Category Archives: Uncategorized

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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It’s ALSO that time of year: Respiratory Syncytial Virus

Symptoms: Over 2 to 3 days development of wheezing, a so called “tight” wheezy cough, fever (usually low grade), cyanosis, tachypnea, retraction, fatigue.

Diagnosis:

Upon physical exam the above symptoms are noted, on auscultation inspiratory crackles and wheezing are usually present. Hydration status should be noted, as RSV is a diffuse small airway disease, leading to bronchiolitis.

Non-specific lab tests such as ABGs, CBC, and O2 sat., and age of child help determine candidates for admittance. Secretions can be analyzed using PCR but are expensive, a sophisticated virology lab is required in terms of antigen detection.

Imaging X-Ray is commonly ordered, revealing (nonspecific) hyperinflated lung fields, diffuse interstitial infiltrates, and in more advanced cases focal atelectasis.

DDx: Asthma, bronchitis, adenovirus, pneumonia, metapnuemovirus, influenza.

Treatment:  See part 2 coming soon!

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2012 in review

The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 3,800 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 6 years to get that many views.

Click here to see the complete report.

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