RnR Rounds Podcast

60yo male with past history BPH, bipolar, cognitive impairment, and hypertension

- Admitted with vertebral compression fracture and pain management

o Meds straightforward

o Managing other conditions well

Developed fever, delirium, and possible urinary retention with signs and symptoms of: Diaphoretic, tachycardia, hypertension, febrile, Altered LOC– unreliable historian

Unremarkable physical exam

Differential – Sepsis, Pyelonephritis or bacteremia

Case 1

Acute abdominal or pelvic pain in women of childbearing years – ectopic pregnancy considered until proven otherwise

28yo female G3 P2 A1 – miscarried 5 weeks ago and has ongoing bloody discharge.

Was monitoring Beta HCG that peaked at 6000 Beta HCG dropped to 500 and patient did not follow up afterwards.
Came in with sharp shooting pain in left lower pelvis.
- Urine sample use POC if available rather than waiting for lab.
Scan with ultrasound – uterine vault appears empty. Transverse view – 1cm cyst noted (difficult to fully appreciate due to empty bladder and patient having more adipose tissue)
- Urine test – positive
Query heterotopic pregnancy?
Consult obstetrician – accepts patient. Patient received injection (methotrexate)to resolve pregnancy vs surgical option.

Diagnostic ultrasound – 2x3cm heterogeneous soft tissue mass within the distal left cornea suggestive of a failed of interstitial ectopic pregnancy.
- Failed pregnancy – not truly ectopic due to placement but is still considered ectopic.
When you see a pregnancy location in the uterus want to make sure you have at least 8mm uterine myometrium around gestation in all locations to rule out intrauterine implantation in the wrong part of the uterus.

Case 2

36-week G2P1 followed by obstetrics due to placenta previa.

Came in with bright red painless bleeding initially hemodynamically stable. Site capable of obstetric support.

BP mid-90s HR 120s – concerned with significant blood loss - ATLS - Class 3 shock 30-40% circulating blood loss – unsure if validated for pregnant women – considered for this case to estimate blood loss.

Pressure infused first unit of O-neg blood, 1g TXA given - second unit infused on route with EMS - receiving hospital 25min away

If longer transport and site has surgical capabilities, consider surgical intervention before transport.

Perimortem c-section – last ditched effort.

Get consult with expert ASAP to have them on hand to work through case.

*Speed is of the essence in cases of bleeding. TXA 1g IV over 10min loading dose. Consider a second dose as per local protocol if the patient is going to stay for longer. Consider what options for blood products are in your area*

EtOH Withdrawal

Long-term chronic alcoholic (normally visits ED 1-2 times per week).
Clinical Institute Withdrawl Assessment (CIWA) scored high.
Typically treated with a benzodiazepam based on CIWA score.
Patient was initially treated with 20mg of diazepam every hour for first 22 hours. Pt was unable to settle and remained very agitated with a high CIWA score. Other test were ordered to rule out any other possible causes to patient behaviour. Most were normal and some were slightly outside range. Antibiotics admin – due to possible risk of sepsis. CT scan – nothing acute.

Vitals P – 120, R – 32, BP – normal, slightly elevated, SPO2 97% on RA. T – normal.
Consult to regional hospital for transport due to the inability to maintain current treatment plan for patient.
Change in patient condition next day.
Vitals – P - 110, R- 32, BP - normal, SPO2 – 87% now on NRB @ 7LPM increase SPO2 to low 90s, T – 38.2 with acetaminophen suppository. Soft restraints due to increasing agitation and being altered – GCS 6 (2/2/2)

Lungs and heart normal. SPO2 – solid reading at 97% on NRB – changed to NC @ 2lpm with patient maintaining SPO2 in low 90s once sedation started to take effect.
Considerations for intubation for transport – don’t think it is necessary. Consulted with the regional hospital for management.
More diazepam was ordered – last 4 hours received 100mg. Increased dose to 50mg dose IV.
Ketamine - 0.3mg/kg for sedation to 0.6mg/kg (double dose). 50mg ketamine total given. No max dose of diazepam – risk of increased dose is apnea – be prepared to intubate if the patient becomes apneic.

Learning Objectives

1. Protocols sometimes do not match patient needs. This patient required more medications than needed. Don’t be afraid to phone a friend to explore options beyond typical pharmacological intervention.
2. Maintain larger situational awareness. Don’t just assume this patient is a straight-up alcohol withdrawal and be sure to rule out other differential diagnoses.
3. If you have someone who is agitated and you cannot perform interventions have a low threshold to add in a secondary medication.

Factors to decide sedation

1. What is the developmental age of child in front of you?
2. What level of parental insight do parents or guardians bring? Can be great help or barrier
3. What is the sedation/analgesia for?

Case 1 - 6yo with 3cm laceration to foot – very strong. The parent not helpful very anxious. Patent weighs about 25kg.
Dosing based on agitation 5-9mg/kg
- Highest volume per nare is 1ml.
- Highest concentration seen is 15mg/ml.
IM considerations – not worth poking this child with a needle due to severe agitation and being very strong. Opted for multiple doses of Intranasal (IN) ketamine

Use an atomizer for IN

Tips for IN
- Explain process
- Lay supine – use of staff if not cooperative
o Once med in is to use
- Use 3 ml syringe
o More stable less space to compress
- Give 30 seconds to admin second dose

Case 2 - 21-month-old ICU/ECMO survivor who suffered from a stroke causing some lower extremity mobility issues.
2cm Laceration to forehead
Very agitated
Mom and aunt very patent/calm
IV placed - young enough to overpower and hold for an IV.
- Have mom hug patient with arm around back and have staff hold arm to start IV.
Patient weight 12.5kg – dose at .3mg/kg – upped it to .4mg/kg for total dose of 5mg of ketamine
Patent started to react quickly but was still fighting having vitals assessed
- Waited until sedation took greater effect
IV propofol – normally 0.4mg/kg is starting dose, patient given initial dose of 5mg. This was not enough due to patient age and agitation. Doubled dose of 10mg and then given subsequent dose of 5mg. In total patient had 25mg to achieve desired effects
IV meds allow for better titration

Case 3 - 7yo with fishhook stuck in lower leg.
Use of technology to help distract patients TBID tablet-based interactive distraction.
Screen time plus parental present equates to .5mg of midazolam.
Talked to pt about process and was able to discuss just use of lidocaine.

Takeaway
Can use ketamine as a solo agent. Exceeding doses of 9mg/kg consider risk of dissociation
IN midazolam and IN Fentanal are also acceptable use caution
- Higher probability of managing apnea
- Ketamine has higher risk of salivation – have suctioning ready
o Can also potentially cause laryngospasam. Manage with aggressive jaw thrust and BVM
IN Ketamine 5-9mg/kg
- Use 3 ml syringe
- Divide per nare
Target is not to have them sleeping, rather sufficient amnesia and reduction of pain is goal
Sedations need to be titrations

Phase two – Diagnosis

Review - 70yo male - unconscious, bradycardia – EMS tried transcutaneous pacing, intubated

- Now stabilized

☙ Blood work

- Full septic workup

- Extended electrolytes

- ABG including lactate

o Want to know if ventilator settings and ETCO2 readings are adequate - PaCO2 and his pH.

☙ ETCO2 reading 24 LOW (Normal PaCO2 between 30-40. Normal ETCO2 35-45)

☙ PACO2 – 34 within range

- Know the delta to correct for the ETCO2 is to add 10 points to get PaCO2

☙ EKG – junctional rhythm (no p-waves) at 60bpm, with wide QRS – left bundle branch block (LBBB)

- LBBB can hide ischemia

Wide QTC (580ms)– can be a sign of hypomagnesemia

- This area of Fort St. Knowwhere has endemic problem of hypomagnesemia

- Alcohol combined with malnutrition in area is leading cause of hypomagnesemia

- 2g of magnesium over 10 min – decreased QTc to 560ms

o Reduce risk of Torsade’s de Point

☙ Past Hx

- Known cardiovascular history

- T2DM – BGL 10

- Depo shots to treat schizophrenia

☙ Need to worry about structural brain issues causing LOC

- CT Scan – normal

- Didn’t add to treatment of patient

- Risk of transport for scan (med pumps, ventilator maintenance)

☙ Ultrasound – made larger difference in prognosis in patient

- Electrical mismatch

- Hypoperfusion

☙ Labs

Troponin 0.2

WBC – 13

Mag – 2.12 drawn before giving magnesium

Electrolytes – potassium normal

Lactate 1.7

GFR – 9 down from baseline of 30

- Probably renal problem that is acute in nature

Final diagnosis - Primary pacemaker problem in heart

- Probably needs a pacemaker

Phase 3 – Transport

40min on phone talking to specialist for site to sent to

- Needs pacemaker and dialysis

Patient breathing on his own – kept on ventilator due to patient needing flights out (5 hours by ground transport)

Take home points

1. Important to maintain high-level view to establish priorities.

2. When in resuscitation mode you need to be aggressive until patient is stable.

3. Diagnosis phase comes once patient is stabilized. High effort diagnostic procedures can be deferred (CT Scan).

4. Try and assign team to multi-task when possible. Walk and talk – ex. getting history while putting on BP cuff.

5. Ultrasound made big difference in rapid diagnosis of cardiogenic shock within 60s.

Case: 70yo male found unresponsive at home (large man but not obese - BMI 28-29) BP 70 Pulse 40. Paramedics IV bolus of crystalloid, Intubate, transcutaneous pacing @ 100BPM using 100mA – unknown if truly captured

Hx – pt doesn’t see doctors often, saw cardiologist x 2 weeks ago unknown what was discussed.

- No time to review records online due to patient being unstable **Don’t get caught up in computer info. Treat the patient**

Vitals at hospital

BP 82/40

P – 100 (unknown underlying HR)

T – afebrile

R – ventilated by hand 16-20/min

SPO2 – 99% on 15 lpm BVM

ETCO2 – 20-25

Physical Assessment

- Femoral pulse – slow? Query ability to palpate.

- Use of ultrasound to visualise heart – see it beating independently of pacing at 40bpm with pool LV contraction. No RV enlargement, no pericardial effusion.

- Differential Diagnosis – could be poisoned myocardium, consider electrical block

Find out goals of care – R1 - full resuscitation

Stopped Transcutaneous pacing as it is not working. Consider changing of patch placement to anterior/posterior.

Pharmacology – norepinephrine typically preferred vasopressor – takes time to set up (5-10 min).

- Consider epinephrine– 1mg in 1000ml NS (doesn’t matter if you use 1:1000/1ml or 1:10,000/10ml so long as your total dose of epi is 1mg) for total concentration of 1mcg/ml.

- Pacing at 70bpm with A/P pad placement at 200mA, and epinephrine running – new BP 157/95

o Titrate the Epinephrine IV down to lower BP to more optimal range.

o Pacing: lowered the mA (from 200mA to lowest possible setting to keep capture) and bpm (from 75 to 65) on monitor – heart rate remained the same at 70bpm despite the changes in settings

*Always monitor patient/mechanical output and not the monitor*

Ultrasound now showing better left ventricular(LV) contraction. Eventually discontinued epinephrine drip once BP at 110/70. Changed to nor-epinephrine. Started at lowest dose due to hemodynamically stable.

- mcg/kg/min is calculated dosing

Know your vasopressors alpha and beta effects.

- Nor-epinephrine – has greater alpha and slight beta effects.

- Epinephrine – strong alpha and beta effects.

Find dosing based on weight and titrate.

**Frequent titrating is key**

☙ If arterial line available, use them as they give beat to beat measurement of actual BP and mechanical HR, as well as drawing off any lab test.

☙ Non-invasive BP cuffs are least reliable measure of blood pressure in extreme highs and lows and take time for results.

☙ Ventilation – still being hand bagged. Not optimal treatment as if you hyperventilate a patient to much or for too long you can cause infarcts in brain. CO2 levels in blood are important – use of ventilators important. Use of pressure support control to help support patient with his own breathing.

Dr. Reuben Strayer – Experience with gabapentin

Has abuse liability/potential. Some degree of euphoria and sedation. Many people who use opioids gabapentin provides a complementary bump to how opioids make them feel. Still questioning if gabapentin can increase risk of overdose with opioids.

Not overly concerned with people taking too much or being on gabapentin as the risks for overuse not deadly. Doesn’t cause impairment (except in elderly patients and renal patients) and is completely cleared by kidneys.

Gabapentin toxicity – causes confusion, stumbling around, falling, and sedation
- Not comparable to addiction concerns with opioids and benzodiazepines

Used in alcohol withdrawal and abuse – starting dose is 300mg tid daily

Used in a variety of different treatments. Do not see the same drug seeking behaviours concerning addiction around gabapentin use compared with opioids.
- Does not deny there are not inherent risks and acknowledges it might be different
based on location, but in personal experience and literature Dr. Strayer has not found any evidence to suggest gabapentin as a drug of abuse.

Epiglottitis

☙ Cause of sore throats are often viral and do not require antibiotics.
Case - 45yo female with sore throat – seen day before in ED who did not take the prescribed pain medications.
Vitals
P – 125
BP – 135/85
T – 37.8
R – 18
Spo2 – 95% RA

Alert and oriented, sore throat x3 days (colleague diagnosed with viral pharyngitis – throat swabs with culture and sensitivity done previous day, and manage symptoms with over the counter analgesic and regular hydration)

☙ Patient is back due to minimal pain relief despite 6 tablets of ibuprofen, and a noted change in voice, newly coughing yellow phlegm

Exam - Able to swallow, and denied any neck stiffness, shortness of breath, trismus, headache, or photosensitivity. Protecting airway with no drooling and managing secretions well. Swelling below the chin which was new. Neck supple but pain with range of motion but had appearance of bulls neck. Oropharyngeal exam dentition was poor. No induration below tongue. No uvular deviation. At the back there appeared to be large fungating mass.

☙ Hx – tonsillectomy in childhood.

☙ Tx

- Labs – CBC (WBC – 21.9)

- 12mg dexamethasone PO

- IV ceftriaxone

Consult – ENT – lingual tonsilitis

- Added IV Metronidazole

- Reassess in 24h - Reassessment next morning – patient improved, ENT recommended another 24h observation and continue with IV antibiotics and steroids and if still improving could go home on oral amoxi-clav. Patient still improving – reassessed and follow up with ENT to ensure that mass was not malignant, and that she did have epiglottitis

Discussion points

☙ Lingual tonsils

o Posterior and inferior to tongue and superior to epiglottis

☙ Lingual tonsilitis – inflammation and infection of lingual tonsils and typically has a degree of epiglottitis that accompanies it. If left untreated it can lead to severe airway compromise.

☙ Epiglottitis is rare due to vaccination against Haemophilus influenzae type b (Hib)

o Can also be viral, and caused by staph or group A strep

☙ Consult with ENT to discuss use of fiberoptics

☙ Soft tissue lateral x-ray to see if there is thickening of epiglottitis

Management

☙ Previous understanding was that epiglottitis was acute airway concern, but some can be managed with antibiotics and sterioids. Many still need to have airways managed.

☙ Stick to meds you know best

Approach to throat pain – any patient of any age

- Vitals and appearance

o Are they drooling, any change in voice – does voice sound muffled

o Stridor?

o Difficulty speaking

o Tripoding

o Difficulty or inability to lay flat

- Specific symptoms and risk factors.

o Quick onset and progression over days is more dangerous and typically suggests. more sinister cause

- Red flag symptoms

o Trismus

o Odynophagia to dysphagia to inability to handle secretions (drooling)

o Neck pain with or without movement – if unilateral thing peritonsillar abscess

o Dysphonia dyspnea

- Contacts

o Strep or virus

o Mono

o Sexual contacts

- Medications

o Are they on an ACE inhibitor – Angioedema

- Diabetic

o Can increase risk for intubation in epiglottitis

- Any immunocompromise

- Vaccination status

**If concerned about airway do not stimulate them to much as it can cause laryngospasm**

Exam – look for

- Lips – swollen or normal

- Neck – lymphadenopathy, range of motion/pain.

- Oropharynx

o Dentition – poor? Risk factor for significant oropharyngeal infections

o Tonsils – any exudate? Any unilateral swelling?

o Under tongue – any woodiness or swelling (Ludwig’s angina)

o Tongue – thrush?

- Uvula – swollen? deviated?

- Lungs – any stridor

Bedside ultrasound – looking for peritonsillar abscess, can use to look for epiglottitis and retropharyngeal abscess.

Differential diagnosis of sore throat

- Most benign

o Pharyngitis (viral or bacterial)

o Mono

o Thrush

- Life Threatening

o Angioedema

o Ludwig’s angina

o Epiglottitis

o Bacterial tracheitis

o Peritonsillar abscess

o Retropharyngeal abscess

o Uvulitis

o Lemierre Syndrome – Septic thrombophybitis to the internal jugular vein that due. to extension of soft tissue neck infection.

Treatment

- Labs – CBC, CRP, Cultures

- X-ray – lateral soft tissue

- Epiglottis – appears like a thumbprint – wider than 6.3mm (75.8% sensitive, 97.8% specific)

- Retropharyngeal abscess – look for swelling in prevertebral/retropharyngeal space.

o >7mm at C2 abnormal

o >14mm in kids abnormal at C7

o >22mm in adults abnormal at C7

- Bacterial tracheitis – look for subglottic narrowing (steeple sign)

- CT Scan

- Fiberoptics

Treatment – management of unstable airway – ideality have anesthesiology or ENT to back up. Call in additional help

- Mark the neck in preparation for possible cricothyrotomy.

Best approach is an awake intubation.

- Preoxygenate with NC

- Topical lidocaine

- Sedate with benzodiazepine and ketamine – lightly

- Use fiberoptic scope, then use video or direct visualization.

- Once tube is secure induce the patient with propofol

*Do not paralyse them as it may cause you to lose the airway*

03:18 – use of ultrasound in day-to-day practice
04:55 – when to use over other technologies
06:30 – use in procedures and diagnostics
07:30 – working in isolated community – ferry access for ground transport or flights
08:30 – having support in community and getting comfortable with own practice
09:25 – knowing where to find info and when to consult
10:30 – Dunning-Kruger effect
11:30 – advise for rural family medicine
12:40 – importance of locum and finding community to support
14:00 – BC government support of family physician
14:50 – discuss change in fee for service
16:50 – incentivised to clinic hours
17:50 – advise for people to train for ultrasound or do fellowship
19:00 – need for basic skills of locum – FAST, lung, cardiac
20:15 – fellowship discussion – need to invest with time
21:49 – scholarships and bursaries to cover ultrasound training
22:05 – self-study – online learning

Case 1 - Paraphimosis of 26yo male with ongoing issues x 1 week. Tried to retract head of penis night before coming into emerge with no success.

☙ phimosis – where foreskin orifice is to small to retract and is stuck out at distal tip of head of penis. Typically, men able to urinate. Can lead to collection of bacteria leading to infection and swelling. Can lead to sexual disfunction. Typically, not urgent
Paraphimosis – ring of foreskin can retract over the head onto shaft of penis. Still tight enough to cause slight compartment syndrome. Swelling at distal end of penis causes venous constriction – no adequate drainage.
- More urgent

Need to get fluid out of end of penis to allow for adequate drainage.
☙ Treatment – penile block which is basically a ring block but around the base of the penis.
Big concern is causing trauma
1% lidocaine in two locations. Pubic symphysis put 2/3 (12-13ml) lidocaine in and second location is inferior aspect of penis – shaft scrotal intersection about 1/3 (6-7ml) lidocaine.
Do NOT use lidocaine with epinephrine
Give block enough time to take affect min 15min.

Urologist stated that procedure can be done without anesthetic.

Reduction – get fluid out of head of penis with manual constriction. Squeezed as much as possible. Squish in conical motion.

Urologist – Expect popping sensation from patient because it is possible reduce things enough to have the skin of the foreskin can slip over the head of the penis and look more normal, but you haven’t actually moved the head of the penis or the shaft through the constriction ring. Make sure you feel for no constrictive band.

Post procedure – avoid sexual activity, masturbation, erection until penis has returned to complete normal size and function. Avoid for 2 weeks.
☙ Consider referral for circumcision – if it happened once can happen again.

☙

Case 2

50 yo female with lumps in inguinal area bilaterally. Today right side lump worse and painful.

☙ Left larger – reduces with change in posture

☙ Right – hard and unable to reduce

Ultrasound – mass seen above facial plain. Nebulous looking. Color flow had periphery of vessels and no strangulation.

Pt needed surgical intervention. Previous hernia repair had mesh plug that goes into inguinal canal to prevent bowel from going into canal. Plug moved into canal and was causing the discomfort.

☙ Able to fix left sided hernia at same time.

Case 3

Late 40s male with 30pack year history smoking - COPD exacerbation – 5 days SOB no meds helping.

Initial SPO2 65% - ash grey color. Resp Rate (RR) 54

Methylprednisolone, Ventolin MDI, face mask @ 10L/min with improved SPO2 93% with RR of 45

Lungs –Right side wheezes with poor air entry. Left side almost silent despite 20min of treatment.

IV salbutamol

☙ 5mg/ml concentrate that you would put in a neb.

☙ Draw 1ml (5mg) into 9ml of NS for total of 5mg/10ml. 500mcg/ml.

☙ Use a 1ml syringe and fill to 1ml line. This equals 250mcg/1ml – Administer dose between 100-250mg. Flush with NS.

Within 30s SPO2 increased to 97% and right lung wheezing subsided dramatically. Left lung has good air entry with slight wheezes. RR – 24 and SPO2 almost normal. Monitor for several hours due to potential for tachycardia and to ensure treatment effective.

*Patient acidotic and hypercarbic . Use caution if considering intubation.

Learning Objectives

1. What is approach to acute non bloody diarrhea
2. Treatment and management of infective colitis
3. Anchor bias – how to avoid

Case 50yo female – syncopal episodes following two day history of large volume non blood diarrhea every 15-30min of mostly water. No vomiting, nauseous from dehydration. Decreased PO intake and urinary output. No recent travel, known exposure to illness, or recent antibiotic usage.
- Recent visit to ED had resulted in pt taking three different NSAIDS daily (for chronic back pain)

1. What is approach to acute non bloody diarrhea

Vitals – BP 95/65, no tachycardia, no fever

Past history – HA, GERD, chronic back pain

Labs

- Creatinine 436

- Elevated urea

- All other labs normal

- No anemia or hemolysis or hematuria

suggestive of hemolytic urea syndrome (not seen in E.coli)

IV boluses to replenish hydration. Admitted to hospital with ongoing 250ml/h fluid replacement

2. Treatment and management of infective colitis

Abnormal Left shift with CBC

IV Ceftriaxone

CRP – 408

- Don’t normally see such a high CRP in a viral infection or low grade

infection

Ultrasound scheduled to check kidneys – changed to CT pelvis to have better look

- Severe pancolitis

- Transmural thickening and free fluid

- No perforated bowel, ischemic bowel, or bowel doweltations or toxic

mega colin

Blood cultures positive for salmonella

- Risk factors – poultry, turtles, reptiles

o Had canned oysters that tasted funny

o Feed dogs raw diet

o Has a turtle

Day 3 started having bloody diarrhea

Creatinine started to normalize

CRP trending down

Antibiotic therapy for salmonella can fluctuate based on sensitivity. Based on patent presentation both with labs and overall patient stating feeling better infectious disease consult agreed with treatment and continue with empiric therapy.

- Duration of antibiotic therapy – initially considered 7 days

- Due to source being GI bacteremia it is appropriate to treat for 10 days

with 3rd generation cephalosporin

PEARLS – duration of treatment depends on site of infection

- Bacturemia that occurs in immunocompromised patients as well as extremes of age more frequently associated with osteomyelitis. Seeding of bacteria in the blood stream and often have a propensity for seeing into the growth plates in children as well as in osteoarthritic joints. Treatment increases to six weeks.

- In healthy middle aged adults (non-diabetic) with known source of infection 10 days is sufficient

- Given severity of this patients infection – need to screen for HIV and immunocompromised

- Due to nature of infection treatment sufficient to move to PO antibiotics cefixime started for reminder of 10 day treatment

- GI consult recommended continuation of Tinzaparin for DVT prophylaxis until resolution of diarrhea

3. Anchor bias – how to avoid.

Initial impression of case and anchored to that presentation and trying to have new information fit into patient presentation.

Reviewing case with colleagues was helpful to identify key pieces of information that changed thought process for diagnosis and treatment.

If you have to convince yourself of something – take a deeper look into it. If something benign shows up take a pause because something more severe can be hidden in subtle changes.

***Be open minded***

Talk dedicated to Elana Fric – Murdered by intimate partner.

Intimate Partner /Violence (IPV) – refers to any behaviour within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship.

Power and Control – Current or past relationships

Rule of Thumb – based on 1700 expression that was the thickness of a stick a man was legally allowed to beat his wife with

Statistics
Global – 1:3 women affected
Health impact
- 2x more likely to suffer depression
- 2x more likely to suffer alcoholism
- 16% more likely to have low birthweight baby
- 42% experience sexual or physical violence at hands of partner resulting in injuries
- 1.5x more likely to acquire HIV
- 1.5x more likely to contract syphilis, chlamydia, or gonorrhoea
- 38% of all murders globally reported as being committed by intimate partner

Canadian Statistics
- Prairie provinces have higher rates of IPV
- 4/10 women affected
- 1/3 of men affected
- 3x more likely to be afftected than any other province
- 11% of ALL crime
o 71% involve current partner
o 29% involve previous partner
- 47% of women homicide related to IPV (1 ever 36h)

Leaving is the riskiest behaviour – Homicides are greatest in times of separation

Homicide is a leading cause of death in pregnancy NOT obstetrical emergencies/complications

Impacts of COVID on Violence
- Reporting decreased
- Increased calls to police
Economic Impact – 2009 government look at dollar figure associated with IPV – 7.4Billion
People are more likely to disclose to ED rather than family physician
44% of murdered women accessed ED, 93% had IPV related injuries – only 5% of physicians recognized IPV.

Signs/symptoms/suspicions
- Injuries at different stages of healing
- Posterior rib fractures
- Unexplained injuries, such as bruises, fractures or burns
- Injuries that don’t match the given explanation
- Late presentation of injury
- Untreated medical or dental problems

LISTEN
- Sit down and look at patient directly and truly engage and ask if they are safe

Tools – 13 screening tools
- WAST
- HITS
- OVAT

Medical Management comes before forensic considerations. Give patent complete autonomy and inform them of everything you are doing.
CTA for strangulation injuries – document if you consider it.
In Canada you CANNOT breach confidentiality if you do not get consent in an adult unless there are children in the home (even if they are not suffering the abuse)
Referral to specialized care. Website to consider
https://www.sadvtreatmentcentres.ca

Documentation
- Use patients own works
- Write out exactly what patient was saying
- Never use words “claims, alleged”
- Do not use other words to describe abuser such as perpetrator/assailant
- If the clinics observations conflict with the patient statement record reason for difference
- AVSS NAD – do not use

Diagnosis – you can write IPV/domestic violence

Takeaways – Listen, Be Kind, Be Curious

Link to Video: https://vimeo.com/822556396/5cbc1b0084

General approach to resuscitation and critical care problems.
ACRON – CPS.ca - Disclaimer – no financial benefit to promoting

Case - Call to help with maternity case – preterm labour – unable to transport. Baby born arrival (4 min later)
- G5, A1, T4, P1 (previous twins). 35weeks 6 days.
- Baby looks well

ACRON – basic concepts - Points to consider (scores)

☙ Respiratory

☙ Cardiovascular

☙ Neurological

☙ Surgical

☙ Fluid and Glucose

☙ Jaundice

☙ Thermoregulation

☙ Infection

Consult with specialist who recommended based on baby not acutely sick and stable.

- Keep warm, feed baby, check BGL q2, draw cultures, and admin ampicillin and gentamycin – specialist helped calculate doses

- Discussed urgency of needing cultures due to tertiary centre 25min away and comfort of staff in obtaining sample

o Recommended trying up to two pokes for labs and if unsuccessful waiting till tertiary centre.

o Discussed with mom – overwhelmed unable to give definitive answer.

o Discussed with maternity nurses – consensus was to wait.

Transport – logistics

- Dispatched Neonatal team – unable to use one the night of and needed to wait (approx. 3 hours)

- Debated between ground vs air – opted for ground due to patient being stable.

- Delayed ground transport due to resource scarcity.

Takeaway – take the time to organize (if patient condition allows) to show specialist that you have made an effort to find answers to patient presentation with information such as scores mentioned, vitals, weight, etc.

Case:
70yo male involved in MVC rollover at highway speed at approx 0600h
- fell asleep at wheel, no clear medical cause (queery intoxication?)
- Wearing seatbelt no airbags deployed

Pt presented to ED 12 hours later after going home to sleep
☙ Chief complaint - lower back pain
- physical exam - complains of pain to shoulder
- ATLS assessment and remainder of exam unremarkable
☙ past medical history
- Polysubstance abuse
- Opioid dependency
☙ Vitals - Stable
- patient falling asleep when left alone but easily roused

Issues surrounding patient care
☙ at a site that does not have beds to admit patient for observation
☙ Patient remained in ED for monitoring of signs of deterioration. 125ml/h NS to motivate patient to have to pee in the morning. Toradol and Tylenol for pain over night - patient able to sleep
☙ no immobilization due to pt free moving since accident and walking on own. No POCUS - no pain to indicate need.

Next morning assessment
- patient still c/o pain
- Ordered X-ray - Chest, Lumbar spine, Pelvis

Findings - Compression fracture of L2-L3 unclear if acute or ongoing compression fractures.
- Uncomfortable walking but able to remain strong and balance

Pt Discharged home still complaining of left shoulder pain, chest wall, and lower spine
Radiology called after discharge to discuss concern if patient has apical cap – concerned for possible pneumothorax. Subtle fracture of 4th rib. Recommended CT scan to check.
- Attempted to contact pt - called family and multiple agencies to locate
- Family took pt to regional hospital - Contacted site to inform of concerns.

Take Aways
☙ Standard of care differs in rural vs city (different resources available)
☙ Programs through Canada that allows physicians who are isolated/only practitioner on site that they have colleagues to consult with

Content and Timing

2:50 – Routes to becoming an emergency physician

3:22 – FR program – 5-year program

4:15 – Exam year in 4th year

5:00 – Royal college of physicians and surgeons vs college of family physicians of Canada

5:49 – Third option for emergency medicine

7:05 – Exam – written component and applied component

9:44 – What does exam year look like CITE exams throughout

11:50 – Exam based off of Rosen textbook

14:26 – Exam prep what average week looks like

17:17 – Advise to those looking at program

18:50 – Mental health – finding routine and breaks to help decompress

21:10 – Pressure in health care education

LEARNING OBJECTIVES:

☙ When to consider diagnosis of pulmonary embolism
☙ Tools
☙ Transport and management

1. When to consider diagnosis of PE

- Different presentations – anyone with chest pain, breathlessness, low SpO2

☙ 50% of PE come from DVT origin in leg. Lower in DVT in arms, many with unknown cause

2. Tools

- ECG – not overly helpful about 44% of patents have sinus tachycardia. Changes to look for S1, Q3, T3 – Deep S wave in lead I, Q wave in lead III and inverted q wave in lead III – not overly sensitive to help with diagnosis.

o Any right heart strain findings – Right Bundle Branch Block (RBBB), right axes deviation, right ventricular strain pattern in leads II, III, AVF.

- POCUS – visual on right ventricle – is more sensitive than EKG.

o Wedge infarct

o Assess for RV strain – when RV is larger than 0.7:1 ratio. When ratio is 0.9:1 is easy to think it is normal.

o DVT

o D Sign – D shaped septum – left ventricle forms D shape when it should be round. Peri sternal short access – evident when interventricular septum is being affected such as paradoxical movement or early right ventricular overload.

- Labs – D-Dimer – qualitative test needs to be above the cut off. Degree of elevation does not influence severity or likelihood of thrombolytic disease.

o Major trauma or some inflammatory disease can impact lab.

o WELLS and PERKS score – if pre-test probability low - don’t order lab.

3. Transport and management for CT scan

- Apixaban

- Stable patients can wait for scan or go with family or alternative transport and unstable patients with ambulance. Consider what resources are readily available.

https://srpc.ca/rr2023

https://emupdate.ca/

https://ubccpd.ca/learn/learning-activities/course?eventtemplate=430-bc-rural-health-conference-2023

LEARNING OBJECTIVES:

☙ When to consider PE diagnosis
☙ What tools in rural hospitals, med toolbox to assess likeleyhood of PE
☙ Nuances of management and patent transport

PE - generally difficult to diagnose. No reliable historical or exam factors. Rely on risk factors, Gestalt principals.

First Patient - 44yo female with c/c left sided chest pain for one week.

- Vitals

o BP – 156/117

o P – 110

o R – 24

o Spo2 – 95% RA

o T – 36.7

☙ Assessment – uncomfortable, anxious, chronic smokers cough (pack a day smoker). Complains of pain laughing, coughing, and palpation. Not feeling SOB. No swelling in legs.

☙ Positive history – recent thrombophlebitis in R arm dx 2 weeks prior. Taking aspirin. Unprovoked DVT In 2017. Chronic hip pain on Percocet and duloxetine. Benign lesion in liver.

☙ Med review – oral contraceptive x 15 years stopped two weeks ago

☙ Physical Exam: CVS normal. RESP clear air entry throughout. No b-lines, good slide bilaterally. No ventricular strain. MSK normal no swelling. Pain on palp to chest wall

☙ Differential dx – ACS, PE, msk costochondritis, ruled out pneumothorax, dissection , and boerhaave's

☙ Treatment - ECG, Labs - normal (except lightly elevated platelets), **D-dimer - 5172**

- Dose of apixiban and sent off for CT - confirmed bilaterally pulmonary emboli with moderate clot burden and no evidence of heart strain.

*** Ultrasound – put over top of where pain is – linear probe for high-definition changes in plural line – if localizable – look to see if there is a reverse pyramid sticking to bottom of pleura -wedge infarct – highly suggestive of PE. Look at legs if patient has history of DVT

POCUS Study - looked at 1. Wedge infarct 2. Right ventricular heart strain 3. DVT

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366382/#:~:text=Point%2Dof%2Dcare%20ultrasound%20(POCUS)%20can%20be%20used,angiogram%20or%20further%20diagnostic%20testing

- https://onlinelibrary.wiley.com/doi/10.1111/acem.13774

- https://litfl.com/ecg-changes-in-pulmonary-embolism/

- https://radiopaedia.org/articles/pulmonary-embolism

- https://www.mdcalc.com/

Second Patient - 78 yo female – complains of SOB x 2-3 weeks on exertion relieved with rest

Vitals

- Pulse – 94

- Temp – 36.4

- BP – 112/75

- R – 22

- Spo2 – 89% RA

☙ Past Hx – CKD, MS, overactive bladder, chronic back pain, left breast ductal carcinoma treated with mastectomy and radiotherapy

☙ Exam - Alert, no respiratory distress, able to speak full sentences, good air entry. Calves no tenderness or swelling. . No pain, no chest pain, no hemoptysis, no swelling or pain in legs

☙ Meds – zopiclone, cetirizine, gabapentin, rabeprazole,

☙ POCUS - no B-lines, good lung sounds, thickening of right ventricle – almost as thick as left side. Hindsight – query if dilated. No Pneumothorax.

Differential Diagnosis – plural effusion, CHF

☙ Tx - ECG – appeared normal, Labs – normal except CBC – new thrombocytopenia (consulting physician thought thrombocytopenia was consumptive process from the clot), Chest x-ray – normal

Consult – recommended D-dimer and trial diuresis – if she felt better after treating would lean more towards CHF. ***D-dimer – 15000***. Started apixaban – and send for transport with pt daughter.

Radiologist – Saddle PE extending into multiple segmental and subsegmental arterial branches with r greater than left with findings of r heart disfunction elevation of RV to LV ratio

057 Pediatric Potpourri - Finger nail, Nasal FB, H.A.T, intranasal sedation

Published: 1 Apr 2023
https://podcasters.spotify.com/pod/show/jonathan-wallace-md/episodes/Pediatric-Potpourri-finger-nail--nasal-FB--H-A-T---intranasal-sedation-e20bevj

Avulsed Fingernail

4yo female finger slammed in door. Nail pulled distally out from nail bed from proximal nail fold. Nail intact but shifted.

Consult with plastic surgeon – don’t need to do anything. Conservative measures due to nail matrix likely to be intact. Keep wound clean and dry, wash with soap and water, wrap with cling gauze.

Nasal Foreign body
2 ½ year old with Styrofoam up nose.

Typical treatment is for parent to do mouth to mouth while obstructing unaffected nare. Causes startle response and glottis to close allowing for pressure to build up behind foreign body to pop it out – very effective.

Parents attempted mouth to mouth with no effect, tried to hook it and did not help.

Consult ENT – recommended leaving foreign body in for a week and allow for mucous to coat foreign body (cautioned it would start to smell) to allow for it to be removed without worrying it would break apart.

Head Laceration

PECARN - MD Calc website tells risk – if imaging, monitoring, or nothing.
Leave print out with parents on how to manage head injuries.

HAT - Hair Apposition Technique – use hair to close wound and apply skin glue
https://www.youtube.com/watch?v=Aj9chhWJfPo&ab_channel=BrianLin

Pediatric sedation – Intranasal ketamine and some screen time
The younger the patient the higher the amount of anesthetic
3-9mg/kg – the more upset they are the higher the starting dose

LEARNING OBJECTIVES:

☙ Terminology
☙ Risk factors:
☙ Treatment

Peak ages <5 yo, 15-24yo, and Elderly

Near drowning no longer used - Drowning does not have to be a fatal even and is defined as respiratory impairment or failure from submersion event. It can be immediate or within a few hours. Salt vs fresh water drowning does not change managment.

Risk Factors associated with drowning

☙ alcohol

☙ syncope

☙ seizure

☙ cardiac events

☙ suicide

Injuries associated with drowning

☙ hypothermia

☙ spinal injury - very rare (0.5%) only use cervical precaution when history dictates

☙ aspiration

Treatment

☙ manage any hypothermia - disrobe, warm blankets, bear warmer

☙ antibiotics - NOT given. Many practitioners concerned about composition of water and bacteria but what is more important is the volume injested and how long they were submerged for.

☙ BiPAP - if unable to maintain SPO2 - Know the difference between patients fighting BiPAP and being fatigued. Fighting BiPAP is when patient unable to sync up with machine.

☙ Intubation - use lung protective strategies similar to those for ARDS

☙ propofol used rather than ketamine due to ketamines side effect of increased secretions (though it was not contraindicated in this patient)

☙ https://rebelem.com/benefit-lung-protective-ventilation-ed-lov-ed/

*** patients are sensitive to pressure. If you have two HEPA filters (one on tube, one on ventilator) it can dramatically reduce pressure getting to patient ***

- you can always call and phone or video consult with RT

Concern with drowning is washout of surfactant causing non-cardiogenic pulmonary edema. This can be significant if patient is requiring intubation and can cause fluid to fill airway. Have yaunker suctioning to help with fluid and secretions.

LEARNING OBJECTIVES:

Head trauma with PEA

Learning Objectives

* How to tell if fluid draining in head injury is cerebral spinal fluid (CSF)

* Management of fluid obscured airway

* PEA with head injury management

Case: man in his 80s fell and hit his head. EMS responded and pt was alert and talking with EMS. When EMS went to sit pt up blood and clear fluid were noted from patients left ear. Patient reported feeling dizzy and unwell and proceeded into cardiac arrest. CPR in progress as EMS arrived at ED and after several minutes of CPR, ROSC was achieved.

Head to Toe

☙ Airway - snoring respirations

☙ Circulation - pulses present in all limbs and normal S1, S2

☙ LOC - Obtunded

* Bruising behind left ear with positive ring test (halo) of blood around clear fluid on gauze or tissue.

☙ NOTE: fluid can come from two places - otorrhea and rhinorrhea. To determine if fluid is CSF vs snot you can use either a glucometer or urine dip to see if glucose is present. Positive for glucose=CSF

Tests

☙ Labs - including cardiac markers

☙ EKG - showed sinus rhythm. Compared to EMS - PEA

☙ FAST - Negative

☙ CT scan - Head to neck showed clear fracture in occiput into left external auditory canal. No blood noted.

*Intubated - even though pt appeared unconscious still gave sedation to make sure pt would not remember.

☙ Cords visualized and immediately fluid and emesis filled airway

☙ SALAD - Suction Assisted Laryngeal and Airway Decontamination

☙ insert largest suction device down to esophagus to clear away fluids while intubating

☙ NOTE: video laryngoscopy not always helpful in this airway due to video being obscured with moisture.

LEARNING OBJECTIVES:

Treatment
☙ cyclobenzaprine
☙ gabapentin
☙ ketorolac
☙ Consider anxiety and emotional distress
Discharged and sent with prescription for gabapentin and to return to ER if pain gets worse.
Differential diagnosis - did consider compartment syndrome, no trauma or acute MSK injury, possible previous re-inflammation of previous shin splints
High suspect of disproportionate pain
☙ necrotizing fasciitis
☙ compartment syndrome
Consider Disproportionate Pain (or other Sx)
☙ lots of times it may be nothing (e.g. anxiety contributions), but once in a while it will be something
☙ in those cases Disproportionate Pain may be the only clue early on.
☙ keep your antennae up! Go slowly. Tread lightly.
Links

https://www.ncbi.nlm.nih.gov/books/NBK544284/

https://www.youtube.com/watch?v=XXp0EtKtlF8&ab_channel=EM%3ARAPProductions

https://www.youtube.com/watch?v=H2Sj1v_yDVU&ab_channel=Traumavideo

LEARNING OBJECTIVES:

Necrotizing Fasciitis

Risk Factors

☙ Trauma - blunt, penetrating, minor lacerations

☙ Skin Breach

☙ Recent Surgery

☙ Mucosal Breach - Hemorrhids, Rectal Fissure, Episiotomy

☙ Immune Suppression - NIDDM, SGALT 2 inhibitors, Cirrhosis, Neutropenia, HIV, CA,Obesity, ETOH Abuse

Signs/Symptoms

☙ Erythema - without sharp margins

☙ Edema extending beyond area of concern

☙ Severe pain out of proportion for what you think is going on

☙ Fever - tachycardia, systemic toxicity, hypotension (sepsis)

☙ skin crepitus - necrosis/ecchymosis

Priorities

☙ Antibiotics

- Carbapenem - not readily available in rural sites

- Pip-taz

- Vancomycin

- Clindamycin

☙ Transport to nearest surgical centre

Consult and transport depends on where wound is located. General Surgery will manage sites on central thorax, upper arms and thighs. Plastics manage upper limbs down to hands. Urology will get involved if you have a fournier's gangrene. Orthopaedics also involved if wound is in upper and lower limbs

Take Aways

☙ Never forget to addition of clindamycin with Piperacillin Tazobactam (pip-taz) or vancomycin

☙ Surgical consult ASAP to expedite process

☙ Necrotising Fasciitis typically don't fit "normal" picture.

LEARNING OBJECTIVES:

Someone Acutely Intoxicated / Withdrawing / Delusional
☙ doesn't mean that they don't have a concurrent medical problem
☙ Go slowly. Tread lightly.
☙ general approach: sedation as required, time & observation
☙ "Pan Scan" CT is not safe or cost-effective (especially when there is no clear indication / pathology to assess)
Poorly behaved patients require sedation
☙ safety of patient; safety of family / friends; safety of team
☙ lots of options for "non threatening" patients: PO, IV, etc. see Episode 003 for more discussion
☙ threatening patients (e.g. homocidal; active risk to team)
☙ ketamine 5mg/kg IM (e.g. for 80kg person = 400mg = 8mL IM(!)
☙ REMEMBER: you can safely give up to 20mL IM in a single site(!)
☙ probably should intubate for transport (so heavy sedation can be safely continued)
☙ probably DO NOT require paralysis in ER with lots of hands, lots of drugs and continuous monitoring
☙ probably SHOULD be paralyzed for transport, especially in an aircraft
Always Remember to monitor Disproportionate Pain (or other Sx)
☙ lots of times it may be nothing (e.g. anxiety contributions), but once in a while it will be something
☙ in those cases Disproportionate Pain may be the only clue early on.
☙ keep your antennae up! Go slowly. Tread lightly.
☙ don't automatically write things off as anxiety / toxicity / psychiatry
Wise Words of Wisdom (Dr Johnannes Giede, psychiatry)
☙Of all Health Care Professionals:
☙ "We are in the business of Mercy, not in the business of Justice."

Volume 03:

Quick Links:

Volume 03: #051 - present

075 - Neuroleptic Malignant Syndrome - Tox 1 Mini-series

074 - Maternity Emergencies

073 - Procedural Sedation & Anesthetic Agents in Urgent Care

https://pubmed.ncbi.nlm.nih.gov/28160494/https://pubmed.ncbi.nlm.nih.gov/27745766/https://pubmed.ncbi.nlm.nih.gov/16447828/https://pubmed.ncbi.nlm.nih.gov/9051365/

072 - Pediatric Sedation (Intranasal Ketamine)

071 - EMU2023 Airway Panel Discussion

Description: 30 Minute Video from UBC-CPD's GPA Refresher Course (2021)

070 - Cardiogenic Shock (Part B)

Phase two – Diagnosis

069 - Cardiogenic Shock (Part A)

Case: 70yo male found unresponsive at home (large man but not obese - BMI 28-29) BP 70 Pulse 40. Paramedics IV bolus of crystalloid, Intubate, transcutaneous pacing @ 100BPM using 100mA – unknown if truly captured

068 - Gabapentin, Epiglottitis (Feat. Dr. Reuben Strayer & Dr. Narain Verma)

067 - Rural Med Spotlight and U/S Education with Dr. Andrew O’Farrell

066 - Constriction/Herniation Day

065 - Toxic Diarrhea

064 - RnR Program Update

063 Interpersonal Violence

062 - Approach to preterm neonates + other infrequent zebras

061 Muddy Rollover -MVA

060 Royal College EM Exam

Content and Timing

059 Pulmonary Embolism (Part B)

LEARNING OBJECTIVES:☙ When to consider diagnosis of pulmonary embolism ☙ Tools☙ Transport and management

058 - Pulmonary Embolism with Dr. Narain Verma (Part A)

LEARNING OBJECTIVES:☙ When to consider PE diagnosis ☙ What tools in rural hospitals, med toolbox to assess likeleyhood of PE☙ Nuances of management and patent transport

057 Pediatric Potpourri - Finger nail, Nasal FB, H.A.T, intranasal sedation

056 - Drowning

LEARNING OBJECTIVES:☙ Terminology ☙ Risk factors:☙ Treatment

055 - Closed Head Injury/PEA Arrest (Dave Collins)

LEARNING OBJECTIVES:

054 - Disproportionate Pain "The Soccer Wimp" with Kathy Yu

LEARNING OBJECTIVES:

053 - Disproportionate "Rash" Pain (Colton Lewis)

LEARNING OBJECTIVES:

052 - Disproportionate "Pancritis" Pain

LEARNING OBJECTIVES:

051 Rural Ultrasound: Level-Up Your Practice

Quick Links:

https://pubmed.ncbi.nlm.nih.gov/28160494/
https://pubmed.ncbi.nlm.nih.gov/27745766/
https://pubmed.ncbi.nlm.nih.gov/16447828/
https://pubmed.ncbi.nlm.nih.gov/9051365/

LEARNING OBJECTIVES:

☙ When to consider diagnosis of pulmonary embolism
☙ Tools
☙ Transport and management

LEARNING OBJECTIVES:

☙ When to consider PE diagnosis
☙ What tools in rural hospitals, med toolbox to assess likeleyhood of PE
☙ Nuances of management and patent transport

LEARNING OBJECTIVES:

☙ Terminology
☙ Risk factors:
☙ Treatment