DENTAL BLOCKS (quick procedure review)

submitted by Amit Kumar, M.D.

Easy procedures providing big-time opioid-free relief!

Can mix 50-50 lido and bupivacaine for quicker onset + longer analgesia combo.

Infraorbital nerve block:

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Retract cheek, insert needle next to 2nd premolar, 0.5cm from buccal surface. Advance parallel to tooth

3) You’ll palpate it next to foramen (under palpating finger) at depth of approx 2.5cm

4) Confirm location, aspirate, then inject 2-3 cc local anesthesia

5) Massage tissue for 15 secs to hasten onset

*Intraoral approach provides nearly 2x duration of anesthesia compared to extra-oral approach

 

 

 

 

 

 

Inferior alveolar nerve block:

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Palpate coronoid notch with thumb, and stretch bucally (index & middle finger at angle of mandible outside)

3) Inject 2-3 cc of anesthesia at the site where middle of your thumb nail and pterygomandibular raphe biset

4) Massage tissue for 15 secs to hasten onset

*Will also anesthetize lingual nerve (anterior 2/3 of tongue in that side)

*Anesthetize long buccal nerve of that side, but injecting just distal and buccal to last molar

Reference(s):  Hedges, Jerris R., and James R. Roberts. Roberts and Hedges clinical procedures in emergency medicine. Philadelphia, PA: Elsevier Saunders, 2014. Print.

strength in numbers: blood transfusion risk

via a recent emdocs article (click through for the full read), some ballpark numbers that might help you when you consent your next patient for a blood transfusion:

<1% (~0.63%) had a transfusion reaction, based on data from 2011

only 317/8,000,000 (~ 1 in 25,000) had a serious reaction requiring ICU-level care

risk of viral transmission:

• HIV -> 1: 1,467,000 units
• Hepatitis C -> 1: 1,149,000 units
• Hepatitis B -> 1: 357,000 units

 

in comparison, for reference:

• odds of a royal flush (5-card poker): ~1 in 650,000
• odds of a four-of-a-kind (5-card poker): ~1 in 4000
• odds (in a single year) of dying in a motor vehicle accident: ~1 in 9000
• odds (in a single year) of dying in an “air and space transport” accident: ~1 in 770,000

 

References: emdocs article; poker probabilities; mortality risk

quick tip: easy fluorescein staining

via a recent post from the Procedural Pause:

use a saline ‘bullet’ (dropper), drip a little saline on the fluorescein strip, then draw it back up.

 

handy for peds, or for squirmy adults, too

 

 

I’ve also seen the strip dropped in the back of a 10 cc syringe, or a saline flush used similarly as with the dropper above (see this ALiEM post for more).

 

There you go. Add it to the toolbox.

 

References: procedural pause post, ALiEM post

 

 

vomiting during intubation? tube the esophagus

quick handy tip from this EMCRIT podcast for a vomit (or blood) laden oropharynx during intubation:

blindly (since you can’t see anything) insert an ETT; if it happens to be tracheal, great.

more likely, it’ll be in the (esopha)gUs.  LEAVE IT THERE.  you can intubate around it shortly, and you now have a landmark to intubate over. 

now here’s the tip: INFLATE the cuff on the esophageal ETT.  Also remember to tilt the now vomit-spewing ETT to the side, but this is now an outlet for the blood/vomit that won’t obscure your DL view

now, suction, and intubate the trachea.

 

Easy concept, handy tip.  Add it to the toolbox.

(check out the podcast for some more tips, but I thought that was the handiest).

 

References: EMCRIT podcast; picture

Torticollis (quick review)

submitted by Christina Brown, M.D. 

 

Definition – “Twisted neck” (L. tortus, twisted + collum, neck).

Synonyms: Cervical dystonia, wry neck

Self-limited, symptoms resolve in 1 to 2 weeks

Possible Etiologies:

• Fracture
• Dislocation, subluxation
• Cervical spine disease
• Infections
• Spondylosis
• Tumor
• Scar tissue–producing injuries
• Ligamentous laxity in atlantoaxial region
• Drug induced
• Otolaryngologic:
  • Vestibular dysfunction, Otitis media
  • Cervical adenitis, Pharyngitis, Retropharyngeal abscess
  • Mastoiditis
• Esophageal reflux
• Syrinx with spinal cord tumor

 

Physical Exam

• Intermittent painful spasms of sternocleidomastoid (SCM), trapezius, and other neck muscles
• Head is rotated and twisted to one direction

 

Management:

Imaging

• Plain film if cervical fracture is suspected.
• CT or MRI of cervical spine if retropharyngeal abscess or tumor suspected

INITIAL STABILIZATION/THERAPY: Cervical spine immobilization if fracture is suspected

ED TREATMENT/PROCEDURES

• Soft collar and rest,
• Physical therapy,
• Massage,
• Local heat,
• Analgesics

 

MEDICATION:

• Diphenhydramine (for drug-related dystonia)
• Valium: 2–5 mg IV, 2–10 mg PO t.i.d. (peds: 0.1–0.2 mg/kg per dose IV or PO q6h)
• Botulinum toxin is an option for treating non-drug-induced torticollis, though this is not typically administered in the ED setting.

 

References:
1. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Torticollis. Rosen’s and Barken’s 5-Minute Emergency Medicine Consult. http://www.r2library.com.proxy.its.virginia.edu/Resource/Title/1608316300/ch0020s16613
2. Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol 1997; 111:1183.
3. Soundappan SV, Darwish B, Chaseling R. Traumatic spinal epidural hematoma-unusual cause of torticollis in a child. Pediatr Emerg Care 2005; 21:847.
4. Mutsaers P, Fick M, Plötz FB. Acquired torticollis as the only initially presenting symptom in a child with a brainstem glioma. Eur J Pediatr 2007; 166:1075.
5. Shanker V and Bressman S.: What’s new in dystonia? Curr Neurol Neurosci Rep. 2009; 9:278–284.

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Cauda Equina Syndrome

submitted by Christina Brown, M.D. 

 

Definition – Compression of lumbar and sacral nerve fibers in cauda equina region

RISK FACTORS 

• Neoplasm
  
• IV drug use
• Immunocompromised state.

ETIOLOGY

• Herniated disc most common:
  • L4–L5 discs > L5–S1 > L3–L4
  • Most common in 4th and 5th decades of life
  • Mass effect from: Myeloma, lymphoma, sarcoma, meningioma, neurofibroma, hematoma
  • Spine metastases (breast, lung, prostate, thyroid, renal)
  • Epidural abscess (especially in IV drug users
• Blunt trauma
• Penetrating trauma

 

SIGNS and SYMPTOMS

• Low back pain
• Sciatica/radicular pain (unilateral or bilateral)
• Lower extremity numbness or weakness
• Difficulty ambulating owing to weakness or pain
• Bladder or rectal dysfunction (Retention or incontinence)

 

Physical Exam

• Lumbosacral tenderness
• Lower extremity sensory or motor deficits (May be asymmetric)
• Decreased foot dorsiflexion strength
• Decreased quadriceps strength
• Decreased deep tendon reflexes
• Saddle hypalgesia or anesthesia
• Decreased anal sphincter tone

 
Postvoid residual volume (PVR):

• Estimate by bladder catheterization or using US.
• >100 mL is considered abnormal.
• Residual increases with age.

 

Labs – Depends on differential diagnosis. Options include CBC, urinalysis, ESR, and C reactive protein (CRP)

IMAGING – MRI of spine is definitive study. CT myelogram if MRI unavailable

ED Treatment/Procedures:

• Immediate neurosurgical consultation in all cases
• Initiate antibiotics for epidural abscess in consultation with neurosurgery.
• Controversy exists regarding urgency of decompression:
  • Recommendations range from within 6 hr of onset to within 24 hr.

 

Disposition:

• All patients with acute cauda equina syndrome must be admitted to neurosurgical service.
• Patients have good prognosis with rapid surgical decompression.
• Treatment should not be delayed.
• Patients presenting late (>48 hr) also benefit from surgical decompression.

 

References:

1. Fraser S, Roberts L, and Murphy E.: Cauda equina syndrome: A literature review of its definition and clinical presentation. Arch Phys Med Rehabil. 2009; 90(11):1964–1968.
2. Hussain S A, Gullan R W, and Chitnavis B P.: Cauda equina syndrome: Outcome and implications for management. Br J Neurosurg. 2003; 17(2):164–167.
3. Shapiro S.: Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine. 2000; 25(3):348–352.
4. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Cauda Equina Syndrome. Rosen & Barkin’s 5 Minute Emergency Medicine Consult.

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Peds “step by step”(for FWS)

submitted by Amit Kumar, M.D.

 

“Step by Step”

-Algorithm to identify pediatric patients (<90 days) with fever without a source (38°C, in patients with a normal PE and no respiratory symptoms or a diarrheal process) as low risk for invasive bacterial infection

-Developed by European group of EPs, validated

-Identifies “low risk” group not requiring LP and empiric antibiotics, and fit to be managed outpatient

-Found to be more sensitive than Rochester Criteria and Lab-score

(Pediatric Assessment Triangle = appearance, work of breathing, circulation)

(PCT = procalcitonin)

-There, add it to your toolbox!

References:
Gomez, B., Mintegi, S., Bressan, S., Dalt, L. D., Gervaix, A., & Lacroix, L. (2016). Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics, 138(2). doi:10.1542/peds.2015-4381

Pediatric assessment triangle article