Are you prepared to help a neighbour in trouble?

We’re all familiar with the parable of the Good Samaritan from Old Testament times.  Regardless of religious affiliation, it’s a positive affirmation of the fact that the vast majority of humans are prepared to help another in times of need.

Of course rural folk are used to this.  One of the things I love about living in a small rural community is the fact that we’re ‘all in this together’ and folk are prepared to help each other out.

In the most extreme case, imagine the case of a sudden cardiac death in the community.  Urgent help is needed.. every minute counts!

The HeartSAFE programme

The past two years have been busy for the small team at HeartSafeKI.  We’ve trained community members how to perform CPR and use an Automatic External Defibrillator (AED).  We’ve also gathered support from community groups such as Lions, CWA, Sports Clubs, Progress Associations and a few small business operators.

The end-result is we now have over 10% of the island trained and a network of Public Access Defibrillators, available in the event of a sudden cardiac death.  As such Kangaroo Island is now Australia’s first designated ‘HeartSafe’ community joining the international collaborative of HeartSAFE communities.

The next phase of this programme is to ensure people are aware of their nearest defibrillator and to utilise the help of community responders.

Imagine the situation.  Someone collapses in the shop or house next door.  Would you even know about it?  Probably not, until you heard the ambulance arrive, which is likely to be many minutes later.  This is the real danger, despite having many people trained in CPR.  If only there was a way to alert trained individuals to a nearby incident!


Introducing smartphone technology & GoodSAM

That’s where the Good SAM App comes in – a tool utilising the latest in App development that intends to alert those with medical training to nearby emergencies so that potentially life-saving interventions can be given before the arrival of emergency services. 

Many people nowadays have a ‘smart’ phone – a communication device (phone) coupled with apps including location services (maps, GPS).  The power in your pocket can now be used to save a life!

The GoodSAM app is available for download for iOS, Android and Windows systems.

The ‘Alerter’ app is designed to be used by the lay public (it will notify ambulance via 000) and advice you of location of the nearest defibrillator.  Trained CPR-providers can also download the ‘Responder’ app and, when integrated into the Emergency Operations Centre, can be used to alert responders in the event of a nearby cardiac arrest.

The premise is simple – in a capital city, you are probably never more than a few hundred metres away from an off duty doctor, nurse or paramedic.  These people can now volunteer to be notified of a cardiac arrest via Ambulance, and respond to provide basic life support (CPR) until he ambulance service arrive.

Mates from Medical School – Mark Wilson & Kevin Fong

GoodSAM is a ‘social enterprise’ venture – the brainchild of an old mate from medical school (neurosurgeon and HEMS clinician Mr Mark Wilson), the app is now adopted across the world.  It’s free for users and by joining you will be part of a GLOBAL SOCIAL ENTERPRISE VENTURE to be a ‘good samaritan’.  There is no obligation to respond and the usual caveats re scope of practice and so on are found online at goodsamapp.org

For every minute that passes, survival drops by 10%

I am excited that SA Ambulance has announced that it will be launching GoodSAM at some point in the future.  As such they will join other agencies including Ambulance Victoria, NSW Ambulance Service, New Zealand and a host of services overseas (not least in London, where GoodSAM originated).

 

GoodSAM responders are located globally – and the app works wherever you are!

The use of GoodSAM responders is certainly not to replace existing ambulance responses – but instead to provide essential CPR in those vital few minutes between collapse, alerting ambulance and arrival of trained paramedics.

 

Many emergency responders are registered with GoodSAM in Australia

With the imminent adoption of GoodSAM in South Australia, there is now a ‘Kangaroo Island First Responders’ group within GoodSAM, so that existing emergency service volunteers (ambulance, SES, CFS, Coastguard, Parks etc) and doctors, nurses – indeed ANYONE with CPR training – can be registered on the GoodSAM system and mobilised in the case of an incident.

Of course the GoodSAM system can be used for more than just responding to cardiac arrests.  The system allows us to see the approximate location of responders and to message them in the case of a nearby incident – such as car accident, fire, flood or similar. It also shows the location of the nearest defibrillator, guiding the responder.

The notion of the ‘Good Samaritan’ is familiar to most of us from the Old Testament and school.  In rural Australia there is a strong culture of ‘helping a mate’ in a crisis.  The GoodSAM app allows us to build on existing community services and allow increased resilience in a crisis.

 

So what do I need to do now?

If you are not trained in CPR, you can still help!  Download the free GoodSAM ‘Alerter’ app and you can use this to both call emergency services (anywhere in the world) and locate the nearest defibrillator.

If you are trained in CPR, then please register online as a GoodSAM responder – see goodsamapp.org and select the ‘Kangaroo Island first Responder Group’.  You will need to provide an email address and some form of proof that can perform CPR (membership of a recognised emergency organisation such as ambulance, SES, CFS, Coastguard etc).

Once you’ve done that, download the free GoodSAM ‘Responder’ app and leave it running on your device.

As the system grows and particularly once the ‘responder’ database is incorporated into SA Ambulance, this free app will allow the best chance of improved survival from out-of-hospital cardiac arrest.

In rural locations, GoodSAM can be used to add increased community resilience, allowing the rapid GPS location and alert of individuals in real time, categorised according to parent organisation (ambulance-SES-CFS-Coastguard etc) and flexible messaging between members.  Basically if you have your phone with you and the app running, then you can be located and mobilised according to need.

Go to GoodSAMapp.org to log in (see details below)

 

FOR MORE DETAILS, CHECK OUT:

ONLINE goodsamapp.org

NEWS ARTICLES AND VIDEOS https://goodsamapp.org/media

 

HOW TO REGISTER AS A COMMUNITY RESPONDER : A WALK THROUGH…

Go to GoodSAMapp.org to log in – select the ‘Register as a Responder‘ tab


Select country as ‘Australia
…and navigate the the ‘Kangaroo Island First Responder‘ group

Now you need to select which category to register as!  I would suggest SA Ambulance Ambulance Officer (volunteers) respond as ‘Ambulance Technician, CFS/SES may opt to register as ‘First Responder’ (I can assign to CFS and SES categories afterwards), Coastguard as Coastguard.  Other responders may select ‘other’ or ‘first aider’.

 

Nearly there!  It will ask you to select a ‘registration body’ and ‘registration number’

Fortunately on KI it’s fairly easy to confirm who is/isn’t in a registered emergency responder group.  It may be hard to locate your paperwork, so you can always upload a photo.  GoodSAM DOES require some form of ID at this stage.

For first aiders (teachers, employees with a first aid certificate and so on) then either provide a copy of your Basic Life Support of Senior First Aid certificate (or equivalent) or message me so we can verify credentials.

Once you’ve done all that I will approve applicants.

You will need to have the ‘GoodSAM app’ running on your smartphone – it runs in background and uses very little processor power.

If you REALLY want to help out, please ensure that your settings allow first and last name to be displayed. this means you can be easily identified in the case of a major incident and ‘push’ notifications sent to you…

The post Are you prepared to help a neighbour in trouble? appeared first on KI Doc.

Eponymythology: Atraumatic Abdominal Ecchymosis

LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Overview

We review the original descriptions of 5 eponymous signs (n=6) associated with non-traumatic abdominal ecchymosis.

These commonly cited eponyms involving the abdominal wall and flanks (Grey Turner, Cullen and Stabler); scrotum (Bryant) and upper thigh (Fox) may be useful clues directing the examiner to consider potentially serious causes of abdominal pathology.

Cullen sign

Thomas Stephen Cullen (1869–1953) was a Canadian gynecologist

Non-traumatic peri-umbilical ecchymoses associated with intra-abdominal haemorrhage, originally described in ectopic pregnancy – Cullen sign

Original publication: (n=1)

1918 – Cullen first described a bluish black discoloration of the periumbilical skin in a female patient with a ruptured extrauterine pregnancy with ‘no history of injury

Cullen originally described the finding at the 43rd annual meeting of the Transactions of the American gyecological society, Pennsylvania May 16-18 1918 [Am J Obstet Gynecol 1918;78:457]. He concluded that the umbilical appearance was due to intra-abdominal haemorrhage secondary to an ectopic pregnancy

cullen sign

Clinical context

  • Despite the original description, most literature relates Cullen sign of periumbilical ecchymosis to acute pancreatitis (being recorded in 1-3% cases) rather than secondary to an ectopic pregnancy.
  • In most described cases, it takes 3-5 days for Cullen sign to present and the sign been associated with a broad range of clinical conditions

CauseReference
Ruptured abdominal aortic aneurysmArmour et al 1978
Acute PancreatitisBosmann et al 2009
Percutaneous liver biopsyCapron et al 1977
Splenic ruptureChung et al 1992
Perforated duodenal ulcerEvans DM 1971
Rectus sheath hematomaGuthrie, Stanley 1996
Ischemic and gangrenous bowelKelley ML 1961
Hemorrhaging ascites from hepatic tumorMabin, Gelfand 1974
Bilateral acute salpingitis with IUPOrient JM, Sapira JD 2005
Cirrhosis with portal hypertensionOrient JM, Sapira JD 2005
Hepatocellular carcinomaOrient JM, Sapira JD 2005
Hypothyroid myopathyOrient JM, Sapira JD 2005
Ovarian cyst hemorrhageOrient JM, Sapira JD 2005
Renal sarcoma metastatic to the peritoneumOrient JM, Sapira JD 2005
Strangulation of ileum with hemorrhageOrient JM, Sapira JD 2005
Strangulated umbilical herniaOrient JM, Sapira JD 2005
Retroperitoneal necrotizing fasciitisPryor et al 2001

Epperla N et al. A Review of Clinical Signs Related to Ecchymosis. WMJ • APRIL 2015

Grey Turner sign

George Grey Turner (1877–1951) was an English surgeon

Non-traumatic abdominal ecchymosis, in particular – bruising of the flanks associated with retroperitoneal haemorrhage, originally described in acute pancreatitis – Grey Turner sign

Original publication: (n=1)

1919 – George Grey Turner submitted his article for publication as following a “…cursory examination of the voluminous literature on pancreatitis”, where he was unable to “…observe any mention of this sign”

1920 – George Grey Turner published ‘Local discoloration of the abdominal wall as a sign of acute pancreatitis‘ citing two cases of acute pancreatitis with fat necrosis and retroperitoneal haemorrhage [Br J Surg. 1920;7:394-395]

  • Case 1 [1912]: 54 year old female with three days of abdominal pain presenting with an area of discoloration (a bluish colour), about 6 inches in diameter involving the abdominal wall surrounding the umbilicus (see Cullen sign…).

“…the patient suffered from acute pancreatitis, with much effusion into the peritoneal cavity. She lived nine days after operation, and the post-mortem examination disclosed a sloughing pancreas with much fat necrosis

  • Case 2 [1917]: 53 year old male soldier with a history of recurrent bouts of self-limiting abdominal pain. He presented with unremitting abdominal pain and a rigid abdomen…looking ‘distinctly toxic’

The tenderness over the gall-bladder region was very marked, and I now noticed two large discoloured areas in the loins. They were about the size of the palm of the hand, slightly raised above the surface, and of a dirty-greenish colour.

Grey Turners Sign Original Photo 1919 COLOR
Grey Turners Sign: Original Photo: 1917. Colourised: 2017 Tor Ercleve

Clinical context

  • Incidence of 3-5% in patients with acute pancreatitis, associated with increased mortality (30-40%) and increased risk of pseudocyst formation. [Surg Gynecol Obstet. 1984 Oct;159(4):343-7.]
  • CT scanning has helped to define the anatomic pathway by which extravasated pancreatic enzymes and their effects lead to these cutaneous discolorations. [Pancreas. 1998 May;16(4):551-5.]. Extraperitoneal diffusion from the anterior pararenal space between the two leaves of the posterior renal fascia; to the lateral edge of the quadratus lumborum muscle and may then extend to the posterior pararenal space and the structures of the flank wall. The lumbar triangle, a site of anatomic weakness on the flank wall, provides an external window into the internal proteolytic events.
  • In most described cases, it takes 3-5 days for Grey Turner sign to present and the sign been associated with a broad range of clinical conditions

CauseReference
Acute PancreatitisBosmann et al 2009
Bilateral acute salpingitis with IUPOrient JM, Sapira JD 2005
Ischemic and gangrenous bowelKelley ML 1961
Retroperitoneal necrotizing fasciitisPryor et al 2001
Ruptured abdominal aortic aneurysmArmour et al 1978
Rectus sheath hematomaGuthrie, Stanley 1996
Sclerosing peritonitisPryor et al 2001
Cardiac catheterizationArmour et al 1978
Intra-aortic balloon pump insertionRob, Williams 1961

Epperla N et al. A Review of Clinical Signs Related to Ecchymosis. WMJ • APRIL 2015

Stabler sign

Francis Edward Stabler (1902–1967) was an English gynaecologist and surgeon

Non-traumatic abdominal skin ecchymosis in the inguinal-pubic area associated with intra-abdominal haemorrhage, originally described in ectopic pregnancy – Stabler sign

Original publication: (n=1)

1934 – Stabler published a paper titled ‘A case showing Cullen’s sign‘ concerning a patient presenting with an ectopic pregnancy: with left illiac fossa pain of fourteen days duration and ilioinguinal ‘bruising’, 7 weeks post last menstrual period

Clinical examination

C.S. Aged 34:One inch below and to the left of the umbilicus was a purple, almost black, clearly cut mark 3/4 in. by 1/4 in. shaped like a comma. Below it, about the junction of the upper third and lower two-thirds of the distance from the umbilicus to the pubes, was a ” bruise,” bluish in colour, about 1 in. in diameter, whilst abutting on the inguinal fold was a reddish-purple mark like a fresh bruise, shaped roughly like the ace of clubs, about 2 in. in diameter. The whole was within the triangle formed by the midline and a line drawn to the umbilicus from the middle of the left inguinal ligament. On bimanual examination a soft mass the size of a hen’s egg was evident in the left tubal region.”

Operative findings

At operation the distal half of the left Fallopian tube contained an ampullary pregnancy surrounded by blood clot. The tube was not ruptured, but a little dark blood was oozing from the abdominal ostium. In the peritoneal cavity there were not more than 3 or 4oz (88-118mL) of dark fluid blood…incision into the subcutaneous fatty tissue proved the stains to be true ecchymoses.

Hypotheses

It is an interesting speculation as to how the blood reaches the subcutaneous tissues. In the present reported case I forecast that there would be an intraligamentary rupture of the tube with a broad ligament haematoma from which blood had tracked up extraperitoneally as far as the umbilicus, possibly following the obliterated hypogastric artery by which the lateral spread of the discoloration was limited.

Clinical context

  • Initially described as an inguinal-pubic extension of the peri-umbilical ecchymosis of Cullen sign
  • Further cases of bruising to the inguinal-pubic area reported with AAA rupture and acute hemorrhagic pancreatitis
  • Although rare, this sign has most commonly been identified in neonates secondary to adrenal hemorrhage. This is associated with obstetric injury, perinatal hypoxia, and sepsis [Urology. 2002 Apr;59(4):601]. Rarely, it may be due to ruptured neuroblastoma.

Fox sign

John Adrian Fox English surgeon

Non-traumatic ecchymosis over the upper outer aspect of the thigh. Ecchymosis is parallel with, but distal to the inguinal ligament with a well demarcated upper border defined by attachment of the membranous layer of the superficial fascia (Scarpa’s fascia). Originally described with retroperitoneal haemorrhage. – Fox Sign

Original publication: (n=2)

1966 – JA Fox (London) detailed 2 fatal cases of non-traumatic ecchymosis determined as a diagnostic sign of retroperitoneal haemorrhage. In both cases, this sign was noticed late in the course and produced by tracking of the fluid extraperitoneally along the fascia of psoas and iliacus beneath the inguinal ligament until it became subcutaneous in the upper thigh.

Case 1: Fourteen hours after admission bruising was noted in both upper outer thighs. It had a sharp upper margin, was dark blue, and was quite distinct from the patchy mottling of her legs below [Post mortem: acute suppurative pancreatitis]

Fox's Sign 1966

Case 2: A man, of about 50…with severe abdominal pain and circulatory collapse. Resuscitatory measures were of no avail and he died within 24 hours of admission. Before death bruising was noticed in the upper outer aspect of one thigh. He had not been given injections in this region and no other cause for the bruising was apparent. [Post-mortem: dissecting and ruptured abdominal aortic aneurysm]

Hypotheses

..seems likely that the clinical sign seen in the above 2 cases is produced by tracking of the fluid extraperitoneally along the fascia of psoas and iliacus beneath the inguinal ligament until it becomes subcutaneous in the upper thigh.

Cadaver Experiment: This sign has been reproduced in two stages in the recent cadaver. A solution of methylene blue in normal saline was injected from a height of 10 feet into the loin for several hours. The blue dye was then traced by dissection until it was seen to pass beneath the inguinal ligament”

Clinical context

  • Initially recorded in acute pancreatitis and ruptured aortic aneurysm
  • Subsequently described with strangulated ileum, urethral instrumentation, reaction to subcutaneous injections, and pulmonary infarction.

Bryant sign

John Henry Bryant (1867–1906) was an English physician

Scrotal ecchymosis associated with ruptured abdominal aortic aneurysm (AAA) – Bryant sign

Original publication: (n=1)

1903 – Bryant described scrotal ecchymosis associated with ruptured AAA during two lectures in which he had evaluated 18,678 necropsies and the 325 deaths secondary to abdominal aortic aneurysm rupture. [Clin Jour. 1903;23:71-80].

In these two articles Bryant describes the diffuse nature of the atheromatous changes, the possible clinical presentation of AAA as apparent renal colic, and the scrotal and abdominal discolourations as diagnostic clues

In one case blood was effused into the right spermatic cord, and the corresponding half of the scrotum was much ecchymosed…When blood is extravasated into the anterior abdominal wall ecchymoses may appear…‘ [Clin Jour. 1903;23:79]

Bryant sign

1987 – RM Ratzan et al proposed eponymous historical attribution of lower abdominal/scrotal discolouration secondary to aortic aneurysmal disease to John Henry Bryant. [J Emerg Med. 1987 Jul-Aug;5(4):323-9]

Clinical context

  • Bryant sign is rare.
  • Blood must transverse the inguinal canal and spermatic cord down to the subcutaneous scrotal tissue.
  • It requires specific pathological circumstances such as a closed (retroperitoneal hematoma) or sealed (surrounding retroperitoneal and aortic tissue) rupture of abdominal aortic aneurysm. It requires a slow rate of aneurysmal leakage and a prolonged interval prior to final rupture.
  • Most recorded cases of Bryant sign occur three to six days after onset of abdominal symptoms – Pearlman (1940), Barratt-Boyes (1957) and Beebe (1958).

Summary

The original publications of the eponymised cases often include careful clinical descriptions and anatomopathophysiological hypotheses in an era devoid of adjunctive diagnostic aids. However, we now have the benefit of comparing the diagnostic validity of the signs in a vast array of published clinical cases illuminated by enhanced imaging techniques and a more in-depth understanding of pathophysiology.

The original n=1 published cases represent a springboard for us to review arcane terminology by first understanding the historical folksonomy and then to redefine in clinical context to reduce descriptive confusion and narrowing of our diagnostic differentials.

For example, in 1918 Cullen described a single case of umbilical ecchymoses in a patient with an ectopic pregnancy. Over the subsequent 100 years at least 17 alternate diagnoses have been ascribed to the external abdominal manifestation of his eponymous sign.

Of significant note, the topographic location of atraumatic abdominal ecchymosis does not point to the aetiology with any degree of certainty and these signs may be potentiated by anticoagulation therapy or qualitative/quantitative platelet abnormalities.

Of course there is a certain historical interest in relating these signs to pioneers in descriptive medicine. However, we may be better to describe ‘non-traumatic abdominal wall ecchymosis’ as a potential sign of intraperitoneal or retroperitoneal pathology which requires further evaluation…

[…unless you enjoy a ‘down and dirty‘ eponym spat with the inpatient specialists? Then read on, and prepare your semantygdala for the symphonic cacophony of ‘I told you so...’]

References

Eponymythology: Atraumatic Abdominal Ecchymosis Mike Cadogan