Check Please!

Greetings EMBS readers, welcome back! It's been a minute since my last post, due mostly to recent orphanage from residency (St Vincent's, I now feel your pain) and travels abroad. Speaking of which, I've just returned from amazing Australia, a land where Fosters pours from drinking fountains and blooming onions sprout from cracks in sidewalks. Not really. But Australia is truly beautiful.

My time was spent working with Air Ambulance Victoria, a team of the most advanced, capable, brave, and friendly paramedics I've ever encountered. I learned so much from them and had the opportunity to accompany the Air MICA's on helicopter and fixed wing missions (think: intubate in a swaying aircraft or sunny beach).

Arriving on scene for a job. (Photo: yours truly)

To top it all off my trip culminated at a 3-day gathering of the world's most impressive names in EMCC--Scott Weingart, Minh Le Cong, and all the blokes of LITFL to name just a few. That's right--I'm talking SMACC!

Best conference ever

Perhaps one of the most important take-away points from presenters at SMACC and ride-alongs with Air MICAs is the utilization of airway (RSI) checklists. It's a discipline ubiquitous to most EDs and paramedics in Australia and--from what I gather--some spots in the US. In this author's opinion it should be used everywhere. In fact, if you've read Atul Gawande's latest book on checklists you might agree. Checklists are in!

I've sifted through several featured airway/RSI checklists and picked out my two favorites, which are attached below. In a nutshell, a uniting theme among the lists can be precipitated out:

"PET Fail", or Patient, Equipment/meds, Team and a Failed airway algorithm or back-up plan.

Putting this into a mnemonic will help with recall in a pinch but I strongly suggest reviewing it thoroughly and then posting one up in your ED in case a checklist/algorithm is not already available. And if you're not convinced just ask yourself "What Would Weingart Do?"

Ruben Strayer Checklist It's incredibly thorough, including medications/doses and algorithms all into one 2-page set.

George Durous Checklist (as featured in LITFL) It's simpler to read and is broken down into 2 separate pdf's--one for an initial checklist, the second as a failed airway algorithm.

Enjoy and stay tuned for lots more to come very very soon!!

We put the SSSS in aSthma

Happy new year! I apologize for the delay in publishing a new post--the holidays can be quite hectic!

Well it's winter time again and the downward trend in mercury levels has given rise to increasing numbers of URI's  presenting in EDs. And with more URIs, naturally, come more asthma exacerbations.

Like any other chronic disease capable of flare-ups asthma exacerbation exists within a spectrum of severity. The emergency physician's management and level of aggression in treating asthmatics should parallel degree of acuity. Certainly, we wouldn't intubate an asthmatic speaking in full sentences with adequate saturation just as we wouldn't halt efforts at albuterol/atrovent on someone tripoding for air.

After reviewing current literature*, trends, guidelines, and expert opinions** I've compiled my 4 S's of Asthma management in the ED, a useful tool to guide a physician through a progression of pointed care.

1. Smoke: Alluding to the tell-tale hissing mist of nebulized ("nebs") bronchodilators, this first-line modality is indicated for all-comers in exacerbation and--like high-quality chest compression and defibrillation in ACLS--is your most important disease reversing therapy. When severe, keep the smoke flowing.
The short acting bronchodilator albuterol is no worse than it's isolate counterpart levalbuterol. Add anticholinergic ipratropium bromide (atrovent) to your first 3 doses only (adults).

Product currently only available in California and Mexico

2. Steroids: If your patient can talk and swallow, give it orally and give it early (within the first hour of arrival). If they're severe aim for IV. Optimal dose has never been elucidated--nor has steroid type. Like bronchodilators, steroids also have proven benefit in disease reversal and should be given to all-comers presenting with exacerbation. Just remember to have your patient complete an oral course of therapy after discharge.

"It's for asthma. Swear."

------------------- (line of separation emphasizes increase in acuity/aggression)

3. Supplements: analagous to the potpouri GNC packets of vitamin and mineral supplements taken by some, this refers to the various medical therapies we throw at patients in severe exacerbation. Like the GNC pills, the following list of commonly used modalities may be effective but are less substantiated in literature. They are indicated for use in severe exacerbations only. When smoke and steroids aren't cutting it, reach for:

• Magnesium sulfate: calcium channel blocking properties, it helps bronchodilate. No benefit in mild-moderate asthma.
• Epinephrine: adrenergic effect increases bronchodilation. Caution in patients over 40 or those with underlying CAD/PVD
• Terbutaline: essentially similar to epinephrine (may substitute)
• Ketamine: is there anything this drug isn't good for? Use here for anxiolysis and bronchodilation. Use smaller doses (1 mg/kg IV)

"Crap. Which one's the cyanide again?"

4. Support: Inspiratory support, that is. If you've gotten this far down the list your patient is likely tripoding, tachycardic, diaphoretic, pale, and relatively close to buying the plastic (intubation). While the literature is not strong (no RCT to date) to support it, there are numerous case studies--not to mention personal experience--showing benefit to BiPAP in critical asthmatics with signs of diaphragmatic fatigue. 

Be sure to minimize PEEP (EPAP) to the lowest allowed setting (their alveoli are super-recruited as is) and start at a generous IPAP of 8-10 cm H20 to remove any burden of poor diaphragm contraction from the failing patient. Make sure to keep nebs flowing through the BiPAP!

The IPAP is the counter-weight assist. The tired arms are the diaphragm. More IPAP is more counterweight.

That's it! Try it out and let me know what you think. 

e-Medicons ;)

Recently I watched a TED talks video in which the presenter comments on the decline of inter-person dialogue and conversation as we know it owing to the rise of text messages, facebook, and other forms of digital communication. Is it surprising after all when such media gives people the ability to edit what they're going to say and the freedom to decide when they're going to say it? Not when you consider it as an escape from social awkwardness and public discomforts. Put differently, it allows people to make thier impressions on others seemingly perfect.  At least that's how I feel when texting or facebooking someone I had met the night before and carefully script a clever request for a date. No more broken conversations or anxiously stumbling over words on the telephone!

Now what if the above translated over to the practice of medicine? As a matter of fact, in many ways, it already has and continues to do so. Albeit slowly. Eric Topol in a headline interview in this October's edition of Annals of Emergency Medicine describes the 'failure of modern medicine' to adapt more quickly to the growing body of web-based media and improved instrument technology. He claims that because of obstructive conservatism (a term I've adopted from yet another TED presenter) we lag behind the times, the same way physicians had resisted change when Lanaek first invented the stethoscope.

The ability, for instance, to monitor blood pressure (HTN), sugar (DM), and pulse oximetry (COPD) from home using automated recording devices, and instant uploads to a physician's database theoretically offer a unique convenience not only to the patient--who would no longer have to await periodic reviews during scheduled follow-ups--but also to the physician, who may intervene sooner and more effectively before deterioration could occur. This is preventative medicine and is the drive behind Topol's argument. In my opinion it's the future of the practice of medicine. Texting and communicating (in a HIPAA friendly manner of course) health information to achieve such preventative medicine are only the beginnings to this concept and are fundamental to telemedicine or telehealth.

Take another lasix. LOL! ;p  

Visit the ATA website to learn more about this growing body of medicine and what's to come.

During my recent medical mission trip to the Dominican Republic, I worked closely with other volunteer physicians of different subspecialties, ranging from rheumatology, gynecology, and surgery to dermatology, pediatrics, gastroenterology, and emergency medicine (me!). If a patient had an unfamiliar condition with a difficult management or unrecognizable presentation, calling in your colleague from the next room over offered a type of instant consultation--not a practical or simple feat in the United States. But what if instantaneous consultation became the norm, done via a network of sub-specialists linked to each other through a platform analogous to Skype or Google chat?

The fact is in more ways than not, we continue to practice what I regard as antiquated medicine. The tools to change this mode of practice are out there, waiting to be harnessed, consolidated, and put to use. Speaking from an emergency medicine perspective, having to ask unreliable patients about their entire medical history and list of medications seems nonsensical. Such information should be pre-recorded and readily uploaded for quick reference to guide us in proper and expeditious management. Taken even further, with at-home monitoring and reporting, the prevention of hospital readmission for several chronic diseases may soon become commonplace (several attempts have already been made, none have yet proven entirely successful). Needless to say spending on behalf of hospitals and the government would as a result be cut dramatically.

David Newman stated in a previous podcast that some patients prefer to relay health information by text. Whether this stems from convenience of not having to see or talk to their doctor in person, a better understanding of information, or simply because it is what they're accustomed to the foundation already exists. Now it's our turn, as physicians and healthcare providers to jump on the bandwagon.

Chest Tube Hero

Don't worry Mark, I did this back on "ER"!

Placing a tube thoracostomy, like an intubation or emergent cricothyrotomy, is one of several critical interventions performed by emergency physicians.  These procedures can quickly change the patient's course away from certain demise offering us a sense of instant gratification. That, and it's pretty darn sexy.

However, like proper endotracheal tube positioning and strict adherence to the cricothyroid membrane, placing a chest tube involves more than just incising the tissue and blindly pushing a tube until the last hole goes in. In this post we review select pearls for optimal passage of the thoracostomy tube to achieve proper posterior-apical placement, as well as a solid approach to securing the tube once you're in.

As a means of crediting my fellow Shock Trauma teammate/thoracic surgery-enthusiast Dr. Brian "Mitz", who first showed me the technique, we shall henceforth refer to this approach as the Mitz method of tube thoracostomy.

Step 1: Know your landmarks before you cut

If you don't cut through the muscle (borders), your patient will thank you

In the above schematic of the axilla (done to the best of my abilities on Microsoft Paint) you'll notice the optimal site for your incision--which should be no longer than 2 cm, just large enough to accommodate your finger--located in the 4th (depicted here) or 5th intercostal space. The trick to never missing your mark, especially with those patients whose habitus does not lend itself to Netter's, is palpating out your borders:

• follow the lateral fold of the pectoralis major superiorly (patient supine)
• follow the border of the the lattissimus dorsi inferiorly (supine)
• find the apex where these two landmarks converge cephalad
• feel (if possible) the inferior angle of the scapula
• in large females, find the inferior mammary fold

Step 2: A "rightful" passage

The trick to getting your tube positioned posterior-apically with beautiful surgical precision is to guide the tube toward the posterior (concave) surface of your corresponding rib (that's rib 4 in the 4th IC space and 5 if entering through the 5th IC space) with the clamp. Getting your tips to the back end of the rib may require some pivoting caudally-inferiorly against the patient's skin surface (see images below). Once you feel the clamp's tips touching the rib surface, unlatch while continuing to hold in place and carefully advance the tube.

Note: incision NOT to scale! (Tube not shown)

The following image depicts guiding the clamp (with tube) toward the posterior rib surface. Always make sure your clamps track along the top of the rib so as to avoid lacerating the neurovascular bundle in the inferior angle.

Black is air (pneumothorax), pink is lung (partially collapsed)

Step 3: Securing the tube (like a boss):

Once you've passed the tube posteriorly (and apically) and the final perforation is within the pleural cavity, it's time to lock it down (suture it down, that is). In the Mitz method, securing the tube involves a series of "figure-4" ties. 

"Did someone say figure 4?? Woooooo!"

• Start with a simple interrupted on one side of the tube
• Form a "figure-4" with one tail over the tube (cut the needle off first, it's no longer needed)
• Repeat with your other tail--the two ends should remain on opposite sides after
• Tie these down using a surgeon's knot (double throw) and cinch down the tube. This will be your most important knot. 
• Wrap each tail around the tube
• Tie down again, no surgeon's knot needed here

See figure below for an illustration

Now apply your favorite dressing, connect to a vac system, and get your chest x-ray champ.

Stay tuned for a video representation of the technique....

A Pain in the @$$

"Say Cheese!"

Just like lower back pain, asymptomatic hypertension, and headaches, a bleeding anus--specifically hemorrhoidal--can often be a royal pain in the you-know-what (ok, pun intended there). Probably because there are so many treatment options available, both conservatively and invasively, for this highly prevalent nuisance we often stumble or even fall short in our ED-based management of these little bloody butt dwellers.

This post serves to clarify (and simplify!) diagnosis and classification of hemorrhoids--sometimes a challenge in and of itself--so that proper evidence-based and guideline supported management may be followed.

The first step in correctly managing hemorrhoids is correct diagnosis. While a full discussion of perianal disease is beyond the scope of this posting, essentially our first task is to differentiate between internal and external hemorrhoids.

1. History: while the old dogma of internal hemorrhoids being painless and external hemorroids (when thrombosed) being painful probably holds true there are other clues in the history that may assist in your differentiation. Internal hemorrhoids prolapse with Valsalva and reduce spontaneously (stage II) or manually (stage III), unless they are incarcerated (Stage IV), in which case they are an emergency. External hemorrhoids are, well, always external.

2. Physical: look at the overlying skin. External hemorrhoids share the same epithelium as the surrounding anus so the appearance is essentially the same. Internal hemorrhoids are covered by mucosa and carry a shinier wet appearance--or at least are unlike the surrounding external tissue.

Management:

If you grouped all hemorrhoid types and grades therein, you find three basic courses of action that you, as the emergency physician, can take. Presented in order of increasing immediacy, they are:

1. TLC or Therapeutic Lifestyle Changes - are essential in all cases and varieties of hemorrhoids and should always be recommended. According to the literature, simple TLC--especially in cases of non-thrombosed external and low-grade internal hemorrhoids--alleviates symptoms and decreases hemorrhoid size (sometimes entirely). A plethora of OTC supplements and such exist, however the most efficacious (and supported) are sitz baths, fiber dietary supplements, and topical analgesics. See here for more detail.

2. Excision of thrombus - When an external hemorrhoid clots, an excision--not incision and drainage--is indicated if presentation is within 72 hours of symptom onset. If patients come in later, spontaneous dissolution and resorption occurs and conservative management (TLC) is acceptable. A quick video illustrating the procedure can be viewed here.

3. Call a surgeon. With hemorrhoids, there are basically two reasons to immediately involve your specialist: stage IV internal hemorroids and clotted circumferential external hemorrhoids (or at least too big to handle yourself). Also, never incise or excise internal hemorrhoids--thrombosed or not. Have a surgeon take a look.

"I will find all your hidden treasures."

Sources:

http://www.ncbi.nlm.nih.gov/pubmed/20109630

http://www.fascrs.org/gedownload!/Practice_Parameters_for_the_Management_of_Hemorrhoids.pdf?item_id=12244001&version_id=12244002

http://www.ncbi.nlm.nih.gov/pubmed/22534276

The Ultimate Shock-Block: How to Take Back “Charge” in Your ED

I recently had the following case:

52 year-old male presents to your ED from the cardiologist’s office complaining of shortness of breath and palpitations since this morning. This is the first episode. Vitals: BP 100/60, HR 135 – 148, RR 22, T 98, O₂ sat on RA 93%. On exam, the patient appears mildly uncomfortable and has mild crackles in his lung bases with an irregularly irregular heart rate on auscultation. No other significant exam findings are noted. An EKG is quickly obtained revealing atrial fibrillation with rapid ventricular response.

It was a gift from god. Well, maybe not for the patient—but for an ambitious EM resident like myself any chance at shocking a human heart is well received.

The criteria for D/C cardioversion were met, but no sooner than I could wipe away the dribble of saliva from my chin and tear through the plastic packaging of pacer pads like a child on Christmas (er, Hannukah) did the cardiologist arrive. “Hold on son, let’s just give cardizem 20” he said. And so we did. Grinch.

I got shock-blocked in my own ED, by an outside cardiologist no less! The implications of territorialism are beyond this entry, but for now let’s just discuss when to shock AFib.

If you answered: “when it is unstable”, you are correct! From what I’ve witnessed, however, there seems to be much confusion about what defines unstable atrial fibrillation (or tachydysrhythmia for that matter).  When in doubt you can use my mnemonic: “ACS”

A – is for ACS, anything from unstable angina to full blown MI

C – is for CHF. That is, acute exacerbation of old, or a new onset pulmonary edema

S – is for symptomatic hypotension

In the above case, the patient had acute pulmonary edema (no history of CHF), later confirmed by chest XR. And, lo and behold, he also threw a troponin of 0.5.

So why the fear and avoidance of cardioversion? It’s safe and actually carries less risk than pharmacologic cardioversion. And when any of three “ACS” criteria are met, it’s the right call. Still don’t believe me? Just follow the current guidelines from the AHA/ACC on management of atrial fibrillation.

Now that you’re convinced and excited about shocking your patient, here are some key points on successful cardioversion.

Sedation.

D/C cardioversion is painful—duh!—so use sedation.

"Check Pad Placement"

A nice go-to alternative to the classic versed/fentanyl combo (acceptable) is etomidate/fentanyl. Etomidate is advantageous due to its rapid onset/offset and stable cardiovascular profile. I use “half-dose” etomidate or 0.15 mg/kg. Remember, you’re not looking to intubate—only briefly sedate for a quick jolt. Scott Weingart describes sedating an unstable atrial fib patient in his EMCrit podcast.

Pad placement.

Optimal energy delivery to overcome the dense mass effect of fibrillating atria is best achieved with anterior-posterior pad configuration. Anterior-lateral is less successful. Rob Orman of ERcast discusses pad placement and cardioversion with an electrophysiologist in his podcast.

Device.

When available, opt for biphasic—it carries an overall higher success rate for cardioversion when compared to monophasic (94% vs 79%, respectively and 99.1% vs 92.4% in another study) and requires less energy. Less energy translates to less skin damage.

Energy.

Current recommendation is to start at 100 J on biphasic and 200 J in monophasic and titrating upward as needed every minute between shocks until cardioversion is achieved. Worried about causing myocardial damage? Evidence does not support clinically significant injury or troponin elevation in patients even when levels as high as 400 J are used.

For an amazingly brilliant 15 seconds of entertainment watch this: video

Anti-coagulation.

As we’ve all learned in medical school, prolonged periods of persistent fibrillation result in blood pooling and stasis in the atria leading to clot formation. Once cardioverted, any existing thrombus is at risk of dislodgement and embolization with the return of an atrial kick.

For patients known to be in fibrillation over 48 hours, the current guideline recommendation is to co-administer a heparin bolus (unless contraindicated) followed by drip when performing cardioversion in the ED. Coumadin is initiated thereafter on the floors once properly anticoagulated.

If fibrillation is acute (less than 48 hours), just shock.

Interested in more? Check out this in-depth review brought to you by the guys of Life in the Fast Lane. Oi Aussie!!

Case Files: The Best Incision and Drainage Technique. Ever!

This will be the first installment in a series of case files on the blog, where I review anecdotally novel techniques, procedures, and other tools used by myself or colleagues in the ED. As usual I welcome your stories and experiences as well!

Last night I encountered a patient who presented with a pilonidal cyst abcess with surrounding cellulitis over the left gluteus. There were no complicating factors (DM, HIV etc).

Recently I came across Dr. Rob Orman's cast and elegant summary on the LOOP abscess drainage technique, which comes from a recent publication in the Journal of Pediatric Surgery. In short, the traditional technique of making a large incision and inserting packing with scheduled changes is replaced by two smaller (more cosmetic friendly) incisions and tunneling a small rubber cathether or drain tied together to make a loop. This obviates the need for painful packing changes, possible premature wound closure, and need for repeat procedure. See schematic below:

credit: Michelle Lin, Academic Emergency Medicine

In the case above, I followed the same procedure described in Dr Orman's video and made some minor adjustments to accomodate the nature of the pilonidal abscess. A second small incision was then made superior to the point of drainage and, with the hemostat, a tunnel was burrowed between the two points. I work in an emergency department with limited resources and equipment, so surgical vascular tubing used in the video were not availbale. Instead I cut off the vacutainer and needle of the two ends of a butterfly and used it in its place. Aftercare instructions were provided as in the paper and video.

The patient afterward was extremely pleased, smiling, and I must confess--I was too :)