Sesiones de los PAC: Taller de RCP en el paciente pediátrico

La imagen es de aqui
Hoy hemos celebrado el segundo de los talleres sobre RCP pediátrica programados dentro de nuestras sesiones mensuales de los PAC, el primero de ellos se llevó a cabo el pasado 13 de enero. Hay talleres que no fallan, que nunca defraudan y este es uno de ellos: por su importancia, por su buena organización y por la indiscutible calidad de sus docentes.
Han sido dos mañanas dedicadas a recordar los fundamentos de la RCP, en especial en la edad pediátrica; a la resolución de casos prácticos, a trabajar con el desfibrilador, el DEA, al manejo de la vía aérea...todo ello bajo la batuta de cuatro excelentes maestros. Nos queda el trabajo personal de revisar de vez en cuando la base teórica, tener los distintos algoritmos almacenados en el cerebro, y guardar la calma si se da el caso de tenerlos que poner en práctica.
Y desde aquí agradecer muy mucho el trabajo de nuestros compañeros: Aitor Arrese-Igor, Luis Moles, Coro Aristegi y Aitziber Barandiaran; contamos con vosotros para próximas ocasiones. Mila, mila esker!

Aprovechamos para avisaros que la próxima sesión a cargo de Raquel González, médica del PAC de Hernani, se celebrará el día 26 de febrero  a las 11 horas en el Colegio de Médicos. Raquel nos hablará sobre el diagnóstico de la apendicitis aguda. Os esperamos.


Sesiones de los PAC: Taller de RCP en el paciente pediátrico

La imagen es de aqui
Hoy hemos celebrado el segundo de los talleres sobre RCP pediátrica programados dentro de nuestras sesiones mensuales de los PAC, el primero de ellos se llevó a cabo el pasado 13 de enero. Hay talleres que no fallan, que nunca defraudan y este es uno de ellos: por su importancia, por su buena organización y por la indiscutible calidad de sus docentes.
Han sido dos mañanas dedicadas a recordar los fundamentos de la RCP, en especial en la edad pediátrica; a la resolución de casos prácticos, a trabajar con el desfibrilador, el DEA, al manejo de la vía aérea...todo ello bajo la batuta de cuatro excelentes maestros. Nos queda el trabajo personal de revisar de vez en cuando la base teórica, tener los distintos algoritmos almacenados en el cerebro, y guardar la calma si se da el caso de tenerlos que poner en práctica.
Y desde aquí agradecer muy mucho el trabajo de nuestros compañeros: Aitor Arrese-Igor, Luis Moles, Coro Aristegi y Aitziber Barandiaran; contamos con vosotros para próximas ocasiones. Mila, mila esker!

Aprovechamos para avisaros que la próxima sesión a cargo de Raquel González, médica del PAC de Hernani, se celebrará el día 26 de febrero  a las 11 horas en el Colegio de Médicos. Raquel nos hablará sobre el diagnóstico de la apendicitis aguda. Os esperamos.


LTC Podcast 1 – Chest Trauma

Podcast 1 Pic

In the first of my official LTC podcasts recorded live at the conference I interview Mr Doug West, Consultant Thoracic Surgeon at Bristol Royal Infirmary. During this interview we discuss his talk on surgical fixation of flail chests, finger thoracostomy, and the potential dangers of chest drains – yes, complications happen, and when they do, they can be bad – always proceed with caution!

For those who would like to review the literature yourselves I’ve included references below with links to the NICE guidelines for chest fixation(3) and the references for those(4).

While the concept of rib fixation isn’t new, with initial attempts dating back to the 1950s. There has been a recent move towards formal internal fixation of flail chests that is supported by evidence from several RCTs.

I include below a summary of the review of some of this literature by Leonie Walker, a 5th year medical student who recently completed a placement with the orthopaedic team who are performing rib fixation at Aintree University Hospital in Merseyside.

Tanaka et al 2002(1)

  • N = 37 patients with flail chest (> 6 ribs fractured)
  • Randomised 5 days post injury

o   18 to surgical stabilisation

o   19 to internal pneumatic stabilisation (positive pressure ventilation to stabilise the rib internally)

  • Surgical group had:

o   Fewer ICU days (mean 16.5 vs 26.8)

o   Fewer mechanical ventilation days (mean 10.8 vs 18.3)

o   Lower incidence of pneumonia at 21 days (22% vs 90%)

o   Fewer tracheostomies at 21 days (3 vs 15 patients)

o   Better return to full time work at 6 months (11/18 vs 1/19)

Granetzny et al. 2005(2)

  • N = 40 patients with flail chest (≥3 fractured ribs with paradoxical movement)
  • Randomised 24 hours after arrival to ICU

o   Group I – Conservative management with strapping and packing for 7-10 days.

o   Group II – Surgical fixation within 24-36 hours of ICU admission

  • Surgical group had:

o   Fewer ICU days (9.6 vs 14.6)

o   Fewer mechanical intervention days (2 vs 12)

o   Lower incidence of pneumonia (10% vs 50%)

o   Reduced hospital length of stay (11.7 vs 23.1 days)

o   Lower incidence of chest wall deformity

o   Better FVC at two months

There are several other studies used in the formulation of the NICE 2010 Guidance, and they are included by the NICE evidence summary(4).

As discussed in the podcast, the MTC at Aintree University Hospital has orthopaedic surgeons performing rib fixation, lead by Sharon Scott, Consultant Orthopaedic Surgeon & Clinical Lead for Trauma. Sharon has kindly provided me with a copy of their clinical guidelines for management of these patients which you can find in the appendix.

Author: David McCreary (@dmccreary85 / @FOAMedNW)

With thanks to: Leonie Walker, 5th Year Medical Student, University of Liverpool & Mrs. Sharon Scott, Consultant Orthopaedic Surgeon & Clinical Lead for Trauma, Aintree University Hospital, Merseyside

References 

1)    Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients… including commentary by Wilson RF. Journal of Trauma 2002;52(4):727-32.

2)    Granetzny A, Boseila A, El-Aal MA, Emam E, Shalaby A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interactive Cardiovascular and Thoracic Surgery 2005;4(6):583-7.

3)   https://www.nice.org.uk/guidance/ipg361/resources/guidance-insertion-of-metal-rib-reinforcements-to-stabilise-a-flail-chest-wall-pdf

4)   http://www.nice.org.uk/guidance/ipg361/evidence/insertion-of-metal-rib-reinforcements-to-stabilise-a-flail-chest-wall-overview2

Appendix One

Guidelines on Surgical Management of Rib Fractures at Aintree University Hospital

image

 

Thomboembolic events after cardioversion in afib

Clinical Scenario:
55 year old with past medical history of hypertension presents with sudden onset palpitations and chest pain that awoke him from sleep at midnight.  Patient presents 3 hours later with complaint of palpitations, chest pain, shortness of breath with stable vitals.  EKG demonstrates atrial fibrillation (a.fib).  Patient undergoes successful synchronized cardioversion.

Clinical Question:
In a patient who is electrically cardioverted within 48 hours of symptom onset of new atrial fibrillation, what is the incidence of thromboembolic complications?  Do you still have to anticoagulate?

Literature review:
Based on the Finnish CardioVersion Study, which included 2,481 patients who had a.fib for less than 48 hours and underwent cardioversion and were NOT started on oral anticoagulation nor peri-procedural heparin, there are certain groups who have higher risks for thromboembolic events.  Of the group as a whole, 0.7% (95% CI 0.5-1.0) had thromboembolic events within 30 days with a median of 2 days and mean of 4.6 days.  The three highest risk factors were female gender (OR 2.1 95% CI 1.1 to 4.0), heart failure (OR 2.9 95% CI 1.1 to 7.2), and diabetes (OR 2.3 with 95% CI 1.1 to 4.9).  Those with no heart failure who were younger than 60 years old had the lowest risk of thromboembolism (0.2%). 
Example of Afib


Additionally, when deciding between low molecular weight heparin or unfractionated heparin in cardioversion, based on the ACE trial (Anticoagulation in Cardioversion using Enoxaparin), there is no significant difference between the two with regard to embolic events, death, and bleeding complications.  This study included 428 people, and it was a randomized prospective multicenter trial.  Of the enoxaparin patients 7/216 vs. 12/212 heparin patients had primary end point incidents (p=0.016).

Take home points:
-Consider anticoagulation in patients who have heart failure/diabetes who must undergo electric cardioversion

-Low risk patients do not need anticoagulation when cardioverted within 48 hours of onset of a.fib
-No difference between enoxaparin or heparin

References:
1. Airaksinen KE, Grönberg T, Nuotio I, Nikkinen M, Ylitalo A, Biancari F, Hartikainen JE. Thromboembolic complications after cardioversion of acute atrial fibrillation: the FinCV (Finnish CardioVersion) study. J Am Coll Cardiol. 2013 Sep 24;62(13):1187-92.
2. Stellbrink C, Nixdorff U, Hofmann T, Lehmacher W, Daniel WG, Hanrath P, Geller C, Mügge A, Sehnert W, Schmidt-Lucke C, Schmidt-Lucke JA; ACE (Anticoagulation in Cardioversion using Enoxaparin) Study Group. Circulation. 2004 Mar 2;109(8):997-1003.


Submitted by Lydia Luangruangrong, PGY-3.
Edited by  Steven Hung (@DocHungER), PGY-2
Faculty reviewed by Doug Char

The Blind IJ Central Catheter

Co-authored by Andrew Ketterer & John Sarwark 

Co-authored by Andrew Ketterer & John Sarwark 

To today's young burgeoning emergency physicians, ultrasound guided internal jugular central catheters have more or less become standard of care.  And for good reason!  They are safe, and after a good amount of experience, quite easy to perform.

But technology has a tendency to break down. You might be working someplace that has only one ultrasound machine at its disposal, and just when you have a septic patient who could benefit from some central access and pressors, your probe stops working. You start to sweat, because while femoral access is easy, it has a limited lifespan infection-wise, its SvO2 readings will be inaccurate, and everyone will question your CVPs (though theoretically the water column of your central venous system should be the same pressure everywhere in a supine patient, and CVPs are useless anyway.

Well fear not, dear reader, because you too can be like those grizzled colleagues of ours who point out that in their day, every IJ central line was done blind.


First off, some basics are probably worth going over. The IJs lie parallel and lateral to the carotid arteries until the level of the clavicle, at which point they migrate medially to overlie the carotid. Obviously, differences will exist between patients, but this is a good rule of thumb to start with.

It will be worth your time to maneuver to give yourself the biggest possible target, especially if you’re doing this blind. In most people, the right IJ is slightly larger than the left owing to its more direct connection to the RA. For this reason, and also because your catheter will have a more direct path to the SVC-RA junction, the right IJ is preferred.

You will also want to give yourself a little Trendelenberg (assuming, of course, your patient isn’t at too high a risk for aspiration). This will use gravity to force some blood back into the IJ and make your target even bigger.


  Approach to the Internal Jugular Vein. Click image to enlarge. 

Approach to the Internal Jugular Vein. Click image to enlarge. 

 

You can access the IJ anteriorly, centrally, or posteriorly. These refer to your entry point in front of, at the bifurcation of, or behind the sternocleidomastoid muscle, who will be your best friend for this procedure.

The Anterior Approach

The Anterior Approach

The anterior approach is probably most user-friendly, since at this spot the carotid artery is most easily palpated, and can be retracted by your non-needle-bearing hand. Place one hand on the carotid, and insert your needle at an angle of 30-45° to the skin on the anterior edge of the SCM about 2-3 fingerbreaths above the clavicle. Aim the point of your needle toward the ipsilateral nipple. Be advised that statistically, this approach has the highest likelihood of hitting the carotid.

The Central Approach

The Central Approach

The central approach is the most commonly used. Find the bifurcation of the SCM muscle and insert your needle just caudal to its apex at a 30° angle, aiming toward the ipsilateral nipple. The IJ will often be a little more lateral than you expect with this approach, and can move around depending on how much your patient’s head is turned. This approach does have the highest likelihood of causing a pneumothorax, so if you don’t get blood within 3 cm or so, don’t keep advancing your needle.

The Posterior Approach

The Posterior Approach

Finally, the posterior approach is probably the hardest landmark-wise, but it carries the lowest likelihood of complications. Find the posterior border of the SCM muscle, and insert your needle about halfway up the muscle at an angle of 45°, with the point aimed toward the sternal notch. Make sure to lift the body of the SCM out of the way as you advance, and wave at the EJ as you pass by. Blood should come out around 5cm in most people.


The official New England Journal of Medicine video on IJ placement is largely ultrasound driven, but they do have some pretty impressive graphics regarding positioning in an ultrasonographically poor world.

  

Scott Weingart has a demonstration on the EMCrit blog:

  

This is just part of a fantastic piece on central lines that can be found here.  I highly suggest you check it out. See our post on ultrasound guided central lines here

Just as always, these posts are meant for EDUCATIONAL PURPOSES ONLY.  Are you still only comfortable with doing these with a probe?  Maybe you should go practice on a model first.

Stay tuned, folks--Procedures Club Videos are coming to a website near you!

jps & ak



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Sources:

  • Roberts and Hedges' Clinical Procedures in Emergency Medicine.  Chapter 22
  • New England Journal of Medicine Videos in Clinical Medicine
  • EMCrit.org
  • Life in the Fast Lane Website, Central Venous Catheters

Take home points from an HMIMMS course

Before christmas I finally got another one of the alphabet courses under my belt – The Hospital Major Incident Medical Management & Support course. Or HMIMMS for short.

To be perfectly frank major incidents weren’t exactly on my radar – I like to describe emergency medicine in Ireland as one long protracted major incident so there’s a little bit of incredulity involved in actually planning for some major disaster when we can’t even manage the day to day.

Having done the course I now see why it’s considered as mandatory for training in emergency medicine. Emergency physicians will always be front and central in such scenarios, and the more senior you are the more important the management bits will be. The clinical stuff is easy but making sure your patients and staff get to where they need to be is a whole different story.

The table top exercises are some kind of cross between Monopoly and Settlers of Catan so it allows to unleash your inner geek a bit too.

Below are a few scribbled notes I took during the course and from reading the manual (which of course @EMManchester is an author of… that guy gets everywhere…)

Major incident

  • events that owing to the number, severity, type or location of live casualties require special arrangements to be made by the health services.
  • can also be put as “major incidents occur when the resources available are unable to cope with the workload from the incident”
  • A major incident can remain “uncompensated” when still unable to manage despite mobilisation of additional resources

7 main principles (abbreviated as the fairly unpronounceable CSCATTT)

  1. command
  2. safety
  3. communication
  4. assessment
  5. triage
  6. treatment
  7. transport

Phases of a major incident

  • pre hospital
  • reception
  • definitive care
  • recovery

The Collapsible Heirarchy

  • still not sure if i like the term
  • refers to the system used to delegate staff
  • roles can be coloured red yellow green in order of importance
  • some folk may fill multiple roles until further help arrives
    • for example at 2am the only surgical doctor in the hospital may be the poor surgical SHO who will assume the role of “senior surgeon” (in charge of entire surgical response) until someone more senior arrives and the SHO can go and change his underwear, or perhaps even his career.

Essential clinical roles that need filled ASAP

  • medical coordinator
  • senior EP
  • senior MLSO(lab)
  • senior surgeon
  • senior physician (often overlooked as we assume all major incidents are traumatic when they’re not – they can be toxicological or environmental

Triage

  • the most important thing is that the expectant cases are low down the list. A resuscitative thoracotomy may not be appropriate when your resources are over stretched
  • start with a triage sieve, so simple you don’t need to be clinical to use it. For example if you can walk then you’re immediately a lower priority.
  • a triage sort is a bit more detailed that involves some physiologic variables (GCS, HR, RR) to determine your level of priority (which is essentially which physical space you are assigned to in the ED).

There are some specific Irish documents available online looking at this in the Irish context. Your hospital will of course have it’s own major incident plan. it is no doubt dusty and out of date somewhere…

[Featured Image: Nuclear Explosion – Wikimedia Commons, CC License]

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