sinaiem.org

I wanted to add some pearls from Dr. Strayer on Anita’s case from today:

* The literature and expert consensus have evolved over the past decade to favor anticoagulation for below the knee (distal or calf) DVTs. The classic teaching has been that distal DVTs are benign, so ultrasonographers often do not routinely evaluate the calf veins. Because this is no longer thought to be true, consider requesting calf vein assessment if you are suspicious.

* The finding of superficial venous thrombosis warrants a search for DVT. The treatment of superficial vein thrombosis is controversial and ranges from NSAIDs to compression stockings to anticoagulation. There is no consensus on treatment–the key EM issue is to rule out DVT.

* Patients who are moderate or high risk for DVT should be anticoagulated while awaiting ultrasound. If a DVT precipitant is not clear, consider calling hematology to inquire about hypercoaguable state labs to send before administering heparin.

* Many patients with DVT are optimally managed as an outpatient with daily LMWH shots. Visiting nursing services can help.

* Our interface with outside referring physicians is complex, and navigating their requests is fraught with pitfalls. If you don’t agree with their plan, the best course of action is usually an attempt to harmonize over the phone.

Wise words.

We began the new year with Dr. Shearer explaining the program’s policies & procedures. You can find copies under the ‘Policies’ tab above. As for logging procedures, duty hours, presentations and evaluations, use the New Innovations link under the ‘Clinical’ tab.

Our first talk of the year was given by Ram, who lectured on penetrating chest trauma. Below are some points that merit repeating:

• - Unstable patients with stab wounds to ‘the box’  are either hypovolemic, have PTX, or tamponade. So get some blood ordered and get an ultrasound probe.
• - Pericardiocentesis is a pretty cool procedure that has almost no role in trauma at academic centers. The volume of blood that causes tamponade physiology is scant in trauma, and even if you can aspirate that blood, it will rapidly reaccumulate. For medical effusions, pericardiocentesis can be more easily done by ultrasound guidance — I refer the reader to p76 of Dr. Nelson’s ultrasound book, or to Dr. Hoffman’s website.
• - Ram pulled a great slide from Degiannis 2006 (PMID 16773259, figure 1) that lays out your options in penetrating cardiac trauma in various clinical scenarios. After PTX has been ruled out, the lifeless patient needs endotracheal intubation and ER thoracotomy. Accept it, and it will be easier to cut. Dr. Weingart has reviewed this procedure on his website, and he has also listed other indications and contraindications for thoracotomy.

Dr. Rabin delivered her core lecture on emergencies in malignancy.

• - Neutropenic fever is defined as an absolute neutrophil count below 500 and a temperature of 38.4C (or over 38C for more than an hour). Calculating ANC is easy (this calculator and others can be found under the ‘Clinical’ tab above). The admonition to avoid rectal temps in neutropenic adults is not evidence-based, though digital rectal exams remain contraindicated.
• - Work with the patient’s oncologist in deciding ABx therapy in neutropenic patients. Vancomycin should be avoided unless indicated by cultures, course or instability.
• - Be vigilant for tumor lysis syndrome: Order a uric acid and PO4 level on your chemo patients with nonspecific symptoms. Obviously you’ll get a potassium and treat hyper-K appropriately (perhaps avoiding Ca++ unless absolutely necessary) but the urate will need urine alkalinization, and high PO4 gets phosphate binders, plus insulin+glucose.
• - Hypercalcemia (stones, moans, bones, psych overtones) needs treatment if the patient is symptomatic or over 14 mEq. Correct the calcium if the patient’s hypoalbuminemic. Treat with hydration, lasix (after hydration), bisphosphonates, and dialyze if AMS or ARF.
• - Finally, be vigilant for DVT/PE, SVC, and spinal cord mets (said to manifest with back pain that’s worse upon lying down).

Dan presented the first (and second) M+M of the year. He gave a nice introduction to the various kinds of error we are prone to, and how cheese is the answer.

• - Dan also took us through the crash airway, difficulty airway, and failed airway algorithms (you should have a copy of Ron Walls’ book, and parts are freely available online).
• - Like our reluctance with thoracotomy, cricothyroidotomy is something we have to expect, so that it’s easier to cut when we have to. Here’s the NEJM cricothyroidotomy video. Youtube has other videos. And for the hardcore among you, here’s a keychain cric kit I once blogged about.
• - While we can recognize the importance of neuro status checks for our colleagues in neurosurgery, sedating intubated patients is crucial, especially with more planned trips to the CT scanner. The agent of choice? Propofol (the milk of oblivion — rapid on, rapid off, and recommended by the BTF for ICP control). And if propofol is lowering the BP, well, this is one time where pressors in trauma makes sense.

If you want to address some of the topics above, or other aspects from conference, please comment below.

Drs. Nelson, Baumlin and Basavaraju wrote up an interesting case that was featured in the Correspondence section of the September 2006 Annals of Emergency Medicine (Vol. 48, No. 3, pp339-340). The letter was titled, Sonographic Diagnosis of Axillary Artery Aneurysm Presenting As Painful Axillary Mass and features some vivid photos. The summary is excerpted below:

Although the assessment of abdominal aortic aneurysms has long been a standard indication for bedside ultrasound, this case represents a previously unreported presentation (possible abscess) of a rare condition (axillary artery aneurysm). In this case, rapid assessment using bedside ultrasonography was able to unequivocally exclude abscess from the differential diagnosis, and allow the proper consultants to become involved earlier in the course of the ED visit. Furthermore, identification of the axillary artery aneurysm led to obtaining a computed tomography scan which revealed a larger and potentially lethal aortic aneurysm. Although it is unlikely that an emergency physician would have attempted to incise and drain a pulsatile “abscess,” it is useful to distinguish a mass impinging on a vessel from a mass which is a vessel.

Incidentally, the letter to Annals immediately following this one is from a former classmate. It is indeed a small EM world.