Tag Archives: estes

Catheter-related upper extremity DVT

26 Mar

QUICK PEARLS:

The majority (70-80%) of thrombotic events in the upper extremity deep veins (subclavian, axillary, brachial) occur in the presence of IV catheters.

 

Any catheter has the potential to cause thrombosis. Think about PIV, PICC, tunneled and non-tunneled central catheters, ports and pacemakers.

 

In addition to the classic risk factors that you commonly consider for DVT (prior surgery, malignancy, h/o DVT, etc.), specifically catheter-associated thrombosis is more likely with:

large-diameter catheters (more likely to have stagnate blood v. free flowing)

PICC as compared to centrally placed catheters

-catheter malposition (In one study, DVT developed in 46% of patients whose catheter tip was in the innominate vein or junction of the immoninate vein with the SVC, compared with 6% of patients with a properly positioned catheter)

-chemical irritation (potassium chloride, antibiotics such as vancomycin, diazepam, hypotonic and hypertonic electrolyte solutions)

 

Clinical presentation: inability to withdraw blood, phlebitis, extremity edema

 

Diagnosis is made with Doppler ultrasound.

 

Treatment involves observation, anticoagulation to prevent embolization, and removal of the catheter. Prophylactic systemic anticoagulation is not routinely recommended in this population.

 

Submitted by K Estes.

 

References:  Luciani, et. Al. Catheter-related upper extremity deep venous thrombosis in cancer patients: a prospective study based on Doppler US. Radiology. 2001;220(3):655. PMID 11526263

Uptodate.com; picture

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Penetrating Neck Injuries (PNI) – a few important reminders

23 Mar

REMEMBER THIS:NeckInjuryZones1

 

  • Penetrating neck injuries (PNI) are defined by injuries that violate the platysma
  • Zones of injury (see picture) have been defined to help the clinician describe the injury and attempt to predict degree of morbidity
  • PEARL: If clinical signs of vascular or aerodigestive injury or if hemodynamically unstable, then the treatment is operating room exploration
  • Otherwise, obtain CT angiogram and the following management depending on the corresponding zone:
    • Zone 1 -> esophageal imaging, bronchoscopy, angiography
    • Zone 2 -> angiography, esophageal imaging, bronchoscopy, operating room for mandatory exploration
    • Zone 3 -> angiography
  • PEARL: there are conflicting studies, but it is usually safe to clear the cervical spine in a patient with PNI and no focal neurologic deficits

 

  • Pitfalls:
    • Never remove objects impaled in the neck
    • Avoid probing neck wounds and clamping vessels in the neck
    • Never discharge a patient with PNI and no injuries identified on CTA; always admit these patients for observation
    • To avoid morbidity (mediastinitis, abscess, empyema), never delay esophageal imaging in patients with potential esophageal injury

 

 

Submitted by K Estes

 

References: Critical decisions in emergency medicine. October 2011, vol 26, number 2.

Propofol Infusion Syndrome

19 Mar

A rare complication of propofol infusion (estimated <1%) with high mortality (upwards of 33%)

 

Risk factors include

  • High doses (>4 mg/kg/hr or >67 mcg/kg/min)
  • Prolonged use (>48 hours)
  • Young age
  • High fat and low carbohydrate intake
  • Inborn errors of mitochondrial fatty acid oxidation
  • Concomitant catecholamine infusion

 

Presentation

  • Bradycardia
  • Severe metabolic acidosis
  • Cardiovascular collapse (EKG appears “brugada-like” with convex-curved ST elevation in V1-V3, also RBBB, arrhythmia, heart block)
  • Rhabdomyolysis
  • Hyperlipidemia
  • Renal failure
  • Hepatomegaly
  • Lipaemic serum (say what??? -> milky white serum due to high fat content- see picture)

lipaemic serum

Treatment

  • Discontinuation of propofol
  • Consider pacing
  • Carnitine supplementation (theoretical benefit)
  • Hemodialysis and ECMO (benefit in a few case reports)
  • Good ol’ fashioned supportive care

 

Submitted by K Estes

 

References:  uptodate.com; lifeinthefastlane.com

Rash to Remember: Toxic Shock

11 Dec

A few pearls to help distinguish the badness of toxic shock syndrome from just any old rash

-involves skin and mucous membranes

-macular, resembles a sunburn

-involves the palms and soles

-more severe cases develop vesicles and bullae

-non-pitting edema due to increases in interstitial fluid

-late onset (1-3 weeks) develops into a pruritic maculopapular rash with desquamation of the palms and soles

 Macular_erythema_tss

Source: uptodate.com

 

Submitted by K. Estes

Management of Metacarpal Fractures

8 Dec
  • These fractures account for 40% of all hand injuries
  • treatment based on which metacarpal and the acceptable angulation of the fracture; general rules to remember:
    • index 10°
    • long 20°
    • ring  30°
    • little 40°
  • physical exam pearls:
    • fight wounds over MCP joint are open until proven otherwise
    • assess malrotation by examining “cascade” -> line up fingernails while fingers in full flexion

 

 

  • reduction and splinting if acceptable angulation and no immediate operative indications
    • “jahss” technique for reduction -> flex the patient’s MCP and PIP 90°, then apply dorsal force to proximal phalanx

 

    • intrinsic plus technique for splinting -> MCP flexed to 60-70°, IP fully extended, and wrist held in 10° less than maximal extension.

 

Submitted by Kelly Estes.

 

Sources: Content and Picture1 (orthobullets.com), Picture 2 (Aliem.com)

LVAD: do you know enough?

29 Sep

Raging Hypothetical:

You are working overnight in a single coverage emergency department and the next patient walks in with a wire hanging from his chest and no palpable pulses. He needs help because the alarm on his device is going off. You look at the external device and it reads “low volume”. Before you start to treat this patient, a few important things to keep in mind…

 

Who gets LVADs?

Severe heart failure

EF <25%

VO2max <15

And a few other less common criteria

 

What in the world is it?

LVAD = Left Ventricular Assist Device 

=An external pump unit outside the body with an intake channel (draining blood from the left ventricle) and output channel (ejecting blood into the aorta)

 

Why might these patients come into the ED?

Infection of the driveline at skin insertion site

Bleeding (these patients are anticoagulated while using this device)

Hypovolemia

Pump thrombosis

Machine alarming

Patient is coding or pump not running (this is pretty much the same thing)

 

What to do?

All situations:

-contact the patient’s VAD coordinator

-listen over the heart to hear if the monitor is working (sounds like a “muffled blender”)

-evaluate mental status, skin color for perfusion, skin driveline site for infection

-evaluate the machine for battery function, lines plugged in, alarms of “low flow” or “low volume”

MAP should be 65 on manual Doppler (automated cuffs less accurate)

EKG to look for RV problems, arrhythmia, STEMI

-consider beside echo to assist with your differential (heart failure, focal wall motion abnormality, PE, etc.)

 

The patient should have extra batteries or there should be a special power pack option to plug into the wall

 

VADs love volume! Fluid bolus if poor perfusion, give PRBC if bleeding, but… think twice about correcting elevated INR or reversing coumadin (is this worth clotting off the patient’s device???)

 

Consider inotropes. Right heart failure à dobutamine; sepsis or reduced afterload à norepinephrine

 

Signs of pump thrombosis à hot device, working hard with high RPM, dilated RV/LV on bedside echo, low MAP. Consider heparin bolus.

 

And for the coding patient… avoid CPR. You can rip out the driveline. Yikes! But use your clinical judgment. The patient may need CPR if the pump is not working and the patient has lost their BP (MAP = zero).

 

Submitted by K Estes.

 

Sources: EMCrit Blog, EM:RAP podcast; picture

Examination of the collateral ligaments of the thumb

23 Sep

Gamekeeper’s thumb or skier’s thumb -> injury to ulnar collateral ligament (UCL) of the metacarpophalangeal (MCP) joint

 

  • due to forceful abduction and hyperextension
  • clinical presentation of pain at the base of thumb
  • stabilize the MCP joint, then apply a valgus force (radially deviating the thumb) while positioned in flexion and extension
    • In 30-40 degrees flexion, the “proper” UCL can be assessed for laxity
    • In extension, the “accessory” UCL can be assessed for laxity
    • To test for a completed UCL tear, you must examine both the proper and accessory components
  • If in doubt, place a thumb spica splint and refer to a hand specialist

 UCL

 

Submitted by K Estes.

 

Source: EM:Rap (text and photo)