Grand Rounds Recap - 12/10/14

Abscess Management by Dr. Betham and Dr. Derks

1. Should ultrasound be used for abscess management?

• US changes management in 18% of cases according to 1 paper
• US + physical exam greatly increases sensitivity and specificity of physical exam alone
• In people with cellulitis and no signs of abscess: US changes management in 56% of cases according to 1 study
• Conclusion: in patients where you are not sure if there is an abscess, US can help you make the decision and changes management

2. Methods of Abscess Drainage

• I&D has been the gold standard
• Need to incise about 2/3 of the area of fluctuance along lines of skin tension
• Needle aspiration should not be done due to high failure rate and need for subsequent I&D following needle aspiration
• Loop drainage: placing a penrose drain vs vessel loop into abscess cavity and tying a loose knot in order to keep abscess cavity open
  • This is less invasive and has similar or possibly lower rates of failure as I&D as well as improved cosmetic result

If you are an EM:RAP listener, this is the video I talked about in the November episode on abscess managment. It goes through the steps of a new technique for draining a cutaneous abscess. I am a huge fan of this procedure and use it on most abscesses that I would have otherwise packed. Why I like it: there is no packing to change, the incisions stay open because of the drain and the incisions themselves are much smaller than we historically use.

3. Should we irrigate abscess cavity?

• No good evidence for or against
• Surgeons do irrigate
• Tap water and saline are equivalent for lacerations, so likely both ok to use for abscesses

4. Should abscess cavity be packed?

• Higher pain and no difference in outcome with packing according to several small studies

5. Primary Closure of Abscess

• Usually done with a vertical mattress suture in order to close cavity space and prevent fluid from recollecting
• Improves time to healing
• Studies have not shown increase in abscess recurrence or complications
  • BUT these studies come from the OR and surgical literature and most people got a dose of IV antibiotics
• There is a small RCT done in ED: randomized to packing vs primary closure but use of antibiotics not standardized
  • There was no difference among groups
  • Better cosmesis with primary closure

6. Do these patients need PO antibiotics?

• Patients who have recurrent abscesses, are immunocompromised or have poor wound care compliance may benefit from antibiotics
• Consider antibiotics in extreme of age, surrounding cellulitis, immunocompromized patients
• According to IDSA guidelines, no need for culture or antibiotics in mild disease
• If pts have systemic symptoms, then they will need antibiotics
• Recommendations is 5 days of antibiotics (Bactrim+Keflex vs Clindamycon)
• Patients with valvular disease should get 1 time dose of antibiotic prophylaxis (2 g of keflex PO vs 600 mg of clinda PO): give 30 minutes prior to procedure or within 2 hours after

Other Useful FOAM Resources

• http://emlyceum.com/2014/03/31/abscess-answers/
• EPMonthly Article on Abscess Management

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Hand and Wrist X-Ray with Dr. Dang

Missed orthopedic fractures account for the largest source of malpractice claims and hand injuries account for 5-10% of ED visits.

ABCS method for Interpretation

• A: adequacy/alignment. Correct patient and limb with full image without ulnar or radial deviation
• B: bones. Need at least 2 views
• C; cartilage and clear spaces. All joints should be uniform
• S: soft tissues

Tuft fracture: typically due to crush injury

• No specific treatment. Can splint for comfort
• Nail bed injury = open fracture and need antibiotics

Mallet finger: forced flexion of extended DIP joint

• Can be associated with small avulsion fracture
• Splint in hyperextension

Jersey finger: forced extension at flexed DIP

• Won't be able to fully flex at DIP
• Surgical management

Skier's thumb: hyperabduction of thumb with FOOSH

• Thumb spica splint

Boxer's fracture: metacarpal neck fracture with volar angulation

• Make sure this is not a fight bite: need antibiotics

Metacarpal neck fractures: need to know degree of angulation as it determines need for ORIF

Scaphoid fracture: most common fractured hand bone

• Tenderness of anatomic snuff box or with axial loading of thumb
• 30% may not be apparent on initial x-ray
• Increased risk of AVN, so splint and follow up for repeat imaging

Triquetrum fracture: can be associated with ulnar nerve injury, splint with a polar wrist splint

Scapholunate dissociation: injury to the ligament connecting the 2 bones

• Look for increased gap in between scaphoid and lunate ( < 3 mm)
• Cortical ring sign: scaphoid superimposes onto itself and creates higher density
• Radial gutter splint
• Highly associated with lunate and perilunate dislocation
  • Due to hyperextension of wrist
  • Need early reduction and likely surgical repair
  • This is an unstable injury with high risk of re-dislocation and arthritis
• Perilunate dislocation: apple out of the cup
• Lunate dislocation: spilled teacup

Perilunate Dislocation. From http://radiopaedia.org/articles/perilunate-dislocation

Lunate Dislocation. From http://radiopaedia.org/articles/lunate-dislocation

Distal radius fractures

• Need a thorough neurovascular exam
• Sugar tong splint to level of MCP joint to maintain finger flexion

Colle's fracture: distal radius with dorsal displacement

• 60% of cases have ulnar fracture

Smith fracture: distal radius with volar displacement

Radial styloid fx: high association with ligament injuries

Galeazzi fx: distal radius fx with dislocation of radial/ulnar joint

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R4 Capstone Lecture with Dr. Chinn

67 yo M with arm pain and numbness after a bug bite. Exam concerning for compartment syndrome. Goes to OR for fasciotomy. Becomes hypotensive on the floor with continued bleeding and oozing from fasciotomy site. Diagnosed with Acquired Factor VIII deficiency

Acquired factor VIII Deficiency

• Very rare with 1-4 in a million incidence
• Median age 60-70
• Mortality 8-22%
• Majority will require transfusion
• Caused by development of inhibitors to factor VIII
• Usually presents with soft tissue bleeding as opposed to hemarthrosis in hemophilia A
• Majority are idiopathic though can be associated with autoimmune diseases
• Diagnosis: prolonged pTT with normal PT/thrombin time/platelet count
• Diagnosed based on mixing study, factor VIII level or inhibitor titers

Treatment:

• DDAVP and factor VIII infusions do not work as patients have inhibitors and auto antibodies
• Recombinant factor VIIa: bypasses Factor VIII pathway. Short half life (2 hr)
• PCC also works
• Inhibitor elimination: plasmapheresis, immunosuppresion with steroids, IVIG, anti-cancer agents, rituximab
• Most common cause of death is infection due to immunosuppression

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Getting Paid with Dr. Ryan

1. Things that will/could impact EM

• Hospitals are moving into insurance business in order to control cost
• Urgent cares are everywhere and stealing our volume
• Accountable Care Organizations (ACOs)
  • These systems "own" their patients and get paid accordingly
  • Manage their pts in order to keep them out of EDs and hospitals
• Medicare cuts
• Medicaid expansion: should increase number of patients that do pay for their care
• Increase in high deductible plans: pts less likely to go to hospital
• Bundled payments: likely the future and will encourage efficiency

2. Types of EM groups

• Independent contractor: you get a higher hourly rate, but it does not include anything (benefits, taxes). Offers lots of flexibility
• Hospital employee: benefits are great. No group to rally behind you if something bad occurs. 
• Independent group: very rare
  • Partnership: after x years you are a full partner with occasional buy in
  • Shareholder: shares based on years of service
• Multi hospital group
• Mega groups

3. When comparing, you should consider contracts "apples to apples", including: salary, malpractice, health, disability, life insurance, pension, bonus, tuition break, CME

• Occurrence- based malpractice insurance: covered for all encounters while you are with the group
• Claims made model: covered while working with the group, if leave the group, then not covered even if you saw the pt while with the group. so need to get a tail (costly)
• Life insurance: term vs whole

4. Pay models: billings, RVU, salary, hourly, combo

• RVU components: physician work for a certain diagnosis, expense of physician practice (supplies, computers, nurses, etc), professional liability insurance

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Pediatric Simulation/Oral Boards/Procedures

Neonatal LP keys to success

• Positioning is key! Doesn't matter if it is sitting up or lateral decibitus, whatever you/your holder are comfortable with
• Leave the baby's diaper on to prevent accidents....
• Sweet-EZ is your friend
• Prep a wide area so that you can palpate landmarks once sterile

Oral Boards

7 week old baby presents with vomiting. Arrives at OSH and stops breathing. Gets intubated and is transferred to you. On exam, he has a missing R radius but otherwise warm and well perfused. Glucose is 53, so receives D25. 

T 33.7, P 153, BP 87/54. 

Labs show a pH 7.1 with base deficit 14. lactate is 9.5. WBC 16 with 68% neutrophils and 4% bands. UA negative. 

CXR initialy unremarkable. EKG with R axis deviation. 

The baby then becomes hypotensive with worsening tachycardia and hypoxia. Minimally responsive to fluids, though hypoxia worsens. Repeat CXR shows diffuse pulmonary edema.

Differential diagnosis: sepsis, sepsis, sepsis, metabolic disorder, congenital heart disease, nonaccidental trauma 

Diagnosis: Total Anomalous Pulmonary Venous Return

• 3 types based on anatomy: supracardiac, cardiac, infracardiac
• Feel for liver edge after volume resuscitation: If pt develops hepatomegaly, then likely congenital heart disease. 
• Treat with diuretics and pressors (E, NE) as needed for hypotension.
• Vomiting is a frequent presenting symptom in cardiac kids

Tips for sick baby:

• MAP should be close to their gestational age in weeks
• Antibiotic choice in babies younger than 4 weeks: ampicillin + cefotaxime/gentamicin
• Antibiotics if older than 4 wo: Rocephin +/- vancomycin

Sim Case

10 day old with poor feeding and increased sleepiness. Grunting with periodic breathing on exam. HR 180s-200s, O2 sat in low 90s.

DDx: sepsis, metabolic, congenital heart disease, NAT

• Grunting in an infant is their way to do auto-PEEP
• What to look for in congenital heart disease: BP/pulse in all 4 extremities, pre and post ductal O2 sat, hepatomegaly, rales, murmur
• Try Hi-Flow O2 for early respiratory distress
• If you are in the community, do not delay transport
• RSI in neonates: give atropine and need to wait 3 minutes. Same for lidocaine if concerned for head injury