UMEM Educational Pearls

For penetrating neck trauma:

1. Does it violate the platysma if no, close wound and discharge 

2. If yes, are there any hard signs of injury like enlarging hematoma, air from the wound, difficulty swallowing, blood in the airway, respiratory distress then to the OR

3. If no, Ct angio of the neck. If negative and no other findings admit for observation or discharge. If positive, to the OR. If equivocal, endoscopy and broncoscopy. 

   No longer think about the zones of the neck. Treat them all the same. 

Does physician altruism influence quality metrics? This study suggests yes.

45 physicians were defined as “altruistic” based on their willingness to share a $250 cash prize with a stranger in an on-line version of the dictator game, something you might have played in an economics class.

Of 250 physicians drawn from primary care and cardiology, 45 met the definition of altruistic and 205 did not. 

Overall, patients of altruistic physicians:

• Were less likely to experience ambulatory care sensitive admissions (absolute decrease of 1%, relative decrease of 38%, adjusted odds ratio 0.6 (0.38-0.97))
• Were less likely to experience ambulatory care sensitive emergency department visits (absolute decrease of 1.5%, relative decrease of 41%, adjusted odds ratio 0.64 (0.43-0.94)
• Had lower total spending (adjusted decrease of $800, relative change of -9.3% (16.2-2.3). [Note: the unadjusted results run in the other direction.]

The authors suggest that this difference may be on account of altruistic physicians being more willing to consider the appropriateness of tests or treatment or “devote more time and energy to their patients.”

They also note that while most physicians were categorized as not altruistic, at 18% this group of physicians exceeds the 5% of the general US population that would meet this definition. 

Perhaps there is something quantitatively demonstrable to being a “good” doctor.

See https://jamanetwork.com/journals/jama-health-forum/fullarticle/2824419

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Intravascular Volume and the IVC

• Point-of-care ultrasound (POCUS) assessments of the inferior vena cava (IVC) are frequently used in the fluid resuscitation strategy for critically ill patients.
• Numerous factors determine the appearance of the IVC, including intraabdominal pressure, mean systemic filling pressure, central venous pressure, intrathoracic pressure, and right heart function.
• Given these multitude of factors, it is not surprising that literature has demonstrated that the IVC is not a reliable marker of fluid responsiveness.
• Rather, focus on the use of the IVC has shifted towards assessing fluid tolerance, venous congestion, and its use as a marker on when to stop fluid administration.
• POCUS assessment of the IVC is commonly performed in the long axis a few centimeters distal to the diaphragm.  
• Rola, et al. highlight that this location may be misleading and recommend  that a more appropriate assessment be a short axis scan through the entire intrahepatic segment of the IVC, while taking into account the intrapleural and intraabdominal pressures.

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Recent guidelines from anesthesia societies and recent literature emphasize the use of gastric POCUS for aspiration risk assessment. While the role of gastric POCUS in the emergency department is still being explored, one recent article highlighted its use in assessing patients with upper gastrointestinal bleeding (UGIB).

Performing Gastric POCUS:

Patient Position: Place the patient in the right lateral decubitus position, if unable can perform in supine position.

Probe Selection & Placement: Use a curvilinear probe in the sagittal position at the level of the subxiphoid process, similar to the longitudinal view of the proximal abdominal aorta.

Scanning Technique: Fan the probe left to right to assess the gastric antrum.

Interpretation of Gastric Antrum:

Empty Antrum: Appears as a "bull's eye" or flat, with no visible liquid inside.

Full Stomach: Distended antrum with floating contents. 

Intermediate: Shows a small amount of anechoic fluid without floating contents.

Quantitative Evaluation:

It is also possible to perform a quantitative evaluation of the gastric antrum to further assess stomach contents, this may be more useful in patients with intermediate gastric antrum.

For more details, refer to the articles and videos cited.

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This article serves as a reminder that trauma can and will precipitate adrenal insufficiency and crisis in those trauma patients who are on steroids pre-injury. Look for prednisone or hydrocortisone as well as autoimmune or rheumatologic diseases  on pre-injury medication list and history. Consider the diagnosis in trauma patients with refractory hypotension not responsive to vasopressors. Replacement therapy with hydrocortisone is the therapy.

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These authors looked at reported demographics, specifically focusing on sex and gender reporting, from studies in a number of high profile, multi-disciplinary fields.

They found that often only sex- referring biological sex assigned at birth- was reported.  They found that the terms male/female as opposed to man/woman were the primary designations used, and a vast majority of studies and journals significantly underreported transgender, intersex and nonbinary demographics. 

This study reinforces the need for more accurate reporting of SOGi data in research studies, to improve the equity of this patient population in up and coming research

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CHECK-CALL-COMPRESS  is the recommended algorithm by the International Liaison Committee on Resuscitation to teach school age children.  Several studies show that school aged children are highly motivated to learn and perform CPR.  They also serve as CPR multipliers meaning they go home, talk about what they have learned and inspire others to learn.

By age 4, children are able to assess the first step in the chain of survival - CHECK - assessing for responsiveness and breathing.  By age 6, children can dial the emergency number and give the correct information for the location of the call.  By age 10-12 children are able to get correct chest compression depths and ventilation volumes in CPR manikins.  Hands-on training is more beneficial compared to verbal only instruction.

Areas where CPR is taught to school age children as a part of the school curriculum have higher rates of bystander CPR.

Bottom line: CPR should be introduced to elementary school children.

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Rectal injuries are rare and are usually associated with penetrating trauma or significant pelvic fracture from blunt injury.  Diagnosis starts with physical exam including inspection for signs of trauma as well as a digital rectal exam looking for blood, bony protuberance and abnormal sphincter tone.  Normal digital rectal exam does not exclude injury. 
Imagining is important in making the diagnosis. 

“Findings on CT associated with rectal injury include a wound tract extending to the rectum, a full-thickness wall defect, perirectal fat stranding, extraluminal free air, intraperitoneal free fluid, and hemorrhage within the bowel wall….A CT with any suggestion of rectal injury should therefore be followed up with rigid proctoscopy to confirm the diagnosis and location of injury, as a combination of CT and endoscopy has a sensitivity of 97% in the diagnosis of rectal injury.”

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Question

EMS may call the hospital to obtain online medical direction when a patient does not wish to come to the hospital.  One difficult task faced by the physician at the hospital is determining the decision making capacity of the patient.  There is currently no nationally recognized standard protocol for physicians providing EMS oversight in this situation.  

The four components involved in the determination of capacity are: understanding, appreciation, reasoning and expression of choice.  This study used a modified Delphi approach with 19 physician experts to develop standardized steps to guide best practices for physicians who are called in real time about a patient refusing EMS transport.  Consensus was defined as 80% agreement.  

The example worksheet with the compilation of recommendations is attached.

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Attachments

Refusal checklist table-670fb6a9192a8.docx (105 Kb)

Getting reliable venous and arterial access is crucial when resuscitating critically ill patients. These lines can be difficult due to patient and situation specific variables. 

Micropuncture kits contain a 21-gauge echogenic needle, a stainless-steel hard shaft/soft-tip wire, and a 4 Fr or 5 Fr sheath and introducer. The micropuncture kit offers several advantages that can help overcome difficult situations:

• Small, Sharp Needle: Easier puncture of compressible vessels.
• Echogenic Design: Improved visibility under ultrasound.
• Smooth Tissue Penetration: Moves through tissue more easily than a typical 18-gauge needle.
• Flexible Wire Tip: The 0.018-inch wire is soft, lacks a J-loop, and navigates tight corners and calcifications better than a standard J-tip wire. This is especially useful when entering at a steep angle or accessing small vessels.

To use a micropuncture kit, gain vessel access with the needle and wire, railroad the sheath and introducer into the vessel, remove the wire, then remove the introducer. Now you have a 4 Fr or 5 Fr sheath in the vessel. This is typically used to introduce a normal central line wire. 

For arterial lines, you can place them directly over the wire without dilation. Keep in mind that the 4 Fr sheath (1.3 mm OD) and 5 Fr sheath (1.7 mm OD) are larger than a typical arterial line catheter (18g = 1.27 mm OD). If you dilate then you will cause hematoma.

Find out where your department stores micropuncture kits and get familiar with their components. While it adds an extra step to the procedure, it could make the difference between securing the line or not.

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Rectal injuries are rare. The majority are secondary to penetrating injuries. Trauma care providers “should have a high clinical suspicion of rectal injury with any missile with a trajectory near the rectum; transpelvic gunshot wounds; stab injuries near the perineum, buttocks, groin, or proximal thighs; or open pelvic fractures. A digital rectal examination with a focus on sphincter tone, presence of blood, palpable defect, or bony protrusion should be carried out. Of note, a normal digital rectal examination does not exclude rectal injury.”

Ct scan with IV contrast (not PO or rectal) is used to identify rectal injuries but will be diagnostic in only  33% of injuries. 

Rectal Injury Grading Scale

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Shoulder Abduction Test aka Bakody’s Sign

Used clinically in the evaluation of patients with suspected cervical radiculopathy

Unlike Spurling’s test, where we create discomfort, this test attempts to relieve it.

Specifically, evaluates for nerve root compression at C4-C6/7

To perform:

1. Have the patient sit or with their back straight.
2. Instruct the patient to raise the symptomatic arm and place the hand on top of their head.

            Arm Abduction can be active or passive

     3. Instruct the patient to hold this position for 30 seconds.

     4.Observe the patient for any relief of symptoms (A positive test)

           Decrease in pain, numbness, weakness or tingling

     5. Repeat on the unaffected side for comparison.

Sensitivity: 17–78% Specificity: 75–92%

Note: when asked about what alleviates their pain, patients will frequently describe and demonstrate the maneuver.

Consider adding this simple maneuver in your assessment of patients with suspected symptomatic cervical radiculopathy

Hypernatremia in Pediatric patients is less common than other electrolyte abnormalities occurring in <1% of hospitalized patients. The most common cause is water loss, either from poor absorption in the cases of vomiting, diarrhea, malabsorption or insensible losses, or via diabetes insipidus. Congenital disorders may cause decreased thirst receptors resulting in inadequate intake. Finally, excess sodium intake can occur via hypertonic fluids, ingestions or hyperaldosteronism or hypercortisolism. 

Symptoms are often nonspecific- including fatigue, vomiting, hypertonia or hyperreflexia in lower states, but may result in lethargy, mental status changes or seizures as levels approach and exceed 160mmol/L

Treatment is similar to adults - free water deficit should be calculated: 

Total body water (%) x weight (kg) x [(serum Na)/140 - 1]  

Total Body Water (TBW) varies by age:

24-31 weeks- 90%

32-35 weeks - 80%

Term -  12 months - 70%

12 months and up - 60%

IV fluids should be started with a goal of decreasing the sodium level by 0.5 mmol/L/h with close monitoring of sodium levels.

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Historically, there has been limited and inconclusive data regarding the utility of Rh (D) immunoglobulin (RhIg) in preventing alloimmunization for patients with early pregnancy loss or abortion at <12 weeks gestation. Although previous guidelines recommended routine administration of RhIg in Rh(-) patients after abortion of pregnancy loss at <12 weeks gestation, updated recommendations have been published as of September 2024. 

The following are the updated recommendations from ACOG for patients who are less than 12 0/7 weeks gestation and undergoing abortion (managed with uterine aspiration or medication) or experiencing pregnancy loss  (spontaneous or managed with aspiration or medication):

-ACOG recommends forgoing routine Rh testing and RhIg prophylaxis

-Rh testing and administration of RhIg can be considered on an individual basis with the help of shared-decision making regarding potential risks and benefits

These updated recommendations are based on recent studies that show a very low likelihood (although not entirely zero) of Rh alloimmunization associated with these populations. Many other Obstetric expert guidelines (such as those from the World Health Organization, Royal College of Obstetricians and Gynaecologists, and the Society of Family Planning) mirror these recommendations. 

Summary: Consider shared decision-making regarding RhoGAM administration in patients who have an abortion or early pregnancy loss  at <12 weeks  gestation.

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Background:

Epinephrine administration is a critical component of treating severe allergic reactions, and delayed administration is associated with increased morbidity and mortality. Epinephrine auto-injectors are the current standard of care and allow for rapid administration in all care settings, but compliance issues can limit their use. The most common reason patient’s site for failure to administer or delayed administration of auto-injectors is needle phobia (particularly with pediatric patients). This has led to interest in developing needle-free epinephrine delivery devices that are easy to administer.

New Drug Approval:

This August, the FDA approved an epinephrine nasal spray (brand name: Neffy) for use as emergency treatment for Type 1 allergic reactions, including life-threatening anaphylaxis. The approval was based on four studies, including 175 total patients, comparing epinephrine 2 mg nasal spray with an epinephrine 0.3 mg intramuscular injection in healthy adults and children. These studies showed similar blood concentrations of epinephrine between treatment arms through 60 minutes after administration. In addition, both treatment arms showed similar elevations in heart rate and systolic blood pressure.

• Who is it for?
  • Epinephrine 2 mg nasal spray is approved for all adult and pediatric patients who weight more than 30 kg (66 lbs).
• How is it supplied?
  • Epinephrine 2 mg nasal spray comes in single-use devices, as a unit-dose spray. This is the same device that is used for many other commercially available internasal products, including Narcan (naloxone) nasal spray.
• How it is given?
  • Epinephrine 2 mg nasal spray device should be fully inserted into one nostril pointing straight into the naris, and then the plunger should be depressed. If symptoms do not improve or worsen after the first dose, a second dose of epinephrine 2 mg nasal spray should be given into the same nostril.
• Common side effects?
  • The most common side effects are throat irritation, intranasal paresthesia, headache, nasal discomfort, feeling jittery, paresthesia, fatigue, tremor, rhinorrhea, nasal pruritis, sneezing, abdominal pain, gingival pain, oral hypoesthesia, nasal congestion, dizziness, nausea and vomiting. 

Bottom Line:

Epinephrine nasal spray is a newly approved option for the treatment of severe allergic reactions and anaphylaxis. While this approval was based on studies in healthy adults and children who did not currently have anaphylaxis, this medication may be worth considering for patients who have issues or concerns about using an injectable device to administer epinephrine.

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Background:

Septic shock is a severe and common critical illness that is managed in the emergency department.  Our current foundation of treatment includes IV fluids, empiric antibiotic coverage, vasopressor therapy, source control and corticosteroids for refractory shock.  The levels of nitric oxide (NO) and hydrogen sulfide (H2S) are elevated in sepsis and associated with worse outcomes.  Hydroxocobalamin is an inhibitor of NO activity and production and a scavenger of H2S [1,2].  Most of the current data is limited to observational studies looking at hydroxocobalamin in cardiac surgery related vasodilatory shock with few case series and reports for use in septic shock.  The available data has shown an improvement in hemodynamics and reduction in vasopressor requirements in various vasodilatory shock states [2].  Chromaturia and self-limited red skin discoloration are common side effects but current data has not shown significant adverse events [3,4].  Patel et al, performed a phase 2 single-center trial to evaluate use of high dose IV hydroxocobalamin in patients with septic shock. 

Study:

• Single-center, double-blind RCT, 20 patients (10 hydroxocobalamin, 10 placebo)
• Included patients >/= 18 years of age within 48 hours of admission with a diagnosis of septic shock (based on Sepsis 3 criteria) who were receiving norepinephrine (NE) of 0.10 mcg/kg/min for at least 15 minutes or an equivalent dose of alternative vasopressor.
• Notable exclusion criteria were patients with a history of urinary calcium oxalate crystals, active hemolysis or bleeding, impending death.
• Intervention group received a single dose of 5 grams of IV hydroxocobalamin administered over 15 minutes
• Primary outcome – Feasibility Study (*Initial primary outcome was reduction in vasopressor dose but was changed during the COVID-19 pandemic to a feasibility study*)
• Secondary outcomes – Change in H2S levels and NE dose from randomization to 30 minutes and 3 hours after IV hydroxocobalamin.

Results

• Achieved feasibility with enrollment goal, receiving intervention, no contamination and good follow up.
• For secondary outcomes the study group showed a statistically significant relative decrease in vasopressor dose compared to placebo at 30 minutes (-36% vs 4%, p < 0.001) and 3 hours after infusion (-28% vs 10%, p = 0.019). 
• Non-statistically significant reduction in H2S levels in the intervention group compared to placebo.
• Tertiary outcomes of hospital mortality, ICU mortality, ICU and vasopressor free days did not show any significant difference between the groups. (The study was not designed with the power to look for a difference in these outcomes).  

Take home

There is a low risk of serious adverse events from high dose hydroxocobalamin use [3,4].  For now, it may be reasonable to consider in cases of septic shock refractory to standard care but there isn’t enough data to support its regular use yet.

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The authors reviewed the literature surrounding use of pigtail catheters for traumatic hemothorax and found:

“these data support using percutaneous thoracostomy as a safe and reliable treatment option for hemodynamically stable adult patients with traumatic hemothorax and are backed by major trauma society guidelines including the Eastern Society for the Surgery of Trauma and the Western Trauma Association.1,3 It has the added benefit of the insertion being less painful with the understanding that the percutaneous thoracostomy can always be upsized to a thoracostomy tube.”

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Emergency Medicine Cases offers these excellent tips on pigtail catheters placement. Their video/website is worth a look. 

PEARL # 1 – LOCATION/LANDMARK: Minimize skin to pleural distance.

• Often the region with the least amount of adipose/muscle tissue will be in the 4th to 5th ICS, mid to anterior axillary line. This is often more superior than expected. Palpating along the 5th rib at the level of the nipple/breast fold, and following it posteriorly as it travels superiorly can be helpful.
• In certain circumstances, an anterior approach in the 2nd ICS, mid-clavicular line, may be desired. PITFALL: Remember that the clavicle ends at the acromion, and so the mid-clavicular line is often more lateral than expected.

PEARL # 2 – ADEQUATE LOCAL ANESTHESIA: This can obviate the need for sedation.

• Enter the rib space slightly above the rib below, to avoid major neurovascular bundles running underneath the rib, and collaterals running above the rib.
• Advance your needle in small increments. Aspirate first, and then inject. Once you enter the pleural space, pull back again until you feel resistance once more. Your needle should now be sitting in between the internal intercostal and innermost intercostal muscle. This is where the neurovascular bundles travel – inject the rest of your local anesthesia here.
• BONUS TIP: This should also help you estimate the depth of the chest wall (skin to pleural distance).

PEARL #3 – DILATING: Do it in a controlled manner.

• PITFALL: First make sure to make a big enough nick in the skin. Your guidewire should be able to move side to side through this small nick.
• Once you insert the dilator, avoid the urge to push through the resistance with force. Instead, with a bit of force directed towards the chest wall, twist your dilator to try and catch some of the fascia, and then pull back as if to try and tear it. This will likely require a few attempts, but you should feel the loss of resistance once you are successful.

PEARL #4 – USING THE OBTURATOR: Needless to say, it is there for a reason.

• Insert the obturator all the way into the pigtail catheter with the stop cock, and lock it in place. This will ensure that your chest tube is rigid and make it easy to feed over the guidewire and through the chest wall. This will also assist you in aiming the tube (superiorly and anteriorly for pneumothorax).
• Advance until the second line on the pigtail catheter, then pull back the obturator part way, and advance the pigtail catheter to the third line. Then completely remove the obturator and guidewire.

PEARL #5 – INTERPLEURAL BLOCK: Provide your patient with ongoing analgesia.

• Inject long acting local anesthetic (e.g. bupivacaine) through the pigtail catheter into the pleural space. This provides your patient with ongoing analgesia.
• Common dose: Bupivacaine 0.25% 10-20ml (even up to 30ml).

PEARL #6 – STOPCOCK AND ONE-WAY VALVE IN THE CORRECT POSITIONS

• The tap points to the off position.
• The blue port connects to the patient side.
• Confirm with cup of water and patient cough. Look for bubbles. This confirms the presence of an air leak and the correct positioning of stopcock and one-way valve.

PEARL #7 – USE A GOOD SUTURE: Don’t let that chest tube come out.

• Use a large suture (Size 0 or bigger) with good tensile strength (Silk)

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This Canadian study looked at the safety of paramedics using the modified Canadian C-Spine Rule to determine which pre-hospital blunt trauma patients required immobilization. These were MVC and fall patients predominately. Bottom line: appropriately trained paramedics can use the modified Canadian C-Spine rule to clinically clear cervical spines in the field. 

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Background:
Despite a lack of reliable evidence, sodium bicarbonate (SB) still appears in various protocols as a potential therapy for patients in cardiac arrest. Local EMS protocols also endorse the use of (SB) in specific scenarios such as: tricyclic overdose and hyperkalemia. EMS systems struggle to articulate best practices with respect to indications for SB administration. 

Patients/methods:
Study authors conducted a scoping review of existing literature. The review included in hospital and out of hospital patients with cardiac arrest. Despite multiple studies looking at this question, a total of 12 were included in the final analysis. Criteria for inclusion were as follows: RCT or observational studies looking at patients aged 18 or older who experienced a cardiac arrest. Important outcome metrics incorporated: neurological recovery and survival to discharge. 

Results:
The retrospective review failed to demonstrate a reliable association between survival and administration of sodium bicarbonate. Despite significant limitations (different study populations, retrospective designs), there remains insufficient evidence to consider routine administration of bicarb in the setting of cardiac arrest. 

Bottom line:
Empiric administration of SB is not linked to a reliable benefit. SB may be considered for specific indications (tricyclic overdose, hyperkalemia) but is unlikely to improve outcomes such as neurologic recovery or hospital discharge. EMS systems should avoid recommending routine SB administration for patients with out of hospital cardiac arrest.

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