Conference Notes 4-23-2013
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Patel M & M
Pt with pneumonia, sepsis and hypotension. Central line placed for management of hypotension.
Central line was placed in carotid artery. This was not identified until pt went to ICU. Initial CXR reading did not identify misplacement. CXR image was not visualized by ED physicians, only the report was reviewed.
CVP complications range from 5-19%. Femoral lines tend to have a higher rate of mechanical complications (arterial puncture, malposition of catheter) than IJ and SC lines. IJ and SC lines have similar complication rates (arterial puncture, malposition of catheter, pneumothorax). Infectious complications are thought to be higher in femoral lines but there is some controversy about this.
5 steps to Reduce infections of central lines: hand hygiene, chlorhexidine prep, barrier precautions/sterile gloves,gown,drape,mask, avoid femoral approach, and remove lines as soon as no longer needed.
Identifying venous vs arterial line placement: color of blood and pulsatile flow are non-sensitive and non-specific especially when patients are septic/hypoxic/hypotensive. Pressure transducer is a much more accurate way of identifying arterial flow but it is harder to do. An easier trick is to hook up an iv line flushed with saline and connected to a liter bag to the catheter and hold it vertically over the chest. If the column of blood reaches 10cm above the patient's chest, it is likely arterial. Another option is to do an ABG of the blood from the line. Elise comment: ABG is a fast and accurate way to identify arterial placement of a central line.
U/S guidance has significantly lowered the incidence of arterial sticks. However arterial puncture may be missed on a short axis view. A long axis view may improve your ability to identify arterial puncture or the needle passing thru the back wall of the IJ. (Blaivas study 2009)
The operator needs to personally visualize the radiology images after all procedures.
Elise comment: If unsure of location of line, replace the wire and shoot a quick cxr to confirm location prior to dilating the passage. Barounis comments: U/S can help you see where the wire and line is located. If you inject 10ml of saline through the line with an U/S probe on the heart you should see a “splash” in the right atrium on U/S. Recent research has suggested that Infectious complications and DVT are not more common in femoral lines. Harwood comment: The most common problem is that the needle passes through the IJ into the carotid. He has also seen an uncommon location for a central line, the azygos vein.
Central line in the azygos vein.
Fort Trauma Lecture
23yo female transferred to ACMC following a T-strike MVC. Pt was hypotensive and had a pelvic fracture that is bleeding out through a wound in the vagina. Harwood comment: If you are working in a non-level 1 hospital and a patient has a pelvic fracture always transfer that patient. All trauma centers will accept pelvic fractures.
Massive transfusion protocol initiated and pelvic binding applied.
Salzman comments: Patient is unstable. Vaginal bleeding is a big problem. FAST scan is critical in this situation. There is a high incidence of bladder and urethral injuries with pelvic fractures. Steve felt that you can make a case for gentle placement of a foley in a male patient with blood at the meatus prior to doing a urethrogram. If you hit any resistance stop attempt. Girzadas comment: I would do a urethrogram prior to placing a foley in a patient with suspected pelvic fracture and blood at the meatus. Female patients are a different story. There is less risk of urethral injury due to shorter urethra.
Salzman comments: Vaginal laceration makes it harder to control pelvic fracture bleeding. Binding the pelvis decreases the pelvic volume (potential space for bleeding) but with a laceration you can’t easily decrease the potential space the patient can bleed into. Pelvic binding needs to encircle the iliac crests. For IV access in a trauma resuscitation, triple lumens are bad, they do not provide large volume infusion capacity. Nothing beats a 14g angio in the antecubital fossa (short and large guage catheters have the highest flow rates). Cordis is next best. IO may also have value but flow rates are alittle slower than large bore iv's or cordis. FAST scan is important to identify significant intra-abdominal bleeding as a cause of shock vs. shock from pelvic fracture. Key Decision is does patient go to OR first or IR first? She will eventually need to go to both. No role for CT scanning in the unstable pt with a pelvic fracture. If FAST shows intraperitoneal blood, pt will go to OR first and IR second.
Harwood comment: Pt should be intubated prior to going to IR or OR or if being transferred.
Xray shows bad ass pelvic fracture with diastasis of the pubic symphasis and left SI joint widening. FAST showed no intraperitoneal blood.
Resident comments: Give TXA in this situation. Salzman agreed and said patient needs to go to IR.
Salzman comment: If you decided to do a DPL, use a supraumbilical and open approach. If you initially aspirate blood, you know the injury is intraperitoneal and you are going to the OR. IF no blood on aspiration, you are going to IR for the pelvic fracture.
IR embolization of pelvic arteries was performed.
Cystogram after patient is stable. Instill 300ml of contrast under gravity into the bladder prior to getting images.
Pt had ORIF of pelvis. Pt had repair of vaginal wound.
Morel-Lavellee Lesion: proximal thigh ecchymoses associated with severe pelvic or lower extremity trauma increases risk of infection of pelvic fracture.
They typically occur as a result of the skin and subcutaneous fatty tissue abruptly separating from the underlying fascia.The initial injury represents a shearing of subcutaneous tissues away from underlying fascia. The initial potential space created superficial to the fascia is filled by fluid of variable make up ranging from serous fluid to frank blood. The collection may then spontaneously resolve, or become encapsulated and persistent. It classically occurs over the greater trochanter of the femur 1. Although strictly speaking a Morel Lavallée lesion is only over the greater trochanter, similar biomechanical forces to the lumbar region, over the scapula or the knee can result in identical lesions 1,3. (Radiopedia.org)
Morel -Lavellee Lesion R hip on CT
Morel-Lavellee lesion left hip Clinically
Bottom line: Pelvic fracture with hemodynamic instability: bind pelvis/do FAST/resuscitate with fluids and blood/plasma/platelets. If FAST is positive go to OR. IF fast is negative go to IR. Pelvic fracture that is hemodynamically stable: Go to CT and may need IR. Harwood/Elise comment: If you are in a non-Trauma Center ED, transfer the unstable pt with a pelvic fracture out of your ED ASAP. Start PRBC’s/FFP/Platelets ASAP for the hemodynamically unstable pt with a pelvic fracture. Intubate early as well.
Collander/Williamson Oral Boards
Case 1 TCA overdose Critical Actions: Assess airway, IV fluid, identify overdose and substance, treat with IV bicarb, admit to ICU. EKG showed wide terminal R wave in AVR and QRS widening diffusely which are classic findings for TCA overdose. Pt also had signs of anticholinergic toxidrome.
EKG of TCA Overdose. Note R wave is wide and tall in AVR. Also QRS is widened in all leads
Case2 AAA Critical Actions: Recognize shock, use U/S to identify AAA, start resuscitation with IV fluids and PRBC’s, consult vascular service for emergent surgery. AAA more common in older men who are smokers.
Case 3 Chemical Exposure(dishwasher soap) to Eye of child Critical Actions: Irrigate the eye, check visual acuity after irrigation, check ph after irrigation, consult opthalmology. Andrea Carlson comment: If a child orally ingest dishwasher or clothing detergent, it can cause severe respiratory injury or gi injury. These are strong alkali’s.
McKean CPC Presentation
Williamson CPC Presentation
Kettaneh Ketamine for Continuous Sedation ICEP Research Presentation
Dissociative agent that provides sedation and analgesia. Preserves respiratory reflexes/breathing.
Side effects include: emergence phenomenon, salivation and bronchorea, used to be thought to increase ICP but this has been called into question.
Retrospective study at ACMC. Enrolled patients admitted from the ED to the ICU. This was an overall sick/hypotnesive group of patients. Ketamine was used in the ED and ICU for continuous sedation.
Don’t want to give away all the data prior to presentation but bottom line: Average dose of 2mg/kg/hour. It worked well. Patients were generally well sedated. There were 2 cases of agitation requiring a change to benzos. There were 2 cases of afib that may or may not have been due to ketamine. Amazingly this is the first study to assess ketamine as an agent for continuous ICU sedation.