Grand Rounds Recap - 10/15/2014

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Prescription Drug and Opiate Epidemic with Dr. Shawn Ryan

The US is the #1 country in the world for opiate prescription drug utilization

  • The numbers quoted are likely greatly underestimated due to inconsistent documentation
  • Death rate from opiate pain medication (OPM) has quadrupled in the time span of 1999-2010
  • Death rate in 2012 was 5.6 per 100,000
  • In 2011, 44 people per day died from opiate overdose in the US
  • In 2007, unintentional opiate overdose became the leading cause of death in the US for young population
  • OH death rate has grown faster than the national rate. At this time 5 people/day die in OH from opiate overdose

ED is the largest prescriber of all opioids (39% of all prescriptions)

  • In 2009 misuse and abuse of OPM accounted for 475,000 ED visits
  • In 2006 cost of nonmedical use of OPM was 53.4 billion

Prevention of OPM abuse

  • Increase education and awareness among patients, healthcare providers and general population
  • Research and develop new pain therapies and tamper-proof medications
  • Track and monitor opioid prescriptions
  • Clarify pain management expectations
  • Encourage proper disposal of unused and expired medications

Treatment of OPM abuse

  • There are approximately 2000 physicians currently who specialize in abuse            medicine with need for 15,000

Goals for the future

  • Improve access to abuse treatment centers
  • Decrease insurance barriers to obtaining addiction therapy
  • Come up with evidence based treatment strategies
  • Increase capacity and willingness of healthcare providers to serve more patients

Advanced Wound Care with Dr. Alexander Trott

Wound Care Myths, Debunked

1. Betadine causes tissue damage... 

  • There are 2 different betadine solutions. One comes with the detergent (we do not have this in the ED) and this can cause damage to tissues. Betadine solution without added detergent is safe to use. Mix it in a 10:1 ratio with NS and irrigate and wash around the wound

2. There are multiple ways to irrigate a wound. 

  • Wrong. There is only one effective way to irrigate a wound. You need 6-9 psi of pressure in order to effectively rid the wound of bacteria and debris. You cannot achieve this with a bulb irrigator or the faucet. You have to use the syringe, otherwise, you are just wasting your time.  Wound irrigation is the single most important thing you can do to prevent infection.
  • Tap water may be as safe as saline - see http://www.thennt.com/nnt/tap-water-for-wound-irrigation/

3. 2 point discrimination accurately identifies nerve injuries. 

  • Again, wrong. The way we test this (bent paperclip) lacks standardization in pressure and orientation. There is poor inter-rater reliability. There are also patient factors such as excessive callus, pain and impairment that prevent reliable exam. If there is a difference in perception of light touch, the patient needs close follow up and referral to hand. 

4. Paronychia drainage requires digital block.

  • Nope. There are no nerve endings in the nail plate and minimal sensation of the cuticle. With good technique, this can be done without a digital block. Use an 11 blade or an 18G needle. Also, no need for antibiotics!

5. Antibiotics and wound infection prophylaxis.

  • All wounds are contaminated with debris and bacteria. There is a 3 hour latent period before bacteria is able to grow. There are no studies out there that support effective prophylaxis with PO antibiotics, however it may be reasonable to give a single dose of IV antibiotics if it is within 3-5 hours after the wound occurred,

Other pearls for wound repair

  • Flap stitch: consider using this for corner lacerations as you can close complex wounds with just 1 stitch
  • Delayed primary closure: if somebody shows up with a lac outside the "golden period", consider cleaning the wound and starting the patient on antibiotics. Have the pt return in 3-4 days and close the wound then. This significantly drops the risk of infection. If you wait 3-4 days, you may need to undermine the wound in order to facilitate skin closure. This is done by gently separating the dermal layer.
  • Lip lacs: close the muscle layer first (5-0 absorbable) followed by vermillion border (6-0). Be very careful in closing the vermillion border as it matters cosmetically
  • Nose lacs: local anesthesia with 27G needle. You only need to close the skin as cartilage will reapproximate well without direct closure.
  • Ear lacs: use auricular block. Can also get away with just closing the skin. Make sure you drain any perichondral hematomas and place a pressure dressing if there is a hematoma in order to avoid cauliflower ear
  • Eyelid lacerations
    • Its ok to close with 6-0 suture unless there is fat visible, which is concerning for injury to orbital septum, which is where levator muscles attach
    • Eyelid lac with visible fat or vertical eyelid lacs should be closed by                    ophthalmology
  • Tongue lacs: only need to be closed if the wound is gaping or leads to cosmetic deformity
  • Boxer's fracture: if the patient has scissoring of the fingers, they need reduction and likely surgery
  • Tendon injuries: need to be repaired if more than 50% of tendon is damaged
    • Do not close flexor injuries as these need to be done by surgeons
    • Extensor tendon injuries on the dorsum of the hand are ok to close in the ED

PTA Drainage with Dr. Andra Blomkalns

Is this tonsillitis or a PTA: PTA is usually unilateral and leads to uvula deviation

Recipe for success, aka from drooling to Doritos:

  1. Patient comfort and control
  2. Appropriate analgesia
  3. Effective visualization
  4. Appropriate equipment

A's of success:

Anxiety: PO valium or ativan, though can do a small dose IV

Analgesia: opiates, toradol, tylenol

Anti-inflammatory: decadron IM

Antibiotics: a dose of Unasyn IV and home with clindamycin (due to higher prevalence of MRSA)

Aspiration with a large bore needle is enough

Materials to acquire:

  • 4% nebulized lidocaine
  • 1% lido with epi 
  • 18G spinal needle with trimmed sheath to 1 cm 
  • Laryngoscope blade for visualization and light
  • Suction
  • Ice water for the patient

Procedure 

  1. Stick at the top of the uvula, just lateral
  2. Stay in the tonsillar pillar and aim posterior, that way you will avoid the carotid 

Errata

  • These patients do not need CT scans, unless they have bilateral PTAs
  • Dispo: most of these patients can go home (if tolerate PO) vs CDU
  • Send home with pain meds and PO antibiotics (augmentin vs clindamycin)

Peripheral Nerve Blocks with Dr. Blomkalns

Use vascular probe if US-guided

The goal is to infiltrate around the nerve, not stick the nerve

If you hit the nerve, it may take days-months to heal, so mention this to patients during your consent process

Use combination of marcaine/lidocaine (There is no literature than any of the other additives - i.e. Bicarb - work)

Facial Blocks

  • Infra-orbital: will cover cheek and upper lip
  • Mental: lip and chin
  • Supraorbital: forehead

Femoral nerve block: may need up to 30 mLs of anesthetic!

Wrist blocks: make sure you document neurovascular exam first!

Ankle block

Digital blocks: try a palmar approach

  • Inject at the palmar surface at the proximal part of the knuckle

Ebola Update with Dr. Calhoun

There is a detailed video coming to your email, please watch it

We are in the process of acquiring suits with head gear 

Ebola patients need droplet precaution only

  • Do wear an N95 mask if intubating and full decon gear
  • Double glove and tape bottom glove to the gown

Minimize who is coming in and out of these patients' rooms

Call public health if you have a patient with suspected Ebola and they will contact patient's family

It is your responsibility to contact EMS

These patients will go to B23 and B24

No imaging and limit the labs you order

  • Alert lab early if you are ordering labs on suspected Ebola patient

Dental Emergencies with Dr. Calhoun

By Kaligula (Own work (based on Human dental arches.svg)) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

By Kaligula (Own work (based on Human dental arches.svg)) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

  • Learn the correct way to number/letter teeth
  • The tooth has 3 layers: enamel, dentin and pulp
  • Periodontal ligament holds the tooth in place

Red flags in odontalgia patients:

  • Uvula deviation
  • Pain with tracheal manipulation
  • Pain with neck movement
  • Trismus
  • Tongue elevation
  • Swollen, indurated or tender sublingual area
  • Lesions that you cannot identify
  • Fluctuance
  • Fractures

Pulpitis: inflammation from erosion

  • Usually not tap tender
  • Abscess is tap tender

Periodontal abscess is something we can drain in the ED

  • Stab incision
  • Discharge home with warm saline rinses, 7 days of antibiotics (penicillin vs                      clindamycin) and dental follow up in 1-2 days

Patients who come in just with dental pain alone without other signs or symptoms of systemic infection do not need antibiotics

  • Evidence of systemic infection: fever, trismus, lymphadenopathy, facial or intra-oral swelling

Perichoronitis: pain and swelling of gingival flap surrounding wisdom teeth

  • Treat with warm saline rinses and antibiotics if patient is febrile

Alveolar osteitis: dry socket

  • Occurs 3-5 days following an extraction due to premature loss of clot
  • Analgesia with dental block
  • Irrigate and pack the socket (use socket paste or gelfoam soaked in clove oil)

Dental trauma pearls

  • Always find the avulsed tooth!
  • If the tooth is avulsed, put it back in asap unless it is a baby tooth
  • If the tooth has been out for more than an hour and has not been preserved, it will not re-implant
  • Stabilize with splint or arch bars

Dental fractures

  • Ellis I: through enamel only, do not require treatment
  • Ellis II: enamel and dentin, cover with dermabond and follow up in 24 hours
  • Ellis III: enamel, dentin and pulp. Rate of necrosis 10-30%. Need tetanus and dental follow up asap

Musculoskeletal Quick Hits with Dr. Leenellett

If the patient FOOSH'ed (fell on outstretched hand), you need to examine the elbow for evidence of occult radial head injury

  • Posterior fat pad/sail sign on x-ray
  • Tenderness at the elbow and difficulty supinating the hand
  • Sling vs splint
By Hellerhoff (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

By Hellerhoff (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

In patients with elbow fractures, always examine the wrist for disruption of radioulnar joint

  • Document posterior interosseous nerve function: finger and wrist extension

Wrist fractures: scaphoid bone is the most commonly fractures wrist bone

  • Snuffbox tenderness
  • Thumb spica splint even if x-ray is negative as there is high risk of nonunion
  • 13-40% rate of avascular necrosis 

Patients with perilunate or lunate dislocations require urgent hand referral as they have high morbidity

Flexor tenosynovitis

  • Kanavel sign: pain with passive flexion of the digit
  • Sausage finger
  • These patients need hand consult, antibiotics and likely OR drainage

Thompson test: tests Achilles tendon injury

  • Patient needs to be prone with foot hanging off the bed at knee level
  • If you squeeze the calf, you expect the ankle to plantar flex. If you don't see it, be concerned for Achilles injury
  • These patients need urgent ortho eval and early OR

Ankle sprains: use Ottawa rules for imaging

Maisonneuve-syndesmotic injury

  • Proximal fibular fracture in patients with ankle fracture

Lisfranc fracture: 2nd metatarsal bone fracture with an increased gap between 1st and 2nd metatarsal

  • If you are concerned for this and x-ray is inconclusive, get a CT

Eye Emergencies with Dr. Hooker

1. Amaurosis fugax

  • Seconds to minutes of unilateral, painless vision loss due to an obstruction in blood flow to a small arteriole
  • This is a TIA equivalent and patients should get appropriate stroke work up
  • Could also be seen in temporal arteritis, though more rare

2. Central retinal artery occlusion

  • Cherry red spot on fundoscopic exam
  • Painless total vision loss in 1 eye
  • A. fib is the most common cause
  • Treatment: the goal is to dislodge the clot
    • Ocular massage (watch out for vagal syncope!)
    • Topical beta blockers (timoptic 0.5%)
    • Acetazolamide 500 mg IV
    • tPA

3. Herpes keratitis

  • Red and painful eye with photophobia
  • Dendrites on fluoresceine
  • Treat with oral acyclovir and ophtho follow up in 1-2 days
  • Never prescribe eye steroids unless you are an ophthalmologist

4. Central retinal vein occlusion

  • Painless monocular vision loss
  • Blood and thunder on fundoscopic exam: optic disk edema and hemorrhages
  • Treat with daily aspirin

5. Acute angle closure glaucoma

  • Sudden increase in intra-ocular pressure (normal is 10-21)
  • Poorly reactive pupil
  • Cloudy cornea
  • Perilimbic flush
  • Decreased visual acuity
  • Treat with topical beta blockers and IV acetazolamide

6. Retinal detachment

  • Curtain sign on fundoscopic exam
  • Patient complains of floaters and flashes of light
  • Vision may be preserved initially
  • Try looking with US

7.  Periorbital cellulitis

  • Pre-septal = periorbital
  • Post-septal = orbital cellulits

8. Chalazion

  • Pain and swollen lid without visual change or eye pain. 
  • Chronic. 
  • Commonly no overlying redness. 
  • Caused by blocked Meibomian gland. 

9. Corneal ulcer

  • Inflammatory or infectious.
  • Increased risk in contact wearers. 
  • Significant uptake on fluorescein exam.

10. Pinhole occluder

  • Use these to get a corrected visual exam when patient doesn't have their corrective eyewear