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Conference Notes  6-4-2013

Herrmannh/Kettaneh     Study Guide  Potpourri 

Frostbite:  Treat by warming frostbitten extremity with 39C temperature  water.  Update tetanus shot.  Pain management.  Topical aloe and po ibuprofen may be beneficial and are of low risk.  There is emerging data for intra-arterial TPA.

Thrombolysis - Because frostbite is associated with vascular thrombosis of the affected tissue, administration of intravenous heparin along with either intravenous or intra-arterial tissue plasminogen activator (tPA) has been studied as a potential means of improving outcome [35,36]. A single-center, retrospective review of 32 patients with severe frostbite treated with tPA within 24 hours of injury found the incidence of digital amputation to be 10 percent, compared with 41 percent among patients with comparable injuries not treated with tPA [36].

Evidence in support of thrombolytic treatment of severe frostbite is retrospective and involves only a small number of cases. Nevertheless, treatment options for patients with severe frostbite are limited and outcomes often poor. Therefore, in patients at high risk for life-altering amputation (eg, multiple digits, proximal amputation), without contraindications to the use of tPA, who present within 24 hours of injury, we suggest treatment with intra-arterial tPA. Whenever possible, treatment should be performed at or in consultation with a center experienced in the use of tPA for frostbite.

In the study demonstrating benefit from tPA, a bolus of two to four mg was followed by an infusion started 0.5 to 1 mg/hour given via the femoral or brachial artery [36]. Repeat angiograms were performed every 8 to 12 hours. Treatment continued until perfusion was restored or a time limit of 48 hours was reached.  (Up to Date)

Acetaminophen OD:  Loading dose of IV Nac is 150mg/kg then 50mg/kg for 4 hours then 100mg/kg over 16 hours.  PO loading dose is 140mg/kg followed by 70mg/kg every 4 hours X 17 doses.   The toxic metabolite of APAP is NAPQI.  The 4 hour  level indicating treatment  is 150 on the nomogram.

Kawasaki’s DZ: mucocutaneous lymph node syndrome.  Fever for 5 days/bilateral conjunctivitis with perilimbal sparing is present in 90% of cases/mucositis/rash/indurated edema of hands and feet (last manifestation to develop).   Most common complication is coronary artery aneurysms.  Patients can also get CHF and peripheral arterial occlusion, arthritis, aseptic meningitis.

Bilateral conjunctivitis with perilimbal sparing seen in Kawasaki's (Up to Date)

Edema of hands seen in Kawasaki's  (Up to Date)

Antidote for Cesium-137  is Prussian blue.  It binds Cesium in the GI tract and allows it to be excreted in the feces.   Prussian blue can cause hyperkalemia and bluish discoloration of body fluids.

Oral commissure burn from a child biting electrical cord.  Child will need surgical debridement and possibly reconstruction of the angles of the mouth.   Patients can have severe delayed bleeding at 5-10 days from damage to the labial artery.

Dextrose  for hypoglycemia:  Newborn/ infant gets D10,  Child gets D25,  Older kid or adult gets D50. Divide 50 by the age appropriate D number to calculate the ML/KG dose.     So for example, a newborn: 50 divided by 10 results in 5ML/KG of D10.  Girzadas comment: Important info to know but in resuscitation situation have an app like Pedi Stat on your phone to decrease the risk for error.

Ductal dependant cyanotic heart lesions in infants: Give prostaglandin E1. There is a risk of apnea, hypotension, and tachycardia  when giving prostaglandin E1. So, have airway equipment and resuscitation meds readily available.

Vitamin A toxicity: Intracranial hypertension similar to pseudotumor cerebri.   Adults can have headache, nausea/vomiting, and vision changes.   Infants will have irritability/vomiting/bulging fontanelle.

Fakhouri   Fingertip amputations, Flaps and Other Hand Emergencies

Fingertip Amputations:  Save the tip.  Wrap it in moist gauze, put it in a plastic bag, then place it on ice.   The thumb is the most important digit of the hand; It is worth ½ the hand.   Don’t rongeur anything on any finger.  If bone is exposed,  just wash and cover with xeroform dressing followed by dry dressing.  Needs hand evaluation within 24 hours.   The thumb is critical, it has to be rescued/reimplanted at all costs.   For the other fingers, if the amputation is at the PIP or proximal, the patient will probably loose the finger.  Reimplantations at the PIP joint  or proximal have very limited function.   Consider admitting any injury more severe than a tip avulsion.  If you see macerated or mangled soft tissue, it likely is not re-implantable.   Save every amputated digit until the surgeon evaluates the patient.

Nailbed  Injuries:  Fix the nailbed with absorbable suture.  Trephinate the nail inside to out, Replace the nail into the nailfold and suture in place.   Nail needs to be sutured in place for 2 weeks.  Place suture through nail and then through the superficial eponychium proximally and through the nail and the soft tissue distally.

Scapholunate dissociation:  3mm or more between the scaphoid and lunate.  These patients if untreated will develop arthritis in the long term.

Dorsal dislocations of PIP splint in flexion after reduction.   Reduction is best obtained with distal traction and applying pressure with the physician’s thumb on the volar aspect of the distal portion of the proximal phalanx.  Again, splint reduced finger in flexion at the PIP joint.

Erickson/Salzman    Trauma Lecture

You need to intubate with an 8.0 tube for trauma patients in case the patient needs to have bronchoscopy.

Salzman comment: Aspiration is a disaster.  Consider cricoid pressure to prevent passive aspiration.

Although Sellick's maneuver may reduce gastric insufflation during bag-mask ventilation, evidence that cricoid pressure reduces the incidence of aspiration of gastric contents is scant and consists primarily of observational clinical studies and experimental data [23]. Several studies suggest it may contribute to airway obstruction and difficulty intubating in some cases, even when a video laryngoscope is used [23-27]. Until more definitive literature is published, we suggest that the use of Sellick's maneuver during RSI and bag-mask ventilation be considered optional.(Up to Date Reference)

A systematic review of cricoid pressure studies noted the following [23]:

• The literature provides evidence both for the success and failure of cricioid pressure to prevent aspiration
• Cricioid pressure is often used improperly
• Cricoid pressure may impair the function of the lower esophogeal sphincter 

Possible risks from cricoid pressure include movement of unstable cervical spine fractures and esophageal injury.   (Up to Date Reference/Ellis DY et al. Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis Annals of EM  Dec 2007)

Girzadas comment: Cricioid pressure carries some risk of esophageal rupture if used in a patient with active emesis.

Salzman comment: Criteria for OR based on Chest Tube output: 1500ml initial output.   250ml/hour output over 4 hours.

Salzman recommended large caliber chest tubes for trauma 36-40F.   Harwood comment: Smaller patients’ intercostal spaces may only accommodate 32F tubes.   Both agreed that it was critical to make sure the tube was well secured to the chest wall.

Discussion of pain medication for rib fractures:  There was consensus between Salzman and ER faculty that aggressive pain medication was warranted in trauma patients.  The risk of respiratory depression in trauma patients due to opioids is low.  Dr. Salzman made note of an exception to this rule regarding elderly trauma patients who may be more likely to have respiratory depression.

Case vignette: 25yo male with traumatic amputation at distal tib-fib.   Salzman’s point: Don’t focus on the mangled  extremity.  Stick to your primary survey initially prior to dealing with the more visually graphic extremity injury.   Similar issues apply to other emotionally traumatic situations like injured children/pregnant women/other visually stunning injuries.

Barounis   Last Lecture

Case: 6wk old male.  Vomiting.  Eval in ED for pyloric stenosis.  U/S showed hepato-splenomegaly.  MRI of abdomen showed diffuse neuroblastoma.    Dave cared for the patient in the ICU and got to know the family.   Every time the patient left the ICU he seemed to have some complication such as ET tube dislodgement.  Parents became wary of procedures.   Dave became the family’s trusted clinician.  They wanted him there anytime a procedure was done.   Dave learned the importance of earning the trust of the patients and families that come to the ER.

Passion in the ER/for the ER: latin pascio=suffering.   You give up a lot to become an ER doc.   Create your own mission statement to kindle your passion for whatever you do.

If you want to understand someone, you have to consider things from their point of view.  Climb into their skin and walk around in it.

As a leader, Better than telling others what to do, Inspire others to do what needs to be done.

Don’t be a problem identifier, be a problem solver.

All eyes are on you.  People watch you as a leader and follow your example.    Be a positive example for people.

Be decisive in the ED.  Even if you are wrong, it’s better than being indecisive.

Be the change you want to see.

Big rocks in the jar analogy.  Schedule time for the things most important to you first.

Senior Pearls Lecture    Excellent Humorous Advice from Graduating EM3's

Not intended for publication on the website other than Ted Toerne's Advice: The fastest way to discharge a patient from the ED is to "Click the Discharge Button on the EMR"