Mar 22

Lit of the Week- CT C-spine alone for obtunded, blunt trauma patient

Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Feb;78(2):430-41.

Clinical question / background:

  • In the obtunded blunt trauma patient, can cervical collar be removed after a negative high-quality CT c-spine alone?

Definitions:

  • Unstable injuries: fracture or fractures of involving contiguous columns or levels, bone misalignment (subluxations, listhesis, interspinous widening or splaying), or a single-level ligamentous injury involving all three columns.
  • Obtunded: GCS<15, altered, intoxicated, intubated, unconscious, and/or unreliable exam.

Design:

  • Systematic review
  • 1718 subjects in 11 studies
  • Inclusion criteria:
    • Age 16 or older
    • Blunt trauma
    • Undergone CT C-spine with axial thickness less than 3mm
    • Obtunded – defined as above
  • Exclusion criteria:
    • Excluded studies that did not specify CT axial thickness or axial thickness greater than 3mm.

Intervention

  • Each patient underwent C-spine CT that was read as normal and was then retested with comparator adjunct imaging and/or physical examination.

Outcome:

  • Does removal of c-collars in obtunded blunt trauma patients after evaluation by only high-quality c-spine CT change the incidence of peri-clearance events. Listed in order of importance: neurologic change after c-collar removal (paraplegia, quadriplegia), unstable c-spine injury, stable c-spine injury, post-clearance imaging, false-negative CT imaging result on re-review, pressure ulcers, and time to cervical collar clearance.

Results:

  • In 11 studies, with 1,718 subjects, there were no unstable c-spine injuries missed on CT scan alone. There was a 9% incidence of stable injury: mostly ligamentous injury
  • In five studies with 1,017 subjects, there were no new neurologic changes (paraplegia, quadriplegia) following cervical collar removal.

Take-home:

  • In the obtunded, blunt trauma patient, C-spine CT scan alone is sufficient to clear cervical spine. There were zero unstable injuries missed and no new neurologic deficits.

Weaknesses / Critiques

  • Low quality evidence in included papers. Need further study.

Further reading

Patel MB, Humble SS, Cullinane DC, et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Feb;78(2):430-41.

Mar 22

Weekly Report – Foot Pain

This week’s Weekly Report comes to us from Dr. Davlantes.

30 F with a history of obesity and obstructive sleep apnea presents with bilateral foot pain after losing her balance.  She was trying to step over her child who was crawling around on the ground, and twisted her feet when she “landed funny.”  She is now unable to bear weight on either foot. Here are her x-rays:

Screen Shot 2016-02-26 at 10.16.16 Screen Shot 2016-02-26 at 10.17.43

What do you see?

The foot has a 2nd metatarsal fracture.  This is an easy sell as to why the patient is having trouble walking on that foot.  But what else is going on in this XR?  The space between the first and second ray of the foot (medial cuneiform + 1st metatarsal and middle cuneiform +2nd metatarsal) is widened.  You can especially see this when compared to the normal R foot x-ray.  This indicates a Lisfranc injury.

The Lisfranc ligament attaches the medial cuneiform to the base of the 2nd metatarsal.  This ligament is often injured by an axial load on the foot combined with twisting.  Common mechanisms include sporting activities, falls or impact over a dorsiflexed foot. It is also possible with low-energy falls as described in this case, especially with twisting.The radiographic finding is subtle, with x-ray often read as normal or only showing a slight increase in the distance between the medial and middle cuneiform.  It may help to compare x-ray of both feet and obtain weight bearing films to better assess this distance. CT or MRI maybe be obtained if x-rays are nondiagnostic but clinical suspicion remains high. If missed, this injury results in severe foot instability and lifelong arthritis.  Treatment is typically surgical repair, though some are managed with casting.

If your patient is unable to bear weight on a foot even if x-rays are read as normal, have a high suspicion for Lisfranc injury!  Other clinical signs include ecchymosis to the sole of the foot, or foot swelling out of proportion to injuries seen on radiographs.

Mar 21

FOAM of the Week – Pneumothorax, Chest Trauma

Lot of great FOAM stuff on pneumothoraces and chest trauma from this past week’s lectures:

 

Mar 21

Image of the Week – Appendicitis

This week’s Image of the Week features images from two patients. The first seen by Dr’s Meloy and Sizemore, then second by Dr’s Shah and Middlebrooks. Both presented with right lower quadrant pain. Take a look at the images and see if you can identify the pathology.

Both of these patients were diagnosed with appendicitis. In the videos for the first patient the operator measures the diameter of the appendix as 9.7 mm, which is enlarged.  In the video from the second patient you can see both transverse and longitudinal views of the appendix. In transverse it appears as a circular, target-like structure. In longitudinal it is seen as a blind-end tube. In both views the operator applies compression with the ultrasound probe which does not cause collapse of the structure. To evaluate a patient in which you suspect appendicitis, place the probe in the right lower quadrant at the point of maximal tenderness and then pan looking for a blind-ended tubular structure as seen in the images. If one is found the diameter should be measured and pressure should be applied to assess for compressibility. Findings suggestive of appendicitis include:

  • aperistaltic, noncompressible, dilated appendix ( >6 mm outer diameter)
  • appendicolith (white with distal shadowing)
  • distinct appendiceal wall layers
  • echogenic prominent pericaecal fat (bright white on ultrasound)
  • periappendiceal fluid collection
  • target appearance (on axial section)

When using bedside ultrasound, it is important to understand the limitations of the modality. Both the sensitivity and specificity have high reported variability in the literature, though the largest meta-analysis reported them as 88% and 94% respectively in the pediatric population and 83% and 93% in the adult population. This is highly dependent on operator skill. In many patients it may be difficult to identify the appendix on ultrasound secondary to patient habitus, anatomy, or bowel gas, particularly if the appendix is normal. If your patient has a concerning presentation coupled with ultrasound findings suggestive of appendicitis, you should be consulting your surgeon and can likely spare that patients from the radiation exposure of a CT scan. However, if you are unable to identify the appendix on ultrasound but are concerned by the history and exam further evaluation with CT should be obtained. Ultrasound should be considered the first line diagnostic modality in the pediatric population as well as in pregnant patients.

References:

  • Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986; 158 (2): 355-60.
  • Doria AS et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006; 241(1):83.

Thanks for all your great images this week! Happy Scanning!

===============================

Eric Deutsch
Department of Emergency Medicine
Emory University SOM

Mar 15

Lit of the Week – Sepsis 3.0

sepsis flow

Lit of the Week – 3/15/16

Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287. PubMed PMID: 26903338

 

Clinical question / background:

  • Definitions of sepsis and septic shock were last revised in 2001
  • SIRS criteria have been criticized for lack of specificity and inadequate representation of the patient with sepsis
    • NEJM in 2015 – SIRS misses 1/8 septic patients
  • Better understanding of sepsis inappropriate immune response to infection causing life-threatening organ damage vs a continuum of inflammation
    • Dysregulated host response = both pro and anti inflammatory factors
  • Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) redefined sepsis with the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

 

Design:

  • 19-member task force; Critical care, ID, Surgery, Pulmonary, Anesthesia
    • No Emergency Medicine physicians
  • For sepsis, retrospective + validation cohort study performed of adult patients with suspected infection
    • UPMHC Health Care System, Kaiser Permanente, U.S. VA System, Kings County Washington Hospitals, 1 German Hospital
    • Outcomes: Hospital mortality and overall mortality, ICU stay of 3 days or longer, or both
    • Compared area under ROC curve for SIRS, SOFA, and LODS (Logistic Organ Dysfunction System)
  • For septic shock, systemic review and Delphi consensus process to identify 3 variables (Hypotension, Elevated lactate, need for pressor) that correlated with mortality
    • Retrospective and validation cohort study
    • Outcome: in-hospital mortality

 

 

New Definitions:

  • Sepsis
    • Life-threatening organ dysfunction caused by a dysregulated host response to infection
    • Suspected / Documented Infection AND
      • Organ Dysfunction identified as an rise in total SOFA score ≥ 2 as a consequence of infection
        • SOFA score assesses Six Organ Systems — CNS, CV, Respiratory, Liver, Renal, Coagulation
        • Baseline SOFA 0 assumed in healthy patients
        • SOFA MDCalc
        • Overall mortality 10% (mortality from STEMI is ~8%)
      • Potential septic patients identified with ≥ 2 qSOFA criteria
        • Hypotension (SBP ≤ 100 mm Hg), Altered Mental Status (GCS < 15 or subjective determination), Tachypnea (RR ≥ 22/min)
        • qSOFA MDCalc
        • These patients are at high risk for poor outcome and should be assessed for evidence of organ dysfunction with full SOFA and measurement of lactate
      • Septic Shock
        • Subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality
          • SEPSIS + Vasopressors to maintain MAP ≥ 65 AND Lactate > 2 mmol/L after adequate fluid resuscitation
            • Fluid resuscitation not defined objectively
          • In hospital mortality ~42%

 

Take-home:

  • Patient with suspected infection
  • A qSOFA Score of ≥2 suggests a high risk of poor outcome; these patients should be assessed for evidence of organ dysfunction, including lactate levels
    • They should also have a SOFA Score calculated (with a SOFA Score ≥2 meeting criteria for the new clinical definition of sepsis, as a proxy for organ dysfunction)
    • Patients should receive standard interventions for sepsis, including but not limited to adequate fluid resuscitation, antibiotics, and source control
  • If SOFA score of ≥2, and after correcting for hypovolemia, pressors are required to keep MAP ≥ 65 mm Hg and measured lactate > 2 mmol/L, patient is in septic shock
  • Sayonara to SIRS and Severe Sepsis

 

Strengths:

  • Data-driven with large patient cohorts supporting clinical criteria for definitions
  • Simple clinical criteria with the qSOFA to identify patients without lab tests who may be at risk for poor outcomes (i.e. prolonged ICU course and death) in the presence of infection

 

Weaknesses / Critiques

  • There is still no known precise pathophysiological feature defining sepsis
  • Unclear how to interpret studies (EGDT, ProCESS, PROMISE, ARISE) with new definitions
  • Not endorsed by ACEP or SAEM as emergency providers were not included
  • qSOFA and SOFA are mortality predictors, NOT designed to be tests for sepsis
  • qSOFA has not been prospectively validated
  • Compared to SIRS, qSOFA is more specific (but less sensitive) for predicting mortality
  • Prospective validation is needed to determine the real-world performance of Sepsis-III

 

Additional Links / Sources

 

http://emcrit.org/pulmcrit/problems-sepsis-3-definition/

http://stemlynsblog.org/sepsis-16/

http://icmwk.com/2016/02/25/sepsis-3/

 

Mar 14

Weekly Report – Seeking Closure

You are working a busy trauma shift when a 19 year old male comes in after a dirt bike accident. Fortunately for him he has no significant injuries, but he does have a number of lacerations that require closure including a scalp lac, full thickness lip lac, eyelid lac, and multiple extremity lacs. As you ponder your wound care approach you remember that the trauma committee just recently posted their Wound Closure Guidelines:

 

BACKGROUND

  • Improper technique during wound closure in the trauma patient can result in infection and/or wound dehiscence contributing to increased rates of morbidity and healthcare expenditure.
  • The following guidelines will serve to aid in choosing appropriate materials and proper technique for optimal wound closure.
  • This is a guideline for lacerations that do not involve life threatening or arterial bleeding. These lacerations would be assessed on the secondary assessment of major trauma patients.

 

CLINICAL PRACTICE GUIDELINES

I. Initial Evaluation

  • Initial evaluation of a laceration must include thorough neurovascular and functional exam. An abnormal exam should be addressed by consultation of appropriate subspecialty service. Consider consultation in:
    • Flexor tendon injuries in the upper extremities
    • Wounds involving joint spaces
    • Wounds involving large vessels
    • Wounds requiring large debridement
    • Avulsion injuries of ears, nose, penis
  • Note that a patient request for an emergent subspecialty consult is not an indication to consult (i.e. plastics for an uncomplicated facial laceration)
  • Assessment of wound includes thorough cleaning and exploration. Jagged wound edges, stellate shape, visible contamination and wound depth all increase risk of infection.
  • Patient history is important. Risk factors for delayed wound healing and infection include advanced age, diabetes, and vascular disease (chronic venous insufficiency, peripheral artery disease).

 

II. Preparation

A. Cleaning

  • Sterile saline and tap water equivalent
  • Irrigation (50-100ml per cm of laceration)
  • Pressure: need to overcome bacterial adhesion to tissue. However too much pressure causes tissue damage and increases infection risk by driving bacteria into tissue.  Ideal pressure is 8-12 psi.

B. Imaging

  • X-ray, ultrasound, CT scan can detect presence of radiopaque foreign bodies in the wound
    • Glass, metal, shrapnel, teeth
  • Does not replace wound exploration for identification of radiolucent material
    • Organic material, clothing

 

III. Materials

A. Vicryl: Braided, absorbable suture

  • Maintains tensile strength for 3-4 weeks.
  • Indications: preferred material for subcutaneous closure
    • Deep closure of muscle, fascia, subcutaneous tissue
    • Should not be used to close skin
  • Purple vicryl can tattoo skin when used in the subcutaneous tissue

 

B. Prolene/Nylon: Monofilament, non absorbable

  • Indications
    • Skin closure, tendon repair
  • Extremities (Arms/legs)
    • 3-0 or 4-0, consider 2-0 over large joints or areas of tension
    • Remove in 7-10 days
    • If laceration is overlaying joint, consider orthopedic surgery consultation to ensure joint space not violated.
  • Distal extremities (hands/feet)
    • No smaller than 4-0
    • Remove in 7-10 days
  • Chest/abdomen
    • 3-0 or 4-0
    • Remove in 7-10 days
  • Face
    • 5-0 or 6-0
    • Remove in 3-5 days
  • Tendon
    • 2-0 or 3-0

 

C. Chromic Gut: Coated, biologic,

  • Maintains tensile strength for 10-14 days
  • Indications
    • Palms and soles
    • Inside the mouth
  • Chromic gut is not an appropriate choice for skin closure or for deep sutures

 

D. Fast gut: Biologic

  • Low tensile strength, absorbed within 4-6 days
  • Indications
    • Face on children
    • Face for selected adults (those unlikely to follow up, small, superficial wounds under no tension)
    • Can be re-enforced with wound tape

 

IV. Suture technique

  • Buried stitches (deep stitches) for use in multi-layer closure
    • For subcutaneous closure in gaping wounds
    • For closure of fascia over muscle
  • Vertical mattress –This is a stitch that is meant to close wounds under significant tension
    • For skin closure of gaping wounds
    • Closure over joints
  • Horizontal mattress –This stitch is for hemostasis only, not for wounds under tension
    • For skin closure of a wound with significant bleeding from the skin edge
  • Figure of eight –This stitch should be applied to an actively bleeding vessel only o Use Silk (3-0) for this stitch in an arteriolar bleed
    • If the bleed is truly an arterial bleed, a small silk (3-0 or 4-0) should be used
  • Running subcuticular –This stitch should be used to close skin, for cosmesis only after deep Vicryl stitches have been applied
    • Use Monocryl only (4-0 or 5-0)

 

V. Wound type

  • Contaminated wounds
    • Copious irrigation
    • Lacerations or wounds over joints should be challenged with saline load to ensure no joint involvement. Recommend orthopedic surgery consult.
    • Grossly contaminated wounds should be cleaned thoroughly and left open. Wet dressing applied. Need daily dressing changes and referral to follow-up with General Surgery
  • Delayed presentation
    • Copious irrigation with debridement as needed
    • Facial wounds may be closed up to 24 hrs after presentation
    • Wounds in the extremities may be closed up to 12 hrs after presentation
    • If the wound is too large to leave open or heal by granulation, can place retention sutures sparingly to loosely approximate skin edge. Avoid placing deep sutures in these wounds and consult appropriate service for follow up.
  • Special considerations
    • Exposed cartilage should not be sutured. Perichondrium should be the deepest stitch. Exposed cartilage needs to be covered with skin completely.
    • Lip: Through and through lip lacerations often require multi-layer closure. The muscular layer should be closed with vicryl, anything inside the mouth should be closed with chromic gut and anything outside the mouth (including the vermillion border) should be closed with nylon or prolene. All sutures should be 5-0.
    • Complicated facial lacerations involving the lacrimal duct, eye lid edge, eye lid function should prompt a consult to ophthalmology
    • Facial lacerations with neurovascular compromise, muscular impairment, or concern for cosmetic outcome should prompt a consult to face coverage (ENT, OMFS, plastic surgery)
    • Involvement of joint space, tendon/bone exposure warrants an orthopedic surgery consult.
    • Lacerations of the hand need to be carefully examined for neurovascular status, tendon involvement, or violation of tendon sheath. Hand consult teams are orthopedic surgery and plastic surgery.

 

VI. Antibiotics

  • Not indicated for simple lacerations
  • Prophylactic antibiotics for:
    • Human/animal bites
    • Extensively contaminated wounds (soil, organic material)
    • Higher risk of infection with poor perfusion: anatomical (scalp lower risk than extremity) and chronic disease states (PAD, chronic venous stasis)

 

References

1 Hollander JE, Singer AJ, Valentine SM, Shofer FS (2001) Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med 8(7):716–720

2 Chisholm CD, Cordell WH, Rogers K, Woods JR (1992). Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Ann Emerg Med 21(11):1364–1367

3 Moscati, R. M., Mayrose, J., Reardon, R. F., Janicke, D. M. and Jehle, D. V. (2007), A Multicenter Comparison of Tap Water versus Sterile Saline for Wound Irrigation. Academic Emergency Medicine, 14: 404–409.

4 Mehta PH, Dunn KA, Bradfield JF, Austin PE. Contaminated wounds: infection rates with subcutaneous sutures. Ann Emerg Med 1996; 27:43.

5 Subcuticular sutures and the rate of inflammation in noncontaminated wounds.

6 Al-Mubarak L, Al-Haddab M. Cutaneous wound closure materials: an overview and update. Journal of cutaneous and aesthetic surgery 2013;6:178-88.

7 Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol 1992; 18:785.

8 Nicks B, Ayello E, Woo K, Nitzki-George D, Sibbald G. “Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations.” Nt J Emerg Med (2010) 3:399-407.

9 Eron LJ (1999) Targeting lurking pathogens in acute traumatic and chronic wounds. J Emerg Med 17(1):189–195

10 Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am 2003; 21:205.

11 Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med 1995; 13:396.

Mar 14

FOAM of the Week – Shock and Fluid Responsiveness, Asthma

Got some great posts and podcasts on shock and asthma from lecture this week:

Mar 12

Image of the Week – Small Bowel Obstruction

Courtesy of Dr Wetendorf:

This week’s image is brought to us by medical students Robbins and Lee.  The patient presented with hypotension and emesis. Bedside ultrasound quickly captured the image below.

SBOmeasured

Video captures several signs of small bowel obstruction (SBO):the classic “keyboard” sign (visualization of the plicae circulares), abnormal (bidirectional)peristalsis, and dilated loops of bowel. To diagnose SBO with US, use the curvilinear probe and scan systematically over the abdomen. Look for fluid-filled, dilated loops of bowel (defined as >2.5cm). You may also see “back and forth” movements within the lumen as bowel contents move with dysfunctional peristalsis. The plicae circulares can be prominent as seen in the video, and helps you identify the bowel loop as small bowel. Although history, physical exam, and XR findings are the “classic” method to diagnose SBO, an ultrasound in skilled hands performs with a higher sensitivity and specificity vs traditional abdominal XR.

 

Hefny AF, Corr P, Abu-Zidan FM. The role of ultrasound in the management of intestinal obstruction. Journal of Emergencies, Trauma, and Shock. 2012;5(1):84-86. doi:10.4103/0974-2700.93109.

Alice Chao, MD and Laleh Gharahbaghian, MD, FACEP. Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? http://www.acep.org/Content.aspx?ID=100218.

Thanks for all of your great images this week!

Mar 06

FOAM of the Week – Intubating the Acidotic, Electrical Storm

Some random stuff from recent shifts for class week. FOAM away.

Feb 29

Image of the Week – Liver GSW

Image of the Week courtesy of Dr Sierra Beck:

The image of the week comes to us from Drs Pearl Ann Arnovitz and Todd Taylor who used ultrasound to evaluate a patient with a GSW to the right thoracoabdomen.  Can you identify the pathology present?

Thanks for all of your great images this week!
Happy Scanning!

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