Grand Rounds Recap 1.16.19
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Orthopedic Pearls and Pitfalls WITH DR. SAYAL
Medical education in the United States and Canada has been found to be lacking in respect to musculoskeletal injuries. Approximately 15 to 20 percent of all presentations to an emergency or primary care physician are for musculoskeletal complaints. Emergency medicine providers must be intentional in their approach to learning how to appropriately evaluate musculoskeletal complaints in order to care for their patients. Dr. Sayal comments that too commonly we will give a “diagnosis of soft tissue injury” when X-rays of the affected area are negative. He believes that we can do better by taking a more detailed history and physical exam and intentionally seeking out opportunities to learn more about the various injuries and how they present.
Carpal Injuries
Scaphoid injuries comprise 70% of all carpal injuries.
Scaphoid fractures carry a high risk of avascular necrosis if not identified and managed.
SLAC wrist: Scaphoid Lunate Advanced Collpase)
Advanced arthritis of the radiocarpal and midcarpal joints caused by a chronic scapholunate ligament injury.
The second most common carpal injury is the Triquetral chip fracture accounting for 15 to 20% of carpal injuries.
Usually occurs due to a fall with the wrist in dorsiflexion and ulnar deviation.
Hook of the Hamate fractures are more rare but require consideration. Only estimated to account for 2% of carpal fractures.
Most often seen in “club sports” such as baseball, golf, or hockey.
The patient will often describe striking their club against a stationary object (such as the ground) and then experienced pain.
Presentation involves hypothenar pain that is often made worse with a tight grip.
If you have a high suspicion for this fracture you can request a carpal tunnel view X ray (sometimes called a hook of the hamate view) to further evaluate for this fracture.
A high suspicion (even with negative X-rays) should prompt immobilization with an ulnar gutter splint and follow up evaluation.
Knee Injuries
Seven injuries you cannot miss when evaluating a painful knee:
Septic Arthritis
Quadriceps Tendon rupture
Knee Dislocation
Tibial Plateau fracture
Compartment Syndrome
Patella Tendon rupture
Referred pain from the hip (hip fracture)
Patient and physician dissatisfaction WITH DR. david Thompson
Most Common Patient Complaints
“It took too long”: Often in reference to length of stay in the emergency department or in relation to completing a test or procedure. Expectation setting and providing a realistic (and possibly over-estimated) time to completion of a task can help prevent this complaint.
“It was too expensive”: As the physician it is important to try to focus the conversation on the patient’s health and well-being. If patient’s have questions about the cost associated with their medical care you can often refer to them registration or the office within your institution that handles those types of inquiries. It is very important that you not provide a false estimate of the cost as that can lead to significant patient dissatisfaction in the long term.
Wound care delays: Patient’s often present with lacerations, dried blood, and mud/dirt on their skin, especially after a traumatic event. Often times these smaller injuries can be overlooked by the physician while they focus on more pressing issues; however, to the patient and family these are of great importance. Quickly applying basic wound care and identifying team members who would have time to address cleaning the patient can help prevent this complaint.
“My doctor was dismissive”: It is important to validate and address patient concerns even when they may seem small to you. Reassurance is a large part of the job of the emergency medicine physician. You never want a patient to leave the emergency department thinking that you are of the opinion they should never have come in the first place.
“My pain was not addressed”: Pain control is a difficult subject to address especially with the recent healthcare focus of the opioid issue the United States; however, it remains important to validate a patient’s complaint of pain and work to discuss pain control options that you believe reasonable based upon your history and physical exam.
“You did nothing for me”: Expectation setting is key. Try to discuss your plan of care after evaluating the patient including what lab tests, imaging studies, and therapeutic plans you intent to implement. As the encounter comes to a close go to the bedside and discuss the results of your tests/imaging and next steps for the patient including follow up when indicated.
Retained foreign bodies in wounds: Prior to wound closure discuss with patients that there is a risk for a retained foreign body. Discuss with them the steps you have taken to lessen that risk such as wound exploration after anesthetic or X-ray imaging. Document these discussions and provide appropriate documentation about the wound closure techniques you employ.
Most Common Consultant Complaints
Oversedation: Be careful when providing anxiolysis or sedation for a patient who already has intoxicants in their system. Consider high-level monitoring in patients who require anxiolysis or sedation such as end tidal CO2 monitoring and direct physician observation.
Appropriate use of bedside ultrasound: It is important to utilize ultrasound within your scope of practice and to avoid conflicting information within the medical record. The scope of bedside ultrasound is expanding and this is a great addition to our bedside work ups. The trouble begins when a provider practices outside of their own limitations. Having a way to save your images and allow for consultants to readily access them is a great way to provide collaborative care.
Delay in consultation in time-sensitive conditions: Know your clinical environment and the preferences of your consultants. It is often reasonable to call a consultant prior to the result of a diagnostic study if your clinical suspicion for a time dependent condition is high enough.
Predictable return visits: The most common cause of this is when you do not review the medical record prior to discharge. It is important to clearly review all results from tests performed, final vital signs, and to document any discrepancies that you notice. Conflicting documentation from provider and nursing staff can also lead to this problem.
Procedural complications: When performing a procedure that is new to you or that you have performed in the recent past make sure to review the procedural steps as well as the common complications. Always use sterile technique when indicated. Ensure appropriate documentation of the risks and benefits in the written consent from the patient.
Lack of continuity of care: Be clear in your hand-offs especially for those patients that you are admitting to the hospital. Clear explanation of what has been done and what steps are pending is expected. Closed loop communication with consultants can help to prevent downstream mistakes. Re-contacting providers who refer a patient into the ED can also ensure that all concerns from that physician have been addressed prior to disposition.
Poor physical exam documentation: Physical exam documentation short cuts can be an effective way to increase efficiency in your charting especially with commonly performed exams; however, it is important to ensure that you performed all documented exams and that what you discovered is accurately conveyed by your documentation. Poor documentation will lead to downstream frustration with your consultants/admitting teams when there is conflicting information in the medical record.
R3 Taming the SRU: sources of Hemorrhage WITH DR. habib
Case
A male in his thirties presents to the emergency department after being struck by a motor vehicle at low speed where he was subsequently pinned against a stationary object for a brief period of time. His past medical history was significant for morbid obesity, hypertension, and diabetes. EMS personnel were unable to acquire venous access and therefore placed a left lower extremity IO through which they provided IV fluids. The patient was found by EMS to be hypotensive and mildly tachycardic but otherwise stable and no other interventions were performed.
On arrival to the ED the patient was again found to be tachycardic and a manual blood pressure revealed approximately 70/palpable. His primary survey was intact. His secondary survey was only remarkable for a left medial thigh laceration with some moderate swelling. A FAST exam was performed and was adequate and negative. Chest and Pelvis X-rays were performed and were without acute abnormality. A left femur X-ray showed a comminuted midshaft femur fracture.
A right femoral central line was placed and given his marked hypotension he they began transfusion with blood products. He was stabilized and taken to the CT scanner where scans of his head, chest, abdomen, pelvis, and spine were all negative. They further performed CT of his left femur which showed a large hematoma with dehiscence of the deep fascia and subcutaneous tissue.
The patient was ultimately taken to the operating room where his large three liter hematoma was evacuated and underwent surgical repair of his femur. He was discharged from the intensive care unit ten days later with a wound vac in place.
Sources for Massive Hemorrhage
Chest
Abdomen
“Floor” (external bleeding)
Pelvis
Retroperitoneum
Femur
Internal degloving injury
Closed Internal Degloving Injuries
Occurs when a traction force is applied between the fascia and subcutaneous tissues causing a shear injury. This leads to creation of a potential space.
Bridging vessels and lympatics are also impacted leading to bleeding and accumulation of a hematoma.
If a large area is affected (such as in this patient) this can lead to significant hemodynamic instability.
Management differs based on hemodynamic stability
Stable patients require compression and occasionally aspiration of the hematoma
Unstable patients require surgical intervention
Once stabilized these injuries can lead to chronic formation of a capsule with overlying skin changes that can be dissatisfying to patients cosmetically. Additionally, they remain at risk for re-bleeding into the affected space.
R4 Simulation and Small groups WITH DRs. Baez, shaw, and summers
Shoulder Dystocia Management
Shoulder dystocia involves impaction of the fetal anterior shoulder behind the maternal pubic symphysis. This causes the inability to exit the vaginal canal and can lead to complications for both mother and fetus. The mother is at higher risk for tears at the vagina and perineum and the fetus is at risk for hypoxic brain injury, brachial plexus injuries, clavicular fractures, and death.
HELPER acronym
Help: Call for help as this is a medical emergency. Have someone contact your OBGYN colleagues while you continue management.
Evaluate for Episiotomy: Episiotomy is not the first line maneuver for managing shoulder dystocia; however, can help to allow for more access for the providers hands for the other maneuvers listed below.
Legs: McRoberts’ maneuver involves raising the mother’s legs through flexion and abduction of her hips. This increases the relative anterior-posterior diameter of the pelvis and increases the likelihood of the passing the anterior shoulder.
Pressure: The Rubin I maneuver involves applying suprapubic pressure. This reduces the fetal bisacromial diameter and can rotate the fetal anterior shoulder into the pelvis.
Enter vagina: Attempt the Rubin II maneuver or Woods Corkscrew maneuver.
The Rubin II maneuver involves manual anterior rotation of the fetal shoulder to decrease shoulder diameter.
The Wood’s Corkscrew maneuver involves inserting two fingers into the vagina posteriorly and applying pressure to the anterior surface of the posterior shoulder to rotate the infant 180 degrees.
Remove posterior shoulder: Insert one hand into the vagina along the posterior arm and flex the arm until the forearm or hand can be grasped and swept onto the fetal chest. This may result in fracture of the clavicle or humerus.
Simulation
A female in her thirties presents to the emergency department with shortness of breath and palpitations. She is 35 weeks pregnant with her first pregnancy and is otherwise healthy. Her initial vital signs are: HR 120, RR 20, BP: 90/60 and SpO2 96% on room air.
Shortly after evaluation she develops a ventricular fibrillation cardiac arrest. Patient receives standard ACLS care including an attempt with defibrillation which does not produce return of spontaneous circulation and she remains in ventricular fibrillation.
The decision is made to perform a resuscitative hysterotomy which is performed successfully.
Resuscitative Hysterotomy / Peri-Mortem C-Section
Indicated after 24 weeks of gestation. If the fundus is at or above the level of the umbilicus you can estimate that the fetus is at approximately 24 weeks. This procedure is considered resuscitative for both the mother and the fetus and therefore could be indicated for the maternal benefit below 24 weeks; however, the likelihood of fetal survival at that before 24 weeks is very low.
Timing of the procedure should be as soon as possible after maternal cardiac arrest. Fetal mortality increases with time post maternal cardiac arrest.
Technique:
Make a large vertical incision from the xiphoid to the pubis.
Cut through the subcutaneous tissue to arrive at the peritoneal wall.
Use scissors to cut through the peritoneum and deliver the uterus.
Cut a vertical incision into the uterus until you reach the fetus.
Deliver the fetus and clamp the umbilical cord.
Continue resuscitation for the mother and fetus.
