UCONN Emergency Medicine Interest Group

Archive for June, 2011|Monthly archive page

Upcoming meeting

In ANNOUNCEMENTS on June 24, 2011 at 3:08 PM

The next EMIG meeting has been scheduled for Monday, June 27th at 6 PM at Dr. Regan’s. Further details available by contacting lburns@up.uchc.edu.

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Spotlight Lecture: Chest Pain Risk

In TALKS on June 20, 2011 at 10:53 PM

This is a brief review of a talk given by Dr. David Newman of the SMART EM podcast and thennt.com; it can be found here.

First, as background: the SMART EM podcast is a relatively new EM podcast that does “deep dives” into the EM literature, meaning that they actually look at the primary studies and evidence (or lack thereof) that guide the way that EM is practiced. It is a fantastic listen for anyone that is really interested in practicing evidence-based medicine, and often there are surprising finds that make you take pause.

This talk in particular is about evaluating the risk of chest pain in the ED, and specifically, the 2 patient-oriented outcomes that are important to us: MI, and death (generally within 30 days or 6 months). In brief, there were several important points that were discussed:

1. Framingham risk factors are not useful for predicting the risk of negative outcomes from chest pain except in patients younger than 40 and with >3 risk factors. Dr. Newman makes the point that the Framingham study and the risk factors derived thereof were developed to determine the risk for developing CAD, NOT acute MI.

2. Dr. Newman reviewed several well-done, large, prospective randomized studies that looked at the risk of bad outcome in several cohorts, from low risk chest pain under 40 years old (1:500), low risk chest pain over 40 years old (1:250), and moderate risk chest pain (1:125).

3. It is suggested that these risk statistics can be used to start a conversation with the patient about how to proceed and thus facilitate a shared decision making process.

References

Ultrasound Case #3

In RADIOLOGY on June 16, 2011 at 8:43 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: RLQ abdominal pain.

HPI: 25 yo female presents to ED with severe right lower quadrant abdominal pain beginning yesterday.  LMP about 7 weeks ago.  Denies vaginal discharge or bleeding.  No history of abnormal pap smears, STI’s or previous pregnancies.  Sexually active without protection.

FH: denies alcohol, smoking or drug use.

PE: Afebrile. VSS.  Abdomen tender to palpation suprapubic, right and left lower quadrants.  Pelvic exam with bilateral adnexal tenderness.  Cervical os closed.

Labs: Urinalysis negative for infection.  Urine pregnancy positive. H/H stable.  Quantitative B-hCG: 83,000.

Bedside U/S: (see beginning of post for 1st still image): click for video.

What is the next step in management? (click below to see answer below the fold)

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Journal Article Synopsis: Bedside Ultrasound for Pediatric Long Bone Fractures

In JOURNAL CLUB on June 13, 2011 at 11:00 AM

Summary for “Bedside Ultrasound for Pediatric Long Bone Fractures ” by Keith Cross in Clinical Pediatric Emergency Medicine Vol 12 (1); pp 27-36

What is already known on this topic:
Almost all suspected fractures are currently evaluated by radiographs, with fractures requiring reduction often requiring multiple radiographs and/or fluoroscopy. Bedside ultrasound may provide an alternate imaging modality with advantages of decreased radiation exposure, identifying occult fractures in young children with poorly ossified bones, and use in austere conditions without ready access to X-rays.

What question this study addressed:
Can bedside ultrasound be used in pediatric patients with suspected long bone fracture to diagnose fracture accurately?

Which long bone fractures have the best evidence for ultrasound diagnosis?

What was the study design:
Brief reviews of several studies for diagnosis of radius/ulna injuries and fractures, reduction of forearm fractures, humerus injuries, clavicle injuries, femur injuries, tibia/fibula injuries. The technique for identifying long bone fractures by ultrasound is described with recommendations on transducer choice and imaging settings.

What this study adds to our knowledge:
Sensitivity and specificity for diagnosing pediatric long bone fractures was high for a wide variety of suspected fractures. One study demonstrated highest accuracy for simple fractures of the femur, humerus, and forearm bones, and lowest accuracy for compound fractures, small bone fractures, and Salter-Harris type I injuries. Several studies showed ultrasound-guided forearm fracture reduction was very frequently successful on first attempt. Diagnosis of proximal and midshaft humerus fractures has good evidence; diagnosis of supracondylar fractures has less evidence and may be more challenging. Diagnosis of clavicle fractures has excellent evidence and may be suitable as a primary imaging modality, and offers the advantages of avoiding radiation to thyroid tissue. Femur fracture diagnosis currently has limited evidence, but some case reports and case series suggest it may be feasible for midshaft fractures. Tibia and fibula fracture diagnosis also has limited evidence, and the largest study thus performed shows a lower sensitivity for identification of these fractures.

The author recommends using a 10 to 15 Mhz linear transducer with the vascular preset setting. Fractures may be identified as a disruption of the echogenic line of cortical bone, a hematoma over the bone at the point of fracture, an avulsed bone fragment, or callus formation appearing as a hypoechoic mass around the bone.

How this is relevant to clinical practice:
Ultrasound diagnosis may be a more rapid and less painful way to diagnose some pediatric fractures with less radiation exposure and potentially less time required and decreased pain to the patient, particularly for forearm and clavicle fractures.

Other considerations:
Many of the studies were performed by radiologists or orthopedists as the sonographers; it would be helpful to see more studies using emergency physicians as the primary sonographers.

EM Images #3

In IMAGES on June 10, 2011 at 9:34 PM

Syndicated from the UCONN EM Residency website; credit to Dr. London for images and text.

This is a case of a 13 year old otherwise healthy female who presents to the ED with a rapidly progressive rash over the past 2 days which initially started on her trunk and then spread to her extremities. There is no face, neck or mucosal involvement. The rash is pustular rather than vesicular and is follicular in distribution. This came on several days after going in a hot tub which was newly opened for the season. She is fully vaccinated for varicella.

What is the first-line treatment for this disease?

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Book Review: Wounds and Lacerations – Emergency Care and Closure

In REVIEWS on June 3, 2011 at 6:19 PM

This review is for the book Wounds and Lacerations: Emergency Care and Closure, 3rd edition by Alexander T. Trott, MD, which can be purchased here. The reviewer has received no financial renumeration for this review.

This is a book which I picked up for my outpatient surgery clerkship in preparation for both that rotation and my upcoming EM rotations. I had hoped to learn from a reputable source the very basics involved in wound repair, which I felt were somewhat lacking in the general curriculum, as well as some advanced techniques. I was looking for a book that was evidenced-based, rather than tradition-based, and covered a fair amount of ground while not being overly arduous to get through in a 3 week period.

Overall, I feel that this book fulfilled those goals, and generally quite well. The text of the book, not including the index, is 316 pages long and divided into 22 chapters. It begins with an overview of emergency wound care and assessment, and gradually builds up in a logical succession in a sequence of how you would close a wound in the ED, beginning with assessment, followed by anesthesia, then cleansing, then choosing suture material and instruments, then techniques both for repairing simple and complex wounds. The book then transitions to special situations, such as facial or hand wounds, bites, burns, foreign body removal, etc. The book makes sure to cover even the “simple” but essential issues involved in wound care which are probably not ever going to be formally taught. For example, in the chapter on wound cleansing, there are subsections dedicated to what sort of solutions to use, how to irrigate properly and with the correct instrument, positioning the patient, and so on. Likewise, there is a 28-page chapter on wound dressing and bandaging with copious illustration.

Strengths of the book included brevity of the writing and many illustrations (tri-color only, unfortunately) and attention to all portions of wound care in a primary survey of the subject. Weaknesses included the fact that the text and the illustrations were sometimes a bit awkwardly out of sync, which might be confusing if attention was not paid to which figure number in the text matched up to which figure (in other words, the figures on one page often were referenced to on the previous page, rather than the current page). The subsections could also sometimes occasionally be a little too brief, although I am hesitant to consider this a significant weakness, since it ensured that the most essentially information didn’t get lost in text (as I feel often happens in textbooks).

Overall score (out of 5 stars):

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