<![CDATA[Emergency Medicine Education - Emergency Medicine]]>Sat, 19 Apr 2014 17:39:18 -0800Weebly<![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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<![CDATA[Clearing the Cervical Spine Clinically]]>Tue, 11 Feb 2014 05:57:37 GMThttp://emergencyeducation.net/1/post/2014/02/clearing-the-cervical-spine-clinically.htmlOne of the most common problems we come across in the ED in trauma patients is neck pain following a traumatic injury.
When you see these group of patients, the first question you should ask yourself is - can I clear their neck clinically?

Fortunately there are several clinical decision rules that you can use to help you "clear the cervical spine"

The first is the NEXUS clinical decision rule - and this is the rule that I will always use first.
The sensitivity of this rule is 99.6%
It comprises of 5 key features;
1. No evidence of intoxication (patient should not appear intoxicated or smell of alcohol)
2. No focal neurological deficit
3. Normal level of alertness (GCS 15/15, ability to recall 3 objects at 5 minutes and no delay in answering questions)
4. No painful distracting injuries (chest and abdominal trauma requiring surgical consultation, long bone fractures, large lacerations or degloving injuries and any injury causing functional impairment)
5. No midline tenderness (palpate the midline of the neck and if the patient volunteers that there is pain or grimaces, then this is a positive finding)

If there are none of the above findings, then the patient can have their cervical spine cleared clinically.

Occasionally you will not be able to clear the cervical spine because of midline tenderness only.
In this setting, I will use the Canadian C-Spine Rule which does not rely on midline tenderness. This rule is only validated for patients between the ages of 16 and 65.

The patient should have no high risk features for a cervical spine and these include fall from greater than 3 feet or 5 stairs, axial load to the head, MVA > 60 kph, rollover or ejection, recreational vehicle collision or bicycle collision.


If there are no high risk features and the patient has a low risk mechanism
as defined by simple rear end MVA, sitting position in the ED, ambulatory at any time, delayed onset of neck pain, then you shoud assess for range of motion in the neck. If the patient can actively rotate the neck 45 degrees to the left and the right even with pain, then the neck can be cleared clinically.

Using the combination of the 2 clinical decision rules you can markedly reduce the amount of medical imaging of the neck you require to clear the cervical spine.

References

1. Hoffman JR, Wolfson AB et al. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998; 32(4) 461-9
2. Hoffman JR, Mower WR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. NEJM 2000 343(2)94-9
3. Stiell IG, Clement CM et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. NEJM 2003; 349(26)2510-8

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<![CDATA[New Oral Anticoagulants]]>Fri, 17 Jan 2014 04:07:55 GMThttp://emergencyeducation.net/1/post/2014/01/new-oral-anticoagulants.htmlThe new oral anticoagulants (NOAC's) are a group of drugs that act as direct anti-IIa or anti-Xa inhibitors.

Dabigatran is a direct thrombin inhibitor, with rivoroxaban and apixaban being direct inhibitors of Factor Xa.
They have simple fixed dosing, either once or twice daily, and there are no significant dietary interactions.
Dabigatran is excreted predominantly via the renal route, apixaban via the biliary and faecal route and rivoroxaban excreted both hepatically and renally.

All 3 agents are approved for the use in prevention of post-op DVT's in orthopaedic patients and prevention of stroke in patients with non-valvular AF. Rivoroxaban has the additional indication of treatemt of recurrent DVT and PE.

All NOAC's are at least as effective as warfarin in preventing systemic embolism and stroke with lower rates of major bleeding when compared to warfarin.

Routine blood testing is not required for NOAC's because of their predictable responses and low incidences of interactions. In situations where there is major bleeding, routine testing can be of use. A normal PT/ INR suggests that levels of rivoroxaban or apixaban are low. A normal APTT excludes the presence of significant
levels of dabigatran, and a thrombin clot time is particularly sensitive to dabigatran.

The main concern with the NOAC's is their lack of reversibility.

Haemodialysis is effective in dabigatran toxicity as the drug is poorly protein bound and should be considered in patients with major haemorrhage or severe renal impairment.

Prothrombin Complex Concentrates (PCC's) have greater efficacy against Factor Xa inhibitors, with less evidence for their use in direct thrombin inhibitors - dosage is 50 U/kg. Data is based on animal models that show correction of prolonged PT, APTT and bleeding times, however whether this correlates with a clinical outcome has not been answered yet.

Factor VIIa has been used off-label for the treatment of major haemorrhage for many years without clear benefit. Theoretically it should overcome the inhibitory effects of NOAC's if given in a sufficient dose. In animal models, there has been a mixed response in the reversal of NOAC's - overall it appears to have minor activity as a reversal agent and should only be used when other agents have failed. The dose required for efficacy is 100-8000 mcg/kg which is greater than the usual therapeutic dosage (30-120 mcg/kg).

In dabigatran toxicity, the use of a monoclonal antibody fragment (FEIBA) may be of benefit. This has 350 times the binding to dabigatran compared to dabigatran binding to native thrombin. In animal models, it has been shown to be effective in reducing blood loss. There are phase 2 trials underway looking at the effctiveness of an antidote to rivoroxaban (andexanet alfa) - this product is undergoing accelerated development.

Current recommendations for major bleeding with NOAC's include the use of tranexamic acid, although there are no clinical ltrials to support its use.

Reference

New oral anticoagulants: An emergency department overview. Wood P. EMA (2013) 25; 503-514
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<![CDATA[Asymptomatic Hypertension in the ED]]>Fri, 17 Jan 2014 02:25:26 GMThttp://emergencyeducation.net/1/post/2014/01/asymptomatic-hypertension-in-the-ed.htmlACEP have just updated their clinical policy on the management of patients with asymtomatic hypertension in the ED.

Markedly elevated blood pressure was defined as a systolic pressure greater than 160 mmHg or a diastolic pressure greater than 100 mmHg.


2 new Level C recommendations were made;
1. Routine screening in ED patients with asymtpomatic markedly elevated blood pressure to identify target organ injury (serum creatinine, urinalysis and ECG) is not required.In patients who are likely to have poor follow-up, screening of the creatinine should be considered.
2. Routine medical intervention in the ED for patients with asymptomatic hypertension is not required. These patients should have a timely outpatient follow-up with their primary care physician. If there is poor follow-up as an outpatient, then long term management can be initiated ffrom the ED.

Reference

Clinical Policy: Critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Wolf SJ et al. Ann Emerg Med 62(1); 59; July 2013

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<![CDATA[Methylene Blue for Anaphylaxis]]>Fri, 17 Jan 2014 02:04:06 GMThttp://emergencyeducation.net/1/post/2014/01/methylene-blue-for-anaphylaxis.htmlMethylene Blue interferes with the vasodilating activity of nitric oxide and blocks the effects of mediators of anaphylaxis.
 It's use has been suggested in cases of anaphylaxis refractory to adrenaline. There have been several sucessful case reports of its use in this setting. The dosage is 1.5-2.0 mg/kg given as an infusion over 20 minutes. Side effects are rare. Methylene Blue can interfere with pulse oximetry resulting in a factitious oxygen desaturation.

Methylene blue for the treatment of refractory anaphylaxis without hypotension. Bauer CS et al. Am Journal Emergency Medicine 31(1): 264, January 2013
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<![CDATA[Emergency Medicine Viva Examination - Term 3]]>Tue, 17 Sep 2013 10:07:24 GMThttp://emergencyeducation.net/1/post/2013/09/emergency-medicine-viva-examination-term-3.htmlQuestion 1
A 25 year old female presents to the ED with right iliac fossa abdominal pain.
a) List your differential diagnosis - the list is large, but should have included
  • Ectopic pregnancy
  • Ovarian Torsion
  • Ovarian Cyst
  • Appendicitis

The differential diagnosis should be tailored to the patients age and gender. While AAA is an important entity not to miss, it is not seen in this age group. Gastroenteritis does not present with focal abdominal signs and should not have been included.
b) What Investigations would you order?
The pivotal tests were a beta-HCG and Pelvic USS. Urinalysis should have also been included. Ancillary blood tests included FBC, EUC, CRP.
c) Her vital signs were P 120 bpm, BP 70/50, RR 20, Pulse Ox 100%, GCS 14/15. How would you manage this patient?
The key to this was to recognise the patient was in shock. You needed to call for senior help soon and refer early to eother O&G if pregnant or to the general surgery team if not. Fluid resuscitation was important - initial fluid should have been normal saline or Hartmanns with a target SBP of 80 mmHg (concept of hypotensive resuscitation). A few of the candidates discussed the potential need for blood products if there was no response to crystalloid resuscitation. Analgesia is also important and was not addressed by a large number of candidates - should have been judicious use of parenteral narcotics.

Question 2.
A 36 year old male presents with acute onset of shortness of breath. He has a history of asthma.
a) What are the signs of severe respiratory distress?
  • Inability to speak
  • Diaphoresis
  • Tripod positioning
  • Extreme tachypnoea (RR > 30)
  • Hypoxaemia (Pulse Ox < 90%)
  • Accesory muscle use, intercostal recession
  • Tracheal tug
  • Stridor
  • Silent chest on auscultation
  • Tachycardia or bradycardia
  • Pulsus paradoxus
b) What investigations would you order
  • ABG
  • CXR
  • Spirometry
  • Ancillary blood tests - FBC, EUC, CRP
c) Your patient has severe acute asthma. Outline your management of this patient.
  • Supplemental oxygen
  • Continuous salbutamol nebulisers
  • Ipratropium Bromide 500 mcg x 3 doses nebuliser
  • Prednisone 50 mg STAT or Hydrocortisone 100 mg iv STAT
  • Consideration of BiPAP
  • Adjunctive therapies if initial therapies fail - Magnesium, adrenaline, inhaled anaesthetic agents
  • Intubation and mechanical ventilation if BiPAP failure

Question 3
An 84 year old male presents to the ED with chest pain. Shortly after arrival, he becomes unresponsive. He is in ventricular fibrillation. Outline your management of this patient.
This was a basic question and for which you needed to describe basic and advanaced life support as per the algorithms. You needed to recognise that this was a shockable arrhythmia, and their should have been a discussion about the 

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<![CDATA[Emergency Medicine Viva Examination]]>Tue, 09 Jul 2013 10:26:11 GMThttp://emergencyeducation.net/1/post/2013/07/emergency-medicine-viva-examination.htmlHere are the answers to the viva examination from last week.

1. A 72 year old female falls onto her oustretched arm. Please describe her X-ray findings.
The X-ray demonstrated a fracture to the distal radius. No displacement. Approximately 45 degrees of dorsal angulation. This is consistent with a Colles fracture.
In the answer, you were expected to describe the fracture. This should include discussion about the bone involved, site, displacement and angulation. Some of you commented on whether the fracture was open or closed - this is a clinical assessment - not a radiological assessment.

2. An 80 year old male collapses in the local shopping centre. He is brought to the hospital by ambulance and his rhythm strip is shown.
This was a rhythm strip showing a bradycardic rhythm with a ventricular rate of approximately 30-40 bpm. There is atrial activity. There is no relation between the atrial and ventricular activity. This patient has 3rd degree AV block.

3. A 21 year old male presents with sudden onset of SOB. Describe the findings on his chest X-Ray.
There is a large left sided pneumothorax with complete collapse of the left lung. There is significant mediastinal shift to the right. These radiological findings are consistent with tension pneumothorax.


4. A 70 year old male presents with sudden onset of right flank pain radiating into his groin. He has a past medical history of hypertension. His vital signs are; T 37.5, P 100, BP 100/60, GCS 15. Urinalysis shows moderate microscopic haematuria. What is your provisonal and differential diagnosis.
Most of you gave answered with renal colic as your provisional diagnosis, however this would be unusual in an elderly male with no history of renal colic. This patient has a AAA until otherwise proven (in fact a significant proportion of patients with AAA will have haematuria) The differential diagnosis for this presentation would include renal colic and testicular torsion. The key to this differential was the sudden onset of pain, ruling many of the other pathologies out which were proposed. ]]>
<![CDATA[Painful visual loss]]>Sat, 25 May 2013 08:26:22 GMThttp://emergencyeducation.net/1/post/2013/05/painful-visual-loss.htmlA 32 year old female presents to the ED with a 3 day history of visual loss and pain on eye movement. There is no history of trauma. She describes a similar episode 2 years previously which she did not seek medical attention for. She notes that red objects appear pink in her affected eye.
On physical examination, her visual acuity is 6/60 in the affected eye. There is no visual field defect and the pupil reflexes are normal. The eye is not red and the anterior chamber is normal. Fundoscopy is unremarkable. Based on her symptoms a provisional diagnosis of optic neuritis is made.

Optic neuritis is a condition that causes a reduction in visual acuity. It is frequently painful particularly with eye movement and can be unilateral or bilateral. Colour vision is more commonly affected and there may be visual field defects. The red desaturation test can be used to identify optic neuritis. The patient should be asked to look at a dark red object. Objects will appear pinker in the affected eye. An afferent pupillary defect is commonly present.
Fundoscopy will show papillitis in 30% of pateints, the remainder will have a retrobulbar neuritis.

Optic neuritis is commonly idiopathic or a manifestation of multiple sclerosis. Other causes include viral infections such as measles, mumps, chickenpox, herpes zoster and mononucleosis; inflammatory causes that are contiguous with the optic nerve (meninges, orbit, sinuses), vaccinations and other infections such as syphillis, tuberculosis, crytpococcus and sarcoidosis.

The differential diagosis includes;
  • Ischaemic optic neuropathy
  • Hypertensive retinopathy
  • Orbital or intracranial tumour
  • Toxic or metabolic neuropathy (alcohol, heavy metals, chloroquine)


The work-up of these patients should include a MRI of the brain.

The optic neuritis treatment trial supported the use of intravenous steroids, but not oral steroids. Referrals to neurology and opthalmology should be made. 
Picture
Papillitis seen in Optic Neuritis
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<![CDATA[Paediatric UTI - Dispelling the Myths]]>Fri, 24 May 2013 09:26:40 GMThttp://emergencyeducation.net/1/post/2013/05/paediatric-uti-dispelling-the-myths.htmlUTI is a problem that is frequently reported as a source of infection in children, but in a recent paper by Newman, Shreves and Runde some of the dogma surrounding this common problem was examined with some interesting conclusions;
  • Asymptomatic bacteriuria is as common in children as it is in adults, which suggests that a significant proportion of children labelled as having a UTI may just have asymptomatic bacteriuria rather than a pathologic infection.
  • True urosepsis in the paediatric population is rare and less often life threatening than other causes of sepsis and usually limited to high risk groups such as neonates and those with congential anomalies.
  • UTI frequently progresses to pyelonephritis in the paediatric population, and scarring of the renal cortex is a common sequelae of this process.
  • The current evidence does not support the fact that renal scarring results in longer term kidney problems such as hypertension and the need for dialysis.
  • The majority of the literature shows no change in incidence of renal scarring with early vs. late antibiotic administration
  • Prophylactic antibiotics appear to be non-beneficial (although a small benefit may possible)
  • Surgical correction of vesicoureteral reflux is non-beneficial.
  • Imaging of the renal tract after UTI leads to little yield.

Reference
  1. Newman D, Shreves A, Runde D Pediatric urinary tract infection: does the evidence support aggresively pursuing the diagnosis? Annlas of EM; 2013; 
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