<![CDATA[Emergency Medicine Education - Blog]]>Thu, 31 Jul 2014 12:34:44 -0800Weebly<![CDATA[How to manage menorrhagia in the ED.]]>Tue, 29 Jul 2014 09:26:41 GMThttp://emergencyeducation.net/1/post/2014/07/how-to-manage-menorrhagia-in-the-ed.html
  • Menorrhorrhagia is a very common problem seen in women.
  • 20% of women with mennorrhagia will have some sort of bleeding disorder
  • Serum pregnancy test is mandatory as the causes of bleeding vary greatly between the 2 groups.
  • Complete blood count and film to screen for anaemia and platelet dysfunction should be done as should a ferritin level.
  • An APTT, PT and TT should be ordered, and a screen for von Willebrand disease should also be done due to the high incidence of the disease in women with menorrhoagia.
  • Acute surgical management of haemodynamically unstable bleeding includes intrauterine balloon tamponade, gauze packing, curettage, uterine artery embolisation and hysterectomy (last 2 options do not preserve fertility).
  • Medical therapy can include high dose oestrogen (25 mg premarin in 5ml saline over 2 minutes - this can be repeated in 5-6 hours if ongoing bleeding). There is a high incidence of nausea and vomiting with this medication and anti-emetics frequently have to be used.
  • Alternative non-hormonal therapy can include the use of tranexemic acid (10 mg/kg intravenously every 8 hours or 1-1.5 g PO every 8 hours.)
  • In patients with known haemostatic defects, the use of desmopressin, factor concentrates and blood products are all indicated.
  • Long term treatment can include COCP, IUD's, tranexamic acid, NSAID's or cyclical progestogens.
  • Supplemental iron should also be considered.

Reference
  1. Pai M et al. How I manage heavy menstrual bleeding. Br J Haem. 2013;162(6);721
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<![CDATA[Muslim Patients and their Expectations.]]>Tue, 29 Jul 2014 06:07:59 GMThttp://emergencyeducation.net/1/post/2014/07/muslim-patients-and-their-expectations.htmlSome useful cultural tips when dealing with Muslims in the emergency department;
  • Many muslims tend to express their symptoms in vague, non-specific terms.
  • Most prefer active treatement with pills and injections - if other therapies are indicated, you need to explain the importance of these as they may not hold as much sway (e.g physiotherapy)
  • The preferred conversational distance is about 2 feet.
  • Gender concordant care is preferred - if this is not possible, then the use of gloves to prevent skin to skin contact is helpful.
  • Sensitive questions should be posed in private, and family members should generally be involved in medical decision making.
  • Muslims would like to be provided with a quiet space for prayer, and have accommodations made for their dietary restrictions.


Reference
  1. Ezenkwele UA et al. Cultural competencies in emergency medicine: caring for muslim-american patients from the middle east. J Emerg Med. 2013;45(2);168
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<![CDATA[Early Goal Directed Therapy for Patients with Septic Shock]]>Tue, 29 Jul 2014 05:57:06 GMThttp://emergencyeducation.net/1/post/2014/07/early-goal-directed-therapy-for-patients-with-septic-shock.html
  • EGDT has been used in the treatment of patients of septic shock.
  • This large randomized controlled trial (PROCESS) looked at whether using EGDT improves patient outcomes (1341 patients). This study found no improvement in patient outcomes using early goal directed therapy when compared to standard therapy for management of patients with septic shock.
Reference;
  1. The PROCESS investigators. A randomized trial of protocol-based care for early septic shock. NEJM March 18, 2014
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<![CDATA[Tranexamic Acid for the management of Epistaxis]]>Tue, 29 Jul 2014 05:56:00 GMThttp://emergencyeducation.net/1/post/2014/07/tranexamic-acid-for-the-management-of-epistaxis.htmlIn this study of 204 patients from Iran, patients presenting with anterior epistaxis in the abscence of a bleeding disorder, shock or a visible bleeding vessel were randomised to management with anterior nasal packing or nasal packing with pledglets soaked in tranexamic acid.
Bleeding stopped in 71% of the tranexamic acid group within 10 minutes compared to 31% of the nasal packing group. There was no significant difference in complication rates between groups and the rebleeding rate was significantly less in the tranexamic acid group.

Reference
Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: A randomized controlled trial. Am J Emerg Med; 2013; 31(9);1389
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<![CDATA[Blood Pressure Targets in Patients with Septic Shock]]>Tue, 29 Jul 2014 04:39:49 GMThttp://emergencyeducation.net/1/post/2014/07/blood-pressure-targets-in-patients-with-septic-shock.html
  • The surviving sepsis campaign recommends a target of MABP > 65 mmHg for patients with septic shock.
  • This new study looked at whether a higher blood pressure target of 80-85 mmHg improved outcomes. There was no change in patient mortalilty in the patients with a higher blood pressure target, however patients with chronic hypertension who were treated in the higher blood pressure target group required less renal replacement therapy. Recommendations are for patients with chronic hypertension should be treated with a higher blood pressure target of 80-85 mmHg.


Reference;
  1. Asfar P et al. High versus low blood-pressure target in patients with septic shock. NEJM March 18, 2014
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<![CDATA[Tranexamic Acid]]>Sun, 27 Jul 2014 03:55:11 GMThttp://emergencyeducation.net/1/post/2014/07/tranexamic-acid.html
  • Tranexamic acid is an inexpensive antifibrinolytic that has been shown to reduce the need for blood transfusions in routine surgery.
  • CRASH-2 Trial  - double-blind prospective randomised, placebo controlled trial (274 hospitals in 40 countries) with 20, 211 trauma patients who were deemed to be at risk of bleeding. Tranexamic acid safely reduces the risk of death in bleeding trauma patients if given within 3 hours of injury.
  • Roberts et al -  These authors concluded that tranexamic acid may be safely administered to a wide spectrum of patients with traumatic bleeding and should not be restricted to the most severely injured patients, although the mortality benefit appears to be more pronounced in those with a higher baseline risk of death.
  • CRASH-2 Intracranial Bleeding Trial -  The authors concluded there was no evidence for moderate benefit or moderate harmful effect while treating patients with traumatic brain injury with tranexamic acid.
  • Morrison et al -  The authors concluded that the use of tranexamic acid after combat injuries improves survival among all patients requiring blood transfusions and most prominently among patients requiring massive transfusion.


References
  1. CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23-32.
  2.  Roberts I et al. Effect of tranexamic acid on mortality in patients with traumatic bleeding: pre-specified analysis of data from randomised controlled trial. BMJ; 2012;345;e5839
  3.  Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012;147:113-119. 
  4. CRASH-2 Collaborators. Effect of tranexamic acid in traumatic brain injury: a nested randomised, placebo controlled trial (CRASH-2 Intracranial Bleeding Study). BMJ. 2011;343:d3795.
  5. Harvey V et al. Does the use of tranexamic acid improve trauma mortality? Annals of Emerg Med; 2014;63;460-462
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<![CDATA[Do you need a CT Chest if the CXR is normal in blunt trauma?]]>Sun, 27 Jul 2014 03:43:10 GMThttp://emergencyeducation.net/1/post/2014/07/do-you-need-a-ct-chest-if-the-cxr-is-normal-in-blunt-trauma.html
  • This was a study of 791 patients who had both CXR and CT chest following blunt traumatic injury.
  • CXR was reported normal in 75.8% and CT chest was normal in 82%. Injuries were identified in 18%.
  • CT scanning in patients with a normal  CXR identified major injuries in 2%, injuries of minor clinical significance in 13.2% and no clinical significance in 2.7%.
  • Chest CT has a relatively low yield in blunt trauma patients with a negative CXR. Injuries detected on CT scan are usually of low or no clinical significance.
Reference
Kea B et al. What is the clinical significance of chest CT when the chest X-ray result is normal in patients with blunt trauma? Am J Emerg Med; 2013; 31;1268
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<![CDATA[Aortic Dissection]]>Fri, 25 Jul 2014 07:30:40 GMThttp://emergencyeducation.net/1/post/2014/07/aortic-dissection.html
  • Aortic dissection classically presents with sudden onset of severe tearing chest pain which is migratory. It can also present with sudden onset of back pain or abdominal pain, however there is a significant proportion of  patients that can present with painless dissection. These presentations can include neurological symptoms, abscent pulses on clinical examination, syncope and acute AR with CCF. Painless dissection can occur in up to 33% of cases.
  • Aortic dissection occurs in all age groups, but it is most commonly seen in older patients with hypertension. Other risk factors include aortic aneurysms, bicuspid aortic valves, aortic coarctation, connective tissue disorders like Marfan's syndrome and Ehlers-Danlos Syndrome, cocaine use and pregnancy.
  • A plain chest x-ray can miss the diagnosis in up to 20-40% of cases. If suspected a contrast spiral chest CT is the preferred imaging modality. MRI is also very accurate, but tends to be less available. Transoesophageal echocardiography is an excellent test in the diagnosis of dissection, particularly in the haemodynamically unstable patient that cannot be transferred to the CT scanner.
  • Chest X-Ray findings include a widened mediastinum, blurring of the aortic knob, left pleural or pericardial effusion, displacement of the oesophagus or left mainstem bronchus, left apical cap.
  • D-dimer has been purported to be of value in the diagnosis of aortic dissection. While it has a high sensitivity of 98-100%, it should not be used as the sole screening test in rulling out a d-dimer.
  • In type A dissections, there may be acute occlusion of the ostia of the coronary arteries. If this happens cardiac ischaemia could occur and mimic ACS / STEMI. Most of the time ECG changes are non-specific, however rarely  the ECG may mimic an STEMI. Giving thrombolytics in this setting invariably results in a poor outcome.
  • The emergency medical treatment of aortic dissection is aggressive blood pressure control. The mainstay is with beta-blockade with medications such as labetalol (20 mg as bolus, then 0.25-3 mg/kg/hr) or esmolol (500 mcg/kg bolus followed by infusion of 25-300 mcg/kg/min) to reduce the force of cardiac contraction. If a beta-blocker is contraindicated, then the use of calcium channel blocker such as diltiazem (0.25mg/kg or 20 mg followed by infusion of 10-15 mg/hr) or verapamil (5-10 mg over 10 minutes followed by infusion of 5 mcg/kg/min) can be used instead. The theoretical advantage to using labetalol is that not only does it reduce contractility, it also decreases the blood pressure. Once the patient is adequately beta-blocked, if they are still hypertensive then you can you use sodium nitroprusside (0.5-4 mcg/kg/min)

References

  1. Gerber O et al. Painless dissections of the aorta presenting as acute neurologic syndromes. Stroke. 1986; 17(4);644
  2. Ranasinghe A et al. Acute aortic dissection. BMJ. 2011;343;4487
  3. Hagan P et al. The international registry of acute aortic dissection (IRAD): New insights into an old disease. JAMA. 2000;283(7);897
  4. Harris K et al. Correlates of delayed recognition and treatment of acute type A aortic dissection: The international registry of acute aortic dissection (IRAD). Circulation. 2011;124(18)1911
  5. von Kodolitsch Y et al. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116;73
  6. Sutherland A et al. D-dimer as the sole screening test for acute aortic dissection: A review of the literature. Ann Emerg Med. 2008;52(4)339
  7. Weiss P et al. How many patients with acute dissection of the thoracic aorta would erroneously receive thrombolytic therapy based on the electrocardiographic findings on admission? Am J Cardiol. 1993;72;1329



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<![CDATA[Pulled Elbow]]>Thu, 06 Mar 2014 23:42:59 GMThttp://emergencyeducation.net/1/post/2014/03/pulled-elbow.htmlThis is a common injury seen in children between the ages of 1-4.
In 50% of cases there is no history of a pull on the arm.

Children present not using the arm and the elbow is held in extension with the forearm held in pronation.
There is marked resistance and pain with supination of the forearm. There is usually no pain on palpation of the elbow and no swelling or deformity of the elbow.

Routine X-rays are not required unless there is clinical suspicion of a fracture or attempts at reduction fail.

There are 2 methods for reduction;
1. Supination of the forearm followed by flexion of the elbow
2. Hyperpronation of the wrsit followed by flexion of the elbow

You can expect distress and pain during the procedure. A click may be felt over the radial head on reduction. The child should be rexamined after 10 minutes.

In a study comparing the 2 methods, the hyperpronation method was found to be more sucessful with less attempts at reduction than the traditional supinatiion-flexion method.

Reference.
1. Macias CG et al. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Paediatrics 1998. 102; e10
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<![CDATA[The Steeple Sign in Croup]]>Fri, 21 Feb 2014 02:02:50 GMThttp://emergencyeducation.net/1/post/2014/02/the-steeple-sign-in-croup.htmlA 4 year old male presented to the emergency department with respiratory distress and a barking cough. On examination he had severe respiratory distress and biphasic stridor with oxygen staurations of 85%.

He was diagnosed with croup and commenced on steroids and adrenaline nebulisers.

A portable chest x-ray was performed.
The x-ray shows a steeple sign (also known as a wine bottle sign). This shows tapering of the upper trachea similar to a church steeple. This appearance is classically seen in croup, although the appearance is not specific and may be seen in children with epiglottitis. A pseudo-steeple sign can be seen at varying times during the respiratory cycle in some children without croup and can be a normal variant.

The patient did not respond to nebulised adrenaline, and was transferred to the operating theatre for a gaseous induction and fibreoptic intubation to secure the airway.
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