Category: FOAMed

Ethical Approval

ethical approval
~ Arif Alper Cevik ~ Leave a comment

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 9th episode is “Ethical Approval”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

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Journal Club 10/18/21: The Global Burden of Disease

~ Global EM Student Leadership Program ~ Leave a comment

Global Health and the Global Burden of Disease presented by Denise Manfrini

Global burden of disease is the quantity of disease (conditions, illnesses, injuries) and their impact on a population. The impact is measured in disability-adjusted life years (DALYs), which is the years of life lost from premature death and years of life lived in less than full health. There are other metrics used as well to compare countries, such as incidence, prevalence, mortality, and fertility rate.

In order to determine these metrics to measure global burden of disease and see where a country’s health system should focus, disease surveillance is required. This led to the creation of the Global Burden of Disease (GBD) Project in 1992. It aims to develop a consistent way to estimate disease burden in eight global regions (established market economies and formerly socialist economies) using the metrics described above, particularly the DALY. The project initially quantified 107 conditions and over 400 sequelae and has been expanding and updating its findings in the following years. This level of detail has allowed tracking of disease changes over the years and given insight into which interventions are effective. Initial results have shown high disease burden, premature mortality, and health disparities when comparing established market economies and impoverished countries; notably, developing countries suffered more from infectious and parasitic diseases, respiratory infections, and maternal and perinatal disorders. Developed countries suffered more from diseases due to poor lifestyle, such as cardiovascular disorders. Results from 2019 indicate shifts. Overall health is improving worldwide since those results in 1994 (GBD 2019 Diseases and Injuries Collaborators 2020). As seen in the chart, diseases affecting primarily children, such as respiratory infections, diarrheal infections, measles, neonatal disorders, tetanus, malaria, have decreased significantly. The prevalence of diseases affecting older adults, such as ischemic heart disease, diabetes, stroke, lung cancer, has increased and indicates that health care systems need to be prepared to manage an older patient population.

An alternative approach advocated for the right to health of every individual as envisioned in the Universal Declaration of Human Rights. The 1978 Alma Ata Declaration proposed that the fulfillment of these rights belongs to the international community through international collaboration. The past several decades has seen an increasing movement towards this idea and away from one based on economics. An example of this would be the recognition in the 1990s that citizens of developing nations with HIV are inherently as deserving of treatment as those from developed nations. By taking an approach rooted in human rights, the international community was able to lower the cost of HIV medication and provide treatment for patients in the developing world.

Change in worldwide burden of disease from 1990 to 2019. Red - infections/perinatal/maternal conditions; Blue - noncommunicable disease; Green - Injuries/accidents. Source: GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.

Once burden of disease can be quantified, how do we decide how to tackle it? Enter priority setting to determine how to best allocate resources. A few models have been proposed. In 1971, Abdel Omran posited four stages through which developing countries progress, called the epidemiological transition. The four stages are: age of pestilence and famine; age of receding pandemics; age of degenerative and manmade disease; and age of delayed chronic disease. Developed countries would be categorized in this final stage. However, the stages do not have clear divisions nor is the progression so clear-cut; a country can be in more than one stage simultaneously. For example, developed countries are currently suffering from the Covid pandemic and from chronic diseases. Thus, priority setting based only on the epidemiological transition would provide incomplete aid to countries encountering more than one stage. Another model is the idea of cost-effectiveness. For an intervention to be considered cost-effective, it must cost no more than 3x the per capita health costs. This is difficult to achieve in countries where the per capita health cost is extremely limited and not enough to cover a worthwhile intervention. After recognizing that poor health leads to limited economic development and to address the challenge of figuring out which interventions need investing, the Disease Control Priorities (DCP) Project was created. It aimed to enable countries to choose and prioritize interventions that maximally impact disease burden and that are supported by their health budgets. The latest DCP project promotes equity and advocates for universal health coverage. Both the DCP and GBD projects are ongoing.

Discussion Questions:

•To what extent should developed countries provide economic support to developing countries?

•Which diseases can we anticipate becoming a larger portion of the burden of disease and what can we do to prepare? 

Tuberculosis: Global Policy and Impacts of COVID-19 presented by Andrew McAward

Prior to the current COVID-19 pandemic, tuberculosis was the leading cause of death from a single infectious disease. In 2020, 1.5 million people worldwide succumbed to TB, while an additional 10 million were infected with primary TB. However, major global health organizations agree that tuberculosis is both curable and preventable. For this reason, combating tuberculosis continues to remain at the forefront of global health efforts today.
The pathology of the TB is caused by Mycobacterium tuberculosis infection, which classically results in the development of granulomatous lesions in lung tissue. This disease can be latent, acute, or systemic/miliary in nature. Updated treatment protocols continue to recommend using derivations of the “RIPE” therapy regime for up to 6 months. The BCG vaccine is widely used in countries with high TB burden, providing strong protection against tuberculosis meningitis and miliary TB spread in children. However, this vaccine’s lack of effectiveness in adults and contraindication in both pregnant women and the immunocompromised has prompted the WHO to initiate new vaccine development. Additionally, the rising concern of multidrug-resistant TB has increased global efforts to establish new treatment options and a more effective vaccine.

Global health organizations have renewed their ambitions to mitigate the spread of TB. In 2014, the World Health Organization’s “End TB Strategy” set a goal to reduce TB incidence by 80% and death by 90% by 2030. The organization’s intention was to embolden local governmental policies and increase research efforts such as through the development of a new adult candidate TB vaccine, M72/AS01E. Similarly, the United Nations joined the WHO’s response by including the elimination of the tuberculosis epidemic on a list of 17 Sustainable Development Goals (SDGs) to be achieved by the year 2030. Despite these efforts, the progress made in battling TB has been halted by COVID-19. New cases of tuberculosis markedly fell in 2020 due to lack of access to diagnostic services, while global deaths increased for the first time in over a decade. The current COVID pandemic has also worsened prognostic outcomes of patients currently undergoing treatment for tuberculosis. Prior successes of global TB health policy, such as maintaining steady drug supply chain or providing healthcare personnel to assist with direct observation drug therapy, have been disrupted due to the economic and social implications of the current pandemic.
Since 2000, over 66 million lives worldwide have been saved through the diagnosis and successful treatment of tuberculosis. Despite dramatic setbacks caused by COVID-19, the global health community should remain optimistic about the long-term mitigation of this disease.

Discussion Questions:

• How can global health policies help to overcome the challenges caused by COVID-19 in the diagnosis and treatment of TB?

• How can healthcare professionals continue to further the progress made against TB burden in their own communities?

Journal Article: Five insights from the Global Burden of Disease Study 2019 Presented by Rachael Kantor

1. Double Down on Catch-up Development
Improvements in SDI have increased universally at an exponential rate since the 1950s. Originally (and predictably) we saw high SDI countries developing at a much faster rate than low SDI countries BUT since the start of the millennium counties of lower SDIs have been progressing at a rate much faster than those of high SDI statuses showing catch-up development. To close the gap, we must “double down” by increasing economic growth, expanding access to education, and improving the status of women in lower SDI countries. **Socio-demographic Index (SDI) is a measure used in the GBD to identify where a geographic area sits on the spectrum of development.
2. The Minimum Development Goal Health Agenda HAS been working
It’s no secret that since the early 2000s the global health community has focused heavily on decreasing mother and child mortality and decreasing the burden of communicable diseases (specifically TB, HIV, and malaria). The good new is these efforts have been incredibly successful BUT we owe it to ourselves to pay close attention to non-communicable disease (NCD) trends. Population growth and aging have led to a steady increased in NCDs.
3.Health Systems need to be more agile to adapt to the rapid shifts to NCDs and disabilities
As health profiles and SDI rankings change, universal health coverage must adapt to meet current health needs. This means increased focus on NCD coverage and greater attention to disorders causing functional health loss (MSK, substance abuse, mental health, etc.) to reduce the massive policy gap.
4. Public health is failing to address the increase in crucial global health risk factors
As global SDI has increased, many risk factors have seen a sharp decline. However, risk factors including High SBP, FBG, and BMI, as well as alcohol and drug use have increased alarmingly by > 0.5% a year.
5. Social, fiscal, and geopolitical challenges of inverted population pyramids
The GBD has estimated that by 2100 there will be over 150 countries whose death rate exceeds its birth rate; this compared to 34 countries in 2019. Many country populations will decrease—resulting in tremendous controversy regarding workforce maintenance, the ongoing immigration debate, and fertility incentivization2.

Discussion Questions:

•Many editorials/opinions call the neglect of chronic illness, and the exponential rise of preventable risk factors the “perfect storm” to fuel the COVID-19 pandemic.   What sort of policies (concrete or abstract) should be put into place to take urgent action against this “failure of public health,” making countries more resilient to future pandemic threats?

•The authors of this study have concluded that exposure to/smoking tobacco has fallen 1-2% a year worldwide since 2010 due to the major efforts to implement international tobacco control policies rather than providing information to consumers about the harms of tobacco. However, the rate of exposure to other risk factors are increasing by more than 0.5% a year. Given the successes/failures of the efforts to decrease tobacco exposure, what place does government and international legislation have in the efforts to reduce these other risk factor exposures?   

~This second discussion question provided an excellent conversation on the importance of individual autonomy and governmental policy influence, as well as those factors, including social determinants of health that limit both the individual and a government’s ability to take viable action to reduce risk factor exposure.  

 

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Picture of Denise Manfrini, MS4

Denise Manfrini, MS4

University of Florida

Picture of Andrew McAward, MS2

Andrew McAward, MS2

Marshall University, Joan C. Edwards School of Medicine

Picture of Rachael Kantor, MS4

Rachael Kantor, MS4

The Medical School for International Health at Ben Gurion University

Sources and Further Reading:

  • Mukherjee, J. (2017). Chapter 4: Global Health and the Global Burden of Disease. In An Introduction to Global Health Delivery (pp. 89–105). book, Oxford University Press.
  • GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.
  • Global Health CEA registry database with publications from different countries about cost-saving interventions – https://cevr.shinyapps.io/LeagueTables/
  • Kant, Surya, and Richa Tyagi. “The Impact of Covid-19 on Tuberculosis: Challenges and Opportunities.” Therapeutic Advances in Infectious Disease, vol. 8, 9 June 2021, p. 204993612110169., https://doi.org/10.1177/20499361211016973.
  • Kirby, Tony. “Global Tuberculosis Progress Reversed by COVID-19 Pandemic.” The Lancet Respiratory Medicine, 2 Nov. 2021, https://doi.org/10.1016/s2213-2600(21)00496-3.
  • Roy, A., et al. “Effect of BCG Vaccination against Mycobacterium Tuberculosis Infection in Children: Systematic Review and Meta-Analysis.” BMJ, vol. 349, no. aug04 5, 2014, https://doi.org/10.1136/bmj.g4643.
  • “Tuberculosis (TB).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Oct. 2021, https://www.cdc.gov/tb/default.htm.
  • “Tuberculosis (TB).” World Health Organization, World Health Organization, 14 Oct. 2021, https://www.who.int/news-room/fact-sheets/detail/tuberculosis.
  • GBD 2019 Viewpoint Collaborators. Five insights from the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1135-1159. doi: 10.1016/S0140-6736(20)31404-5. PMID: 33069324; PMCID: PMC7116361.
  • Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396: 1160-1203

 

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Question Of The Day #67

question of the day
~ Joseph Ciano, USA ~ Leave a comment
SS Video 2 Large Pericardial Effusion

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

  • A) High cardiac preload
  • B) Low cardiac afterload
  • C) Low cardiac output
  • D) High cardiac output

This patient arrives in the Emergency Department after sustaining penetrating chest trauma and is found to be hypotensive, tachycardic, and with a low oxygen saturation on room air. The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient’s ultrasound shows fluid in the pericardiac sac which in combination with the patient’s hypotension and tachycardia, this supports a diagnosis of cardiac tamponade.  See the image below for labelling.

Cardiac tamponade is considered a type of obstructive shock.  As with other types of obstructive shock, such as pulmonary embolism and tension pneumothorax, there is a state of reduced preload and elevated afterload.  This causes a reduction in cardiac output (Choice C) which leads to hypotension, tachycardia, and circulatory collapse.  High cardiac preload (Choice A), low cardiac afterload (Choice B), and high cardiac output (Choice D) do not occur in cardiac tamponade.  Treatment for cardiac tamponade includes IV hydration to increase preload, bedside pericardiocentesis, and ultimately, a surgical cardiac window performed by cardiothoracic surgery. Correct Answer: C

Want Another Question?

References

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Establishing Registries

establishing registries
~ Arif Alper Cevik ~ Leave a comment

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 8th episode is “Establishing Registries”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

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Catching Necrotizing Fasciitis Early in the ED

~ Helena Halasz, Hungary ~ Leave a comment

A well-known adage is that necrotizing fasciitis, which is colloquially abbreviated to “nec-fasc,” is a rapidly progressive and often fatal disease that proves difficult to diagnose.

Image Courtesy of DermNet NZ

Nomenclature and Background Information

Necrotizing fasciitis is a subset of a larger group of diseases known as necrotizing soft tissue infections or NSTIs. In this blog post, the term NSTI will be used in an effort to be inclusive of infection that may be affecting the muscles (myositis), deeper dermis and subcutaneous tissue (cellulitis) or fascia (fasciitis).

The first known reference to the disease process can be traced back to the 5th century; Hippocrates, who is often referred to as the father of medicine, wrote, “[m]any were attacked by the erysipelas all over the body when the exciting cause was a trivial accident…flesh, sinews, and bones fell away in large quantities…there were many deaths.” The description from over two thousand years ago still holds true today, and although NSTIs are rare, the average mortality reported has been around 20% in the past 20 years (ranging from 15% to 45%, depending on the study examined).

Classification

The types of NSTIs can be classified either by anatomical location (i.e. most commonly affects the extremities, or, if there is perineal, genital and perianal involvement, it is known as Fournier gangrene) or bacterial involvement (divided into the following types).

  • Type 1: polymicrobial (aerobic and anaerobic) – more common than type 2
    • elderly patients, comorbidities (DM, ulcers), previous surgical intervention
  • Type 2: monomicrobial (Group A streptococcus, MRSA)
    • in any age group and even patients without underlying disorders
    • 50% of cases have no clear portal entry
  • Type 3: gas gangrene (Clostridium sp.)

Risk Factors

Although NSTIs can occur in patients without significant medical disease, there are definite risk factors that increase one’s chance of developing an NSTI:

  • patient-related factors: diabetes mellitus, obesity, peripheral arterial disease, chronic alcohol abuse, immunosuppression, malignancy, end-stage renal disease
  • barrier integrity-related factors: cutaneous lesions like insect bites or penetrating trauma, injection drug use, surgical incisions (for example, neonatal circumcision), mucosal breach (such as hemorrhoids, episiotomy)

Sign and Symptoms

  • hard signs (note that only 1/3rd of patients may present with these “textbook” signs): bullae, crepitus, violaceous hue, “dishwater” discharge
  • systemic signs: low-grade fever with tachycardia (out of proportion to the fever)
    • other non-specific signs: malaise, myalgias, diarrhea, anorexia
  • edema, brownish skin discoloration, decreased sensation in affected limb, a sense of heaviness
    • PEARL: make sure to mark the borders of the erythema to track progression
  • mental status changes (delirium, irritability)

In an article titled, “Pitfalls in Diagnosing Necrotizing Fasciitis,” Table 2 outlines the evolution of physical signs from early to late disease.

Diagnosis

The gold standard for diagnosis is via surgical exploration; however, in order to get a patient to surgery in a timely fashion, there are important tests that can raise suspicion that there is an underlying NSTI.

In laboratory tests, the following findings may be suggestive of NSTI, but there is no one specific sign that would be pathognomonic. A patient may have metabolic acidosis, coagulopathy, leukocytosis with left shift, anemia, thrombocytopenia, elevated CRP/ESR, myoglobinuria, signs of renal or hepatic dysfunction, and interestingly, hyponatremia and well as hyperlactatemia.

One notable finding is that elevated serum CK or AST concentrations suggest deep infection involving muscle or fascia rather than more superficial cellulitis. Furthermore, another source considered the utility of trending procalcitonin levels as a representation of adequate infection source control.

In terms of imaging tests, radiography can be useful but is not a necessity. If suspicion for NSTI is high, patient should immediately be sent to surgery. The best imaging modality is CT, and the presence of gas is nearly pathognomonic. Other signs suggestive of NSTI may be:

  • presence of fluid collections or abscess
  • heterogeneity or absence of tissue enhancement
  • edema at or below level of fascia

LRINEC (Laboratory Risk Index) Score

While there is a score for screening NSTIs, known as the Laboratory Risk Index, it has not been externally validated as of 2017. Nevertheless, looking at the components of the score on MDCalc gives a clinician an idea of what type of parameters might be of interest in diagnosing necrotizing soft tissue infections. 

The LRINEC score determined that the laboratory findings of interest are: CRP, WBC, hemoglobin, sodium, creatinine and glucose. The score has “high specificity but low sensitivity” – what does this mean? This means that if your LRINEC score is low or normal, this does not rule out an NSTI; however, if it is 6 or higher, that raises the suspicion and further workup is recommended.

Differential diagnosis

  • cellulitis
  • dermatological rash (contact dermatitis)
  • pyoderma gangrenosum
  • pyomyositis
  • deep vein thrombosis
  • calciphylaxis (cutaneous manifestations)

Treatment

The two pillars of treatment are surgery and antibiotics.

Broad spectrum antibiotics should be given intravenously as soon as necrotizing infection is suspected, but only aftertwo sets of blood cultures have been taken. The antibiotic of choice, according to Tintinalli’s Emergency Medicine Manual (8th) edition are the following:

  • vancomycin 1 gram IV every 12 hours PLUS meropenem 500 to 1000 mg IV every 8 hours
  • alternatively: vancomycin (same regimen) PLUS piperacillin/tazobactam 4.5 gram IV every six hours
  • clindamycin can be added to the regimen (mechanism of action: inhibits toxin synthesis)

Surgical debridement is key. In severe cases, surgery will need to be radical and aggressive to ensure optimal outcomes and include fasciotomy or even amputation.

Other considerations:

  • aggressive intravenous fluid resuscitation (IV crystalloids)
  • may consider: blood transfusion (if hemolysis results in severe anemia)
  • may consider: tetanus prophylaxis (based on mechanism of injury)

Mortality

Certain clinical characteristics have been associated with higher mortality; these vary by study; the list below compiles the features that are frequently mentioned across the board:

  • advanced age
  • female sex
  • multiple comorbidities
  • sepsis upon presentation

Potential Treatment Delays

Treatment of NSTIs is unequivocally surgical debridement, but unfortunately surgery doesn’t always happen within 24 hours. There are a few factors that inhibit prompt treatment, which can be broken into three larger categories: patient delay (not seeking care early enough), physician delay (not recognizing the signs) and system delay (logistical issues within a hospital system). Issues in one or all of these categories can result in catastrophic outcomes.

Two out of these three categories are outside a physician’s control; however, with thorough training and continuing medical education, we can work to minimize the cases in which the delay is due to a “missed diagnosis” on the part of the clinician.

Tips for Recognizing NSTIs Early

Always maintain a high index of suspicion. What does that mean? It means that the threshold for considering (and ruling out) necrotizing soft tissue infections needs to be low.

Host of the Trauma ICU Rounds podcast Dr. Dennis Kim stated that for him, a patient who presents with soft tissue infection with swelling, erythema, pain out of proportion (POOP) to physical exam with systemic symptoms is enough to consider a surgical consultation.

Although knowing the classic signs and symptoms of necrotizing soft tissue infections is paramount to a timely diagnosis, it is prudent to keep in mind that not all cases will present “classically.” 

Here are some important considerations:

  • patient need not have comorbidities to develop an NSTI
  • fever may be absent; this could be due in part to use of over-the-counter NSAIDs
  • although classically associated with a break in the skin, bacteria can travel hematogenously from other sites (like Streptococcal pharyngitis)
    • in fact, patient may not have cutaneous manifestations superficially
  • infection can be acute (developing over hours) but can also be indolent (like in DM foot ulcers)
  • pain out of proportion in what appears to be a simple cellulitis should raise warning bells

References and Further Reading

  • Goh T, Goh LG. Pitfalls in diagnosing necrotizing fasciitis. Patient Safety Network. https://psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis. Published August 21, 2014. Accessed September 1, 2021.
  • Ho, Wong Chin. MDCalc: LRINEC Score for Necrotizing Soft Tissue Infection. LINK
  • Kim, D. (Host). (2021, June 07). Necrotizing Soft Tissue Infections (No. 39) [Audio podcast episode]. In Trauma ICU Rounds. Surgery Academix Corps. LINK
  • Nawijn, F., Smeeing, D.P.J., Houwert, R.M. et al. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 15, 4 (2020). https://doi.org/10.1186/s13017-019-0286-6
  • Stevens D. Necrotizing soft tissue infections. UpToDate. https://www.uptodate.com/contents/necrotizing-soft-tissue-infections#H1. Published August 25, 2021. Accessed September 2, 2021.
  • Tintinalli, Judith E, and David Cline. Tintinalli’s Emergency Medicine Manual (8th ed.). New York: McGraw-Hill Medical, 2017.
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Question Of The Day #66

question of the day
~ Joseph Ciano, USA ~ 1 Comment
40.1 - Pneumothorax 1

Which of the following is the most likely diagnosis of this patient’s condition?

  • A) Hemorrhagic shock
  • B) Traumatic tension pneumothorax
  • C) Cardiac tamponade
  • D) Traumatic non-tension pneumothorax

This man presents to the Emergency Department with pleuritic chest pain, shortness of breath after a penetrating chest injury. He has tachypnea and low oxygen saturation on exam, but he is not hypotensive or tachycardic.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

This patient should immediately be given supplemental oxygen for his low oxygen saturation.  The history of penetrating chest trauma and hypoxemia also should raise concern for a traumatic pneumothorax, and oxygen supplementation is part of the treatment for all pneumothoraces.  The patient’s chest X-ray shows a large left sided pneumothorax indicated by the absence of left sided lung markings.  There is some left to right deviation of the heart and the primary bronchi.  There is no large left sided pleural effusion in the costodiaphragmatic recess to indicate a pneumo-hemothorax.  There is also no deviation of the trachea, hypotension, or tachycardia to indicate a tension pneumothorax (Choice B).  The patient is hemodynamically stable, so he cannot be in hemorrhagic shock (Choice A) or have cardiac tamponade (Choice C).  Although the pneumothorax is large with mild deviation of the heart, the lack of hemodynamic instability supports the diagnosis of a traumatic non-tension pneumothorax (Choice D).  The treatment for this would include 100% oxygen supplementation and placement of a chest tube.  A CT scan of the chest is more sensitive imaging test than a chest X-ray and should be considered to evaluate for additional injuries (blood vessel injuries, rib fractures, etc.). Correct Answer: D

Want Another Question?

References

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Animal and Human Research

~ Arif Alper Cevik ~ Leave a comment

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 7th episode is “Animal and Clinical Research”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

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Interview – How To Write A Manuscript and Answer Reviewers’ Comments

~ Arif Alper Cevik ~ Leave a comment

The International Emergency Medicine Education Project (iem-student.org) is pleased to provide Fundamentals of Research in Medicine. Our guest for this session was Prof Fikri Abu-Zidan, one of the world experts on trauma and disaster medicine research. He reviews around 60 manuscripts a year and has various roles in editorial teams of multiple journals. Prof Abu-Zidan will share his 40 years of experience and recommendations on two topics. We hope you enjoy watching this interview.

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Question Of The Day #65

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Longitudinal Orientation

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

  • A) Exploratory laparotomy
  • B) Begin packed red blood cell infusion
  • C) CT scan of the abdomen and pelvis
  • D) Order urinalysis to check for hematuria

This patient arrives in the Emergency Department after an assault with penetrating abdominal trauma and is hemodynamically stable on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has no free fluid between the right kidney and liver.  There also is no free fluid above the diaphragm to indicate a hemothorax. The question stem notes that all other FAST exam views are nonremarkable.  Therefore, this patient has a negative FAST exam.  See labelling of the FAST exam image below.

An exploratory laparotomy (Choice A) would be indicated in a patient with penetrating or blunt trauma, a positive FAST exam, and hemodynamic instability. This patient has a negative FAST exam and is hemodynamically stable.  Packed red blood cell infusion (Choice B) would be indicated in the setting of hemodynamic instability and trauma, as this is assumed to be hemorrhagic shock.  This patient is not tachycardic or hypotensive. A urinalysis to check for hematuria (Choice D) may be a helpful adjunctive investigation to evaluate for renal or bladder injury, but it is not the most crucial next step in management. Performing a CT scan of the abdomen and pelvis (Choice C) is the best next step as the patient is hemodynamically stable with a negative FAST exam and a penetrating abdominal injury.  The CT scan will help further evaluate for any internal injuries that may require operative repair.  See the algorithm below for further detail on an abdominal trauma work flow. Correct Answer: C

undifferentiated trauma patient
undifferentiated trauma patient
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Common mistakes that researchers do

Common mistakes that researchers do
~ Arif Alper Cevik ~ Leave a comment

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 6th episode is “Common mistakes that researchers do”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

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Emergency Medicine Perspectives of Students – Europe

~ Arif Alper Cevik ~ Leave a comment

Dear EM family,

The International Emergency Medicine Education Project (iem-student.org) has completed three years. As you may know, the iEM Education project aims to promote Emergency Medicine and provides copyright-free resources to students and educators around the world. Now we have reached more than 200 countries. We would like to thank again our contributors. Without them, such a project would not be possible. This experience has shown us once again how passionate our international EM community is to help and teach each other.

In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce alive activity series, Emergency Medicine Perspectives of Students Around the World. Our guests for the third session are Nadine Schottler from UK, Helena Halasaz from Hungary, and Gregor Prosen from Slovenia.

Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.

Here are the video and audio records of this session. 

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Question Of The Day #64

question of the day
~ Joseph Ciano, USA ~ Leave a comment
Left Upper Quadrant

Which of the following is the most appropriate next step in management?

  • A) CT scan of the chest, abdomen, and pelvis
  • B)Exploratory laparotomy
  • C) CT scan of the head
  • D) Bedside diagnostic peritoneal lavage (DPL)

This patient arrives in the Emergency Department after an assault and has pallor (paleness), hypotension, and tachycardia on exam.  The first step in evaluating any trauma patient involves the primary survey.  The primary survey is also known as the “ABCDEFs” of trauma.  This stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (Focused Assessment with Sonography in Trauma).  Each letter should be assessed in alphabetical order to avoid missing a time sensitive life-threatening condition.  The primary survey should be conducted prior to taking a full history.  After the primary survey, a more detailed physical exam (secondary survey) is conducted, followed by interventions and a focused patient history. 

The FAST exam is a quick sonographic exam that requires the practitioner to look at 4 anatomical areas for signs of internal injuries.  The 4 areas are the right upper abdominal quadrant, left upper abdominal quadrant, pelvis, and subxiphoid (cardiac) areas.  The addition of views for each lung (1 view for each lung) is known as an E-FAST, or extended FAST exam.  The presence of an anechoic (black) stripe on ultrasound indicates the presence of free fluid.  In the setting of trauma, free fluid is assumed to be blood.  The presence of free fluid on a FAST exam is considered a “positive FAST exam”.   This patient has free fluid between the left kidney and spleen in combination with hypotension and tachycardia.  This patient is in hemorrhagic shock until proven otherwise and needs prompt operative management.  See labelling of the FAST exam image below.

us image showing bleeding
us image showing bleeding

 

A CT scan of the chest, abdomen, and pelvis (Choice A) and a CT scan of the head (Choice C) may be helpful in the evaluation of this patient, but this patient is hemodynamically unstable.  Radiographic tests that require the patient to leave the Emergency Department should be avoided if the patient is unstable.  The specific location or cause of the hemodynamic instability can be diagnosed in the operating theater where there are opportunities to control the intraperitoneal bleeding (i.e., splenectomy, vessel ligation or cautery, etc.).  Bedside diagnostic peritoneal lavage (Choice D) is not indicated in penetrating abdominal trauma when there is a negative FAST exam and CT scanning is available.  This patient sustained blunt abdominal trauma, so a DPL is less informative.  The best next step for this patient is exploratory laparotomy (Choice B) in the operating theater.  Hemodynamically unstable patients with a positive FAST exam should always go to the operating theater for further diagnosis and treatment.  See the algorithm below for further detail.

 

undifferentiated trauma patient
undifferentiated trauma patient

 

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References

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