Category Archives: #FOAMed

Reduction of Uncomplicated Shoulder Dislocation in the ED

At long last, UK EMIG QuickHits returns from hiatus with a rundown on shoulder dislocations and how to handle them in the ED, from 4th year UK med student Michael Greene

Quickhit: 

-Shoulder joint dislocations are a common reason for a visit to the emergency department (50% of all joint complications treated in the ED) so it’s important to be familiar with them

-Pathophysiology: Glenohumeral dislocation. Usually occurs with indirect force applied to the shoulder through the arm during abduction and external rotation, leading to the humeral head slipping out of the glenoid fossa.

-Up to 95% are anterior dislocations but posterior and inferior dislocations occur

-Further subdivided into subcoracoid, subglenoid, subclavicular, or intrathoracic, depending on where the humeral head ends up

-Workup: Most important is history and physical. Shoulder x-ray in three planes (AP, lateral, axillary) is the initial imaging modality of choice.

-As with any MSK injury, be sure to do a neurovascular check distal to the dislocation, including the axillary nerve innervation of cutaneous deltoid distribution. If vascular or neurological deficits are identified, more rapid reduction is required.

-Management: Rapid, closed reduction! The sooner the reduction is performed the easier it is, as prolonged dislocation increases the muscle spasms and tightness which is keeping the humeral head from moving back into place

-For all methods (see below for more details) listen or feel for the clunk. With the awake patient, look for relief of pain and improvement of range of motion

-Complications: Bankart’s lesions and Hill-Sach’s deformities. While initial x-rays should pick them up, more subtle presentations may only be seen on CT or MRI.

-Post-reduction care: sling for three weeks to let the shoulder girdle recover and tighten. Ortho follow-up, particularly with recurrence or complications

Also… most things here apply only to anterior shoulder dislocations. Posterior or inferior dislocations are less common and more prone to long-lasting complications. An ortho consult is always in order for these.

Keep reading for a more in-depth take on shoulder dislocation reductions

As mentioned above, the shoulder is most commonly dislocated joint. It’s the most mobile joint in the human body, but with great mobility comes great instability. As we can see in the image below, there’s not much keeping the humeral head nestled in the glenoid fossa besides soft tissue stabilizers like rotator cuff muscles, ligaments and the joint capsule. It is most commonly dislocated anteriorly via indirect pressure applied to the arm during abduction and extrinsic rotation. It can be sub-categorized based on where the humeral head ends up: subcoracoid, subglenoid (the two most common) or subclavicular or intrathoracic (both very rare).  There is a bimodal distribution in the patient population seen with shoulder dislocations: young, active men and elderly women.

shoulder anatomy

Image source: via https://www.studyblue.com/notes/note/n/shoulder/deck/1978417

Presentation: Patients typically come in with a history of trauma supporting their flexed, externally rotated arm. The shoulder will have a classic squared off appearance and a gap between the humeral head and the acromion can be palpated. Usually not the trickiest diagnosis, although the image below is dramatic.

dislocation-of-the-shoulder2

Image source: http://www.firstaidevents.com/articles/dislocation-of-the-shoulder

X-ray will verify the dislocation and can also visualize any associated bony lesions or fractures

anterior-shoulder-dislocation-1

Image source: Case courtesy of Dr Frank Gaillard, From case 7958

Reduction methods:

The goal of reduction is to restore pain-free, functional anatomy and range of motion while maintaining shoulder stability. In order to accomplish this, the muscular spasm which occurs during dislocation and keeps the humeral head from spontaneous reduction must be overcome to relocate the humeral head into the glenoid fossa.

There are as many methods to do this as there are ways to dislocate your shoulder, but we’re going to highlight some of the most popular. For all methods, listen or feel for the clunk. With an awake patient, look for relief of pain and improvement of range of motion

Traction/Countertraction

  • Often used in the ED for its simplicity and ability to quickly overcome tight muscles from prolonged dislocation
  • Detractors point to the increased use of force and potential neurovascular complications or enlargement of bony complications

fx_traction_countertraction_shoulder

Image source: dundeemedstudentnotes.wordpress.com

Stimson

  • Patient lies in the prone position with the effected arm hanging off the bed, attached to a 5-10lb weight
  • Over the course of 20-30 minutes the muscles of the shoulder girdle will grow tired and relax, allowing the humerus to slip back into place

stimson

Image source: intranet.tdmu.edu.ua

Milch

  • Forward elevation: arm initially is elevated 10 to 20 degrees in forward flexion and slight abduction. Forward flexion is continued until the arm is directly overhead. Abduction is increased, and outward traction is applied to complete the reduction.

    Figure 25. Milch Technique

    Image source: www.ebmedicine.net/

Snowbird

  • The patient is seated in a chair, and the affected arm is supported by the patient’s unaffected extremity.

    A 3-foot loop of stockinette is placed along the forearm with the elbow at 90 degrees.

    The patient sits up and gets some support from the physician. Traction is directed downward on the forearm by a foot in the loop, while the forearm is supported and the provider’s other hand is free for pressure or rotation as needed.

External rotation

Scapular manipulation

Involves repositioning the glenoid fossa rather than the humeral head; can be used with minimal analgesia or muscle relaxation. Traction on the arm is placed either by the hanging method or by an assistant. During gentle traction, the inferior tip of the scapula is rotated medially, while the superior portion of the scapula is stabilized.

shoulder manipulation

image source: www.hawaii.edu/medicine/pediatrics/pemxray/v4c12.html

Kocher

  • Leverage, adduction, and internal rotation

    -No longer recommended because of a high incidence of associated complications (axillary nerve injury, humeral shaft and neck fractures, capsular damage)

Hippocratic

  • Like the Kocher, not used as much due to potential for complications
  • Traction with the foot in the axilla

hippocrates

image source: http://www.wjgnet.com/2218-5836/full/v5/i1/57.htm

Pain control:

Procedural sedation with benzos, opiates, propofol, ketamine or etomidate has long been the mainstay for reductions in the ED. It’s common, providers are familiar with it, it can give some muscular relaxation and the patients are easy to work with, for obvious reasons. However, it is expensive and requires continual observation and cardiopulmonary monitoring during the course of the sedation.

For those whose time and manpower is limited, intra-articular lidocaine injections have proven to be effective. For the horde of ultrasound enthusiasts, ultrasound-guided interscalene brachial plexus block can also provide effective regional anesthesia for reduction. Some advantages of these methods and avoiding procedural sedation are to reduce cardiopulmonary compromise, to reduce staffing required for monitoring, reduce ED length of stay, and reduce cost. There are some risks, well addressed elsewhere, of vascular puncture during injection and temporary phrenic or recurrent laryngeal nerve paresis, although this is operator dependent.

To rehash some basic anatomy, the brachial plexus runs from C5-T1, under the clavicle, to the axilla and provides innervation to the upper extremities. The interscalene block of the brachial plexus involves the infiltration of lidocaine at the level of the trunks, seen below, which when viewed in the transverse with ultrasound gives you the classic “traffic-light” sign of the three stacked nerve trunks.

brachialplexus

Image source: mymedlife

ACEP_Feb2012_Fig5

Image source: ACEP

lovolanim

Image source: Neuraxiom

Complications:

The common pimp question complications from shoulder dislocation are the Hill-Sach’s and Bankart’s lesions. They are basically the glenoid and the humerus acting on each other. In the Hill-Sach’s deformity, the humeral head is the injured party and in the Bankart’s lesion, the glenoid rim is injured. I keep them straight by the H’s: [H]ill-Sach’s=[H]umeral head

Hill-Sach’s deformity: compression fracture of the humeral head from sliding across the glenoid rim

Bankart’s lesion: avulsion fracture of glenoid rim from impact of humeral head

bankart+hillsachs

Image source: littlemedic.org

More bony injury: greater tuberosity fracture, coracoid fracture, humeral neck/shaft fracture

Ligamentous injury: inferior glenohumeral ligament, more common in younger patients

Muscular: rotator cuff strains and tears, more common in older patients

Neurological: axillary nerve, supplying motor innervation to teres minor and deltoid, and sensory innervation to lateral upper arm over the deltoid.

Vascular: axillary artery; look for it in association with axillary nerve injury

Joint instability and recurrent dislocation is the ultimate outcome for many of these complications, especially Hill-Sach’s, Bankart’s, and inferior glenohumeral ligament injury. All of these complications need an ortho consult, and surgical intervention can help prevent recurrence.

Additional info:

For all you wilderness med maniacs out there, here’s a study published by the Wilderness Medical Society of a reduction method that can be done without assistance, equipment or medications. All it takes is patience and a willing patient.

http://www.ncbi.nlm.nih.gov/pubmed/25823603

Also:

Cunningham’s method

FARES method

-All things shoulder dislocation and reduction:

www.shoulderdislocation.net

-Ultrasound-guided interscalene block guide:

http://www.acep.org/Continuing-Education-top-banner/Focus-On–Ultrasound-Guided-Interscalene-Approach-To-the-Brachial-Plexus-Nerve-Block/

http://www.sonoguide.com/interscalene_plexus_block.html

http://www.neuraxiom.com/html/low_volume_interscalene_block.php

-As always: Rosen’s, Tintinalli’s

Contributor: Michael Greene

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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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What is #FOAM and why this website matters to you?

Source: http://lifeinthefastlane.com/2012/10/come-join-the-foam-party/

Hope this will inspire more readers and more contributors to our growing website.

As always, thanksto all the wonderful blogs and podcasts we always refer back to. We strive to improve our site as we  are continually inspiried by EM docs leading the way with innovate change to medical education

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Weekly Highlights

Hey everyone! With the large number of blogs (growing everyday), and the new emphasis toward #FOAMed, we decided to do a weekly post w/ highlights from around the interwebs. We tried to find a few that are still relavent at the med student level, and especially important as we slowly head toward the transition between medical student and residency.

We always have cool posts and interesting articles linked on our Twitter, so join us there too!

  • “Why are you ordering that test?” Asked by every attending when you present your plan and very important question to think about. [LINK = EM Res Podcast] 
  • Tweet pearls complied by the guys over at Academic Life in EM [LINK = AcademicLifeinEM] 
  • Study shows ED docs are as good as radiologists at gallbladder ultrasound. Learn from the pros at ultrasound podcast (and do forget to get their 1 min ultrasound app for you phone. One of the best resources for quick tips right before performing ultrasounds)
    [LINK = Ultrasoundpodcast] 
  • Speaking of ultrasound apps, check out Sonospot for a collection of websites and phone apps for bedside ultrasound [LINK = Sonospot]

  • MUST read before going into the ED (shadowing, rotation, for anything!). Initial assessment and management for trauma from Life in the Fast Lane [LINK = LITFL] 
  • Advice to new interns from Better in Emergency Medicine. Relevant for med students as well to see “The Ten Commandments of Emergency medicine” [LINK = Better in Emergency Medicine]

Check out these posts. Learn em well. Sound really smart. Come back for more post and links soon!

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