Avalanche Resuscitation in the Emergency Department

Image Credit: Wikipedia

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Authors: Vivek Abraham, MS4

Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Ivan Yue, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine
AAEM/RSA Publications and Social Media Committee

Alexander Li, MS4
Medical Student
Uniformed Services University F. Edward Hebert School of Medicine

Introduction
Avalanches are among the most feared events to occur in mountainous areas. Although the morbidity and mortality statistics are underreported worldwide, in North America and Europe combined there are roughly 140 avalanche-related deaths per year.[1,2] The majority of victims include snowboarders, skiers, mountaineers, and snowmobilers. With more people seeking to participate in snow sports or explore the mountains as part of expeditions, preparing to treat avalanche-related injuries is essential for an emergency physician working or traveling near a mountainous area. This article details the resuscitation guidelines that physicians can implement for those who fall victim to an avalanche as well as recommendations for mitigating avalanche exposure risk.

Board Review: Debunking Dysbarism

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Image credit: Brett Seymour

Authors: Patrick Wallace, DO PGY-2

Emergency Medicine Resident

University of Nevada Las Vegas

AAEM/RSA Education Committee

Laurie Bezjian Wallace, DO PGY-2

Family Medicine Resident

Mike O’Callaghan Military Medical Center

Intro
“Dysbarism” collectively refers to diving-related disorders. These disorders are relatively common and range in severity. This topic is high yield on board exams and is also important for emergency medicine providers to recognize so as to administer timely interventions. This article differentiates and categorizes disorders by those occurring with descent, at depth, and with ascent (Table 1).


DISORDERS OF DESCENT
Facial Barotrauma (Mask Squeeze)
Negative pressure within the mask and over the eyes must be equalized. This is often done by exhaling through the nose. Failure to equalize leads to a negative pressure effect on the periorbital and ocular vessels, resulting in edema and subconjunctival hemorrhage.[1,2] Emergent complications are rare but may include hyphema, subperiosteal orbital hemorrhage, and intraorbital hematoma. In these cases, emergent ophthalmology consultation should be obtained as surgery or needle aspiration may be required.[3,4] However, the majority of facial barotrauma cases are benign and do not require treatment.[1,3,4]
Key Phrases: Conjunctival edema, subconjunctival hemorrhage, and petechial hemorrhage after diving.

Blast Injuries

Image by: Samuel King Jr., Team Eglin Public Affairs

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Author: Gregory Jasani, PGY-2

University of Maryland School of Medicine Department of Emergency Medicine

INTRODUCTION
Whether through an accident or intentional act, explosions have the potential to cause injuries to many people at the same time, resulting in significant morbidity and mortality and potentially overwhelming local healthcare resources. The resulting blast injuries are something that all emergency medicine providers need to be able to promptly recognize and treat.

Blast injuries are unfortunately not uncommon. In 2014, there were over 10,000 blast injuries in the United States due to fireworks. According to the Federal Bureau of Investigation, detonation of bombs or incendiary devices caused over 4,000 injuries and 448 deaths in the United States between 1987 and 1997.

Geriatric Trauma: Not Just Older Adults, An Interview with Christopher Colwell, MD

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Christopher Colwell, MD FACEP

Author: M. Kaitlin Parks, MSIV
Medical Student
Oklahoma State University COM
AAEM/RSA Publications and Social Media Committee

Interviewee: Dr. Christopher Colwell, MD FACEP
Chief of Emergency Medicine
San Francisco General Hospital and Trauma Center, Professor, UCSF

Just as any pediatrician would tell you, “a child is not just a small adult”. The same goes for the geriatric population. There are many physiologic differences in the geriatric population that are important to understand in order to deliver the best and most tailored care. An area where this is especially pertinent to the emergency physician is in the setting of trauma. A lot of what we know about trauma has come from military medicine, which sees a strong bias towards the young and healthy. As our population ages, we are seeing an increasing number of geriatric trauma patients in the emergency department (ED).[1,2] Older patients have higher morbidity and mortality in the setting of trauma.[3] Our geriatric patients are also more likely to have comorbidities and medications that both worsen their response (such as anti-coagulation and clotting) or blunt their capacity to compensate (such as beta-blockers and heart rate).[4] Age has been integrated into Trauma Triage criteria but many criteria are based on vitals that may not adequately measure the severity of select trauma cases in the geriatric population.[5]

Pre-intubation Optimization of the Neurocritical Care Patient

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Image Credit: Wikimedia

Author: Tim Montrief, MD MPH
Jackson Memorial Health System/University of Miami
AAEM/RSA Publications and Social Media Committee Member

The catastrophic neurologic emergency remains one of the most challenging presentations managed by emergency physicians. Stress, diagnostic uncertainty, and time-sensitive nature lead to challenging management decisions. Likewise, the intubation of the neurocritical care patient provides many challenges, and requires a modified technique to avoid the harmful consequences of intubation, including an exaggerated reflex sympathetic response to laryngoscopy, hypotension due to induction agents, and exacerbation of elevated intracranial pressure (ICP). Additionally, maximizing first past success and minimizing hypoxia is especially important in patients with central nervous system (CNS) pathology, in particular, unsecured aneurysmal subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), and stroke. Optimization of the neurocritical care patient is of upmost importance, and many of the techniques are familiar to the emergency physician. For instance, apneic oxygenation via a nasal cannula on the patient at 15 L/min maximizes oxygenation prior to intubation. Additionally, one may raise the head of the bed, which decreases ICP and has a ben­eficial effect on oxygenation. While ninety degrees is the ideal angle, elevation of the head of bed to thirty degrees is also an option. Finally, if faced with an agitated, combative patient, delayed sequence intubation (read more about it here) may be an option to optimize preoxygenation.

TXA Literature Review

Author: Alexandra Murray
Mercy St. Vincent Medical Center Emergency Medicine

Originally Published: Modern Resident December/January 2016

What is tranexamic acid (TXA)?
When the body experiences vascular injury, the hemostatic system tries to maintain circulation by balancing the formation and degradation of blood clots. In response to severe blood loss, this balance is challenged and hyper-fibrinolysis can occur. The conversion of plasminogen to plasmin plays a large role in fibrin binding and degradation. Tranexamic acid is a synthetic derivative of lysine that reversibly blocks binding sites on plasminogen and inhibits fibrinolysis.[1] TXA has been approved by the FDA since 1986 as an antifibrinolytic and has been marketed for menorrhagia (Lysteda) and dental hemorrhage in hemophiliacs (Cyklokapron).[2,3] More recently, TXA has been investigated as a treatment for posttraumatic hemorrhage, postpartum hemorrhage and prevention of surgical blood loss.

The Case of the Buffalo Chest

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Author: Jeffrey Chen, MSIII
UCSF School of Medicine

Case:
A 73-year-old man with a history of severe multi-vessel CAD status post CABG surgery 9 weeks ago presents after a high-speed motor vehicle collision with worsening SOB and chest pain. On exam, he is in acute distress, with a pulse of 102, blood pressure of 129/64, respiratory rate of 28, and saturating at 91% on 100% Oxygen NRB. The left chest has decreased breath sounds and is hyperresonant to percussion. Trachea is midline. A rapid chest X-ray shows a fractured left 7th rib and a corresponding large pneumothorax on the left with no evidence of tension. A chest tube is placed without any complications and connected to suction; his oxygen saturation improves to 98%, and his other vitals stabilize. A repeat CXR confirms successful placement of the tube, mild reinflation of the left lung, and a small pneumothorax on the right side that was not noted on the previous X-ray.

Diagnosis and Management:
In this gentleman who suffered a blunt traumatic pneumothorax on the left, there are a few possibilities to explain why he subsequently developed a pneumothorax on the right. First is a small traumatic pneumothorax that was already there on the right that was not visualized on the first film. Next is mediastinal damage during the placement of the left-sided chest tube, though there were no complications described in this case.

Tips for Tackling the Pediatric Trauma

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Author: Shyam Sivasankar, MD
Emergency Medicine Resident
Stanford-Kaiser Emergency Medicine
AAEM/RSA Publications Committee Member

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I am very fortunate to train at a facility with a child life specialist present in the emergency department. Their presence has helped me learn a lot about running pediatric trauma surveys and resuscitations, and I have picked up a few pearls along the way. The following are some of their tips, tricks, and suggestions.


1. Calming Distractions 

A trauma resuscitation can be quite overwhelming for an adult, let alone for a child. Use age appropriate interventions for each child including, but not limited to:

• Infants and Toddlers:
• Stuffed animals (for comfort) 

• Bubbles (to encourage deep breathing and relaxation) 

• Elmo Calls (Facetime™ with Elmo, a fun game for distraction) 

• School Age/ Teens: 
• iPads (or smart phones for distraction and teaching moments with patients) 

• Simply Sayin’ (a smart phone application, created in part by Phoenix Children’s Hospital. This application provides illustrations, a free-draw option, and video clips to help both patients and their parents understand what is happening while simultaneously lowering the anxiety level in the room.) 

• Stress ball for relaxation and stress management 

• Deep breathing techniques to support relaxation  

Maisonneuve Fracture - A can’t miss diagnosis!

Author: Benjamin Lindquist, MD

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Chief Resident
Stanford/Kaiser Emergency Medicine Residency

A 50 year-old male pedestrian presented to the emergency department by ambulance after having his left foot struck by a bicyclist while the foot was firmly planted on the ground. He complained of severe pain to his medial ankle but denied knee or hip pain. He had no other injuries. On examination, he had slight eversion at the ankle with significant tenderness over the medial malleolus. He also had tenderness over his proximal fibula. He had normal strength, sensation and pulses.

X-ray showed widening of the medial tibiotalar joint space (Image A) and a comminuted fracture of the proximal fibula (Image B). These findings are suggestive of a Maisonneuve fracture with syndesmotic ligament disruption. He was placed in a splint and referred to orthopedic surgery. Ten days later, he underwent operative fixation of his syndesmotic ligament injury.

In evaluating patients with ankle injury, it is imperative to assess for concomitant proximal fibular fractures. As in this case, it is common for patients to complain only of ankle pain and not pain around the proximal fibula. However, Maisonneuve fractures are often unstable and require surgical fixation, whereas isolated fibular fractures or deltoid ligament sprains are managed nonsurgically.

Image A: Anteroposterior view L ankle

Image B: Anteroposterior view L tibia-fibula

References:

Taweel NR, Raikin SM, Karanjia HN, Ahmad J. The proximal fibula should be examined in all patients with ankle injury: a case series of missed maisonneuve fractures. J Emerg Med. 2013;44(2):e251-5. PMID: 23079149