Summer Series: Lumbar Puncture, Suturing, and Pediatric Resuscitation

Last week’s summer series was an excellent session on lumbar punctures, suturing, and pediatric resuscitation.

Lumbar Puncture and Suturing

Dr. Eric Mutter and Dr. Karen Graham walked us through how to perform a lumbar puncture, both with and without ultrasound guided landmarking prior to the procedure – an especially useful skill in those patients whose anatomy or body habitus makes external landmarking more difficult. Dr. Sharleen Hoffe led a parallel session on suturing – reminding us of the basic principles of wound management and showing us some spiffy new techniques. It turns out that pigs feet are excellent models to practice skin and tendon repairs! Check out the infographic below for a summary of some important tidbits or click here to download the pdf: LP & Suturing.

Summer series LP:suture

For a more in depth look at extensor tendon repair, Sharleen directs us to this acep article.

Pediatric Resuscitation

We spent the afternoon in the SIM lab working through a series of pediatric resuscitation cases with Sharleen and Tim. This topic is a scary one for many of us and I found it very helpful to go over a few potential pediatric patients. Some take home points from the day were as follows:

  1. Use the broselow tape! Yell out the colour and estimated weight so that everyone is on the same page. If the child looks heavy for their age, increase the medication doses but keep the equipment sizes the same.
  2. Sepsis response is age related! Kids will often get hypocalcemic + hypoglycemic so watch out for those. In general, treat septic shock with norepinephrine if there is no response to 2 boluses of fluid. (Epinephrine is suggested instead of norepi in cases of “cold shock”)
  3. Remember to initiate CPR in the bradycardic kid with a pulse <60bpm.
  4. Intubation should be a last resort in asthmatics – just like in our adult population!
  5. Treat DKA with judicious fluids + skip the insulin bolus – we want to avoid cerebral edema if we can!
  6. Delegate math/dose calculations. You will have too many other things to think about running a resuscitation.
  7. Refer to the Canadian Pediatric Society Guidelines for a great overview of the most up to date expert recommendations.

Summer Series: Optho 101 and Procedural Sedation

Two weeks ago now (sorry for the delay), we had a great morning session from Dr. Rob Brison – let’s call it Rob’s optho 101. He started out at Hotel Dieu with some slit lamp tricks and tips – did you know that it takes 5-10 minutes for corneal abrasions to uptake fluorescein fully? Put it in early and complete the rest of your eye exam before using the cobalt blue setting. Remember to use it with all elderly patients with conjunctivitis – you may be surprised with what you find. We discussed conjunctivitis – allergic (bilateral, papillary pattern), viral (uni/bilateral, follicular pattern), and bacterial (purulent discharge, unilateral); and many other common eye complaints that we see in the ED. Take home points: (1) always use fluorescein (2) call optho when unsure or to arrange close follow up when concerned.

Check out this article by Rob published in 1993 on the utility of antibiotics in corneal abrasions.

 

Procedural Sedation

After lunch Dr. Caley Flynn and Dr. Eric Mutter (under the watchful eye of Dr. Jaelyn Caudle) taught us a thing or two about procedural sedation. See the infographic below for a crude summary, or click here : Procedural Sedation for a pdf to download.

Summer series PS

The discussion was rich and interactive. We worked through several examples of the ETCO2 tracings that we use to monitor our sedations in the ED – it’s definitely not as simple as it seems! For more practice, try out a few cases on capnography.com.

Additionally, two drugs that were not included in the infographic, but were discussed at rounds were ketofol (ketamine + propofol) and dexmedetomidine (Precedex). Ketofol is theoretically meant to be a combination that allows the use of a lower dose of each drug individually, therefore decreasing the incidence of adverse effects of both. Practice seemed to vary with few using the 1:1 combination, opting instead for a good dose of ketamine followed by a titrating dose of propofol as needed. For some further reading on this topic, check out David and Shipp 2011 and Andolfatto et al. 2012. Dexmedetomidine, on the other hand, is an EXPENSIVE alpha-2 agonist that provides “cooperative sedation” (analgesia + sedation + anxiolysis) and is widely used in the ICU. Caley and Eric predict that it may soon become more common in the ED, so stay tuned!

 

 

Summer Series: Central Lines and Trauma

In this week’s edition of the summer series we learned about central lines and trauma. Though these sessions were on the same day, don’t forget that the central line is not a resuscitative line…unless it’s a cordis.

Central Lines

In the morning Bruder and the senior residents introduced us to a number of different central lines and we had the chance to practice seeing the anatomy in real-time. Though one of our first year residents claimed the largest IJ in the crowd, I was pleasantly surprised at my ability to expand my IJ.

Central lines are really best learned in the sim laboratory and we are fortunate to have a curriculum in central line placement as second year residents. This session allowed for the sharing of some more practical tips and tricks, similar to these central-line tips and tricks from Haney Mallemat.

Trauma

In the afternoon Tim and Chris led us through high fidelity simulation of four difficult trauma cases. The lessons learned ranged from Simulationa discussion of cyanide toxicity (covered by Shar in a previous rounds here) to difficult airways to neuroprotective intubation. Towards the end of the day we were thirsty to learn more and one resident asked where we might learn more about trauma. We have compiled a list of some trauma learning resources.

Text books: Chris and Tim both recommended that textbooks are a great place to start to develop a framework for trauma management. Rosen’s/Tintanalli’s are a good start but there are a ton more in our resident library. Make sure to check them out.

Trauma Guidelines: The Eastern Association for the Surgery of Trauma provides comprehensive guidelines for the management of most trauma related injuries that you can access here. Unbeknownst to most of us, there is also a Western Trauma Association and publish a number of helpful algorithms. It seems these two groups might benefit from joining forces…

Journals: Keeping up to date on trauma literature means surveying the literature. The Journal of Trauma and Acute Care Surgery and Trauma are starting points.

Online Resources: Below are a number of websites that we have found helpful when reading about trauma. IVLine (for the very basics), The Crashing Patient (a rather comprehensive overview of everything trauma),  Life in the Fast Lane (a large number of trauma related posts), The Trauma Professional’s Blog (case discussions, pearls, tips and tricks).

Just in Time Resources: We learned in this session that everyone should have easy and ready access to a paediatric app such as pedistat or PalmEM to help mitigate the stress of medication doses and equipment size in paediatric trauma.

Please comment below if you have additional resources about learning about central lines or trauma! Look forward to seeing you for the next session!

Journal Club: Asthma Exacerbations and high sensitivity troponins – is less really more?

Our last journal club of the year was held at Dr. Dagnone’s house in beautiful patio weather (sorry for the delay in posting), where we discussed dexamethasone versus prednisolone for pediatric asthma exacerbations as well as the implications of the new high sensitivity troponin assay.

A Randomized Trial of Single-Dose Dexamethasone Versus Multi-dose Prednisolone for Acute Exacerbations of Asthma in Children Who Attend the Emergency Department

by John J. Cronin et al. published recently in the Annals of Emergency Medicine Journal

Dr. Heather White and Dr. Nick Cornell lead the group through a critical look at the recent article in Annals of Emergency Medicine regarding optimal management of acute asthma exacerbations in children. This was an intention to treat, randomized, and open label non-inferiority study looking at single dose dexamethasone compared to 3 days of prednisolone for treatment of acute asthma exacerbations in children. The conclusion was that dexamethasone (0.3mg/kg) was found to be non-inferior to a 3 day course of prednisolone (1mg/kg/d) as measured by the mean PRAM score on day 4.

The discussion was rich and the consensus seemed to lean away from practice changing impact. Several concerns were raised with the study including the generalizability to our practice environment and the bias introduced with open label methodology. The study was done in Ireland using a 1mg/kg dose of prednisolone, which is typically dosed at 2mg/kg here up front in the ED followed by 1mg/kg/day at home. The PRAM score was felt to be a reasonable surrogate for asthma control and severity, but the exclusion criteria was extensive and we thought that the differences in PRAM would be difficult to pick up. In the end, for a child with mild-moderate asthma exacerbation who does not tolerate prednisolone, single dose oral dexamethasone is a reasonable choice!

forest plot

 

Derivation of a 2hr high-sensitivity troponin T algorithm for rapid rule-out of acute MI in ED chest pain patients

presented at CAEP 2016 by A McRae

The staff article this week was a very topical abstract presented at the 2016 CAEP conference by the University of Calgary’s Andy McRae. Dr. Colin Bell had a lot to add to Dr. Dagnone’s points after presenting a Grand Rounds on this topic earlier this year. Before going any further, the importance of knowing your own center was highlighted – at Kingston General Hospital, the lab is using the cTnI assay, which has increased sensitivity compared to the cTnT assay utilized in Calgary and the focus of the abstract.

The abstract described a study performed in Calgary to derive a 2-hr high sensitivity cTnT testing algorithm to rule out acute MI in ED chest pain patients. Their conclusion was that acute MI can be ruled out safely with a high sensitivity cTnT algorithm in 58.5% of chest pain patients within 2 hours of ED arrival. Apart from the obvious issue with a different assay, the logistics of the above mentioned time points in our ED, the definition of low risk chest pain and quantification of such, and the lower sensitivity of the algorithm for major adverse cardiac outcomes compared to acute MI made us all a little hesitant. The future sure looks promising, but we concluded that we’re yet ready for use of the 2-hr delta troponins across the board. It is probably okay for low risk chest pain patients, but the 6-hr test is definitely safer. Although there is lots more work to be done on this topic, the Calgary group has done a great job thus far and we’d like to congratulate them on the well deserved Grant Innes Research Award for top ranked CAEP abstracts this year in Quebec City!

Stop Colin or Damon next time you run into them to ask about their opinion – they have a wealth of information to share!

 

*as a useful side note, it came to light that a delta troponin (using our local cTnI assay) should only be considered different if it is >8

 

Summer Series: Deliberate practice, airways, and chest tubes

Round two of the summer series was led by the dynamic duo of Bob McGraw and Carly Hagel. They spent the day teaching us a very deliberate approach to airway and they also employed an impressively engineered model to practice chest tube placement. Perhaps the most important lesson of the day, DON’T CLAMP THE CHEST TUBE.

The 7 P’s of Intubation

Dr. McGraw highlighted the importance of an unchanged routine in preparing for airway management to free up cognitive space. One thing we did not directly discuss but we might consider implementing into practice in our next intubations is a checklist to ensure that we have not forgotten any of the important equipment or mental steps.

We repeated our setup dozens of times throughout the morning with direct and immediate feedback. This deliberate practice is one step in the movement towards expertise. Here is a reminder infographic on the 7 P’s of intubation that we practiced on Thursday. For more information about how to “Own the Airway” check out these links on Life in the Fast Lane.

summer-series-airway

To download a pdf of this infographic click here.

As Dr. McGraw pointed out, positioning is an often overlooked, critical aspect of the successful intubation. Though an article from the anesthesia and critical care world, this is an interesting review of some (low quality) literature discussing Back Up, Head Up positioning for intubation in a population of high risk patients that may be similar to those we see in the ED. Food for thought at the least!

Chest Tubes

The pretty nifty simulated model for chest tube insertion was a great way to practice the technical skill, outlined by this NEJM article and videos. The skill was easy when compared to the discussion of how chest tubes work and how to trouble shoot when things go wrong. We got deep into a discussion respiratory physiology. There were many take aways but the main was:

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

DON’T CLAMP THE CHEST TUBE! 

Clamping the chest tube is one way to make the patient much worse. Clamping the tube can cause a tension pneumothorax, making a bad situation for the patient much, much worse. When you are trouble shooting, get back to the basics. Take a deep breath, slow down and remember the circuit, even draw it if you have to!

Please share any resources you have found helpful or comment on your approaches to deliberate practice, airways or chest tubes!

Grand Rounds: Chemical Asphyxiation

And here it is – the long awaited last grand rounds post of the school year! On June 23, Dr. Sharleen Hoffe provided a great summary of 3 types of chemical asphyxiation that may be encountered in the Emergency Department: carbon monoxide poisoning, methemoglobinemia, and cyanide toxicity. She gave a fantastic presentation full of practical tips and interesting tid bits – did you know that both the EMS Lifepaks and our special co-oximetry device (found in section A) test for COHb at the bedside? Our regular bedside monitors do not have this capability, but our lab sure does. Don’t forget to ask for the COHb and MetHb along with the blood gas if you are suspicious for either – both of these can be added to the VBG/ABG and will be back within 15 minutes!

Check out the infographic summary below for a quick overview of Sharleen’s talk. Pick her brain about it next time you are on shift together – she has tons of knowledge to share.

June 23 Grand Rounds

To download a pdf of this infographic, click here: June 23 Grand Rounds

Critically Appraised Topic Project: Point of Care Ultrasonography (POCUS) versus Radiology Ultrasonography (RUS) to rule in acute cholecystitis for adult patients presenting to the emergency room with right upper quadrant pain

Dr. Rowan Henry presented his CAT project this week instead of staff rounds, providing an excellent overview of the literature available to compare POCUS and RUS for the diagnosis of cholecystitis in the emergency department. After an extensive literature search, Rowan presented a summary of the most relevant studies, 4 prospective observational studies with small sample sizes, to guide our clinical decisions. The bottom line: POCUS was found to be comparable to RUS with respect to sensitivity and specificity for the diagnosis of acute cholecystitis in adults with right upper quadrant pain.

The question that was brought up by Rowan and the audience was, ‘what should be the gold standard for diagnosis in acute cholecystitis?’ We all know that even RUS is not 100%. Will this change your practice pattern? Rowan is no longer in Kingston, but would have a lot to contribute to a rich discussion about his interpretation of the literature if you can find him.

 

 

Summer Rounds: Ultimate Introduction to Ultrasound

The posts over the summer months are going to change in format! The structure of our academic program in the summer is such that we cover core topics and skills in emergency medicine in weekly, daylong sessions. We will either pick something interesting from the session to focus on or provide a look at some available online resources for each session.

Our first 2016 summer series session was an ultrasound extravaganza to give the newcomers to QEmerg a feel for ultrasound, the basic concepts and get them ready to start acquiring scans. It also gave those with some experience the chance to practice and teach as well! We covered the aorta scan, subxiphoid view, FAST and gyne scans. Thanks to Louise, Joey and Connor for putting on an awesome session with tons of hands on time! If you had fun on the day here are a few neat articles and resources you might want to check out.

  • SonoMojo provides an outlined curriculum of basic ultrasoScreen Shot 2016-07-08 at 10.56.15 AMund skills with links to podcasts and videos to brush up on the basics. I especially like their cheat sheets for a quick reminder.
  • One Minute Ultrasound is an app that provides quick
    reminders of key landmarks and techniques.
  • Matt and Mike’s ultrasound podcast is great or check out their awesome iBOOK “Introduction to Bedside Ultrasound”  complete with videos, it truly is an unreal learning tool.
  • Tons more FREE ultrasound resources are outlined on this LITFL blog post

Feel free to add your favourite ultrasound resources in the comments section below but don’t forget, none are a substitute for hands on probe time with teachers showing you the ropes! Happy scanning!

Grand Rounds: Ischemic Stroke

This week Dr. Allison Lainey provided us with an excellent overview of acute ischemic strokes, delving into the evidence behind our current practice with tissue plasminogen activator (tPA) and looking forward to the changes that are occurring with the introduction of endovascular therapy (EVT). I was certainly intrigued and with a recent claim of “the biggest thing ever to happen to neurology”, it will be interesting to watch our practice evolve in the emergency department.

Allison finished her presentation reminding the audience that although EVT is looking quite promising, we shouldn’t forget about the intervention with the best evidence for improving outcomes – rehabilitation on multidisciplinary, dedicated stroke units. Try to catch her before she heads to Peterborough as a staff to discuss her thoughts on the current state and future of stroke management!

gr-june-16

To download a pdf of this infographic click here: June 16 Grand Rounds.

Critically Appraised Topic Project: Should we be using an age adjusted D-dimer in the emergency room to rule out pulmonary embolism?

Instead of staff rounds, Dr. Mike Mason presented his CAT project on the utility of an age adjusted D-dimer to rule out PE. He took us through a complete summary of the literature, concluding that age adjusted D-dimers increase specificity with a minimal and acceptable decline in sensitivity in low risk patients. According to Dr. Jeff Kline, adjusted D-dimers are ready for prime time!

Refer to the ADJUST-PE Study for more information, and a prospective validation study of this test. Mike reminded us all that regardless of the adjustment, D-dimer is only useful as a rule out test in patients with a low risk of PE in the first place.

Grand Rounds: Hypothermia and Rescue of Avalanche Victims

This week Dr. Heather White provided us with a fantastic overview of primary accidental hypothermia and the rescue of avalanche victims. Some new and interesting “buzzwords” for me included circumrescue collapse, afterdrop, and paradoxical undressingHypothermia can make people do some crazy things.

Check out this simple summary below and discuss with Heather next time you see her on shift – she has some really cool experiences and a ton of knowledge to share!

gr-june-9

To download a pdf of this infographic click here: June 9 Grand Rounds.

Heather is taking her wealth of knowledge and moving onwards and upwards towards a ‘Fellowship in the Academy of Wilderness Medicine’. If this also interests you, check out this website, and feel free to ask Heather for more details!

Critically Appraised Topic Project: Are systemic corticosteroids helpful in treating adults with acute lumbosacral radiculopathy?

Instead of staff rounds this week, Dr. Jeff Wachsmuth presented an overview of his deep dive into the literature behind the use of corticosteroids for acute lumbosacral radiculopathy. He explained a frustratingly heterogeneous group of studies from the literature and did an excellent job of collating the data into a summary that means something to the practicing physician. The take home point: systemic corticosteroids provide mild short-term symptomatic relief of acute lumbosacral radiculopathy at best. They are a reasonable tool to add to the treatment of acute lumbosacral pain from radiculopathy in the ED.

 

Grand Rounds: Migraines

On June 2, Dr. Nick Cornell provided us with a nice overview of the definition of migraine and took a deep dive into the literature behind some treatments that we use everyday in the ED and in the outpatient setting. I was especially intrigued by the use of magnesium for refractory migraine with aura and will keep it in mind next time I see a migraine on shift. Pick his brain next time you see him – he’s got a ton of information to share!

gr-june-2

To download a pdf of this infographic click here: June 2 Grand Rounds.

Keep your eye out for the next summary of today’s Grand Rounds on Accidental Hypothermia and the Resuscitation of Avalanche Victims.

Staff Rounds:

Dr. Michael McDonnell presented a paper by Talen et al. published in NEJM this year, Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess.

It was a superiority trial conducted at 5 EDs in the USA examining whether a course of trimethoprim-sulfamethoxazole (x 7days) would be better than placebo in patients with an uncomplicated abscess treated with drainage. It showed an absolute difference of 7% better cure rate for patients who received antibiotics versus placebo at 7-14 days. Is that enough to change your current practice?

Staff discussion of the article was rich. Applicability of the conclusions was questioned as MRSA is more common in the USA and thus the population studied represents a different population from ours here in Kingston. Some staff shared their own clinical pearls including consistent treatment of high risk patients (such as IV drug users) with Septra after drainage; and considering a loop drain for treatment of abscesses to keep them open.

Ask Mike if his practice has changed because of this article next time you see him!