to do the LUE as well.

How did I perform the procedure you ask? Well, it was with the Trauma fellow standing at the foot of the bed giving instructions and guidance . .. I had never seen anything like this except for textbook cases of a circumferential burn to the chest/trunk. This procedure is not on our sign off list, required list, or on anything that I had seen in cadaver lab.

While these procedures are as rare as a Trauma fellow eager to teach at 2 am, you may be faced with the same in a rural ED or with a wedge stuck in the OR, etc.

Advice: Be nice to your colleagues. And, more importantly, prepare.

Here are some very informative links that would’ve been great to have seen or reviewed prior.

Step 1: Read the Overview

Video 1: Robot voice explanation: Best display of lines for incision, but more from a surgical perspective

Video 2: Australian Escharotomy How-to

FYI:

Suprapubic catheter was also placed in the ED prior to the pt going to the OR. Another rare procedure, not required, but useful to know.

Just say NO to DESAT

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I was about to spend a lot of time on a post here about pre oxygenation, specifically re: apnea oxygenation with nasal cannula. I was inspired be yet another favorable article in this month’s Academic EM (which by the way is going to be online ONLY as of Jan 2017).

Then realized Weingart had of course already posted a ridiculously good synopsis of what was out at the time.

If you plan at anytime in the future to intubate a human patient, STOP what you are doing and read the Emcrit post before your next intubation.

Add to his post the new article. And the common sense that a nasal cannula has no risk to the patient. There is just no reason not to place a 10L or greater nasal cannula on all patients during intubation.

Just finished writing the post and noticed EMLitofNote just reviewed this article, also linked to a LITFL post and a Rebel EM post. Their conclusions are similar, though they call for an RCT. Not sure we need to spend a bunch of money on an RCT. I say just use the cannula for 5 minutes while you intubate.

A Mysterious Death in a 21 yo Healthy White Female, and the Larson Maneuver

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My wife is at work at a hand surgery pre-op care clinic. It is her birthday. In walks a middle-aged male who is about to have tendon reconstruction after he sustained a crush trauma, and is excited about the possibility of returning to work. He is slightly abrasive and somber, despite the prospect of receiving the surgery.

My wife asks him if he is concerned about the procedure, asks if he is feeling well, asks if there is anything she can do to help. With a quiet manner he states all is well. To make discussion my wife states today is her birthday and she is excited to celebrate when she gets home. He smiles and states today is also his daughter’s birthday. She was born the same year as my wife. He states today is always a rough day for him because she passed away in an emergency room 7 years ago at 21 years of age.

We can never fully understand where those we treat are coming from, their life experiences, or what their home situations, thoughts, fears, dreams, and worries entail; and this was a reminder for me. He stated that his daughter was healthy,woke up without issue on that day, but later developed difficulty breathing and wheezing. She was diagnosed with an acute asthma attack. She had one episode in the distant past but was not on any routine medications. She was given albuterol and experienced a negative reaction to the albuterol and completely stopped breathing. She was brain dead by the time she was intubated. They withdrew care in the emergency department.

After my wife shared this with me, I searched to find any case reports of paradoxical reactions to albuterol. Below are three related cases, however bronchospasm becoming worse with beta-blockers is exceptionally rare.

Case reports of paradoxical bronchospasm to inhaled beta agonists:

What I think more probable, and possibly related to the above case reports, is acute laryngospasm. The albuterol she received may have further irritated her vocal cords potentially worsening, rather than relieving her vocal cord dysfunction. Both Resus.me and LITFL (Life In The Fast Lane) have very useful articles describing management (see below for links). Here is a brief synopsis:

Laryngospasm

What is it?: a potentially life-threatening closure of the vocal chords (can occur spontaneously). Often misdiagnosed as asthma—especially exercise-induced asthma (more common in white females).

How to diagnose (and differentiate from asthma):

  • Stridorous sounds are usually loudest over the anterior neck, beware wheezing sounds transmit throughout the lungs
  • Typically, albuterol has minimal to no beneficial effect.
  • Subjectively more difficulty on inspiration than expiration

   Clues in history: recent exercise, GERD, ENT procedures, or extubation

   Common causes & some that are not-so common:

  • Post extubation
  • Exercise
  • GERD
  • Medications (e.g., (1) ketamine sedation, incidence 1-2 %; (2) versed (very rarely), which can be reversed with flumazenil)
  • Near drowning/ aspiration
  • Inhalants (smoke, ammonia, dust, cleaning chemicals)
  • Related to anxiety
  • Strychnine (plant based poison, sometimes used as a pesticide for birds and rodents, also the poison reportedly used to kill Alexander the Great in 323 BC)

Treatment of laryngospasm:

Initially:

  1. Jaw thrust with Larson Maneuver
  2. CPAP/ NIPPV
  3. Heliox might be helpful if available, (also topical lidocaine can be applied to larynx if available)

If conservative measures fail:

  1. Low dose propofol (0.1 mg/kg) ~ give 10 mg
  2. Low dose succinylcholine (AKA: suxamethonium) 0.1-0.5 mg/kg IV
  3. All else fails: intubation with succinylcholine 1.5 mg/kg IV
    • If no IV access, then succinylcholine IM (3-4 mg/kg). Experts advocate IM injection into the tongue.
    • Perform chest thrust maneuver immediately preceding intubation to open the vocal cords and allow passage of the ET tube.
    • Monitor for negative pressure pulmonary edema—(from patient pulling hard against closed glottis in the setting of acute asphyxia).

Flow chart from Resus.me

Larygospasm_flow_high_res

What is the Larson Maneuver? (Published 1998 in Anesthesiology)

It is a manipulation jaw thrust technique targeted at the ‘Larson’s point‘, AKA: laryngospasm notch.

  • Place middle finger of each hand in the laryngospasm notch, located behind the lobule of each ear, between ascending ramus of the mandible and the mastoid process.
  • Press very firmly inward toward the base of the skull with both fingers
  • At the same time lift the mandible at a right angle to the plane of the body (perform jaw thrust).

Reportedly will convert laryngospasm within one or two breath cycles to laryngeal stridor, and in after a couple more breath cycles, to unobstructed respirations. As proposed by Larson, it is likely that the painful stimulus relaxes the vocal cords by way of either the parasympathetic or sympathetic nervous systems through the glossopharyngeal nerve.

Diagram from LITFL

Larson_man

References:

  1. Resus.Me: http://resus.me/laryngospasm-after-ketamine/
  2. LITFL (Life In The Fast Lane): http://lifeinthefastlane.com/ccc/laryngospasm/
  3. UpToDate: https://www.uptodate.com/contents/paradoxical-vocal-fold-motion?source=machineLearning&search=Laryngospasm&selectedTitle=1~150&sectionRank=1&anchor=H3#H3
  4. Larson, Philip, MD. Laryngospasm-The Best Treatment. Anesthesiology. 1998. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1947036
  5. Paradoxical bronchospasm: a potentially life threatening adverse effect of albuterol. South Med J. 2006 Mar;99(3):288-9. http://www.ncbi.nlm.nih.gov/pubmed/16553105
  6. Paradoxical response to levalbuterol. J Am Osteopath Assoc. 2008 Apr;108(4):211-3. http://www.ncbi.nlm.nih.gov/pubmed/18443029
  7. Paradoxical reaction to salbutamol in an asthma patient. Pneumologia. 2012. Jul-Sep;61(3):171-4. http://www.ncbi.nlm.nih.gov/pubmed/23173379

A-fib with RVR + sepsis + hypotension = conundrum

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How do we slow the rate without lowering the BP? Will slowing the rate even help the BP? How do we raise the BP without speeding up the rate?

The patient who inspired this post came in for a bowel obstruction. Cards was initially consulted for possible new a-fib, but there really wasn’t much to do from a cardiac standpoint. THEN he perforated his bowel and went for emergency surgery, where he required pressors and went into a-fib with RVR. He was packed open and taken to the SICU, where he was hypotensive to SBP 70s, tachycardic to 160s, and intermittently hypoxic.

If you want to skip my thoughts on the case and head straight for the facts, here is an interesting article about a-fib in critically ill patients. It talks about the various options for management and the pros/cons of each.

If expert opinion is more your style, try this.

Of course, there is also controversy around slowing down a-fib when it is caused by sickness. Should we let the body do its thing to try and compensate? Here’s one article that suggests maybe we shouldn’t get so hung up on rate control in sick people.

Now back to the case. The surgery resident and I were of the mind that slowing the rate and organizing the rhythm should help with cardiac output. There are several reasons why this logic still seems to be in the majority.

– With a-fib you lose atrial kick. That little extra oomph from the atrium may not seem like a big deal, but it can have a significant impact on cardiac output. Here’s a fun article from 1965 that shows a 53% increase in cardiac output from converting a-fib to sinus (using quinidine because 1965). The results have obviously been redemonstrated in more recent studies, but how often do you get to reference quinidine? Not that often.

– Diastolic filling is important for stroke volume. With any tachyarrhythmia, less diastolic filling time means lower stroke volume. However people who do “math” would argue that increasing the rate would likely keep cardiac output about the same. This logic holds up with regular rhythms, but studies show that irregular rhythm decreases cardiac output compared to regular rhythm. Here’s one such study.

– In real life, we went for amiodarone and electrical cardioversion. From the a-fib in critical care article above, it seems like that’s still the best option.
Here’s a good article I wish I had read before embarking on a cluster of a cardioversion. P.S. Put the pads on correctly. Anterior-posterior pads definitely worked better for this 350 pound patient. Anterior pads = fail x3. AP pads = success!

– It’s worth noting that this is not one of the scenarios when you’re worrying about giving someone a stroke with cardioversion. This guy’s risk of death was much greater than his risk of stroke.

Another consideration for this situation was the choice of pressors. Eventually the patient ended up maxed on pretty much all pressors, but that may not always be the case.

Surviving Sepsis guidelines are all about Levophed as a first line pressor, which is usually a great option. But guidelines are just guidelines. How many of our patients are otherwise 100% healthy and just have a little sepsis? Not that many.

– In this case, I think phenylephrine may have been a better first option. Pure alpha agonist activity vasoconstricts without Levophed’s cardiac effects, which probably didn’t do us any favors with the RVR.

– Based on the EMCrit blog above it also seems like phenylephrine might have allowed us to use a beta blocker without worrying about blocking the effects of the pressor or a calcium channel blocker without exacerbating hypotension. Thoughts?

– Anyone have other ideas about pressors in this scenario?

There was a lot more to the case after that, but this post has already ended up way longer than I intended. In the end, it was a 350 pound unhealthy guy with a less than ideal heart, so unfortunately, his family ended up withdrawing care. I doubt anything we could have done would have changed his outcome, but maybe there’s something to learn from it that will help someone else someday. I’ve talked to several people about this case and gotten different opinions from each one, so I figure why not open it up for a few more opinions to really confuse clear things up.