Tag Archives: surgery

Useful Tool: Necrotizing fasciitis score

6 Jul

the LRINEC = laboratory risk indicator for necrotizing fasciitis


-the score is based off of a retrospective observational study comparing laboratory results of patients with confirmed necrotizing fasciitis and those with severe cellulitis or abscess


-six criteria: CRP, WBC, hemoglobin, sodium, creatinine, glucose


-each of the criteria are weighted with a point value


-values totaling a LRINEC score >6 had a sensitivity of 90% and specificity of 95%; PPV 92% and NPV 95%


-useful tool? Sure. But also keep in mind this cut-off still missed 10% of patients with necrotizing fasciitis


-Summary: a LRINEC score > 6 could be used as a potential tool to rule in necrotizing fasciitis, but a score <6 should not be used to rule out the diagnosis



Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (laboratory risk indicator for necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004 Jul; 32 (7):1535-41. PubMed PMID: 15241098.; MDCalc site; picture


Submitted by K Estes




Prolene pros and cons

13 Jan

quick refresher via a handy article from last months EM News mag on eyebrow lac repairs:

PROLENE: (= polypropylene, non-absorbable)


  • best tensile strength
  • least tissue reactivity (vs. nylon and silk)
  • its blue! (easier to identify vs. eyebrow hairs, unless your patient has some interesting hair coloring)
  • low friction (more knot trouble, but slips easily through tissue)



  • least secure (knot security)
  • more “memory” (springs back to its original position); makes it trickier to handle (e.g. with lesser knot security)


Food for thought for your next facial lac repair.


References: EM News article; FP notebook (& picture)



procedure video: one-handed surgical knot

10 Nov

came across this useful refresher video on Youtube.  If you only have 60-seconds, start watching at the 2:00 mark for the first pass/tie.

Then skip to the 3:00 mark for the 2nd pass/tie.


If you want to watch it done with actual suture (with some trippy music in the background), check out this one.

There you go.


References: video with audio explanation; trippy music video.


spontaneous pneumothorax: needle aspiration or tube thoracostomy?

11 Mar

it depends… (awesome answer, no?)

A 2008 Annals Review on primary spontaneous pneumothorax:

Three randomized trials with acceptable quality standards met the inclusion criteria.

no significant difference between needle aspiration and tube thoracostomy when outcomes of

  • immediate failure,
  • 1-week failure,
  • risk of complication,
  • 1-year recurrence rate


needle aspiration was associated with

  • lower rates of hospitalization: relative risks of 0.26 (95% confidence interval [CI] 0.17 to 0.39) and 0.51 (95% CI 0.36 to 0.74).
  • shorter length of hospital stay (~0-3 days)
  • less analgesia requirement in one trial and lower pain scores in another.


on the other hand… (via Up to date):

Secondary spontaneous pneumothorax

  • well-described complication of giant bullae (e.g. COPD); also consider interstitial lung dz, neoplasm, collagen vascular dz
  • should be hospitalized because the diminished pulmonary reserve due to underlying lung disease increases the risk of an adverse outcome (eg, persistent air leak, hypoxemia, respiratory failure).
  • Subsequent management is directed at preventing recurrence (e.g. pleurodesis via VATS, bullectomy).
  • Tube thoracostomy is generally preferred over needle aspiration 
    • In one trial, 28 patients got tube thoracostomy, 33 patients got needle aspiration.
    • tube thoracostomy group was more likely to have their pleural air completely evacuated than the needle aspiration group (93 versus 67 percent).
    • The lower success rate of pleural aspiration in SSP than primary spontaneous pneumothorax may be due to a higher rate of persistent air leakage


Submitted by Heather Reed-Day.


References: pubmed article; uptodate.com; picture

Perirectal abscess

10 Oct

from a 1995 Annals article by Marcus et al:

retrospective chart review, 92 patients with discharge dx of perirectal abscess



Patients with perirectal abscesses often delay seeking medical attention.

Pain is almost always a presenting symptom (98.9% of cases)

  • Thus, in communicative patients, perirectal abscess is unlikely in the absence of pain.

External perianal and digital rectal examination identified an abscess in 94.6% of patients.


Missed diagnosis of a perirectal abscess is common. Perirectal abscesses are most commonly misdiagnosed as hemorrhoids.

The presence of severe pain, however, should suggest the possibility of a perirectal abscess.

Culture results indicate that aerobic and anaerobic bacteria from the skin, bowel, and, rarely, vagina are the causative agents…Mixed infections are common.

mainstay of treatment is I&D, usually in the OR; +/- antibiotics as adjunct therapy (WITH I&D), particularly for:

  • systemic symptoms,
  • immunocompromised,
  • heart valve abnormalities,
  • associated cellulitis or extensive abscesses.


Perirectal abscesses frequently recur, probably as a result of

  • fistula-in-ano formation (after incision and drainage),
  • underlying disease (eg, inflammatory bowel disease, hidradenitis suppurativa, immunocompromised state),
  • inadequate drainage (eg, missed abscess component).


Submitted by H. Reed-Day.


References: article; picture


12 Aug


Your next patient is a 39 year old female with no past medical problems presented with acute RLQ pain.

No nausea or vomiting. No fevers or chills. No urinary complaints. No vaginal discharge.  Her abdomen is pretty decently tender on the whole right side.  

After a benign pelvic and pelvic ultrasound, and a negative urinalysis & HCG, you decide to send her through the Donut of Truth (CT)…

Shortly after, you get a call from radiology with a prelim read: 8 cm right renal angiomyolipoma with evidence of hemorrhage and gross hemoperitoneum and retroperitoneal blood.  Now what?


Most common benign tumor of the kidney.

Composed of blood, muscle, and fat tissue. (angio-myo-lipo-ma)

Strongly associated with Tuberous Sclerosis, although 80-90% of cases are sporadic.

Most angiomyolipomas do not require intervention unless life threatening bleeding is present.

Hemorrhagic complications are significantly more common (approximately 20% per year) once tumor size surpasses 4 cm.

Important information for EM docs:
1) Most cases are benign and require no treatment unless actively bleeding, size is large (>4cm), or there is evidence of large aneursym.

2) Treatment for large, bleeding, or aneurysmal AMLs is supportive with IVF, blood products, pressors, etc. until embolization can be done
3) Nephrectomy is last line and is generally only recommended for refractory cases.

Submitted by K. Dabrowski.

Resources: Loffroy R, Rao P, Kwak BK, Ota S, De Lin M, Liapi E, Geschwind JF. Transcatheter arterial embolization in patients with kidney diseases: an overview of the technical aspects and clinical indications. Korean J Radiol. 2010 May–Jun;11(3):257–68. PMID 20461179.; picture

Rasmussen’s aneurysm (a.k.a. massive hemoptysis is bad)

28 Jun


Your next patient is a 40 year old male who comes in because he is coughing up blood. Your differential is broad, and you eventually send him for a CTA of his chest.  

On the way back from CT, he starts having severe respiratory distress thanks to the massive amount of blood he is spraying into the air with each labored breath/cough.  

As you are intubating, the clerk says the radiologist is on the phone saying something about Rasmussen and an aneurysm….what does this mean?



Rasmussen’s aneurysm is a pulmonary/bronchial artery aneurysm adjacent or within a tuberculous cavity.

occurs in up to 5% of patients with such lesions

slowly expands because of inflammatory erosion of the external vessel wall until it bursts (this is bad)

(hemoptysis with active TB more commonly from bronchiolar ulceration with necrosis of adjacent blood vessels and distal alveoli)

MASSIVE HEMOPTYSIS differential includes:

  • Bronchiectasis
  • Tuberculosis (+/- rasmussen’s aneurysm)
  • pneumonia/other lung infections (e.g. fungal)
  • carcinoma
  • Bronchitis
  • vasculitis
  • pulmonary embolism
  • coagulopathy
  • trauma
  • tracheo-inominate fistula



ABCs (airway comes first)

blood products



thoracic surgery



TB + massive hemoptysis, worry about Rasmussen’s aneurysm.



Submitted by J. Stanton.


References: uptodate.com: Massive hemoptysis: Causes, Initial Management, Clinical manifestations and evaluation of pulmonary tuberculosis; picture