UCONN Emergency Medicine Interest Group

Archive for July, 2011|Monthly archive page

Journal Article Synopsis: Glidescope vs. Direct Laryngoscopy

In JOURNAL CLUB on July 31, 2011 at 2:57 PM

Summary for “Tracheal Intubation in the Emergency Department: A Comparison of GlideScope® Video Laryngoscopy to Direct Laryngoscopy in 822 Intubations” by John C. Sakles et al. in The Journal of Emergency Medicine.

What is already known on this topic:
While video laryngoscopy has been available for ED physicians, there hasn’t been much done in terms of study in comparing the success rates of video versus conventional direct laryngoscopy, especially in the ED. Most studies have been conducted in the OR or simulation laboratory.

What question this study addressed:
This study addresses the question, “How successful are first attempt intubations of using video versus conventional direct laryngoscopy?” It also addresses the success rate of second attempts, the key features and reasons for failure between the two devices.

What was the study design:
This study is a 24 month retrospective observation study on data collected concurrently between July 1, 2007 to June 30, 2009 on all ED patients intubated in a single academic ED with a Level I trauma center, belonging to a tertiary urban university. A one-page data collection sheet was completed by the operator upon completion of each intubation. The data forms were cross-referenced with the billing form to make sure missing forms were filled out. Video laryngoscopy (GVL) was done using GlideScope® standard, Colbat or Ranger. Conventional direct larygoscopy  (DL) was done using a traditional Miller/Macintosh laryngoscope.

What this study adds to our knowledge:
Prior studies in the OR and/or simulation laboratory have shown GVL to have faster and greater first time success rates compared to DL, especially in cases of cervical immobilization. However, most studies showed minimal to no difference in the use of either of these devices.

From this study, it showed that GVL indeed had a higher first time success rate in comparison to DL, especially in instances where there were two or more predicators for a difficult airway. However, in instances where more than one attempt was required, DL had better success rate than GVL. This is because the factors that cause GVL failure usually can’t be improved much, and physicians often abandon GVL for another device after failure of a first attempt, whereas with a DL, more attempts are usually tried before switching to another device, and failed attempts were usually improvable by adjusting the laryngoscope into a better position for a view of the glottic opening. Also, there were fewer esophageal intubations using GVL versus using DL.

How this is relevant to clinical practice:
This is relevant to clinical practice because intubation is a life-saving procedure that is performed in the ED on a daily basis. For patients with difficult airways, GVL is a viable solution to assist the physician in being able to acquire a view of the glottic opening for the intubation. GVL has been used by anesthesia in OR patients, and studies of its efficacy has been published. With these results of the use of GVL versus DL in the ED, this could possibly assist ED physicians in their choice of laryngoscopic device for patients.

Other considerations:
Future studies should be conducted regarding the comparison of each device in difficult airway situations.

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Pearl/Pitfall: Hypoglycemia

In PEARL/PITFALL on July 25, 2011 at 2:15 PM

Based on two discussions I had with Dr. Nowicki and Dr. Price:

Always check a blood glucose level in patients with altered mental status or neurologic deficits. The clinical presentations of hypoglycemia are protean; Dr. Nowicki told me about a case in which a patient presented with an isolated unilateral CN VII palsy in a patient with no prior neurologic history, which completely resolved after the hypoglycemia was corrected. It is both embarassing to the provider as well as potentially dangerous for the patient for delay in diagnosis of this condition. It is very simple and fast for this to be ruled out as a likely cause of the patient’s symptoms, and the stakes are high. However, there are several things that should be considered as pitfalls here.

First, the blood glucose level at which nondiabetic patients and diabetic patients display symptoms may differ considerably. In one study in NEJM (reference provided below), poorly controlled diabetics first developed symptoms at a mean glucose of 78 mg/dL, while nondiabetics developed symptoms at a mean glucose of 53 mg/dL. The implication is that a so-called “normal” glucose level, which may not be flagged as abnormal by the lab (which has no knowledge of the patient’s history) may actually be hypoglycemic in terms of their body’s altered metabolism.

Second, it is important not to undertreat hypoglycemia. The initial treatment, of course, is IV dextrose; adult patients typically require 0.5-1.0 g/kg D50. Since an amp of D50 has 25 g of dextrose, a single amp of D50 will usually not be sufficient to match this requirement (consider that the “standard” patient is 70 kg; this implies that they will need at minimum 35 g, and up to 70 g of dextrose, which implies they will need at least 2 and potentially 3 amps). Once the patient is able, this initial bolus of dextrose should then be followed by a meal; this provides sustained calories over time (if the patient cannot eat, dextrose infusions may be necessary). Otherwise, the patient may rebound back into hypoglycemia!

References:

Boyle PJ, Schwartz NS, Shah SD, et al. Plasma glucose concentrations at the onset of hypoglycemic symptoms in patients with poorly controlled diabetes and in nondiabetics. N Engl J Med. 1988;318:1487-1492.

EM Images #5

In IMAGES, RADIOLOGY on July 18, 2011 at 7:22 PM

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

This slideshow requires JavaScript.

Patient is a 75 year old man c/o lower abdominal pain for 8 hours. Diaphoretic w/ chills and pain worsening for 2 hours; has never had this pain before; last BM 8 hours ago. no normal BM x 2 days.

PMH: CAD, CVA, Diabetes, High cholesterol/lipidemia, HTN

PE: VS: 97.8, 188/97, RR 18, 94% sat RA; HR 112
Pt had epigastric pain with some guarding and ? rebound. Rectal exam heme negative.

Labs: normal CBC, lytes, LFTs, lipase; only lab abnormality is glucose of 259.

Plain films from present admission and 2004 visit for bladder cancer, as well as CT from 2009 shown above in slideshow. What do they show? What are the radio-opacities in RUQ, and what is their relationship to the present illness? (click below to see answers below the fold)

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Journal Article Synopsis: Is ED Hyperglycemia a Poor Prognostic Marker in Intracerebral Hemorrhage?

In JOURNAL CLUB on July 11, 2011 at 3:21 PM

Summary of “Emergency Department Hyperglycemia as a Predictor of Early Mortality and Worse Functional Outcome after Intracerebral Hemorrhage” By Latha G Stead et al, Neurocritical Care vol 13: pp. 67-74. 2010.

What is already known on this topic:
Hyperglycemia upon admission was already known to be a predictor for poor outcome in ischemic stroke. A relationship between hyperglycemia and mortality in intracerebral hemorrhage (ICH) had been suggested, but little data was present to define its prognostic ability.

What question this study addressed:
Is hyperglycemia at arrival associated with early mortality and functional outcome in patients with non-traumatic ICH?

What was the study design:
A prospective, cohort study of 237 adults presenting to the ED with CT confirmed, spontaneous ICH between 1/06 to 12/08, with a blood glucose measurement at presentation. Data was collected by two independent, blinded abstractors.

What this study adds to our knowledge:
This study showed that hyperglycemia (defined as blood glucose of ≥140) in both diabetic and non-diabetic patients is a prognostic predictor of higher mortality within 7 days. Among non-diabetics, it is also a predictor of poor clinical outcome  when controlled for stroke severity, age, and volume of hemorrhage. Furthermore, higher blood glucose values correlated with more severe stroke, measured by the NIH Stroke Scale. There was no significant difference shown among diabetic patients when glucose levels were used as a predictor for poor clinical outcome or stroke severity.

How is this relevant to clinical practice:
This study allows confirms that hyperglycemia is a red flag among patients presenting to the Emergency Department with ICH and gives clinicians an early, easily obtained prognostic indicator for mortality and outcome in these patients.

Other considerations:
Further research can be done to see if control of hyperglycemia may lead to better outcomes among ICH patients. This study is limited in its design- it only considered outcome at the end of the hospital stay, but did not control for the length of stay. More research should be done to determine if there is a difference in outcome at  specific time points over a greater length of time (eg. 3, 6, and 12 months).

Pearl/Pitfall: Right-sided MI

In PEARL/PITFALL on July 11, 2011 at 12:40 AM

From didactics with Dr. Regan:

Understanding the presentation of posterior MI on EKG is not that complicated, and need not require any mirrors or special tricks! It can be relatively easily understood simply by recalling the coronary anatomy and lead placement. Remember that anatomically, the right coronary artery takes a path that goes to the posterior portion of the heart, then the inferior portion of the heart. This means that a posterior MI must* have an associated inferior MI; if the inferior leads (II, III, aVF) do not show signs of MI on EKG, then there is no posterior MI. Recall also that the chest leads V1-V6, just like the other leads, measure a vector of electrical activity pointing anteriorly. This implies that the vector goes from posterior to anterior. So, it should be expected that posterior MI should show reciprocal ST-T changes in the anterior chest leads. If they do not, this implies that the MI is a more distal pure inferior MI (which has a significantly better prognosis). If the chest leads do show reciprocal changes, right sided chest leads should be placed to obtain a right-sided EKG to determine if the obstruction is more proximal, resulting in a complete right sided MI, or more distal, resulting in a posteroinferior MI. In other words, the right-sided EKG should demonstrate ST-T changes consistent with MI if there is a complete right-sided MI (eg. ST elevation).  If they do not, the diagnosis is posteroinferior MI (again, remember that a posterior MI requires there to be an accompanying inferior MI).

* Note: as with everything in medicine, there are exceptions to the rule, and so it is possible for variants in coronary anatomy to make this idea not always hold. However, Dr. Regan informs me that he has only seen this occur several times in his nearly 20 years of practicing EM.

** Note: please remember that not all MI present with EKG changes. In fact, the sensitivity of the first EKG in acute MI is only 13-69%, and considering the evolution of all EKG abnormalities (ST, T, Q waves, LBBB) over time, the sensitivity is  87%.

References:
http://www.bestbets.org/bets/bet.php?id=75
http://www.uptodate.com/contents/electrocardiogram-in-the-diagnosis-of-myocardial-ischemia-and-infarction?source=search_result&selectedTitle=4~150

Journal Article Synopsis: Air mattress vs. backboard in patient comfort and tissue pressure

In JOURNAL CLUB on July 7, 2011 at 3:26 PM

Summary for “Revolutionary advances in enhancing patient comfort on patients transported on a backboard” by Richard F. Edlich, Shelley S. Mason, Rober J, Vissers, et al. American Journal of Emergency Medicine Vol 29 (2); pp. 181-186.  2011.

What is already known on this topic:
Spinal cord injuries can cause short term discomfort and lead to long term disability. Stabilization of patients with spinal cord injuries is an import aspect of prehospital care. Care of trauma patients involves the use of backboards to immobilize the patient’s head, neck, and back. Studies have shown that the use of backboards causes discomfort and frequently leads to the formation of pressure ulcers.

What question this study addressed:
The Back Raft system is designed to reduce skin interphase pressure as well as patient discomfort. The purpose of this study is to record the rating of patient pain and to measure the tissue interface pressures at the occipital, scapula, and sacral regions.

What was the study design:
The Back Raft is an inflatable air mattress that can be applied to standard 16 and 18 inch spinal backboards. Ten healthy volunteers who had taken no pain medication and were not experiencing back pain were studied lying on backboards with and without the raft for 30 minutes. Pain was measured at the start and in 15 minute intervals using the 10-point Visual Analog Scale. Additionally, patients were asked to access their comfort level. Contact pressures between the patients and surface of the raft or backboard were measured at the occipital, scapula, and sacrum regions using a Tactilus pressure evaluator. Tactilus software converts the pressure recording in measurements of millimeters of mercury.

What this study adds to our knowledge:
Subjects of different genders and BMIs reported there was a less drastic difference in pain level during the 30 minutes when using the Back Raft. Tissue interface pressure levels were higher in all subjects when using only the backboard.

How this is relevant to clinical practice:
In addition to providing an increase in patient comfort, use of the Back Raft could benefit the cost of care because the use of the raft lowers the risk of developing pressure ulcers. Implementing the raft in prehospital care of trauma patients can help avoid the development of hospital acquired conditions. Additionally, the Back Raft is radiolucent, a characteristic that would be beneficial in time critical situations.

Other considerations:
This study was only conducted on healthy patient subjects. One would hope patients with injuries would report the same benefits from using the Back Raft.

Book Review: Minor Emergencies – Splinters to Fractures

In REVIEWS on July 3, 2011 at 4:51 PM

This review is for the book Minor Emergencies – Splinters to Fractures, 2nd edition by Philip Buttaravoli, MD, which can be purchased here. The reviewer has received no financial renumeration for this review.

This is a book that I purchased because I felt that many of the everyday clinical problems that I might encounter in the ED (or just walking around in a hazardous world) had not been formally taught in the curriculum, and had not been encountered by myself yet in my outpatient rotations. We learn a lot about carcinoid tumors, pheochromocytomas, the histology of thyroid cancers, and enzymatic pathways, but not very much about how to handle poison ivy exposure, finger dislocations, torn earlobes, or foreign body removal- despite the fact that we are very likely to encounter these problems at some point in our career. The author makes the point in the preface that the assumption is that “if you haven’t completed your training, you can’t do any harm if the conditions to which you are assigned responsibility aren’t very serious”; however, “care still needs to be appropriate so that the condition won’t deteriorate into a true threat to life or limb”. I fully agree with the author that minor emergencies, as much as any other medical issue, deserve to be treated seriously and with an eye towards providing evidence-based, cost-effective, and efficacious evaluation and treatment.

To this end, I believe that this book definitely fulfilled those goals. The text of the book, not including the index, is 807 pages long and divided into 184 chapter (and 8 appendices). Each chapter ranges from about 2 to 6 pages in length. The chapters are organized in sections, ranging from Neurologic and Psychatric Emergencies to Musculoskeletal Emergencies. Each chapter follows a uniform format with an initial discussion of the presentation of the complaint, followed by recommendations on what to do, and recommendations on what not to do, and concluding with a general discussion  of the topic. There are numerous references provided in case you want to explore a topic more deeply. The book is in full color and there are both photographs and clearly done illustrations. Notably, there are no tables in the book, which I take as a refreshing change from the usual medical textbook, which I feel often substitutes tables for clear and concise writing.

Strengths of the book included brevity of the writing, excellent illustrations, comprehensiveness, and attention to practical detail. The only disadvantage that I can see is that the book cover promises that there is handheld software included with the book; however, I contacted the publisher (Elsevier), and they informed me that the service used to run the software has been discontinued.

Overall score (out of 5 stars):

EM Images #4

In IMAGES, RADIOLOGY on July 2, 2011 at 11:38 AM

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

AP (left) and lateral (right); click to enlarge

Click to enlarge

The patient is a 62-year-old female who yesterday suffered a fall from a standing height when she slipped on her kitchen floor feeling immediate pain in her left knee. She felt pain in no other area. She was able unable to get herself up, but her husband showed up shortly after she fell and helped her to the couch. She was brought by ambulance to the ER this morning for evaluation of her left knee. She was having no previous fevers, chills or sweats. There has been no back pain, chest pain or shortness of breath. She has had no previous injury to the left knee. She has joint-line tenderness laterally in the left knee. She has good range of motion from about 100 to 110 degrees from full extension. She does not tolerate the exam to varus or valgus stress secondary to pain. Similarly, she does not tolerate the anterior-posterior drawer, Lachman’s secondary to pain. She has no pain to palpation along her back or neck.

PMH: HIV, HTN, asthma, depression, anxiety.

PSH:
1. Left hip ORIF versus hip replacement (the patient is unsure which); she fell and broke her hip a few years ago and was treated at New Britain Hospital.
2. Right ankle ORIF for a fall similarly.

Medications: 1. Truvada. 2. Reyataz. 3. Norvir. All are for her HIV. She does have asthma but no longer takes medication for this.

Allergies: Percocet, which causes itching.

SH: 3 cigarettes a day x 30 years. ETOH occasionally. Denies IV drug abuse.

FH: noncontributory.

Plain films were ordered, which you can see at the top of the post; the reading is as follows:

Clinical Indication: Pain and swelling. Four views of the left knee show no evidence of joint effusion there is there is osteophytic spur arising from the lateral tibial plateau but no definite fracture is seen. Alignment is generally anatomic except for some minimal degenerative change. No other significant findings are seen.

What is the likely diagnosis? What would you do next? (click below to see answer below the fold)

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