Rural Pearl – There is no hand

You have just recently started a lucrative position in a small rural hospital in Northern Vermont.  In your first week you are working a single provider overnight shift and a patient presents for a laceration to their left hand.

 

History: 25 year old right handed male, at home cutting a steak when the knife slipped and he sustained the injury below.

He has sensation in the distal left 2nd digit and good capillary refill.  Motor exam reveals difficulty with full extension of the left 2nd digit.  After the exam you go back to your desk and try to remember if it is orthopedics or plastics covering hand, then you remember… There is no hand.  

 

Lacerations to the posterior hand can be complex and require complex repair.  This review of extensor tendon lacerations is provided via ACEPnow.

 

The first step in assessing lacerations to the hand prior to closure are to rule out foreign body retention and neurovascular compromise.  Then after extensive irrigation underlying tissue damage can be evaluated.  

 

Flexor tendon injuries are not frequently repaired in the ED.  It is important to achieve hemostasis/closure to prevent infection and then splint with prompt follow up.  

 

For extensor tendon injuries it is important to remember the zones of the hand.  

Zone  I injuries: Generally closed with or without repair via the roll stitch (pictured below) and splinted in the hyperextended position at the DIP.  

Zone II Injuries: Open extension injuries to the middle phalanx can be repaired by ED physicians similarly to zone 1 (roll stitch).  More complex lacerations, should be splinted and have close hand surgery follow up.  

 

Zone III Injuries: Open Lacerations involving the tendon should be closed without repair of the tendon, and splinted with 30 degrees of extension and wrist, 15 degrees of flexion at the MCP and PIP in neutral position with close specialist follow up.  

 

Zone IV injuries: Tendons in zone IV become larger and easier to repair.  Tendons with >50% laceration can be repaired with the Kessler technique (See below).  After repair patients should be splinted like zone 3 injuries and have close OP follow up.  

 

Zone V: The fight bite region.  Patients should be treated as a fight bite until proven otherwise.  Irrigate, start the patient on antibiotics, splint and have return for wound check in 24 hours or to a hand specialist in the same time frame.  Do not close these wounds if there is any suspicion for human bite.  

 

Zone VI: Larger tendons in this area make for easier repair.  Using the modified Bunnel technique (see below) the tendon can be repaired.  Patients should then be closed, splinted with wrist in 30 degrees of flexion, all other joints neutral and  the have close follow up with a hand surgeon.

 

 

Zone VII and VII: larger involvement of muscle belly makes these zones outside the scope of EM physicians.  Close the wound, place patient in a volar splint and give close follow up.  

 

Key points:

  • Do not repair flexor tendon injuries, irrigate, close and splint with close follow up.
  • If there is any doubt if a tendon injury is present, splint and follow up.
  • In general if you are unable to repair the tendon, splint and give close (within 1 week)
  • In Zone 1 injuries, patient adherence to splinting is most predictive of functional outcome.

Sources: Mcgovern, McNamee, I. “Emergency Department Management of Extensor Tendon Lacerations” http://www.acepnow.com/article/emergency-department-management-of-extensor-tendon-lacerations/2/?singlepage=1

Cystic Fibrosis in the Emergency Room

This series is designed to discuss topics that we might not routinely encounter during our training or how to manage patients we would normally triage to a sub-specialty service.  

This pearl comes courtesy of an excellent review on emDoc. “Cystic Fibrosis ED Management Pearls and Pitfalls” http://www.emdocs.net/cystic-fibrosis-ed-management-pearls-pitfalls/

 

Basic Pathophysiology:

Cystic Fibrosis (CF) is an autosomal recessive disease that can affect multiple organ systems.  Many people remember back to medical school when we learned that CF is a mutation in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) which is a chloride channel.  The general consequence of this mutation is that mucous and exocrine glands have decreased ability to secrete chloride. This generally affects the lungs, intestines, biliary system and pancreas.   

 

Acute Pulmonary Disease:

  • Special considerations:
    • In CF patients 85% of mortality is due to progressive pulmonary disease.  
    • CF patients have chronic lung infections leading to persistent cough and obstructive lung disease.  Most pulmonary exacerbations are triggered by expansion of colonized strains of bacteria, not newly acquired infections.  
    • Spontaneous pneumothorax is more common in older patients and those with advanced disease.  
    • Trace/Minor hemoptysis is common, does not always require extensive workup
    • Pneumonia: Staph Aureus and Haemophilus Influenzae are common early in life.  Pseudomonas once colonized is functionally impossible to eradicate.  In general management is with high dose antipseudomonal (aminoglycosides + B-lactams) but ideally should be tailored off of the patient’s last sputum culture.  
    • Allergic Bronchopulmonary Aspergillosis (ABPA) should be kept in the differential for wheezing CF patients.  Diagnosis of ABPA is not commonly made in the ED but the treatment is steroids.  
  • General management
    • Inhaled hypertonic Saline is beneficial in acute exacerbations when followed with chest PT.
    • Bronchodilators have an unclear efficacy but have a benign risk profile so may be considered.  They are more effective when dosed immediately before hypertonic saline.  
    • NIV: Observational studies show that NPPV may be useful in acute CF exacerbations.
    • According to the CF Foundation there is insufficient evidence to recommend use in an acute exacerbation.
    • Antibiotics as mentioned above.

 

Coagulopathy:

  • Patients with CF have chronic vitamin malabsorption.  When bleeding is part of their presentation an INR should be checked due to Vitamin K deficiency.  

 

Acute GI disease:

  • Distal Intestinal Obstruction Syndrome (DIOS) is a pathology unique to CF patients.  It is a partial or complete obstruction at the ileocecum by fecal material.  It is more common in adult patients and presents as abdominal pain, usually located in the RLQ.  This mass can generally be palpated due to its large size and can been seen as “granular” or “bubbly” stool on plain film x-ray.  These can generally be managed with PO therapy.  

 

 

SOURCE: Tassin, S. et al “Cystic Fibrosis Pearls and Pitfalls” http://www.emdocs.net/cystic-fibrosis-ed-management-pearls-pitfalls/

 

Buruli Ulcer

The following scenario is based on a case that was seen in the Sinai ED this past week.

A 52 yo M with hx of poorly controlled DM and HTN p/w rapidly progressing ulcer over the past 3 weeks of right lower extremity.  He has been afebrile and has normal vital signs in the ED.  Of note he just returned from Cameroon after living there for 5 years. The ulcer has the following appearance:

What could it be you ask? In this case it was a Buruli ulcer.

A Buruli ulcer is caused by Mycobacterium ulcerans. It is  is a chronic disease that affects skin and bone. Transmission of the disease is not currently known but it is believed to be associated with contaminated water sources in wetland areas. It is most commonly found in  West Africa but may also be seen in Mexico, South America, China, Japan, and Australia.

In terms of severity, the disease has been classified into three categories: Category I – single small lesion (32%), Category II – non-ulcerative and ulcerative plaque (35%) and Category III – disseminated and mixed forms such as osteitis, osteomyelitis, joint involvement (33%).  The disease often starts as a painless nodule or a large painless area of induration. Because of local immunosuppressive properties the disease often progresses in the absence of pain or fever. Without treatment, the nodule or area of induration erodes within 4  weeks creating the classical appearance of an ulcer with undermined borders. Occasionally, bone can be affected as well which causes visible deformities of the affected area.

there are currently four laboratory tests which can be used to confirm the diagnosis: IS2404 polymerase chain reaction (PCR), direct microscopy, histopathology and culture. PCR is the most commonly used method. The World Health Organization offers a guide on all of these testing modalities.

There are two different treatment options for Buruli ulcers. Both regimens require 8 full weeks of antibiotic treatment. They are as follows:

  •  a combination of rifampicin (10 mg/kg once daily) and streptomycin (15 mg/kg once daily)
  • a combination of rifampicin (10 mg/kg once daily) and clarithromycin (7.5 mg/kg twice daily). This regimen is preferred in pregnancy.

Additional treatment with urgical debridement and wound care is also necessary for many of these patients. Physiotherapy and long term rehab may also be required depending on the extent of involvement of the ulcer.

52 in 52 – Interrupted vs continuous compressions in cardiac arrest

Title: “Trial of Continuous or Interrupted Chest Compressions during CPR”

Article Citation: Nichol G, Leroux B, Wang H, Callaway CW, et al; ROC Investigators. Trial of Continuous or Interrupted Chest Compressions during CPR. N Engl J Med. 2015 Dec 3;373(23):2203-14. PMID: 26550795

What we already know about the topic: Animal models have demonstrated that interruptions in cardiac arrest result in decreased survival. There has not been any human studies confirming this to date.

Why this study is important:  This study is the first attempt to demonstrate that there is survival benefit from continued compressions in humans in cardiac arrest in the pre-hospital setting.

Brief overview of the study:  From 2011 to 2015 patients in cardiac arrest were randomly assigned to either an intervention group (continuous chest compressions at 100/min with 10 ventilations/minute = 12,653 patients) or to a control group (compressions interrupted for ventilations = 11,058 patients) in 114 EMS systems. Outcome measures included rate of survival to discharge, neurologic function at discharge (suing modified Rankin Scale), adverse events, and hospital-free survival days (ie number of days alive outside of hospital for 30 days).  The study found no statistical difference between either group’s rate of survival to discharge or neurologic function.  Of note the study demonstrates with statistical significance that the compressions-only group was less likely to be transported or admitted to the hospital, and this group also had shorter hospital-free survival.

Limitations: My primary issues with this study are: (1) These findings were performed by EMS and so can only be applied reliably to the pre-hospital setting. (2) The study did not account for in-hospital interventions (catheterizations, thrombolytics, etc) (3) The study excludes EMS-witnessed arrest, traumatic arrest, hypoxic arrest, exsanguination, and others.

Take home points: Outcomes for compressions-only CPR and interrupted CPR were very similar. This is the best data we have available to date describing these two approaches. While we cannot reliably apply these data to the hospital setting it does change how our patients will be managed prior to arrival.

Spanish Phrases Parte Dos

Must Know Spanish Phrases:

We are going to discharge you – le vamos a dar de alta

You can go home today – Hoy se puede ir a casa

You need to be hospitalized – Necesita ser hospitalizado

You have to stay in the hospital – Tiene que quedarse en el hospital

You will be in the hospital for at least a few days – Estara en el hospital unos dias por lo menos

When was the last time you were admitted to the hospital – Cuando fue la ultima vez que lo (la if female) han internado en un hospital

I will make you a primary care clinic appointment for next week – Le voy a pedir una cita con la clinica de atencion primaria para la semana que viene

I am going to speak with a specialist regarding this problem – Voy a hablar con un especialista sobre este problema

We need your consent in order to do this procedure – Necesitamos su permiso para hacer este procedimiento

You need to sign a consent form – Tiene que firmar un formulario de consentimiento

We can help you manage the pain – Le podemos ayudar a controlar el dolor

we need to check you vital signs before you go – Tenemos que chequear los signos de vitales antes de que se vaya

Medical Professionals:

Nurse – la enfermera, el enfermero (if male)

cardiologist – el cardiologo, la cardiologa

Gynecologist – la ginecologa, el ginecologo

Neurologist – el neurologo, la neurologa

Oncologist – la oncologa, el oncologo

Ophthalmologist – el oftalmologo, la oftalmologa

Pediatrician – la/el pediatra (same ending)

Obsstetrician – el/la obstetra

Psychiatrist – la/el psiquiatra

Orthopedist – el/la ortopedista

Radiologist – el radiologo, la radiologa

Urologist – la urologa, el urologo

Surgeon – el cirujano, la cirujana