Beta-blockade early in the course of myocardial infarction was once fashionable – until COMMIT demonstrated an excess of early cardiogenic shock detracting from subsequent late, favorable effects. This led to beta-blockade initiation being deferred until after hemodynamic stability established.
This study, METOCARD-CNIC, is a trial of early intravenous metoprolol prior to primary PCI in patients with anterior STEMI. 270 patients were randomized over two years to receive IV metoprolol pre-reperfusion versus standard initiation following PCI. These two publications describe a surrogate outcome based on infarct size seen in follow-up MRI, and patient-oriented outcomes of 2-year MACE and heart failure progression. And, overall, it’s a good thing – infarct size at 1 week was reduced from 32.0 to 25.6 grams, and long-term MACE at median 2-year follow up was reduced from 18.3% to 10.8%.
However, long-term MRI follow-up at twelve months showed infarcted myocardium measured at 15.7 grams in the intervention group versus 18.2 grams in the control – no longer statistically significant. And, the patient-oriented outcome of MACE is a combined endpoint of death, heart failure admission, reinfarction, and malignant arrhythmias – with most of the separation in groups coming from heart failure admissions and malignant arrhythmias, as opposed to hard endpoints.
But, at the minimum, this is worth continuing to investigate. There are likely patients, such as this anterior STEMI cohort, with Killip Class II or lower at presentation, that reasonably have a greater chance of benefit than harm from early metoprolol. This is also quite small study – but taken in the context of the prior evidence, an argument could be made to cautiously re-introduce this treatment strategy, ideally as part of prospective investigation.
A 16-year-old football player presents to the emergency department directly from a game. He was tackled, falling onto his right shoulder. The patient is complaining of right-sided chest pain. On exam, there is tenderness over the right sternoclavicular joint (SCJ) with a prominent medial clavicle. Range of motion is limited in the right arm. What diagnostic studies need to be performed? What treatment is warranted in the emergency department?
Sternoclavicular Joint Dislocations
SCJ injuries are generally rare. However, due to the increasing amount of contact sports being played, emergency physicians must be aware of how to diagnose and treat these injuries.
The SCJ serves as an important fulcrum for movement of the shoulder girdle. It is the only true articular attachment of the upper extremity to the axial skeleton. Dislocations account for only 3% of all dislocations around the shoulder .
The clavicle is the first bone to ossify, but the medial physis is the last fuse, typically between the ages of 23-25 years of age . The medial clavicle sits in a shallow, saddle joint with the superomedial manubrium. The joint requires the subclavius muscle and four separate ligaments for stability . There is an intraarticular fibrocartilanginous disc between the clavicle and the manubrium, which is analogous to the meniscus of the knee . Instability of the joint may be acute, recurrent, or persistent. Displacement can be directed in an anterior, posterior, superior, or inferior direction.
Mechanism of Injury
Dislocations typically are the result of a motor vehicle collision or a sports-related injury. Anterior dislocations are more common that posterior dislocations, but the posterior dislocation is the more concerning injury of the two with a mortality of 3-4% . This is true for two reasons [1,3]:
The force required for a posterior dislocation is 1.5 times that of an anterior dislocation.
There is a greater chance (about 30%) of damaging underlying structures, including the brachial plexus, vascular structures, trachea, and esophagus.
Anterior dislocations are the result of a force directed on the shoulder while the arm is held in the abducted position. Posterior dislocations can result from two different mechanisms. First, a medially directed force to the shoulder with the arm adducted and flexed can cause a posterior dislocation. Alternatively, a direct blow to the anteromedial aspect of the clavicle can cause a posterior dislocation.
The examination of the patient with a potential SCJ injury should be completed in the seated or standing position. Supine positioning may exacerbate severe pain, as may arm motion. The patient will have localized pain and swelling to the joint. Many times the arm will be held across the chest to minimize glenohumeral and scapulothoracic movement. Anterior dislocations will often have a prominent lump from the dislocated medial clavicle. Differentiating the anterior SCJ dislocation from a fracture of the medial clavicle can be challenging. A posterior dislocation can be quite subtle. There may be depression over the SCJ. Associated symptoms such as stridor, dysphagia or shortness of breath indicate compression of the trachea or esophagus, requiring urgent reduction.
Standard antero-posterior radiographs may be difficulty to interpret due to the confluence of other bony structures. However, a chest x-ray should be performed to exclude other pathology, including pneumothorax, pneumomediastinum, or hemopneumothorax. The addition of the Serendipity view (40 degree cephalic tilt) allows visualization of a SCJ dislocation on plain radiographs . CT has superseded plain films in the diagnosis of SCJ dislocations. CT provides a definitive diagnosis and shows the dislocation in relation to the underlying mediastinal structures.
The goals of treatment are:
Provide adequate pain control
Reduce or immobilize joint
Address associated injuries
Arrange appropriate referral
Potential complications of SCJ injuries include:
Reduction of dislocations can be done either closed or open. Indications for early surgical intervention include failure of closed reduction and any sign of neurovascular compromise .
Closed Reduction Technique of Anterior Dislocation
Acute dislocations (within 7-10 days) are amenable to closed manipulation under procedural sedation in the ED or in the operating room. A bolster should be placed between the scapulae of a supine patient. Traction should be applied to the abducted ipsilateral arm. Pressure is then applied to the medial clavicle. With successful reduction, sling support with scapular protraction should be provided for up to 4 weeks. It is important to remember that there is a greater than 50% rate of repeat dislocation.
Closed Reduction Technique of Posterior Dislocation
Closed reduction of a posterior dislocation is indicated within 10 days of injury. After 10 days, open reduction in the operating room is recommended . There are multiple methods for reducing a posterior dislocation in the literature.
Probably the most well known is the technique of using a towel clip to grasp the medial clavicle and pulling anteriorly until reduction is complete. There is also the abduction-traction technique, where the ipsilateral arm is abducted to ninety degrees and traction is applied. This extension force may translate the medial clavicle anteriorly .
Deren et al. described another method which involved extending the ipsilateral arm and abducting it with traction applied. Anterior-posterior pressure is then applied to both shoulders, over the glenohumeral joints . No matter the technique used, a figure of eight splint is recommended for 6 weeks to encourage scapular retraction. Also, some authors recommend that all posterior SCJ dislocations should be admitted for observation, due to the close proximity of vital structures .
You suspect an anterior SCJ dislocation based on the history and physical exam in this football player. You obtain a CT scan of the chest, which confirms the diagnosis. After obtaining consent and under procedural sedation, you easily reduce the dislocation. The patient is placed in a sling and follow up is arranged with orthopedics.
Clinical Bottom Line
Traumatic dislocations of the SCJ are rare, but with increased involvement in contact sports, these injuries will be seen in the ED. Maintain a high clinical suspicion for these injuries, given the proper mechanism. Also be on the look out for associated injuries for posterior dislocations. Reduction can be completed in the ED with subsequent immobilization and orthopedic referral.
Sewell MD et al. Instability of the sternoclavicular joint: current concepts in classification, treatment, and outcomes. Bone Joint J 2013; 95-B: 721-31. PMID: 23723264
Deren ME et al. Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury. Orthopedic Reviews 2014; 6: 5245. PMID: 24744842
Balcik BJ et al. Evaluation and treatment of sternoclavicular, clavicular, and acromioclavicular injuries. Prim Care Clin Office Pract 40 (2013): 911-923. PMID: 24209725
Matt Astin, MD
ALiEM Guest Contributor
Clinical Assistant Professor of Emergency/Internal Medicine
Mercer University School of Medicine
Houston Medical Center (Warner Robins, GA)
Sono perplesso. Il quadro non mi è famigliare: non ho mai assistito ad una presentazione così rapida. Tutto sta accadendo ad una persona sana e in un breve arco temporale dall’esordio dei sintomi. Tuttavia è proprio l’evoluzione così rapida che non consente molte dilazioni per arrovellarsi sulla causa. La saturazione è ballerina e sopratutto la CO2 è in […]
The phrase “critical illness does not respect geography” is often quoted, reflecting the fact that mishap can affect anyone, anytime, anywhere.
We are lucky to have excellent tertiary level emergency departments & intensive care units in Australia to deliver specialist care. Developments such as FOAMed help to narrow the knowledge-translation gap from publication to practice. Furthermore, the widespread dissemination of information via asynchronous learning (such as slide sets, podcasts, videos hosted on websites, or corridor conversations via twitter) means that geographical isolation alone is no excuse for the rural clinician to be the ‘weak link’ in provision of care.
But Australia is a vast continent – making the provision of immediate care problematic in the more rural & remote areas. Certainly we have excellent prehospital & retrieval services; but although road and rotary-wing responses are rapid, they are limited in timely response when distances are large. The sheer size of Australia means that even responses by fixed-wing aircraft may take hours to arrive. My job as a rural doctor is to deal with ‘anything & everything’. We offer primary care as a core skill, along with a smattering of emergency care. Many rural doctors have advanced skills in obstetrics, anaesthetics and surgery. ACRRM considers involvement in local disasters and emergencies as part of the rural doctor primary curriculum skill set. It makes sense that the doctors with ongoing exposure to resuscitation & airway management (typically rural GP-anaesthetists) are called when there is a rural emergency.
But is the involvement of rural doctors a good thing?
Perhaps not. The experts in delivery of prehospital care are those with specific training and resources – classically State-based ambulance services, supported by services with retrieval expertise (eg: RFDS, CareFlight, HEMS, medSTAR etc). As a hypothetical, I think that if I was involved in a vehicle rollover, I would want to be looked after by the experts, not an ‘enthusiastic amateur’ GP.
So there is the dilemma. The further from a tertiary centre, the longer it will take for retrieval services to arrive. The more remote you are, the more likely that ambulance responders will be unpaid volunteers, not career intensive-care level paramedics…and the more likely that local clinicians will need to be involved in care.
A 2012 survey of rural GP-anaesthetists surprised me; just under 60% of responders stated that they had been involved in some form of pre-hospital incident in the previous 12 months. However of those responding, very few had training in prehospital care, very few had equipment to deliver care and most were tasked to the scene in an ad hoc manner (no formal call out criteria). As a consequence, the quality of responder on scene is highly variable – you may get a senior rural doctor with regular exposure to advanced airway management…or you may get a relatively inexperienced GP with very little emergency experience, let alone skills useful to prehospital care.
I can certainly empathise with the notion of ‘no room for enthusiastic amateurs, leave it to the experts’. Yet interestingly, the request for rural clinicians to attend such incidents came from the experts in prehospital care – ambulance comms and retrieval coordinators, usually because of the severity of the incident and dearth of readily available resources.
There are several systems worldwide aimed to deliver immediate care when and where needed.
At a basic level, community first responder schemes such as PulsePoint and GoodSAM (smartphone activated medics) allow crowd-sourced delivery of basic life support to patients even before ambulance services arrive. Responders are typically volunteers, with senior first aid, paramedic, nursing or medical qualifications who are prepared to respond if an incident (cardiac arrest, impact brain apnoea) happens in the immediate vicinity. Activation is via the GPS in smartphones.
At the top end of prehospital care are ambulance and retrieval services, with trained teams, dedicated equipment and service delivery aimed solely at best practice.
Somewhere in-between are systems integrate appropriately-trained volunteers to support ambulance services and deliver care before retrieval services arrive. Examples include the UK BASICS (British Association of Immediate Care Schemes) and NZ’s PRIME (Primary Response in Medical Emergencies). Responders are typically nurse or doctor, with high-level resuscitation skills (typically rural GP, emergency physician, intensivist). They are tasked under defined activation criteria and are trained, equipped and audited. UK BASICS are generally unpaid and work is taken on additional to NHS duties; PRIME is paid.
South Australia has an embryonic scheme, RERN (Rural Emergency Responder Network), utilising experienced rural doctors to respond to prehospital incidents in their community, only when attendance of a doctor will ‘value add’. This can be useful where local ambulance responders are volunteers, when local expertise (career paramedic) resources are overwhelmed and/or when arrival of specialist retrieval services will take some time. As such RERN responders are equipped with standard prehospital equipment, undertake ongoing training and case audit. Participation (and indeed attendance) is voluntary; remuneration is on a fee-for-service basis. You can download a presentation from Dr Peter Joyner here or watch a youtube video from CountryHealthSA featuring medSTAR’s Bill Griggs on the RERN model here.
Some other States have standardised Hospital ‘emergency bags’ for use in a disaster (such as Western Australia’s Parry Pack); yet no formal training for their use or clinician involvement in such incidents. NSW is leading the way with not just standardised equipment bags but also open-access training for rural clinicians.
So is the BASICS-PRIME-RERN model one which could be applied elsewhere in rural Australia? I think so, but only in certain locations and in certain circumstances. Clearly the ethos of rural doctors responding to local emergencies is congruent with that of ACRRM. Historically rural doctors were called as default; this has (sensibly in my opinion) been superseded by delivery of specialist care via ambulance or retrieval services, offering a far higher level of care. Yet rural doctors are still being called, often by the same experts!
To continue with ad hoc responses by whichever local GP is available is nonsensical, especially without appropriate training and equipment. Equally to ignore the fact that many rural doctors have ongoing experience in initial emergency management and airway skills via work in local hospital ED and Theatre may deny rural patients access to lifesaving skills. Of course one has to be mindful that experience in the Operating Theatre or ED does not translate to the roadside and the experts remain paramedics and retrievalists…when available.
Other countries recognise the fact that there is a therapeutic vacuum between initial incident and arrival of retrieval services; that geographically-constrained countries such as the UK and NZ have these systems and yet Australia does not is puzzling, especially when considering the tyranny of distance and unique skill set of Australian rural clinicians.
Take the Survey
What do you think? The link below is to a survey which will go to rural doctors registered with ACRRM and the RDAA; however it would be good to get feedback from a wider cohort – from established retrievalists, from paramedics, from nurses – in fact, ANYONE who is involved in critical care.
As Karel Habig said at smaccc2013: “Good critical care is good critical care, wherever you are.”
I think it would be good to ensure systems to deliver appropriate care where gaps exist. But it has to be something that rural doctors are prepared to engage in – and has to be embraced by other services.
To put it bluntly, either we include rural clinicians in the system or we do not. The latter may be ideal from a metrocentric perspective, insistent on gold-standard specialist-lead prehospital care. This is the service I would want as a rural patient! But a pragmatic approach recognises that there will be temporary service gaps due to distance or lack of available personnel and that plugging these gaps already involves rural clinicians – yet in an unstructured, unequipped and untrained manner.
I reckon that we can and should do better than that in Australia.
recognise that rural clinicians are already being called to attend prehospital incidents; ensure that such responses are by trained/equipped/audited responders, not ad hoc
utilise those rural clinicians with ongoing experience in trauma, emergency medicine and anaesthesia, who maintain skills through regular exposure in hopsital ED and Theatre
task rural clinicians only when their presence will ‘value add’ to the prehospital scene eg: IV access, ketamine for extrication, needle/finger/tube thoracostomy, prehospital airway management
establishment of State or Nationwide cadre of rural responders may provide extra resilience in case of disaster eg: earthquake, bushfire, flooding [and may be acceptable to existing State-based agencies]
prehospital environment is very different to hospital; requires skills best delivered by ambulance and specialist retrieval services, not amateurs
presence of a rural clinician may not value add (local GP arriving in boardshorts and thongs with no kit/training is worse than useless), detract from delivery of care by local resources
potentially high cost to equip and activate responders (PPE, prehospital kit, pagers etc)
relative infrequency of incidents carries risk of skill fade