Auricular Hematoma Drainage

Auricular hematomas are common complications after direct trauma to the auricle of the ear. A shearing force causes capillary rupture and hematoma formation. If a patient  presents within 7 days of the injury, it falls within the EM Physicians skill set to evacuate the hematoma. The following is a video that walks one through the procedure…

ROCKSTARS: Ultrasound vs Chest X-ray in the Detection of Traumatic Pneumothorax

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Picture this…A 45 year old male is activated as a trauma after falling off 30 feet off scaffolding. He is flown from the scene and the report from the paramedics notes concern for spinal cord injury, as he has no sensation below the nipple line and flaccid extremities. On primary exam the resident notes diminished breath sounds on the right, however he asks the question to the rest of the trauma team: “are the decreased breath sounds from a pneumo/hemothorax or from a partially paralyzed/weakened diaphragm, in a patient with a high c-spine injury”. In a minute of clinical reasoning in an otherwise algorithmic setting, the resident challenges his clinical exam (inspection, palpation, auscultation) and places an ultrasound on the patient acquiring the following images:

Video: Lung point–the most specific sign for pneumothorax on thoracic ultrasound.

Lung Sliding

Image 1: M-mode of lung point showing both seashore and stratosphere

A chest tube is placed and the remainder of the trauma survey proceeds.

At our institution, we wait for a chest x-ray that shows no pneumothorax before sending a patient to the CT scanner. This is despite the studies that show the sensitivity of supine chest x-rays is 28 % to 75%.[i] This begs the question, would a bedside ultrasound be quicker and more sensitive to evaluate for a pneumothorax. A quick review of the literature says a definitive yes.

Three articles are at the core of the US for pneumothorax evidence. First in 2005, Blaivas et al published a paper that used EM attendings in a prospective single blinded trial to evaluate 176 patients for pneumothorax. They used 4 protocol views in each hemithorax (2nd intercostal mid clavicular, 4th intercostal ant. Axillary, 6th intercostal midaxillary and 6th intercostal post axillary) and evaluated only for lung sliding. No M-mode, no doppler. Their results were compared to the Trauma attending read of the supine CXR and the Radiologist’s view of the chest CT.

In this study: the sensitivity and specificity for thoracic US was :

Ultrasound (95% CI) CXR (95% CI)
Sensitivity 98.1% (89.9%-99.9%) 75.5% (61.7-86.2%)
Specificity 99.2% (95.6%-99.9%) 100% (97.1%-100%)

Wilkerson and Stone in 2009 published a meta-analysis of 4 trials including the Blaivas trial noted above. This meta-analysis looked at EM physicians as US operators in the analyses of pneumothorax or no pneumothorax in the setting of trauma. This study again found superior outcomes for thoracic ultrasound:

Ultrasound CXR
Sensitivity 86%-98% 28%-75%
Specificity 97%-100% 100%

Lastly in 2012, Hyacinthe et al. published a paper that aimed to assess the ability of thoracic ultrasound to detect, on arrival, the occurrence of common thoracic lesions in a cohort of chest trauma patients. This is likely the most relevant study as the methods consisted of a prospective observational cohort study where two separate EM physicians were used. First the physician taking care of the patient primarily used the Clinical Exam (Inspection, palpation, percussion and auscultation) and chest x-ray to determine the presence of pneumothorax. The physician performed their exam, looked at the supine chest x-ray then was asked to give the patient a score of how likely they are to have a thoracic lesion (0=no chance, 3=sure presence of lesion). A separate EM attending blinded to the initial exam and CXR then performed a thoracic ultrasound in both lung fields, including the upper, middle and lower parts of the anterior and lateral regions of both chest walls. Pneumothorax was defined as the absence of lung sliding or by the presence of lung point. The performing physician then, in a similar way, recorded their findings on a scale from 0-3. Results for this study included the sensitivity and specificity for each modality however, given the scales of probability entered by each physician, the more encompassing statistic is the area under the curve (AUC) for each modality.

Ultrasound CE+CXR
Sensitivity 53% 19%
Specificity 95% 100%
Area Under the Curve, mean (95% CI) 0.75 (0.67-0.83) 0.62 (0.54-0.70)

These articles make a strong case for the increased use of ultrasound in trauma. In the hands of an experienced user, a bilateral thoracic ultrasound takes 2-4 minutes, is arguably shorter than the time to call an x-ray tech, shoot the x-ray, develop the images and walk down the hall to view them, not to mention the test is overwhelmingly more sensitive.

References:

[i] Gentry Wilkerson, R. and Stone, M. B. (2010), Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Academic Emergency Medicine, 17: 11–17. doi: 10.1111/j.1553-2712.2009.00628.x

[ii]Blaivas, M., Lyon, M. and Duggal, S. (2005), A Prospective Comparison of Supine Chest Radiography and Bedside Ultrasound for the Diagnosis of Traumatic Pneumothorax. Academic Emergency Medicine, 12: 844–849. doi: 10.1197/j.aem.2005.05.005

[iii]Hyacinthe AC, Broux C, Francony G, et al. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma.Chest. 2012;141(5):1177–83

 

Tricks of the Trade: A-Line Kits for Vascular Access

Ever struggle with vascular access?

Ever tried a 20G A-Line kit?

Even if you have,  once a flash is obtained it is common to not be able to thread the wire. If you pull the needle out of the catheter, it is rigid and difficult to replace in the catheter and rarely results in salvaging the attempt. In this video, I show you that by cutting the white cap off the back of the a-line kit, it will liberate the guide wire allowing the proceduralist to use it as a backup if the first attempt at placing the catheter fails. I have found,  many times when a flash is obtained but the wire doesn’t pass, the attempt can be salvaged with this technique. Enjoy…

 

Passed out…Peace out. Who can go home after syncope?

Discussing: Quinn et al. Annals of Emergency Medicine. Prospective Validation of the San Francisco Syncope Rule to Predict Patients With Serious Outcomes

Main Points:
1. This 2006 prospective cohort trial aimed to validate a clinical rule to help risk stratify patients presenting to the ER with syncope in relation to short term outcomes. The rule was validated to have a sensitivity of 98% in preventing serious outcomes after syncope within 30 days.

2. The San Francisco Syncope rule is positive if the patient has a chief complaint of “shortness of breath”, a medical history of CHF, a presenting SBP <90mm Hg, a hematocrit <30%, or an abnormal ECG result (any non-sinus rhythm or new changes).

Background:

Approximately 25% of the general population will have an episode of syncope in their lifetime. Patients with syncope account for 1-2% of all Emergency Department visits and hospital admissions. Patients admitted for syncope, however, have been shown to receive little to no further diagnostic care, nor do they often receive a firm diagnosis concerning the cause of their syncope. Given this, the authors’ purpose was to validate the decision rule in a prospective cohort of consecutive ED patients by determining whether it can predict short-term serious outcomes.

Syncope was defined as “transient loss of consciousness with return to baseline neurologic function,” and patients presenting with acute syncope or pre-syncope were screened for the study. When a clinician had finished working up the selected patient, a short Web-based questionnaire was completed to evaluate for aspects of the history, ECG, vitals or lab results that pertain to the decision rule. In this trial, the decision rule was 98% sensitive and 56% specific to predict a serious outcome within 30 days. If applied in the study cohort, this clinical rule may have decreased syncope admissions by 24%.

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