Asking patients to fill up their history. Interesting idea to cut time and error.
Reference - Witting MD, et al. Emergency Department Medication History Taking: Current Inefficiency and Potential for a Self-Administered Form. J Emerg Med. 2013 Apr 17.
Link - http://www.ncbi.nlm.nih.gov/m/pubmed/23602792/
Diagnostic Imaging Pathways
When deciding on the best radiological investigation it is nice to have a flowchart on which to base your decision-making process. The Diagnostic Imaging Pathways project is a constantly reviewed, literature-based website that fits this bill.
The website is developed in Perth, Western Australia but has universal applicability, and includes pathways appropriate for emergency medicine. Best of all, it's free!
The site can be found here
The website is developed in Perth, Western Australia but has universal applicability, and includes pathways appropriate for emergency medicine. Best of all, it's free!
The site can be found here
How to Find Foreign Bodies
Despite being a relatively common cause for presentation to Emergency Departments, there is often some confusion over the best imaging modality for identification and localisation of foreign bodies.
Of course some foreign bodies don't require imaging at all, but if there is uncertainty as to the presence of a foreign body or its precise location, there are a few basic rules that can help decide the initial modality of choice.
And now for some pretty examples...
Of course some foreign bodies don't require imaging at all, but if there is uncertainty as to the presence of a foreign body or its precise location, there are a few basic rules that can help decide the initial modality of choice.
Plain Radiography
- excellent for detection of dense foreign material in the peripheries (glass, metal)
- excellent for detection of foreign bodies within the abdomen (particularly bowel/rectum)
- not useful for plant or other organic material in the peripheries
- can be difficult around the orbits and jaw
Ultrasound
- excellent for subcutaneous foreign bodies of any density
- particularly useful for wood/splinters, marine spines
- good for assessing associated tendon/ligament injuries
- can be used for removal of foreign body in real-time
- can not see through bone and has difficulty seeing through air (for example sand/gravel in messy open wounds can be hard)
Computed Tomography
- modality of choice for swallowed fishbones and orbital foreign bodies
- good for all densities of foreign body
- good for problem solving difficult cases
- good for localising small foreign bodies within joints
- probably overkill for most clinical scenarios
And now for some pretty examples...
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| Bullet in Brain |
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| Ginger Ale in Rectum |
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| Palm Frond in Shin |
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| Shotgun Pellets to Leg |
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| Stingray Barb to Foot |
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| Fish Bone to Foramen Transversarium |
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| Swallowed Matchbox Car in Descending Colon |
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| Wood in Maxillary Sinus |
Webucation 18/4
Education from all sectors beckons:
- Left atrial enlargement - superb U/S delineation of this pathology
- Imaging-case-of-the-week - an abdominal sign not to forget
- 1st law of trauma - self explanatory
- NEC in paeds- embedded in this are also pearls on neonates and vomiting
- Good manners - are you really a complete physician?
- 30:60 rule for interventional radiology - when to and when not to dally
Right on Target – In a Blink
Prof Goh Siang Hiong is someone that does not need an introduction in our Emergency Medicine fraternity. He is an educator with many awards, and also my mentor and teacher. Recently, in the Annual Scientific Meeting of the Society for Emergency Medicine in Singapore, he gave this top notch lecture on heuristics and critical thinking in emergency medicine. We re-recorded it for the benefit of everyone (especially residents!) and here it is.
Reflections of a social creature
We are social creatures. Sometimes we need to meet just to know we like to meet.
One of these was a robust trauma session gave us aphorisms aplenty. My personal favourite has to be:
More wisdom ensued with Prof Peter Manning listing the words that should never pass your lips in an ED. Samples of blasphemy included:
The recent SEMS Annual Scientific Meeting 2013 in Singapore was a blur of activity. From the pre-conference workshops (hypothermia, tox, airway) to the 2 day main schedule packed with goodness to the torrent of information made available to the post conference options. All this interspersed by food glorious food (the obligatory Singapore past-time).
Some of the plenary highlights included A/Prof Benjamin Abella taking us to the cutting edge of Emergency Medicine. His personal examples of tele-medicine and networked care showed us not just a swish vision of the the future but the glories of the present as well.
Break out sessions yielded more treasure of pearls & nuggets from actual ED experience. From current toxicology to established paediatrics to future education trends. Following sessions encompassed the ever challenging fields of critical care, trauma and pre hospital care.
One of these was a robust trauma session gave us aphorisms aplenty. My personal favourite has to be:
"The only time my registrar is allowed to use the word "stable" in a P1 trauma case
when there is an actual horse in the ED"
when there is an actual horse in the ED"
- Its not a heart attack
- There's no rib #
- Let him sleep it off
More snippets and full talks can be had here for those who couldn't make it.
The pervading theme that was intoxicating throughout the whole conference centre though, was one of sheer camaraderie. A feeling that only comes with a shared experience. A brotherhood of sorts or, a fellowship if you will, which transcends geography, experience, finance and politics. All cognizant of the historical truth that the human race only got better when we exchanged perspectives and collaborated.
Few things are comparable to the unbridled joy of kinship. Knowing that across the globe, "pit docs" just like you work in the same proverbial trenches and face the same access block, chronic under resourcing, educational challenges, interdepartmental woes and enforced performance indicators. However, allied to this are their similar aspirations for their department, the longing for open access education, the desire for equipoise in research and a little more office space (oh yes, its the same cramped junkyard all over the world)!
I've been to numerous congresses for over the decade on many continents and the fellowship is always a source of warmth, but it's gratifying to have it in your own backyard for once. So kudos to the organisers (the chair being Emergence Phenomena's own Dr Phua DH) and we shall see you at next year st SEMS 2014 - for social creatures are we...
The pervading theme that was intoxicating throughout the whole conference centre though, was one of sheer camaraderie. A feeling that only comes with a shared experience. A brotherhood of sorts or, a fellowship if you will, which transcends geography, experience, finance and politics. All cognizant of the historical truth that the human race only got better when we exchanged perspectives and collaborated.
Few things are comparable to the unbridled joy of kinship. Knowing that across the globe, "pit docs" just like you work in the same proverbial trenches and face the same access block, chronic under resourcing, educational challenges, interdepartmental woes and enforced performance indicators. However, allied to this are their similar aspirations for their department, the longing for open access education, the desire for equipoise in research and a little more office space (oh yes, its the same cramped junkyard all over the world)!
I've been to numerous congresses for over the decade on many continents and the fellowship is always a source of warmth, but it's gratifying to have it in your own backyard for once. So kudos to the organisers (the chair being Emergence Phenomena's own Dr Phua DH) and we shall see you at next year st SEMS 2014 - for social creatures are we...
Antibiotics as First Line Management for Appendicitis
Antibiotics as First Line Management for Appendicitis - not a new treatment, but challenges our conception. I think what is useful is to remember to prescribe antibiotics the next time an appendicitis patient AMA.
Reference- Antibiotics as first-line therapy for acute appendicitis: evidence for a change in clinical practice. Hansson J, et al. World J Surg. 2012 Sep;36(9):2028-36. doi: 10.1007/s00268-012-1641-x.
Link
Reference- Antibiotics as first-line therapy for acute appendicitis: evidence for a change in clinical practice. Hansson J, et al. World J Surg. 2012 Sep;36(9):2028-36. doi: 10.1007/s00268-012-1641-x.
Link
Early Beta-Blocker Administration Is Associated with Better Survival After STEMI
In the study below, the probability of death after 48 hours was 11% with immediate treatment versus 19% with delayed treatment.
However I would reserve the use of bisoprolol 2.5mg in the hypertensive patient with STEMI until practice is endorsed by more RCTs and/or AHA/ACC.
Hirschl MM et al. Benefit of immediate beta-blocker therapy on mortality in patients with ST-segment elevation myocardial infarction. Crit Care Med 2013 Mar 29;
However I would reserve the use of bisoprolol 2.5mg in the hypertensive patient with STEMI until practice is endorsed by more RCTs and/or AHA/ACC.
Hirschl MM et al. Benefit of immediate beta-blocker therapy on mortality in patients with ST-segment elevation myocardial infarction. Crit Care Med 2013 Mar 29;
New Neurosurgical Guidelines Warn of Harm from Steroids in Acute Spinal Injury
Revised Congress of Neurological Surgeons and the American Association of Neurological Surgeons recommendations ;
- Methylprednisolone is not recommended for acute spinal cord injury, because no class I or II evidence supports its benefit. Class I, II, and III evidence indicate a higher incidence of infection, sepsis, complications, increased intensive care unit length of stay, and death with steroid use. (Level 1 recommendation)
- Computed tomography is the imaging study of choice for obtunded or un-evaluable patients with potential cervical spine injuries. (Level I)
- Computed tomographic angiography is recommended to assess for vertebral artery injury in selected patients who meet the modified Denver Screening Criteria after blunt cervical trauma. (Level I)
- Spinal immobilization and imaging are not recommended in patients with penetrating or blunt trauma who have normal mentation, no neck pain or tenderness, no focal neurologic findings, and no distracting injuries. (Level II)
ACP Recommends Physicians 'Pause Before Posting' on Social Media Sites
- consider what the content of their posts to blogs and social media sites say about them professionally;
- consider routinely searching for their name online and correcting inaccurate information.
- reserve e-mail and text communications for patients who will follow-through with face-to-face appointments;
- maintain separate personal and professional personas online
Webucation 12/4/13
Myriad of topics ranging from social media to ultrasound to heart tracings. Enjoy and remember to credit the content originators.
- ECG of the week - new squiggly conundrum at JL's site
- All trials - a solid intiative to try and get transparency for the good of mankind.
- How-much-of-a-social-media-profile-can-doctors-have? - self explanatory
- Gentamycin dosing - something to remember next time you dose someone.
- U/S tips on the RUQ - morrison's view from the masters down under
Flumazenil for Acute Poisoning?
Is it safe to give flumazenil to acutely poisoned patients, some with unknown poisoning. The authors of this retrospective study suggest it may. Of 904 patients only 13 seized and 1 died after flumazenil administration.
I think one need to have very very good reasons before take the risk to patients in reversing a safe poisoning when observation and supportive care will suffice. Not to mention the agitation...
Reference: A poison center's ten-year experience with flumazenil administration to acutely poisoned adults. Kreshak AA, et al. J Emerg Med. 2012 Oct;43(4):677-82. doi: 10.1016/j.jemermed.2012.01.059. Epub 2012 Jul 4.
I think one need to have very very good reasons before take the risk to patients in reversing a safe poisoning when observation and supportive care will suffice. Not to mention the agitation...
Reference: A poison center's ten-year experience with flumazenil administration to acutely poisoned adults. Kreshak AA, et al. J Emerg Med. 2012 Oct;43(4):677-82. doi: 10.1016/j.jemermed.2012.01.059. Epub 2012 Jul 4.
30th ACEM ASM
Here's a shout out for one of our colleagues down under.
Adelaide is hosting the 30th ACEM ASM.
Great for trainees to present and even better for networking with our Aussie colleagues.
You can find more conferences on our "synposia" page.
Adelaide is hosting the 30th ACEM ASM.
Great for trainees to present and even better for networking with our Aussie colleagues.
You can find more conferences on our "synposia" page.
Selected podcasts from SEMS ASM 2013
A recent congress was held in Singapore on behalf of the Society for Emergency Medicine in Singapore. Participants from accross the globe with 2 days of excellent discussion, dynamism and downright delicious food.
Click here to listen/download some of the talks
Click here to listen/download some of the talks
The NaCl debate
The human race markedly improves with civilised discussion, questioning and research. The recent critical care study regarding overuse of Normal Saline was reported by one of our authors here. That's not the whole story though. Ryan Radecki from EMLITOFNOTE does a good breakdown (crediting another in the process also) and its well worth a read.
JAMA editors let us down
JAMA editors let us down
Webucation 5/4/13
The goodness from the web this week includes excerpts from kids to ecgs to iodine dye.
- Critical paediatric procedures - how much to trainees really get to do?
- Knee xray - Trevor Jackson goes through a not uncommon knee xray finding
- Periorbital cellulitis - the ins and outs of this common paediatric condition
- All about iv-contrast - Rob Orman gives a comprehensive podcast on all things contrast
- ECG of the week - as it says, get your weekly heart rhythm fix here
Remember to spread the education and support the original authors.
Primary closure for I&D of cutaneous abscesses?
In the recent issue of Acad Emerg Med, Singer et al did a randomised controlled trial of primary versus secondary closure (healing by secondary intention) of skin abscesses.
- Singer AJ, Taira BR, Chale S, Bhat R, Kennedy D, Schmitz G, Zehtabchi S. Primary versus secondary closure of cutaneous abscesses in the emergency department: A randomized controlled trial. Academic Emergency Medicine 2013, Jan;20(1):27-32.
Of note, as mentioned in the opening paragraphs of this article, this is not a new concept. There are quite a few studies which described primary closure after I&D leading to faster healing than secondary closure, and are just as safe. The caveat is, the majority of these studies are done in the OT by surgeons, under GA, and involve mainly the anogenital region.
What this latest study show, is that primary closure of garden variety skin abscesses seen in an ED, is non-inferior to secondary closure. The healing rate and treatment failure rate as defined by the authors were similar. Of note, these were small abscesses, patients with significant cellulitis (>5cm) were excluded, as well as immunocompromised patients or DM patients. Also, I&D done under procedural sedation were excluded.
The limitations described by the authors were;
- selection bias (big, angry looking abscesses were excluded).
- small study – not sufficiently powered to detect differences in primary outcome.
- small abscesses thus only small incisions were performed. If large abscesses with longer incisions were made, the difference may be significant.
- limited followup of 7 days.
- selection bias (big, angry looking abscesses were excluded).
- small study – not sufficiently powered to detect differences in primary outcome.
- small abscesses thus only small incisions were performed. If large abscesses with longer incisions were made, the difference may be significant.
- limited followup of 7 days.
Take home:
Primary closure of I&D wounds may not be as bad as you think. There is certainly a role for this, especially in larger abscesses or abscesses in areas where cosmetics is of concern. Patient selection or preference may help to select successful outcomes when primary closure is performed. The authors also note an interesting point made in an earlier study: packing may not be necessary after all in wounds left to close secondarily; less painful and heals just as well.
Primary closure of I&D wounds may not be as bad as you think. There is certainly a role for this, especially in larger abscesses or abscesses in areas where cosmetics is of concern. Patient selection or preference may help to select successful outcomes when primary closure is performed. The authors also note an interesting point made in an earlier study: packing may not be necessary after all in wounds left to close secondarily; less painful and heals just as well.
- O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscess is painful and probably unnecessary. Acad Emerg Med. 2009; 16:470–3.
However, it is worthy to note that in larger abscesses, there is also the loop incision and drainage technique, first described in this pediatric study.
- Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: A minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg 2010, Mar;45(3):606-9.
Anecdotal reports suggest its efficacy in adult patients as well. So there you have it, three dogma changing possibly practice changing points in therapy of skin abscesses in the ED.
- Primary closure works just as well, possibly better than healing by secondary intention.
- Wound packing is probably unnecessary.
- Loop incision and drainage is a good option for large abscesses.
Finally, a youtube video of the loop I&D technique; enjoy!
Strand and deliver
This was a standard KUB done for renal colic but there is something odd about it.
Normal patient haemodynamically and in all other ways.
Any guesses?
Bariatric complications explained
A comprehensive talk on complications of bariatric surgery by Dr Andrew Wong, Dept of General Surgery, Changi General Hospital, Singapore.
It's more complex than you think and its good to have a review of what can go wrong post op.
It's more complex than you think and its good to have a review of what can go wrong post op.
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