@WUSTL_EM #EMConf: #FOAMed Supplement No. 18 & 19

Conference October  21st [LJ]
1. Interesting Case Conference
Sometimes its important to know the atypical presentations of common diseases.  This week we discussed Kawasaki Shock syndrome.  emdocs discusses the reasons for delayed diagnosis in Kawaski disease. f you are having trouble remember all the diagnostic criteria, check out the ALiEM  card for Kawasaki's disease.

2. Abscess/Cellulitis and Antibiotics
- Dr. Willman gave a great presentation discussing the benefit of antibiotics in patients with abscess/cellulitis.
- EP Monthly promotes skipping the antibiotics unless systemic illness or severe immunosuppression is present.
- FOAMcast discusses the ISDA guidelines suggesting that Bactrim is probably sufficient as a single agent for MRSA and Strep Coverage.
- On a related topic, the SGEM discusses Clinda vs Bactrim for SSTI

3. EMS and the changing the healthcare landscape. 
Dr. Brent Myers discussed the coming tide of payment reform and its effect on EMS.  JEMS discusses EMS and bundled payments.

Conference October 27th [MD]
1. ECGs in PE
- We covered Amal Mattu's episode of ECG findings of PE.   Take home:  Inferior + Anteroseptal T waves inversions > think PE!
- Everyday EBM EKG Challenge No. 5 reviews an interesting case of  ST elevation in PE.
- Dr. Smith's ECG blog covers the ECG findings in PE

2. #RightCare in Emergency Medicine
- To Read More about the Lown Institute, check out their webpage or focus specifically on Right Care Action week here.
- If you did not get a chance to read the Wired article about David Newman, do so now and make sure to check out the NNT.com
- To read more about the silent epidemic of preference misdiagnosis check out these two blog posts at the BMJ: 1 and 2.
- Shared Decision Making is one technique to avoid Preference Misdiagnosis.  Read about Emergency Physicians Perceptions of Shared Decision Making in this article in Academic Emergency Medicine.
- Check out our own Hippocratic Medicine series about examples of the harms of overtesting or overuse, and stay tuned for an upcoming post on Lessons from #RightCare Week at the Barnes Jewish ED.

Enjoy,
Louis Jamtgaard (@Lgaard)
Maia Dorsett (@maiadorsett)

For the Sake of the Trach: Tracheostomy Basics & Complications in the ED

Clinical scenario: You’re working in the ED when you receive a pre-arrival page: 62 y M with trach in respiratory distress, unable to obtain sats, ETA 5 min.  As you are setting up suction in the resuscitation bay, EMS arrives with a pale, elderly male gasping for air.  What's your next move?

Review: Although (hopefully) not something we see in the emergency department every day, this is absolutely something we need to be comfortable stabilizing, if not definitively managing, on our own. In order to have a better understanding of tracheostomy complications, it’s important to understand some terminology and anatomy first.  

Differentiating tracheostomies from laryngectomies 
A critical piece of information to obtain in patients with a tracheostomy is to determine whether or not they have had a laryngectomy as well. A tracheostomy is simply an opening in the trachea created with an incision through the anterior neck. Some reasons for needing a tracheostomy include chronic mechanical ventilation, maxillofacial trauma, or upper airway obstruction such as from a mass. A laryngectomy—usually performed on patients with laryngeal cancer—is a complete removal of the larynx with separation of the airway from the mouth, nose, and esophagus. Since there is no connection between the mouth and the patient’s airway, laryngectomy patients can NEVER be orally

intubated. Outwardly, a laryngectomy patient looks like any other patient who has had a tracheostomy, so it is impossible to tell if a patient has had a laryngectomy simply by looking at his or her neck. While occluding the stoma of a patient who has only had a tracheostomy may not cause complete loss of the ability to ventilate (assuming that have at least a somewhat patent upper airway), occlusion of the stoma in a larygectomy patient will absolutely in all cases make it impossible for the patient to breathe, since the stoma is the only possible connection to the lungs in a laryngectomy patient. Despite being a “never” event, attempts at oral ventilation on a laryngectomy patient have been reported in the past [1].   If a patient with a total laryngectomy requires bagging and the trach tube is displaced, the stoma is the only way to ventilate them.  As an initial measure, an laryngeal-mask airway or neonatal mask can be applied to the stoma and used for bagging.


Tracheostomy basics 
To better understand tracheostomies in general, some basics are worth reviewing. Tracheostomies can be performed percutaneously at the bedside in the intensive care unit or surgically in the operating room. Various methods for a tracheostomy exist, but the neck incision is usually made midway between the cricoid cartilage and the sternal notch, well below where a cricothroidotomy is usually performed, and the trachea itself may be opened with a vertical or horizontal incision. A few safety features are sometimes integrated into the tracheostomy: stay sutures and Bjork flaps. Stay sutures are temporary sutures placed through 2-3 tracheal rings that allow for the trachea to be pulled back up to the skin should decannulation occur. This allows for visualization and easier reinsertion of the tracheostomy tube, thereby decreasing the risk of creating a false passage if the tracheostomy tube needs to be reinserted before the tract fully matures in about 7 days. Stay sutures are usually removed after 7 days, so patients presenting to the ED are not likely to have these. A Bjork flap is an upside-down U-shaped section of trachea that not only creates the tracheostomy, but the free edge of the flap is sutured to the skin of the neck, essentially creating a path for tracheostomy tube reinsertion and reduces the risk of creating a false passage when reinserting a tracheostomy tube prior to tract maturation [2]. 

Tracheostomy Tube Features 
Tracheostomy tube designs vary widely but most tracheostomy tubes have a number of parts in common. A few important details to know about every tube include the size of the tube, the brand or type, and whether or not the tube has a cuff. For example, when speaking with a consultant, one might say, “this patient has a size 6 cuffed Shiley.” The cuff is an important feature of many

tracheostomies as it allows for the airway to be sealed off, allowing for positive pressure ventilation and reducing the risk of aspiration. Deflating the cuff will allow the patient to breath through his or her mouth to some degree (assuming a patent upper airway), which serves as a backup for ventilation should the tube become occluded. Having the cuff down also allows for the patient to phonate when they occlude their tracheostomy tube, since air will be able to pass around the deflated cuff and tube through the vocal cords. Some tracheostomy tubes will have both an outer cannula and inner cannula, which allows for the inner cannula to be removed and cleaned or replaced without changing the entire tracheostomy tube. The downside to having an inner cannula, however, is that the effective inner diameter of the tube is decreased, so the patient may experience increased resistance to airflow.


Tracheostomy tube complications 
Setting up for the patient
Patients with tracheostomy tubes will on occasion present to our emergency department, and as the initial responders to these emergencies, it is important to be aware of the common or potentially life threatening complications associated with tracheostomy tubes. In the patient who is not rapidly decompensating, eliciting a brief history focused on the tracheostomy tube should be performed. Necessary details such as when the tracheostomy was placed, what size tube the patient uses, and why the tracheostomy was needed may be management altering pieces of information. When the patient arrives to the ED, supplies and equipment should be assembled in anticipation of potential worsening of the patient's complication. Personal protective equipment (face shield, gloves, fluid-resistant gown), suction catheters, Yankauer suction, replacement tracheostomy tubes (of the same and also one size smaller), tracheostomy tube ties, and a supplemental oxygen source should all be at the bedside ready for immediate use. Endotracheal tubes with intubating equipment (if the patient has a patent upper airway) should be readily available as well, if not at the bedside. 


Tracheostomy tube obstruction
Secretion buildup will often result in a narrowing of the effective tube diameter, commonly leading to increased resistance to flow and manifesting as respiratory distress in the patient. Inadequate suctioning, poor hydration, and decreased mobility are all risk factors for obstruction from secretions. The initial step in patients with a possible tube obstruction is to attempt passing a suction catheter through the tracheostomy tube. Instilling a few milliliters of sterile saline may help loosen secretions. If the suction catheter cannot be passed easily beyond a few centimeters or the length of the tube, the tube may either be obstructed or dislodged. In tubes with an inner cannula, the inner cannula should be removed and inspected or replaced, but if there is still resistance to passing a suction catheter, the tracheostomy tube is likely dislodged with the distal tip in the soft tissues of the neck and will need to be removed immediately and replaced [2]. 


Accidental decannulation
Although most patients will have a mature tracheostomy tract when they present to the ED, it is prudent to ask when the tracheostomy was placed. Tracheostomies that are less than 7 days old presenting with a decannulation of the tube should never be replaced blindly because of the risk of creating a false passage upon reinsertion. In a patient with a mature tract, he or she should be optimally positioned for reinsertion, preferably laying supine with a shoulder roll to extend the neck, which will help align the tissue planes and mimic the position by which the tracheostomy was originally created (likely supine on a operating table). Preoxygenating the patient oronasally or via the stoma will reduce the risk of oxygen desaturation should any difficulties arise during the procedure. Always use an obturator or introducer if available to avoid injuring the soft tissues with the end of the tracheostomy tube. Water-soluble lubricant or a lidocaine containing jelly should be applied to the tube. Holding the tube and obturator as one unit, the tube should be inserted with the tip initially pointed perpendicular to the stoma and then gently curved downward into the trachea following the bend of the tube. If the tube has been out of the stoma for more than several hours, the stoma may have begun to stenose and require dilation by an otolaryngologist prior to reinserting a tube. A chest x-ray should be performed to confirm placement. Alternatively, if available, a nasopharyngoscope or bronchoscope can be used to directly visualize the carina via the tracheostomy tube, which would guarantee proper tracheal placement.  For a video demonstration, see this you tube video.


Bleeding from the tracheostomy
Tracheostomy bleeds can be from a number of possible sources. Superficially, the skin underlying the flange of the tracheostomy tube should be checked, as malpositioning of the tube or patient may result in pressure ulceration. The tracheostomy tube may need to be removed to fully inspect the stoma and surrounding skin, and local bleeding can be controlled with pressure or topical silver nitrate. Often, granulation tissue, which are new growths of connective tissue and small blood vessels, can arise from the stoma site, or even within the trachea itself. Minor bleeding from around the stoma can similarly be treated with pressure or silver nitrate. Granulation tissue within the trachea is diagnosed by direct visualization with a nasopharyngoscope or bronchoscope, and needs to be definitively treated by ENT, usually by cauterization. Other potential sources of tracheostomy bleeding may come from the tube eroding into the thyroid vessels, thyroid gland, or tracheal wall. A tracheoinnominate fistula is perhaps the most feared complication of a tracheostomy tube and occurs when the tip of the cannula erodes through the anterior tracheal wall and into the innominate artery. This rare condition occurs in less than 1% of all patients with a tracheostomy tube but carries a mortality rate approaching 100% given the catastrophic bleeding into the airway. Approximately 75% of patients with a tracheoinnominate fistula will present within 3 to 4 weeks of tracheostomy tube placement, and some of these patients will have an initial "sentinel bleed" that may be relatively minor before developing massive hemorrhage [2,4]. Hemorrhage in these cases can be temporized by hyperinflating the cuff of the tracheostomy tube or endotracheal tube placed through the stoma as an attempt to tamponade the bleeding. These patients will need emergent thoracic and ENT consultation. Endovascular embolization of the innominate artery may be another option in these patients and has been demonstrated to be successful in a few case reports [5]. 


Cardiac arrest
Suppose a patient with a tracheostomy is brought into the emergency department with CPR in progress. Provided that the patient's stoma remains patent, a small cuffed endotracheal tube (e.g. a 6.0 tube) can be inserted through the stoma to ventilate a tracheostomy patient in this code scenario. Intubation of the stoma is not only is much faster than attempting oral intubation, but also avoids the potential attempt at oral intubation on a laryngectomy patient (which, again, should never occur) if his or her medical history is unknown. A laryngeal mask airway (LMA) can be placed over the stoma to ventilate if an endotracheal tube is not readily available, but the patient's mouth and nose should be covered if upper airway patency is unknown. Alternatively, should the stoma be stenosed (for example, if the tracheostomy tube has been out for hours) and the patient is known to have a patent upper airway, the stoma can be occluded and the patient can be ventilated with bag-valve-mask via the mouth and nose. 


Take Home Points 
Tracheostomy complications can quickly become life-threatening, and knowing some basic concepts about tracheostomies can allow us to better respond to and take care of patients with these complications. As with any patient, getting an adequate history should be the first step, and in particular, knowing if the patient has had a laryngectomy can prevent the “never event” of an orotracheal intubation attempt. Before performing any interventions on a patient where there is time to set up (i.e. on a relatively stable patient), one should gather appropriate equipment such as personal protective gear, extra tubes, and suction. Finally, consider the potential for a tracheo-innominate fistula in a bleeding tracheostomy patient given the extremely high associated mortality. 

Submitted by Phil Chan, PGY-3
Faculty Reviewed by jason wagner  (@TheTechDoc)
Everyday EBM Editor: Maia Dorsett (PGY-4, @maiadorsett) 

References

[1] El-Sayed IH, et al. Identifying and Improving Knowledge Deficits of Emergency Airway Management of Tracheotomy and Laryngectomy Patients: A Pilot Patient Safety Initiative. Int J Otolaryngology. 2010;2010:1-7.
[2] Morris LL, et al. Tracheostomy Care and Complications in the Intensive Care Unit. Crit Care Nursing. 2013;33(5):18-30.
[3] D. Doyle J, Scales DC. Tracheostomy. In: Hall JB, Schmidt GA, Kress JP. eds. Principles of Critical Care, 4e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com/content.aspx?bookid=1340&Sectionid=80032214. Accessed September 24, 2015.
[4] Epstein SK. Late Complications of Tracheostomy. Respir Care 2005;50(4):542-549.
[5] Hamaguchi S, Nakajima Y. J Vasc Surg. 2012;55:545-547

@WUSTL_EM #EMConf: #FOAMed Supplement No. 17

1.  Core Content: Tick Born & Viral Illness
- emdocs covers Diagnosis and Treatment of Rocky Mountain Spotted Fever in the ED.
- What's the data surrounding tamiflu use for influenza?  EP Monthly reviewed it in this article and EM Lit of Note addressed here. The NNT.com also analyzed the numbers for treatment of influenza with tamiflu

2. Rural  & Farm Trauma
- Life in the Fast Lane discusses Trauma's Golden Hour.
- Here is a lecture from Free Emergency Medicine Talks about Farm Related Trauma.
- Refer to Life in the Fast Lane's post on management of open fractures to help with all those Auger-related injuries!

3. Difficult Case(s)
- Beware "unintentional blindness" - the "blocking" effect that occurs when you are performing a challenging task.  A great example is this NPR story on Why Even Radiologists Can Miss a Gorilla Hiding in Plain Sight.
- Radiopedia covers the LeFort Classification.
- The MayoClinic EM Blog covers management of Facial Trauma.
- Everyday EBM assesses the evidence surrounding antibiotics for mandibular fractures.
- EMCrit covers treatment of Aortic Dissection

4. Chest X-ray pathology - for a nice revew, work through this tutorial on Chest X-ray anatomy & pathology

5. Foot Problems
- Taming of the Sru covers the approach to the Foot X-ray.
- Use Northwestern's excellent Orthopedic Teaching site to cover Foot Cases.

Enjoy,
Maia  (@maiadorsett)

@WUSTL_EM #EMConf: #FOAMed Supplement No. 16

1. Airway Cases - The Severe Asthmatic
- How to manage the ventilator once you've intubated: EMCrit on Ventilator Settings for the patient with obstructive airway disease. [MD]
- EM Rap covers Ventilator Basics in Ventilators 101  Part 1  and Part 2. [AR]
- Annals of Emergency Medicine covers whether Non-Invasive Positive-Pressure Ventilation Improve Outcomes in Severe Asthma Exacerbation? [MD]
- Annals of Emergency Medicine Systematic Review Snapshot covers whether IV Magnesium reduces hospital admission in patients with acute asthma. [MW]
- Our own blog covered the evidence regarding the use of ketamine in acute asthma exacerbation.

2. Termination of Resuscitation (in the Field)
- We recommend reading this retrospective study in JAMA regarding criteria for Prehospital Termination of Resuscitation for Cardiac Arrest.
- Journal of EMS covers Resuscitation past the 25 minute mark. [BS]
- This NPR story covers the post-resuscitation/death "Pause", making the ever-important case to stop what we are doing for a moment, not leave the room, and appreciate the person in the bed. [BF]

3. Emergency Deliveries
- Maternity Training International offers a wealth of educational resources (including instructional videos) to help you prepare for the emergency delivery. [MD]

4. C-spine Clearance
- A bit of an oldie for the FOAMed world, but here is a 2011 podcast from EMCrit on evaluation for C-spine injuries. [SM]
-(Free from EMRA members):  the July 2015 EM-RAP paperchase covers the most recent guidelines for C-spine clearance. [SM]
- Taming the Sru covers interpretation of C-spine CT. [SM]

Enjoy,
Maia Dorsett (PGY-4, @maiadorsett)
Sara Manning (PGY-4. @EM_SaraM)
Mike Willman (PGY-2)
Brendan Fitzpatrick (PGY-4)
Bridgette Svancarek  (EMS Faculty)
Adam Rieves (PGY-1)

Gettin' jiggy wit it ... Stick a Catheter in it? Consider the Peripheral IJ.

Clinical scenario: You are taking care of a patient with a history of IV drug use who presents to the emergency department with a large abscess in her arm requiring drainage under conscious sedation. Nursing is unable to obtain IV access after multiple attempts. You look for an EJ or an ultrasound-guided peripheral IV and find no suitable sites. The patient is likely to be discharged so a central line seems unnecessary. You scope out the patient's neck under ultrasound and see the plump internal jugular (IJ) vein and wonder, why don't I just put an IV in that? 

Clinical Question: Is there any literature to support or refute the use of the peripheral IV in a central vein? 

Literature Review: In patients who are critically ill with difficult IV access, the decision to move forward with intraosseous or central venous access is relatively clear. However, stable patients requiring intravenous access that have no sites amenable to ultrasound guided peripheral IVs or external jugular access and are likely to be discharged present more of a conundrum.
One proposed alternative to placement of central venous access for these patients is the "peripheral IJ", an angiocatheter placed into the internal jugular vein. Anatomically speaking, a "peripheral IJ" is not a central line. Like the external jugular vein, which also drains into the subclavian, the catheter tip is far superior to the cavo-atrial junction and thus does not constitute central access. 

In 2009, a Letter to the Editor published in the Journal of Emergency Medicine described a technique in which the internal jugular was cannulated under ultrasound guidance with a 48 mm -peripheral angio catheter. The technique described involved the following steps: 

1. Place the patient in trendelenberg
2. Prep the neck with chlorhexadine as you would for a central line
3. Use a linear ultrasound probe covered in a sterile probe cover and sterile gel to identify the internal jugular vein
4. Cannulate the vein and advance catheter over needle
5. Flush & Dress with bio-occlusive dressing
No sterile drapes were used. 

In the report, the technique (anecdotally) had been safely performed many times, but presented no supporting data. 

Following this initial letter, two subsequent case series have been published supporting the peripheral-IJ as a reasonable alternative for temporary venous access. The first case series of 9 patients placed them in patients with unobtainable IV access [2]. 64 mm angiocatheters were used to cannulate the IJ under ultrasound guidance using the above-described technique. All catheters were labeled for removal within 72 hrs. All patients were followed up via chart review one year later. Two of 9 catheters failed due to kinking within the first 48 hrs. There were no apparent adverse outcomes in any patient including deep vein thrombosis, bacteremia, endocarditis or pneumothorax. A second group conducted a prospective case series in which 9 patients underwent placement of a ‘‘peripheral IJ” (PIJ), when other access could not be obtained and the patient did not initially require a central line [3]. The authors attempted follow-up with all patients within a week. On follow-up, the seven patients who were successfully contacted denied any fevers, chills, swelling or pain at the site of catheter entry. One likely reason for the decrease in complication rate is that the placement of a "peripheral IJ" does not require dilation of the vessel.

Take Home: In the patient with a need for short-term intravenous access and in whom ultrasound peripheral IVs or external jugular access cannot be obtained, consider placement of a peripheral-IJ. This procedure should be completed under sterile precautions above that used for standard ultrasound guided IV. Larger studies are needed to verify the safety of this technique on a broader scale. If you’re patient is morbidly obese (a common theme for difficult IV access) keep in mind that an even longer IV catheter may be required to keep it safely intravenous after placement.

Submitted by Daniel Kolinsky, PGY-3
Edited by Maia Dorsett (@maiadorsett), PGY-4
Faculty Reviewed by Evan Schwarz 

References
1. Moayedi S. Ultrasound-guided venous access with a single lumen catheter into the internal jugular vein. J Emerg Med 2009;37:419.
2. Zwank, M. D. (2012). Ultrasound-guided catheter-over-needle internal jugular vein catheterization. The American journal of emergency medicine, 30(2), 372-373.
3. Teismann, N. A., Knight, R. S., Rehrer, M., Shah, S., Nagdev, A., & Stone, M. (2013). The ultrasound-guided “peripheral IJ”: internal jugular vein catheterization using a standard intravenous catheter. The Journal of emergency medicine, 44(1), 150-154.