Do you always get a troponin for patients who sustain blunt chest trauma?
Hopefully your answer is no. Of note, it is also NOT indicated as a screening test for those in whom you suspect a blunt cardiac injury (BCI). It can be normal in the setting of arrhythmias and it can be falsely elevated in the setting of catecholamine release or reperfusion injury from hypovolemic shock.
The initial screening test should include an EKG and a FAST ultrasound exam. If you have abnormal EKG findings, then a troponin is warranted (in addition to hospital admission).
Below summarizes a suggested algorithm from the recent EM Clinics of North America publication series. Definitive statements are challenging because there is no gold standard to diagnose BCI.
Feel free to download this card and print on a 4'' x 6'' index card.
Last week, Dr. David Johnson shared his trick to elicit a Valsalva maneuver out of his patient. Here's another trick that I saw one of our EM residents use in an attempt to break a SVT rhythm.
Trick of the Trade: Instruct the patient to blow into a 10 cc syringe in an effort to "blow out" the syringe plunger.
I was amazed to find a journal article in Emergency Medicine Australia, which documented that an appropriate Valsalva force is generated when a patient is able to move the plunger of a 10 cc syringe by blowing into the syringe! Apparently larger syringes don't generate enough force (< 40 mmHg) and smaller syringes require too much force (> 40 mmHg).
Reference
Smith G, Boyle MJ. The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre. Emerg Med Australas. 2009 Dec;21(6):449-54. Pubmed.
Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol, methanol), this Paucis Verbis card focuses on isopropyl alcohol toxicity, which is commonly found in rubbing alcohols. In this toxic alcohol, fomipezole is actually NOT indicated because you want to have alcohol dehydrogenase convert the toxic parent compound (isopropyl alcohol) into the nontoxic metabolite (acetone).
Note that these are merely guidelines and you should tailor management plans with your toxicologist and nephrologist.
Feel free to download this card and print on a 4'' x 6'' index card.
A patient presents to triage in rapid SVT rhythm. While you are trying to get an IV in the patient and drawing up adenosine, you have the patient perform a Valsalva maneuver to see if increased vagal tone itself will break the arrhythmia. Unfortunately, she is unable to understand your instructions.
Trick of the Trade:
Apply firm pressure to the abdomen and have the patient push you away
Thanks to Dr. David Johnson (Stanford-Kaiser EM resident) for sharing this tip, which broke a patient with pre-excitation syndrome with a narrow complex heart rate of about 200 bpm. Here's his explanation:
I feel that this is an easy, coachable way for a patient to vagal themselves.
Lay a patient supine and have them relax their abdomen.
Place your hands near the umbilicus and apply firm pressure.
Place your hands and take a stance similar to performing chest compressions.
Warn the patient that you will place a lot of pressure as you slowly press into the abdomen.
When you have a moderate degree of pressure, then ask the patient to lift you up or push you away with their stomach.
They will tense their abdominal muscles and bear down as you are pushed away.
Be prepared cause most are quite strong and you will actually want to put a lot of your weight on your hands as you encourage the patient to continue to push you up with their abdominal muscles.
I have been meaning to share this list of great tips about building a productive academic team. Major projects often require an interdisciplinary team of experts who are equally motivated towards a shared goal. I was recently at the 2012 Society of Academic Emergency Medicine where Dr. William McGaghiegave an inspiring CDEM keynote speech. He has been on a myriad of successful academic teams and he shared with us his top 10 list of pearls for team-building.
William C. McGaghie, PhD
Jacob R. Suker, MD, Professor of Medical Education
Professor of Preventive Medicine
Director of Evaluation, Northwestern University Clinical and Translational Sciences (NUCATS) Institute
Northwestern University Feinberg School of Medicine Center for Education in Medicine
I am in the process of building a big academic team myself, comprising of rheumatologists, software engineers, instructional design experts, and an education research expert. This list came in quite handy for me and so I thought I'd share.
The team should have:
Shared goals—common mission & vision
Functional diversity (everyone should have different defined roles)
Clear leadership—may change or rotate
Shared mental models & language
High standards, recognition, & credit
Sustained hard work / commitment
Physical proximity
Minimize status differences within the team
Maximize status of the team
Shared activities that breed trust
While these tips may seem obvious, they are a worthwhile reminder nonetheless. Dr. McGaghie shared examples where different members took the lead on different manuscripts within the overarching project and that everyone's opinions were valued. I found it interesting that he felt that physical proximity contributed to the success of his projects. In-person meetings and check-ins seem to have provided added value.
Continuing on the theme of Toxic Alcohols (osmolal gap, ethylene glycol), this Paucis Verbis card focuses on methanol toxicity. Useful are the American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis. I redrew the flowchart based on what's relevant to the ED in the initial stages (I used Google Docs' Drawing feature).
Note that these are merely guidelines and you should tailor management plans with your toxicologist and nephrologist.
Feel free to download this card and print on a 4'' x 6'' index card.
Kraut JA, Kurtz I. Toxic alcohol ingestions: Clinical features, diagnosis, and management. Clin J Am Soc Nephrol. 2008;3:208-225. Pubmed.
Jammalamadaka D, Raissi S. Ethylene glycol, methanol, and isopropyl alcohol intoxication. Am J Med Sci. 2010;339(3):276-281. Pubmed.
Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health-Syst Pharm. 2012;69:199-212. Pubmed.
Barceloux DG, Bond GR, Krenzelok EP, Cooper H, Vale JA; American Academy of Clinical Toxicology Ad Hoc Committee on the Treatment Guidelines for Methanol Poisoning. American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol. 2002;40(4):415-46. Pubmed.
A patient re-presents to the Emergency Department with a foreign body sensation in his heel after stepping on a broken window. Despite a negative xray and bedside ultrasound yesterday, the patient still believes that a small foreign body is still in there. You are unable to find a foreign body despite excising the overlying skin with a scalpel and exploring with forceps.
Trick of the Trade:
Use a punch biopsy instrument to excise the soft tissue
For non-cosmetically important and neurovascularly low-risk areas where there is a high suspicion for a small retained foreign body, you can use a small punch biopsy tool (1-2 mm diameter) directly over the maximally tender point to remove the foreign body. Apply LET or inject lidocaine with epinephrine before the biopsy. After excising the core, examine it for the presence of a foreign body.
Watch the YouTube video starting around 00:43 min to see how to use a punch biopsy tool. This example shows one with a 4 mm diameter, which may be too large for your procedure, but it illustrates the technique well.
Thanks to Dr. Matt Silver (Kaiser Permanente, San Diego Medical Center) for the tip. He recently removed a 1 mm x 1 mm glass shard from a patient's heel using this technique despite a negative XR and US. Way to go!
Following last week's Paucis Verbis card on calculating the osmolal gap, here is the first installment of the Toxic Alcohols cards. First up -- ethylene glycol. There are useful American Academy of Clinical Toxicologists recommendations on when to administer an antidote (fomipezole) and when to perform hemodialysis.
Here's a quick review of the metabolism of the different toxic alcohols. The parent compounds for ethylene glycol and methanol are innocuous and the metabolites are toxic.
Feel free to download this card and print on a 4'' x 6'' index card.
A 3 month old baby presents with distal erythema and swelling of one of her toes. A hair tourniquet is identified. Typically one can try manually unwrapping the tourniquet using forceps, but often only part of the tourniquet can be removed. The distal toe remains swollen and erythematous with delayed capillary refill.
As demonstrated by the image above, it can be difficult to identify the hair because of the edema and the thin nature of the hair (especially if the same as the patient's skin color). In a 2006 review of hair tourniquets in the Annals of Plastic Surgery, they recommend incising down to the bone along the lateral edge of the digit to ensure tourniquet release. It seems a bit aggressive...
Trick of the Trade:
Cut the hair tourniquet using a "conventional cutting needle"
I shot a quick video (above) using a thick piece of chicken fat to demonstrate the principles.
This is a tip provided by Dr. Sarah Morris (Univ of Virginia EM resident) in conjunction with Dr. Robert O'Connor (UVA faculty), and Dr. William Woods (UVA faculty). Here are her great pearls:
Key points:
There are different kinds of suture needles. Cutting needles have the sharp edge on the concave side (internal curvature), and reverse cutting needles have the sharp edge on the convex side (external curvature).
Fear the hair tourniquet - complete resolution is more difficult than it seems
Consider a cutting needle to cut through the hair causing the tourniquet and avoid making a large incision.
For a patient we encountered, we used a PC-1 cutting needle to sever the tourniquet. Following this, the hair appeared from the swollen toe and was able to be removed with forceps. The toe regained normal circulation, and skin indentation was improved but not resolved. The parents were instructed to clean the laceration on the plantar surface with soap and water, to follow up for a re-examination, and the child was placed on prophylactic keflex for 3 days.
A literature review suggests incising the hair with a scalpel (making a lateral incision of toe through skin and to the bone) or soaking in deploratory cream if one is unable to reduce the tourniquet with forceps. We are not aware of prior attempts using cutting needles to reduce hair tourniquet.
Removing a tourniquet is essential. Unsuccessful reduction may need operative management and can result in significant complications including digital loss, flexion deformities and amputations. Hair tourniquet removal can be very difficult as the hair eventually cuts through the edematous skin and becomes embedded in the subcutaneous tissue, making the hair virtually invisible. It is not uncommon for a constricting fibrosis to remain after removal of the tourniquet. If the hair tourniquet appears to have been removed, close follow up is needed to ensure a subcutaneous, invisible tourniquet is not present, as these have been known to cause bone erosion in the past.
Reference
Mat Saad AZ, Purcell EM, McCann JJ. Hair-thread tourniquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Ann Plast Surg. 2006 Oct;57(4):447-52. Pubmed.
We often talk about calculating the anion gap in the evaluation of patients. What about the osmolal gap? When do you calculate this? What's the differential diagnosis for an increased osmolal gap?
I recently came upon a nice 2011 review in the American Journal of Kidney Disease called "Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis". It's always nice to revisit and review this concept. You'll always learn something new. For instance, I didn't know that salicylates cause anion gaps as well as osmolal gaps.
So don't forget to calculate an osmolal gap for patients with unexplained an metabolic acidosis anion gap.
Reference
Kraut JA, Xing SX. Approach to the evaluation of a patient with an increased serum osmolal gap and high-anion-gap metabolic acidosis. Am J Kidney Dis. 2011 Sep;58(3):480-4. Pubmed.
