Video – Panel Discussion – EM Education in Asia

This blog post includes one of the presentations of Emergency Medicine Education in Asia Webinar organized by Asian Society for Emergency Medicine on July 9, 2022. 

Video – International Emergency Medicine Education Project

This blog post includes one of the presentations of Emergency Medicine Education in Asia Webinar organized by Asian Society for Emergency Medicine on July 9, 2022. 

Video – Road Forwards in Emergency Medicine Education

This blog post includes one of the presentations of Emergency Medicine Education in Asia Webinar organized by Asian Society for Emergency Medicine on July 9, 2022. 

Question Of The Day #100

question of the day
Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the Emergency department with 1 week of melena and fatigue.  His medication list includes an antiplatelet and an anticoagulant medication.  There is tachycardia and melena noted on examination.  This patient likely has an upper GI bleed based on his signs and symptoms with peptic ulcer disease as the most common cause.  The patient’s anticoagulation serves as a risk factor for GI bleeding and is an important contributing factor in this scenario.  Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Gastroenterology consultation for emergent endoscopy (Choice B) is not necessary as the patient is not acutely unstable.  He may need a diagnostic and therapeutic endoscopy during an inpatient admission, but the GI consultants do not need to be called emergently for this procedure.  An acutely unstable upper GI bleed patient, such as a patient with hemodynamic instability, requiring intubation for airway protection, receiving multiple blood product transfusions, or with brisk (rapid) bleeding on exam should prompt GI consultation for an emergent endoscopy for source control.  Surgery consultation for gastrectomy (Choice C) is not a first-line treatment for upper GI bleeding.  Gastroenterology should first perform a diagnostic and therapeutic endoscopy for most upper GI bleed patients.  Surgical esophageal transection, gastrectomy, colectomy, and other surgical procedures are last resort measures to control GI bleeding.  Administration of IV Ceftriaxone (Choice D) is not needed in this scenario and should not be given routinely in upper GI bleeds.  This patient has no infectious signs or symptoms.  Antibiotics, such as Ceftriaxone or quinolones, should be given to upper GI bleed patients with chronic liver disease (i.e., cirrhosis), or presumed gastroesophageal variceal bleeds.  Antibiotics have been found to have a mortality benefit in this patient population with GI bleeds. 

The best next step in management is to treat the patient’s tachycardia with normal saline (Choice A) for volume resuscitation.  This patient may eventually need blood products, but crystalloid IV fluids are okay to start until the Complete Blood Count results return.  This patient is not in overt hemorrhagic shock, so blood products can be held until there is evidence that the hemoglobin is below 7g/dL.  Reversal of the patient’s anticoagulation with Vitamin K and fresh frozen plasma may also be needed depending on the INR level.  Reversal can wait until coagulation studies are complete since the patient is not acutely unstable. An unstable patient should have their anticoagulant reversed immediately. Correct Answer: A

References

 
 
Cite this article as: Joseph Ciano, USA, "Question Of The Day #100," in International Emergency Medicine Education Project, August 12, 2022, https://iem-student.org/2022/08/12/question-of-the-day-100/, date accessed: October 2, 2022

Video – Educator in Emergency Medicine

This blog post includes one of the presentations of Emergency Medicine Education in Asia Webinar organized by Asian Society for Emergency Medicine on July 9, 2022. 

Question Of The Day #99

question of the day

Complete Blood Count

Result

(Reference Range)

BUN

36.2

5 -18 mg/dL

Creatinine

1.1

0.7 – 1.2 mg/dL

Hemoglobin

9.2

13.0 – 18.0 g/dL

Hematocrit

27.6

39.0 – 54.0 %

Which of the following is the most appropriate advice for this patient’s condition?

This patient arrives to the Emergency department after a single hematemesis episode.  On exam he has a borderline low blood pressure and tachycardia.  The laboratory results demonstrate an elevated BUN and a low hemoglobin and hematocrit.  The patient’s vital signs in combination with the laboratory values point towards a diagnosis of an upper GI bleed with early signs of hemorrhagic shock.  The history of alcohol abuse also should raise concern for possible gastro-esophageal variceal bleeding as the cause of the GI bleed.

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Although this patient is not acutely unstable, his vital signs are abnormal and he should receive volume resuscitation and close observation in the Emergency department.  After initial resuscitation and treatment, it is sometimes difficult to know the best disposition for the patient (admit versus discharge).  The Glasgow-Blatchford Score isa validated risk satisfaction tool used to assist in determining the disposition of patients with an upper GI bleed.  The scoring criteria and instructions on how to use the score are below.

Glasgow-Blatchford Score

 

A validated risk stratification tool for patients with upper GIB

Scoring Criteria

Numerical Score

BUN (mg/dL)

<18.2

18.2-22.3

22.4-28

28-70

>70

 

0

+2

+3

+4

+6

Hemoglobin (g/dL) for men

>13

12-13

10-12

<10

 

0

+1

+3

+6

Hemoglobin (g/dL) for women

>12

10-12

<10

 

0

+1

+6

Systolic blood pressure (mmHg)

>110

100-109

90-99

<90

 

0

+1

+2

+3

Other criteria

Pulse >100 beats/min

Melena present

Syncope

Liver disease history

Cardiac failure history

 

+1

+1

+2

+2

+2

Instructions:

Low risk= Score of 0.  Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery. Consider admission for any score over 0. 

This patient has a Glasgow-Blatchford score of 15, and should not be discharged home.  A plan to discharge with gastroenterology follow up in 1 week (Choice A) or discharge with instructions to return if there are repeat hematemesis episodes (Choice B) should not be followed. This patient may have future hematemesis episodes in the Emergency department, be at risk for aspiration, require endotracheal intubation, and become more hypotensive.  A Sengstaken-Blakemore tube (Choice C) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Placement of this tube is considered an invasive procedure that is only used after a patient has been endotracheally intubated to prevent aspiration.  Once placed correctly, the balloons in the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube is used as a last resort measure prior to endoscopic treatment for presumed gastro-esophageal variceal bleeds. 

The best advice for this patient would be to admit the patient for monitoring and endoscopy (Choice D).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #99," in International Emergency Medicine Education Project, August 5, 2022, https://iem-student.org/2022/08/05/question-of-the-day-99/, date accessed: October 2, 2022

Video – Challenges in Emergency Medicine Education

This blog post includes one of the presentations of Emergency Medicine Education in Asia Webinar organized by Asian Society for Emergency Medicine on July 9, 2022. 

Question Of The Day #98

question of the day
Which of the following is the most likely cause for this patient’s condition?

This man presents to the Emergency department with epigastric pain and hematemesis.  His exam shows hypotension, tachycardia, pale conjunctiva, and a tender epigastrium and left upper quadrant.  This patient likely has an upper GI bleed based on his signs and symptoms. 

Please refer to the chart below for a list of causes of GI bleeding, GI bleeding signs and symptoms, and the initial Emergency Department treatment of GI bleeding. 

Risk factors for GI bleeds include alcohol use, anticoagulant use, NSAID (non-steroidal anti-inflammatory drug) use (i.e., ibuprofen, aspirin, naproxen), recent gastrointestinal surgery or procedures, prior GI bleeds, and a history of conditions that are associated with GI bleeds (i.e., gastritis, peptic ulcers, H. Pylori infection, ulcerative colitis, Chron’s disease, hemorrhoids, diverticulosis, or GI tract cancers).  Fatty meals (Choice A) can trigger gastroesophageal reflux disorder (GERD) symptoms or biliary colic symptoms from cholelithiasis.  However, fatty meals do not increase the risk for GI bleeding.  Physiological stress, such as sepsis or bacteremia (Choice B), can increase the risk for GI bleeding.  This patient does not have any infectious exam signs or symptoms that would support the presence of bacteremia. Acetaminophen use (Choice D) can cause liver failure if taken in excess, but acetaminophen does not cause GI bleeding.  NSAIDs, unlike Tylenol, are associated with GI bleeding. 

Systemic steroid use (Choice C) can increase the risk for GI bleeding and is the likely cause of this patient’s upper GI bleed. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #98," in International Emergency Medicine Education Project, July 29, 2022, https://iem-student.org/2022/07/29/question-of-the-day-98/, date accessed: October 2, 2022

Video – EM Education Across Asia – EM Residents

This blog post includes one of the presentations of Emergency Medicine Education in Asia Webinar organized by Asian Society for Emergency Medicine on July 9, 2022. 

Question Of The Day #97

question of the day
Which of the following is the most appropriate next step in management for this patient’s condition?

This patient arrives to the Emergency department after multiple episodes of hematemesis.  Her exam shows tachycardia, borderline hypotension, and mild tachypnea.  While in the Emergency department the patient decompensates after more hematemesis episodes and develops altered mental status.  This patient has an upper GI bleed most likely from a gastroesophageal variceal bleed.  Gastro-esophageal (GE) varices are dilated blood vessels at the GE junction that result from portal hypertension.  Variceal bleeding can be catastrophic and cause hemorrhagic shock and problems with airway patency as seen in this scenario.  The management of GE variceal bleeding, like other GI bleeds, begins with management of the “ABCs” (Airway, Breathing, and Circulation).  Unlike in other causes of upper GI bleeds, IV antibiotics and IV octreotide are used in GE variceal bleeds.  IV antibiotics have a mortality benefit when used in this setting.  Early gastroenterology consultation is another important component of GE variceal bleed management for definitive diagnosis and treatment with variceal banding or ligation.  Please see the chart below for further details on general GI bleed causes, signs and symptoms, and ED management.

This patient with a depressed mental status needs to have a definitive airway established to prevent aspiration with bloody vomitus.  IV Pantoprazole (Choice B) is used in upper GI bleeds from peptic ulcers but has no role in this acutely ill variceal bleed patient.  The airway should be established prior to medications, such as pantoprazole are considered.  A cricothyrotomy (Choice D) would establish an airway, but this is an invasive approach to airway management and not the best approach in this patient.  A cricothyrotomy involves piercing a needle or scalpel in the anterior neck (cricothyroid membrane) to establish an airway surgically.  This procedure is performed in special situations where a patient cannot be intubated through the trachea (i.e., angioedema of the lips and tongue, facial mass, facial trauma) and cannot ventilate independently (i.e., depressed mental status).  This patient does not meet the criteria for this invasive procedure.  Endotracheal intubation should be attempted first on this patient.  A Sengstaken-Blakemore tube (Choice A) is a specialized oro-gastric tube with a gastric and esophageal balloon.  Once placed correctly, the balloons on the tube can be inflated to tamponade any bleeding variceal vessels in the distal esophagus or stomach.  This tube should be placed only after intubating a patient and is used as a last resort measure prior to endoscopic treatment.  The best next step in management of this patient is to perform endotracheal intubation (Choice C) for airway protection. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #97," in International Emergency Medicine Education Project, July 22, 2022, https://iem-student.org/2022/07/22/question-of-the-day-97/, date accessed: October 2, 2022

Traumatic Bucket Handle Mesenteric Injury

Author: Ines Obolo

Introduction

Trauma represents a leading cause of mortality worldwide. Abdominal trauma represents 7% of trauma cases[1] and 15-20% of severe adult trauma cases[2]. Abdominal trauma can be classified into blunt or penetrating trauma. Blunt abdominal trauma includes injury to solid and hollow viscus organs. Frequently injured organs: spleen, liver, small bowel[3]. Traumatic hollow viscus mesenteric injury (HVMI) are rare, life-threatening injuries[4,5]  and can be due to direct impact, deceleration, and increased luminal pressure[6]. With the deceleration mechanism, there is a rapid change in velocity with the differential movement of mobile and fixed parts of the body. Mesenteric disinsertion, also known as bucket handle mesenteric injury is an example of deceleration injury[7]. A bucket handle mesenteric injury is an avulsion of a mesentery out of a segment of bowel due to shearing forces in blunt abdominal trauma [7]. This injury results in intestinal ischaemia and if left untreated may progress to intestinal necrosis, perforation and peritonitis[1,8]. This injury is commonly encountered in the course of a motor vehicle accident, often associated with restraint device injury (lap seat belt, shoulder harness)[2,9,10]. Under the umbrella of traumatic HVMI, small bowel injuries represent more than half of the cases. Bruising in a seatbelt pattern is associated with intra-abdominal injury in 20–60% of cases[6]. The diagnostic modality for HVMI depends on the hemodynamic status of the patient. Stable patients get CT scan, while the unstable get an ultrasound – Focused Assessment with Sonography for Trauma (FAST). The early management of traumatic HVMI begins with a primary survey and resuscitation. The injury is commonly missed during the first days following trauma. Treatment involves resection of devitalized bowel segment and anastomosis of the bowel[8]. Surgery should not be delayed in patients presenting with hemodynamic instability, pneumoperitoneum, peritonitis and CT signs of mesenteric ischaemia[6,8].

Case Presentation

A 53-years-old patient who diagnosed with type 2 diabetes mellitus over 5 years ago, on metformin non-compliant to treatment, known hypertensive, treated with indapamide is presented to the ED. He was involved in a motor vehicle accident involving a head-on collision of two vehicles at fast speed. He was a passenger and was compressed by his lap seat belt at the moment of collision. He complained of diffuse abdominal pain, no loss of consciousness. On clinical exam, the patient was stable, with a right flank ecchymosis, diffuse abdominal tenderness and tender Douglas pouch. CT scan done found peri-hepatic hematoma with no free air in the peritoneal cavity. A laparotomy with midline incision was done and the peroperative findings were: about 1.5L of bloody intra-abdominal fluid, 3cm perforation of the ileum 80cm proximal to the ileocecal junction, ileal mesenteric disinsertion with bowel necrosis.  The repair consisted of resection of devitalized ileum and end-to-end anastomosis. Post-operatively, the patient had pulmonary sepsis with acute respiratory distress syndrome, grade II hypertension and hyperglycaemia and was managed at the intensive care unit. The evolution was favourable on day 14 post-op with medication: antibiotics, insulin and antihypertensive (calcium channel blocker – amlodipine). Sutures were removed on day 14 post-op and he was discharged on day 20 post-op.

Discussion

Blunt abdominal trauma results in injury to the bowel and mesenteries in 3—5% of cases. It has a variable presentation with hematoma, seromuscular tear, ischaemia, perforation[5,6]. Our patient is male and aged 53 years comparable to studies[2,3] that demonstrate the predominance of male sex in abdominal trauma with a mean age range of 30-39 years with extremes at 15 and 67years. The patient incurred a blunt abdominal trauma in the course of a motor vehicle accident and presented with a seat belt sign this is similar to studies that report patients often being victims of motor vehicle accidents [2,8,11] with or without restrain devices. The use of restraint devices is responsible for traumatic lesions to hollow organs. Literature review incriminates poor seat belt usage in particular lap seatbelt as a cause of mesenteric injuries during blunt trauma[12]. Diffuse abdominal tenderness and tenderness on digital rectal examination (DRE) were present on physical exam. Tenderness on DRE is rare[2] while abdominal tenderness is a non-specific sign of abdominal trauma and is encountered in all types of injury involving the abdomen[6].  A CT was done for the patient which found peri-hepatic hematoma and no mesenteric lesion. CT scan represents the most sensitive diagnostic imaging modality with a sensitivity ranging from 59% to 95%[13] though cases of false negatives (lesions found during laparotomy absent in CT) have been reported. The perioperative findings were small bowel ischaemia following mesenteric disinsertion, necrosis and perforation consistent with review findings [6,12]. The lesions were located over the ileal segment. This is consistent with studies as the small bowel is the most injured organ in blunt abdominal trauma[2,3,5].  The surgical management consisted of resection of the ileal segment and end-to-end anastomosis per studies[2,3,5] that mention the management of traumatic HVMI  to be the removal of devitalized bowel and restoration bowel continuity. Traumatic injuries to hollow viscous and mesenteric represent a diagnostic challenge, admission delays aggravate prognosis and are due to the lack of functional emergency services in our context[8]. The patient presented with hypertension, hyperglycaemia and pulmonary sepsis after his surgery with no cardiovascular event nor kidney injury. According to a review[7], hypertension increases perioperative cardiovascular complications by 35% and the management depends on other comorbidities with beta-blockers often used. In diabetic patients undergoing surgery, an assessment of glycaemic control with recent capillary blood sugar level is recommended as diabetes could present several risks including cardiovascular events, acute kidney injury and infectious complications[14]. This emphasizes the need for proper postoperative management of high-risk patients. This case highlights the reality of hollow viscus and mesenteric injuries despite their scarcity and the fact that they often present as missed lesions with high mortality[8,10]. These injuries represent a challenge in clinical assessment and management, especially in high-risk patients who should be closely monitored pre and postoperatively[7,14].

Conclusion

Traumatic Bucket handle mesenteric injuries are rare and challenging to diagnose. As with this case, a high suspicion should exist for every patient involved in a motor vehicle accident wearing a restraint device. Equally, the physician should rely on the findings of a thorough physical examination. Early management is key to reducing morbidity and mortality.

References and Further Reading

1. Arumugam S, Al-Hassani A, El-Menyar A, Abdelrahman H, Parchani A, Peralta R, et al. Frequency, causes and pattern of abdominal trauma: A 4-year descriptive analysis. J Emerg Trauma Shock. 2015 Dec;8(4):193–8.
2. Engbang JP, Chasim CB, Fouda B, Motah M, Moukoury TJK, Ngowe MN. Epidemiology, diagnostic and management of abdominal trauma in two hospitals in the city of Douala, Cameroon. Int Surg J. 2021 May 28;8(6):1686–93.
3. Abebe K, Bekele M, Tsehaye A, Lemmu B, Abebe E. Laparotomy for Abdominal Injury Indication & Outcome of patients at a Teaching Hospital in Addis Ababa, Ethiopia. Ethiop J Health Sci. 2019 Jul;29(4):503–12.
4. Watts DD, Fakhry SM, EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the East multi-institutional trial. J Trauma. 2003 Feb;54(2):289–94.
5. Mingoli A, La Torre M, Brachini G, Costa G, Balducci G, Frezza B, et al. Hollow viscus injuries: predictors of outcome and role of diagnostic delay. Ther Clin Risk Manag. 2017 Aug 23;13:1069–76.
6. Bège T, Brunet C, Berdah SV. Hollow viscus injury due to blunt trauma: A review. J Visc Surg. 2016 Aug;153(4 Suppl):61–8.
7. Aronow WS. Management of hypertension in patients undergoing surgery. Ann Transl Med. 2017 May;5(10):227.
8. Patrick SE, Roger BMG, Aristide BG, Arthur E, Bernadette NN, Daniel BB, et al. Surgical Management of Abdominal Trauma: Indications and Outcomes in Two Emergency Units with Limited Infrastructure Resources in Yaoundé (Cameroon). Surg Sci. 2021 Oct 25;12(10):720–6.
9. Nonterah EA, Atindama S, Achumbowina E, Kaburise MB, Saanwie E, Ewura A, et al. Isolated Jejunal Perforation and Mesentery Injury following a Kick on the Abdomen of a College Student: A Case Report from a District Hospital in Northern Ghana. Waxman KS, editor. Case Rep Crit Care. 2020 Mar 26;2020:3063472.
10. American College of Surgeons, Committee on Trauma. Advanced trauma life support: student course manual. 2018.
11. Wisner DH, Chun Y, Blaisdell FW. Blunt intestinal injury. Keys to diagnosis and management. Arch Surg Chic Ill 1960. 1990 Oct;125(10):1319–22; discussion 1322-1323.
12. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg. 1997 Oct;63(10):885–8.
13. Extein JE, Allen BC, Shapiro ML, Jaffe TA. CT Findings of Traumatic Bucket-Handle Mesenteric Injuries. AJR Am J Roentgenol. 2017 Dec;209(6):W360–4.
14. Cheisson G, Jacqueminet S, Cosson E, Ichai C, Leguerrier A-M, Nicolescu-Catargi B, et al. Perioperative management of adult diabetic patients. Preoperative period. Anaesth Crit Care Pain Med. 2018 Jun;37 Suppl 1:S9–19.

Video – EM Education in India – Medical Students

This blog post includes one of the presentations of Emergency Medicine Education in Asia Webinar organized by Asian Society for Emergency Medicine on July 9, 2022.