Consultant Teachings No. 3: Evaluation of Tendinous Hand Injuries for the Emergency Provider

Clinical Case:  You are working in a community emergency department one evening when a woman presents with a laceration across the fingerpad of her right thumb that she sustained after falling onto a piece of glass.  The laceration itself is pretty small - about a centimeter across - and has minimal bleeding.   The X-ray ordered by the triage nurse is negative for retained foreign body.  Before you just sew this up and send the patient on her way, you appropriately decide to do a thorough hand exam, including for tendonous injury.  The patient keeps saying that its hard to bend her finger because it hurts...
 
Consultant Teaching: Tendon Injuries to the hand are often complex entities that are subject to ongoing research regarding optimal procedures for management and rehabilitation. The flexor and extensor tendon anatomy is quite complex. Both are divided into numerous “zones” created to help clarify the optimal treatment, which can vary markedly depending on injury location. Missed tendon injuries increase morbidity by complicating later management and are therefore a leading cause of malpractice claims in the world of Emergency Medicine. The most important and fundamental aspect of evaluation in these patients is a detailed hand exam. Outlined below is a guide for the evaluation and management of any patient presenting to the ED with a suspected hand injury.

Flexor Tendon Injuries
The first step is to obtain a detailed history of the mechanism of injury. Was the injury caused by a rusty farm knife or a sharp chard of glass? What was the position of the patient’s hand when the injury occurred? This is a frequently missed point to mention. You can imagine that, if the patient was lacerated with flexed fingers while gripping a knife, the location of the tendon injury itself may be in a very different location than the skin laceration when evaluating the hand in a more extended posture. Just because you can no longer see the damaged tendon in the wound doesn’t mean it’s not there.

Step 1: Observation 
Evaluate the location and depth of the laceration. Look at the resting posture of the hand and the

patient’s digital cascade. When in doubt, you can usually find clues by looking at the resting finger position of the uninjured hand. Your clinical suspicion should be raised if a particular finger rests in a more extended position relative to the others.

Step 2: Passive Range of motion
These hand injuries can be really painful. A good place to start is assessment of passive motion with a maneuver that elicits the tenodesis effect. Try it on yourself - With a relaxed hand, when you passive flex your wrist, your MCP/PIP/DIP joints will extend. Similarly, wrist extension will cause passive flexion of those digits. If you passively extend the patient’s wrist and there is persistent extension of the DIP or PIP joints, you may have a flexor tendon injury in that digit. 

Step 3: A detailed (ie purposeful) neurovascular exam 
Flexor tendon injuries are frequently associated with neurovascular injury because of the palmar

location of these structures. The best way to assess nerve function is with a two-point discrimination exam. This can easily be performed with a paper clip. Remember that each finger has proper digital nerves on its palmar aspect on both the radial and ulnar sides: test them both. *Tip 1* If you get abnormal results that don’t make sense given the injury, test the other hand! Your patient who forgot to mention his terrible neuropathy will appreciate this. *Tip 2* Under NO circumstances should a digital block be performed if you are planning to consult the hand service on call. If analgesia is an issue, let the hand service know and proceed with necessary oral/IV medications until your consulting service is able to evaluate the patient’s neurovascular status. This is not only important for our documentation, but is critical for possible surgical planning.

Sensory territories of the hand (Source: wikipedia)

There are multiple ways to assess the vascular status. Assessment of cap refill, a digital Allen’s test (same concept as the wrist, but with compression of the radial and ulnar palmar arteries of each finger) and pulse oximetry can all help establish whether or not a concomitant vascular injury is present.



Step 4: Flexor Tendon Exam
A quick anatomy review is necessary here because, in the hand, form truly follows function. The flexor digitorum profundus (FDP) and superficialis (FDS) tendons are both extrinsic hand muscles that power finger flexion. The FDP lies deep to FDS and then attaches distally to the distal phalanx of the 2nd-5th digits. The FDS attaches at the base of the intermediate phalanx of these digits. Why is that important to know for your physical exam? Since these muscles share a common belly and are intimately associated with one another, you must carefully isolate the desired tendon on each digit. Asking a patient to “wiggle their fingers” is an easy way to improperly assess hand function and miss isolated tendon injuries. To test the FDS: all adjacent digits must be held with all joints in extension while the patient flexes the finger at the PIP joint. To test the FDP: hold the middle phalanx in extension while asking the patient to flex just their distal phalanx. Another reason not to digital block these patients is that pain with these movements may clue the examiner into a possible partial tear or laceration.

For completeness, it is also important to document motor testing for all muscles with separate nerve innervations, regardless of its proximity to the wound in question.

Extensor Tendon Injuries 
Like the flexor tendons, these also can be diagnostic challenges due to the complex anatomy of the extensor mechanism. This region is comprised of extrinsic muscles that power digit extension, like the extensor digitorum communis (EDC) and an extensor aponeurosis with multiple connecting bands and ligaments. Again, a detailed history will provide valuable insight and context for your exam. Is it a result of a fight-bite injury? A crushing mechanism?

The general principles of the physical exam addressed above regarding observation, passive range of motion and a detailed neurovascular exam still apply. As diagrammed in the image above, for the dorsal hand, it is especially important to assess both the radial and ulnar nerves.

With regard to hand posture, take note if there is a resting flexed position of the digit, a mallet finger, or boutonniere deformity. This should heighten your suspicion for a tendon injury.

Assessment of the Extensor Tendon 
A few important considerations are noteworthy here. First, do not be fooled by the action of the lumbricals! Remember, these muscles provide extension of the PIP and DIP joints via the lateral bands. Have the patient lay their hand flat on a table (extends the MCP joint and helps remove the influence of lumbricals) and extend at the MCP joint against resistance. Extension along an affected digit may still be possible even after complete laceration, due to the multiple contributions to the extensor mechanism. Look closely for a lack of hyperextension or differential extension in the affected finger that may be a sign an extensor tendon injury has occurred. The junctura tendinae are intertendinous fascial connections located around the MCP joint that attach tendons of the EDC and help coordinate their movements. This anatomic structure is important to keep in mind because the junctura may allow for some extension of an injured digit if the tendon injury is proximal to them.

Lastly, if you are concerned about an injury to the “central slip” (eg. a lac or crush injury to the middle phalanx), then an Elson test can be performed. To do this test, flex the PIP 90 degrees over a table and have them extend against resistance. If the central slip is intact, the DIP joint will be supple. If it is ruptured, there will be weak extension of the PIP and a rigid DIP due to the action of the lateral bands.

So, I did my hand exam… What next? Management of these injuries is often multifactorial and depends on the location of the injury, the structures involved, patient and other factors that are beyond the scope of this post. Doing a correct and detailed physical exam is the first, and most important, step in making sure a patient doesn’t walk out of the ED with an undiagnosed tendon or neurovascular injury.  When practicing in the community, if you suspect that there is an associated tendonous injury based on your clinical exam, clean and repair the laceration as you otherwise would but subsequently place the patent in a dorsal blocking splint, with 15-20 wrist flexion with the hand in intrinsic plus position (MCPs at 70-90 degrees and DIP/PIP straight) and make sure they have follow-up with a hand surgeon.  

 
At the end of the day, it’s important to keep a high level of suspicion - a referral to a hand surgeon for a suspected tendon injury is just as valid as a referral for a definite tendon injury. 

Check out these videos:
Tenodesis effect: https://www.youtube.com/watch?v=j0RBU_phUKw 
Elson test: https://www.youtube.com/watch?v=wudDvOiSUlw
Generic hand exam: https://www.youtube.com/watch?v=imPQve7ZL3o

Submitted by Chris Cosgrove, MD. Ortho PGY2
Reviewed by: Daniel Osei, MD. Hand Attending

EverydayEBM Editor: Maia Dorsett (@maiadorsett)

Consultant Teachings No. 2: Thoracolumbar Spinal Fractures - A Spine Consult Isn't Always Necessary

Clinical Scenario:  You are working one evening in the emergency department when an intoxicated young female is brought in by EMS after being involved in a reportedly high speed MVC.  She is clinically intoxicated, uncooperative and tachycardic.  She gets a pan-scan CT which identifies some facial fractures and isolated transverse process fractures of the thoracic spine.  As you decide on the next steps to take care of the patient, you debate whether to discuss the patient with a Spine specialist.

Clinical Question: Which spinal fractures should you discuss with a Spine specialist?  Are there some that do not require any intervention at all?

Literature Review:  With the increased availability and increased utilization of CT scanners in the ED, it has become common practice to “pan-scan” patients who present after a trauma, especially those patients who are obtunded/intoxicated or present following a high risk mechanism.  The use of the CT scan to identify thoracic or intrabdominal injuries has concomitantly lead to an increase in diagnosis of fractures of the thoracic and lumbar spine.  As an example, in one retrospective study conducted in the UK of 303 blunt trauma patients who had a Chest/Abdomen/Pelvis CT performed, only six scans (2%) identified thoracic injury and four (1.3%) demonstrated intrabdominal injury while 51 scans (17%) demonstrated an injury to the thoracolumbar spine [1].

With respect to screening for thoracolumbar spinal injuries specifically, the Eastern Association for the Surgery of Trauma practice guideline now recommends CT scan as the primary imaging modality [2]. This is based on a body of evidence that strongly supports that CT scan is more sensitive than X-ray for detection of thoracolumbar spinal injuries.  For example, in one small German study of 107 minor trauma patients, radiographs had a sensitivity of only 49.2% and specificity of 54.7% for thoracolumbar spinal injury compared with CT scan which served as "gold standard" [3].

While CT scan is more sensitive, not all the spinal fractures that are found are clinically significant (i.e. requiring spine precautions or bracing/surgical intervention) [4].  For example, in the small German study cited above X-ray alone missed 16/28 fractures of the the mid thoracic spine, but none of these were considered  unstable [3].  Of the 94 fractures identified in 51 patients by Chest/Abdomen/Pelvis CT in the UK study, 43 (46%) were considered not clinically significant [1].  Thus, the increased sensitivity of our diagnostic evaluation of trauma not only increases our detection of clinically important fractures, but otherwise stable spinal trauma.

Spine consultation for certain types of stable spinal injuries often comes at the expense of increased patient wait times, prolonged spinal precautions,  increased institutional cost, decreased patient satisfaction, and possibly even poorer outcomes if such consultation delays a patient’s transfer to the floor or ICU [4].   Below is a guide to approaching and managing two types of commonly seen fractures in the Emergency Department.

Transverse Process Fractures  

Source: www. waybuilder.net

Transverse Processes (TPs) of the vertebrae primarily function as sites of paraspinal muscle and ligament attachments. They are part of the posterior column in the classic Denis “three column” classification, which divides the spinal column into anterior, middle and posterior structural elements. The vertebral body consists of the anterior and middle columns and is the main axial load bearing part of the spinal unit. The posterior column consists of the elements behind the vertebral body, with the most important components being the pedicles, facet joints and ligamentous complex. Stability for the spinal column is maintained through a series of attachments between the various spinal elements (anterior, middle and posterior). An isolated TP fracture is a stable fracture and does not compromise spinal stability. Additionally, isolated TP fractures are not associated with neurologic deficits. The spinal cord and nerve roots are not in proximity to the TPs, nor are they at high risk of displacing in a manner that would put the nerve root or cord at risk.

A small 2008 retrospective study from the University of Missouri looked at a cohort of 84 patients with TP fractures; 47 were isolated and 37 were associated with other spine fractures [5]. In this study, no patients with isolated TP fractures required surgery or bracing for spinal stability. Furthermore, none of these patients had any neurologic deficits. The authors concluded that conservative management of isolated TP fractures was appropriate, without the need for orthopaedic or neurosurgical consultation. However, if the TP fracture is associated with another spinal fracture such as a vertebral body fracture, a specialist consultation is warranted for treatment recommendations regarding the associated injury, but not necessarily the TP fracture itself. Of course, a cervical TP fracture that extends into the transverse foramen also necessitates additonal imaging and likely spinal consultation, as it may warrant a CT angiogram for evaluation of vertebral artery damage.

Compression Fractures

Vertebral compression fractures are the most common fragility fracture, affecting approximately 25% of people over the age of 70. Compression fractures are a result of axial force on the anterior column that results in a wedge deformity of the vertebral body. The vast majority of compression fractures do not require surgical intervention. Moreover, these fractures are often stable due to their impacted nature. No study has proven that bracing vertebral compression fractures prevents further vertebral collapse, decreases pain, or improves patient satisfaction. Treatment of most vertebral body compression fractures can focus on reducing associated pain with appropriate pain medications. A thorough approach to a patient presenting with an acute compression fracture should include the following:

1: Patient factors: What was the mechanism of injury (simple fall or high-energy injury)? Is the patient ambulatory, bed or wheelchair bound? Are there significant medical comorbidities (ie morbid obesity, extensive pulmonary disease) that would make bracing an ineffective or even dangerous treatment option? Is the patient’s pain controlled enough to obtain an accurate neurologic exam? Is the patient tender over the spinal segment in question?

2: Fracture factors: Is the fracture stable or unstable? The best way to evaluate is to use the patient’s own physiologic forces to see if there is further displacement of the fracture. Barring any neurologic deficits, plain supine AND upright radiographs of the affected area should be obtained. The goal is to see if there is any significant height loss or increased kyphosis between the series. If not, it’s a safe bet that the fracture is stable.

Given a stable fracture, the next step is determined primarily by patient comfort level. If the patient is able to tolerate sustained physiologic loads (ie sitting or standing), it is reasonable to send them home with observation only, no bracing required. Follow up could be provided by their primary care provider or PM&R. If they are in too much pain to stand or sit despite appropriate analgesia, an extension orthosis (like an off-shelf TLSO) is sometimes beneficial and can be provided by the spine consultant on call. If the compression deformity is acute and deemed to be unstable, if there are any neurologic deficits or other associated spinal pathologies, certainly a spine consultation is necessary and appropriate at that time.

Take Home Points:  The increased use of CT imaging, especially in trauma, may lead to the identification of injuries that do not necessarily warrant intervention other than pain control.  For neurologically intact patients, it is useful for the emergency physician to be aware of which fractures warrant either bracing or surgical intervention as unnecessary  consultation can lead to prolonged length of stay and increased cost without significant benefit to the patient.

Submitted by Chris Cosgrove, Orthopedic Surgery PGY-2
Faculty Reviewed by : Lukas Zebala, MD, Assistant Professor, Orthopaedic Surgery

Everyday EBM Editor Maia Dorsett (@maiadorsett)

References:
1. Venkatesan, M., Fong, A., & Sell, P. J. (2012). CT scanning reduces the risk of missing a fracture of the thoracolumbar spine. Journal of Bone & Joint Surgery, British Volume, 94(8), 1097-1100.
2. Sixta, S., Moore, F. O., Ditillo, M. F., Fox, A. D., Garcia, A. J., Holena, D., ... & Cotton, B. (2012). Screening for thoracolumbar spinal injuries in blunt trauma: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 73(5), S326-S332.
3. Karul, M., Bannas, P., Schoennagel, B. P., Hoffmann, A., Wedegaertner, U., Adam, G., & Yamamura, J. (2013). Fractures of the thoracic spine in patients with minor trauma: Comparison of diagnostic accuracy and dose of biplane radiography and MDCT. European journal of radiology, 82(8), 1273-1277.
4. Homnick, A., Lavery, R., Nicastro, O., Livingston, D. H., & Hauser, C. J. (2007). Isolated thoracolumbar transverse process fractures: call physical therapy, not spine. Journal of Trauma and Acute Care Surgery, 63(6), 1292-1295.
5. Bradley, L et al. Isolated transverse process fractures: spine service management not needed. J Trauma 2008 Oct; 65(4):832-6.

Too many choices: Ankle sprain treatment - ace wrap, brace, or boot?

Clinical Scenario:
A 22 year old was running in the park when she accidentally rolls her ankle on the uneven ground.  There is significant swelling over the lateral malleolus that is tender to palpation.  She is unable to bear weight on her ankle so you obtain x-rays, which are normal.  As you are about to send her home, you debate what is the best treatment for her ankle.

Clinical Question:
In a severe ankle sprain, what is the preferred treatment – ace wrap, aircast brace, or air walker boot?

Literature Review:
Grade I injury is a mild stretching of the ligament without joint instability, Grade II injury is a partial rupture of the ligament with mild instability, Grade III is a complete rupture of the ligament with joint instability.   Generally grade II or III are considered severe sprains.

A study released in the Lancet in 2009 compared 584 participants with severe sprains who received a below-knee cast for 10 days, ace wrap, aircast brace, or an air walker boot.  The patients were followed up at 3 months and assessed for quality of ankle function, pain, symptoms, and activity.  The superior method of treatment was the 10 day below-knee cast (when compared to the ace wrap) for overall quality of ankle function (mean difference 9%; 95% CI 2.4-15.0).  The aircast brace was also found to improve quality of ankle function compared to ace wrap and air walker boot, but was not superior with regard to pain, symptom, or activity.  The air walker boot was not superior to the ace wrap.  Another study from 2005 compared ace wraps to the aircast brace for lateral ankle sprains and also found that the aircast ankle brace was superior to an ace wrap at 10 days and one month. In a systematic review published in Sports Med in 2011, they too concluded the superiority of an ankle brace over an ace wrap with regard to functional outcome.

The British Medical Bulletin in a systematic review concluded that for mild to moderate ankle sprains, functional treatment options (ace wrap, aircast brace) where found to be statistically better than immobilization.  For severe ankle sprains, a short period of immobilization in a below-knee cast resulted in a quicker recovery than other functional treatments

Take home points:

-The most practical approach is to offer an aircast brace, which has been shown to offer better functional outcome compared to ace wrap and air walker boot.
-In severe ankle sprains, short below-knee cast immobilization resulted in the best functional outcome

References:

1. Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med. 2005 Feb;39(2):91-6.

2. Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW; Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet. 2009 Feb 14;373(9663):575-81.

3. Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. 2011 Mar 1;41(3):185-97.

4. Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35.

Images from: www.1staidsupplies.com, www.betterbraces.com, orthotape.com.

Submitted by Lydia Luangruangrong, PGY-3.

Edited by  Steven Hung (@DocHungER), PGY-2

Faculty reviewed by Chris Brooks

@WUSTL_EM FOAMed Digest #7: Best of the Best of the Best Sir! ...With Honors

To build on my “Intro to FOAMed” lecture from Tuesday, I thought I would use the Digest this week to highlight some of the highest-quality resources out there for those of you just dipping your toes into the FOAMy goodness. You can’t go wrong adding these to your Feedly. Well-referenced, expert review, open discussion with prompt response – they’re really setting the bar for the FOAMed world.

And don’t worry – in the spirit of FOAMed the lecture and slides will be posted as soon as the video editing is done.

Now come on in, the water’s fine!

Three Stars:

1. Academic Life in EM (ALiEM) continues to be one of the paragons of the FOAMed community. Check out this “Diagnose on Sight” case from this week – don’t want to give it away, but you will see it time and time again during your Children’s shifts. Make note of the reference list and pre-publication review from a practicing clinician. Supremely high quality.

2. I must credit my inspiration for this FOAMed Digest – the LITFL Review from Life in the Fast Lane. Curated by some of the sharpest tacks around, it’s a great way to get familiar with the variety of resources out there. Lots of good stuff this time around, including links to Amal Mattu’s EKG video review of QT prolongation, the latest edition of FOAMCast (all about the spleen!), and the St. Emlyn’s view of the new NICE guidelines for managing acute heart failure.

EXTRA CREDIT: If you need help keeping up with the EM primary literature, the Research & Reviews in the Fastlane segment is a great place to start!

3. EM Lyceum takes the “flipped classroom” concept to the next level. Every month or so, they publish a series of clinical questions focused on a particular topic. This time, it was trauma. The point is to ponder those questions, discuss them in a group, and maybe even do your own research. The EM Lyceum group then publishes the best evidence-based answers they could find in an exceptionally well-referenced summary. Pearl from this month: Bust out the PCC for ICH on warfarin, but no good evidence for PCC in your “average” coagulopathic trauma patient.  

...And We All Fall Down... Eventually : Nonpharmacologic pain management for hip fractures in the elderly?

Your patient is an elderly male with history of dementia and multiple medical comorbidities who is sent to the emergency department after a fall from standing. He complains of left hip pain and his X-rays demonstrate a comminuted intertrochanteric left hip fracture. Since the elderly and demented constitute an at-risk population for inadequate analgesia as well as increased risk of fall, respiratory depression and delirium from polypharmacy, you wonder what nonpharmacologic pain control interventions may supplement your pain control management for this patient?

Clinical question: 

Are nonpharmacologic pain control interventions effective in treating pain associated with hip fracture? Do nonpharmacologic pain control interventions reduce the need for opiates in patients with hip fracture?

The Literature: 

Several studies have examined the efficacy of skin traction (foam boot connected to weight via pulley) versus position of comfort (pillow support) for pain relief in patients with various hip fractures. In two randomized studies, skin traction showed no benefit over pillow support:
The first study, published in 2001, was a randomized study enrolling 100 participants. They compared skin traction with a 5lb weight versus pillow support. The authors found that patients who were treated with pillow support required less pain medication and reported statistically significantly lower pain scores prior to surgery (after overnight stay awaiting operative intervention) than their traction treated counterparts (p 0.04). They had an average reduction of pain score of 2.82 points versus a reduction of 1.76 points. The average age of patients in the study was 78 and nearly half had intertrochanteric hip fractures (other half were femoral neck fractures). The study was limited in that they excluded demented patients in their study as they were felt unable to demonstrate adequate understanding of the pain scale and reliably report pain scores.
The second study, released in 2010, included 108 patients randomized to either weighted traction, unweighted traction apparatus or pillow support. Similarly, they observed no difference in pain control between pillow and weighted traction. However, unweighted traction had a statistically significant improvement in pain control compared to the other two. They attributed this to a placebo effect as it provided no actual support of the fracture fragments and did not restrict movement.
Neither study reported negative outcomes associated with pillow treatment, however both observed minor negative outcomes with skin traction either weighted or unweighted. These included blistering, pressure sores and neurapraxia.

Take home: 

- At least two studies demonstrate no improvement in pain control by employing skin traction over pillow support. 
- Moreover, while the pillow group had no reported negative outcomes related to treatment, the skin traction groups in both studies reported wounds, blistering, nerve compression, and pain with application of the treatment. 
- In this population with advanced age, comorbid illness, and potentially limited ability to sense or communicate discomfort with a boot, these minor problems could develop important long term sequelae.
- My treatment plan for the next elderly hip fracture: Pillow support + adequate pharmacologic analgesia + consideration for local nerve blocks. 

References:
1) Rosen, JE et al, “Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study,” 2001. Journal of Orthopedic Trauma. Vol. 15(2) 81-85.
2) Sayqi, B et al, “Skin traction and placebo effect in the preoperative pain control in patients with collum and intertrochanteric femur fractures.” 2010 Bulletin of the NYU Hospital for Joint Diseases. Vol. 68(1) 15 - 17.


Contributed by Sara Manning, PGY-3

#FOAMed Digest No. 2: Breathless Love

Welcome back! Fresh new FOAMy goodness for you, this time with an emphasis on airway and pulmonary care. Let’s do it!

Three Stars:

1. No way around it: “Delayed Sequence Intubation” is the new hotness. If you want to be one of the cool kids, you better get on board. I’ll let the more graphically-minded folks at EMCurious lay it all out for you with a prototypical case. Don’t miss the links – more excellent FOAMed resources on DSI.

(And Weingart’s seminal paper on the subject is required reading at this point.)

(And, oh yeah, ketamine does NOT increase ICP. Let’s use these two systematic reviews 1 & 2 to stop the foolishness already.)

2. Someday you will need to perform a cricothyrotomy. Accept it as reality, and do everything you can to prepare for it. Start here, with Weingart’s lecture on the surgical airway delivered at the SMACC Gold conference last fall. This page from the EMCrit blog has compiled all sorts of great surgical airway resources from around the FOAMed world all in one spot, including can’t-miss stuff about the scalpel-finger-bougie technique and Weingart’s pre-intubation checklist. You should probably add it to your favorites list now.

3. Wouldn’t be a FOAMed Digest without getting a little off-topic, and Rick Body’s recent contributions over at St. Elmyn’s regarding ACS & “low-risk” chest pain in the ED are too good to pass up. Great post analyzing his recent paper, which concluded ED physicians simply aren’t capable of ruling out ACS in chest pain patients with an acceptable accuracy using only the clinical exam. Dr. Body also gives you a run-down of how to properly utilize high-sensitivity troponin in his talk from SMACC Gold.

(Link to Body's paper here.)

Oldie But Goodie:

By the end of our Ultrasound rotation, we can all diagnose pneumothorax with ultrasound at the bedside. It’s time to take it next-level. A-lines, B-lines, pneumonia vs edema…the experts at the Ultrasound Podcast help you figure it all out in a two-part 1 & 2 podcast.

F(FN)OAMed:

Sanjay Arora and Mike Menchine, hosts of the PaperChase segment on EM:RAP, summarize the current literature about how terrible we are at adequately sedating patients after RSI. Roc lasts longer than Sux – the patients won’t be able to tell us they need sedation!

(Links to relevant papers in the show notes.)

The Gunner Files:

1. Brett Sweeny at EMDocs provides an exhaustive review of FOAMed resources regarding permissive hypotension in trauma. Great lectures and podcasts from some of the brightest minds in EM & trauma surgery.

2. We’re seeing it already – asthma cases are starting to pile up over on the SLCH side. Luckiliy for you, Pediatric EM rockstar Andy Sloas just published an excellent podcast on the evaluation and management of asthma in the Peds ED.

3. Next time you’re consulting Ortho or Plastics for a hand injury, sound like you know what you’re talking about. The folks over at EMin5 hit you with the quick rundown on the neuro exam of the hand.

4. Last week, St. Elmyn’s helped the rooks get up to speed when it came to dealing with the dyspneic patient in the ED (and I bet the seniors learned a thing or two as well). This time, get your mind right when faced with a syncopal patient.

5. Who doesn’t love infographics? And if they actually help us learn something about managing septic patients, that’s just a bonus! Very well done by EMCurious, with embedded links to the relevant studies!

6. New podcast from R.E.B.E.L.EM, summarizing the results of a meta-analysis just published this month in Annals which concluded prehospital application of NIPPV in patients with severe respiratory distress regardless of cause reduced need for intubation (NNT 8) and in-hospital mortality (NNT 18). 

w00t prehospital medicine!
(Original pub here.)

That’s all, folks! Go get your learn on!

Sam Smith, PGY-3