Ocular Trauma

Up next – something you may see fairly often in the ED – vision issues.  Contributor Raevti Bole takes us through a quick look at the eye in this Quickhit:

 

Ocular Trauma – the Quickhit

Ocular trauma is a very common reason for patients to go to the emergency department, and makes up about 3% of ER visits in the US.  There are different types of injuries you may see:

Closed globe injury- intact cornea/sclera (e.g. corneal abrasion, eyelid laceration, orbital blow out fracture, retinal detachment, lens dislocation, hyphema)

Open globe injury- breached cornea/sclera from blunt force or penetrating force (globe rupture)

-Intraocular foreign body: injury with a foreign body remaining in the eye, making up 41% of open globe cases

Steps:

-Take detailed patient history (time of injury, cause, potential for getting worse)

-Examine

External exam of the eyes and surrounding facial structures

Corrected visual acuity (Snellen chart) and pinhole acuity if 20/20

Pupillary reactions

Extraocular movements

Ophthalmoscopy

Confrontational fields

-Determine whether to refer to ophthalmologist following ED treatment

The MOST URGENT injuries are chemical burns and open globe injuries. These usually require immediate consultation with an ophthalmologist. All other injuries should be followed-up with an ophthalmologist, preferably within 24 h.

 

That’s everything you should know about the eye in 60 seconds or less!  Read below for further information and discussion on specific issues!


 

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Seizure and Status Epilepticus in Adults

More new content? Christmas came a little late this year, but here you go:  A great post by regular contributor Nick Mancuso on Seizure and Status Epilepticus in adults:

Approach to Seizure and Status Epilepticus in Adults

Seizure Causes/Ddx

VITAMINS

-Vascular (Stroke , AV-malformation )
-Infection (Meningitis, abscess, encephalitis )
-Trauma
-Autoimmune (CNS vasculitis)
-Metabolic (HypoNa , hypoCa , hypoMg , hypoglycemia, hypoxia, delirium tremens, drug OD\withdrawal )
-Idiopathic
-Neoplasm
-pSychiatric

 

Determine Type

See “Discussion” below

Treatment

Check ABC’s, and continue to check as well as vitals, as these drugs induce apnea, long lasting seizures effect the body as seen in Table 1

First Line Benzos: 2mg IV lorazepam most common, x5 (10mg max)

Second Line if 1st fails: fosphenytoin/phenytoin 15-20mg/kg loading, 4-6mg/kg/day maintenance

Third line if 1 and 2 fail to control seizure: In “refractory SE” mortality jumps. Grey zone as to which choice. Secure airway then consider:

  • Barbituates: phenobarbitol 20 mg/kg, but can be given up to 30 mg/kg for refractory seizures
  • propofol
  • others choices: midazolam, valproic acid, or Levetiracetam

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Balloon Tamponade of Gastrointestinal Bleed

I’d like to apologize for the recent dearth of updates.  However, we now have a nice backlog of new content to share with you, and it should be going up quickly over the course of the day.

First up, regular contributor and fourth year UK Med stud Chris Belcher shares some thoughts on the Minnesota Tube and its use in the ED.  Take it away, Chris:

 

So pretend that you’re a hot shot resident on your second night of moonlighting in a small community ED.  For conversation’s sake, let’s pretend that you’re way out in the hills of Eastern Kentucky (it’s clinically relevant).  You’re cool as a cucumber because your last shift was smooth sailing—you converted an SVT with a whiff of adenosine, sewed up a few lacs, and eased the fears of the worried well.  You expect nothing but blue skies.

An hour into your shift a patient is rushed into your ED on a stretcher and there is blood EVERYWHERE.  And it appears to be coming straight from the patient’s mouth. Excessively.  And let’s pretend that on quick glance this Eastern Kentucky patient has a large, protruding abdomen with a tint of yellow to both the skin and eyes (along with shades of rouge now from all the blood.)

Vitals are BP 90/40, HR 130, O2 sat 90% on NC on full blast, RR 30 and the patient is obviously having trouble breathing because of all the blood.

Most likely, a (BAD) variceal bleed in a cirrhotic patient.  Who is actively trying to die.

So, Maverick, what will you do?

Firstly, two things. The patient can’t protect their airway.  They need some plastic in their throat (DUAL MEANINGFORESHADOWING!)   And the patient is bleeding out.  Activate a massive transfusion protocol of some type.

But now how will you control the bleeding?  Endoscopy, right?  But you’re in the middle of nowhere Kentucky and the closest GI doc is sleeping soundly in their bed an hour away.  This patient is actively trying to elope from your ED in the worst possible way.  So how you gonna control the bleeding without endoscopy?!?   If your own HR is less than 100 bpm at this point, you must be beta blocked.  For a temporary and possibly lifesaving fix, we turn to our great friends of the North and the great state of Minnesota for their contribution to the world of GI bleeds—The Minnesota Tube.

MT1

Note:  Dr. Sakib actually had nothing to do with the creation of the Minnesota Tube.  But is there living the awesome intern life.  Enjoy winter, my Yankee friend.

MT2

What is this Tube of the North?

The Minnesota Tube is a 4-port tube placed in the esophagus in order to tamponade bleeding—most commonly bleeding esophageal varices.  The four ports connect to two balloons (an esophageal and gastric balloon) and two aspiration ports (again, eso and gastric).

The original idea is credited to Blakemore and Senkstaken and was a 3-port design with no esophageal aspiration port.  This was appropriately named the Senkstaken-Blakemore tube but is most commonly referred to as the Blakemore.

MT3

Minnesota tube with four ports.  Also note pt vomiting sparklers.

MT4

Blakemore with no esophageal aspiration port

When does one use this Blakemore?

Indications for both tubes are when your patient is actively trying to expire due to ruptured esophageal varices or other gastro-esophageal bleeding issues that may be suspectible to tamponade.  More commonly seen in cirrhotic patients or others who are susceptible to increased portal pressures and varices. Once again, it’s less likely that either tube is necessary if GI is available for scope unless the patient’s status can’t wait for GI or GI isn’t able to stop the bleeding.  In short, use as a last ditch effort to stop bleeding when medical or endoscopic treatment fail or aren’t available.

MT6

Strawberry ice cream or esophageal varices…?

MT5What do I do with my hands..? (aka how to use it)

Chris Nickson has already done a very easy to follow step-by-step guide on lifeinthefastlane.com so I won’t reinvent the wheel.

http://lifeinthefastlane.com/education/ccc/senkstaken-blackmore-and-minnesota-tubes/

But some key points:

  1. Know your equipment (at least have practiced with it before trying to pull it out for the first time in this situation)
  2. Always have the patient intubated beforehand.  If they have enough bleeding to warrant a Minnesota tube, they’re not able to protect their airway. And emesis (and aspiration) is more likely after tube placement.
  3. Consider sedation.  These are not comfortable.  And they should be intubated already.
  4. Test pressures of inflated gastric balloon beforehand to help decide if you’re in the stomach when inflating inside the patient.  Major cause of morbidity/mortality is inflating the gastric balloon in the esophagus. Don’t be that guy.
  5. Consider confirming position of gastric balloon with x-ray before inflation.
  6. This is only a temporary measure until definitive treatment can be made due to the high risk of complications.

 

End result/Complications

-Complications are numerous–emesis/aspiration, perforation of the esophagus or GE junction, very uncomfortable for pt, more bleeding, balloon migration, and necrosis

-Balloon migration is especially dangerous in the non-intubated patient as the balloon can block the hypopharynx.  Yet another reason to go ahead and intubate beforehand.

-Different sources cite different lengths of time but the balloons should not be left in place due to the risks of complications, especially pressure necrosis.  Less than 24 hrs. is a good goal.

 

MT7

End product. Strong work, Maverick.

Quick Hits Summary

- Blakemore and Minnesota Tubes are used for tamponade of bleeding varices

-Blakemore= 3 lumens (gastric balloon, eso balloon and gastric aspiration ports); Minnesota= 4 lumens (above+esophageal aspiration port)

- Used when medical treatment and endoscopy fail/aren’t available

-TEMPORIZING AGENT before definitive therapy; can’t leave in long

- intubate before and check placement of gastric tube before and after inflating

- watch for complications

Contributor: Chris Belcher

References

1. Attar BM. Chapter 52. Balloon Tamponade of Gastrointestinal Bleeding. In: Reichman EF, Simon RR, eds. Emergency Medicine Procedures. New York: McGraw-Hill; 2004. .

2.  Witting MD, Hooker EA. Chapter 89. Gastrointestinal Procedures and Devices. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011

3.  Nickson, C.  Sengstaken-Blackmore and Minnesota Tubes.  http://lifeinthefastlane.com/education/ccc/senkstaken-blackmore-and-minnesota-tubes/

 

 

Keeping it Straight: Priapism

To start off your week, we have a quick and handy guide to a sensitive topic: priapism.  Second year medical student Raevti Bole takes us through the basics with this Quickhit:

Quickhit

What is it?

A prolonged (usually between 4-6 hours), painful erection not associated with sexual desire. It’s not a very common complaint in the ED, but if someone does present with this, it’s considered a true urological emergency.

Pathophysiology

There are two types of priapism: High-flow priapism (non-ischemic), and low-flow priapism (ischemic). Only ischemic priapism is an emergency.

In an emergency situation, blood cannot exit the penis. This causes oxygen levels to drop leaving the patient in pain and the cavernosal tissue at risk of fibrosis and then necrosis (time dependant).

Treatment

Time is critical, because longer you wait to treat, the higher the risk of future erectile dysfunction in a patient with ischemic priapism.

Diagnose: first determine what type of priapism it is (physical exam, blood gas measurement, Ultrasound, Blood test, toxicology)

Treat: Aspiration therapy (including saline flush), medication, and finally surgery if all else fails. Also treat primary causes of low-flow priapism, such as giving O2 and hydration to sickle cell anemia patients.

Complications

Erectile dysfunction

Penile necrosis and disfigurement

 

Read below to get more information!

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Getting the Point – Soft Tissue Foreign Bodies

This week, I’ll be sharing a slew of handy information to keep in mind when dealing with foreign bodies in the Emergency Medicine setting.  This post is also an introduction of sorts – Since taking over editor-in-chief duties from Sakib, the founder of this blog, my work thus far has been mostly behind the scenes editing.   I’ve also done some back-editing on recent posts that should make scrolling through the Quickhits site while browsing topics much easier.  I hope you enjoy!  (PS – I apologize for any puns in advance)

Corey Warf, EiC

First, the Quickhit:

Pathophysiology

  • Foreign bodies in tissue generate an inflammatory response which varies in intensity based on the composition of the object:  inert materials (glass, plastic, metal) generating less of a response than organic materials such as bone, spines, woody plants, or vegetative material.
  • Likewise, risk of infection varies based on foreign body material: inert materials are relatively low risk, while organic materials pose a much higher risk of infection.
  • Composition of infections often vary based on material as well: tooth fragments increase the risk of polymicrobial infections while woody materials may increase the risk of fungal infections, e.g.

Presentation and Exam

  • Lacerating or penetrating injuries with an object that may break, shatter, or splinter have higher odds of a foreign body being present in the wound.
  • Wounds deeper than 5mm or those that cannot be fully explored have a higher risk of foreign body presence.
  • An adult who senses a foreign body’s presence in a wound has double the risk of a retained foreign body, compared to an adult who does not sense a foreign body with a similar injury (Note: this only holds true for adults, not pediatric populations, even if verbal).
  • Keys to a good exam are adequate lighting, hemostasis, and anesthesia.  Try to visualize the entirety of the wound.  Puncture wounds can be extended with a scalpel to improve visualization.
  • For deeper wounds involving glass or metal, insert a closed hemostat and withdraw – scraping on the way out may indicate a retained foreign body.

Diagnosis

  • If a foreign body is suspected, order imaging!
  • Appropriate imaging studies varies based on situation – no single imaging modality is appropriate for every situation.
  • Radiopaque objects such as leaded glass, metal, bone, rocks, and some plastics can be detected with X-ray; however, x-ray often does a poor job with organic materials that are not hard bone.
  • CT scan is fairly sensitive for foreign bodies, but has the drawbacks of increased cost and radiation exposure.  Also, a weird quirk of CT scan is that wood can sometimes mimic the appearance of air bubbles in soft tissue, which may confuse a foreign body (not-as-bad) with a gas-producing infection (extremely-very-hyper-bad).  So keep that in mind.
  • Bedside ultrasound has the benefits of being quick, non-irradiating, and performable by the physician at the bedside.  As an added bonus, it allows for guided removal of hyperechoic foreign bodies such as glass.  However, it can be a difficult skill to master, and false positives may lead to you digging around tissue.  Other hyperechoic structures (soft tissue calcifications, bones, tendons) can mask the presence of foreign bodies.
  • Again – there is no single best imaging study to order for all situations.  Think about the injuring material and its properties.  Physics may be boring, but a little bit of knowledge can go a long way.

Treatment and Disposition

  • Not all foreign bodies have to be removed!  Step One –  figure out if it even requires removal.
  • Good indications for removal include: toxic material; risk of infection; involvement of nerves, tendons, blood vessels or potential to migrate to those structures.
  • Some foreign bodies may require special removal techniques – see relevant discussion below.  Foreign bodies that are in very deep tissue or embedded in hands or face may require special surgical consult or specialist follow-up.
  • After removal, closure depends on infection risk.  Low-risk wounds can be closed with primary intent – all the good evidence shows that these wounds do not require prophylactic antibiotic use.
  • Wounds at risk for infection (think heavily contaminated materials, like teeth fragments) may require healing by secondary intent or delayed primary closure.  However, in the absence of active infection, prophylactic antibiotic use is currently of unclear benefit at best (I guess if there were active infection, it would no longer be considered “prophylactic antibiotic use” anyway).
  • Ensure the wound is cleaned and irrigated post-removal.
  • If suspected retained foreign bodies exist after removal, obtain a post-procedure radiograph.
  • After discharge, appropriately inform the patient of the risk for a retained foreign body and document, document, document – don’t let them show up 6 months later with a frivolous lawsuit because they had “no idea” a piece of glass would fall out of their arm (even though you told them multiple times).

Continue reading below for further discussion:

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Using Ultrasound in Central Line Placement

This week, we have a post from regular contributor Nick Mancuso on how to excel when performing a procedure common in the ED as well as upstairs: ultrasound guided central line placement.

 

The three most common veins used in central line placement are the internal jugular (IJ), subclavian (SV), and femoral (FV). I will focus on IJ placement and the use of dynamic ultrasound.

Procedure:

  • Sterile technique is paramount (if time permits).
  • Linear array probe is used with a sterile probe cover, and sterile gel. A CVC kit is obviously required, along with sterile personal protective equipment. This procedure can be done with one person, but two can be helpful especially during training.
  • Operator on the isiplateral side of the pt, pt in Trendelenburg, probe indicator to the left of operator, in transverse position.
  • Place probe superior to clavicle, IJV usually larger, lateral to carotid artery.
  • The IJV will compress with pressure, vs. the artery. If hypotensive or dehydrated, may disappear with inspiration.
  • Center vein on screen, lidocaine can be used to anesthetize pt. Use center of probe as guide, while not looking at monitor, stick pt skin with entry needle.
  • Look at monitor after puncture. Visualize needle or tissue compression. Puncture vein looking at monitor.
  • If needle can’t be visualized, a long-axis (longitudinal) view can help
  • It is extremely important to visualize the needle tip and not proceed with advancement of the needle without visualization of the tip.  The tip can be followed with slow fanning or sliding of the probe distally as you advance.  The most common mistake is not following the tip of the needle and letting the needle get “ahead of” the probe.  This leads to visualization of the proximal portion of the needle while the tip is in a different location in the neck, possibly causing complication.
Ultrasound visualization of neck vasculature

Ultrasound visualization of neck vasculature (Source)

Top: Internal jugular vein (IJV) and carotid artery (CA) in the transverse view with the transducer held on the skin without pressure (left) and with pressure (right). Note that with pressure, IJV appears compressed while the CA has retained its shape. Bottom: These blood vessels in the longitudinal plane. (Source: http://pie.med.utoronto.ca/OBAnesthesia/OBAnesthesia_content/OBA_ultrasonographyBasics_module.html)

Top: Internal jugular vein (IJV) and carotid artery (CA) in the transverse view with the transducer held on the skin without pressure (left) and with pressure (right). Note that with pressure, IJV appears compressed while the CA has retained its shape. Bottom: These blood vessels in the longitudinal plane. (Source)

Video: Ultrasound Guidance for Central Venous Access – SonoSite

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Keep it Cool with Frostbite

This week – the return of the King.  Sakib himself shares some information on appropriate care for frostbite injuries

Play it cool with frostbite

Quickhit:

-       Risk of cold injuries such as frostbite correlated with temperature, windchill, moisture

  • Risk is <5% when ambient temp (including wind chill) is >5 F (-15C)
  • Most often occur at ambient temp < -4 F (-20C)

-       Pathophys = freezing alone not sufficient to cause tissue death, Thawing contributing to endothelial damage is cause of majority of damage (see continue reading below)

-       Zone of injury = Zone of Coagulation, Zone of Hyperemia, Zone of Stasis

-       Treatment = Rapid re-warming with warm water. Do not debride any tissue initially.

-       Complications

  • 65% pt. experience sequeulae from their injuries
  • Hypersensitivity to cold, pain, ongoing numbness
  • Asthritis, bone deformities, dystrophia

Read below to get more thorough treatment maneuvers and further info on Frostbite Injury!

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eFAST – The Quick Hit

Everything you need to know about the eFAST in 60 seconds or less (120 seconds if you count the one minute ultrasound video).

Who Needs an eFAST Ultrasound:

  • Blunt and penetrating abdominal trauma
  • Blunt and penetrating chest trauma
  • Ectopic pregnancies
  • Any patient you suspect has abdominal or thoracic free fluid or bleeding

The Technique: 5 scans in 1 exam

Heart

  • Probe position: subxyphoid
  • Image: four chambers of the heart and pericardium
  • Evaluation for: pericardial effusion and cardiac tamponade

Right Upper Quadrant (Perihepatic)

  • Probe position: RUQ
  • The image: Morrison’s Pouch (liver and kidney), diaphragm, and some chest
  • Evaluation for: intra-abdominal bleeding or fluid and hemothorax

 Left Upper Quadrant (Perisplenic)

  • Probe position: LUQ
  • The image: Spleen, kidney, diaphragm, and some chest
  • Evaluation for: intra-abdominal bleeding or fluid and hemothorax

Pelvis

  • Probe position: above the bladder
  • The image: in men- bladder and rectum, in women- bladder, uterus, and rectum
  • Evaluation for: intra-abdominal bleeding or fluid

Lungs

  • Probe position: anterior chest at the 3rd and 4th intercostal space
  • The image: ribs, pleura, and lung
  • Evaluation for: pneumothorax

eFAST 1 minute ultrasound

Submitter: Jennifer Cotton

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Life in the eFAST Lane: extended Focused Assessment with Sonography for Trauma (Part 2)

 We’re back! Last time we reviewed eFAST basics and part of the eFAST technique. Hopefully you’ve been practicing the heart, RUQ, and LUQ scans like my friend below. So without further adieu…. I give you eFAST Part Deux!
Figure 1 - An eFAST Rockstar in Training

Figure 1 – An eFAST Rockstar in Training

How to Do I Do an eFAST? (Continued from Part 1)
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Life in the eFAST Lane: Extended Focused Assessment with Sonography for Trauma (Part 1)

The Case: There are just too many eFAST cases to choose from. Which one to tell you…? Should I tell you about my first eFAST patient, the supposed-to-be-simple-but-really-wasn’t, on-coumadin guy who laid out his motorcycle? What about the lady from the rollover down a twenty foot embankment? Or the teenager from a horseback riding accident? Should I tell you about the night I hung out in resuscitation and did an eFAST on every patient that came through? A night in December I like to think of as Ultrasound Christmas. A night when a trauma alert rolled in and before I knew what was happening, the resident put the ultrasound probe in my hand and said “Go for it!” Needless to say it was AWESOME! Like do-a-secret-happy-dance-in-the-hallway-afterwards kind of awesome. I’m definitely still lovin’ the ultrasound elective, especially since I’ve become competent at eFASTs.

So what’s an eFAST you ask? It’s simple, really. It’s a systematic ultrasound scan to check for pneumothorax and free fluid (usually blood) in the abdomen and chest. It’s quick, easy, and incredibly useful. You don’t have to be a genius for this stuff. And it’s an ultrasound scan, so it means fewer patients being radiated by CT scans. Remember? Radiation bad. No radiation good. If you’re going to spend time in the ED, you should learn the eFAST. End of story. Plus if trauma’s your scene, you’ll get close to some wicked traumas. So now that you’re convinced… just how do you do an eFAST?

What’s eFAST All About?

The eFAST is a fast (pun intended) and easy way to check for blood in the chest and abdomen. eFAST is an acronym for extended Focused Abdominal Scan for Trauma. It’s an ultrasound exam designed for trauma patients that can be used at the bedside without interrupting ongoing care. Unstable patients with positive eFAST scans can then receive definitive care (get a chest tube, go to surgery, etc.) without the delay of waiting for a CT. The exam is a set of scans that quickly visualize free fluid (like blood) in the anatomical sites it most commonly collects, so the trick to quickly interpreting an eFAST exam is learning just where free fluid tends to collect. An eFAST looks at the right upper quadrant (RUQ), left upper quadrant (LUQ), pelvis, heart, and lungs. (Lungs are the extended part of the exam. Without the lung component it’s just called a FAST exam.) So that’s five ultrasound views, six if you’re picky about the whole 2 lungs thing, and you’ve completed an eFAST exam. It takes less than 5 minutes to complete, but more like 2 minutes as you approach ultrasound rock star status. Plus it’s more sensitive than x-ray for conditions like pneumo or hemothorax. Basically, eFASTs are a great ultrasound scan for rapidly identifying bleeding and other common injuries in the trauma patient.

The Patient: Who Gets an eFAST? 

  • Blunt and penetrating abdominal trauma
  • Blunt and penetrating chest trauma
  • Ectopic Pregnancies
  • Suspected abdominal or thoracic free fluid or active bleeding

How Do I perform an eFAST?

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