Episode 17: Important Topics in Emergency Ophthalmology

In this episode of the EM Res Podcast, we welcome back Dan Kaminstein, MD.  Dr. Kaminstein is our director of the section of International Medicine in the Emergency Department at Wellspan York Hospital, and a guru of ultrasound.  Dan got in touch with an old residency pal, Dr. Emory Patterson from Athens, GA to talk about all things Emergency Ophthalmology.  Lots of great leaning points and practical tips to be had.  Some of the highlights from the discussion:

  • You must know three things when you call the ophthalmologist: visual acuity, pupils, and pressure.

  • If you can’t get a visual acuity, have them count fingers, then identify hand movement, and if all else fails, ask about light perception.

  • If the patient has a detached retina - whether mac on or off - call the ophthalmologist.
  • If you are going to dilate, use a shorter acting agent, such as 2.5% phenylephrine and 1% tropicamide,
  • There are few, if any, conditions you will diagnose in the ED that require acute topical steroids when it comes to eye complaints.  You don’t need to prescribe them in the ED for the most part, and if you need to, you should at least talk with an ophthalmologist
  • When it comes to retrobulbar hematoma - know the pressure.  Just because they have one does not mean it is causing elevated pressure, which is why you do the lateral canthotomy.  
  • Dilute proparicaine is probably not ready for primetime.  Make sure you are talking to your local ophthalmologist about stuff like this before jumping on a small amount of data.  
  • When it comes to ocular exposure to alkali or acid, anything you can flush with is better than acid or alkali.  Normal saline is fine.  So is tap water.  

New EM Residents, Attendings, and Dogmalysis

There is a bunch out there in social media and FOAMed lately about “dogmalysis,” or the idea that some of the things we do have no evidence base, and should not be done.  I love it.  Being quite cynical and skeptical myself, I love to see us start to question our practice’s evidence base to try to come up with the best care for our patients.  But new EM residents and new EM attendings may want to take some of this content with a grain of salt.  

Here’s my take:

  • New EM Residents: Before you go quoting advanced topics and dogmalytic principles (the “I heard it on a podcast” phenomenon), make sure you are well read and understand the basic concepts first.  I think it is great people are questioning things like Kayexalate for hyperkalemia, but make sure you know how to diagnose and treat the condition otherwise.  Lay the foundation before you spend too much time on advanced topics.  
  • New EM attendings: Get the lay of the land for the first 6-8 months.  You are not going to change an entire hospital system in one day, and you may in fact hurt your chances of effecting change in the future by being known from day one as the guy who pitched a hissy fit about protonix for an upper GI bleed on your first shift out when that is the standard of care across all practices at your place.  Remember change takes time, and educating your colleagues, both within your specialty and without, takes time and trust.  


New EM Residents, Attendings, and Dogmalysis

There is a bunch out there in social media and FOAMed lately about “dogmalysis,” or the idea that some of the things we do have no evidence base, and should not be done.  I love it.  Being quite cynical and skeptical myself, I love to see us start to question our practice’s evidence base to try to come up with the best care for our patients.  But new EM residents and new EM attendings may want to take some of this content with a grain of salt.  

Here’s my take:

  • New EM Residents: Before you go quoting advanced topics and dogmalytic principles (the “I heard it on a podcast” phenomenon), make sure you are well read and understand the basic concepts first.  I think it is great people are questioning things like Kayexalate for hyperkalemia, but make sure you know how to diagnose and treat the condition otherwise.  Lay the foundation before you spend too much time on advanced topics.  
  • New EM attendings: Get the lay of the land for the first 6-8 months.  You are not going to change an entire hospital system in one day, and you may in fact hurt your chances of effecting change in the future by being known from day one as the guy who pitched a hissy fit about protonix for an upper GI bleed on your first shift out when that is the standard of care across all practices at your place.  Remember change takes time, and educating your colleagues, both within your specialty and without, takes time and trust.  


Episode 16: Are you sure you want that scan?

We have all answered that call from radiology or a radiology tech.  In this episode, we talk about the myths and truths behind the use of oral contrast in the ED, ED imaging in pregnancy, and contrast induced nephropathy.

1. Oral Contrast in the ED: With new generation scanners, most patient with non traumatic abdominal pain do not need oral contrast.  Multiple studies have shown that with new generation scanners, CT for appendicitis does not suffer when oral contrast is not administered. In high grade bowel obstruction, the American College of Radiology (ACR) actually says we should NOT be giving oral contrast as it is bad for the patient (potential aspiration), and may obscure radiologic evidence of bowel wall ischemia.  With motion artifact reduction in new generation scanners, it really isn’t adding much to diverticulitis, either.  







2. Imaging in pregnancy: Remember this is all about how we communicate risk.  We always want to follow the ALARA (as low as reasonably achievable) principle, but we must not punish the patient for being pregnant by not doing the appropriate study.  CT versus VQ is controversial, but I feel this guideline from the American Thoracic Society/Society of Thoracic Radiology is a reasonable approach:



Abdominal imaging can be tricky, but the answer should generally be US first in the pregnant patient, followed by MRI if possible.  Again, if they need the CT, discuss the risk/benefit ratio and educate your patients.  



3. Contrast Induced Nephropathy (CIN): The incidence of CIN is likely lower than we thought previously.  In general patients with a GFR < 30 are at highest risk, and those with a GFR between 30-45 may be at higher risk.  The majority of are patients, however, are at a minimal risk of CIN.  To prevent it in high risk patients, the best we can try is hydration with isotonic fluids and educate the patients.  But again, if you need the scan, you need the scan.   




Listen to the podcast, and let me know what you think!

Image of the Week 008

A 62 year old man presents after he tripped and fell on his R shoulder.  His only complaint is of R shoulder pain, and on exam his pain is localized to the distal clavicle.  The R shoulder X Ray shows the following.  What is your interpretation?  What are the different types of this injury?  What is your treatment plan?



The above image shows an acromioclavicular (AC) joint separation.  This should be considered in anyone who falls onto the the shoulder, particularly the apex, or an outstretched hand.  If you watch (American) football, think about the running back you see who gets tackled with his arms holding onto the ball, and they land right on the shoulder pad while being driven down.  Patients may complain of generalized shoulder pain and limitation of their range of motion, but will have point tenderness over the AC joint.  As with any injury, make sure to do a full neurovascualr exam distal to the injury, palpate the entire clavicle, and evaluate the ribs for possible injury and consider pneumothorax if you suspect thoracic injury.  And, as with any upper extremity injury, determine the handedness of the patient.  

It is important to know that there are different grades for AC injury.  The common classification is known as the Rockwood classification, and describes six types of AC injury.  To understand them, we must understand the anatomy involved.  



The Rockwood classification system requires interpretation of a few things:

  1. The acromioclavicular ligament
  2. The coracoclavicular ligament
  3. The AC joint capsule
  4. The deltoid
  5. The trapezius
  6. The relation of the clavicle to the acromion

There are six types of AC injury (Type I -VI).  A great description of each of the above factors in each type can be found here.  If pictures are more your thing, this will help: 



It is important to know what type it is as it relates to treatment.  Types I-II are generally treated conservatively with a sling and no surgical intervention, although severe type II injuries may require surgical intervention depending on occupation, severity, and clinical course.  Management of Type III is controversial, but may require operative intervention as well.  Types IV-VI require operative correction, and probably warrant more urgent orthopedic evaluation and consultation at the time of injury.  If you suspect an AC injury, but your film does not show a clear unobstructed view of the AC joint that allows you to evaluate the relationship of the inferior border of the acromion and the clavicle, consider a Zanca view (the XR gets a bit of cephalic tilt to allow clear visualization of the AC joint).  

So what about our patient?  The image shows that the inferior border of the clavicle is elevated when compared to the inferior border of the acromion, but does not pass its superior border, so this is likely a type II AC Joint injury.  The patient should be placed in a sling, given analgesia, and referred for urgent orthopedic evaluation.  

References:

  1. http://emedicine.medscape.com/article/92337-overview
  2. http://radiopaedia.org/articles/acromioclavicular-joint-injury-classification-rockwood
  3. Macdonald PB, Lapointe P.  Acromioclavicular and sternoclavicular joint injuries.  Ortho Clin North Am.  2008 Oct; 39 (4): 535-545.  

Image of the week 007

A 14 year old presents to your ED after a fall on an outstretched hand during a basketball game.  He is complaining of left wrist pain.  He is tender diffusely over the distal radius and ulna with associated soft tissue swelling, but is neurovascularly intact throughout the left upper extremity with no pain above or below the wrist.  He denies snuffbox tenderness, or wrist pain with axial loading of the thumb.  You obtain the following radiographs.  Click each question below for the answer.  




[ Open All | Close All ]

1] How would you describe this fracture to your orthopedic colleagues?
There are two major abnormalities here, one involving the distal radius, and one involving the distal ulna. There is a comminuted distal radius fracture at the metaphysis that extends to the physis, and is approximately 25% displaced dorsally with minimal angulation. There is also an ulnar styloid fracture with probable physeal injury here as well.

2] What are the important features you need to include when describing fractures to your colleagues?
There are a few important features you should be able to tell your colleagues, and that will be important for your orthopedic specialist to know. There are various mnemonics out there that try to help you remember what to look for and describe. I am not a big believer in mnemonics, as I find people often have trouble remembering the mnemonic itself, much less what it aims to help you describe or remember. So here is what you need to talk about when describing a fracture:
  • What is their hand dominance? Consider this with all upper extremity injuries. Much like you start an OB presentation with the G’s and P’s, let your orthopedist know if the patient is Right or Left hand dominant.
  • What kind of fracture is it (i.e. transverse, oblique, buckle, etc.). Is the fracture comminuted or not?
  • What is the location of the fracture - midshaft, distal, metaphyseal, etc.
  • Is the fracture displaced, and if so in what direction? Remember, this refers to the relation of the distal segment with the proximal segment. So in the case above, the distal segment is displaced dorsally. You describe this with a percentage of the distal segment that is displaced.
  • Is the fracture angulated? Again, this is described by the direction and angle of the distal segment, and the angle of the distal segment compared to the axis of the proximal segment.
  • Is the fracture rotated or impacted?
  • Is the fracture open? It is crucial to take any dressings down to identify any signs of an open fracture.


3] What should I document in terms of an exam?
It is important to identify a few things. Obviously, if someone shows up with a deformed limb, make sure to do a full H/P, and identify any other injuries. Once you are focusing on the suspected (or confirmed) fracture, you want to inspect at least the joint above and below the area of injury. Document pain, swelling deformity, and range of motion. You also want to document a good neurovascular exam. Remember, the vascular exam should include skin color, temperature, capillary refill, and pulses. Neurologically, make sure you document motor and sensory function. Also, be sure to document any skin findings over or around the area of injury. Breaks in the skin, bruising, swelling or deformity are all important to note.

4] Why all the fuss? Can’t I just call this a Colles fracture and be done?
I guess you could, but that fails to describe some important information. A Colles fracture is technically a radial fracture about an inch from the radiocarpal joint with dorsal displacement and/or angulation, but just saying a Colles fracture tells you nothing of how displaced, comminuted or not, the neurovascular status, or any other bony involvement. Being as descriptive as possible helps paint the picture for our colleagues. In general, I hear mixed things from my orthopedic colleagues about fracture eponyms. Colles is well known, but do you know a Barton or Rolondo off the top of your head? Know the difference between a Jones and a Pseudo-Jones? These things often are taught and come up on board exams, but at 2 AM describing the fracture as above paints a much better picture and keeps you from calling a Monteggia a Galeazzi.


I would advise that in order to best learn how to interpret plain radiographs, read them yourself, and do so before you read the radiology interpretation.  At many EM training programs we have  24 hour radiology coverage, and the tendency is to wait for the radiologist’s interpretation.  Try reading it, make a commitment to a read, and see how radiology interprets it.  Many places you will eventually practice do not have real time reads for plain films, and your staff and patients will be counting on you to get it right.  

Questions, comments, additional thoughts?  Feel free to let me know below, or send an email to bobstuntzmd@gmail.com