Webucation 29/9/13

Web musings this week come from the worlds of critical care, paediatrics, orthopaedics and even the dermatologists! A lot of the below has risk management and error reduction pearls included. So visit and support the content creators as always. 

• Pneumonia detection - difficult x-rays in children, but not impossible
• Splinting upper/lower - EM in 5 gives a great rundown about casting limbs
• Is it Nec Fasc? - ALiEM relate a fascinating case, with a bit of risk management thrown in
• Variability of different BVMs - this article was a surprise to me. Click to be surprised as well.
• Is this distracting? - Ryan Radecki breaks down another myth. This  time about c-spine clearance.
• What is a wide mediastinum? - The trauma pro answers this much asked question
• Vent settings in asthma - what to do AFTER the intubation

The last link is a good reminder to trainees and professionals alike on the subtler aspects of holistic critical care. Additionally we would like to remind our readers of an old adage: 

                            "If you are intubating an asthmatic, you have failed him/her medically"

It's not a judgement but rather to remind you that there are tons of things that you can do prior to mechanically ventilating an asthmatic (most of the time). So make sure you have thought of the following prior to attempting this very high risk procedure:

• Broncho-dilator maximisation 
• Continuous nebs
• Ipratropium
• IV infusions of beta agonists 
• Theophylline (old school I admit)
• Adrenaline 
• Magnesium
• Non invasive ventilation and nebs via that route (anecdotally works great in our XP)
• Steroids

Emcit has the best crashing asthmatic talk over here.

About time re: Sternal #s

Thanks to JournalWatch for this update: Isolated Sternal Fractures May Not Warrant Hospital Admission Richard D. Zane, MD, FAAEM Reviewing Odell DD et al., J Trauma Acute Care Surg 2013 Sep 75:448 Most patients can be safely discharged after emergency department evaluation.

Sternal fractures are usually associated with high-energy trauma. Conventional wisdom has been that patients with sternal fractures require hospitalization because of the injury mechanism (usually motor vehicle crash), potential for occult associated injury, and severity of pain. In this retrospective study of 1867 patients with sternal fracture who were admitted to Israeli trauma centers over a 12-year period, the authors compared in-hospital events between patients with isolated sternal fractures (26%) and those with sternal fractures associated with other injuries (polytrauma; 73%). Patient characteristics and mechanisms of injury (mostly motor vehicle collisions and falls from significant height) were similar in the two groups. Compared with patients with polytrauma, those with isolated sternal fractures less frequently exhibited tachycardia, hypotension, tachypnea, Glasgow Coma Scale score ≤14, and Revised Trauma Score ≤11. No patients with isolated sternal fracture required endotracheal intubation, chest tube, thoracoscopy, or resuscitative thoracotomy; these procedures were performed in 17% of patients with polytrauma. EDITOR DISCLOSURES AT TIME OF PUBLICATION Disclosures for Richard D. Zane, MD, FAAEM at time of publicationEditorial boardsPocket Emergency Medicine CITATION(S): Odell DD et al. Sternal fracture: Isolated lesion versus polytrauma from associated extrasternal injuries — Analysis of 1,867 cases. J Trauma Acute Care Surg 2013 Sep; 75:448. (http://dx.doi.org/10.1097/TA.0b013e31829e227e)

Full definition of anaphylaxis

Its been a interesting phenomenon taht the definition of anaphylaxis was quite unclear until the last few years. Here's a good reminder in case you get quizzed by someone! Now if only we could get see the end of "steroids or not" debate.

What's not in conjecture is the primary treatment for the below >>> ADRENALINE

Thanks to JournalWatch for this table:

 Full Definition of Anaphylaxis for Emergency Health Professionals^1–3

Part 1. Working Definition: Anaphylaxis is a serious reaction that is rapid in onset and may cause death. It is usually due to an allergic reaction but can also be non-allergic.

Part 2. Clinical criteria to diagnose an acute anaphylactic episode: Anaphylaxis is highly likely when any one of the following 3 criteria is fulfilled:

1. Acute onset (minutes to several hours) of an illness involving the skin, mucosal tissue, or both (e.g., generalized hives, pruritus or flushing, swollen lips-tongue-uvula) AND AT LEAST ONE OF THE FOLLOWING:

a. Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)

b. Reduced blood pressure (BP) or associated symptoms of end-organ dysfunction (e.g., hypotonia, syncope)

OR

2. Two or more of the following that occur rapidly (minutes to several hours) after exposure to a likely allergen for the patient:

a. Involvement of the skin-mucosal tissue (e.g., generalized hives, itch-flush, swollen lips-tongue-uvula)

b. Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)

c. Reduced BP or associated symptoms of end-organ dysfunction (e.g., hypotonia, syncope)

d. Persistent gastrointestinal symptoms (e.g., crampy, abdominal pain, vomiting)

OR

3. Reduced BP occurring rapidly (minutes to several hours) after exposure to known allergen for the patient

a. Infants and children: low systolic BP (age specific) or > 30% decrease in systolic BP

b. Adults: systolic BP < 90 mm Hg or > 30% decrease from baseline

References:

1. Simons FE, Ardusso LR, Bilo MB, et al. World Allergy Organization guidelines for the assessment and management of anaphylaxis. J Allergy Clin Immunol 2011;127:587–93.
2. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010;126:477–80.
3. Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010;126(Suppl 1):S1–58.

Webucation 12/9/13

Web wonders this time stretch from the world of paediatrics to geriatrics, from ECG to trauma and even some words of wisdom from an "old" ED hand. be sure to support the original content creators.

• 10 things i wish i had started doing the day i began practicing - the "Fickle Finger" gives us his laments, triumphs and ultimately much wisdom. Well worth a read.
• JHC ecg-of-week - excellent explanations now follow weekly ECGs at John Larkin's site
• Pain, honeymoon and torsion? - not the typical testicular test. another great example from Larry Mellick
• A time based approach to elderly patients with AMS - think geriatrics don't have time sensitive issues? Think again.
• Dissecting it in in 5 mins - the all knowing K. Wang sets the record straight on Aortic Dissections
• LFTs and liver lacerations - the Trauma Pro clears the air on investigating these
• Avoid oxygen desats - Paeds EM Morsels argues that there should never be desats in children either.

The last point echoes on from NODESAT policies from airway gurus around the world. We cannot but echo them further to all our readers. Prepare, prepare, prepare. The boy scout mentality staves off lots of trouble for your patient. Our ventilation guide is here.

The Eagles simplify medicine

James McCormack combining a few of my favourite things: Simplification, understanding perspective and The Eagles.

Watch his other videos here. Highly recommend the Gotye guidelines video.

Webucation 1/9/13

Web therapy this time from sources which contain nuggets from experienced examiners to nutrition advice to paediatric pearls and even to Arthur Conan Doyle. As always, visit and support the content providers.

• Mediterranean Diet does help - no surprises here. Just facts.
• Age adjusted D-dimer cutoffs - helpful reminder when dealing with older patients
• Amal Mattu on over-diagnosing - how to get rid of your biases the next time you think about calling it AF
• NIV for kids - the when, why and how on whether you should in kids
• Come along Watson, we're diagnosing - Colin Parker on how we can be Sherlock if we try
• Mesenteric injuries on CT - the Trauma Pro sheds more light on the topic
• CXR... exam style - Trevor Jackson on how to do well in ED visual aid question exams
• Transfer from haemodialysis - how many times have you wondered on what to do with this type of patient!

• Early goal directed what?? - sedate your patients and sedate them early.

This last point resonates with us in critical care as it not only points towards sensible science but also gives us a window into how we treat patients. Be kind to your patients. They're already having a bad day (tubed, probed, irradiated, catheterised etc). Sedate them for kindness sake.