IDEA Series: Teaching ECGs through a Written Competition

The Problem

Idea Series LogoECG interpretation is a cornerstone of Emergency Medicine (EM). It requires both rapid identification of life-threatening abnormalities and fastidious attention to detail. This pairing can intimidate some junior learners, and identifying an effective and engaging method for teaching ECGs is important to resident education. We report a teaching method that addresses this problem with an annual residency ECG competition.

The Innovation

Emergency medicine residents completed a timed ECG competition. Each resident had 30 minutes to complete a written exam developed by the residency program. A secondary goal was to help residents identify any individual ECG abnormalities or components of interpretation needing personal improvement.

Target Learners

EM residents, combined EM and Pediatrics residents, and combined EM and Internal Medicine (IM) residents ranging from PGY-1 through PGY-6 participated in the challenge. We stratified learners into categories based on post-graduate experience: PGY-1, PGY-2, PGY-3, and higher.

Group Size

We invited all residents (approximately 60 trainees) to participate. Small groups of 10-15 residents rotated through the multiple stations.

Materials Needed

We used previously compiled ECGs of both common and uncommon arrhythmias and diagnoses that EM providers should be able to identify. High quality images are preferred.

Description of the Innovation

In the months preceding the competition, residents received ECG study materials and had opportunities to ask questions during scheduled ECG didactics.

On the day of the competition, we divided residents into groups of 10-15 trainees. Each group rotated between simulation cases and the written ECG competition.

We evaluated ECG interpretation and fund of knowledge through a variety of formats:

  • Identifying classic ECG findings (ischemia and common arrhythmias)
  • Identifying management or next-steps in response to an ECG
  • Short answer and “list” questions to describe more nuanced components of ECG interpretation

At the end of the activity, participants received an answer key, which we reviewed at a subsequent didactic session. Experienced faculty facilitated the review session. The top trainees in each category were recognized at the annual resident graduation dinner.

Dr. Amal Mattu’s ECG Weekly website features EKGs from the competition, as well as answers to prior ECG competition exam questions.

Theory Behind the Innovation

This exercise corresponds to Kolb’s 4-stage cyclical theory of experiential learning, a model of learning that combines experience, perception, cognition, and behavior. According to Kolb, “learning is the process whereby knowledge is created through the transformation of experience.”1,2

During the ECG competition, a learner applies knowledge to specific cases in a safe environment where mistakes can be made without severe consequences. This reflects the “concrete experience” stage of learning. After the competition, learners have an opportunity to review their answers. This represents the observation and reflection stages of experiential learning. Finally, residents progress to the stages of cognition and behavior: identifying areas to improve their ECG interpretation, and influencing behavior by applying this knowledge to patient care.

Lessons Learned

Though a simple concept, the ECG competition is now a popular annual event at our residency program. Residents have expressed enthusiasm for the event and its ability to emphasize key principles of ECG interpretation in a fun, engaging manner.

Closing Thoughts

ECG interpretation is critical to providing emergency medical care. It requires an attention to detail that often intimidates both junior learners and even some experienced providers. Pairing targeted, high yield practice materials with a competitive ECG exam is an effective method for teaching ECGs to residents, and provides an opportunity to develop this skill in a fun and safe environment.

Read more about the IDEA Series.

1.
Kolb D A. Experiential Learning. Englewood Cliffs, N.J. : Prentice-Hall; 1984.
2.
Experiential Learning (Kolb). Learning Theories. https://www.learning-theories.com/experiential-learning-kolb.html. Published February 13, 2007. Accessed September 19, 2017.

Author information

Sumit Patel, MD

Sumit Patel, MD

Emergency Medicine Resident
Department of Emergency Medicine
University of Maryland

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SplintER Series: Splint Principles 101

splint plaster materialWhy do we splint? Splinting is one of the fundamental procedures of the Emergency Department (ED). How well-versed are we with it? Why do we even splint? By the end of this post, you will know the reason why we splint, when to splint, and just as importantly — when NOT to splint in the ED.

Learning Objectives

  1. Understand the types of splint applications
  2. Understand when not to apply a splint

The Bottom Line

Splints are not just used for fractures and sprains. They are also used for laceration repairs, tendon lacerations, and severe soft tissue injuries. They can definitively treat some fractures and serve as a temporary treatment for others. Acutely, they are preferred to casts because they allow room for swelling. Be cautious when considering splinting a musculoskeletal injury if the fracture is open, or there is concern for compartment syndrome, acute neurovascular compromise, chronic neuropathy, infection, and/or complex regional pain syndrome.

Background

Compared to a fully circumferential cast, a splint is a non-circumferential immobilizer. Both are aimed at stability, flexibility, and protection, but a cast is less flexible and does not accommodate swelling as well. Commonly thought of as an initial stabilizer, splints can also sometimes serve as definitive treatment for fractures and sprains. In the immediate setting, splints have been shown to reduce pain and prevent injury to surrounding nerves, vessels, and soft tissue.1–3 The goal in applying a splint is to restore musculoskeletal limb function (appropriate alignment, muscle strength, sensation, and pain-free range of motion).4 Compared to casts, splints promote quicker healing, earlier return to function, and mobility in injuries such as ankle sprains. As a result, patients are more satisfied.5–7

Uses and Advantages

Splints are an excellent ED tool that can temporarily stabilize fractures requiring orthopaedic intervention,2 more definitively treat certain stable fractures,1,2,8–10 reduce pain, and speed healing in soft tissue injuries such as a sprain.2,6,11

With the appropriate training, splints are easy and quick to apply. By molding the splint material (the next post will describe this more in detail) appropriately, you direct bone alignment by exerting pressure (but not too much!) on the soft tissues.12 Splints are non-circumferential and allow for the inevitable swelling that follows an acute musculoskeletal injury. Depending on the type of injury, a splint can be applied to prevent motion or to assist in functional movement.9 In comparison, a cast is more technically difficult and given its circumferential nature, increases the risk for compartment syndrome and pressures sores.13

Be aware that splints are not limited to only fractures and sprains. They are also useful in protecting severe soft-tissue injuries and laceration repairs across joints.2

Indications for a splint

  1. Definitive management for certain fractures 1,8–10
  2. Stabilization of fractures that require definitive care 2,14
  3. Sprains 2,6,11
  4. Reduced joint dislocations 15
  5. Severe soft-tissue injuries 2
  6. Laceration repairs across joints 2
  7. Tendon lacerations or ruptures 2

Open fracture of tibia-fibula (image credit)

When should I NOT splint immediately?

There are no absolute contraindications to using a splint. But there are some reasons not to splint immediately. Reconsider if you should be splinting a patient when you have any of the following:16,17

1. Open fracture

  • While a splint can be used to stabilize an open fracture to maintain length and alignment,18 an open fracture will require operative irrigation and debridement before appropriate reduction and splinting.17

2. Concern for compartment syndrome or acute neurovascular compromise

  • If there is concern for impending compartment syndrome or neurovascular compromise, a splint can apply enough pressure to compressible tissues to cause worsening vascular compromise and necrosis.17

3. Chronic neuropathy or complex regional pain syndrome

  • Any neuropathy, such as diabetic neuropathy, increases the risk for pressure ulceration in a splint/cast due to chronic vascular compromise. This may result in the patient not feeling whether an ulcer is developing within the splint/cast.16,17

4. Evidence of infection

  • Splinting over an infected area can create an optimal growing condition for bacteria while also preventing direct visualization needed for serial skin examinations.17

Throughout this year, we will delve deeper into when and how to splint. Each post will highlight splinting techniques and teaching pearls for different extremity injuries. We will also be releasing a database of suggested splints and associated photos and videos. Thanks for reading and stay tuned for Splint Principles 102!

Test Question

In which of these instances should a splint NOT be considered?

Choice Explanation
A An 18 year old male who has a grade 3 ankle sprain
B A 33 year old female who had a complex laceration repair to her knee
C A 6 year old male who fell from the monkey bars and has a Grade 1 supracondylar fracture
D A 45 year old chef who cut her finger with tendon involvement
E  A 20 year old female who has a swollen, very painful leg and paresthesias found to have a tibial fracture.

 

Answer: E

This female is at increased risk for compartment syndrome. On average, 2-9% (20-22) of tibial fractures will result in compartment syndrome. Test compartment pressures if you are comfortable – otherwise consult your nearest orthopaedic specialist!

1.
Geiderman J, Katz D. General principles of orthopedic injuries. In: Marx J, Walls R, Hockberger R, eds. Rosen’s Emergency Medicine – Concepts and Clinical Practice E-Book. Elsevier Health Sciences; 2013:460.
2.
Boyd A, Benjamin H, Asplund C. Splints and casts: indications and methods. Am Fam Physician. 2009;80(5):491-499. [PubMed]
3.
King J. Splinting procedures. In: King C, Henretig F M, eds. Textbook of Pediatric Emergency Procedures. Lippincott Williams & Wilkins; 2008:919.
4.
Lusardi M M, Jorge M, Jorge M, Nielsen C C. Orthotics and Prosthetics in Rehabilitation. Elsevier Health Sciences; 2012.
5.
Hockenbury R, Sammarco G. Evaluation and treatment of ankle sprains: clinical recommendations for a positive outcome. Phys Sportsmed. 2001;29(2):57-64. [PubMed]
6.
Eiff M, Smith A, Smith G. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med. 1994;22(1):83-88. [PubMed]
7.
Kemler E, van de, Backx F, van D. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. 2011;41(3):185-197. [PubMed]
8.
Boutis K, Willan A, Babyn P, Narayanan U, Alman B, Schuh S. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6):e1256-63. [PubMed]
9.
Plint A, Perry J, Correll R, Gaboury I, Lawton L. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117(3):691-697. [PubMed]
10.
Stewart H, Innes A, Burke F. Functional cast-bracing for Colles’ fractures. A comparison between cast-bracing and conventional plaster casts. J Bone Joint Surg Br. 1984;66(5):749-753. [PubMed]
11.
Gravlee J, Van D. Braces and splints for musculoskeletal conditions. Am Fam Physician. 2007;75(3):342-348. [PubMed]
12.
Browner B D. Skeletal Trauma. Elsevier Health Sciences; 2009.
13.
Halanski M, Noonan K. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008;16(1):30-40. [PubMed]
14.
Buckley R. General Principles of Fracture Care. Emedicine. http://emedicine.medscape.com/article/1270717-overview. Accessed September 17, 2017.
15.
Itoi E, Hatakeyama Y, Sato T, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am. 2007;89(10):2124-2131. [PubMed]
16.
Do T. Splinting. Emedicine. http://emedicine.medscape.com/article/1997864-overview. Accessed September 17, 2017.
17.
Ramirez M. General Splinting Techniques (Emergency Medicine). ClinicalKey. https://www.clinicalkey.com/#!/content/medical_procedure/19-s2.0-mp_EM-069. Accessed September 17, 2017.
18.
Jones C, Wenke J. Open Fractures. In: Browner B D, ed. Skeletal Trauma. Elsevier Health Sciences; 2009:465-487.

Author information

William Denq, MD

William Denq, MD

Chief Resident
Department of Emergency Medicine
George Washington University

The post SplintER Series: Splint Principles 101 appeared first on ALiEM.

SplintER: A New Series on Orthopedic Injuries and Splinting

splintingThe purpose of the SplintER series is to teach the fundamentals and introduce advanced concepts of splinting to the Emergency Medicine (EM) professional. Humans have been splinting their injuries since 1300 B.C.1 Although the fundamentals have not changed, splint selection and application require some thoughtful consideration. A 2017 prospective, observational study in the Journal of Pediatric Orthopaedics demonstrated that more than 90% of splints applied in the Emergency Department were inappropriate (30% applied by EM attendings), as evaluated by orthopaedic surgeons.2 While that number may not be representative in your institution, it certainly highlights the inadequacies that many of us feel when approaching a splint!

Starting tomorrow and then throughout this academic year, we will cover extremity injuries and splints. All information is expert peer-reviewed and edited by an Emergency Medicine / Sports Medicine specialist, such as Dr. Elizabeth Delasobera, the Sports Medicine Fellowship Director at Georgetown.

Any feedback is appreciated!

1.
Browner B D. Skeletal Trauma. Elsevier Health Sciences; 2009.
2.
Abzug J, Schwartz B, Johnson A. Assessment of Splints Applied for Pediatric Fractures in an Emergency Department/Urgent Care Environment. J Pediatr Orthop. January 2017. [PubMed]

Author information

William Denq, MD

William Denq, MD

Chief Resident
Department of Emergency Medicine
George Washington University

The post SplintER: A New Series on Orthopedic Injuries and Splinting appeared first on ALiEM.