Author Archives: M2E Too! Mellick's Multimedia EduBlog

05.02.13
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Lessons Learned from a Medical Mission

Nurses can serve as excellent physician extenders.
My mentors in austere medicine warned me that with an interpreter I would be lucky to see 30 patients per day. That concerned me because the local missionaries indicated at our first organizational meeting in the Dominican Republic that we were expecting to see 100 patients per day. On top of that, 100 cards were being handed out at each of the four locations we would be visiting.
 
As the single physician in the group of 19 team members (seven nurses), these seemed like very high expectations. Working in a setting that uses physician extenders and emergency medicine residents, my first thought was to ask the nursing team members to assume a new role. At each location, we set up three tables with at least one nurse and a translator. The advanced practice nurses would see the patient, collect historical data, perform an examination, and present their finding to me as I went from table to table. It worked very well, and the nurses loved the opportunity to practice supervised medicine. We also had a local physician as a fourth provider who also often consulted with me.
 
Be careful to not cause complications.
It wasn’t long before I became aware of a pattern. Every patient had “just run out” of his blood pressure medication. Unfortunately, the medications they were taking were often combination drugs with some components not known to the US market. We simply tried at first to match as many medications as possible using our stock, but eventually I found myself recommending that they go back to their own local source for medications. I no longer trusted that we were being given an honest history, and my worst fear was that our patients would start mixing medications and sustain a complication.
 
Take a shotgun approach to sexually transmitted diseases.
It was obvious at several locations that sexually transmitted diseases were a frequent complaint. I could do a private examination behind curtains looking for vaginal discharge at the perineum, but I was warned to have the local female physician present to prevent false allegations about Americans performing an inappropriate private examination. It seemed best to treat for everything because we had no laboratory to view discharge under a microscope or KOH to test for various organisms. Doxycycline, metronidazole, a shot of ceftriaxone, and Diflucan to be taken at the end of treatment were given to most of our female patients with vaginal discharge.
 
Ultrasound can serve well when no other imaging options exist.
I trained in the pre-ultrasound days of emergency medicine, and I have limited ultrasounds skills (in my opinion). Nevertheless, years of sitting in lectures and hanging out with excellent ultrasound physicians help ultrasound skills develop with time. I took a small portable ultrasound machine with me, and was delighted with the role it served. The ultrasound proved to be a valuable tool for pregnancy confirmation, finding lung rockets for congestive heart failure, assessing level of hydration by viewing the inferior vena cava, and assessing right upper quadrant pain. It was awkward at times and we had limited options for finding a darkened work area, but were delighted with the benefits of ultrasound in the austere environment.
 
Albendazole and other expensive medications can be purchased locally and cheaply.
Our medication options for treating parasites were limited because mebendazole is now off the market and albendazole is very expensive (75$ for two doses). Fortunately, we were able to purchase a plentiful supply of this medication in the Dominican Republic. We were again forced to treat many patients empirically because we had no resources to test for parasites. The risk-benefit ratio for this practice seemed to be excellent, and we treated many patients based on history and examination findings.
 
Be prepared to provide team members with medical care.
Our preparation for providing emergency care to team members also proved valuable. I had an emergency bag filled with medications and equipment specifically dedicated to caring for the team. Three team members became incapacitated with traveler’s diarrhea and required treatment. All three team members had recovered within 24 hours of treatment. Ciprofloxacin was used to address the E. coli, loperamide to slow the diarrhea, promethazine for nausea, and sometimes dicyclomine to manage crampy pain that developed. Intravenous fluids were often suggested, but I followed the World Health Organization’s perspective that oral rehydration is commonly all that is needed. That truism proved correct, and no intravenous fluids were ever needed.
 
One team member with a severe peanut allergy developed an anaphylactic reaction as our airplane was loading for our return trip to the mainland. Our preplanning paid off and aggressive management with two sequential EpiPens, oral diphenhydramine (H1 blocker), ranitidine (H2 blocker), prednisone, and six to eight puffs with an albuterol inhaler successfully controlled the reaction. Even though we missed our flight, we were able to avoid a trip to the local hospital.
 
Published: 5/2/2013 9:45:00 AM
05.01.13
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A Novel Way to Select the Blade Length of a Pediatric Laryngoscope

Whenever I research on techniques for selecting pediatric laryngoscope blade length, I continue to find that the only English article ever published on the topic was the one I did in 2006. (Pediatr Emerg Care 2006;22[4]:226.) I have to admit that this apparent lack of interest in the subject has caused me to have fleeting thoughts that maybe I am the only emergency physician insecure about his ability to select the most appropriate laryngoscope blade length for a pediatric intubation. I doubt that is the case, and I recently found an Iranian article that appears to duplicate my study and results in 60 pediatric patients. (Iran J Pediatr 2006;16[4]:413.)
 
The truth is that pediatric intubations are few and far between, and experience is relatively limited outside the pediatric operating room. A recent video study published in the Annals of Emergency Medicine seemed to document that we are not as smooth and proficient at pediatric intubations as we like to think. (Ann Emerg Med 2012;60[3]:251; Ann Emerg Med 2012;60[3]:261.)
 
The bottom line for me was the need to find a way to double-check my choice of laryngoscope blades without being dependent on an external resource. It also seemed ideal to develop a technique that mimicked other familiar techniques using facial landmarks to estimate the appropriate size for oral and nasopharyngeal airways. Consequently, a blade length selection technique was developed that used immediately and easily accessible anatomical landmarks to guide the laryngoscope blade size selection process. My study found that intubations were accomplished more consistently on the first attempt when the laryngoscope blade (excluding the handle insertion block) is placed at the upper midline incisor teeth and the tip is located within 1 cm proximal or distal to the angle of the jaw.
 
Straight and curved blades with arrows demonstrating the portion of the blade used in the measurement.
 
The blade is measured (excluding the handle insertion block) from the upper central incisors to the angle of the mandible.
 
We compared unsuccessful (more than one intubation attempt) with successful intubations for blade lengths considered shorter, longer, or within the proposed standard of 10 mm proximal or distal to the angle of the mandible. Laryngoscope blades were designated as too short if they were more than 10 mm proximal to the angle of the mandible.
 
We found there was a significant association between the blade lengths and whether the intubations were unsuccessful or successful (χ22=7.64, P=0.022). Our study found that blade lengths considered too short were more likely to be associated with more than one attempt at intubation. Only 57.1 percent (12/21; 95% confidence interval [CI], 36.5-75.5) of the intubations were successful when the shorter blade was used as compared with 89.7 percent (26/29; 95% CI, 73.6-96.4) of the intubations using the standard length or 85.7 percent (6/7; 95% CI, 48.7-97.4) of the intubations using blades extending longer than 10 mm past the angle of the mandible. And success of the procedure was independent of the age of the child (χ22=0.27, P=0.986). (Pediatr Emerg Care 2006;22[4]:226.)
 
I am confident that the technique is simple and easily taught, but the single part of the step that will cause confusion is remembering that the block part of the blade that attaches to the laryngoscope handle is NOT used in the measurement. Consequently, only the flat part of the blade is used when the measurement from the central upper incisors to the angle of the mandible is made. Hopefully, the figures and the video included with this blog “bring it home,” and nicely demonstrate the critical elements of this technique.
 
Tags: pediatric laryngoscope, blade length
Published: 5/1/2013 1:25:00 PM
04.03.13
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Increasing Success with Infant Spinal Taps

I think infant lumbar punctures are actually easier than spinal taps on older children and adults. Unfortunately, success, as measured by acquiring sparkling clear (nontraumatic) spinal fluid, is sometimes elusive. Twenty to thirty percent of spinal taps in the training setting, in fact, can be traumatic or unsuccessful. (Pediatr Emerg Care 2010;26[7]:487.) Three easy steps, however, can increase one’s odds for success.
 
Use Local Anesthesia
The evidence shows that the success rate is improved when injected or topical anesthesia is used, but this practice is commonly ignored by practitioners. The literature clearly supports using local anesthesia. An article by Pinheiro et al demonstrated a reduction in the infant's "struggling motion score" after lidocaine was applied. (Pediatrics 1993;91[2]:379.) The number of traumatic taps, rate of failure, and number of attempts in that study were not reduced, but subsequent studies have indicated otherwise.
 
A 2006 study by Baxter et al showed that not using local anesthetic was more commonly associated with traumatic or unsuccessful lumbar punctures. (Pediatrics 2006;117[3]:876.) Another study by Nigrovic et al revealed that not using local anesthetic was associated more often with failure. (Ann Emerg Med 2007;49[6]:762.) Two modifiable factors — anesthetic use and stylet removal — influenced the rate of success in that study.
 
A majority of clinicians believe otherwise, for some unclear reason. A study by Quinn et al found that only nine of 198 (4.5%) patients who underwent a lumbar puncture in one academic pediatric emergency department received local anesthetic. (Pediatr Emerg Care 1993;9[1]:12.) Another study by Breakey et al found that pediatrics residents declined to use anesthetic much more commonly (57%) compared with emergency medicine residents (1%). (Pediatrics 2007;119[3]:e631.) Other studies have confirmed the widespread resistance to using anesthesia for neonatal lumbar punctures. (Pediatr Emerg Care 2004;20[12]:816; West J Emerg Med 2008;9[1]:9.)
 
Injection of anesthesia prior to the lumbar puncture.
 
 
Remove the Stylet
Removing the stylet from the needle following penetration of the epidermis and dermis also appears to improve lumbar puncture success rates. (Pediatrics 2006;117[3]:876; Ann Emerg Med 2007;49[6]:762.) Lumbar punctures without a stylet (typically butterfly needles) have been associated with intraspinal epidermoid tumors that develop years later after epidermal elements were implanted into the arachnoid space during the procedure. (JAMA 1977;237[2]:148; Arch Neurol 1986;43[9]:936; J Pediatr 1972;80[4]:638; Lancet 1977;1[8012]:635; J Child Neurol 2007;22[3]:332.)
 
Consequently, residents are commonly advised to keep the stylet in place even after passing through the epidermal elements. But the studies referenced have clearly demonstrated that advancing the needle without the stylet (after passing through the skin) is associated with greater procedural success and a decrease in the frequency of traumatic lumbar punctures. (Pediatrics 2006;117[3]:876; Ann Emerg Med 2007;49[6]:762.)
 

Cerebrospinal fluid contaminated by red blood cells.
 
Reposition the Patient
Holding the infant upright for the spinal tap is also recommended. Data from several ultrasound studies have demonstrated that the subarachnoid space width in newborns was significantly greater in a seated rather than a lateral decubitus position. The authors hypothesize that a seated spinal tap position would more likely be successful. (Pediatrics 2006;118[2]:842; Pediatrics 2010;125[5]:e1149.)
 
An additional benefit of the upright position appears to be better maintenance of oxygenation. Gleason et al found that having infants in the seated position with neck flexion decreased oxygen desaturations during the procedure. (Pediatrics 1983;71[1]:31.) Another small study published in 1983 compared lumbar puncture positions for transcutaneous oxygen level (TcPO2) changes, finding that the mean TcPO2 was lower for standard lateral than sitting or modified lateral positions. (Am J Dis Child 1983;137[11]:1077.)
 
The amount of time that the TcPO2 was under 50 mm Hg was greater for standard lateral positions than sitting or modified lateral positions. It’s my opinion and one shared by others that the landmarks are also much easier to identify in the seated position.
Success with infant lumbar punctures is improved with specific adjustments in procedural technique. Consider these three easy steps if you feel you have room for improvement with newborn spinal taps.
 
Click here to watch a video showing these three easy steps for infant spinal taps.
 

 
Tags: pediatric spinal taps, local anesthesia, stylet, reposition patient
Published: 4/3/2013 3:25:00 PM
03.05.13
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The Controversy over Video Laryngoscope and Direct Laryngoscopy

Don’t get me wrong, being a teaching center, our shop loves new airway technology, and we have one of about everything. In keeping with the M2E Too Blog’s name, I’m jumping into the fray over the predicted early demise of direct laryngoscopy in favor of video laryngoscopy. I have a few observations about the new airway technology that are worth, ahem, airing.
 
The more complicated the technology, the greater number of things that can go wrong and parts that can malfunction.
The days of worrying about blade handle batteries being dead or light bulbs being burned out are being replaced with equipment failures that involve sophisticated and complicated equipment with their video screens, cable connections, fiberoptic light sources, etc. That is exactly what happens based on our early experience. Broken cables, malfunctioning screens, damaged light sources, and missing pieces have occurred on just about every expensive piece of equipment we have. I have to be honest, though; being a busy teaching center with a lot of airway compromised patients, we are very hard on our equipment. Who needs one of those labs that test the durability of a product under hard use when you have our crew?
 
The more complicated the technology, the more expensive the technology; and therefore, fewer parts and blades are immediately available.
This is just a fact of life. Most of the new technology is downright expensive. Consequently, the hospital and department simply can’t afford two of every new airway device or every size and type of blade associated. It’s a far cry from having several direct laryngoscope handles and multiple blade sizes and types in every resuscitation room.
 
Cleaning the equipment is also a problem. What happens when the frequency and speed of arrival of airway-compromised patients outpaces your processes for equipment cleaning and turnaround if you have only one blade size for a particular video laryngoscope? This is a very real problem, and occurs frequently in our shop. Only the new equipment with disposable parts comes close to matching the availability of the old DL equipment.
 
A colleague of mine, Ric Solis aptly sums up the problem. “I was always taught at a minimum to have two laryngoscope handles always available with plenty of assorted blades. However, it's hard to apply the ‘two is one, one is none, always have a backup’ axiom to a $25,000 device.”
 
It is not uncommon just prior to the arrival of an announced Code Blue to see nurses, residents, and attending physicians scurrying from room to room trying to find where the C-Mac or Glidescope was last used because there is generally only one main unit for the newer technology. This occurs in our ED despite a fairly sophisticated equipment storage system and plan.
 
What about the smaller, cash-strapped hospitals and emergency departments? The cost of the new technology is potentially prohibitive to the smaller hospitals and their emergency departments. Our moonlighting residents give accounts of working in smaller, more rural emergency departments where they find that they have no backup airway devices.
 
The new technology has new and unique ways to fail during an attempted intubation.
In other words, the newer technology has a learning curve and requires unique skills and techniques. There are a few new and different ways to fail in addition to the old tried and true ones. Insert the blade too far, get blood and body fluids on the lens, don’t bend the ET tube sufficiently, use the wrong stylet, or don’t rock the blade just right, and you have a failed intubation even with the new equipment. (See first video below.)
 
The bottom line is that we keep a healthy respect for direct laryngoscopy, and see it as our backup when the new gadgets ultimately fail. It seems to be about every other week (or shift) that one of new favorite toys is broken, parts are missing, or they are not cleaned quickly enough. Then we are right back to the basics and the more austere days of emergency airway management.
 
Interestingly and perhaps a little ironically, the new technology is proving to be a great teaching tool for direct laryngoscopy and other rescue airway techniques such as the bougie. It is not uncommon, especially with the Storz C-MAC that the teaching physician takes control of the screen while the resident does plain old direct laryngoscopy or practices placing a gum elastic bougie. (See second video below.) Direct laryngoscopy and teaching it are not ever going to disappear from our training program.
 
Watch Three Failed Video Laryngoscope Intubations here.
 
Watch Bougie Intubation Using the C-MAC here.

 
 
 
Tags: intubation, video laryngoscopy, direct laryngoscopy
Published: 3/5/2013 1:45:00 PM
02.08.13
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Chest Tubes Deserve an Unnecessary Roughness Penalty

By Larry B. Mellick, MD

 

Chest tube placement borders on the barbaric. I am specifically referring to the large-bore chest tubes that continue to be placed in emergency departments for spontaneous and iatrogenic pneumothoraces. I have personally performed or watched the trauma service place chest tubes, and wondered why large-bore chest tubes remain our tool of choice.

 

The insertion process is painful. No matter how much anesthesia is administered, the patient still screams out in pain as the pleura is violated or the opening is expanded by blunt dissection. Aren’t the smaller, kinder, gentler drainage catheters equally effective as the larger bore chest tubes at draining air and fluid? Just where are things with the literature that supports the more minimally invasive and less tissue destructive approach?

 

The research on managing pneumothoraces is generally not the highest quality. Practice guidelines written by national and international thoracic societies, however, attempt to condense the available literature and make recommendations. The continued use of large-bore chest drainage devices is not supported by most practice guideline-writing thoracic societies. In fact, the transition in opinion has been ongoing for several decades. The most mature and developed guidelines are those created by the British Thoracic Society; these were revised in 2010. (Thorax 2010;65[Suppl 2]:ii18.) The British are the apparent leaders in this area, and all other guidelines are less current and more limited, though for the most part they align with the British guidelines. (Chest 2001;119[2]:590; J Trauma 2011;70[2]:510; Acta Chir Belg 2005;105[3]:265; http://bit.ly/Vmlll9.)

 

All pneumothoraxes are not created equal. Primary pneumothorax occurs in patients with no apparent underlying lung disease while secondary pneumothorax is most commonly associated with underlying lung disease and chronic obstructive pulmonary disease. It is recognized that the consequences of a secondary pneumothorax may be greater, and primary spontaneous pneumothorax are potentially more difficult to treat. Symptoms are often more severe in patients with secondary spontaneous pneumothorax even if the pneumothorax is relatively small. Nevertheless, small-bore chest drains are still recommended even for the more conservatively treated secondary spontaneous pneumothorax patients.

 

The British Thoracic Society guidelines recommend that patients with either primary or secondary spontaneous pneumothorax of any size should undergo active intervention if the patient is experiencing significant breathlessness. Observation alone is not considered appropriate for breathless patients because it is felt to herald a tension pneumothorax. (Thorax 2010;65[Suppl 2]:ii18.)

 

Not surprisingly, chest drains and hospital admission are recommended for patients presenting with a tension or bilateral pneumothorax. Conservative management is considered safe and outpatient management is acceptable for primary spontaneous pneumothorax patients if the symptoms are minimal. One article reported that up to 80 percent of smaller (less than 15%) pneumothoraces have no persistent air leak. (Chest 1989;96[6]:1302.) Outpatient therapy is acceptable as long as these patients can easily seek medical attention if their condition deteriorates.

 

Needle aspiration with a 14-16 gauge needle is considered as effective as large-bore (>20 F) chest drains. (Thorax 2010;65[Suppl 2]:ii18.) A 2007 Cochrane report systematically reviewed the published randomized control trials and found no difference in success rates when comparing simple aspiration with intercostal tube drainage for spontaneous pneumothorax in adults. (Cochrane Database Syst Rev 2007 Jan 24;[1]:CD004479.) A small-bore (<14 F) chest drain should be inserted if needle aspiration fails.

 

The British Thoracic Society guidelines acknowledge that many clinicians do not follow the needle aspiration guidelines because the insertion of small-bore (<14 F) Seldinger chest drains may be regarded as a simpler option. The smaller drains are less painful, and the success rate is similar to larger drains. (Intern Med J 2003;33[11]:495; Respir Med 1998;92(3):593; J Thorac Cardiovasc Surg 2002;124(5):1027.) A Heimlich valve can often be attached, and will facilitate mobilization and outpatient care. High-volume, low-pressure suction systems are recommended if suction is applied for the admitted patient. All patients with secondary spontaneous pneumothorax are admitted and receive a small-bore chest drain.

 

Iatrogenic pneumothorax secondary to transthoracic needle aspiration, subclavian vessel puncture, thoracocentesis, pleural biopsy, and mechanical ventilation are also addressed in the British guidelines. The majority of these pneumothoraces are believed to resolve spontaneously on their own and aspiration is thought to be highly successful if an intervention is indicated. A chest drain may be indicated for iatrogenic pneumothoraces in patients with COPD. (Arch Surg 1989;124(7):833; Chest 1994;105(6):1705.) The British guidelines do not cover trauma-associated pneumothorax.

 

These selected comments from the British Thoracic Society 2010 guidelines summarize the recommendations:

  • Patients with primary or secondary spontaneous pneumothoraces and significant breathlessness associated with any size pneumothorax should undergo active intervention.
  • Chest drains are usually required for patients with tension or bilateral pneumothorax who should be admitted to hospital.
  • Observation is the treatment of choice for small primary spontaneous pneumothorax without significant breathlessness.
  • Selected asymptomatic patients with a large primary spontaneous pneumothorax may be managed by observation alone.
  • Patients with a small primary spontaneous pneumothorax without breathlessness should be considered for discharge with early outpatient review.
  • These patients should also receive clear written advice to return in the event of worsening breathlessness.
  • Needle (14-16 gauge) aspiration is as effective as a large-bore (>20 F) chest drain, and may be associated with reduced hospitalization and length of stay.
  • Following failed needle aspiration, small-bore (<14 F) chest drain insertion is recommended.
  • Large-bore chest drains are not needed for pneumothorax.

A basic summary of the British Thoracic Society guidelines: more conservative management with observation for many patients, aspiration for the remainder, and small-bore chest drains for persistent air leaks. The National Guideline Clearinghouse has an even clearer summary of the guidelines: (http://1.usa.gov/XeDVJm.)

 

Primary spontaneous pneumothorax:

  • Observation for small primary spontaneous pneumothorax.
  • Needle aspiration.
  • Small-bore chest drain.
  • High-volume, low-pressure suction system.
  • Referral to a respiratory physician.

 Secondary spontaneous pneumothorax:

  • Admitted to hospital and receive supplemental oxygen.
  • Small-bore chest drain.
  • Referral to a chest physician.
  • Referral to thoracic surgeon with a persistent air leak.
  • Medical pleurodesis.
  • Ambulatory management with a Heimlich valve.

British Thoracic Society 2010 Guidelines

 

Many of us are very entrenched in the idea that we need the larger bore chest tubes, but the evidence just doesn’t support it. While there are probably still clinical indications for a large-bore chest tube, those indications are relatively limited. It’s time to start throwing penalty flags for unnecessary roughness on large-bore chest tubes.

 

Watch a patient with spontaneous pneumothorax managed with a small-bore chest drain.

 

Tags: chest tubes, pneumothorax, needle aspiration
Published: 2/8/2013 10:45:00 AM
01.07.13
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Trigger Point Therapy in the Emergency Department

By Larry B. Mellick, MD

Patients with myofascial pain conditions or trigger point pain commonly present to the emergency department seeking therapeutic relief. It is not rare to see patients with specific areas of unrelenting muscle spasm who have undergone multiple medical therapies and expensive imaging studies without diagnostic or therapeutic success. Unfortunately, the outcome of most emergency department visits for these patients is another failure to accomplish definitive therapy. We usually prescribe more ineffective therapies that simply perpetuate the therapeutic delay. This blog hopes to present hard-hitting therapeutic interventions that rapidly and effectively relieve trigger points and their associated symptoms.

We are not talking about fibromyalgia pain. Fibromyalgia is a widespread pain problem and not really a regional condition caused by specific trigger points that would be amenable to the interventions discussed in this post. Travell defined a myofascial trigger point as “a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band.”1 Although the body has approximately 400 muscles, the one in the neck and upper back seem more commonly to have myofascial trigger points. Associated referred pain or radicular symptoms, autonomic symptoms, and paresthesias are common and partially responsible for the not-so-helpful CT scans and MRI imaging studies that these patients often receive. (J Am Osteopath Assoc 2004;104[6]:244; Arch Phys Med Rehabil 1998;79[7]:863.)

The typical management of trigger points in the emergency department is to prescribe muscle relaxants, opiates, and nonsteroidal anti-inflammatory drugs. Unfortunately, these patients typically go through various permutations of this therapeutic regimen, and three or four trips to the emergency department are not uncommon.

It’s been my observation that emergency physicians are relatively averse to performing intramuscular injections. Our fears are not totally unfounded because it is not rare to see patients presenting with a pneumothorax after trigger point therapy by a physical medicine or pain specialist. Even acupuncture is not risk-free. I have seen at least one pneumothorax as a result of acupuncture therapy, and many similar patients have been described in the literature. (West J Med 1991;154[1]:102; Singapore Med J 2007;48[1]:e32.) Nevertheless, these risks can be minimized with appropriate precautions.

My approach to managing trigger points is twofold. First, I apply manual therapy to the trigger point. The second step is to inject the trigger point with a steroid and anesthetic combination. The application of acupressure or ischemic pressure to trigger points is an important and critical component to treating these patients. The operator finds the area of greatest muscle spasm and pain, and applies direct pressure over that muscle using both thumbs.

      Application of thumb pressure for approximately three minutes over the trigger point.

The elbow is used to apply direct pressure for larger muscles groups such as the piriformis muscle.

            Using the elbow to apply ischemic pressure over a larger muscle group.

The trick is to find the most painful area, warn the patient what will happen next, and begin applying firm, direct pressure (despite the subsequent painful protests from the patient). The pressure is applied until the muscle spasm is noted to collapse and “melt” because of pressure-associated muscle fatigue or possibly ischemia. This application of pressure is usually carried out over three minutes. The pain associated with the procedure confirms that you have correctly localized the area of muscle inflammation and spasm.

This manual technique should be repeated after the trigger point has been injected with a steroid and anesthetized with lidocaine or bupivacaine. This allows the clinician to attain further muscle spasm release as well as diffuse the medication and ensure local hemostasis. Osteopathic physicians, chiropractors, and massage therapists have used ischemic pressure or acupressure for years, and the benefit of this therapy is documented in the literature. (J Manipulative Physiol Ther 2009 Jan;32[1]:14 and 2010;33(5):362; Phys Ther 2000;80[10]:997; J Bodywork Movement Ther 2006;10[1]:3, 2005;9[4]:248, and 2005;9[1]:27.) This therapeutic technique can also be taught to family members.

       The patient’s husband being trained to perform ischemic pressure over a painful piriformis muscle.

The second intervention is the trigger point injection. I do a lot of trigger point injections, and have been quite pleased with the therapeutic outcomes. An anesthetic such as lidocaine or bupivacaine are typically mixed with an injectable steroid. A number of injectable steroids can be combined with the lidocaine or bupivacaine. I prefer to use 40 mg of solumedrol with 3 to 5 mL of 0.5% bupivacaine. Clearly identify the trigger point and sterilize the overlying skin, and then inject the medications into the taunt and painful muscle.

A fanning injection method is used so that multiple injections are accomplished into the same muscle as the steroid and anesthetic are deposited. A portion of the initial mixture is saved for the other injections if several trigger points exist. A greater risk of causing an iatrogenic pneumothorax exists for muscle spasms over the ribs and thorax. For those injections, I typically grasp the muscle between my thumb and index finger and attempt to elevate the painful muscle as I inject the steroid-bupivacaine mixture.

     Grasping and elevating the area of muscle spasm to limit depth of needle insertion.

Another useful adjunct of the technique is the application of a vapocoolant spray to minimize the discomfort of the intramuscular injection.

   Spraying vapocoolant over the injection site prior to injection.

Nevertheless, the insertion of the needle and injection of medications will be quite painful to the patient if you have accurately localized the trigger point. The immediate resolution of the patient’s pain following the injection is your marker of a successful procedure. A prescription for nonsteroidal anti-inflammatory drugs (NSAIDs) is also recommended for pain control and augmentation of the anti-inflammatory effect of the injected steroid. The patient should immediately begin muscle stretching while the anesthetic effect persists.

Potential complications do exist. The most common events are post-injection muscle soreness and procedure-associated vasovagal reactions. Feared complications such as pneumothorax and infections can be avoided by using correct techniques. Hematoma development or allergic reactions to the injected medications are other uncommon complications. Obviously, patients with bleeding disorders or those who are anticoagulated or allergic to anesthetic agents should not undergo trigger point injections.

Finally, warn the patient that he will experience muscle soreness for several days after the anesthetic wears off. The healing muscle will have some tendernessm, but the injected steroid will eventually decrease the acute and chronic inflammation.

Click here to watch a demonstration of the trigger point injection procedure.

Published: 1/7/2013 8:07:00 AM
11.29.12
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Hands On During Defibrillation: ‘I’m Not Clear!’

By Larry B. Mellick, MD
 
It’s a wonder that anyone survives — or survives neurologically intact — with all the interruptions that happen during the recognition, delivery, transfer, and treatment of a patient undergoing cardiopulmonary resuscitation.
 
The American Heart Association and the international resuscitation community have been constantly beating the drum in recent years about quality of chest compressions and the need to decrease interruptions that occur during cardiopulmonary resuscitation. (Circulation 2010;122[18 Suppl 3]:S706, 2010;122[18 Suppl 3]:S640, 2009;120[13]:1241; Resuscitation 2011;82[3]:263; Resuscitation2010;81[10]:1219; Heart 2009;95[24]:1978.)
 
Animal studies have demonstrated that interruptions in chest compressions decrease coronary and cerebral blood flow and worsen survival outcomes. (Circulation 2001;104[20]:2465, 2007;116[22]:2525.) Even pausing a few seconds reduces the chances that the defibrillation shock will be successful. (Circulation 2002;105[19]:2270, Circulation 2004;110[1]:10; Resuscitation 2006;71[2]:137.)
 
Nevertheless, interruptions still continue to occur for intubation, ventilations, AED analyses, charging, and defibrillation shocks. The latest European guidelines recommend continued chest compressions while charging the defibrillator. Those guidelines, however, still recommend chest compressions be briefly paused and all rescuers cleared of the patient once the defibrillator is charged. (Resuscitation2010;81[10]:1219.) Lloyd et al analyzed electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. (Circulation 2008;117[19]:2510.)
 
They demonstrated that the amount of current that flows through the rescuer is minimal and clinically insignificant. Rescuers were instrumented during 43 hands-on shocks in 39 patients in the study. Forty-three shocks were delivered, four at 100 J, 27 at 200 J, and eight at 360 J. None of the 43 shocks was perceptible to the rescuers and the measured electrical currents were well within safe ranges. An accompanying editorial published in Circulation essentially stated that within appropriate guidelines the tradition of “I’m clear, you’re clear, everybody’s clear” is no longer relevant. (Circulation 2008;117[19]:2435.)
 
The guidelines, however, were that hands on during defibrillation should only occur with the use of adhesive, pregelled electrodes and a biphasic defibrillator, and the rescuer should be wearing gloves. Nevertheless, one researcher sounds the alarm for continued caution. (Circulation 2008;118[23]e712; Resuscitation 2012;83[12]:1467.)
 
The bottom line is that it is way too easy and there are far too many opportunities to allow precious seconds to slip by without cardiac compressions. Rescuers may even feel a sense of futility that leads to less caution and attention to those fleeting seconds for patients with a longer downtime or prolonged CPR prior to arrival. We all need to be reminded that continuous chest compressions should be our gold standard. We need to weigh our willingness for risk-taking and consider whether continuous compressions with no pause during defibrillation is the correct action for our patients. That specific discussion is ongoing in our emergency department.
 
 

Published: 11/29/2012 10:54:00 AM
11.05.12
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Six Mistakes of Awake Intraosseous Infusion

By Larry B. Mellick, MD

I’ve been inserting and teaching how to insert an intraosseous (IO) needle for several decades. Like most of you, however, almost all of the IO needle insertions that I have performed were on obtunded or cardiac arrest patients (mostly pediatric and a few adult). Several years ago I did my first intraosseous needle insertion on an altered but awake adult.

Much to my chagrin, I quickly learned that I really didn’t know what I was doing. I even documented my ineptness with a video so that others could learn from my mistakes. Most emergency physicians are comfortable with using IO needles during resuscitation, but their skills and experience in using IO needles in awake patients are not quite as sharp.

Intraosseous access provides fast, safe, and effective access during CPR. Central venous access can be reliably obtained via the IO needle in less than 20 seconds, and medications administered intraosseously work just as fast as medications given through a central line. (Int J Emerg Med 2009;2[3]:155; Ann Emerg Med 1985;14[12]:1135; Pediatr Clin North Am 1994;41[6]:1183; Am J Dis Child 1990;144[1]:112; (J Trauma 1993;34[3]:422.)

It is also suitable for blood transfusion, hyperalimental solutions for overdose management, and chilled fluids for therapeutic hypothermia following resuscitation from a sudden cardiac death. (Am J Dis Child 1984;138[9]:810; Am J Emerg Med 1986;4[1]:34; Am J Emerg Med 1988;6[4]:353; N Engl J Med 1990;322[22]:1579; J Emerg Med 1987;5[2]:97; Ann Emerg Med 1989;18[12]:1348.)

IO infusion is also a viable alternative for vascular access after multiple peripheral IV attempts or as a bridge to central venous access in the awake patient. Hypotensive patients who previously would have had a central line placed in the ED (e.g., a busy, single-coverage ED) could have their resuscitation started through an IO access, with a sterile central line subsequently placed in the ICU. The critically ill patient being transported from a rural environment could also have an intraosseous line placed to allow administration of centrally delivered medications such as pressor agents.

The bottom line is that placing an intraosseous line in an awake adult is not the same thing as the IO line placed during an attempted resuscitation of a moribund patient. That being said, I learned a few lessons learned during my first awake adult intraosseous needle insertion.

1. Be sure to assess for the required needle length before starting. Specific guidelines exist for choosing the correct needle length are provided. Visualization of at least 5 mm or at least one black line on the needle after puncturing through the skin is recommended.

2. Punching the needle through the skin until bone is reached is recommended before drilling. This is part of the assessment of correct needle length that should occur before drilling. This also lessens the natural tendency for the skin to twist around the needle and cause binding of the needle by the elastic skin of the patient.

3. Insertion of the IO needle is not extremely painful, but the extremity should be stabilized prior to and during insertion. A patient who is altered or frightened may withdraw or jump suddenly. The potential for injury or needle insertion failure is increased.

4. Avoid excessive force when drilling. Instead, use steady, downward pressure on the needle. The combination of excessive force and dense bone can cause the needle to stop spinning prematurely. Reduce downward pressure and allow the needle’s revolutions per minute (RPMs) to do all of the work if the driver sounds like it is slowing down during insertion.

5. Infuse adult patients with 1.5-2.0 mL of 2% lidocaine (without preservatives or epinephrine) before using the needle. The real pain of the procedure occurs when fluid is flushed through the needle, but a slow injection of a small amount of 2% lidocaine will dramatically reduce this discomfort.

6. It is mandatory to flush the IO needle with approximately 10 mL of normal saline if you are going to have adequate flow of your fluids through bone marrow. The expression, “no flush, no flow,” says it all. Flushing the needle will allow quicker and easier flow of fluids. Occasional patients may require additional flushes of saline. The flow through an IO needle is slow even after flushing, and additional pressure is needed to achieve maximal flow rates. (Pediatr Emerg Care 1985;1[4]:215.) Don’t hesitate to use an intravenous pump or add pressure bags to maximize the flow rate through an intraosseous needle.

Watch a video demonstrating intraosseous infusion of an awake adult. http://bit.ly/IntraosseousInfusion

 

Published: 11/5/2012 1:39:00 PM
10.02.12
by

Another Arrow for Your Headache Quiver: Cervical Injections

People don’t come to the emergency department for treatment of headaches unless their headache severity or duration is intolerable or the headache is frighteningly different. (Neurol Clin 1998 May;16[2]:285.) Usually, these headaches have failed to respond to their usual and standard therapies. In fact, those who market the migraine-specific triptan drugs recognize that headaches that have progressed to the state of central sensitization simply don’t respond well to their drugs. (Ann Neurol 2004;55[1]:27; Ann Neurol 2004;55[1]:19; Clin Ther 2000;22[9]:1035.)

Central sensitization is an increased response to stimulation that is mediated by amplification of signaling in the central nervous system. It is primarily demonstrated by allodynia, a painful response to a stimulus that does not normally cause pain. (Clin Ther 2000;22[9]:1035; Funct Neurol 2000;15[Suppl 3]:28; Ann Neurol 2000;47[5]:614.)

In other words, headaches in the emergency department are not your garden-variety headaches. We are dealt the most difficult headaches to treat and need as many therapeutic arrows in our quiver as possible.

The injection of small amounts of 0.5% bupivacaine bilaterally in the paraspinous muscles at the C6 or C7 level of the posterior neck was first recognized in 1996, and the first case series was published in 2003. It also appears to have a role in managing orofacial pain. (Headache 2003;43[10]:1109.) A 1.5-inch 25-gauge needle is used to inject 1.5 mL of 0.5% bupivacaine HCl approximately 1-1.5 inches into the paraspinous musculature 2-3 cm bilateral to the spinous process of the sixth or seventh cervical vertebrae. The entire amount is completely deposited in a single injection location. Videos are one of the most effective ways to teach procedures, and this one is no exception. (Click the link below to watch the video demonstrating the procedure.)


The science behind this procedure currently is several case series and one large retrospective review of 417 patients. (Headache 2006;46[9]:1441; www.ncbi.nlm.nih.gov/pubmed/17040341.) Jerome Hoffman, MD, and Richard Bukata, MD, reviewing the article in Emergency Medicine Abstracts called the methods “pristine.” (http://bit.ly/OBj99l) The article was subsequently touted as one of the best articles of the year.

Two other retrospective review articles with fewer patients describes the benefit of this technique for treating headaches in children and orofacial pain. (Pediatr Emerg Care 2010;26[3]:192; J Orofac Pain 2008;22[1]:57.) No prospective studies have been published, but clinical experience with this procedure is growing.


 
How effective is this procedure? I am confident that it is not as effective as intravenous prochlorperazine (Compazine) and diphenhydramine, but it is equal to or better than most of the other therapeutic options currently used. Approximately 65 percent of patients get compete relief, and another 20 percent get partial relief. Overall 85 percent of patients receive benefit from this procedure. (Headache 2006;46[9]:1441.) An important reality is that bad headaches are often difficult to manage. Consequently, some patients require three or four therapeutic arrows from our quiver for treating migraine headaches. The cervical injection is often successful as a rescue medication for other failed interventions, but a Plan B is sometimes needed for failed or partial responses to cervical injections.

What are the drawbacks of this procedure? The first is convincing the emergency physician that the procedure is safe. Something about sticking needles into the back of the neck unnerves physicians. I have been fascinated by the reticence demonstrated by emergency medicine residents and attending physicians to perform this simple procedure. The same physicians who wouldn’t blink an eye at inserting a central line or plunging a chest tube into someone’s thorax are often hesitant about performing a cervical injection. The good news is that anatomically there is nothing but muscle at these injection sites. Muscle soreness the next day is often reported by the patient. Explaining that there may be muscle pain similar to an influenza shot is understandable to the patient. The other downside is that patients who are especially averse to needles may reject the procedure, but most patients with severe headache will allow you to do anything to feel better.


 
What are the benefits of the procedure? First, it is fast. Injections that successfully relieve headache pain often do so in five to 15 minutes. One can quickly move to plan B if the patient does not respond by 20 minutes. Other than the nursing staff delivering the bottle of bupivacaine out of the dispensing device, it does not require much ancillary support. It is possible to have the patient feeling better and discharged before the registration clerk has finished her job.
How long does the benefit last? Our experience has shown the benefit usually lasting until the next headache. On the other hand, the headache may return within hours to days if the inciting cause of the headache persists (toothache, nitroglycerin, viral meningitis, etc.). The bilateral paraspinous cervical injection with small amounts of bupivacaine in the lower neck is another excellent option for managing those extremely tough headache cases we typically encounter in the emergency department. Try it!

Watch a video demonstrating the injection of bupivacaine into the paraspinous muscles.
 

Tags: emergency medicine, emergency physicians, migraine, headache, cervical injections
Published: 10/2/2012 2:22:00 PM
09.05.12
by

Priapism Emergency

Last month I focused on managing a common female genital problem, the Bartholin Gland abscess. In the spirit of equality, this month's blog post looks at an important male genital problem, priapism. Unfortunately, the literature guiding treatment is not the most robust. Nevertheless, we do have recommendations and guidelines created by national and international experts who have digested the available literature. The guidelines created by the American Urological Association are the most frequently touted resource.(1)
 
I have written and delivered several lectures to our residents on this topic over the past several years, and I've reflected on this condition a little and been able to reduce the essentials of managing priapism to the following bullet points and the instructional video below.

o This is considered a compartment syndrome of the penis, and while the urgency to treat doesn't compare with a testicular torsion, a timely intervention is important for future sexual function. It is also important to recognize that priapism comes in ischemic and non-ischemic versions. Non-ischemic priapism is caused by a vascular fistula that results in unregulated arterial inflow, and is not considered an emergency. Penetrating or blunt trauma to the penis, perineum, or pelvis is the most common cause of this rare condition.
 
o If sticking a large-bore needle into an engorged penis makes you squeamish, you need to get over it. This is the cornerstone of emergency therapies for this condition.

o Don't waste your time trying oral therapies. You will still find some sources recommending oral pseudoephedrine or terbutaline for specific settings (priapism under four hours or following self-injection therapy for impotence), and some success has been reported anecdotally.(2-5) Most sources advise you to not waste time with this intervention, however.(1,6-9) That is especially true with patients who present many hours after the onset of the troublesome erection.
 
o Don't be fooled into thinking that simply treating the patient's underlying condition like sickle cell disease or leukemia will relieve the priapism. You can manage those conditions simultaneously, but immediate and aggressive management of the priapism is what the patient needs.
 
o Move immediately to the aspiration (and saline irrigation) procedure. Most resources indicate that this is the primary intervention for penile detumescence. Some evidence suggests that the acidotic, anoxic, hypercarbic, and hypoglycemic condition of the penis will make the injected sympathomimetic agent less effective so aspiration and irrigation is done before the corpora injections with phenylephrine are initiated. After sufficiently aspirating out the corpora cavernosa of the stagnant, crankcase-oil-appearing blood, conditions may be much more conducive to success.
 
o Anesthesia is important to the patient's comfort. Local injections with lidocaine or bupivacaine without epinephrine, a penile dorsal nerve, or a ring block will go far in reducing the pain associated with this condition. Systemic analgesia with your favorite opioid drug of choice may also be indicated.
 
o A single, large-bore, butterfly needle placed proximally at either 2 or 3 o'clock or 9 or 10 o'clock will be sufficient for aspiration and irrigation. An optional second needle or catheter placed on the opposite side of the penis (placed a little more distally) can be used to aspirate when irrigation is performed. One may be tempted to use a 30 or 60 mL syringe for this procedure, but a smaller syringe may prevent excessive suction that can cause vascular collapse. Finally, don't forget to use sterile surgical technique.
 
o Testing of a new, undifferentiated priapism patient should also be done. Possible testing options include a CBC, reticulocyte count, hemoglobin electrophoresis, psychoactive medication screening, urine toxicology, penile blood gas testing, color duplex ultrasonography, and rarely penile arteriography.
 
o Phenylephrine is the recommended sympathomimetic drug. The American Urological Association guidelines seem a little open-ended and state: "For intracavernous injections in adult patients, phenylephrine should be diluted with normal saline to a concentration of 100 to 500 mcg/mL, and 1 mL injections made every three to five minutes for approximately one hour, before deciding that the treatment will not be successful. Lower concentrations in smaller volumes should be used in children and patients with severe cardiovascular disease."
     If followed religiously, it would be possible to give 6-10 mg of phenylephrine by the time an hour rolls by. It appears that no clear recommendations are available about maximum safe dosing. Other sources recommend that phenylephrine be diluted in saline to a 200 mcg/mL concentration and be administered intermittently as 0.5 mL to 1.0 mL doses every 5-10 minutes to a maximum dosage of 1 mg. For comparison, the intravenous pulse dose treatment of shock-related hypotension is 100-500 mcg/dose every 10-15 minutes as needed (initial dose should not exceed 500 mcg).
 
o Monitoring of the patient is essential, and the treatment should be carried out in a monitored room capable of closely tracking blood pressure and heart rate. One case of a CNS bleed associated with phenylephrine injection during treatment for priapism has been reported.(5) The potential side effects are those common to sympathomimetics, and include hypertension, seizures, strokes, myocardial infarctions, tachyarrhythmias, and ventricular arrhythmias.
 
o When these measures are not successful, surgical shunting is the next step. If you have not already consulted the urologist or arranged transfer to a referral center, it's probably time.
 
 
 
References
1. AUA guidelines: http://www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm?sub=priapism.
2. Priapism in Emergency Medicine: http://emedicine.medscape.com/article/777603-overview
3. Int J Impot Res 2004;16(5):424.
4. Paraplegia 1994;32(10):670.
5. Urology 1993;42(1):51; discussion: 53.
6. J Urol 1994;151(4):878.
7. BJU Int 2012;109(Suppl 3):15.
8. J Sex Med 2010;7(1 Pt 2):476.
9. BestBets: The Effectiveness of Oral Terbutaline in Treatment of Priapism: www.bestbets.org/bets/bet.php?id=1955.
10. J Sex Med 2008;5(4):1025.
Tags: priapism, erection, compartment syndrome, penis, phenylephrine
Published: 9/5/2012 2:28:00 PM