Two cases this week! Thank you to Dr. David Kaplan for submitting the first case, while the second case was one seen by myself and Dr. Paul Cheung.
58 y/o male sustained blunt force trauma to the lateral aspect of his right knee. On exam, there is a mild right knee effusion, but no obvious deformities. Pain with ROM. Neurovascularly intact. No ligamentous laxity appreciated. X-rays of the right knee are obtained:
22 y/o male sustained a gunshot wound to the right knee. On exam, there is an entrance wound on the posterior-lateral aspect of the knee, but no exit wound. There is pain with ROM of the knee and a mild effusion is appreciated. No obvious deformities. Neurovasculary intact. No ligamentous laxity appreciated. Initial plain films demonstrate the bullet lodged in the mid-thigh. Physical exam findings and x-rays of the right knee:
Given concern for an open joint, an aspiration is performed prior to irrigation, and the following aspirate is obtained:
What’s the diagnosis?
Discussing: “Preoxygenation, Reoxygenation, and Delayed Sequence Intubation in the Emergency Department” (Weingart SD, J Emerg Med. 2010 Apr 7)
- Patients requiring intubation should be classified by oxygenation saturation as low risk, high risk and apneic.
- Reservoir face masks with oxygen set at the highest rate possible are the recommended sources of high FiO2 during preoxygenation.
- All patients, if possible, should be intubated with the head-elevated position to increase safe apnea time.
- Consider using CPAP masks, noninvasive positive pressure ventilation or PEEP valves on a bag-valve mask in patients who cannot achieve oxygen saturations greater than 93%-95%
- Rocuronium may provide a longer duration of a safe apneic period in patients with a high risk of desaturation.
- A nasal cannula set at 15 L/minute is effective at providing oxygenation during the apneic period.
Intubation is a vital procedure to the Emergency Physician. Yet there is more to it than just placing an endotracheal tube. There is the setup, positioning, oxygenation, sedation, checking tube placement, and more. On top of this, there is the underlying illness to consider. The truth is, the majority of patients intubated in the Emergency Department (ED) are sick. Something is very physiologically wrong, and they are not maintaining adequate oxygenation. It becomes your job to do this for them. The authors in this article did an extensive literature review on pre-intubation and peri-intubation techniques which reduce the risk of hypoxia in the adult patient requiring intubation in the ED. Continue reading
a monthly blog series on procedures
Hunting & Gathering
Find a Workstation on Wheels (WOW) with a functioning Topaz to obtain informed consent.
Place Epic orders for CSF. Print the stickers and sign each with your initials.
Locate an LP tray, its contents, sterile gloves, eye protection, facemask.
Gather these optional supplies:
- Extra spinal needles:
- 20 gauge, 3.5 in Quincke = cutting needle (1 included in tray).
- 22 gauge, 3.5 in Whitacre = atraumatic needle.
- 20 gauge, 6 in “Harpoon” = longer needle.
- Extra 1% Lidocaine (5ml in tray).
- Extra Povidone-Iodine.
- Non-sterile marking pen.
Optional: Tech or RN for positioning assistance during procedure.
Perform the LP (see below).
Collect CSF in 4 tubes and send to lab.
Choosing the right needle
The Whitacre needle (aka a type of pencil point needle, or “atraumatic” needle) contains side ports, and theoretically causes less damage to tissue fibers upon entry. They are more difficult to use for skin entry. However, studies have shown that atraumatic needles decrease the incidence of post-LP headache (1 and 2). As an aside, there is no evidence that lying supine for any fixed period time is helpful in the prevention of post-LP headache(3). Continue reading
Part of our recurring ’52 Articles’ series exploring landmark articles in Emergency Medicine, inspired by the ALiEM blog’s index project,
- Over 23 years 950 patients underwent post injury thoracotomy at Denver Health Medical Center and overall survival was noted to be 4.4 percent with 3.9 percent surviving functionally intact.
- Using various assumptions for cost analysis the authors concluded that “the benefit-charge ratio was strongly in favor of performing EDT [emergency department thoracotomy] at 5.6:1, it was 1.8:1 if adjusted for the cost of maintaining all neurologically injured survivors throughout their lifetime.”
Emergency department thoracotomy remains a hotly debated procedure within the scope of emergency medicine. Not only is it a resource intense process that potentially places providers at increased risk for blood borne infections, but it is also one whose utility has been questioned given the limited success rate of meaningful patient outcomes. The authors of this study reviewed a cohort of consecutive trauma patients presenting to a level I hospital in Denver, CO in hopes of clarifying not only the costs as well as the utility of the procedure. The authors in this study reported “neurologically intact survival at time of discharge” as one of the study outcomes; however, it does not appear that any patients had post-hospitalization follow up to evaluate for any future changes. Continue reading
This is a case I saw in the ED. This case has been deliberately altered to protect the identity of the patient:
28 y/o patient presents to the ED after sustaining blunt trauma to the chest. An EKG is ordered as part of her workup:
Upon further questioning, the patient endorses periods of palpitations over the past couple of months where her “heart was racing”. She denies chest pain, shortness of breath, dizziness, or syncope with these episodes. What’s the diagnosis?
Case #1: Middle-aged patient on Coumadin rollover MVC:
Case #2: Young patient jump off bridge:
Pulmonary contusions were first described during WWI, when the battlefield dead were noted to be without signs of trauma but postmortem exams revealed lung hemorrhage. Pulmonary contusions are caused by direct bruising of the lung parenchyma followed by alveolar edema and hemorrhage. It is most commonly seen after MVC’s with rapid deceleration, high velocity missile wounds, and blast injuries. If sufficient hemorrhage to the lung has occurred, the injury will be apparent on CXR. The treatment is supportive. Here were a few points I learned from these two cases:
- There are no pathognomonic features for pulmonary contusion on CXR. The same increased density of tissue and alveolar consolidation can occur with pneumonia, aspiration, or pulmonary infarction. It is the context of trauma that defines the appearance as contusion.
- The natural history of pulmonary contusions is that it tends to worsen over the first 24-48 hours before it improves over the next 7 days. Therefore, keep a close eye on these folks in the trauma bay, especially when the pulmonary contusion is already visible on your initial CXR. Respiratory distress and hypoxia are indications for intubation.
The first patient died, and the second patient was discharged after a prolonged course in the TICU on ECMO.
Broder, J. (2011). Chapter 6: Imaging Chest Trauma. Diagnostic Imaging for the Emergency Physician.
Simon, B, et al. (2012). Management of Pulmonary Contusions and Flail Chest EAST Guidelines.
We see a ton of people in the ED who visit us for their infectious “emergencies.” Ideally, we start them on the appropriate antibiotics and send them on their way, either out the door or upstairs as the case necessitates. Our best intentions can unfortunately give rise to unexpected side effects. It is well known that taking antibiotics opens you up to developing C. difficile infections which can lead to dehydration, malnourishment, hospitalization, and even death. It costs lots of time and money to care for and treat this untoward outcome. Due to a 2013 Cochrane review, I’ve gotten in the habit of giving an extra med for the folks needing antibiotic treatment – a probiotic.
The Cochrane group included 31 studies (including 24 RCTs) in the review which found that there was a significant reduction in C. difficile associated diarrhea (CDAD) in patients given probiotics. The incidence was 2% in the probiotic group vs 5.5% in the placebo/no treatment groups. The number needed to treat was found to be 29 patients to prevent a case of CDAD. There was also found to be a significantly lower rate of non-C. difficile antibiotic associated diarrhea as well as other adverse events (e.g. flatulence, abdominal cramping, nausea) in the group given probiotics.
Next time you are treating the little old lady with the UTI or the young lady who maybe had CMT, think about throwing on some probiotics to reduce the continuity of care in the ED. It’s pretty low risk with pretty high yield. I’ve been giving out Lactobacillus capsules myself. Feel free to check out the link.
- This study demonstrates that the number needed to treat with therapeutic hypothermia to prevent one unfavorable neurological outcome is 6. The number needed to treat to prevent a single death is 7.
- Overall 75 of the 136 patients in the hypothermia group had favorable neurological outcomes as defined by the Pittsburgh cerebral performance grading scale. Only 54 of 137 patients in the control arm had favorable neurological outcomes recorded.Mortality in the hypothermia group at six months was 41 percent compared to 55 percent in the normothermic group.
The exact mechanism for the beneficial effects of therapeutic hypothermia are unclear with regards to favorable neurological outcomes, but it has been postulated that a reduction in cerebral oxygen consumption or a disruption in the inflammatory and acute phase cascade helps to prevent further brain injury following cardiac arrest. At the time of this study over 375,000 people in Europe were being treated annually for cardiac arrest with overall poor neurological outcomes. Continue reading
Why the 32 French?! It’s not 1970 anymore. Next time you’ve got a simple pneumothorax, consider the pigtail! Chana Rich and Kat Farmer will show you how:
For a more detailed, step by step process, see another great post by Dr. Jay Diamond:
1. The final Canadian C-spine Rule comprises three questions:
A.) Is there a high-risk factor that mandates radiography such as: age≥65, dangerous mechanism, or paresthesias in extremities?
B.) Is there any low-risk factor that allows safe assessment of range of motion such as: simple rear end MVC, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness?
C.) Is the patient able to actively rotate neck 45° to the left and right?
- The Canadian C-Spine Rule was tested on a convenience sample of 8,924 alert and stable trauma patients in 10 Canadian emergency departments with 151 cases of clinically significant C-spine injury and proved to have a sensitivity of 100% (95% CI: 98-100%) and a specificity of 42.5% (95% CI: 40-44%).
Less than three percent of trauma series yield a positive result.
According to the data compiled by the researchers in the Canadian CT Head and C-Spine Study the use of C-spine radiography is quite variable among emergency physician providers based on local culture and the overall cost of C-spine radiography is in the multi-millions. Their research demonstrated that less than three percent of trauma series yield a positive result. Continue reading