UMEM Educational Pearls - By Robert Flint

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)

Show References

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. 

Show References

This meta analysis looked for studies involving community EMS (CEMS) interventions trying to reduce falls. The authors found: 

“CEMS fall prevention interventions reduced all-cause and fall-related emergency department encounters, subsequent falls and EMS calls for lift assist. These interventions also improved patient health-related quality of life, independence with activities of daily living, and secondary health outcomes.”

Further, prospective work needs to be done to look at this on a larger scale. We know falls in elderly patients lead to significant morbidity and mortality. This could be one way  to improve fall mortality.

Show References

This study attempts to validate the use of the Geriatric Fever Score to predict 30 day mortality in patients over age 65 presenting to an emergency department with fever. 
The Geriatric Fever Score uses: leukocytosis, severe coma,  and thrombocytopenia. One point is award for each abnormality. 
Not surprisingly, mortality went up with the higher the score (33%, 42% and 57% for 0,1,2 points)

For me, I’m not discharging anyone with severe coma, leukocytosis or thrombocytopenia in this patient population therefore I’m not sure this scale has much utility for the practicing emergency physician.

Show References

The use of seizure prophylaxes in moderate to severe head injury has been recommended for 7 days post-injury. In general, levetiracetam is used for seizure prophylaxes in this group of patients. This study looked retrospectively at high (over 500 mg BID) vs. low (500 mg bid) dosing and found there was no difference in seizure events in either group.  Overall 6% of patients had a seizure in this seven day window even with medication given.

Show References

Question

Identify this radiographic finding:

Show Answer

Show References

Question

Identify this injury and other associated injuries:

Show Answer

Show References

Predicting which blunt abdominal trauma patients have mesenteric or  bowel wall injuries early in their ED course will decrease morbidity and mortality. It is also a challenge even in the age of advanced CT imaging. This study from India looks at the Bowel Injury Prediction Score as a possible means to catch these injuries early in the course of care. The score uses white blood cell count over 17,000 (1 point), abdominal tenderness at the time of presentation(1 point),  as well as a McNutt's scoring scale grade 4 (1 point) (table). The study found those with a score greater than 2 (out of 0-3) were much more likely to have bowel or mesenteric injury at time of laparotomy.  Tenderness and CT findings were more likely to be predictive of bowel injury than WBC greater than 17,000. “BIPS had 94.5% sensitivity, 72% specificity, 88% PPV, and 86% NPV for identifying patients with sBBMI.”

My take away is an abnormal CT scan or significant tenderness of presentation warrant concern for mesenteric or bowel wall injury and surgical evaluation is appropriate for these patients. An elevated or normal white blood cell count isn't helpful in these patients. Surgeons may use this scale to help them decide if a patient warrants a trip to the operating room  

Show References

This review reminds us that discharging emergency department patients with abnormal vital signs is a risk for the patient and the provider. The more abnormal vital signs that are present, the higher the risk of adverse event and subsequent return to the emergency department. 

“Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians.”

Always address abnormal vital signs in your medical decision making portion of the chart and be very wary of discharging anyone with tachycardia or other abnormal vital signs.

Show References

In this systemic literature review of orthopedic injuries identified in intimate partner violence (IPV) the authors remind us that finger, hand, and especially isolated ulnar fractures are very commonly associated with IPV.  When we see these injury patterns extra effort is required to determine if IPV is involved.  

* IPV = intimate partner violence, UEF = upper extremity fracture, and UEI = upper extremity injury.

† Summary table demonstrating the location prevalence of UEIs caused by cases of IPV. Fractures were quantified separately from other UEIs in this specific table.

‡ In all included articles the most common injury type was an injury to the head or neck; these are excluded because of the study aim.

Show References

This retrospective study of Swiss trauma patients looked at blood gas oxygen levels within 3 hours of arrival to the trauma bay in severely injured patients over age 16. When comparing hypoxic, hyperoxic and normo-oxic patients there was no difference in 28 day mortality. Those with above normal oxygen levels tended toward longer hospital stays. The above normal oxygen cohort also were more likely to be intubated in the field. 

This study fits with others showing around 20% of trauma patients arrive to our trauma bays over oxygenated. More research is needed to see the impact this has on care. Be mindful of over oxygenation especially in intubated trauma patients.

Show References

Deciding who needs exposure to radiation after blunt head injury has been looked at by both the Canadian Head Injury Guidelines as well as NEXUS.  This website has excellent graphics outlining the rules. Note age over 65 alone is predictive of significant intracranial injury. All recent studies indicate age over 65 even with a low suspicion mechanism such as fall from standing is still a significant risk for intracranial pathology.

Show References

A study looking at patients over age 65 with head injuries from falls assessed the association of alcohol use with severity of injury. The alcohol use was self-reported which does limit the findings. The study found “Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use.”  Those daily drinkers had a higher incidence of intercranial injuries.
The authors concluded: “Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.”

Show References

A reminder of two validated tools used to determine the need for cervical spine imaging in adult blunt trauma patients.   A recent meta analysis concluded:

“Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.”

Show References

A just released study published in the Lancet gives us guidance on which pediatric blunt trauma patients need cervical spine imaging.  Age range was 0-17 years.

“Out of 22,430 children included in the study, 433 (1.9%) were found to have Cervical spine injury (CSI). The study identified 4 high risk factors for CSI to be used to triage children to CT (12% risk for a cervical spine injury):

1. Glasgow Coma Scale scores of 3-8
2. Unresponsiveness to on the AVPU scale
3. Abnormal airway/breathing/circulation
4. Focal neurologic deficits

In children without high-risk findings, 5 additional findings identified children with intermediate, non-negligible risk of CSI (3.6% risk of a cervical spine injury):

1. Altered mental status
2. Substantial head
3. Substantial torso injury
4. Midline neck pain
5. Midline neck tenderness”

Show References

This article from JAMA is targeted at inpatient management of asymptomatic hypertension, however,  it’s a great reminder that “hypertensive urgency” is not an entity. We should be treating the patient and not the numbers. Gradual, out patient lowering of asymptomatic hypertension is the safe and proper way to approach this. Spread the word to your friends in primary care, urgent care, dental, and other office based practices.  
 

Show References

This article serves as a great reminder that our older patients are on a significant amount of medications and many of these medications effect cognition. Cognitively impaired patients are at risk of medication errors. High risk medications in older patients include anticoagulants, opioids, anticholinergics, hypoglycemic/insulin and sedating medications.  The authors found: 

• “In unadjusted analyses and analyses adjusted for a variety of demographic and clinical factors, older adults with cognitive impairment living alone were exposed to a similar number of high-risk medications as those living with others, while at the same time receiving less support from others for medication management.”

It is important to ask how the patient takes (or doesn’t take) their medications as well as other social determinate of health such as living alone.

Show References

A cut-off of 35mm on CT  scan has been shown to be predictive of which traumatic pneumothoracies require  thoracostomy tube placement vs. safety of observation.  This retrospective study looked at chest X-ray findings to see if there was a similar size cut-off where patients could be safely observed rather than undergo this invasive procedure. They found 38mm was the size over which observation failed. Of note, lactic acidosis and need for supplemental oxygen also predicted the need for chest tube placement  

Show References

In this prospective, observational study of trauma patients with isolated head trauma, 62% of patients developed  post-intubation hypotension. Comparing patients receiving hypertonic saline, vasopressors, crystalloid, or blood those receiving hypertonic saline and vasopressors had less post-intubation hypotension. 

TBI patients who develop hypotension have worse outcomes. This study reminds us the use of vasopressors in trauma patients to maintain blood pressure is appropriate in the correct circumstances.

Show References

The Infectious Disease Society of America in 2023 recommended a single dose of an aminoglycoside for uncomplicated cystitis treatment in those with resistance or other contraindications to first line oral agents who were otherwise well enough to be discharged. This very small study (13 participants) suggest this strategy works for complicated (“male sex, urinary flow obstruction, renal failure or transplantation, urinary retention, or indwelling catheters”) cystitis patients who could otherwise be discharged home.

Show References