Feb 28

FOAM of the Week – Nephrolithiasis, Peri/Myocarditis, GU Trauma

Some great FOAM stuff related to this past week’s lectures – enjoy!
  • Nephrolithiasis
  • Previous FOAM of the Week on Genitourinary trauma:  Know how to work up your patient for genitourinary trauma? (Hint, the panscan is not sufficient) Check out these questions and answers from Life in the Fast Lane (and definitely read all the links to the Trauma Professional’s Blog for further details): http://lifeinthefastlane.com/trauma-tribulation-021/

Feb 24

Weekly Report – Just Constipation?

Just Constipation?: Functional v. Organic Causes of Slow Stooling (or Defecation Delays)

 

Mom brings a previously healthy 11 month-old male to the Pediatric Emergency Department because the boy has not had a bowel movement for four days and seemed “fussy”. He has continued to eat, is not vomiting, having fevers, experiencing rectal bleeding, and is not lethargic or inconsolable. His vital signs are completely normal, and he is well appearing and playful in mom’s arms. The abdomen is mildly distended but soft, and there is a firm palpable mass extending from the right lower to right upper quadrant. CBC, BMP, UA are normal. The initial KUB obtained in the ED is shown below:

 

Constipation KUB

 

 

Functional constipation is often associated with dietary changes, stool with-holding and trouble toilet training, decreased fiber intake, or decreased liquid intake. It accounts for 95% of cases of constipation in kids.

 

In most cases of constipation, history and physical exam can lower the suspicion for an organic cause and the patient can most often be discharged with the stool softener or poop potion of your choice with outpatient follow up.

 

When considering organic causes, think about some “alarm signs” or physical findings that would warrant further work-up.

 

Alarm Signs:

  • Was there delayed passage of meconium which might suggest CF or Hirschsprung’s disease?
  • Has there been severe abdominal pain or rectal bleeding?
  • Any urinary incontinence to suggest spinal cord abnormality?
  • Are stools “ribbon-like”?
  • Has there been significant weight loss, or is the patient falling off the growth curve?

 

Physical Findings:

  • Are there any focal neurologic findings, especially involving the lower extremities and the rectal exam?
  • Is there any abnormal GU anatomy such as:
    • Lumbosacral dimple or lower spine abnormalities
    • Perianal fistula
    • Tight anal canal
    • Anteriorly displaced anus
  • Is the abdomen significantly distended or are there palpable masses that would suggest obstruction or mass?

 

In the KUB obtained on this patient, there was a visible right-sided abdominal mass that was read as “likely representing stool”. The patient was admitted and taken to the OR for stool evacuation under general anesthesia. The exam was anatomically normal, but a rectal biopsy demonstrated “absence of ganglion cells in the mucosa”. In this case, the diagnosis was Hirschsprung’s disease. The only finding on initial evaluation that led to further work-up was the palpable abdominal mass. Even though more than nine times out of ten, constipation is just constipation, this case serves as a good reminder to keep an open mind when obtaining the initial history and physical examination and to look out for any alarm features that would warrant further testing.

Feb 23

Lit of the Week — Airway Assessment Score and Predictors of Difficult BVM

 

Lit of the Week – 2/2/16

 

Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J. 2005 Feb;22(2):99-102.

 

Clinical question / background:

  • Can an airway assessment score based on the LEMON method detect difficulty at intubation (Cormack and Lehane Grade 2-4) in the ED?

 

Design:

  • Prospective observational study
  • 156 patients in ER population, 1 UK teaching hospital
  • Inclusion: Adult patients requiring intubation
  • Exclusion: None
  • Patients’ airways evaluated using LEMON criteria and given points (0-10)
    • Look (4 criteria used, 1 point each) – max 4 points
      • Signs of airway trauma, large incisors, large tongue, presence of beard
    • Evaluate 3-3-2 rule – max 3 points
      • Interincisor distance (3 finger breadths), mentum to hyoid, (3 finger breadths) floor of mouth to thyroid notch (2 finger breadths)
      • 1 point for each
    • Mallampatti class – max 1 point
      • 1 point for either class III / IV
    • Obstruction – max 1 point
      • ex epiglottitis, PTA, trauma, blood, FB
    • Neck Mobility – max 1 point
      • Chin to chest, extension so as to look at ceiling
    • At time of intubation, Cormack and Lehane Laryngoscopy Grade Score was recorded to objectively determine difficulty of intubation
      • A difficult intubation was a Cormack and Lehane grade 2,3, or 4

 

Results:

  • Of the above LEMON criteria, patients with large incisors (p <0.001), reduced inter-incisor distance (P<0.05), or a reduced thyroid to floor of mouth distance (P<0.05) were each significantly associated with more difficulty laryngoscopic view
  • Patients with high airway score (median score 2) more likely to have poor laryngoscopic view compared to lower (median score 1)
  • 114 Patients with C/L Grade 1, 42 C/L Grades 2-4

 

Take-home:

  • Airway assessment score based on LEMON method can stratify risk of increased intubation difficulty
    • Major criteria were incisor distance, floor of mouth to thyroid distance, and presence of large incisors

 

Strengths:

  • Simple, designed to target ER patient population

 

Weaknesses / Critiques

  • Same practitioner performed LEMON assessment and intubation which may have led to bias
  • Interobserver variability in determining LEMON scores
  • Subjective terms such as ‘large incisors’
  • Difference between airway score for the two groups was only 1 point

 

Follow-up / Real World Application

  • Cormack and Lehane Views
    • Grade 1 – complete glottis visible
    • Grade 2 – posterior glottis and arytenoid cartilage only
    • Grade 3 – epiglottis only
    • Grade 4 – no epiglottis or laryngeal structures visible

 

—————————————

Paper #2

 

Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly M, Ludwig TA. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006 Nov;105(5):885-91.

 

Clinical Question / Background

  • What are the predictors of difficult and impossible bag-mask ventilation in patients undergoing intubation during general anesthesia?

 

Design

  • Prospective observational study
  • 22,660 BVM attempts at a large academic surgical center
  • Inclusion: all adult patients undergoing general anesthesia
  • Exclusion: none
  • Primary outcome: ease or difficulty of BVM defined as below
    • Four-point scale ranging from grade 1 to 4 used to objectify difficulty of BVM with Grades 3 and 4 defined as difficult and impossible, respectively
      • Grade 1 – ventilated by mask
      • Grade 2 – ventilated by mask with oral airway/adjuvant with or without muscle relaxer
      • Grade 3 – difficult mask ventilation defined as BVM that is inadequate to maintain oxygenation, unstable BVM, or BVM requiring two providers
      • Grade 4—impossible mask ventilation noted by absence of end tidal CO2 measurement and lack of perceptible chest wall movement during positive pressure ventilation attempts despite airway adjuvants and additional personnel
    • Secondary outcomes
      • Cormack and Lehane DL view, subjective assessment of difficulty of intubation defined as 3+ attempts, and ability to perform DL

 

Results

  • Incidence of grade 3 BVM – 1.4% (n=313)
  • Factors statistically significantly associated with Grade 3 BVM
    • BMI > 30, presence of a beard, Mallampati III or IV, age 57 or older, severely limited jaw protrusion, snoring

 

  • Incidence of grade 4 BVM – 0.16% (n=1.4%)
  • Factors statistically significantly associated with Grade 4 BVM
    • Snoring, thyromental distance < 6 cm

 

  • Incidence of grade 3 or 4 BVM + difficult intubation – 0.37% (n=84)
  • Factors statistically significantly associated with Grade 3 or 4 BVM + difficult intubation
    • Limited jaw protrusion, abnormal neck anatomy, sleep apnea, snoring, BMI > 30

 

Take Home

  • Advanced age, increased BMI, presence of beard, history of snoring associated with difficult BVM
  • Limited jaw protrusion associated with difficult intubation

 

Strengths

  • Large study, powered to detect statistically significant associations between airway exam and procedural difficulty

 

Weaknesses

  • Surgical patients optimized for intubation so does not apply as firmly to ER population
  • Multiple subjective analyses
  • Presence of beard is only modifiable risk factor that was found
  • Lack of control or uniform conditions applied to all BVM attempts

 

Feb 23

Lit of the Week — Antihistamines in Acute Allergic Reaction

Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L, Tenenbaum C, Westfal RE. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med. 2000 Nov;36(5):462-8. PubMed PMID: 11054200.

 

Clinical question / background:

  • Does combined H1 and H2 blockade result in improved outcomes in patients treated for acute allergic syndromes compared with treatment with H1 blockers alone?

 

Design:

  • Randomized, double-blind, placebo-controlled trial
  • 91 patients, 1 urban academic center emergency department
  • Inclusion: Adults (> 18 y/o) presenting after exposure to ingested food, exposure to drug, or contact with latex with acute urticaria, acute angioedema, acute unexplained stridor, and acute pruritic rash for < 12 hours
  • Exclusion: Pregnant patients
  • Supplemental medications such as O2, IVF, Epinephrine, Steroids, Bronchodilators, Additional antihistamine doses given at discretion of physicians
  • Primary outcome: resolution of urticaria and angioedema at 2 hours
  • Secondary outcomes: changes in vital signs, final disposition

 

Intervention:

  • Diphenhydramine 50 mg IV x1 + Ranitidine 50 mg IV x 1

 

Control:

  • Diphenhydramine 50 mg IV x 1 + saline solution

 

Results:

  • Significant difference in patients without urticaria at 2 hours between Ranitidine group (91.7%) and placebo group (73.8%), p=0.02
  • Number of areas involved with urticaria at 2 hours significantly less in ranitidine group
  • Significantly higher proportion of patients without angioedema and urticaria at 2 hours in ranitidine group (70.5% vs placebo (46.5%), p=0.02
  • OR of ranitidine treatment 2.80

 

Take-home:

  • Benefit of adding H2 blockers to H1 blockers in treatment of cutaneous manifestations of allergic reactions

 

Strengths:

  • Well-designed, double-blinded

 

Weaknesses / Critiques

  • Small sample size, 91 total patients
  • Potential confounders of steroid treatment, bronchodilators, additional antihistamine doses in placebo group
  • Parenteral administration so no data on PO
  • Authors purport epinephrine administration was not a confounder based on their analysis
  • Not enough data to extrapolate to treatment of anaphylaxis

 

Follow-up / Real World Application

  • Allergic reaction – usually skin manifestations of urticaria / erythema
    • H1/H2 blockers +/- steroids (Methylprednisolone 125 mg IV/IM or Prednisone 60 mg PO)
  • Angioedema — Localized subcutaneous (or submucosal) swelling
    • ALL patients – assess for airway compromise
    • Hereditary (C1 esterase deficiency)
      • RX FFP or if available C1 esterase inhibitors (Berinert 20u/kg IV), kallikrein/bradykinin inhibitors (ecallantide30mg SQ), or bradykinin receptor antagonist (icantibant 30mg SQ)
    • ACE-inhibitor induced or Allergic / Idiopathic
      • D/C ACE-I if applicable
      • Methylprednisolone 125 mg IV/IM
      • H1/H2 blockers IV
      • If accompanied by anaphylaxis, Epi 0.3-0.5 mg IM q 15-20 PRN
    • Anaphylaxis
      • Criterion 1 – acute onset of illness involving skin, mucosa (or both) AND
        • Respiratory compromise
        • Hypotension (or symptom such as syncope)
      • Criterion 2 – exposure to potential allergen + 2 or more of following
        • Involvement of skin-mucosal tissue
        • Respiratory compromise
        • Hypotension (or symptom such as syncope)
        • Persistent GI sxs (Nausea/vomiting, diarrhea, abd pain)
      • Criterion 3 – exposure of known allergen + hypotension
      • RX –
        • Epi 1:1000 0.3-0.5 mg IM q5-15 PRN
        • If no response, start epi drip: 1:10,000 2-10 mcg/min IV gtt
        • Peds: Epi 1:1000 0.01 mg/kg (max 0.5 mg)
          • 05-1 mcg/kg/min gtt if infusion necessary
        • Airway management
        • Albuterol, Steroids, H1/H2 blockers

Feb 23

FOAM of the Week – Conversion Disorder, Agitated Patients, Eating Disorders

Some helpful stuff related to lectures this week – enjoy!
  • Conversion disorder-related stuff:
    • Optokinetic drum for patients complaining of blindness:

Feb 15

FOAM of the Week – US guided IVs, In Flight Emergencies

Sorry for the delay this week – a couple good pod/videocasts related to this weeks topics:

Feb 09

Lit of the Week – Preoxygenation

Weingart S, et al. “Preoxygenation and prevention of desaturation during emergency airway management.” Ann Emerg Med. 2012;59:165-175.

Clinical question / background:

·      Patients requiring emergency airway management are at great risk of hypoxemic hypoxia because of primary lung pathology, high metabolic demands, anemia, insufficient respiratory drive, and inability to protect their airway against aspiration. Tracheal intubation is often required before the complete information needed to assess the risk of periprocedural hypoxia is acquired. Desaturation to below SpO2 70% puts patients at risk of arrhythmia, hemodynamic decompensation, hypoxic brain injury and death. This paper reviews the research and makes recommendations for preoxygenation before intubation in the Emergency Department

Sequence of Preoxygenation and Prevention of Desaturation

Preoxygenation Period

·      Position the patient in a semi-recumbent position or in reverse Trendelenberg. Position the patient’s head in the ear-to-sternal-notch position using padding if necessary.

·      Place a nasal cannula in the patient’s nares. Do not hook the nasal cannula to oxygen regulator.

·      Place patient on a non-rebreather mask at the maximal flow allowed by the oxygen regulator (at least 15lpm, but many allow a much greater uncalibrated flow)

·      If patient is not saturating >90%, remove face mask and switch to non-invasive CPAP by using ventilator, non-invasive ventilation machine, commercial CPAP device, or BVM with PEEP valve attached. Titrate between 5-15cm H2O of PEEP to achieve an oxygen Saturday >98%. Consider this step in patients saturation 91-95%.

·      Allow patient to breath at tidal volume for 3 minutes or ask the patient to perform 8 maximal exhalations and inhalations.

Apneic Period

·      Push sedative and paralytic (Preferably rocuronium, if the patient is at risk for rapid desaturation)

·      Detach face mask from the oxygen regulator and attach the nasal cannula. Drop the flow rate to 15lpm.

·      Remove the face mask from the patient

·      Perform a jaw thrust to maintain pharyngeal patency

·      If the patient is high risk (required CPAP for preoxygenation), consider leaving on the CPAP during the apneic period or providing 4-6 ventilations with the BVM with a  PEEP valve attached. Maintain a two-hand mask seal during the entire apneic period to maintain the CPAP

Intubation Period

·      Leave the nasal cannula on throughout the management period to maintain apneic oxygenation

 

 

Feb 08

Image of the Week – Ruptured Ectopic

Courtesy of Dr Beck:

The image of the week comes to us from Drs Shamie Das and Philip Shayne who used ultrasound to evaluate a patient with hypotension and bradycardia. Can you identify the pathology present?

Feb 06

FOAM of the Week – Blunt Cerebrovascular Injury, Peritonsillar Abscess

Since this week was a class day, I’ve included some topics that have come up on my shifts recently. Enjoy!
 
Blunt Cerebrovascular Injury – does every cervical seatbelt sign need a CTA?
 
Some tricks of the trade from ALIEM for peritonsillar abscess drainage:

Feb 03

Image of the Week – Retroperitoneal Hematoma

Courtesy of Dr Beck

The image of the week comes to us from MS4s Clifton Scott and Alex Dandre, and critcal care fellow Esther Lee who used ultrasound to evaluate a patient with a delayed presentation following a stab wound to the left flank. Can you identify the pathology present?

 

 

 

 

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