Life in the Fast Lane Medical Blog &#187; Trauma

Trick of the Trade: Minimizing propofol injection pain - great tips inspired by Andy Neill’s recent contribution to R&R In The FASTLANE.
Paucis Verbis: Pediatric fever without a source (Birth-28 days) - A nice approach guaranteed to come in handy!

Joe’s pick of the week is by Karl Nibbelink on the difficult topic of I Suspect My Colleague Is Using Drugs: What should I do?

“Legal Highs”: new psychoactive drugs - not the greatest article on new psychoactive drugs – but provides some useful facts.
Honey Don’t: grayanotoxins, sex, and affairs of the heart - this honey is most probably not something to spread on your toast. This is an amazing pair of cases.
Bath salts and necrotizing fasciitis: a case report - you have been warned!

Emergency Physicians Monthly.

Left ventricular Aneurysm Morphology Distorted by Right Bundle Branch Block – Mimicking Acute STEMI with RBBB.
Chest pain and hypotension in a patient who is 3 weeks post STEMI - is the patient having ongoing ischaemia or a complication post-STEMI?

11 Benchmarks That Should Matter to EPs. Take home point: Benchmarks serve no purpose if they do not reflect the needs and perceptions of all the stakeholders.
Sickle Cell: 10 Things Every EP Should Know about SCD.

You are twice as likely to die when flying on this aircraft – You wouldn’t fly on this plane with that risk- but patients that attend the emergency department are exposed to the same risk.
53 secrets the ED staff won’t tell you – What there is only 53??
Ian gives a tribute in praise of our wardsmen (and women).

empem.org

Colin and team delve into controversy in this week’s podcast when discussing ISAAC blows wheezy whistle on APAP.

The Rest Of The Best

CLIC-EM

Some excellent little pearls and pitfalls on a common ED resus medication - Know Before You Push — Adenosine - remember help your electrophysiologist out get a good ECG before giving.

Intensive Care Network

Craig Hore shares with us an interesting case in Emergency Pacing - and shares with us some excellent pitfalls in for transcutaneous pacing.

Further Harms of IV Contrast - Just in case you needed another reason to not order a contrast CT.
The Harmful Rush To Hypothermia - Hard to know what to actually do with data. Is early hypothermia truly harmful?

Consult Skills 2: When Agendas Collide or “Physician Know Thyself” – Casey shares his approach to the difficult patient or the difficult conversation.

Michael Winters pearl of the week - SAH and Pulmonary Edema – Think Twice About Diuresis!

Delayed cerebral ischemia (DCI) is the most common cause of secondary neurologic injury in patients with aneurysmal subarachnoid hemorrhage (SAH).
Intravascular volume depletion is one of several factors thought to cause, or worsen, DCI.
Pulmonary edema frequently occurs in patients with SAH.
A recent study in patients with SAH and pulmonary edema demonstrated that many were not volume overloaded. In fact, many were intravascularlyvolume depleted.
Think twice about aggressive diuresis in patients with SAH and pulmonary edema, as this may exacerbate volume depletion and may worsen DCI.

Emergency in the Shed

David smashes out another brilliant podcast episode when he teams up with anaesthetic consultant Simon Pattullo to provides us with an approach to the ‘Can’t Intubate – Can’t Ventilate” scenario – check out Airway-Preparing to Fail.

Revitalising Professionalism - “The fact that medicine rarely cures many of the diseases that we attend to makes it even more morally significant.”
Anatomy for Emergency Medicine – #5 CSF Circulation

Anatomy for Emergency Medicine – #5 CSF Circulation from Andy Neill on Vimeo.

EmergSource.com

Learning to learn - The secret to life long learning is simple. Everyday, and every patient ask yourself ‘Could I have done that better?’

Pediatric Emergency Medicine Morsels

Amit shares with us some of his revision notes on Radiation Illness and High Altitude Illness.
Management of The Mangled Extremity - a new algorithm approach from some recently published literature.
As Australian’s continue to have a love affair with Bali – ED doc’s and nurses need a good understanding on Saturday Night Dengue Fever & Staying Alive - Worth reading!
Bleeding Hell! Dabigatran is Here. Forget the Vit K or prothrombinex its straight of to dialysis for these patients!

This weeks morsel is on how to rotate back the Malrotation.

EMdose

Vasopressors in Neurogenic Shock - Remember: shock in a trauma patient should be presumed to be secondary to hemorrhage until proven otherwise. If you’re certain it’s neurogenic shock, then optimize BP with crystalloid fluids, followed by a pressor as above to increase your MAPs and increase spinal perfusion.
Hypothermia in Trauma - Until further word, preventing and correcting hypothermia is recommended.

The Societal Cost of ED Thoracotomy - Bottom line: use the guidelines and save your own health, safety and hospital resources. Is it really worth it if you know the patient will not survive?
Can Lead Poisoning Occur After A Gunshot? - Not something you come across every day, but some important pearls and pitfalls here on treatment options.
A Cool Way To Remove Embedded Foreign Bodies - This is a very slick technique that promises to dramatically increase the success rate and decrease complications from removing foreign bodies.

More Musings (of a Distractible Kind)

Septic Arthritis and Arthrocentesis - Although arthrocentesis is not a risk-free procedure, synovial fluid analysis is essential for the diagnosis.

Good Things in Medicine #2: Puzzles – Problem solving is central to being a good diagnostician. The quirky and insightful Rob Lambert tells us why diagnosis is cool, and how to get good at it.

Twee-D and Twitcal Care

A holistic orthopaedic surgeon is one who cares for the whole bone and not just the fracture.

January 24, 2012 2:58 pm via Twitter for iPhone ReplyRetweetFavorite

@otorhinolarydoc

Trainee ENT Surgeon

News from the Fastlane

Yosef Liebman’s Emergency Medicine Update January 2012 - is out…so check it out!
There is still time to go into the draw to win in the Test The Textbook Trilogy.

The Final Words

‘Accept ignorance, accept that you just don’t know, once you get that into your head you’ll start to learn.’
- Jim Ducharme
“One of the major biases in risky decision making is optimism. Optimism is a source of high-risk thinking.”
- Daniel Kahneman

That’s it for now…

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The LITFL Review 054

Kane Guthrie — Mon, 23 Jan 2012 07:55:46 +0000

Life in the Fast Lane Medical Blog The LITFL Review 054

Welcome to the mind-boggling 54th edition!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.

The Most Fair Dinkum Ripper Beaut of the Week

EM Basic

Top spot this week is taken out by someone new on the podcasting/blogging scene… Steve Carroll over at the simple yet extremely informative podcast EM Basic. This podcast covers all the pertinent topics in EM in a simplified, easy to follow format. To take out top spot this week Steve provied a nuts and bolts simplified approach to the patient presenting with syncope. He covers what tests need doing, all the way through to who needs to stay for further work-up and who can be discharged. Also check out the bonus section on rehydrating the dehydrate patient in the ED.

The Usual Suspects

RESUS.ME

β-2 agonists could worsen ARDS outcome - the search continues for what actually works and provides benefits in ARDS.
Caution with intraosseous adenosine. Interesting case series – but was the dose and IO position correct?
Adjacent haemofiltration catheters can remove CVC drugs - An important consideration when siting your lines in your critical care patients who require renal replacement therapy.
FIRST: Fluids in Resuscitation of Severe Trauma. Cliffs take on this study: “I’m sure the FIRST trial is going to be quoted for some time to come, including, I suspect, by the manufacturers of certain colloids”.

Leon Gussow highlights The Best Toxicology Articles of 2011 and finishes by taking a swipe at the black box warnings.
Hernia with Acute Pain and Swelling - time to reduced the irreducible.

Paucis Verbis: this week gives us the heads up on what and when to give Antibiotics for open fractures.
Trick of the Trade: A handy approach to managing the often challenging Dental Avulsion/Subluxation.

Larry Raney gets Joe’s pick of the week with a presentation on Should We Be Using More Agonist / Antagonist Pain Medicines in the ER?

ER CAST

Rob is back with another awesome podcast this time teaming up with Ryan Radecki the literature guru from Emergency Medicine Literature of Note to tackle and discuss the ins and outs on Decision Tools: PERC, NEXUS and CURB-65 - they also get some commentary from Scott Weingart from EMCrit, and give LITFL editor Chris Nickson numerous shout-outs.

Prehospital naloxone given by nebulized inhaler - time to start considering that nebulized naloxone is safe and effective treatment in patients with suspected opiate overdose and spontaneous respiration.
Caffeinated energy drinks: do they cause significant acute toxicity? – Are these drinks causing a problem? Leon isn’t convinced what about you?
Carnitine and valproic acid overdose - is it a reasonable approach? The jury is still out – but Leon thinks so.

Emergency Physicians Monthly.

Subtle Anterior Transient Injury Pattern, Not Appreciated -Looks like the LAD occlusion spontaneously reperfused.

Greg Henry promotes a new must read book for emergency doctors and nurses in It is OK to Die. - anybody out there read this book yet? Do you share the same sentiments as Dr Henry? Let us know.
Rick Bukata shares with us some new literature focusing on With Discharge Instructions, Less is More - worth a read!

The Rest Of The Best

Intensive Care Network

Oli is back with another great case-based podcast in An interesting case. Can you try to work out what your differential would be and how you would investigate and manage this case.

PEM + ED

This months podcast is on Clearing The Pediatric C-spine - remember “Your pediatric patient doesn’t need a decision instrument as much as they need a good doctor.”

Lies, Damned Lies, and Tamiflu (oseltamivir) - it doesn’t decrease hospitalisations and only reduces symptoms by about 21 hours – is it worth it??
100,000 Incorrect TIA Diagnoses Every Year – a very disappointing study that made its way into the Annals – how??
Observation For Anticoagulated Head Trauma - will the absence of evidence change our practice in this patient group – be interested to see what others think of this paper

Casey introduces us to the art Consultation Skills: Intro and highlights the two different approach he takes towards his consultations – looking forward to reading other post in this series.
Consult Skills 1: The “normal” strategy: Understand the patient’s point-of-view and prosper. Biggest take home point – “every patient has a story to tell, let them tell it.”
Irukandji syndrome – the swarm hits Broome- a nice review on one of the LITFL team’s favourite topics.

Amal Mattu is back again with more brilliant cardiology pearls. This week looks at coronary risk factors and AMI mortality.

We’ve noted studies in recent years indicating that cardiac risk factors are ineffective at predicting the likelihood of ACS in patients with acute chest pain (in other words, it’s all about the HPI and EKG!).
Now there’s evidence also that cardiac risk factors are ineffective at predicting in-hospital mortality in patients that rule in for acute MI. [1] In fact, this study actually demonstrated that in-hospital mortality is inversely related to the number of cardiac risk factors!
The bottom line is simple: cardiac risk factors are useful at predicting long-term risk for development of coronary artery disease, but they are NOT useful at in the acute setting.
Canto JG, Kiefe CI, Rogers WJ, et al. Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction. JAMA2011;306:2120-2127

NAC for alcoholic hepatitis - the research is looking promising for this intervention – nice find Andy.

EmergSource.com

Your Next Patient: A 62 Year Old Man With Advanced Lung Cancer- Brilliant case, something different for a change, a look towards palliative care in the ED. Palliative care seems on face as far out of the realm of emergency medicine as can be – what do you think?

Pediatric Emergency Medicine Morsels

Posterior Sterno-clavicular Dislocation - check out the key points on identifying and managing this rare and diagnostically challenging presentation.
Dysbarism Made Easy…. A nice revision list of the key terms and points surrounding this topic.

This weeks Morsel is huge with a review on Pediatric Obesity – just when you thought your job was difficult enough.

EMdose

Steroids in Acute Spinal Cord Injury - its not the standard of care – and does the evidence even make it a treatment option?
A nice review and some suggestion on why you attempt to clear patients of the Long Spine Boards asap.
Catheter Size and Fluid Resus -A review on why short and fat is a good attribute for intravenous catheters and some other things about flow.
Needle thoracostomy - looks like its time for a new approach.
Heart rate in hemorrhage - what is the magic heart rate number?

EMpills-pills of Emergency Medicine

Anterior nasal tamponade anchored - a new approach to packing that bleeding nose.

Pet Peeve: “High Index of Suspicion” - interesting, food for thought!!!
Does Initial Hematocrit Predict Shock? - Bottom line: Starling was right! Fluid shifts occur rapidly, and initial hematocrit or hemoglobin may very well reflect the volume status of patients who are bleeding rapidly. If the blood counts you obtain in the resuscitation room come back low, believe it! You must presume your patient is bleeding to death until proven otherwise- a must read post!!!

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Septic Arthritis in patient with HIV- what is the LR give you on the test you order.

Twee-D and Twitcal Care

Anaesthetic's ABCDE. Arrive, blame, criticize, depart, everyone else's problem. #joking #iloveanaesthetistsreally

January 21, 2012 6:09 pm via Twitter for iPhone ReplyRetweetFavorite

@4hrEmergencyDoc

ED Doc

News from the Fastlane

R&R In The FASTLANE 007 is back from its festive break – find out what the experts in EM have been reading lately.
Want to win one of 3 awesome textbooks? Find out how in Test The Textbook Trilogy!!

The Final Words

“Seriousness is the only refuge of the shallow.”
- Oscar Wilde
“There can be as much value in the blink of an eye as in months of rational analysis.”
-Malcolm Gladwell

That’s it for now…

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com

The LITFL Review 053

Kane Guthrie — Mon, 16 Jan 2012 04:08:30 +0000

Life in the Fast Lane Medical Blog The LITFL Review 053

Welcome to the awe-inspiring 53rd edition!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.

The Most Fair Dinkum Ripper Beaut of the Week

EMCrit

Top spot this week is taken out by Scott over at EMCrit when he teams up with Dr Paul Marik to try and answer one of the toughest questions in critical care on assessing fluid responsiveness in the critical ill patients. Check out Podcast 64 – Fluid Responsiveness with Dr. Paul Marik.

The Usual Suspects

Emergency Medicine Updates

Reuben shares with us a new approach to bag-valve mask ventilation 11 minute screencast: emergency ventilation. This screen-cast is pure gold and is a must watch for everyone that is involved with airway management.

Emergency Ventilation in 11 Minutes from reuben strayer on Vimeo.

RESUS.ME

Emergency percutaneous airway - Cliff provides us with an excellent review and pearls from a recent article focuses on emergency needle and surgical cricothyroidotomy.
Prehospital fluids for head injury – keep it simple - Take home point from a team from Melbourne that has reviewed the literature and concluded isotonic crystalloids (Ringer’s or Saline) are as good as anything else.
Ultrasound for pneumonia -Bedside chest ultrasound is a reliable tool for the diagnosis of pneumonia in the ED, probably being superior to CXR in this setting.
Steroid replacement after etomidate: no benefit - is it time we brought this drug to the land down under or forget about it all together?
Vasopressin – what it does and doesn’t do - Cliff sums it all up in a nice review.
Potassium levels and AMI death - time to start aiming for serum potassium levels between 3.5 and <4.5 mEq/L in AMI patients.

Graham Walker shares with us his frustrations On My Emergency Medicine Boards.
Only Mostly Dead- An interesting case!

Paucis Verbis: Interpretation of intraosseous blood- another nifty little card to print of and have handy in your trauma bay.
Trick of the Trade: A removable guidewire - the MacGyver approach making something out of nothing.

Joe’s podcast of the week is by Chandra Aubin with the in’s and out’s on diagnosing Idiopathic Intracranial Hypertension in the emergency department.

ER CAST

Zen and the Art of Shoulder Reduction- Rob gives us an awesome screen-cast and walks us through the Cunningham approach to shoulder relocation.

Potent stimulant PMMA associated with ecstasy deaths - cheaper, gives you an enhanced drug effect- but also results in more fatalities, need to be on the look out for PMMA presentations.
Methadone induces hearing loss- an unusual side effect!
Pick Your Poison- Leon put’s us up to the Q & A challenge.

Serial ECGs confirm initial suspicion of anterior STEMI (LAD occlusion) - Take home point – if the suspicion is there, get your nurses doing serial ECG’s.

Ian provides us with a quirky look at how to collect a mid-stream urine specimen.

empem.org

Dr Colin and Dr Rachel share with us some Well Baby Oddities! Covering everything from periodic breathing through to hormonal withdrawal.

The Rest Of The Best

Emergency in the Shed

David and Jeff are back with part 2 of Avoiding the Pitfalls of Trauma Part 2, after taking out top spot with part 1, part 2 certainly doesn’t disappoint- pack full of amazing pearls that will have you dominating and improving outcomes for your next trauma patient. Worth listening to.

HQmeded.com

Does my patient have measles?

Does my patient have measles? from hqmeded.com on Vimeo.

DrGDH

Scaring the SHO’s or “Can we be sure discharge is safe?” - Take home point: we have to be comfortable accepting a certain level of uncertainty, when discharging patients from the emergency department.

CLIC-EM

Reversal of Novel Anticoagulants in the Bleeding Patient - nice guide to help you face the challenge of reversing these new novel anticoagulants.

PERC – Still (Mostly) Useless - don’t think too many ED docs would disagree with that title Ryan!!
Can We Stop Placing NG Tubes? Bottom line: So, yes, if you wanted to stop placing NG tubes because they’re uncomfortable for patients and apparently don’t change ultimate outcomes – certainly, that may be reasonable.

SUSS IT: Secondary UltraSonographic Survey In Trauma - This post is a must read! Casey provides us with a excellent guide to using ultrasound as part of your primary and secondary assessment of trauma patients.
Dr JRs last week in training before he goes bush. A look back at the lesson’s learned from a year of GP anaesthetic training.
Quit QID? Is Casey just a bad parent? Or is he onto something here? Makes a lot of sense and practicality by changing to BD dosing!!

Amal Mattu shares this week pearl on the painless ACS:

As many as 1/3 of patients with proven ACS have no chest pain at presentation.
Among the more common alternative presentations (anginal equivalents) are dyspnea, diaphoresis, nausea/vomiting, and syncope/near-syncope.
Note also that the absence of pain does not confer a better prognosis.
The overall in-hospital mortality rate for patients with painless presentations is 13% vs. 4.3% for patients with chest pain.

IV Paracetamol vs morphine for pain - a bigger study is needed – but some results look promising for IV paracetamol in acute limb trauma.

EmergSource.com

The time and action specific consultation - some great pearls and pitfalls from Aaron on dealing with interactions with other consultants.

Annals of Emergency Medicine Podcast

Military Abdominal Aortic Tourniquet - how times change with research, the recent wars have shown that limb tourniquets aren’t such a bad thing after all, know we have a whole new concept of the abdominal aortic tourniquet – I’m sure we will all be watching were this device takes us closely!!!
More on Human Factors in Trauma Scenarios - interesting research- worth having a read of this paper!
Myth Buster Episode 4 – the Case of the Stone Heart - nice review on the literature surrounding giving calcium to the hyperkalemic digoxin toxic patient!!
Utility of Chest Radiography in Blunt Trauma- Is it time to change our practise, and individualise our care and tailor it to the patient in front of us?

David and Ashley are back with the January 2012 podcast highlight the latest and greatest published research from a look at Dengue fever through to the effectiveness for steroids in treating Bell’s palsy.

Pediatric Emergency Medicine Morsles

This week’s morsel is on Gradenigo’s Syndrome and Otitis Media.

EMdose

A take on Factor VII -Bottom line: We still need a lot more data before we can officially make a stance on this issue, but for now, it’s probably better to stay away from a medication with no mortality benefit and a possibly bad side effect profile.
Perimortem C-section - the facts on when to, and a short summary on how to!
A little reminder of some important neonatal resuscitation points. Check out - Neonatal Resus!

EMpills-pills of Emergency Medicine

A chest pain resistant to treatment - remember chest pain in young adults isn’t always benign.

Crit-IQ

This week Associate Professor Andrew Davies shares his expert knowledge of Total Parenteral Nutrition – when to start, what to add and how much to give. Have a listen to TPN – Getting it right.

High Inspired O2 Is Not An Effective Pneumothorax Treatment- although the good evidence is lacking, this approach seems to be more of an urban legend.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Soft tissue abscess: clinical plus ultrasound evaluation. Bottom line - Ultrasonography is a useful adjunct to clinical evaluation of soft tissue infection, it increases diagnostic accuracy and guides treatment decision.

Twee-D and Twitcal Care

Anxiety mediated spontaneous cardioversion following suggestion of DC cardioversion. A case report. Chump et al 2012.

January 14, 2012 12:54 am via Echofon ReplyRetweetFavorite

@bungeechump

Chump

News from the Fastlane

Chris highlights the Best Of The LITFL Review 2011 - and the LITFL team wishes him well as he takes up his new post in Alice Springs.
Ed drums out another brilliant tox conundrum in Brain Dead? and Rick Abbott is back with a take on Emergency Imaging In Tassie.

The Final Words

“The real purpose of books is to trap the mind into doing its own thinking.”
-Christopher Morley.
“If we are to learn to improve the quality of the decisions we make, we need to accept the mysterious nature of our snap judgments.”
-Malcolm Gladwell

That’s it for now…

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com

The LITFL Review 052

Kane Guthrie — Mon, 09 Jan 2012 00:00:12 +0000

Life in the Fast Lane Medical Blog The LITFL Review 052

This week the sensational LITFL Review turns 1 years old!!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.

As you troll through this weeks highlights from the EM/ICU blogging world – have a listen to ZDoggMD new smash hit Big Pharma!

http://www.youtube.com/watch?v=vT2Xz5R6ZGs

The Most Fair Dinkum Ripper Beaut of the Week

Top spot this week is taken out by new Aussie Blogger Amit Maini over at ED Trauma and Critical Care. Each week Amit bust out the latest and greatest research and inovations from the literature to change you current practice. Well worth checking out his site.

Deathmatch : Central Access Versus Intraosseous Access. FIGHT! - The IO shines again – time to start using it more!!!
Posterior Myocardial Infarction – Are We Really This Bad? - the literature is telling us we are. Amit provides some nice pearls for identifying the posterior MI.
ClotBust-ER, An Ultrasound Device to Aid Stroke Thrombolysis - Amazing how the times are changing.
Emergency Physicians Should Go HOME - using the HOME pneumonic to assist you in discharging patients home properly.

The Usual Suspects

Treating Extensor Tendon Injuries in the ED- nothing fancy – just the cold hard facts we need to know about managing these common presentations.
Retirement? Heck, No! Refocus. Greg Henry on how productivity suffers as our careers age.
Fugu Me - Leon Gussow gives us the low down on tetrodotoxin… AKA puffer fish poisoning!

Paucis verbis is back with a look at identifying and managing serotonin syndrome.
Trick of the Trade: Hip dislocation Part II - a look at the Whistler technique.
Blog Incubator Experiment: Be the next big thing in blogging- Michelle is giving you the opportunity to become a blogging god or goddess – check out this awesome initiative.

Joe’s pick of the week this week is by Brian Lin, discussing everything you want to know about head injury protection in rapid sequence intubation.

The 2nd Annual Alexander Awards: Leon highlits the Best of the Tox Reading of 2011!. A must read post!
What Color is Your Urine? Leon provides us with the ultimate guide to working what drug has caused a changed in your patients urine colour. Worth knowing about.

The Same Theme: Large Lateral STEMI is Subtle on the ECG. Learning point: Lateral MI may be very large but electrocardiographically subtle. Inferior ST depression is nearly always seen in lateral MI.
Extremely subtle inferior MI - great learning points from this case, also check out the study in learning point 4- are we causing more harm by giving these patients opiates?

Pediatric Emergency Medicine Morsles

Im far too busy drowning to let you know im drowning! After a sad week in Perth with 4 drownings, Ian highlights some key facts about drowning – worth reading!

EMCrit

More on a Diagnostic Strategy for C-Spine Injuries - Scott is back dealing with the controversy he caused in his first podcast on C-spine injuries, providing us with a review on the literature on using plain films for X-rays. Do they still have a role? – you be the judge!

Emergency Physicians Monthly.

Why the Worsening Chest Pain? Great case – the diagnosis isn’t always what you think its going to be!!
The Highly Sensitive Troponin Test: A Step in the Wrong Direction? - Dr. Amal Mattu on how a high-profile article on the HS-TN has prompted a flurry of uncertainty.

The Rest Of The Best

This week’s morsel is on Oropharyngeal Trauma – that popsicle stick is such a pain in the neck!

Crit-IQ

This week podcast gets down and dirty looking at some ground breaking approach to mechanical ventilation. Todd has a chat with Andreas Schibler on NAVA – Is it the gold standard for synchonised ventilation?

EMpills-pill of Emergency Medicine

Paroxysmal tachycardia and vagal maneuvers: What is the evidence – a nice review post.
Inside or outside the hospital: what is best? - should we be managing more patients in the home rather than hospital, does this deliver same outcomes as well as reducing costs – your thoughts?
We recognize the plantar fasciitis? - although not life-saving, appropriate diagnosis of plantar fasciitis will provide some relief to your patient.

CLIC-EM

Algorithm-based Treatment of Hidradenitis Suppurativa - an algorithm approach to this chronic-complicated disease that sometimes presents to emergency departments.

Emergency Ultrasound Podcast

Following taking out last week’s top spot on their ultrasound approach to cricothyroidotomy. This weeks sore the lads getting some feedback from Scott “i have the sexiest podcast voice” Weingart in EMCrit Cric Commentary - although he doesn’t totally discredit their opinion he provides some interesting food for thought, and gives us his two cents on when it can be used and when it shouldn’t even be considered.

The wrap up- from last weeks ectopic case, Casey also provides some excellent link’s to pertinent topics surrounding the case.

Frontline Medicine and EMCrit’s Logistics over strategy - Couldn’t agree more with Andy, the key to a great resuscitation is the team work and logistical approach that delivers the outcomes, and provides the most satisfaction to the team members participating in it.
Electrical Storm - Andy shares with us a few brief points to help you “calm the storm.”
Anatomy for Emergency Medicine – #4 LisFranc Injuries

EMdose

Mike shares some pearls and pitfalls for imaging the pregnant patient – check out Part 1 and Part 2.
A short-sharp review on Peripartum Cardiomyopathy.
How Good is the Pelvic Exam - depends on who is doing it!

Who Knows If Older Platelets Are More Harmful - another example of the difficulties faced with trauma research.
Too Many Traumatic Arrests Are Transported - and costing the health system huge dollars.
Cardiology Corner – More Brugada Tidbits- In Ryan’s words- “A little esoteric, but fascinating.”
Must We Use IV Paracetamol/Acetaminophen? - Although effective the cost is a major downfall.

Amal Mattu provides us this this pearl on clopidigrel and cardiogenic shock. I wonder if this also applies for Prasugrel.

Patients with ACS are often treated early with clopidogrel. However, if the patient with ACS appears to be developing cardiogenic shock, its probably best to withhold the early clopidogrel.
The literature indicates that patients with cardiogenic shock benefit most from emergent PCI, and many of these patients will need CABG. Generally it’s best to avoid clopidogrel in patients heading for CABG.
The use of clopidogrel in patients with cardiogenic shock can be deferred to the cardiologists in the cath lab once they decide whether the patient will need CABG or not.

Thiele H, Allam B, Chatellier G, et al. Shock in acute myocardial infarction: the Cape Horn for trials? Eur Heart J 2010;31:1828-1835.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Pulmonary Embolism and DVT in Trauma.- Some interesting facts and figures about DVT and PE in trauma patients.
How To: Stop Scalp Bleeding. Michael shares his top 5 tips for stopping the scalp bleeder!!
What You Need To Know About Falls From a Height - all the important factors you need to consider when dealing with this mechanism of injury.
Spine Immobilisation in Penetrating Trauma: More Harm Than Good?

Twin Cities Toxicology

Krokodil: Russia’s Designer Drug That Will Eat Your Flesh - a nice review of this menacing street drug!

Twee-D and Twitcal Care

The sound of the blood gas machine calibrating when I want to use it is the sound of my soul dying a painful death.

January 2, 2012 12:08 pm via Echofon ReplyRetweetFavorite

@bungeechump

Chump

News from the Fastlane

Yes thats right – this edition of the LITFL review turns 1!!! I would like to take this opportunity to thank all the readers of the review for your support, comments and feedback, to all the bloggers and podcasters for providing the content that makes this review happen, and finally to Chris and Mike for all the help, support and editing they assist me with each review each week. I’m looking forward to bringing you another years of excellent reviews from the EM/ICU blogging world.
Rick Abbott is back with more writing brilliance in All I Need To Do Is Write A Final Diagnosis, Right?

The Final Words

“You’re only as old as those you inspire.”
-Greg Henry
” The most important part in saving lives in such a resuscitation are the logistics and how the team makes decisions.”
-Andy Neil

That’s it for now…

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com

The LITFL Review 050

Kane Guthrie — Mon, 26 Dec 2011 07:34:44 +0000

Life in the Fast Lane Medical Blog The LITFL Review 050

This week the LITFL Review turns 50!!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.

The Most Fair Dinkum Ripper Beaut of the Week

Emergency in the Shed

Top spot this week heads over to Queensland and is taken out by David Corkhill from Emergency in the Shed. David teams up with Aussie ED doc Jeff Hooper to have a chat about Avoiding the Pitfalls of Trauma Part 1 — they highlight the top 10 common mistakes that they see repeatedly missed in trauma patients, and provide some nice pearls on managing the trauma patient.

The Usual Suspects

Joe’s pick this week is by Scott Melanson with a look at Which Neck Injuries require Vascular Imaging?

Case report: seizures after smoking a synthetic cannabinoid product — a rare occurrence, but something to be familiar with when patients present after using these synthetic cannabinoids.
Review of ricin toxicity. Nice point by Leon: the fact that ricin as never been used as a mass terror weapon — despite its abundance — is a measure of how difficult this process really is.
It’s a bird, it’s a plane . . . OMG, it’s a snake! — Snakes don’t fly….or do they?
Case report: fatality after ingestion of methylone and butylone sold as “ecstasy” — be careful what you pay for.
Leon highlights some Aussies literature reviewing 4 toxic Spider bites!

RESUS.ME

Circulatory support in cardiogenic shock — is it time for ‘out with the old, and in with the new’ inotropes, and maybe throw in some mechanical devices on the side.
Treating sepsis – have we got it the wrong way round? — some food for thought on sepsis from Cliff. What do you think about this?

Academic Life of Emergency Medicine

Trick of the Trade: Tie-over dressing for scalp lacerations — holds the dressing in place, and has your patient looking like they’re from a spiderman movie. Win-win!

Emergency Physicians Monthly

Handling Serious Bacterial Illness in Children — highlights some new articles and concepts for tackling this sometimes deadly disease.
Airway expert Richard Levitan provides us with some tips and tricks for using Video + Direct Laryngoscopy.

Ventricular fibrillation on a 12-lead ECG — Dr Smith explains how this looks like torsdades, but its not – shock it anyway.

Avoiding the death stare. — “Our own emotional response to these situations is not a switch. It is a tide.”
Managing the patient with an intellectual disability. — this post is gold, a must read for every ED nurse and Dr — so we can deliver the care these patient desperately require.

The Rest Of The Best

Andy bounces-back from top spot last week with another excellent vodcast with Anatomy for Emergency Medicine – #2 the Vertebral Artery.

PEM+ED Podcast

This week the team released part 2 of their podcast on Fever of Unknown Source.

Another Review on Ketamine Use in ED — the most unappreciated drug in emergency medicine shines brightly in another excellent review of the literature.
Did Hell Just Freeze Over? — It looks like orthopods are stronger and smarter than anaesthetist — it’s true then that “long term propofol use leads to muscular atrophy and now long term cognitive impairment.”
Amit shares some of his experience on EMRAP regarding Aussie EM Training vs US EM Training — You American docs have got it easy…

Emergency Medicine Education

Cardiac arrest and prognosis — some tips on when we should stop.

Dexmedetomidine Is Not For ED Sedation in behavioural emergencies — but may have a role in procedural sedation and sedation for NIV in the ED.
Under/Overtesting in Fever Without a Source — where is the middle ground.
Nitroprusside Saves Pigs – How About Humans? — They could be onto something— only time will tell.

This week’s pearl is by Rose Chasm on Pyloric Stenosis:

Causes gastric outlet obstruction and vomiting.
1 in every 500 infants; with a 4:1 male-to-female ratio and a family history in another sibling.
Symptoms begin 2-4 weeks after birth, with projectile NON-bilious vomiting.
Firm, mobile, nontender, olive-shaped mass in right hypochondrium or epigastric area.
Diagnosis confirmed with US or upper GI series.
Treatment is a pyloromyotomy, but fluid and electrolyte replacement is vital in ED.

Pediatric EM Morsels

Pierre Robin Sequence — one of the most difficult airway situations an emergency doc can come across — guaranteed sphincter tightening!!!

http://www.youtube.com/watch?v=TveIsbjmakU

Michael highlights some new amazing technology for Real Time Cerebral Blood Flow Monitoring For TBI.
Cricothyroidotomy Using The Scalpel-Bougie Technique — a cool video — demonstrating a simple approach to the surgical airway.

EM dose

Trauma in Pregnancy — some excellent short pearls on managing the pregnant trauma patient — worth reading.
The ins and outs of managing Hypertension in Pregnancy.
An update on managing bartholin gland cysts.
A short, sharp simple guide pack with key-points for Postpartum Hemorrhage.

Twin Cities Toxicology

You have to know about this for your next cyanide exposure… worth knowing about if your going to dialyse your sick cyanide poisoned patients.

ZDoggMD

A special Christmas message from ZDogg and Dr Harry in Feed The Wards (Do They Know It’s Christmas Time?)

http://www.youtube.com/watch?v=iIxhXHds20I

Twee-D and Twitcal Care

"A respirator? And here I've been using my own lungs like a chump!" #Homer

December 21, 2011 3:48 am via Botize ReplyRetweetFavorite

@SimpsonsQuotes_

Simpsons Quotes

News from the Fastlane

The LITFL team would like to wish all our readers a Merry Christmas, and wish you all the best for 2012. We look forward to providing you more online educational goodness next year, and we love you all.

The Final Words

“There was never a genius without a tincture of madness”
— Aristotle
”Destiny is not a matter of chance, but of choice; it is not a thing to be waited for, it is a thing to be achieved.”
— Winston Churchill

That’s it for now…

Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email our roving reporter: kane AT lifeinthefastlane.com

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Fine Tuning the Injured Brain

Kane Guthrie — Wed, 21 Dec 2011 00:00:30 +0000

Life in the Fast Lane Medical Blog Fine Tuning the Injured Brain

When Joe Lex makes his “pick of the week” on Free Emergency Medicine Talks you know its worth listening to. This week’s pick is exceptional. It’s a talk by Bart Besinger, an emergency physician from Indiana, who delivers an excellent current review on the medical management of the severe brain injured patient in the emergency department.

Listen to Bart’s talk for free here: Fine-tuning care of the injured brain.

Many patients with severe brain injury will succumb to their injuries. However, there is a subset of patients for whom optimal early management has a profound impact on their prognosis. If we do things right, some patients have a chance of actually walking out of hospital alive with good neurological function.

Frontal Contusion

The care we provide for the brain injured patient is not always about the big things we do, but more about the little things we do that can make the difference.

Here is a ‘key points’ summary of Bart Besinger’s talk:

Bart Besinger’s Top 5 little things we can do in the ED

Patient Position

Elevating the head of the bed to 30° — will decrease ICP via displacing the CSF and increasing venous outflow.
By elevating the head of the bed to between 30°-45° also decrease the risk of developing ventilator associated pneumonia.
However elevating the head of the bed can be difficult in the patient with spinal precautions.
Bart also recommends avoiding the trendelenburg position (especially when inserting central lines) as this intervention offer’s little benefit but can greatly increase the ICP.

Cervical Collar

C-Spine collar aka “The Brain Tourniquet”.
Clearing the cervical spine of these patients can often be difficult in the comatosed intubated patient.
Removal of the C-spine collar has been showen to decrease ICP by around 2-5 mmHg.
If you are unable to remove the cervical collar check the position, size and tightness of the collar. Bart’s tip: loosen it up a bit so it aids venous return but still supports the head.

Blood Sugar Control

This part of talk gets controversial — the key point is you need to find the right balance for managing the blood glucose level in these patients.
Patients with severe brain injury and hyperglycaemia have an increased mortality, and have poorer neurological outcomes. However research has been unable say if this is a marker of severe injury, or a cause of secondary brain injury.
Remember hypoglycaemia is bad in the severe brain injured patient — the brain is an obligate glucose consumer and needs sugar to function.
Studies show intensive insulin therapy results in more episodes of hypoglycaemia and may even increase mortality.
Bart’s taken home point for managing the blood sugar: don’t aim for strict low blood sugar control… Aim to keep the BSL between 8-12 mmol/L.

Temperature Management

Therapeutic hypothermia has shown great improvement in the cardiac arrest victims, however for the injured brain: “There is no evidence that hypothermia is beneficial in the treatment of head injury”.
See the summary from the Cochrane review.
Therapeutic hypothermia in the injured brain has resulted in more cases of coagulopathy, pneumonia and sepsis.
Bart’s recommend’s we should focus on “therapeutic normothermia” for these patient’s we know cooling is bad, but also fevers and hyperthermia is also detrimental as well.
We know fever increases cerebral metabolic rate and oxygen consumption with associated poor outcomes, however there is currently no good outcome studies to support this.
Take home point: fevers can develop quickly (yes even while the patient is still in ED), so monitor closely and treat aggressively.

Blood Pressure Management

Patients with a severe brain injury often present with an abnormal blood pressure.
Hypotension is profoundly detrimental to these patient and needs to be treated aggressively to maintain cerebral perfusion pressure.
Hypertension can occur through the underlying physiological response to raised ICP, due to an underlying medical condition or may be related to pain and anxiety.
Treatment is generally not recommended in the hypertensive patient, remember these patients require sedatives and analgesia when intubated — providing this can relieve some of the hypertension.
On the rare occasion that you have to treat the high blood pressure, use short acting anti-hypertensive only and dose very gingerly.

In Summary

Keep the patients head up — decreases ICP &VAP.
Check the collar — remove if possible to reduce ICP.
Treat patients with marked hyperglycaemia but avoid hypoglycaemia.
Cooling doesn’t work, but avoid hyperthermia at all cost.
Don’t worry too much about the high blood pressure, but be very concerned about low blood pressure.

Want more on ED neuro critical care?

Check out these articles:

Crashingpatient.com — Severe Traumatic Brain Injury.
Flower, O. & Smith, M. (2011). The acute management of intracerebral hemorrhage. Current Opinion in Critical Care. 17, 106-114. PMID: 21169826.
Mittal, R. et.al. (2009). Critical care in the emergency department; traumatic brain injury. Emergency Medicine Journal. 26, 513-517. PMID: 19546274.

“Remember: what YOU do, matters”
— Mel Herbert

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Adding insult to injury?

Chris Nickson — Tue, 20 Dec 2011 00:00:54 +0000

Life in the Fast Lane Medical Blog Adding insult to injury?

aka Trauma Tribulation 012

You’re in the trauma bay coordinating the assessment and management of a 40 year-old man who was involved in a motor vehicle crash. A nurse passes you a bluey, some KY and sterile gloves as the patient is about to be logged rolled.

Are you going to perform a digital rectal examination (DRE) on this man?

“One finger in the throat and one in the rectum makes a good diagnostician.”
— Wiliam Osler

Questions

Q1. What are you trying to detect when you perform a DRE in a trauma patient?

Th DRE is performed to detect the following key findings:

rectal hemorrhage
rectal mucosal injury or wall defects
loss of anal tone suggesting spinal cord injury
palpable pelvic fractures
a high riding prostate suggestive of posterior urethral disruption

Q2.Is it mandatory to perform a DRE in trauma patients?

No

Traditional ATLS teaching was that a DRE is mandatory in trauma patients: “a finger or tube in every orifice”. This is no longer the case. The 8th edition of ATLS recommends that ‘DRE be performed selectively before inserting an indwelling urinary catheter’ (Kortbeek et al, 2008).

Over the past 10 years or so, the published literature has consistently downplayed the role of the DRE in the assessment of trauma patients. It is clear that:

DRE rarely changes the management of trauma patients.

DRE was felt to change management in only in 1.2% of cases in Porter and Ursic’s prospective observational study (2001) and only 4% in Esposito et al’s prospective study (2005).
Espsoito et al (2005) found that none of 512 patients would have had a significant injury missed had the DRE been omitted.

The DRE is not a useful screening test in trauma patients.

In a retrospective study of over 1400 patients, Shlamovitz et al (2007) found that the DRE was only 23% sensitive for a composite of significant injuries in trauma patients.
This means that about three-quarters of the time the DRE will miss significant injuries (such as GI perforation, rectal mucosal injury, urethral rupture, pelvic fracture and spinal cord injury).

Q3. What are the downsides of performing a DRE in a trauma patient?

Some have argued that despite the poor sensitivity of the DRE, it should still be performed as part of a complete examination as it is “cheap, quick and non-invasive”.

I disagree…

DREs should only be performed selectively

and I certainly don’t consider DREs to be ‘non-invasive’.

Downsides of performing DREs in trauma patients include:

physical discomfort
emotional distress
risk of verbal and/ or physical violence from an agitated patient
litigation
possible infection risk — e.g. contamination of local wounds; risk of transmission of infection to the clinician (likely to be extremely low)
injury — potential for worsening of the patient’s injuries (e.g. unstable pelvic fracture, rectal defects); and also risk of injury to the clinician (e.g. foreign bodies, bone fragments)
the occurrence of false postive and false negative DRE findings

Q4. Why might DREs be unreliable?

Factors contributing to DREs being unreliable include:

DREs are often performed by junior staff
— either because it is considered a menial task, or so that the junior staff ‘gain more experience’.
positive findings on DRE are rare… anyone ever felt a ‘high riding’ prostate?… (i.e. before the diagnosis of posterior urethral disruption was confirmed by some other means…)
the findings on DRE have poor inter-observer agreement
— this is well document for the assessment of prostate size and the detection of rectal tumours… even when performed by ‘experts’ such as urologists and proctologists.

Q5. Are ‘false positive’ and ‘false negative’ DREs a concern?

Yes…

DRE findings may be falsely positive or negative.

Esposito et al (2005) found that 6% of DREs in trauma patients had findings that were later shown to be false (either positve or negative) when other investigations or follow up over time was performed.
Shlamovitz et al (2007) found high rates of falsely negative DREs:

63% for decreased anal sphincter tone
94% for the presence of gross rectal blood
67% for disruption of the rectal wall integrity
100% for palpation of bony fragments
80% for abnormal position of the prostate.

False negative DREs may lead to

injuries being missed, resulting in increased morbidity and/ or mortality
delays in performing necessary investigations and/ or interventions

False positive DREs may lead to:

unnecessary investigations (cost, time, radiation, contrast exposure, decreasing access for other patients, etc)
unnecessary interventions (the possibilities include prolonged time in a c-spine collar, unnecessary fasting, being cut open for no reason, etc)
prolonged observation (possible increase in hospital length of stay)

Q6. Do you need to perform a DRE in trauma patients to detect posterior urethral injury?

Probably not… You can usually rely on other clinical findings and a (gentle) attempt at IDC insertion will reveal all.

Ball et al (2009) found that in patients with posterior urethral disruption, 60% of the time there there were no clinical signs prior to urinary catheter insertion (41 urethral injuries were included in this retrospective study). Possible clinical signs and their sensitivities are shown below:

blood at the urethral meatus (20% sensitivity)
gross hematuria prior to catheter insertion (17% sensitivity)
abnormal prostate position (2% sensitivity)
scrotal or perineal echymosis
inability to void

(Unfortunately likelihood ratios could not be calculated from the data provided in the paper.)

Why is DRE to detect ‘abnormal prostate position’ such a poor test? In addition to the reasons discussed in Q4, examination is often limited by tenderness or the finding of a ‘high riding prostate’ may be concealed by hematoma formation from a coexistent pelvic fracture or vessel injury.

Abnormal prostate position is near useless for detecting posterior urethral injury.

The key finding that should make you think about posterior urethral disruption is the presence of pelvic fractures. Ball et al (2009) found that 95% patients with posterior urethral injuries occurred had pelvic fractures.

Consider posterior urethral disruption if a pelvic fracture is present.

Current ATLS guidelines advise that a retrograde urethrogram be performed before inserting an indwelling urinary catheter (IDC) in trauma patients if posterior urethral injury is suspected. In practice, this rarely occurs. This is partly because posterior urethral injury is often first suspected once frank blood is returned following attempted IDC insertion, or if the IDC is difficult to pass. It probably doesn’t matter in the long run if posterior urethral disruption is diagnosed this way — just be very gentle when you’re passing an IDC!

Suspect posterior urethral disruption if there is hematuria on IDC insertion or if the IDC doesn’t pass easily.

Michael McGonigal describes how to perform a retrograde urethrogram on the excellent Trauma Professional’s blog.

Perform a retrograde urethrogram to confirm posterior urethral disruption.

Q7. Do you need to perform a DRE in trauma patients to detect spinal cord injury?

Probably not, unless the patient has a neurological deficit.

If the patient is otherwise neurologically intact on clinical examination, anal tone is very unlikely to be altered.

Normal anal tone does NOT exclude spinal cord injury.

Sensitivity is too low for DRE to have have much bearing on making a serious diagnosis like spinal cord injury:

Shlamovitz et al (2007) found DRE was only 37% sensitive with a negative likelihood ratio (LR) of 0.66
Guldner et al (2006) had similar findings, with a negative LR of 0.5.

Of course, a positive DRE finding of decreased anal tone is more useful, but these patients are likely to have other reasons for suspecting spinal cord injury (such as paralysis…).

Shlamovitz et al (2007): positive LR = 8.5
Guldner et al (2006): postive LR = 6.8

Two important points about the use of DRE in patients with suspected spinal cord injury:

Assessing rectal tone is of little use if the patient has been given neuromuscular blockers following intubation. Tone may also be reduced in the unconscious patient, as a result of post-intubation sedation or traumatic brain injury for instance.
In the patient with neurological deficits, assessment for sacral sparing is important. This can be assessed by checking anal tone, but anal wink or the bulbocavernosus reflex are alternatives and may be more useful and/or better tolerated.

Q8. Do you need to perform a DRE in trauma patients to detect bowel injury?

Usually not… sensitivity is poor and other investigations are likely to be needed.

The DRE is only 6% sensitive for bowel injury (LR- 0.95), and only 33% sensitive for rectal mucosal tears (LR- 0.65 with confidence intervals that crossed 1) according to Shamlovitz et al (2007). As such it cannot be used a screening test in trauma patients to exclude either of these types of injuries.

Don’t rely on a negative DRE in a patient at high-risk of a bowel or rectal injury. Such patients need further investigation.

On the other hand, Shlamovitz et al (2007) found that a positive DRE was more useful for bowel and particularly rectal injury.

98.9% specific for bowel injury (i.e. PR hemorrhage detected) (LR+ 5.2)
99.8% specific for disrupted rectal wall integrity (LR+ 996)

But we need to take into account the fact that patients with these positive findings are likely to require further investigation anyway based on other findings (such as the spear sticking out of his or her perineum…).

Q9. So, when should you perform a DRE in a trauma patient?

There probably is a subgroup of trauma patients (as yet poorly defined) for whom a DRE is useful and may change management.

This subgroup may include patients with:

pelvic fractures (complications and associated injuries may be detected)
abnormal neurological findings
hypotension
penetrating abdominal or perineal trauma with possible rectal or other GI involvement
abdominal tenderness

Again, even in these patients further investigations are typically indicated anyway, which may render the DRE findings redundant. I suspect that most clinicians err on the side of performing a DRE given that, throughout the ages, we have been beaten over the head with the notion that failure to perform a DRE is a sign of gross incompetence (“if you don’t put your finger in it, you’ll put your foot in it”).

Perhaps it is easier to say which trauma patients don’t need a DRE…

Gulder et al (2004) published an as yet unvalidated clinical decision rule for performing DRE in trauma patients, based on an observational study of 862 patients. They found that there is a 0 to 0.8% probabilty of a ‘true positive’ abnormal DRE in patients with all three of:

a normal neurological exam
aged <65 years
absence of blood at the urethral meatus

Q10. What are the take home messages from all of this?

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The take home messages for me are that DREs in trauma patients:

should be performed selectively
— you must have a reason for performing this invasive examination… don’t feel you have to do it! But make sure your reasoning for not performing a DRE is equally sound. In most patients the DRE won’t be useful.
can often be delayed or be performed at the time of a subsequent investigation (e.g. colonoscopy) or intervention (e.g. laparotomy) if necessary
may be redundant in light of other clinical findings or if further investigation is indicated by other clinical findings
may be best performed by an experienced practitioner (although there is little or no evidence that their findings are any better than those of their junior collegues)… and only once!

References

Ball CG, Jafri SM, Kirkpatrick AW, Rajani RR, Rozycki GS, Feliciano DV, Wyrzykowski AD. Traumatic urethral injuries: does the digital rectal examination really help us? Injury. 2009 Sep;40(9):984-6. Epub 2009 Jun 16. PMID: 19535063.
Esposito TJ, Ingraham A, Luchette FA, Sears BW, Santaniello JM, Davis KA, Poulakidas SJ, Gamelli RL. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005 Dec;59(6):1314-9. PMID: 16394903.
Guldner G, Babbitt J, Boulton M, O’Callaghan T, Feleke R, Hargrove J. Deferral of the rectal examination in blunt trauma patients: a clinical decision rule. Acad Emerg Med. 2004 Jun;11(6):635-41. PMID: 15175201.
Guldner GT, Brzenski AB. The sensitivity and specificity of the digital rectal examination for detecting spinal cord injury in adult patients with blunt trauma. Am J Emerg Med. 2006 Jan;24(1):113-7. PMID: 16338517.
Kortbeek JB, et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma. 2008 Jun;64(6):1638-50. Review.PMID: 18545134.
Porter JM, Ursic CM. Digital rectal examination for trauma: does every patient need one? Am Surg. 2001 May;67(5):438-41. PMID: 11379644.
Shlamovitz GZ, Mower WR, Bergman J, Crisp J, DeVore HK, Hardy D, Sargent M, Shroff SD, Snyder E, Morgan MT. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007 Jul;50(1):25-33, 33.e1. Epub 2007 Mar 27. PMID: 17391807.

The LITFL Review 049

Kane Guthrie — Mon, 19 Dec 2011 03:33:18 +0000

Life in the Fast Lane Medical Blog The LITFL Review 049

Welcome to the ramped-up 49th LITFL Review!

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team will cast the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle.

The Most Fair Dinkum Ripper Beaut of the Week

This week, for the first time, it’s a three-way draw for top spot between Emergency Medicine Ireland, Emergency Medicine Updates and EMRAP: Educators Edition!

Andy takes a deep dive into the world of vodcasting and produces a top-shelf presentation on Anatomy for Emergency Medicine video series – #1 Cervical Spine.

Emergency Medicine Updates

When the patient can’t breathe, and you can’t think: The emergency department life-threatening asthma flowsheet — Reuben is right on the money here with this flow chart, it is one of the simplest, easiest and up-to-date guides I have seen on managing the severe asthmatic in the ED. It covers everything from giving Mg, using ketamine and NIV together, and what to do when the ventilated asthmatic get’s into trouble – a must read.

EM:RAP Educators Edition

Rob is back on the podcast scene with this episode his teams up with two of the giants of the EM podcast world Scott Weingart and Rob Orman to discuss Podcasting in Emergency Medicine. These two podcasting geniuses take us through a journey on how they each set up and produce their top quality podcasts on their respected sites, with some laughs along the way — excellent review guys! The end of the podcast see’s LITFL esteemed editor Chris Nickson give a shout out for R&R In The FASTLANE — are you getting your weekly dose of recommended research and reviews from the experts in emergency medicine?

The Usual Suspects

EMCrit

Needle vs. Knife II: Needle Thoracostomy? — Scott put’s forward an excellent argument for giving the needle the finger when it comes to doing thoracostomies.

Yay… Joe and the team have sorted out their hosting issues and are back with a vengeance with this weeks pick by Bart Besinger fine-tuning the injured brain. Authors note: this is one of the best talks I have listen to on the critical care management of patient’s with a TBI in the ED. A must listen to for all ED docs and nurses.

ED Treatment of Flexor Tendon Injuries — a nice little review article — worth checking out!
Toxicology rounds with Leon Gussow focuses on Toxicology Pearls from the 2011 ACEP Scientific Assembly.
Quick consult: Great Toe Pain and Swelling — I bet you can guess what the diagnosis is.
The Magic Ventilator: Help for Bag-Valve-Mask Ventilation — some nifty pearls and new concepts for providing ventilation.
An update from the journals: Dexamethasone Instead of Prednisone for Acute Asthma in Adults.

Cocaine-associated chest pain: a review of the cardiology literature, unfortunately the authors forgot the toxicology literature and the toxicological perspective in managing this toxicological problem.
Diagnostic smackdown: Dr. House vs. ??? — Its not Tox but it demonstrates the key elements of clinical reasoning, that we all should strive to possess — nice find Leon.
Following the LITFL shout out Leon highlights some awesome new Toxicology blogs and podcasts you should know.
Mushroom poisoning: first-hand account. The biggest worry about this study is that comes from LITFL’s home town…

RESUS.ME

PICCs more complicated than CVCs — Makes sense considering there different use’s and indications.
Listen over the neck when inflating ETT cuff — This interesting study introduces a novel technique for guiding the inflation of tracheal tube cuffs to avoid excessive cuff pressures: listening with a stethoscope over the thyroid cartilage and inflating the cuff until breath sounds change from harsh to soft.

Academic Life of Emergency Medicine

Trick of the Trade: Captain Morgan technique for hip dislocation — will have you popping those tricky dislocated hips back in.
Paucis Verbis: ACLS 2010 cardiac arrest flowchart — simple, high resolution and easy to follow, print them off and stick them up in your resus room.

Emergency Physicians Monthly

Rick Bukata takes a look at PE: Still a Challenging Diagnosis —Despite a wealth of literature, risk stratifying patients for pulmonary embolism remains subjective.
Stuart Swadrom takes us on a journey through Ano-Rectal Disorders, Part Deux —Everything you wanted to know about hemorrhoids and anal fissures, but were afraid to ask.
Gone Fishin’, enjoyed the catch.. Now got a fish bone in there throat … What do you do? Call ENT or read this article and get the bone out yourself.

This ECG is nearly pathognomonic. What is it? — I will give you a hint: it is associated with an anatomic aneurysm about 80% of the time.
Right Ventricular MI seen on ECG helps Angiographer to find Culprit Lesion — Learning point: Even when you have an angiogram, the ECG findings make a difference.

SMART EM

Apart from having an awesome new blog for our viewing pleasure, David and Ashley have taken a deep dive look this month into Cardiac Arrest Pharmacology.

EM:RAP Educators Edition

Rob is back on the podcast scene with this episode his teams up with two of the giants of the EM podcast world Scott Weingart and Rob Orman to discuss Podcasting in Emergency Medicine. These two podcasting geniuses take us through a journey on how they each set up and produce their top quality podcasts on their respected sites, with some laughs along the way — excellent review guys! The end of the podcast see’s LITFL esteemed editor Chris Nickson give a shout out for R&R In The FASTLANE — are you getting your weekly dose of recommended research and reviews from the experts in emergency medicine?

The Rest Of The Best

EDExam

Managing the Obese Difficult Airway — This post is an amazing guide to managing the airway in this sometimes difficult to manage patient group — a must read!!

ToxTalk

A month or so late, but the team at ToxTalk tackle and give a toxicological perspective poisonings around Halloween and then provide a review on Dabigatran, an uncontrollable anticoagulant that will challenge your toxicological skills, and provides emergency doctors with more reasons for their hair turning grey.

Amit launches his first myth buster post with a look at is a recent negative angiogram makes ACS unlikely, right? The answer is is no — these patient still need to be reworked up.
Aggressive fresh frozen plasma (FFP) with massive blood transfusion in the absence of acute traumatic coagulopathy. Bottom line: theire is little evidence to support this practice.
EM RAP Spotlight C3 – Aortic Dissection — a nice summary review of the important facts every ED doc need’s to know about aortic dissection.
Smart Cardiac Arrest Tracking. There’s an app for that. Nice research showing the power of technology might be able to improve outcomes in OHCA.
Myth Buster Episode 2 Hypertension and Epistaxis. Remember there are some emergencies when we need to worry about blood pressure —- this is not one of them!!!

EM Basic

This month’s podcast gives us a simple guide to approaching the patient with Altered Mental Status (AMS).

The Sharp End

Those’s Kiwi lads are back with another monthly newsletter featuring a nice review on High Does Insulin Therapy in toxicology, a brief look at emergency dentistry and much more. Check out the December issue here.

Just Do It — Lytics for STEMI. — Bottom line if you can’t get the patient into the cath lab within 90mins, give them lytics within 30 minutes.
High-Sensitivity Troponin Dead End — As Ryan puts it “Another article trying to work the unworkable — the balance between sensitivity and specificity.”
Why Aren’t You Using Nitrous Yet?— According to this study is has a fairly good safety profile!
Early Heparin Does Not Save Lives in Pulmonary Embolism — this study doesn’t really answer the title of the post — but worth knowing about.

Priceless Electrical Activity

David gives a shout out to The best podcasts he enjoyed in 2011 — what were your favourites? Don’t forget we have all the best free EM/ICU podcasts available in the easily searchable LITFL Podcast Library.

HQmeded.com

Intubating with a Fiberoptic Bronchoscope

Diagnosing Subarachnoid Hemorrhage

It’s sepsis week over at Broome Docs:

Sepsis: Can we pick who’s sick? — A nice simple a look at trying to identifying your patients at risk of sepsis — nice post Casey!
Sepsis: the first “Golden” hour — Some handy pearls to help you reverse your patients mortality from sepsis.
Casey finishes of the week with two difficult sepsis cases in Silent, sitting sepsis and finding fevers’ focus — its time we started recognising and dominate this condition early.

Annals of Emergency Medicine Podcast

Michael Winters share’s with us a great pearl on the crashing patient with pulmonary arterial hypertension:

In recent weeks, we’ve highlighted some pearls regarding the management of patients with pulmonary arterial hypertension (PAH).
In the crashing patient with PAH, think about the following:
Catheter occlusion or malfunction (for those receiving IV prostacyclin analogues)
PE (for those inadequately anticoagulated)
Pneumonia
RV ischemia
GI bleeding
Ischaemic bowel
In the patient receiving IV epoprostenol (Flolan) who presents with a catheter occlusion or malfunction, time is of the essence. Restart the medication through a peripheral IV as soon as possible.

The December podcast is out with some hard hitting articles, from a look at the IO route compared to the IV route in OHCA, the ‘Captain Morgan’ technique for hip dislocation, and does progesterone for acute TBI work? Worth having a listen to.

Pediatric EM Morsels

Paediatric Pulmonary Contusion — remember in kids its the lungs that take a battering not the ribs when it comes to blunt chest trauma.

Soft tissue abscess – the clinical evaluation — it’s good but not that good — maybe ultrasound is the answer!