Buprenorphine Use in the ED

Written by: Diana Halloran, MD (NUEM ‘24) Edited by: Sean Watts, MD (NUEM ‘22) Expert Commentary by: Quentin Reuter, MD (NUEM ‘18) — **Written by:** Diana Halloran, MD (NUEM ‘24) **Edited by:** Sean Watts, MD (NUEM ‘22) **Expert Commentary by**: Quentin Reuter, MD (NUEM ‘18)

The United States has been facing a debilitating opioid epidemic, which has been partially fueled by the over-prescription of these medications in the emergency department setting. In addition, the opioid epidemic has grown exponentially during the COVID-19 pandemic. More than 40 states have reported increases in opioid-related mortality, resulting in an increased burden on an already overstrained healthcare system. (1) Prescribing the medication Buprenorphine in the emergency department offers an opportunity to ameliorate these past faults and rising statistics.

The basics:

Buprenorphine, which goes by the trade name Subutex, works by acting as both a partial mu agonist and weak kappa antagonist on opiate receptors in the brain. (2) This mechanism of action enables buprenorphine to exert analgesic effects, as well as antagonistic effects when additional opiates are consumed. In addition, buprenorphine does not carry significant sedative effects, making respiratory depression extremely rare. (3) Buprenorphine is also safe in pregnancy – a 2016 meta-analysis found no difference in pregnant patients given methadone versus buprenorphine when assessing for congenital malformations. (4) The American College of Obstetrics & Gynecology has released a committee position statement, encouraging the use of buprenorphine in pregnant patients with opioid use disorder. (5)

How to prescribe:

While the DEA X-waiver is required to write a prescription for buprenorphine for addiction treatment, withdrawal, or detox, it is not required to order or administer a dose in the hospital or emergency department. (6) This exception, called the “three-day rule”, allows a patient to come to the emergency department for three consecutive days to obtain a dose of buprenorphine if found to be in opioid withdrawal. (7)

In order to dose buprenorphine in the emergency department, the patient must be in mild acute opioid withdrawal, with a Clinical Opiate Withdrawal Score (COWS) of at least 8. (8,9) Administration of buprenorphine should not occur if the patient does not appear to be clinically withdrawing, as administration in this setting could actually precipitate withdrawal.

Dosing: (10)

4mg of sublingual buprenorphine can be given initially, allowing 20-40 minutes for resolution of withdrawal symptoms with repeat dosing every 1-2 hours as needed. (10)
On Day 2, the patient’s response to Day 1 should be assessed. If the patient’s opioid withdrawal symptoms were controlled, the same dose can be continued. If not, the dose should be increased by 2-4mg. (10)
On Day 3, the patient’s response to Day 2 should be assessed. Again, if the patient’s withdrawal symptoms are controlled then the same dose can be continued. If not, the dose can be increased by 2-4mg for Day 3. (10)
After 3 days this dose should be continued for 3-7 days until steady-state levels are achieved (10)
Doses should be decreased by 2mg if the patient experiences opioid intoxication (10)

Use in the emergency department:

While buprenorphine and long-term treatment of opioid use disorder may seem confined to primary care physicians and psychiatrists, emergency medicine physicians have been shown to be successful providers for initiating buprenorphine treatment versus brief intervention and referral with a result of decreased self-reported illicit opioid use. (11) In addition, Dr. Gail D’Onofrio, chair of the Department of Emergency Medicine at Yale, found that emergency department initiated buprenorphine treatment was associated with the increased self-reported engagement of addiction treatment and reduced illicit opioid use within a two-month interval. (12) Increasing evidence demonstrates that the emergency department provides an opportunity to intervene on opioid use disorder, with more and more emergency medicine physicians becoming X-waiver certified.

References

Issue brief: Reports of increases in opioid and other drug-related overdose and other concerns during COVID pandemic. American Medical Association. https://www.ama-assn.org/system/files/2020-12/issue-brief-increases-in-opioid-related-overdose.pdf. Published December 9, 2020.
Wakhlu S. Buprenorphine: a review. J Opioid Manag. 2009 Jan-Feb;5(1):59-64. doi: 10.5055/jom.2009.0007.
Walsh SL, Preston KL, Stitzer ML, Cone EJ, Bigelow GE. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994 May;55(5):569-80. doi: 10.1038/clpt.1994.71.
Zedler BK, Mann AL, Kim MM, Amick HR, Joyce AR, Murrelle EL, Jones HE. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction. 2016 Dec;111(12):2115-2128. doi: 10.1111/add.13462.
Committee Opinion No. 711 Summary: Opioid Use and Opioid Use Disorder in Pregnancy. Obstetrics & Gynecology. 2017;130(2):488-489. doi:10.1097/aog.0000000000002229
Special Circumstances for Providing Buprenorphine. SAMHSA. https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines/special-circumstances. Published August 19, 2020.
Nagel L. Emergency Narcotic Addiction Treatment. https://www.deadiversion.usdoj.gov/pubs/advisories/emerg_treat.htm.
Wesson DR, Ling W. Clinical Opiate Withdrawal Scale. PsycTESTS Dataset. June 2003. doi:10.1037/t48752-000
D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
Dosing Guide For Optimal Management of Opioid Dependence. The National Alliance of Advocates for Buprenorphine Treatment.
D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. 2015;313(16):1636–1644. doi:10.1001/jama.2015.3474
D'Onofrio G, Chawarski MC, O'Connor PG, Pantalon MV, Busch SH, Owens PH, Hawk K, Bernstein SL, Fiellin DA. Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention. J Gen Intern Med. 2017 Jun;32(6):660-666. doi: 10.1007/s11606-017-3993-2.

Expert Commentary

Thanks to Dr. Halloran and Watts for providing an informative discussion on buprenorphine prescribing from the ED. Buprenorphine continues to emerge as the state of the art treatment strategy for opioid use disorder (OUD) and thus, developing a working knowledge for when and how to use it is essential.

While there is little doubt that the medical field fueled the opioid epidemic through the prescribing of pain medications, EM is often given a disproportionate amount of blame for the current situation. In 2012, EM prescriptions made up only 4.3% of all opioids in circulation (1). Furthermore, I anticipate our specialty will continue to lead the fight against the opioid epidemic as practices such as naloxone prescribing, education around safe injecting practices, reduction and optimization of opioid prescribing efforts, and buprenorphine initiation gain further traction in the ED.

Obtaining a DEA X is the first step to prescribing buprenorphine. In April of this year guidelines for the administration of buprenorphine were updated to allow practitioners to treat up to 30 patients at a time with no extra training (2). While these changes will likely expand buprenorphine prescribing from the ED, it is vital that we do not operate in a silo.

To effectively manage this complex patient cohort, a coherent system of addiction medicine services is vital. EDs must partner with local community resources to make rapid addiction medicine appointments available. Our department utilizes specially trained addiction care coordinators, nurses with extensive training in addiction medicine to help evaluate OUD patients and navigate the fractured array of outpatient services.

Prior to the implementation of our Medication for Opioid Use Disorder (MOUD) program, our clinicians had relatively little to offer patients that directly addressed their underlying addiction. While anecdotal, we believe that by utilizing MOUD, we have begun to rebuild trust between OUD patients and the medical system. A once generally negative relationship between OUD patients and our ED staff has been replaced with a hopeful rapport, confident that recovery for these patients is a distinct possibility. This therapeutic relationship continues to grow and we believe will lead to long-term sustained recovery for many of our OUD patients in the surrounding community.

References

Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. Am J Prev Med 2015;49:409-13.
Reuter Q, Smith G, McKinnon J, Varley J, Jouriles N, Seaberg D. Successful Medication for Opioid Use Disorder (MOUD) Program at a Community Hospital Emergency Department. Acad Emerg Med 2020.

Quentin Reuter, MD

Emergency Medicine Physician

Core Faculty at Summa Health

How To Cite This Post:

[Peer-Reviewed, Web Publication] Halloran D., Watts S. (2021, Sept 13). Buprenorphine Use in the ED. [NUEM Blog. Expert Commentary by Reuter Q.]. Retrieved from http://www.nuemblog.com/blog/buprenorphine

Basic Capnography Interpretation

Written by: Shawn Luo, MD (NUEM ‘22) Edited by: Matt McCauley, MD (NUEM ‘21) Expert Commentary by: N. Seth Trueger, MD, MPH — **Written by:** Shawn Luo, MD (NUEM ‘22) **Edited by:** Matt McCauley, MD (NUEM ‘21) **Expert Commentary by**: N. Seth Trueger, MD, MPH

Continuous waveform capnography has increasingly become the gold standard of ETT placement confirmation. However, capnography can provide additional valuable information, especially when managing critically ill or mechanically ventilated patients.

Normal Capnography

Phase I (inspiratory baseline) reflects inspired air, which is normally devoid of CO2.
Phase II (expiratory upstroke) is the transition between dead space to alveolar gas.
Phase III is the alveolar plateau. Traditionally, PCO2 of the last alveolar gas sampled at the airway opening is called the EtCO2. (normally 35-45 mmHg)
Phase 0 is the inspiratory downstroke, the beginning of the next inspiration

EtCO2 is only one component of capnography. Measured at the end-peak of each waveform, it reflects alveolar CO2 content and is affected by alveolar ventilation, pulmonary perfusion, and CO2 production.

Figure 2. Factors affecting ETCO2 (EMSWorld)

EtCO2 - PaCO2 Correlation

Correlating EtCO2 and PaCO2 can be problematic, but in general, PaCO2 is almost always HIGHER than EtCO2. Normally the difference should be 2-5mmHg but the PaCO2-EtCO2 gradient is often increased due to increased alveolar dead space (high V/Q ratio), such as low cardiac output, cardiac arrest, pulmonary embolism, high PEEP ventilation.

Important Patterns

Let’s go through a few cases and learn some of the important capnography waveforms to recognize

Case 1: Capnography with Advanced Airway

An elderly gentleman with a history of COPD, CAD & CKD gets rushed into the trauma bay with respiratory distress and altered mental status. You gave him a trial of BiPAP for a few minutes without improvement.

You swiftly tubed the patient. It was not the easiest view, but you advance the ETT hoping for the best. Upon attaching the BVM to bag the patient, you saw this on capnography:

Oops, the ETT is in the esophagus, as evidenced by the low-level EtCO2 that quickly tapers off.

2. You remove the ETT, bag the patient up, and try again with a bougie. Afterward, you see…

Figure 4. Capnography with ETT in right main bronchus (EMSWorld)

This suggests a problem with ETT position, most often in the right main bronchus. Notice the irregular plateau--the initial right lung ventilation, followed by CO2 escaping from the left lung. Beware that capnography can sometimes still appear normal despite the right main bronchus placement.

3. You pull back the ETT a few cm and the CXR now confirms the tip is now above the carina. The patient’s capnography now looks like this:

Figure 5. Capnography showing obstruction or bronchospasm (SketchyMedicine)

Almost looks normal but notice the “shark fin” appearance, this is due to delayed exhalation, often seen in airway obstruction and bronchospasms such as COPD or asthma exacerbation.

4. You suction the patient and administer several bronchodilator nebs. The waveform now looks more normal:

Figure 6. Capnography showing normal waveform (SketchyMedicine)

5. However, just as you were about to get back to the workstation to call the ICU, the monitor alarms and you see this:

Figure 7. Sudden loss of capnography waveform (SketchyMedical)

Noticing the ETT still in place with good chest rise, you quickly check for a pulse. There is none.

6. You holler, push the code button and start ACLS with a team of clinicians. With CPR in progress, you notice this capnography:

Figure 8. Capnography during CPR (SketchyMedicine)

Initially, your patient’s EtCO2 was only 7, after coaching the compressor and improving CPR techniques, it increased to 14.

You are also aware that EtCO2 at 20min of CPR has prognostic values. EtCO2 <10 mmHg at 20 minutes suggests little chance of achieving ROSC and can be used as an adjunctive data point in the decision to terminate resuscitation.

7. Fortunate for your patient, during the 3rd round of ACLS, you notice the following:

Figure 9. ROSC on capnography (emDOCs.net)

This sudden jump in EtCO2 suggests ROSC. You stop the CPR and confirm that the patient indeed has a pulse.

8. As you are putting in orders for post-resuscitation care, you notice this:

Figure 10. Asynchronous breathing on capnography (SketchyMedical)

This curare cleft comes from the patient inhaling in between ventilator-delivered breaths and is usually a sign of asynchronous breathing. However, in the post-arrest scenario, it is a positive prognostic sign as your patient is breathing spontaneously. You excitedly call your mom, I meant MICU, about the incredible save.

Case 2: Capnography with Non-intubated Patient

You just hung up the phone with MICU when EMS brings you a young woman with a heroin overdose. She already received some intranasal Narcan from EMS but per EMS report patient is becoming sleepy again.

She mumbles a little as you shout her name, and as you put an end-tidal nasal cannula on her, you saw this:

Figure 11. Hypoventilation on capnography (emDOCs.net)

Noticing the low respiratory rate and high EtCO2 value, you recognize this is hypoventilation.

2. But very soon she becomes even less responsive and the waveform changed again:

Figure 12. Airway obstruction on capnography (emDOCs.net)

The inconsistent, interrupted breaths suggest airway obstruction, while the segments without waveform suggest apnea. You have to act fast.

3. By then your nurse has already secured an IV, so you pushed some Narcan. However, in the heat of the moment, you gave the whole syringe. The patient quickly woke up crying and shaking.

Figure 13. Hyperventilating on capnography (emDOCs.net)

She was quite upset and hyperventilating. The waveform reveals a high respiratory rate and relatively low EtCO2.

As much as you are a little embarrassed by putting the patient into florid withdrawal, you know it could have been a lot worse. Walking away from the shift, you think about how many times capnography has assisted you during those critical moments. “Hey, perhaps we should buy a capnography instead of a baby monitor,” you ask your wife at dinner.

Additional Resources

This website provides a tutorial and quiz on some of the basic capnography waveforms.

References

American Heart Association. 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support. Circulation. 2019; 140(24). https://doi.org/10.1161/CIR.0000000000000732
Brit Long. Interpreting Waveform Capnography: Pearls and Pitfalls. emDOCs.net. www.emdocs.net/interpreting-waveform-capnography-pearls-and-pitfalls/, accessed May 12, 2020
Capnography.com, accessed May 12, 2020
Kodali BS. Capnography outside the operating rooms. Anesthesiology. 2013 Jan;118(1):192-201. PMID: 23221867.
Long, Koyfman & Vivirito. Capnography in the Emergency Department: A Review of Uses, Waveforms, and Limitations. Clinical Reviews in Emergency Medicine. 2017; 53(6). https://doi.org/10.1016/j.jemermed.2017.08.026
Nassar & Schmidt, Capnography During Critical Illness. CHEST. 2016; 249(2). https://doi.org/10.1378/chest.15-1369
Sketchymedicine.com/2016/08/waveform-capnography, accessed May 13, 2020
Wampler, D. A. Capnography as a Clinical Tool. EMS World. www.emsworld.com/article/10287447/capnography-clinical-tool. June 28, 2011. Accessed May 13, 2020

Expert Commentary

This is a nice review of many of the intermediate and qualitative uses of ETCO2 in the ED. For novices, I recommend a few basic places to start:

Confirmation of intubation. Color change is good but it’s just litmus paper and gets easily defeated by vomit. Also, in low output states, it may not pick up. Further, colorimetric capnographs require persistent change over 6 breaths, not just a single change. Waveform capnography uses mass spec or IR spec to detect CO2 molecules. There are so many uses, it’s good to have, I don’t see why some are resistant to use this better plastic adapter connected to the monitor vs the other, worse, plastic adapter.

a. The mistake I have seen here is assuming a lack of waveform is due to low cardiac output, ie there’s no waveform because the patient is being coded, not because of esophageal intubation. There is always *some* CO2 coming out if there is effective CPR; if there isn’t, the tube is in the wrong place. If you really don’t believe it, check with good VL but a flatline = esophagus.

2. Procedural sedation. There’s lots of good work and some debate about absolute or relative CO2 changes or qualitative waveform changes that might predict impending apnea, but for me, the best use is that I can just glance at the monitor for a second or two and see yes, the patient is breathing. No more staring at the chest debating whether I see chest rise, etc. It’s like supervising a junior trainee during laryngoscopy with VL: it’s anxiolysis for me.

a. Using ketamine? Chest movement or other signs of respiratory effort without ETCO2 waveform means laryngospasm. Jaw thrust, bag, succinylcholine (stop when better).

3. Cardiac arrest.

a. Quality of CPR. Higher number means more output. Can mean the compressor needs to fix their technique, or more often, is tiring out and needs a swap.

b. ROSC. There can be a big jump (eg from 15 to 40) when ROSC occurs. Very helpful.

c. Ending a code. 20 mins into a code, if it’s <10 during good CPR, the patient is unlikely to survive. I try to view this as confirming what we know – it’s time to end the code. The mistake here is to not end a code that should otherwise end because the ETCO2 is above 10; it doesn’t work like that, it’s a 1-way test.

4. Leak. One waveform shape I wanted to add that I find helpful: if the downstroke kinda dribbles down like a messy staircase, it’s a leak. Can be an incomplete connection (eg tubing to the vent) or the balloon is too empty or full.

Seth Trueger, MD, MPH

Assistant Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern University

How To Cite This Post:

[Peer-Reviewed, Web Publication] Luo, S., McCauley M. (2021, Sept 9). Basic Capnography Interpretation. [NUEM Blog. Expert Commentary by Trueger N.S]. Retrieved from http://www.nuemblog.com/blog/capnography

Droperidol

Expert Commentary

Thanks to Dr. Payne & Dr. Richardson for putting this together! I think this was well done, they’ve presented a concise overview of the safety and efficacy of droperidol.

There’s a lot of utility in droperidol. It’s great for nausea, migraines, and even as an adjunct for chronic pain. It’s also a very good choice for agitation. I use it most often for nausea. It’s been shown to be as effective as odansetron, and more effective than metoclopramide. Anecdotally, I find it works particularly well for gastroparesis and cannabinoid hyperemesis (with some low-concentration topical capsaicin cream), with less sedation than haloperidol. For migraines, it has been shown to be as effective as prochlorperazine. It works well for sedation in agitated patients as well; IV & IM it has a much faster onset than haloperidol, and so benzodiazepines typically do not have to be co-administered, reducing the level and duration of sedation and need for monitoring.

The black box warning significantly limited droperidol’s availability, such that many of our newer graduates have not had any first-hand clinical experience with the medication. If you’re not familiar with its use, don’t let the black box warning completely dissuade you. Subsequent studies looking at emergency department droperidol use have shown it to be safe, and that complications related to QT prolongation are rare in typical doses. As a rule of thumb, the dose of droperidol is about half of the dose of haloperidol for a given indication. For nausea, migraine, or other pain, I usually start with 0.625-2.5mg IV, twice that IM, and can repeat dosing if needed (my most common starting dose is 1.25mg IV). For agitation, usually 2.5-5mg IM, though up to 10mg IM has been shown likely to be safe. Although it is prudent to be cautious, I think the literature supports droperidol’s use at appropriate doses in otherwise healthy patients.

Matt O’Connor, MD

Emergency Medicine Physician

BerbeeWalsh Department of Emergency Medicine

University of Wisconsin Hospitals and Clinics

How To Cite This Post:

[Peer-Reviewed, Web Publication] Payne, A. Richardson, J. (2021, Aug 30). Droperidol. [NUEM Blog. Expert Commentary by O’Connor, M]. Retrieved from http://www.nuemblog.com/blog/droperidol

Awake Intubation

Expert Commentary

Awake intubation can sound imposing but simply means the patient is still breathing on their own. It is mostly just a matter of using topical lidocaine instead of paralyzing, and sedating the patient a bit to tolerate it. It will almost always require some sedation – ketamine procedural sedation works very well as the patient’s protective reflexes will be intact (until we topicalize) as will their respiratory drive.

It does not take long! Just spray lido instead of pushing NMBA. This is the key concept. If time is really a factor, I atomize the larynx, push ketamine, and then reload and spray more lidocaine as I do laryngoscopy; everything else is just like every other ED intubation.

Glycopyrrolate is nice but if it’s not handy, not worth a delay.

I find nebulizing doesn’t add much, mostly just gets the mouth. I still nebulize if I can get it set up quickly while prepping everything else (and it can help tolerate the atomizer).

Small touches of propofol might help relax the ketamine-sedated patient as well, including spontaneous/dissociated movements and tightly closed mouths. Dexmedetomidine might not be fast enough for ED intubations.

I usually use hyperangulated VL (eg Glidescope S3) – we are usually doing this for predicted difficult intubation, and now not optimizing intubating conditions. Fiberoptic requires a fair amount of skill and time. One of the main things that demystified awake intubation for me is it is a medication choice; it doesn’t always mean awake-fiber optic.

In non-COVID times, I would keep the nasal cannula on at 5-15lpm to keep the patient as oxygenated as possible, which is even better than during RSI because they’re still breathing, now with extra oxygen.

The paradox of awake intubation is that we take the patients we predict to be the most difficult anatomically, and then don’t optimize intubating conditions (no NMBA). Part of the beauty of awake intubation is that we also gain a ton of information even if unsuccessful without losing much; if I get a partial view in non-NMBA circumstances I can make a judgment call about proceeding to paralysis (ie RSI) or calling for help, etc.

Sedation-only or ketamine-only intubation can sound like a good idea but neither makes sense to me. It takes a lot of sedation to knock out protective airway reflexes to allow laryngoscopy, i.e. enough to impair respiratory drive. Topicalization is not hard with atomizers. Similarly, ketamine keeps the airway reflexes intact, which is why it is so safe for procedural sedation, so hard to imagine that laryngoscopy won’t be an issue.

Seth Trueger, MD, MPH

Assistant Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern University

How To Cite This Post:

[Peer-Reviewed, Web Publication] Bigach, P. Whipple, T. (2021, Aug 20). Awake Intubation. [NUEM Blog. Expert Commentary by Trueger, S]. Retrieved from http://www.nuemblog.com/blog/awake-intubation

TPA in Frostbite

Written by: Patrick King, MD Edited by: Nery Porras, MD (NUEM ‘21) Expert Commentary by: Anne Lambert Wagner, MD

TPA in Frostbite

Figure 1. What we would like to avoid (Cline et al.)

It’s an early Saturday morning, and EMS brings in one of your ED’s regulars – a schizophrenic, undomiciled gentleman named Jack who finds occasional work as a day laborer. You walk to bed three to greet Jack who is uncomfortable and shivering while nursing collects vitals. His chief complaint is hand and foot pain. You listen to him speak, but you jump right into a cursory exam as he does – and your heart sinks when you see the icy hard, cyanotic, mottled digits across all four extremities. You wonder what else you might be able to offer in addition to the standard cold injury approach we are taught as emergency residents, and you recall that the What’s New in Emergency Medicine section of UpToDate just recognized growing evidence for yet another off-label use for tPA: severe frostbite.

As we head into the winter months, emergency physicians will continue to see frostbite wreck a significant level of morbidity on our most vulnerable patients – patients who are undomiciled, suffering from addictions or mental illness, and those with preexisting conditions that limit blood flow to extremities (Zafren and Crawford Mechem). This post will address the theory, evidence, and logistics behind tPA utilization in severe frostbite.

The proposed efficacy of tPA in frostbite is related to cold-induced thrombosis. Endothelial damage is sustained both as a direct result of cold-related injury and exacerbated by reperfusion injury during the period of rewarming. During rewarming, arachidonic acid cascades promote vasoconstriction, platelet aggregation, leukocyte sludging, and erythrostasis which further promote thrombosis throughout affected tissues. This process is compounded in instances of multiple freeze-thaw cycles (Cline et al).

Research on tPA in frostbite goes back years. In 2005, Twomey et al. demonstrated in an open-label study that technetium (Tc)-99m scintigraphy (i.e., nuclear bone scan) reliably predicts digits/limbs at risk for amputation. Historical control patients with no or minimal flow distal to radiographically identified “cutoff” points of ischemia on bone scans inevitably all required amputations. Untreated historical controls without flow cutoffs were more likely to retain digits. In contrast, 16 of 19 study patients with identified flow cutoffs responded to intra-arterial (IA) or intravenous (IV) tPA with an amputation rate of only 19% of at-risk digits. In 2017, Patel et al. showed a 15% amputation rate for severe frostbite in eight IA tPA patients compared to 77% in their control group.

Figure 2. Pre-tPA and Post-tPA using technetium (Tc)-99m scintigraphy bone scan (Twomey et al.)

While study results have been impressive in instances of small sample sizes such as the above, a paucity of evidence has prevented widespread utilization of tPA for frostbite use amongst emergency physicians. This year, however, What’s New In Emergency Medicine on UpToDate gave special attention to a 2020 systematic review of 16 studies by Lee and Higgins which wielded a sample size of 209 patients with 1109 digits at high amputation risk. The study, entitled “What Interventional Radiologists Need to Know About Managing Severe Frostbite”, ultimately demonstrated a 76% salvage rate amongst IA tPA (222 amputations amongst 926 digits) and 62% salvage rate in IV tPA (24 amputations amongst 63 patients). Importantly, the 16 studies are not randomized, though several such as Patel et al. and Twomey et al. utilize historical controls. There is also no direct comparison of IA vs. IV tPA, and for unclear reasons, the salvage rate for IA is in terms of digits salvaged out of those at risk while IV is expressed as a function of patients who required no amputations. Though there remains additional research to be done, UpToDate’s Frostbite authors Zafren and Crawford Mechem now give an overall grade 2C recommendation for tPA use in severe frostbite for patients otherwise at risk of life-altering amputations.

Figure 3. Grading severity of frostbite after rewarming (Cauchy et al.)

Figure 4. Grade 4 Frostbite, best seen in far right (Pandey et al.)

TPA utilization in frostbite is straightforward. UpToDate authors recommend tPA consideration for any patients with frostbite in multiple digits in a single limb, in multiple limbs, and/or in proximal limb segments who present within 24 hours of injury. The American Burn Association, which has its own guidelines (largely similar), recommends tPA for patients with cyanosis proximal to the distal phalanx after rewarming (i.e. grade 3 or 4). In more simple terms – injuries expected to be life-altering, as revealed following rapid rewarming, are likely to meet inclusion. Contraindications include general tPA contraindications as well as frostbite-specific considerations such as multiple freeze-thaw cycles which destroy tissue viability via repeated reperfusion injury as discussed previously. An additional frostbite-specific quandary with tPA use is the intoxicated frostbite patient, as substance abuse is a strong risk factor for frostbite, but intoxication can preclude tPA consent.

So you suspect you have a candidate – how do you proceed? Advice from UpToDate’s Zafren and Mechem is representative of many experts’ approaches. Early consultation with centers experienced in advanced frostbite therapeutics is recommended. General immediate frostbite care is undertaken on ED arrival, including 15-30 minutes rapid water bath rewarming at 37 to 39 degrees Celsius, at which point the tissue should change from hard and cold to more soft and pliable. Ensure adequate analgesia, as this rewarming process can be painful. Following rapid rewarming, the grade of frostbite can be assessed (fig. 2,3). Clinical suspicion is then confirmed via technetium (Tc)-99m scintigraphy (bone scan) or by angiography at centers with expertise in intra-arterial tPA use. Angiography is utilized only if IA administration is planned. UpToDate recommends IV tPA for most candidates given the ease of administration unless specific institutional protocol differs.

Specific UpToDate dosing regimen is as follows: “Give a bolus dose of 0.15 mg/kg over 15 minutes, followed by a continuous IV infusion of 0.15 mg/kg per hour for six hours. The maximum total dose is 100 mg. After tPA has been given, adjunct treatment can be started with IV heparin or subcutaneous (SC) enoxaparin. The dose of IV heparin is 500 to 1000 units/hour for six hours or targeted to maintain the partial thromboplastin time (PTT) at twice the control value. Enoxaparin can be given at the therapeutic dose (1 mg/kg SC).”

Additional research remains to be done on this topic. At this time, however, it is reasonable to give your patients – a hand – when it comes to severe frostbite. Consider tPA.

Expert Commentary

Background

Skin and soft tissue are readily susceptible to injury at either end of the temperature spectrum. With exposure to cold, unprotected tissues can readily become frostbitten and/or hypothermic (aka Frostnip); two distinct but often linked injuries. In the past, skin, limbs, and digits sustaining severe frostbite injury had predictable outcomes: sloughing or amputation. The only question was how long to wait to amputate. Essentially no progress was made in the treatment of frostbite until the early 1990’s when the development of a treatment protocol for frostbite patients was developed using thrombolytics to restore blood flow to damaged tissue.

Frostbite has two separate mechanisms to the injury itself. The initial insult is the cold injury that leads to direct cellular damage from the actual freezing of the tissues. Rewarming of the affected tissues leads to the second, a reperfusion injury resulting in patchy microvascular thrombosis and tissue death.

Frostbite Classification

First-degree frostbite: Superficial damage to the skin from tissue freezing with redness (erythema), some edema, hypersensitivity, and stinging pain.
Second-degree frostbite: Deeper damage to the skin with a hyperemic or pale appearance, significant edema with clear or serosanguinous fluid-filled blisters, and severe pain. Frostnip, first and second-degree frostbite will generally heal without significant tissue loss.
Third-degree frostbite: Deep damage to the skin and subcutaneous tissue. Cold, pale, and insensate without a lot of tissue edema. Shortly after rewarming, edema rapidly forms along with the presentation of hemorrhagic blisters. Significant pain often occurs after rewarming.
Fourth-degree frostbite: All the elements of a third-degree injury with evidence of damage extending to the muscle, tendon, and bone of the affected area.

Figure 2. 1st and 2nd degree frostbite (left), 3rd and 4th degree frostbite (right)

Pre-hospital or Emergency Department Management

Determining the extent of frostbite injury starts with a detailed history regarding how the affected area appeared on presentation.
The history of a cold, white, and insensate extremity on presentation is consistent with severe frostbite injury (3rd and/or 4th-degree frostbite).
A severe frostbite injury requires emergent therapy with thrombolytics unless the patient meets one of the exclusion criteria.
If in question regarding the depth of the injury, a clinical exam can be supported by a vascular study as indicated. A digital Doppler exam is a simple and quick modality to further Clarify the diagnosis of severe frostbite.
Complete a primary survey to rule out any traumatic injuries.
Correct hypothermia (warm room, remove wet clothing & jewelry, warmed fluids, etc.)
If there are areas of frozen tissue rapid rewarming is preferred (see next section, rapid rewarming is associated with the best outcomes and salvage rates. However, never thaw until the risk of re-freezing has been eliminated. Patients undergoing freeze-thaw cycles do not respond to thrombolytics and are treated with standard supportive frostbite therapy.
Protect affected areas from further trauma with padding, splinting, and immobilization while transporting.
Keep the patient non-weight bearing to avoid incurring additional injury to frozen tissue (ice crystals) and/or disrupting blisters.
Elevate the affected extremities when able to decrease tissue edema.
Obtain a large-bore peripheral IV & start warmed fluids. Most patients will present with dehydration secondary to hypothermia and/or intoxication.
Avoid direct radiant heat to prevent iatrogenic burns to the cold tissue.
Update the patient’s tetanus status
Expect the patient to have increasing pain as the involved tissue is rapidly rewarmed. Pain management should include scheduled Ibuprofen (800 mg if no contraindication) to block the arachidonic cascade, gabapentin (nerve pain), and narcotics as needed.

Figure 4. Rewarming — Figure 3. Rewarming

Rapid rewarming

Circulating water bath when able. Put each affected area in its own water bath to avoid the tissue “knocking” against each other.

Document start & completion time

Try to keep the water temp at 104 ºF (40º C)
It will take 30-45 min for a hand or foot
If the patient has boots, socks, gloves, etc frozen to the skin do not force off. Submerge the entire area as part of the rapid rewarming process
Continue until frostbitten limb becomes flushed red or purple, and tissue soft and pliable to gentle touch

Air Dry

Avoid any aggressive manipulation to decrease tissue loss and injury
Elevate the affected areas to decrease swelling
Dress the affected areas with bulky padded dressings for transfer to avoid trauma to the areas
Avoid rewarming with a direct heat source (heat lamp, warm IV bag, etc.). This will lead to a thermal injury secondary to the lack of blood flow.

Rewarming will be associated with:

A return of sensation, movement, and possible initial flushing of the skin. The vessels in the case of severe frostbite (3rd or 4th degree) quickly become thrombotic (<20 minutes) with mottling or demarcation, however, the demarcation may be subtle at first and requires careful observation.
In the case that the tissues return fully to a normal color and palpable pulses or Doppler digital signals are present, the patient may not need any further intervention other than close observation (inpatient or daily visits in the clinic) and pain management.
If any question exists, an urgent triple-phase bone scan can support perfusion to the affected area.

Figure 4. Early evidence of demarcation and patchy thrombosis

Indications for Thrombolytics

Patient presenting with frozen tissue (severe frostbite, 3rd and/or 4th degree)
Absent or weak Doppler pulses following rewarming
Clinical exam consistent with severe frostbite
< 24 hours of warm ischemia time (time from rewarming)
Time matters significantly. For each hour after rewarming delaying the start of thrombolytics decreased salvage rates even by 28.1%.
With correct training after discussion with a burn center that does a lot of frostbite care, thrombolytics can be safely started at the outside hospital prior to transfer to the center.

Frostbite Thrombolytic Protocol

Examine for any associated injuries or illnesses. If any question of injury the patient will require a head, chest, and abdominal CT to rule out any sources of bleeding.
The dosing of the thrombolytic requires an actual weight and while infusing the thrombolytic requires ICU status and monitoring for 24 hours.
Following completion of the therapy, the patient will immediately be started on treatment dose Enoxaparin for 1-2 weeks.

Figure 5. Patient before and after receiving thrombolytics

Contraindications to the Thrombolytic Protocol

Absolute contraindications:

> 24 hours of warm ischemia time
Repeated freeze/thaw cycles
Concurrent or recent (within 1 month) intracranial hemorrhage, subarachnoid hemorrhage or trauma with active bleeding
Inability to consistently follow a neurologic exam (eg. intubated and sedated, significant dementia)
Severe uncontrollable hypertension

Relative contraindications:

History of GI bleed or stroke within 6 mo.
Recent intracranial or intraspinal surgery or serious head trauma within 3 months
Pregnancy

Figure 6. Clinical guide for the management of frostbite

Frostbite Take-Home Points

Rapid rewarming of frozen tissue in a circulating water bath is the preferred method of rewarming.
Patients that have undergone trauma in conjunction with the frostbite injury are not an absolute contraindication to receiving tPA.
Starting tPA at the outside hospital, prior to transport, results in significantly improved outcomes even compared to those that receive it at UCH.
Frostbite patients, regardless of whether or not they get thrombolytics, do better at a center that has experience and protocols to take care of frostbite.

Anne Lambert Wagner, MD, FACS

Associate Professor

University of Colorado

Medical Director

Burn & Frostbite Center at UC Health

How To Cite This Post…

[Peer-Reviewed, Web Publication] King, P. Porras, N. (2021, Aug 16). TPA in Frostbite. [NUEM Blog. Expert Commentary by Lamber Wagner, A]. Retrieved from http://www.nuemblog.com/blog/TPA-in-frostbite.

Hanging Injuries

Written by: Vytas Karalius, MD, MPH (NUEM ‘22) Edited by: Nery Porras, MD (NUEM ‘21) Expert Commentary by: Kevin Emmerich, MD, MS — **Written by:** Vytas Karalius, MD, MPH (NUEM ‘22) **Edited by:** Nery Porras, MD (NUEM ‘21) **Expert Commentary by**: Kevin Emmerich, MD, MS

Today’s post was inspired by the near-hanging of young gentleman who ended up passing away due to complications related to his near-hanging. His parents decided to donate his organs to Gift of Hope, allowing the passing of his life to extend the lives of others. While we hope to never see cases like these, they are an inevitable part of our job as emergency medicine physicians. As with most rare and complex pathology, preparation and knowledge can help us with the management of these cases when things often get chaotic. Lastly, as emergency medicine physicians who see the sequelae of mental illness daily in their EDs, I encourage us all to advocate for better funding and access to mental health care in the United States.

Hanging Injury

Terms/Classification [1]

“Hanging” is used to describe a death from a form of strangulation that involves hanging from the neck.
“Near-hanging” is a term for patients who have survived an attempted hanging (or at least long enough to reach the hospital).
“Complete hanging” defines when a patient’s legs are fully suspended off the ground and the patient's bodyweight is fully suspended by the neck.
“Incomplete hanging” defines when some part of the patient’s body is still on the ground and the body's full weight is not suspended off the ground.
“Judicial hanging” classically refers to victims who fell at least the height of their body.

Epidemiology:

Hanging is the 2nd most common form of successful suicide in the US after firearms
Accounts for 23% of >34,500 suicides in 2007
In the jail system, hanging is the most common form of successful suicide
Increasing incidence in US
Risk Factors: male, aged 15-44 years, history of drug or alcohol abuse, history of psychiatric illness

Pathophysiology of Injury:

Spine/Spinal Cord:

When the drop is greater than or equal to the height of the victim, as in a judicial hanging, there will almost always be cervical spine injury.
The head hyperextends, leading to fracture of the upper cervical spine ("hangman's fracture” of C2) and transection of the spinal cord.
Cervical injuries are in non-judicial hangings are rare. [2] One retrospective case review of near-hangings over a 10-year period found the incidence of cervical spine fracture to be as low as 5%. [3]

Vascular:

The major pathologic mechanism of death in hanging/strangulation is neck vessel occlusion, not airway obstruction. [1,4]
Death ultimately results from cerebral hypoxia and global ischemia.
There are two mechanisms by which this happens:
- Venous: The most implicated cause of death is actually venous obstruction. Jugular veins are superficial and easily compressible. Obstruction of venous outflow from the brain leads to stagnant hypoxia and loss of consciousness in as little as 15 seconds.
- Arterial: The risk of damage to the major arterial blood flow to the brain (such as carotid artery dissection) is rare, but should suspected in patients. [4]

Cardiac:

Carotid body reflex-mediated cardiac dysrhythmias are reported, and likely a minor mechanism of death.

Pulmonary:

Airway compromise plays less of a role in the immediate death of complete hanging/strangulation. However, it is a major cause of delayed mortality in near-hanging victims. [1,4]
Significant pulmonary edema occurs through two mechanisms:
- Neurogenic: centrally mediated, massive sympathetic discharge; often in association with serious brain injury and a poor prognostic implication.
- Post-obstructive: strangulation causes marked negative intrapleural pressure, generated by forceful inspiratory effort against extra-thoracic obstruction; when the obstruction is removed, there is a rapid onset pulmonary edema leading to ARDS.
Aspiration pneumonia later sequela of near-hanging injury.
Airway edema from mechanical trauma to the airway, which can make intubation difficult.
Tracheal stenosis can develop later in the hospital course.

Other Injuries:

Hyoid bone fracture
Cricoid or thyroid cartilage injury [5]

Physical Examination:

"Ligature marks" or abrasions, lacerations, contusions, bruising, edema of the neck
Tardieu spots of the eyes
Severe pain on gentle palpation of the larynx (laryngeal fracture)
Respiratory signs: cough, stridor, dysphonia/muffled voice, aphonia
Varying levels of respiratory distress
Hypoxia
Mental status changes

Early Management/Stabilization:

ABCs as always
Early endotracheal intubation may become necessary with little warning.
Patients who are unconscious or have symptoms such as odynophagia, hoarseness, neurologic changes, or dyspnea require aggressive airway management.
If ETI unsuccessful, consider cricothyroidotomy; if unsuccessful, percutaneous trans-laryngeal ventilation may be used temporarily.
Judicious and cautious fluid resuscitation - avoid large fluid volume resuscitation and consider early pressors, as fluids increases the risk/severity of ARDS and cerebral edema.
Monitor for cardiac arrhythmias.
The altered/comatose patient should be assumed to have cerebral edema with elevated ICP.

Imaging/Further Testing:

Chest radiograph
CT brain
CT C-spine
CTA head/neck
Can consider soft-tissue neck x-ray, if CT not immediately available

Further Management:

In patients with signs of hanging/strangulation, there should be a low threshold to obtain diagnostic imaging/testing as discussed above.
Expect pulmonary complications early.
- They are a major cause of delayed mortality in near-hanging victims, as stated above.
Early intubation and airway management are important.
Non-intubated patients with pulmonary edema may benefit from positive end-expiratory pressure ventilation.
Patients with symptoms of laryngeal or tracheal injury (e.g. dyspnea, dysphonia, aphonia, or odynophagia), should undergo laryngobronchoscopy with ENT. [4,6]
Tracheal stenosis has been reported during the hospital course. Address cerebral edema from anoxic brain injury, using strategies to reduce intracranial pressure or seizure prophylaxis. [4]
Address vascular complications seen on CTA and coordinate intervention with the appropriate specialty at your institution.
Therapeutic Hypothermia
- There is some evidence for therapeutic hypothermia in those with cardiac arrest from hanging injury [7,8] and those who are comatose from hanging injury. [9-11] While the evidence is weak, in the absence of better evidence, it is reasonable to consider hypothermia treatment in all comatose near-hanging victims. [1,12,13]
When suicide is suspected, evaluate patients for other methods of self-harm (e.g. wrist lacerations, self-stabbing, ingestions). It is also important to consider drug and alcohol intoxication. [4]

Disposition:

Admit critically ill patients to the appropriate ICU-level care.
Admit patients with abnormal radiologic or endoscopic imaging to the appropriate service and level of care.
Even if the initial presentation is clinically benign, all near-hanging victims should be observed for 24 hours, given the high risk of delayed neurologic, airway and pulmonary complications. [14]
Observe asymptomatic patients with normal imaging.
Psychiatry/Crisis Team consult on all suspected intentional cases.
Emphasize strict return precautions as well as education about possible delayed respiratory and neurologic dysfunction when discharging patients.
Some patients may require transfer to a trauma center if the required services are not available at the initial receiving facility. [1]

Prognostication:

GCS 3/GCS 3T is a predictor of very poor outcome, [15-19] but there is mixed evidence on the GCS as a predictor of outcomes in GCS scores greater than 3, especially with regard to neurologic intactness. [3,19]
Recovery of patients with neurology symptoms is unpredictable. [4]
Patients presenting with cardiac arrest have a very poor prognosis, and might be the strongest predictor of poor prognosis. [4,8,16,18,20]
Other predictors of poor clinical outcome include:
- Anoxic brain injury or cerebral edema on head CT [3,19]
- Prolonged hanging time [18]
- Cardiopulmonary arrest [8,11,19]
- Cervical spine injury
- Hypotension on arrival

Expert Commentary

We’ve all certainly been involved with a patient with reported hanging injury at some point in our time in the ED. They are usually unimpressive if a person does it as more of a gesture rather than a true suicide attempt. When they are unfortunately done “correctly,” they usually result in a trip to the morgue instead of the ED. When the swiss cheese holes align and a true hanging attempt results in a serious but not fatal presentation, things can get quite hairy. I’ve been a part of one such case, and will never forget it. Here are my two cents.

Airway

This should undoubtedly be treated as a predicted difficult airway, not only due to likely cervical spine trauma, but also possibly due to airway edema. Get your ducks in a row for this unless this patient is crashing in front of you. Get your consultants/help (if available), preoxygenate, airway adjuncts open and ready, backup airway supplies if your first plan fails. Most importantly, have a plan and discuss this with your team beforehand. Don’t be afraid to take an awake look with a hyperangulated video laryngoscope, especially if this patient presents with stridor. Ketamine can be your friend here. This should be an airway that you do not undertake without a scalpel, finger, and bougie ready just in case. I like to draw a line on the patient’s skin overlying the cricothyroid membrane beforehand.

Trauma

Self explanatory, but don’t be stingy here. Light this patient up from head to pelvis, including the neck angiogram. Document a repeat neuro exam every time you move this patient.

Overdose/psych

Don’t forget your Tylenol and salicylate levels, EKG in this suicide attempt. If you feel the need to add the useless urine drug screen, I suppose this is fine as well.

Kevin Emmerich, MD, MS

Emergency Medicine Physician

Methodist Hospital

Gary, Indiana

How To Cite This Post:

[Peer-Reviewed, Web Publication] Karalius, V. Porras, N. (2021, Aug 9). Hanging Injuries. [NUEM Blog. Expert Commentary by Emmerich, K]. Retrieved from http://www.nuemblog.com/blog/hanging-emergencies

References

1. Walls RM, Hockberger RS, Gausche-Hill M. Rosen's emergency medicine : concepts and clinical practice. Ninth edition. ed. Philadelphia, PA: Elsevier; 2018.

2. Aufderheide TP, Aprahamian C, Mateer JR, et al. Emergency airway management in hanging victims. Ann Emerg Med. 1994;24(5):879-884.

3. Salim A, Martin M, Sangthong B, Brown C, Rhee P, Demetriades D. Near-hanging injuries: a 10-year experience. Injury. 2006;37(5):435-439.

4. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM. Tintinalli's emergency medicine: a comprehensive study guide. 9th. ed. New York: McGraw-Hill Education; 2019.

5. Tugaleva E, Gorassini DR, Shkrum MJ. Retrospective Analysis of Hanging Deaths in Ontario. J Forensic Sci. 2016;61(6):1498-1507.

6. Hackett AM, Kitsko DJ. Evaluation and management of pediatric near-hanging injury. Int J Pediatr Otorhinolaryngol. 2013;77(11):1899-1901.

7. Hsu CH, Haac B, McQuillan KA, Tisherman SA, Scalea TM, Stein DM. Outcome of suicidal hanging patients and the role of targeted temperature management in hanging-induced cardiac arrest. J Trauma Acute Care Surg. 2017;82(2):387-391.

8. Kim MJ, Yoon YS, Park JM, et al. Neurologic outcome of comatose survivors after hanging: a retrospective multicenter study. Am J Emerg Med. 2016;34(8):1467-1472.

9. Jehle D, Meyer M, Gemme S. Beneficial response to mild therapeutic hypothermia for comatose survivors of near-hanging. Am J Emerg Med. 2010;28(3):390.e391-393.

10. Lee BK, Jeung KW, Lee HY, Lim JH. Outcomes of therapeutic hypothermia in unconscious patients after near-hanging. Emerg Med J. 2012;29(9):748-752.

11. Hsu CH, Haac BE, Drake M, et al. EAST Multicenter Trial on targeted temperature management for hanging-induced cardiac arrest. J Trauma Acute Care Surg. 2018;85(1):37-47.

12. Borgquist O, Friberg H. Therapeutic hypothermia for comatose survivors after near-hanging-a retrospective analysis. Resuscitation. 2009;80(2):210-212.

13. Sadaka F, Wood MP, Cox M. Therapeutic hypothermia for a comatose survivor of near-hanging. Am J Emerg Med. 2012;30(1):251.e251-252.

14. McHugh TP, Stout M. Near-hanging injury. Ann Emerg Med. 1983;12(12):774-776.

15. Kao CL, Hsu IL. Predictors of functional outcome after hanging injury. Chin J Traumatol. 2018;21(2):84-87.

16. La Count S, Lovett ME, Zhao S, et al. Factors Associated With Poor Outcome in Pediatric Near-Hanging Injuries. J Emerg Med. 2019;57(1):21-28.

17. Martin MJ, Weng J, Demetriades D, Salim A. Patterns of injury and functional outcome after hanging: analysis of the National Trauma Data Bank. Am J Surg. 2005;190(6):836-840.

18. Matsuyama T, Okuchi K, Seki T, Murao Y. Prognostic factors in hanging injuries. Am J Emerg Med. 2004;22(3):207-210.

19. Nichols SD, McCarthy MC, Ekeh AP, Woods RJ, Walusimbi MS, Saxe JM. Outcome of cervical near-hanging injuries. J Trauma. 2009;66(1):174-178.

20. Gantois G, Parmentier-Decrucq E, Duburcq T, Favory R, Mathieu D, Poissy J. Prognosis at 6 and 12months after self-attempted hanging. Am J Emerg Med. 2017;35(11):1672-1676.

Posted on August 9, 2021 by NUEM Blog and filed under Airway, Critical care, Trauma and tagged trauma difficult airway psychiatry hanging strangulation.

Scalpel Finger Bougie

Expert Commentary

Establishing an airway via a cricothyroidotomy is a stressful and tense experience. In almost all of these cases, experienced airway staff have already attempted advanced airway maneuvers in patients typically at high risk for inability to intubate. As the oxygen saturation drops and the patient becomes unstable, the most adept proceduralist present (whether emergency department physicians or surgeons) are asked to step in to secure a surgical airway.

The scalpel-finger-bougie technique is one proven and reliable method to secure a surgical airway via a cricothyroidotomy. Some additions to the technique described above are:

Use a vertical incision through the skin and soft tissues. If you are too superior or inferior with your initial incision, then this incision can be easily extended as needed. A horizontal incision commits you to that cranial-caudal level. It is often more of a struggle to identify the cranial-caudal orientation of the cricothyroid membrane rather than the medial-lateral orientation.
In a patient with a stable and flexible neck, retract the neck via cranial pressure on the chin to bring the neck structures better into your working field. Insert a shoulder roll if available (unlikely) to augment this positioning.
After the tube is advanced, listen for bilateral breath sounds. It is common, in this adrenaline fueled procedure, to advance the endotracheal tube too far, leading to a right main stem intubation. This can limit your ventilation and oxygenation and can lead to confusion about the airway placement in the neck. If there are no left lung field breath sounds, then pull the tube back until bilateral breath sounds are confirmed with auscultation.
Always verify tube placement with capnography.
Persistent, moderate volume bleeding is often from injury to the anterior jugular vein. Gentle, directed pressure on the area can control this bleeding while the patient is being transported to the operating room for a more definitive airway.

Joseph Posluszny, MD

Assistant Professor of Surgery (Trauma and Critical Care)

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Wessling, E. Whipple, T. (2021, Aug 2). Scalpel Finger Bougie. [NUEM Blog. Expert Commentary by Posluszny, J]. Retrieved from http://www.nuemblog.com/blog/scalpel-finger-bougie

Seasonal Influenza

Expert Commentary

Thank you for the concise and informative resource guide. Don’t we all yearn for the days when patients with myalgias and fever were typically diagnosed with influenza and sent on their merry way? Believe it or not, there are some interns who may go their entire first winter as physicians without diagnosing influenza.

A large part of our jobs as emergency medicine physicians is reassurance. Patients want to know they are okay, but they always want something to make them feel better faster, which is true for influenza as well as coronavirus. And while most young, healthy patients do not need treatment for influenza, another consideration is time lost from work, even though symptom duration is really only decreased by one day. However, for some individuals, those one to two days of work may be essential, in which case, a prescription should be considered if the patient presents within 48 hours of symptom onset. For all other healthy adults, I discuss the side effects of the medication. Evidence from a Cochrane Review published in 2014 suggests that in healthy adults, the risks of side effects including nausea, vomiting, headaches and psychiatric symptoms likely outweighs any benefit, which again, does NOT include decreased hospitalizations rates or complications. I usually frame it as “yes, your flu symptoms may get better about 16 hours sooner, but you may also have nausea, vomiting and headaches.” Most people, in my experience, will then pass on a prescription for Tamiflu.

Screening for chronic medical conditions, pregnancy, high risk household members is essential in knowing which patients require treatment. High level athletes is another patient population where treatment may be considered to allow them to get back to training faster but also to minimize spread to the rest of the team.

Visits for influenza are also a great time to discuss vaccination with patients, especially during the current pandemic. Emphasis should be placed on how vaccines prevent life threatening complications from influenza and diminish symptom severity. This is a perfect time for vaccine education to hopefully prevent future pandemics.

References

Jefferson T et al. Oseltamivir for Influenza in Adults and Children: Systematic Review of Clinical Study Reports and Summary of Regulatory Comments. BMJ 2014. PMID: 24811411.

Gabrielle Ahlzadeh, MD

Clinical Assistant Professor of Emergency Medicine

University of Southern California

How To Cite This Post:

[Peer-Reviewed, Web Publication] Wedel, L. (2021, May 17). Seasonal Influenza. [NUEM Blog. Expert Commentary by Ahlzadeh, G]. Retrieved from http://www.nuemblog.com/blog/seasonal-influenza

Cocaine Chest Pain

Written by: Maren Leibowitz, MD (NUEM ‘23) Edited by: Zach Schmitz, MD (NUEM ‘21) Expert Commentary by: David Farman, MD — **Written by:** Maren Leibowitz, MD (NUEM ‘23) **Edited by:** Zach Schmitz, MD (NUEM ‘21) **Expert Commentary by**: David Farman, MD

Expert Commentary

Cocaine chest pain was something that was frequently discussed but rarely encountered during my training and during my 11 years practicing in suburban and metropolitan Indiana (we're more of a heroin/meth state). I suspect there is significant regional and local variation in the epidemiology of cocaine chest pain, likely influenced by the economics and local availability or popularity of intoxicants.

When cocaine is more expensive, we tend to see more methamphetamine use. And vice-versa. I was once told by a local sheriff that "people will get high on whatever they can get for less than $20" and I have found that to be true in practice. I wouldn't expect that an emergency physician would be intimately familiar with the local micro-economics of the drug trade, but one should expect there to be a periodic waxing/waning of cocaine chest pain presentations. Similarly, it may be a more frequent complaint dependent on cocaine's local popularity and availability.

When consulting with a Cardiologist about a cocaine chest pain case, it is important for the emergency physician to avoid letting premature closure or psychosocial biases unduly influence the patient's disposition. It is not unheard of for physicians to minimize objective findings (ST segment abnormalities or biomarker elevation) and attribute them to the vasoactive properties of cocaine. I have certainly been tempted to do so myself. However, the article wisely points out the physiologic changes induced by cocaine use, both acutely and chronically. Platelet aggregation and atherogenesis can absolutely promote a scenario that would require PCI in even the most frequent of 'frequent fliers' with cocaine chest pain.

In short, I would have a low threshold to involve Cardiology in a patient who has objective findings regardless of their use of cocaine. Similarly, a Cardiology request for a Urine Drug Screen shouldn't delay a patient's trip to the cath lab if they have a STEMI. An exception to this may be a patient who has had recent coronary angiography that objectively demonstrates normal coronaries. In that scenario I would consider serial markers, conservative management and strong consideration of non-cardiac causes of the pain (dissection, pneumothorax, etc.).

David Farman, MD FACEP

Emergency Medicine Physician

Franciscan Health Lafayette East

How To Cite This Post:

[Peer-Reviewed, Web Publication] Leibowitz, M. Schmitz, Z. (2021, May 10). Cocaine Chest Paine. [NUEM Blog. Expert Commentary by Farman, D]. Retrieved from http://www.nuemblog.com/blog/cocaine-chest-pain

Eliminating health disparities in LGBT individuals begins in the ED

Written by: David Feiger, MD (NUEM ‘22) Edited by: Vidya Eswaran, MD (NUEM ‘20) Expert Commentary by: Will Laplant, MD, MPH '20 — **Written by:** David Feiger, MD (NUEM ‘22) **Edited by:** Vidya Eswaran, MD (NUEM ‘20) **Expert Commentary by**: Will Laplant, MD, MPH '20

Introduction

18% of lesbian, gay, bisexual, transgender, or questioning (LGBTQ) individuals avoided seeking medical attention for fear of discrimination according to a 2017 joint poll conducted by NPR, the Robert Wood Johnson Foundation, and Harvard T.H. Chan School of Public Health [1]. These fears are not unfounded—decades of anti-lesbian, gay, and bisexual (LGB) prejudice in medicine, despite greater social acceptance in the United States have tainted medicine’s perception in the LGB community.

Only in 1987 was “sexual orientation disturbance” removed from the DSM while conversion therapy, the scientifically-unfounded exercise of converting one’s sexual orientation to heterosexual, continues to be legal across much of the United States. In 2015, a pediatrician in Michigan declined to see a child of a lesbian couple which spurred a national debate of refusal of care on the basis of religious freedom [2]. Just this year the Conscience and Religious Freedom Division of the Department of Health and Human Services was established [3]. It is clear why LGB individuals may want to avoid routine medical attention.

As a disclaimer, LGBT individuals are often lumped into one category. We will focus this post on LGB individuals as we believe that the transgender experience, while occasionally overlapping with that of LGB individuals, deserves its own recognition in another post. Many studies and data grouped LGB and transgender individuals as one group and will be cited as such in this post.

Health Disparities

34% of LGBT individuals reported having been a victim of bullying, instituting a fear of discrimination and coming out that can lead to a variety of emotional and psychological consequences [4]. In the National Health Interview Study, 26% and 28% of gay men and women, respectively, and 41% and 47% of bisexual men and women, respectively, reported moderate or severe levels of mental distress compared to 17% of straight men and 22% of straight women [6]. These levels of psychological stress make LGB individuals more prone to emotional disorders leading to suicidal ideation, homelessness, depression, and substance abuse [4].

Furthermore, 18% of LGBT individuals reported having been coerced into sex and 23% sexually assaulted [4]. This victimization increases their risk of unsafe sexual behavior than their peers resulting in a twice greater likelihood of contracting sexually transmitted diseases when compared to straight-identifying men [5]. The fear of seeking medical attention only exacerbates these health disparities.

While much of the focus has been on the modern experience of LGB youth, it is important to be aware the circumstances of LGB seniors that may contribute to health disparities. Due to the social climate in which they grew up, they are less likely to be partnered, have children, or other social supports, increasing their barriers to health care. Furthermore, they often reside in senior communities where they often face continued discrimination [7].

Creating a More Welcoming Environment for All

The emergency department is often the first point of healthcare contact for the vulnerable, and is therefore a prime location to make healthcare more approachable for the LGB community.

The Waiting Room

Patients often spend hours in the waiting room, providing an opportune time to set an inviting tone for LGB patients. LGB individuals constantly seek subtle indications of acceptance in unknown environments [11]. At the most basic level, triage forms can include questions pertaining to sexual orientation and gender identity [7]. In fact, collection of this data has been recommended by the Institute of Medicine and the Joint Commission [8]. These forms can also include the hospital’s non-discrimination policy on the basis of sexual orientation and offer a contact for a patient advocate for those who have been unfairly treated. Staff can wear rainbow flag pins and waiting rooms can offer pamphlets that highlight LGB health among other health topics [7]. These small additions can make LGB individuals feel more welcome.

With the Physician
Despite 78% of emergency physicians believing that patients would refuse to reveal their sexual orientation in the emergency department, only 10% of patient respondents of all sexual orientations (n=1516) to the EQUALITY study reported that they would not answer the question [8]. As summarized by Dr. Adil Haider, the principal investigator of the study, “your patients want to be asked.”

When asking patients about their sexual orientation, it is important to use gender-neutral language. Ask “are you in a relationship?” or “do you have sex with men, women, or both?” to delve into a social history. These types of questions may comfort LGB patients to allow them to expand on details they find relevant [9]. Of course, patients who are not comfortable with their identity may continue to conceal their sexual orientation. Each individual’s coming out experience varies and it is crucial that the physician allows the patient to take his or her own time to reveal their sexual orientation, even if not on this visit. Simply asking the broad questions without judgment may begin to change the patient’s apprehensive attitude towards medicine.

Going Above and Beyond

While important to make the clinical encounter more inviting, more actions can be taken to make a hospital a leader in LGB care.

1. Partner with local LGB organizations

Hospitals can partner with organizations that support the LGB community. Having a presence in health clinics targeting LGB individuals and other local LGB organizations will also allow the hospital to better understand and adapt to the needs specific to the community. Celebrating LGBT awareness months and having staff march in local LGB Pride events is a very public and visible way of showing support for the community [9].

2. Actively recruiting and maintaining LGB staff

Health care providers should actively recruit LGB staff by ensuring equal employment benefits as their heterosexual colleagues by offering supplemental packages that include benefits for both married and unmarried same-sex partners. After hiring, ensure that LGB employees continue to receive support and mentoring by sponsoring LGB employee groups and functions [9].

3. Striving for and achieving a perfect score on the Human Rights Campaign Healthcare Equality Index

The Human Rights Campaign is the largest organization supporting LGBT rights in the United States. Each year, the Human Rights Campaign scores and publishes a list of many hospitals in the United States and grades them on hospitals’ ability to provide inclusive care regardless of sexual orientation. The list evaluates a hospital’s patient and employment non-discrimination policies, visitation rights, LGBT-focused training offering, presence of patient services to LGBT individuals, employee benefits, and commitment to the community for a total score on a scale from 0 to 100.10 For healthcare institutions not achieving a perfect 100 score, this is a great tool to ensure progression to full equity of care for LGB patients.

Summing it Up

Despite rapid social acceptance of the LGB community in the United States within the past decade, remnants of fear and distrust in healthcare remain, exacerbating existing health disparities. While it may take several decades to fully eradicate the apprehension, taking the steps above will certainly make strides to achieve that goal.

Expert Commentary

Thank you for writing about such an important topic. I think we all understand the special position of the emergency department beyond the care of emergencies; it is a point of access for many marginalized communities that have been unable to receive care through other venues. It is our duty as emergency physicians to be able to provide competent and appropriate care for all who walk through our doors.

I think it makes sense to divide the topic of LGBTQ care into two: sexual minorities (those who identify as lesbian/gay/bisexual/queer, etc) and gender minorities (those who identify as trans, genderqueer or otherwise gender nonconforming). While they have much in common, the barriers and healthcare disparities they face are unique and different, and they each warrant a lengthy discussion. I look forward to your article on the care of gender minorities!

Normalizing Care in the Emergency Department

Identifying Those in the Room

Asking “how are the two of you related?” to figure out who else is in the room can prevent mishaps of assuming someone is with their friend, when really they are with their partner. As a major support system after discharge, it’s important to include a patient’s partner in the discussion and plan.

Taking a Sexual History

It’s important to not conflate sexual orientation with sexual behaviors. For example, there is a well defined subsect of men who have sex with men (MSM) but do not identify as gay/bisexual. By asking “do you have sex with men, women, or both?” you ensure that you capture the data you need to treat the patient appropriately. Some people get hung up on the follow up questions to further identify how to treat a patient:

“Do you have anal intercourse?”

“Do you have receptive, penetrative, or both?”

The same model can be used for oral and vaginal intercourse.

Addressing the Sexual Health of Sexual Minorities

If you are addressing sexual health needs in the emergency room, either because of chief complaint (eg. sore throat, rectal pain, vaginal discharge, abdominal pain) or exposure, try and be as comprehensive as possible. The majority of syphilis cases in the US are amongst MSM [1], making it an important consideration. I suppose this blog is also as good a place as any to highlight the recent CDC recommendations for treatment of STIs, including [2]:

Monotherapy with ceftriaxone for confirmed gonorrhea given increasing azithromycin resistance
Increased dosing of ceftriaxone (500mg from 250mg) for gonorrhea treatment, and 1g of ceftriaxone for those >150kg
Doxycycline 100mg BID for 7 days for chlamydia infections
*Notably, compliance with a 7 day course of treatment should be addressed and factored into the decision (with regards to the previous standard of azithromycin 1g as a single dose).

Identifying Bias

Bias comes in two forms: explicit biases, which we are cognizant of, and implicit, which we are not. Implicit bias stems from the confluence of your life experiences and the society you are a part of. If you have been raised in a society entrenched in systemic racism, sexism, ableism and heteronormativity, you have been exposed to stereotypes and prejudices which may subconsciously shape the way you make decisions. Healthcare professionals have been shown to have a similar level of implicit bias compared to the general population [3], and this implicit bias has been correlated with significant patient outcomes. [4] What shapes your decision in who receives narcotic pain medication or who stays in the hospital for observation? I highly recommend taking at least a few tests of implicit bias which are freely available and, in my opinion, highly informative: https://implicit.harvard.edu/implicit/takeatest.html

References

CDC. Sexually transmitted disease surveillance 2013. Atlanta: US Department of Health and Human Services; 2014.
St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon.
FitzGerald, C., Hurst, S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 18, 19 (2017). https://doi.org/10.1186/s12910-017-0179-8
William J. Hall et al. “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review”, American Journal of Public Health 105, no. 12 (December 1, 2015): pp. e60-e76.

Will Laplant MD, MPH

Emergency Medicine Physician

Good Samaritan Medical Center

Brockton, MA

How To Cite This Post:

[Peer-Reviewed, Web Publication] Feiger, D. Eswaran, V. (2021, May 2). Eliminating health disparities in LGBT individuals begins in the ED. [NUEM Blog. Expert Commentary by Laplant, W]. Retrieved from http://www.nuemblog.com/blog/lgbt-disparities

References

“Discrimination in America: Experiences and Views of LGBTQ Americans.” www.npr.org, National Public Radio, Nov. 2017, www.npr.org.
Pear, Robert, and Jeremy W. Peters. “Trump Gives Health Workers New Religious Liberty Protections.” The New York Times, 18 Jan. 2018.
Phillip, Abby. “Pediatrician Refuses to Treat Baby with Lesbian Parents and There’s Nothing Illegal about It.” The Washington Post, 19 Feb. 2015.
Hafeez, Hudaisa, et al. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review.” Cureus, 2017, doi:10.7759/cureus.1184.
Robinson, Joseph P., and Dorothy L. Espelage. “Peer Victimization and Sexual Risk Differences Between Lesbian, Gay, Bisexual, Transgender, or Questioning and Nontransgender Heterosexual Youths in Grades 7–12.” American Journal of Public Health, vol. 103, no. 10, 2013, pp. 1810–1819., doi:10.2105/ajph.2013.301387.
Gonzales, Gilbert, et al. “Comparison of Health and Health Risk Factors Between Lesbian, Gay, and Bisexual Adults and Heterosexual Adults in the United States.” JAMA Internal Medicine, vol. 176, no. 9, 2016, p. 1344., doi:10.1001/jamainternmed.2016.3432.
Understanding the Health Needs of LGBT People. Understanding the Health Needs of LGBT People, National LGBT Health Education Center, 2016.
Haider, Adil H., et al. “Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity.” JAMA Internal Medicine, vol. 177, no. 6, 2017, p. 819., doi:10.1001/jamainternmed.2017.0906.
Ten Things: Creating Inclusive Health Care Environments for LGBT People. Ten Things: Creating Inclusive Health Care Environments for LGBT People, National LGBT Health Education Center, 2015.
Human Rights Campaign. “Healthcare Equality Index 2018.” Human Rights Campaign, Human Rights Campaign, 2018, www.hrc.org/hei.
Eliason, Michele J., and Robert Schope. “Does ‘Don't Ask Don't Tell’ Apply to Health Care? Lesbian, Gay, and Bisexual People's Disclosure to Health Care Providers.” Journal of the Gay and Lesbian Medical Association, vol. 5, no. 4, Dec. 2001.

Posted on May 3, 2021 by NUEM Blog and filed under Advocacy and tagged health disparities LGBT advocacy health policy.

Bariatric Emergencies

Written by: Maurice Hajjar, MD, MPH (NUEM ‘22) Edited by: Philip Jackson(NUEM ‘20) Expert Commentary by: Gabby Ahlzadeh, MD — **Written by:** Maurice Hajjar, MD, MPH (NUEM ‘22) **Edited by:** Philip Jackson(NUEM ‘20) **Expert Commentary by**: Gabby Ahlzadeh, MD

Expert Commentary

Thanks for this great post. Being familiar with the anatomy of these various procedures is essential to understanding the complications and why you cannot be reassured by a benign abdominal examination.

With laparoscopic band procedures, complications are more common early on and are more related to band erosion or migration. Migration of the lap-band is best evaluated with an upper GI series with Gastrografin. Another important question to ask patients is if their lap band has been inflated recently. This is typically done in a progressive manner, where normal saline is instilled within the subcutaneous port. This can also be a source of obstruction, and if emergent, the band can be deflated by aspirating fluid from the port. This should be done under the guidance of a surgeon, if possible.

Asking about dietary indiscretions can also sometimes clue you in to why a person is having abdominal pain or nausea. Especially immediately post-op, these patients have specific dietary guidelines and are often limited to liquids or pureed foods. Dumping syndrome can also occur in this patient population, more common with gastric bypass surgery, due to rapid gastric emptying. Typically, these patients have bloating, sweating, facial flushing, diarrhea, nausea, early satiety about 30 to 60 minutes after a meal. Dumping syndrome is typically diagnosed clinically, though laboratory testing should be performed to rule out electrolyte derangements. Dumping syndrome is typically treated with dietary modifications and should be discussed with the patient’s surgical team.

As these procedures become more common and advanced, some are also performed endoscopically, which comes with its own set of complications. Another newer procedure is the intragastric balloon, which is a saline filled silicone balloon that is inflated in the stomach. In the first few days after placement, patients may experience abdominal pain, nausea, and vomiting. Other complications include balloon rupture, bowel obstruction, gastric outlet obstruction, gastric ulcer, pancreatitis, nonalcoholic steatohepatitis and cholecystitis.

Overall, management of these patients in the emergency department should be done in consultation with the surgeon.

Gabrielle Ahlzadeh, MD

Clinical Assistant Professor of Emergency Medicine

University of Southern California

How To Cite This Post:

[Peer-Reviewed, Web Publication] Hajjar, M. Jackson, P. (2021, Apr 26). Bariatric Emergencies. [NUEM Blog. Expert Commentary by Ahlzadeh, G]. Retrieved from http://www.nuemblog.com/blog/bariatric-emergencies

Thyroid Storm ED Diagnosis and Management

Expert Commentary

For those of you who have not yet cared for a patient in Thyroid Storm, I guarantee that the experience will humble you. As far as endocrine emergencies go, this one is (quite literally) a killer. In 1993, Burch and Wartofsky cited mortality rates as high as 20 to 50% [1]. In more recent literature, the mortality rate of this condition is still at a whopping 10% [2]. As you can see from the beautifully presented infographic above, there are a number of complexities that factor into the diagnosis and treatment of Thyroid Storm. This is in part due to the fact that thyroid hormone affects all organ systems, with clinical manifestations of disease involving everything from cardiac dysrhythmia to profound GI losses secondary to vomiting and diarrhea to acute psychosis. To ground this infographic in clinical reality, where we know that diagnoses are not always easy to make and the decision between one therapeutic option versus another is not always clear, I offer you just a few additional points:

1. Making this diagnosis requires that you actually think about it in the first place. There is no single diagnostic test or image that will clinch this diagnosis for you. The Burch and Wartofsky criteria are clinical findings that you as the provider must use in the correct context for them to be useful. This is a rare condition, and your availability bias will be working against you here. Patient presentations can be vague and there is incredible overlap with other disease processes, with chief complaints ranging from anxiety to vomiting and abdominal pain to leg swelling.

2. Once this diagnosis has been considered or made, understand that these patients have incredibly complex hemodynamics, with multiple potential factors in play at any given time: hypovolemia from profound GI losses, concomitant sepsis, high output cardiac failure, and cardiac systolic dysfunction. With regards to this last point, there is a high incidence of decompensated heart failure in patients with thyroid storm, and those with cardiogenic shock are at some of the greatest risk of mortality [2, 3, 4]. As such, it behooves you to re-assess these patients’ volume status frequently. Examine them closely, and then re-examine them. Use your bedside ultrasound to assess their cardiac output, IVC, and lung windows. While they may be profoundly hypertensive when you first administer a beta blocker, concomitant sepsis and hypovolemia may surface very quickly as the patient’s blood pressure plummets.

3. This leads to my next point: when given the choice between propranolol and esmolol in managing tachydysrhythmia (whether profound sinus tachycardia or atrial fibrillation) in the context of Thyroid Storm, strongly consider esmolol. The Japan Thyroid Association and Japan Endocrine Society Task Force specifically cites increased mortality rates in patients for whom propranolol was used versus esmolol or landiolol (super short-acting beta blocker used in Japan) [3]. Much of the benefit to using esmolol over propranolol is in its much shorter half-life. The alpha and beta half-life for propranolol are 10 minutes and 2.3 hours, respectively, whereas the alpha and beta half-life for esmolol are 2 minutes and 9 minutes, respectively. Once the infusion is stopped, the effect of esmolol will have completely disappeared by 18 minutes [3].

4. When asked during oral boards how you would manage a patient with Thyroid Storm, a response involving antithyroid agents, inorganic iodide, corticosteroids, and beta blockers would score you full marks. However, I would encourage you to also consider thoughtful administration of IV fluids (with frequent re-assessment of volume status), early empiric antibiotics, inotropic agents for patients in cardiogenic shock, and psychotropic medications as needed for restlessness/delirium/psychosis (with olanzapine preferred over haldol) [3].

Diagnosis and management of Thyroid storm in the Emergency Department requires us to draw upon so many of our expert skills in approaching undifferentiated and critically ill patients. I hope that these points help to provide you with just a few more tools to include in your arsenal as you go forth.

References

[1] Burch, HB, Wartofsky, L. (1993). Life-threatening thyrotoxicosis: Thyroid storm. Endocrinology and Metabolism Clinics of North America, 22(2): 263-77.

[2] Akamizu, T. (2018). Thyroid Storm: A Japanese Perspective. Thyroid, 28:1.

[3] Satoh, T, et al. (2016). 2016 Guidelines for the Management of Thyroid Storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocrine Journal, 63: 12 (1025-1064).

[4] Bourcier, S, et al. (2020). Thyroid Storm in the ICU: A Retrospective Multicenter Study. Critical Care Medicine, 48:1 (83-90).

Samia Farooqi, MD

Assistant Professor

Department of Emergency Medicine

UT Southwestern

How To Cite This Post:

[Peer-Reviewed, Web Publication] Luo, S. Chukwuelebe, S. (2021, April 19). Thyroid Storm ED Diagnosis and Management. [NUEM Blog. Expert Commentary by Farooqi, S]. Retrieved from http://www.nuemblog.com/blog/thyroid-storm.

ED Clinical Decision Making Units

Written by: Mitchell Blenden, MD (NUEM ‘24) Edited by: Em Wessling (NUEM ‘22) Expert Commentary by: Tim Loftus, MD, MBA — **Written by:** Mitchell Blenden, MD (NUEM ‘24) **Edited by:** Em Wessling (NUEM ‘22) **Expert Commentary by**: Tim Loftus, MD, MBA

Expert Commentary

Thank you to Dr’s Blenden and Wessling for the excellent overview of ED CDUs including some background and indications for their use.

Several points to highlight and elaborate upon include the following:

The background of the utility of CDUs mostly stems from their early function as rapid diagnostic and treatment centers (RDTCs) for chest pain. The function and utility of CDUs have since grown to demonstrate clinical benefits well-established across a variety of conditions as Dr’s Blenden and Wessling have mentioned, including not only chest pain (rule out acute coronary syndrome) but also TIA, CHF, asthma, COPD, cellulitis, pyelonephritis, pneumonia, etc.

Value and Benefits

The utility and value of ED CDUs will continue to expand. The percentage of all hospital admissions that start in the ED continues to grow -- 67% in 2019, up from 58% in 2004 according to the ED Benchmarking Alliance. Additionally, EDs cared for approximately 158M people as of 2018 (EMNet/NEDI-USA), up 32% over a 10 year period. As the number of admissions continues to grow, and considering that some of these inpatient stays are short, it follows that many of these short inpatient admissions are subject to recovery audit contractors and payor denials. Many clinical conditions which are often subject to short inpatient stays can be cared for in dedicated short stay observation units without adversely affecting, and for the most part improving, the quality of care delivery, safety, satisfaction, cost savings, and reducing subsequent inpatient LOS.

All stakeholders in the health care system benefit from CDU use: patients are more accurately diagnosed before leaving the ED and are discharged home faster, payors avoid costly inpatient admission charges, hospitals keep scarce inpatient bed capacity open for more appropriate patients and avoid audits and denials, and providers deliver care in a setting that more appropriately matches patient needs to resources.

Dedicated Units with Protocolized Care

Observation patients can be managed in a variety of settings and contexts, but best practice that leads to best outcomes would be in dedicated observation units adherent to protocols tailored to the patients’ conditions, the best available evidence, and local institutional resources.

Shorter hospitalizations are more likely to occur in dedicated observation units under protocols than with unstructured hospitalization on inpatient teams and simply billing status changes to observation.

Financial Considerations

Much of the existing evidence has demonstrated that CDUs can provide care that efficiently utilizes resources and results in shorter hospital lengths of stay relative to other projects to expand capacity. Further, hospitals may realize decreased operating expenses for those patients subsequently discharged home from the CDU who have diagnoses or clinical conditions that are not as profitable for the hospital to manage in the inpatient setting - for example, CHF, which can often create a loss for the hospital. That being said, hospitals should be careful about shifting too much acute care into CDUs, because any CDU stay that subsequently results in inpatient admission (about 20% or so) are only paid by a single DRG, which includes that care provided for in the ED, CDU, and hospital unit. Thus, you can risk incurring additional costs without additional revenue. Finally, the duration of observation should exceed 8 hours only to justify the added expense of operating the CDU, because payors, including Medicare, generally do not pay clinical or facility fees for observation stays less than 8 hours.

Another consideration when estimating value created by a CDU is the increasing use by those who would have otherwise been discharged from the ED. It is important to consider the value of a CDU not only by the cost savings to the hospital and patient but also the possible supply-induced demand of health care services and overutilization of those services to a detriment.

CMS, and other payors, do not necessarily exclude payment from observation status patients whose stay lasted longer than 24 or even 48 hours. However, the profit margin and efficiency are reduced when patients are staying in the CDU that long, highlighting an opportunity to evaluate your particular unit’s effectiveness, efficiency, and patient selection.

Final Considerations

CDUs are not appropriate for all EDs, as only about 5-10% of ED patients have been found to be appropriate for a CDU, and in order to optimize operational and financial efficiency, a certain minimum number of beds and fixed costs would need to be overcome.

It is worth mentioning that protocol-driven CDUs in proximity to an ED with dedicated diagnostic and treatment algorithms, patient selection criteria, predetermined outcomes and end points have demonstrated the best outcomes with respect to cost savings, patient satisfaction, safety, and reduction in hospital LOS. For administrative and clinical operations leaders, tracking process and outcome metrics such as LOS, occupancy rate, discharge rate, and bed turns in addition to other clinical and quality outcomes will enable ongoing continuous optimization of the CDU.

Depending on the resources and throughout considerations of each hospital and health system, at times CDUs provide great benefit in being able to flexibly accommodate inpatient holds, pre or postoperative patients, or additional acute ED treatment space as the need allows. Design and construction with this in mind may enable the hospital to best accommodate ever changing dynamics - COVID being one example.

References

Emergency Medicine Network (EMNet). National Emergency Department Inventory – USA. https://www.emnet-usa.org/research/studies/nedi/nedi2018/. Accessed 1 Jan 2021.
Emergency Department Benchmarking Alliance (EDBA). Before there was COVID - 2019 Emergency Department Performance Measures Report. Accessed 1 Jan 2021.
Baugh CW, Liang L-J, Probst MA, Sun BC. National Cost Savings From Observation Unit Management of Syncope. Academic Emergency Medicine. 2015;22(8):934-941. doi: 10.1111/acem.12720.
Baugh, C. W., Venkatesh, A. K., & Bohan, J. S. (2011). Emergency department observation units: a clinical and financial benefit for hospitals. Health care management review, 36(1), 28-37.
Baugh and Granovsky - ACEP Now - https://www.acepnow.com/article/new-cms-rules-introduce-bundled-payments-for-observation-care/?singlepage=1
Making Greater Use Of Dedicated Hospital Observation Units For Many Short-Stay Patients Could Save $3.1 Billion A Year. Health Affairs. 2012;31(10):2314-2323. doi: 10.1377/hlthaff.2011.0926.
Ross MA, Hockenberry JM, Mutter R, Barrett M, Wheatley M, Pitts SR. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Aff (Millwood). 2013;32(12):2149-2156. doi: 10.1377/hlthaff.2013.0662.
Rydman RJ, Zalenski RJ, Roberts RR, et al. Patient satisfaction with an emergency department chest pain observation unit. Ann Emerg Med. 1997;29(1):109-115. doi: 10.1016/s0196-0644(97)70316-0.

Timothy Loftus, MD, MBA

Assistant Professor

Department of Emergency Medicine

Northwestern University

How To Cite This Post:

[Peer-Reviewed, Web Publication] Blenden, M. Wessling, E. (2021, Apr 12). ED Clinical Decision Making Units. [NUEM Blog. Expert Commentary by Loftus, T]. Retrieved from http://www.nuemblog.com/blog/ed-clinical-decision-making-units.

Pelvic Inflammatory Disease

Written by: Niki Patel, MD, MD (NUEM ‘22) Edited by: Luke Neill, MD (NUEM ‘20) Expert Commentary by: Gabby Ahlzadeh, MD — **Written by:** Niki Patel, MD, MD (NUEM ‘22) **Edited by:** Luke Neill, MD (NUEM ‘20) **Expert Commentary by**: Gabby Ahlzadeh, MD

Expert Commentary

Thanks for this clear and succinct post. The differential diagnosis of lower abdominal and pelvic pain is extremely broad in both premenopausal and post-menopausal women. This is when the sexual history becomes important. A question we often overlook as part of the sexual history is asking about dyspareunia, which may help differentiate gynecological from intra-abdominal causes of abdominal pain, specifically in the case of PID.

Patients with PID are frequently misdiagnosed with a urinary tract infection because they may have urinary symptoms, but the urinalysis often shows sterile pyuria, which should raise your suspicion for PID.

And while the utility of the pelvic exam is constantly scrutinized and questioned in patients with vaginal bleeding, it is impossible to diagnose PID without it. Having said that, the clinical diagnosis is only 65-90% specific so even minimal symptoms with no other explanation warrant antibiotic therapy to reduce further complications.

Underdiagnosis is even more significant in the adolescent patient population, who are at highest risk for developing PID. Over 70% of PID diagnoses among adolescents are made in the ED, with approximately 200,000 adolescents diagnosed annually. If the patient is accompanied by a family member or friend, having them step out to better elicit a sexual history is essential. HIV and syphilis testing should also be considered while these patients are in the ED.

Ensuring follow-up for these patients within 48-72 hours is essential and must be emphasized. Patients should understand the complications of PID and the importance of antibiotic compliance prior to discharge, especially in younger patients.

Gabrielle Ahlzadeh, MD

Clinical Assistant Professor of Emergency Medicine

University of Southern California

How To Cite This Post:

[Peer-Reviewed, Web Publication] Patel, N. Neill, L. (2021, Apr 5). Pelvic Inflammatory Disease. [NUEM Blog. Expert Commentary by Ahlzadeh, G]. Retrieved from http://www.nuemblog.com/blog/pelvic-inflammatory-disease

Ketamine Pain Control

Expert Commentary

Thank you both for your excellent overview of ketamine analgesia. For me, the biggest thing is recognizing it is just not a big deal, and the biggest challenge is people's hesitancy to use it because it seems like a bigger deal than it is.

The main principles I highlight:

It's not hard, basically just give 0.1-0.3 mg/kg (20 mg is a good dose for most people).

The key is to give it in a small bag of saline, eg just mix it in 100ml and hang wide open (over about 20 min). This was demonstrated nicely in by Motov and colleagues (https://pubmed.ncbi.nlm.nih.gov/28283340/) and also resonates with my experience with patients.

This slow infusion minimizes (but does not eliminate) dysphoria/"feeling of unreality" some people get, and a slow hand push just does not do the trick. I also aim for 0.2mg/kg as rounding up can get people in the K-hole which is no fun (this is probably the only exception to my general rule of always use more, not less, anesthesia)

Ideally it's nice to do that dose as a bolus and then the same dose as a drip (eg 20mg over 20 min, followed by 20 mg per hour) but many EDs are unable to do that.

The easy way I think about it: a single does essentially replaces a dose of IV morphine- it does not require any more monitoring or have any increased risk of resp depression etc over morphine; ACEP, SEMPA & ENA have a statement on this. (https://www.acep.org/patient-care/policy-statements/sub-dissociative-dose-ketamine-for-analgesia/) It's just simply not sedation or dissociation (hence the term "sub-dissociative") and I have gotten in the habit of calling it "ketamine analgesia."

Perhaps the biggest downside is that for really severe pain, it works well but sometimes only as it's actively dripping in.

The situations I think about using ketamine analgesia are severe pain with contraindications to opioids (eg a patient with a fracture with a history of OUD who does not want opioids) or patients with severe pain where high doses of opioids are not sufficiently helping (eg malignant fractures, severe burns).

Theoretically we could use SDK all the time but there's a chicken/egg problem: we don't use it much, so people aren't very comfortable (plus some other various institutional/historical discomfort with ketamine in some sectors); also, realistically it doesn't last as long as IV opioids. Ideally I would probably use bolus + drip frequently if there weren't barriers.

Dr. Seth Trueger, MD

Assistant Professor of Emergency Medicine
Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Leibowitz, M. McMauley, D. (2021, March 29.) Ketamine Pain Control. [NUEM Blog. Expert Commentary by Trueger, S]. Retrieved from http://www.nuemblog.com/blog/ketamine-pain-control.

SonoPro Tips and Tricks for Acute Cholecystitis

Written by: John Li, MD (NUEM ‘24) Edited by: Amanda Randolph (NUEM ‘21) Expert Commentary by: John Bailitz, MD & Mike Macias, MD — **Written by:** John Li, MD (NUEM ‘24) **Edited by:** Amanda Randolph (NUEM ‘21) **Expert Commentary by**: John Bailitz, MD & Mike Macias, MD

SonoPro Tips and Tricks

Welcome to the NUEM Sono Pro Tips and Tricks Series where Sono Experts team up to take you scanning from good to great for a problem or procedure!

For those new to the probe, we recommend first reviewing the basics in the incredible FOAMed Introduction to Bedside Ultrasound Book and 5 Minute Sono. Once you’ve got the basics beat, then read on to learn how to start scanning like a Pro!

Point of care right upper quadrant ultrasound has been shown to be a highly sensitive (82-91%), specific (66-95%), cost effective and efficient modality for emergency medicine physicians to quickly and effectively identify biliary pathology [1-5]. But despite its widespread utility, right upper quadrant ultrasound can often be a technically difficult study for the beginner sonographer, as there are multiple factors that can influence its ease of acquisition ranging from patient body habitus to bowel gas shadowing, and sonographer experience has been shown to influence its efficacy [1, 6-7].

Beyond the classic patient with right upper quadrant pain, what other scenarios do Sono-Pros use right upper quadrant ultrasound?

Epigastric abdominal pain being “diagnosed” and even over treated as GERD. Pick up the probe in the symptomatic patient taking their PPI, EGD negative, or already treated for H. pylori
Unexplained right shoulder or back pain.
Colicky pain in the right flank but no urinary findings of nephrolithiasis.
My gallstones are back! But my gallbladder is gone. Look for choledocholithiasis.
Chronically ill elderly or immunosuppressed patients with unexplained fever or sepsis.

SonoPro Tips - How to scan like a Pro

Always Start Smart: To Fail to Prepare is to Prepare to Fail whether in ED POCUS or ED Thoracotomy.

Start with the patient in either the left lateral decubitus position or supine with the bed at approximately 30 degrees.
Let the patient know “I’ll be asking you throughout this brief exam to take medium to deep breaths and hold for 5 sec, then automatically breathe out.”

Still not not getting great views?

Scan between the ribs to use the liver as an acoustic window and avoid bowel gas. Switch to a small footprint phased array probe if needed.
- Not sure which intercostal space to use? Try about 7 centimeters to the right of the patient’s xiphoid process!
Ask the patient to position their arms above their head to open the intercostal space.
Ask the patients to bend their knees to relax the abdominal muscles.
In young, thin patients, the gallbladder may be more anterior and superior-- if you are scanning subcostally, try flattening out the probe even more!

Even a Small Pain in the Neck can be a Big Problem!

Don’t forget the neck. There is a reason the gallbladder was so nicely distended and easy to find. Be sure to scan carefully in two orthogonal planes to pick up subtle stones in the neck of the gallbladder!
- If there is a lot of nearby bowel gas, tell your tech to look for these stones if your surgeons require a confirmatory comprehensive radiology ultrasound before operating.

In this GIF, you can see a long-axis view of the gallbladder. When you are initially looking at the body and the fundus of the gallbladder, there are no clear shadowing stones. However, as the sonographer fans to the neck of the gallbladder, they ca… — In this GIF, you can see a long-axis view of the gallbladder. When you are initially looking at the body and the fundus of the gallbladder, there are no clear shadowing stones. However, as the sonographer fans to the neck of the gallbladder, they can visualize multiple stones, which are casting shadows posteriorly. Image courtesy of the POCUS Atlas.

SonoPro Tips - Pro Pick Ups!

Is that a stone or is that something else in the gallbladder? Roll the patient and see if the “stone” moves!
- If the stone in the fundus or body moves, then it’s more likely a mobile stone.
- If it doesn’t move, then consider a polyp or a malignancy. Polyps or malignancies generally are non-shadowing while stones are shadowing!
- Impacted, “non-mobile” Neck Stone = Big Problem and likely to progress to acute cholecystitis.
What’s causing that shadow?
- Stones shadow posteriorly.
- Edges shadow on the sides. Edge artifact results when ultrasound beams scatter passing by a smooth-walled structure, creating an anechoic stripe that could be confused with true shadowing!
What if the entire gallbladder is casting a shadow?
- Think about a gallbladder FULL of stones! This will cause only the most anterior stones to show up on ultrasound.

Here, on the right side of the screen you see a cross section of the gallbladder that has a large stone in it-- this is casting a shadow so you do not see the posterior wall of the gallbladder at all. This is called the wall echo sign-- where you wi… — Here, on the right side of the screen you see a cross section of the gallbladder that has a large stone in it-- this is casting a shadow so you do not see the posterior wall of the gallbladder at all. This is called the wall echo sign-- where you will only see the most anterior surface of the stone. Image courtesy of the POCUS Atlas.

4. What are some of those pesky mimics of acute cholecystitis?

Think about hepatic pathologies! Acute hepatitis can cause a clinical Murphy’s sign. You can also have patients who present similarly when they have a congestive hepatopathy from their CHF. Even cirrhotic patients can present with a tender RUQ!

Here, you can see a dilated gallbladder with a thickened anterior wall and a small amount of pericholecystic fluid, all of which are consistent with acute cholecystitis. Image courtesy of the POCUS Atlas.

In this still image, you can see a thickened gallbladder wall (although be sure to measure the anterior wall, as the posterior wall can be thickened due to posterior acoustic enhancement!) and a small amount of pericholecystic fluid.  Image cou… — In this still image, you can see a thickened gallbladder wall (although be sure to measure the anterior wall, as the posterior wall can be thickened due to posterior acoustic enhancement!) and a small amount of pericholecystic fluid. Image courtesy of the POCUS Atlas.

Here, you can see a dilated gallbladder with an obstructing stone in the neck of the gallbladder. Image courtesy of the POCUS Atlas.

SonoPro Tips - What the Pro’s Do Next!

Infographic courtesy of Justin Seltzer, MD

If you see nonshadowing masses in the gallbladder:
- Measure it! If the polyp is >1cm, then there’s a ~50% chance that this could be malignant, so be sure to refer these patients for additional imaging and close follow up.
What if you’re hoping to be really thorough and get a beautiful image of the CBD, but despite your best efforts, you cannot find it?
- Draw some LFTs! A number of our emergency medicine colleagues, including Becker et. al and Lahham et. al, have done studies on this and it has been shown to be very unlikely that the CBD will be pathologically dilated in the setting of normal LFTs. On the flip side, if the LFTs appear cholestatic in nature, that’s another indication for a right upper quadrant ultrasound! [9-10]

SonoPro Tips - Where to Learn More

Do you want to see more pathologic images that you may see when you are doing a right upper quadrant ultrasound? Be sure to check out The Pocus Atlas by our expert editor Dr. Macias! It’s a great resource that also shows some of the rarer etiologies of gallbladder pathology, such as emphysematous cholecystitis or choledocholithiasis.

If you’re interested in looking at some of the evidence behind the right upper quadrant ultrasound, be sure to check out the evidence atlas here as well!

Expert Commentary

Thank you to NWEM1 John Li for bringing this great idea for a NUEM Blog Series to life. And another thanks to NUEM Blog Founder Mike Macias for his help on both content and graphics!

This new series is intended to push your Sono skills from just good, to really great. We will not rehash the basics. There are already abundant great resources available that we are truly thankful for and utilize everyday. But instead, we will share SonoPro Tips to help you more quickly master challenging POCUS applications and procedures.

And there is no place better to start than Acute Cholecystitis. This is a great differentiator between the average and the expert clinician sonographer. As John outlines, start smart by expanding your indications and positioning your patient properly from the get go. Then breath, not you, the patient. Breath and hold again and again to bring the gallbladder and even difficult to discern pathology into clear view. Go beyond getting stones, and work to pick up, and explain other pathologies, as well as the bile ducts when needed.

Thanks again John and Mike! Looking forward to the next post in this new series...

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

Michael Macias, MD

Global Ultrasound Director, Emergent Medical Associates

Clinical Ultrasound Director, SoCal MEC Residency Programs

How To Cite This Post:

[Peer-Reviewed, Web Publication] Li, J. Randolph, A. (20201 Mar 22). SonoPro Tips and Tricks for Acute Cholecystitis. [NUEM Blog. Expert Commentary by Bailitz, J. Macias, M]. Retrieved from http://www.nuemblog.com/blog/sonopro-tips-and-tricks-for-acute-cholecystitis

References

Jain A, Mehta N, Secko M, Schechter J, Papanagnou D, Pandya S, Sinert R. History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis. Acad Emerg Med. 2017 Mar;24(3):281-297. doi: 10.1111/acem.13132. PMID: 27862628.
Miller, Adam H., et al. “ED Ultrasound in Hepatobiliary Disease.” The Journal of Emergency Medicine, vol. 30, no. 1, 2006, pp. 69–74., doi:10.1016/j.jemermed.2005.03.017.
Shekarchi B, Hejripour Rafsanjani SZ, Shekar Riz Fomani N, Chahardoli M. Emergency Department Bedside Ultrasonography for Diagnosis of Acute Cholecystitis; a Diagnostic Accuracy Study. Emerg (Tehran). 2018;6(1):e11. Epub 2018 Jan 20. PMID: 29503836; PMCID: PMC5827043.
American College of Emergency Physicians: Emergency Ultrasound Imaging Criteria Compendium. Oct. 2014, www.acep.org/globalassets/new-pdfs/policy-statements/emergency-ultrasound-imaging-criteria-compendium.pdf.
Hilsden R, Leeper R, Koichopolos J, et al. Point-of-care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times. Trauma Surg Acute Care Open. 2018;3(1):e000164. Published 2018 Jul 30. doi:10.1136/tsaco-2018-000164
Ma, John, et al. Ma and Mateer's Emergency Ultrasound. McGraw-Hill Education, 2020.
Mallin, Mike, and Matthew Dawson. Introduction to Bedside Ultrasound: Volume 2. Emergency Ultrasound Solutions, 2013.
Macias, Michael. TPA, www.thepocusatlas.com/.
Becker BA, Chin E, Mervis E, Anderson CL, Oshita MH, Fox JC. Emergency biliary sonography: utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis. J Emerg Med. 2014 Jan;46(1):54-60. doi: 10.1016/j.jemermed.2013.03.024. Epub 2013 Oct 11. PMID: 24126067.
Lahham S, Becker BA, Gari A, Bunch S, Alvarado M, Anderson CL, Viquez E, Spann SC, Fox JC. Utility of common bile duct measurement in ED point of care ultrasound: A prospective study. Am J Emerg Med. 2018 Jun;36(6):962-966. doi: 10.1016/j.ajem.2017.10.064. Epub 2017 Nov 20. PMID: 29162442.

Posted on March 22, 2021 by NUEM Blog and filed under Ultrasound and tagged ultrasound gallbladder abdominal pain abdominal ultrasound SonoPro.

Health Risks Imposed by the Beach

Written by: Alex Herndon, MD (NUEM ‘21) Edited by: Ashley Amick, MD, MS (NUEM ‘18) Expert Commentary by: Patrick Lank, MD — **Written by:** Alex Herndon, MD (NUEM ‘21) **Edited by:** Ashley Amick, MD, MS (NUEM ‘18) **Expert Commentary by**: Patrick Lank, MD

With warm weather fast approaching, it’s time to break out the sunscreen and beach gear. Besides protecting oneself from UV rays and heat exhaustion, there are other dangerous pathogens lurking in the sandy shores that are worth being aware of as patients begin to flood the Emergency Department during summer vacation. Here are a few dangerous diseases to consider that masquerade as common chief complaints.

1. More than just swimmer’s itch

A 17 year old female presents to the Emergency Department complaining of a patchy skin rash that developed only a couple days after her first swim of the summer. Freshwater lakes house trematode parasites that upon contact leads to cercarial dermatitis, otherwise known as “swimmer’s itch”. Symptoms typically develop 2 days after exposure and last a week. Relief can be easily obtained with antihistamines and corticosteroid cream. [1]

Now consider that same patient is returning from a trip from Key West, Florida for a Bachelorette Party. You notice that her legs are shaved and there are several small nicks around her ankles. She is presenting with a worsening red rash on her lower leg that is red, warm, blistering, and in some locations has formed superficial ulcers. While it can be easy to chalk this us to severe sunburn and possible superimposed cellulitis, it is important not to miss this deadly necrotizing skin infection caused by Vibrio vulnificus, commonly known as one of many “flesh-eating bacteria.” Unlike the more benign trematode, V vulnificus can be found in brackish or saltwater, and in North America most commonly in the Gulf of Mexico. [2] V vulnificus infects wounds and leads to skin breakdown and ulceration and if not treated immediately infection has a mortality rate of anywhere from 25-50%. [3] Given the virulence of the disease, it is important to treat early and aggressively. The mainstay treatment for V vulnificus includes intravenous 3rd generation cephalosporins along with a tetracycline such as doxycycline. Source control becomes prudent and may require surgical debridement. [4]

2. “It’s just a cough”

With the warm weather finally here, a 60 year-old retiree began breaking in his paddle board along the shores of Lake Michigan. To cool off afterwards, he would hit the public beach showers. One week later he shows up at the Emergency Department complaining of body aches, low grade fevers, and a cough that won’t quit. While the bacteria Legionella pneumophila is typically associated with hot tubs, don’t forget other warm freshwater places this microbe loves to grow, including beach showers, air-conditioning units, and outdoor misters like those seen at amusement parks and sporting events. [4] People fall ill after inhaling aerosolized droplets from the contaminated sources.

Pontiac fever is a mild form of Legionella infection, presenting as vague flu-like symptoms that typically resolve in 2 to 4 days without treatment. However, the more severe form of infection, commonly known as Legionnaires disease, presents as pneumonia with cough, fever and myalgias. Unlike other bacterial pneumonias, Legionnaires is also more commonly associated with gastrointestinal symptoms like nausea, vomiting, and diarrhea, and can also cause hyponatremia. On average 15% of cases per year have been fatal, thus never forget to start atypical coverage for pneumonia, such as azithromycin, which provides adequate coverage for Legionella infection. [5] And if Legionella is diagnosed or highly suspected, alerting local health authorities is important because early containment of possible sources, such as public showers, is imperative to preventing a deadly outbreak.

3. Beyond febrile seizures

A 10 year-old boy is sent to sailing camp in Wisconsin. While he was well upon arrival, after only 3 days his parents get a call that their son has been hospitalized. His camp counselors brought him to the ED after he became febrile and had a seizure a day after capsizing in the lake. They reported throughout the day the boy had been complaining of a headache and was increasingly lethargic. Typically the constellation fever, headache, altered mental status, and seizure heralds bacterial meningitis. However given this child’s unique summer camp experience, one must consider other environmental exposures that pose a risk.

While rare, warm freshwater lakes can house the deadly Naegleria fowleri, more commonly known as “the brain-eating amoeba.” [6] This amoeba enters via the swimmer’s olfactory nerve, reaching the brain where it causes primary amebic meningoencephalitis (PAM). Patients present within 1 day to 2 weeks after exposure, first with flu-like symptoms including fever, headache and vomiting, that eventually progress to involve hallucinations and seizures. Similar to any patient presenting with symptoms concerning for meningitis, performing a lumbar puncture is key in making the diagnosis. N fowleri can be identified within cerebral spinal fluid either via direct visualization, antigen detection or PCR. While the majority of cases have been fatal, with a fatality rate of nearly 98%, survival is possible if identified and treated early with miltefosine, an anti-leishmania drug. [7]

During these warm summer months it is vital to understand where your patients have been and what they have been doing because knowing those details can end up saving their lives.

Expert Commentary

Thank you Drs. Herndon and Amick for these wonderful reminders that there are more things to be afraid of at the beach than sharks (and/or Sharknados). While this blog post contains great tidbits on three diagnoses, I think these cases also highlight times when a careful focused clinical history changes the emergent work-up and treatment. These patients could have easily been diagnosed with another condition and had their definitive care delayed, so thank you for these reminders.

As a native Floridian who grew up within walking distance of the Atlantic Ocean, I think there are a few additional entities for the emergency physician to consider when treating beachgoers. My medical toxicology training is begging me to direct this commentary towards my wheelhouse, but I will resist and will be sure to mention some other diagnoses.

But to start, I have to bring up intoxication. For those readers who do not live in the Midwest of the United States, I want to make you aware that Chicago has a wonderful series of beaches. Having been working in an emergency department in Chicago for 15 years now, I also have to point out that the number one reason patients are brought to the ED from a beach is for alcohol intoxication. Higher temperatures, increased thirst, increased physical activity, prolonged drinking, and possible co-ingestion of other mind-altering substances all increase the chances that a day at the beach will end in the ED. So be careful, warn your teenage/twenty-something family members, and consider checking an ethanol concentration in altered beachgoers.

The geographic proximity our ED has to the beach and Lake Michigan also means we see a lot of drownings. Some are intentional, others accidental; some are associated with traumatic injuries, others with intoxication; some patients are pediatric, some are geriatric. Despite their variations, all drowning should be taken seriously and involve aspects of resuscitation that are worth reviewing when you get a chance. Although it is now a few years old, I recommend reading the review article “Drowning” by D Szpilman, et al. from NEJM in 2012 (DOI: 10.1056/NEJMra1013317). It’s a great review with some helpful references for people interested in reading more.

Finally I would recommend anyone working in a clinical environment where the weather is about to turn warmer should review the clinical features and resuscitation of patients with heat-related injuries and superficial burns. When I was a PGY-1 in Chicago and had my first patient check in with a sunburn, I was in complete shock. Why did this person not know homecare for a sunburn? Easy, I thought: lots of aloe, move like a mummy for a day, and bathe in self-loathing and regret. But years of experience in a northern clime have taught me that changes in seasons are particularly dangerous for these injuries – people are out of practice, they forget, or they simply don’t care. No matter the reason, these early parts of the season are when we see big upticks in significant presentations.

In summary, thank you again for bringing up these infectious complications of having fun at the beach. But if you want to scare some sense into your 15-year-old nephew, don’t only tell him about Naegleria fowleri – please also terrify him with stories of overdoses, drowning, and severe hyperthermia.

Patrick Lank, MD, MS

Assistant Professor of Emergency Medicine

Medical Toxicologist

Department of Emergency Medicine

How To Cite This Post:

[Peer-Reviewed, Web Publication] Herndon, A. Amick, A. (2021, Mar 15). Health Risks Imposed by the Beach. [NUEM Blog. Expert Commentary by Lank, P]. Retrieved from http://www.nuemblog.com/blog/health-risks-imposed-by-the-beach.

References

Parasites: Cercarial Dermatitis. Centers for Disease Control and Prevention. 2012 January. <https://www.cdc.gov/parasites/swimmersitch/faqs.html>
Thompson, H. Eight diseases to watch out for at the beach: “Flesh-Eating” bacteria. The Smithsonian. 2014 August. <https://www.smithsonianmag.com/science-nature/diseases-watch-out-beach-18095234 6/>
Horseman, M. Surani, S. A comprehensive review of Vibrio vulnificus: an important cause of severe sepsis and skin and soft-tissue infection. Int J Infectious Diseases. 2011 March: 15(3): 157-166.
Thompson, H. Eight diseases to watch out for at the beach: Pontiac Fever and Legionnaires Disease. 2014 August. <https://www.smithsonianmag.com/science-nature/diseases-watch-out-beach-180952346 /#mftUupdDj 5cwE00L.99>
Healthy Swimming: Respiratory Infections. Centers for Disease Control and Prevention. 2016 May. <https://www.cdc.gov/healthywater/swimming/swimmers/rwi/respiratory-infections.html>
Thompson, H. Eight diseases to watch out for at the beach: “Brain-Eating” Amoeba. The Smithsonian. 2014 August. <https://www.smithsonianmag.com/science-nature/diseases-watch-out-beach-180952346 /#mftUupdDj5cwE00L.99>
Parasites: Naegleria fowleri - Primary Amebic Meningoencephalitis - Amebic Encephalitis. Centers for Disease Control and Prevention. 2017 February. <https://www.cdc.gov/parasites/naegleria/pathogen.ht ml>

Posted on March 15, 2021 by NUEM Blog and filed under Environmental and tagged wilderness medicine envi infectious disease antibiotics.

Felon

Expert Commentary

Thank you for the handy concise reference for felon management. Some key points of emphasis and elaboration:

A TENSE distal finger pad is what distinguishes a felon from other finger infections. A paronychia can be the portal of entry (as in this case https://www.ortho-teaching.feinberg.northwestern.edu/cases/hand/case14/index.html) . However, a paronychia alone should not cause a TENSE finger pad so check the finger pad before diagnosing a finger infection as a simply a paronychia. Flexor tenosynovitis is not localized to the distal pad and should be readily distinguishable from a felon, which is localized. Whitlow may be confused for a purulent infection but is cutaneous and again, will not have a TENSE pad.

The felon itself is an intense throbbing pain and the procedure is extensive so analgesia is a major point of emphasis for successful management.

The key to understanding the nature and treatment of a felon is knowledge of the anatomy of the distal finger. There are 15-20 discrete, noncompliant, tough fibrous septae of the finger pad which run from the periosteum to the skin. The abscess of a felon affects these unforgiving septae, which is why is it so painful. The incision must enter the septae and the dissection must break up the remaining septae to completely drain the infection. Other abscesses we drain may have loculations but not the tough septations of a felon. So the dissection must be firm enough to break these septations.

There are many different (and interestingly named) incisions that have been described to decompress a felon, like the “hockey stick” (https://lacerationrepair.com/felon-hockey-stick/) or the “fish mouth” (https://lacerationrepair.com/felon-fish-mouth/). Many sources prefer lateral approaches over volar approaches. The volar approaches incise directly through the highly innervated pad and residual paresthesia affecting finger function is a concern.

Be aware that you are dissecting just volar to the phalanx to get into these septae, so this is deep. If the etiology of the felon is direct extension from a paronychia, drain the paronychia first and see if you can access the felon by dissecting through the paronychia tract. Afterwards, insert packing or a drain. I have even seen consultants make bilateral incisions and feed a drain all the way through to facilitate drainage.

Refer all of these patients to hand clinic. One patient I had who was lost to follow up returned to the ED weeks later with osteomyelitis of the distal phalanx (https://www.ortho-teaching.feinberg.northwestern.edu/cases/bone-lesions/case4/index.html).

Matthew R Levine, MD

Associate Professor of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Levine, D. LaPlant, W. (2021, March 8). Felon. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/felon.

Paronychia

Expert Commentary

While paronychia is commonly seen in Urgent Care and Fast Track settings, this is a condition that some EM residents may not get much exposure to during their training. Knowledge of minor conditions such as this may not match the excitement of a critically ill patient, but it is an essential skill set for every EM physician.

The biggest pitfall I have seen in treating paronychia is failure to drain a patient who has a clear fluid collection. Providers not trained to perform the procedure will often give oral antibiotics as treatment, but once purulence has developed these will be ineffective without drainage. We tend to see a fair number of patients who have already been on antibiotics but have failed to improve.

If you see a patient without signs of abscess, provide proper instruction above on soaking and topical antibiotic ointment, but be sure to provide anticipatory guidance that it may still worsen and require drainage - just not yet. Patients appreciate knowing your thought process on why you are providing specific treatment based on their presentation.

When draining a paronychia, I prefer to use an 11 blade laid flat on the nail to make a small incision, then lifting the skin slightly away from the nail. While some tolerate the procedure well, I do offer a digital block to alleviate any apprehension. For those with more extensive involvement, you may place a wick with a short piece of 1/4" iodoform and have the patient remove it in 1-2 days. Be sure to offer a wound check in 48 hours - either in the ED or an urgent care if available. Counsel the patient that the finger will not look completely normal for 1-2 weeks but we want to see a steady improvement over that time.

Although infrequent, patients with diabetes or vascular disease can have further complications, such as an ascending cellulitis, evolution into a deep space infection of the digit, or even osteomyelitis. While the amount of pain typically drives patients to seek care sooner, patients with certain conditions (ie substance abuse, poor access to care, AMS) may go unrecognized for a longer period leading to more serious infection. Complicated cases like this should have imaging (xray) and consultation with a hand surgeon.

Matthew Kippenhan, MD

Medical Director, Emergency Department

Northwestern Memorial Hospital

Assistant Professor, Feinberg School of Medicine

Northwestern University

How To Cite This Post:

[Peer-Reviewed, Web Publication] Castillo, R. Farcas, A. (2021, Mar 1). Paronychia. [NUEM Blog. Expert Commentary by Kippenhan, M]. Retrieved from http://www.nuemblog.com/blog/paronychia.

Knee Dislocation

Written by: Andrew Rogers, MD, MBA (NUEM ‘22) Edited by: Amanda Randolph, MD (NUEM ‘21) Expert Commentary by: Matt Levine, MD — **Written by:** Andrew Rogers, MD, MBA (NUEM ‘22) **Edited by:** Amanda Randolph, MD (NUEM ‘21) **Expert Commentary by**: Matt Levine, MD

Introduction

Tibiofemoral dislocations are a relatively uncommon injury with high risk of morbidity to patients, and therefore represent an injury that the Emergency Physician should familiar with diagnosing and treating. The incidence of knee dislocation is quite low, representing approximately 0.02% of all orthopedic injuries. [1] Morbidity is high, with rates of vascular injury of 7-40%, neurologic injury of 5-40%, and amputation rates of around 12%. [2,3] Delays in identifying vascular injury >8 hours can result in higher rate of amputation approaching 86%. [3,4] Timely identification, treatment, and disposition directly impacts patient’s lives and limbs.

Anatomic Review

The knee is stabilized by ligaments, tendons, muscles, menisci, and cartilage. Figure 1 highlights key anatomic structures that stabilize the knee joint, including the major ligaments of the ACL, PCL, MCL, and LCL. These ligaments, in various combinations, are disrupted in knee dislocations.

The neurovascular anatomy is also important to review and understand (Figure 2). The popliteal artery courses posterior to the joint and is tethered both proximally (at the tendinous hiatus of the adductor magnus) and distally (at the tendinous arch of the soleus muscle), making it susceptible to injury. [2] The sciatic nerve divides into the tibial and common peroneal nerves proximal to the popliteal fossa, with the common peroneal nerve tethered about the fibular neck. This attachment similarly increases the risk of common peroneal nerve injury. [2]

Figure 1: Structural Anatomy of the Knee [5]

Figure 2: Neurovascular Anatomy of the Knee [6]

Mechanism of injury

The mechanism of a knee dislocation can be high-energy, low-energy, or ultra-low energy. [2]

High energy: MVCs, falls from heights, crush injuries – ~50% of knee dislocations
Low energy: Sports injuries – ~33% of knee dislocations
Low energy: Falls from standing - ~10% of knee dislocations
Ultra-low energy: ADLs in morbidly obese (BMI >40) population [7, 8]

Classifications of Knee Dislocations

Two main classifications are used to categorize knee dislocations. [2] The Kennedy Classification defines the injury based on the direction of displacement of the tibia relative to the femur (Figure 3) The Schenck Classification is based on the pattern of ligamentous injury, with the Wascher modifications specifying lateral ligaments ruptured (Figure 4).

Figure 3: Kennedy Classification of knee dislocations with example illustrations [9]

Figure 4: Schenck Classification System with Wascher Modification [2]

ED Evaluation

Approximately 50% of knee dislocations spontaneously reduce so the Emergency Physician should maintain spontaneously reduced knee dislocation on their differential in all patients presenting with knee pain, especially for the obese patient with an ultra-low energy mechanism. [2, 3] Figure 5 is a summary diagram from Gottlieb, et al summarizing the algorithm for evaluation and management of knee dislocations.

Figure 5: Algorithm for the evaluation and management of knee dislocations in the Emergency Department [10]

History

Some historical details to inquire about include:

Mechanism of injury
Sensation of instability
Deformity at any point in time
History of injury or surgery to the joint
Timing of injury

Initial Physical Exam

As 50% of dislocations spontaneously reduce or due to an obese patient population, there may not be an obvious physical deformity. Key points to include (and document) on the physical exam include: [3, 10]

Gross deformity
Vascular exam
- Assess for presence of dorsalis pedis and posterior tibialis pulses
- Look for hard signs of vascular injury: pallor, coolness, pulsatile hematoma, pulsatile hemorrhage, palpable thrill, audible bruit, absent or diminished pulses
Neurologic exam
- Sensory and motor deficits
- Signs of common peroneal nerve injury:
  - Sensory deficit to lateral leg and dorsal foot
  - Inability or weakness in eversion and dorsiflexion of foot
Skin exam
- Look for pinched, discolored, tented, or threatened skin
- Assess for open dislocation or fracture
- Bruising without effusion suggests capsule disruption – may hint toward dislocation [11]
Ligamentous laxity
- May be limited by pain, effusion, or deformity
Compartments exam

In high-energy mechanisms, consider other injuries as a knee dislocation may be distracting, or consider careful examination of the knee if other injuries limit history (for example a head injury sustained in an MVC).

Initial imaging

AP and lateral radiographs of the knee
Recommended to also obtain radiographs of femur, tibia and fibula, as well as ankle and hip joints, although additional radiographs should not delay closed reduction if indicated, and may be obtained after reduction of the knee [11]
If patient cannot tolerate plain films, can consider urgent CT
Assess for dislocation and fractures (Figure 6)
Some subtle signs of spontaneously reduced knee dislocation include: [11]
- Widening of medial joint space on AP film
- Segond fracture – avulsion fracture of lateral tibial plateau which is frequently associated with ACL disruption (Figure 7)
- Fibular head avulsion fracture (AKA arcuate fracture) – avulsion of LCL or arcuate ligament complex (Figure 7)

Figure 6: Posterior knee dislocation [13]

Figure 7: Segond fracture with red circle showing lateral tibial plateau avulsion fracture [14]

FIgure 7: Fibular head avulsion fracture with white arrow showing avulsed fragment [15]

Reduction

Once the diagnosis of knee dislocation is made, reduction should be attempted in the Emergency Department under adequate analgesia and conscious sedation. Early orthopedics consultation is recommended. Reduction technique requires at least two team members to perform, and involves reversing the mechanism of injury (Figure 8). [3, 10] One team member stabilizes the distal femur while the other team member provides in-line traction on the lower leg. If this is unsuccessful, then apply anterior or posterior pressure to the proximal tibia and/or distal femur with in-line traction still applied to facilitate relocation. Avoid applying pressure to the popliteal fossa, which may cause or worsen neurovascular injury. Some knee dislocations may not be reducible in the Emergency Department and may require open reduction by orthopedics in the operating room.

Post reduction

After successful reduction, splint in 20 degrees of flexion and/or use a knee immobilizer to stabilize the joint. [3, 10] Cut out windows in the splint to perform regular neurovascular checks. Prior to splint placement, consider full ligamentous examination while the patient is under conscious sedation prior to splinting to assess ligamentous injury.

Repeat evaluation of neurovascular status is imperative. Evaluation of peripheral pulses is key, but normal pulses may not rule out vascular injury due to collateral flow about the knee. [16, 17] An Ankle-Brachial Index (ABI) should be obtained in all patients (Figure 9). An ABI is <0.9 has been shown to be 100% sensitive for vascular injury requiring operative repair. [3] Patients with an ABI >0.9 still require close monitoring and repeat exams.

Some authors advocate for angiography in all knee dislocations while others advocate for angiography only in those with an abnormal ABI. [3, 17, 19] Given the time-sensitivity of a vascular injury threatening the limb, early consultation with vascular surgery in patients with concern for vascular injury is recommended. Vessel imaging should never delay operative intervention if indicated. [3]

Options for vessel imaging include:

CTA – quick and readily available in the ED with high sensitivity (95-100%) and specificity (99.7-100%) [10]
Direct or selective angiography – considered standard of care but is invasive and introduces risks of vessel cannulation.
Duplex ultrasonography – has good sensitivity (95-100%) and specificity (97-100%) but is operator dependent, may miss small intimal injuries, and availability may be limited. [10]

Disposition

Emergency surgery is indicated for:

Open dislocation
Irreducible dislocation
Ischemic limb
Vascular injury
Compartment syndrome

All patients not taken to the operating room for emergent exploration should be admitted for at least 24 hours of neurovascular and compartment checks. [3,10] The knee should be immobilized as described above, with the leg made non-weight bearing. If evidence of common peroneal nerve injury, will need ankle-foot orthotics and physical therapy. Nearly all knee dislocations will require eventual reconstruction 2-3 weeks post-injury with nerve exploration and repair as indicated at that time. [19]

Summary and Key Points

Knee dislocations are rare but significant injuries that require time-sensitive diagnosis and management.
There is high morbidity, with up to 40% vascular and/or nerve injury, and up to 10% leading to amputation.
Consider early consultation with orthopedic surgery and vascular surgery, as appropriate
Early closed reduction in the Emergency Department is key, with appropriate post-reduction immobilization
The neurovascular exam is critical, both pre- and post-reduction
All patients should have an ABI check post-reduction, regardless of the presence of a pulse, with vessel imaging pursued in those with abnormal ABI
All patients require admission for neurovascular and compartment checks

Expert Commentary

Thank you, Dr. Rogers, for providing an excellent comprehensive review of knee dislocations. Over the course of my career in the last 20+ years, imaging workup for knee dislocations has evolved substantially. It used to be dogma that all knee dislocations get traditional IR angiography. This was based on reports of undiagnosed popliteal artery thrombosis, where patients presented with a clinically and radiographically reduced knee and a palpable dorsalis pedis pulse that progressed to ischemic compartment syndrome and amputation. This paradigm has shifted because:

More recent studies indicate that the true incidence of popliteal artery injury is 7.5-14%. This is lower than initial older data suggested. [1, 2, 3]
The vast majority of intimal tears do not progress
CT angiography has emerged as a less invasive and highly sensitive option.
Emerging data have shown that observation periods for serial pulse checks and ABIs are highly sensitive for detecting clinically significant vascular lesions.

Remember that the first priorities in knee dislocations are rapid diagnosis and reduction. Reduction can restore absent pulses. Remember the algorithm provided by Dr. Rogers depends on what the vascular exam is AFTER reduction, not before.

Time sensitivity for those cases with vascular deficits cannot be emphasized enough. Delay dramatically affects outcome. Residual amputation rates post-surgery are 10%. [1] In cases of delay exceeding 8 hours, amputation rates have been reported to reach as high as 86%. [4] If required, on-table angiography in the operating theatre, rather than in radiology, has been reported to save 3 hours. [5, 6] So patients with ischemia/pulselessness after reduction need to be taken emergently to the OR, not to the CT suite.

Magnetic resonance (MR) angiography has been proposed as an alternative to define the vascular anatomy and diagnose asymptomatic vascular lesions, particularly as all these patients are likely to have MRI at some point to define the extent of ligamentous injury. In a small series of knee dislocations, findings were comparable to traditional angiography. Consider advocating for this when your consultant suggests CTA for patients with normal vascular exams and ABIs.

References:

Boisrenoult P, Lustig S, Bonneviale P, et al. Vascular lesions associated with bicruciate and knee dislocation ligamentous injury Rev Chir Orthop Traumatol, 9 (2009), 621-626.
Harner CD, Waltrip RL, Bennett CH, et al. Surgical management of knee dislocations J Bone Joint Surg Am, 86 (2004), 262-273.
Rios A, Villa A, Fahandezh H, et al. Results after treatment of traumatic knee dislocations: a report of 26 cases J Trauma, 5 (2003), 489-494.
Green NE, Allen BL. Vascular injuries associated with dislocation of the knee J Bone Joint Surg Am, 5 (1977), 236-239.
Lim LT, Michuda MS, Flanigan DP, Pankovich A. Popliteal artery trauma 31 consecutive cases without amputation Arch Surg, 11 (1980), 1307-1313.
Ottolenghi CE. Vascular complications in injuries about the knee joint Clin Orthop Relat Res (1982), 148-156.

Matthew R Levine, MD

Associate Professor of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Rogers, A. Randolph, A. (2021, Feb 22). Knee Dislocation. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/knee-dislocation.

References

Rihn, et al. “The acutely dislocated knee: Evaluation and management.” Journal of the American Academy of Orthopaedic Surgeons. 2004;12(5):334-346
Medina, et al. “Vascular and Nerve Injury After Knee Dislocation: A Systematic Review.” Clinical Orthopaedics and Related Research. September 2014. 472 (9): 2621-2629.
Boyce, et al. “Acute Management of Traumatic Knee Dislocations for the Generalist.” Journal of the American Academy of Orthopaedic Surgeons.” December 2015. 23(12):761-768
Patterson et al. “LEAP Study Group: Knee dislocations with vascular injury: Outcomes in the Lower Extremity Assessment Project (LEAP) Study.” Journal of Trauma 2007;63(4):855-858
“Knee Diagram.” Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Knee_diagram.svg
Morcos, et al. “Popliteal lymph node dissection for metastatic squamous cell carcinoma: A case report of an uncommon procedure for an uncommon presentation.” World Journal of surgical Oncology. October 2011. 9(1):130
Azar, et al. “Ultra-Low Velocity Knee Dislocations.” American Journal of Sports Medicine. October 2011. 29(10):2170-4.
Vaidya, et al. “Low-Velocity Knee Dislocations in Obese and Morbidly Obese Patients” Orthopaedic Journal of Sports Medicine. April 2015. 3(4).
Lasanianos, et al. “Knee Dislocations”. Trauma and Orthopaedic Classifications. Springer-Verlag London 2015. pp339-341.
Gottleib et al. “Evaluation and Management of Knee Dislocation in the Emergency Department.” The Journal of Emergency Medicine. November 2019. 58(1) 34-42.
Lachman, et al. “Traumatic Knee Dislocations: Evaluation, Management, and Surgical Treatment.” Orthopedic Clinics of North America. October 2015. 46{(4):479-93
Murphy, Andrew. “Lateral Knee Dislocation”. Wikimedia Commons. 20 May 2017. https://commons.wikimedia.org/wiki/File:Lateral-knee-dislocation-1.jpg
Duprey K and Lin M. “Posterior Knee Dislocation”. Wikimedia Commons. 2 February 2010. https://commons.wikimedia.org/wiki/File:PosteriorKneeDIsclocation.jpg
Ellisbjohns “Segond Fracture”. Wikimedia Commons. 2 November 2009. https://commons.wikimedia.org/wiki/File:SegondFracture.JPG
Thrush, et al. “Fractures Associated with Knee Ligamentous Injury.” Complex Knee Ligament Injuries, pp149-159. January 2019.
McDonough, E. and Wojtys E. “Multiligamentous injuries of the knee and associated vascular injuries”. American Journal of Sports Medicine. January 2009, 37 (1):156-9
Barnes et al. “Does the pulse examination in patients with traumatic knee dislocation predict a surgical arterial injury? A meta-analysis.” Journal of Trauma; Injury, Infection, and Critical Care. December 2002. 53(6):1109-14.
Jmarchn. “Ankle-Brachial Index” Wikimedia Commons. 14 February 2014.https://commons.wikimedia.org/wiki/File:Pad_abi_ENG.svg
Fanelli, Gregory C. “”Knee Dislocation and Multiple Ligament Injuries of the Knee.” Sports Medicine and Arthroscopy Review. December 2018. Issue: Volume 26(4), p150-152.
Henretig, et al. “Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins. 1997. P1098. https://aneskey.com/knee-dislocation-and-reduction/

Posted on February 22, 2021 by NUEM Blog and filed under Orthopedics and tagged orthopedics sports medicine ortho.

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