Topics in this EM Quick Hits podcast
Heather Cary on the use and misuse of abdominal FAST in pediatric trauma (0:38)
Hans Rosenberg and Arleigh McCurdy on the diagnosis and management of Multiple Myeloma in the Emergency Department (7:57)
David Jerome on wilderness practice tips for managing the drowning patient (13:50)
Brit Long and Michael Gottlieb on the diagnosis and management of Alcohol-Induced Ketoacidosis (31:58)
Navpreet Sahsi on his journey to becoming a humanitarian and global EM doctor (38:13)
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Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Alex Chan, Heather Cary, Hans Rosenberg, Arleigh McCurday, David Jerome, Brit Long, Navpreet Sahsi and Michael Gottlieb, edited by Anton Helman
Cite this podcast as: Helman, A. Cary, H. Rosenberg, H. McCurdy, A. Jerome, D. Long, B. Gottlieb, M. Sahsi, N. EM Quick Hits 48 – FAST in Pediatric Trauma, Multiple Myeloma, Drowning, AKA, Global EM. Emergency Medicine Cases. April, 2023. https://emergencymedicinecases.com/em-quick-hits-april-2023/. Accessed June 2, 2023.
Abdominal FAST exam does not improve outcomes and may complicate pediatric traumas
- Despite abdominal FAST exams being commonly used in North America, literature suggests that FAST has low sensitivity (estimated to be 28% for EM physicians) and high false-negative rate without improving clinical outcomes
- Only two-thirds of children with intraabdominal injuries would have positive FAST with free fluid
- As the majority of intraabdominal injuries are managed conservatively, providers should avoid using positive FAST as the deciding factor to order abdominal CT. They should instead use the clinical picture of the patient and indications such as:
- Significant abdominal wall trauma
- Seatbelt or handlebar sign
- GCS < 14 in blunt abdominal wall trauma
- Abdominal tenderness and/or distention
- Persistent hypovolemia
- PR/NG blood
- Gross hematuria
- Suspected pelvic fracture
- Trauma. 27/11/2018. https://starship.org.nz/guidelines/trauma/
- Andrew Tagg . Thinking FAST, and slow, Don’t Forget the Bubbles, 2018. Available at: https://doi.org/10.31440/DFTB.17324
- Liang, Tian MD∗,†; Roseman, Eric MD∗,†; Gao, Melanie BA∗,†; Sinert, Richard DO∗,†. The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis. Pediatric Emergency Care 37(2):p 108-118, February 2021. | DOI: 10.1097/PEC.0000000000001755
- National Cancer institute. Radiation Risks and Pediatric Computed Tomography (CT): A Guide for Health Care Providers. Reviewed September 4, 2018. Available at: https://www.cancer.gov/about-cancer/causes-prevention/risk/radiation/pediatric-ct-scans
- Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019 Nov;21(6):727-738. doi: 10.1017/cem.2019.381. PMID: 31317856.
Tips on the diagnosis and management of patients with multiple myeloma in the ED
- As patients with multiple myeloma are immunocompromised, they may additionally present atypically with opportunistic infections such as CMV and listeria
Episode 33: Oncologic Emergencies
- McCurdy A, Mian H, Rosenberg H. Just the facts: how to diagnose and manage patients with multiple myeloma in the emergency department?. CJEM. 2022;24(3):256-258. doi:10.1007/s43678-022-00270-8
Understanding drowning -Wilderness Medicine EM Quick Hits series
- Categorization of drowning: fatal or nonfatal, and primary (where it is the only medical issue at play) or secondary (where another medical issue directly precipitated the event)
- There is a trimodal distribution of fatal drowning
- Aged 1-5: The majority of events are primary in nature
- Aged 15-25: Events are usually secondary to high-risk events, traumas, or intoxications
- Aged 55+: Be strongly suspicious of ACS as the precipitating event
- Drowning is primarily a respiratory/hypoxic event and should be managed as such:
- Management should therefore be focused on high PEEP and FiO2
- Arrhythmias will generally progress from sinus tachycardia to bradycardia ultimately to PEA arrest and shockable rhythms are rare
- Ensure the airway is protected and be prepared for vomiting as this occurs in 90% of patients
- Pitfall: Do not suction oral foam expulsion resulting from surfactant washout as this will prevent effective oxygenation
- C-spine collars should only be used if there is a concerning mechanism of injury
- Adjunctive therapies: there is no role for diuretics or prophylactic antibiotics, but ECMO may be considered in patients with profound hypoxia despite invasive ventilation
EM Quick Hits 42 – Subsegmental PE, Trauma Analgesia, Drowning, Polio, Head-up CPR
- Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012 Jul 26;367(4):375-81. doi: 10.1056/NEJMra1013317. PMID: 22830464.
- Sempsrott JR, Sztajnkrycer MD. Drowning. In: Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski J, Cline DM, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill Education; 2020. p. 1094-1101.e1.
- Quan L, Bierens JJLM. Drowning. In: Knoop KJ, Stack LB, Storrow AB, Thurman RJ, editors. The Atlas of Emergency Medicine. 4th ed. New York, NY: McGraw-Hill Education; 2016. p. 465-467.
- Cave DM, Aufderheide TP, Beeson J, et al. Basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S640-56. doi: 10.1161/CIRCULATIONAHA.110.970939. PMID: 20956220.
- Joint Commission International. Drowning: prevention and treatment. In: Clinical Care Program Standards: Hospital. 6th ed. Oak Brook, IL: Joint Commission Resources; 2017. p. CCP.6.4.
Alcohol-induced Ketoacidosis (AKA) – recognition and 4-pronged approach to management
- AKA refers to the syndrome of alcohol use and decreased nutritional stores exacerbated by acute illness or decreased oral intake leading to inadequate glucose breakdown and ketoacidosis
- Search for the underlying trigger
- Reduced oral intake
- Concomitant diabetic ketoacidosis
- Intra-abdominal pathology (perforation, infections, ischemia)
- Toxic ingestions or withdrawals
- The presentation of AKA may be atypical
- While most cases will occur in chronic alcoholics, it can also occur during binge drinking and poor oral intake
- Patients will generally present with nausea and vomiting, and diffuse abdominal pain
- Focal abdominal pain and severe altered mental status should prompt further investigation of other pathologies
- Classic laboratory results include a ketoacidosis with anion gap metabolic acidosis, low glucose, and negative serum alcohol levels
- Serum testing with beta-hydroxybutyrate is the best test for AKA
- Glucose is usually mildly low or normal, though 10% of patients may have severe hypo- or hyperglycemia
- Management of AKA: 4-pronged approach
- Early replacement of fluids with balanced crystalloids
- Glucose repletion with dextrose if hypoglycemic (after ruling out/correcting hypokalemia) and insulin if hyperglycemic
- Electrolyte repletion and monitoring (with specific attention to potassium)
- Thiamine repletion, encourage PO intake, offer addiction services
- Long B, Lentz S, Gottlieb M. Alcoholic Ketoacidosis: Etiologies, Evaluation, and Management. J Emerg Med. 2021 Oct 25:S0736-4679(21)00717-4.
None of the authors have any conflicts of interest to declare
The pediatric trauma, and the drowning parts of the podcast were fantastic.
Regarding FAST with blunt abdominal trauma – the data seems to show it is an imperfect test – sure. But no test is perfect in medicine. The context in this pro-FAST and anti-FAST discussion is that it is just one data point in the global evaluation of the trauma patient. I’m not going to call the OR to pre-notify them or initiate MTP based on a sliver of fluid. I’m going to examine, re-examine, do labs, repeat labs and look at the patient overall – I might or might not CT in consultation with surgery. We don’t have to knee-jerk order CT or push for OR – we can do good old fashioned observation – in the ER or on the ward. Trying to raise up or tear down one test in isolation of the global evaluation of a patient doesn’t make clinical sense. Patients with a negative troponin can leave hospital with 4 stents – many of us have seen it. No test is perfect in isolation of the global evaluation of the patient.