EM Quick Hits 2 Organophosphate Poisoning, TXA for Hemoptysis, Metacarpal Fracture Rotation, Abdominal Stab Wounds, Pediatric IV Cannulation

Topics in this EM Quick Hits podcast

Emily Austin on organophosphate poisoning (0:30)

Arun Sayal on malrotation of metacarpal fractures (7:20)

Andrew Petrosoniak on pitfalls in abdominal stab wound management (13:30)

Anand Swaminathan on tranexamic acid for non-massive hemoptysis (20:15)

Natalie May on pediatric IV cannulation tips and tricks (26:07)

Podcast: Play in new window | Download (Duration: 33:30 — 30.7MB)

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Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Emily Austin, Anand Swaminathan, Arun Sayal, Andrew Petrosoniak & Natalie May, edited by Anton Helman

Cite this podcast as: Helman, A. Austin, E. Sayal, A. Petrosoniak, Swaminathan, A. May, N. EM Quick Hits 2 – Organophosphate Poisoning, TXA for Hemoptysis, Metacarpal Fracture Rotation, Abdominal Stab Wounds and Pediatric IV Cannulation. Emergency Medicine Cases. February, 2019. https://emergencymedicinecases.com/em-quick-hits-february-2019/. Accessed [date].

Organophosphate Poisoning

• Poisoning with an organophosphorus compounds can presents with signs and symptoms of excess acetylcholine in the parasympathetic nervous system, the CNS, at the neuromuscular junction, and at nicotinic receptors in the sympathetic nervous system.
• Cholinergic symptoms tend to dominate: think DUMBELS (diaphoresis and diarrhea; urination; miosis; bradycardia, bronchospasm, bronchorrhea; emesis; excess lacrimation; and salivation) or SLUDGE (salivation, lacrimation, urination, diarrhea, GI upset, emesis), but more importantly the “Killer Bs” of bradycardia, bronchoconstriction and bronchorrhea.
• Treating these patients involves aggressive supportive care, and antidote therapy with atropine as well as pralidoxime.
• Atropine is the most important antidote to give. It should be dosed at 1-2 mg IV to start, and then given at double the dose every 5 minutes until your patient has a clear chest and is hemodynamically stable. Then start an infusion at 10-20% of the total dose of atropine given per hour.

Malrotation in Metacarpal Fractures

• Malrotation of metacarpal fractures is diagnosed clinically, not radiographically.
• Malrotation is easily missed and may lead to functional impairment if not formally addressed.
• Normal alignment is confirmed with all the fingers pointing to the scaphoid while all the PIPs and DIPs are flexed (see images)
• 10-15% of people have some degree of scissoring at baseline or a previous injury, so it’s important to compare to the contralateral hand and ask about previous hand injuries

Normal alignment of the fingers with DIPs and PIPs in full flexion

Malrotation of the 4th finger. Note overlap of the distal 4th finger with the nail of the 3rd finger.

Abdominal Stab Wound Assessment and Management

• Small abdominal stab wounds that appear benign at the skin may be “the tip of the iceberg” with major hemorrhage beneath.
• The indications for immediate operative intervention for abdominal stab wounds:
  • Hemodynamic instability
  • Bowel evisceration
  • Peritonitis
  • Impalement of the weapon/object
• Computed tomography can be helpful to identify signs of intrabdominal injury, but 10-20% of injuries will be missed. Serial abdominal exams over 24hrs is a mainstay of management to monitor for peritonitis.
• Upper abdominal and epigastric wounds may result in thoracic and diaphragm injuries that require further assessment including CT imaging of the thorax.

Update 2022: A prospective cohort study of 256 patients at a level 1 trauma center found that in abdominal stab wound patients without indication for immediate operative intervention, 24 hours of observation was sufficient to determine which patients will fail selective nonoperative management. Abstract

From Western Trauma Assocation 2018 https://www.seton.net/wp-content/uploads/sites/11/2018/05/31.-Martin-abd-stab-wounds-syllabus.pdf

Tranexamic Acid for Post-Tonsillectomy Hemorrhage and Non-Massive Hemoptysis

• Tranexamic Acid (TXA) is an old drug finding some new indications
• The utility in major trauma has been well established in the CRASH-2 trial (NNT ~ 65 when given < 3 hours after injury)
• The WOMAN trial established a modest 0.5% mortality reduction when TXA was given < 3 hours after onset of post-postpartum hemorrhage
• Case reports are emerging on the use of TXA in post-tonsillectomy hemorrhage. Nebulized TXA is a reasonable intervention but, there’s not enough data to rely on this intervention
• A 2018 RDCT of 500mg nebulized TXA in non-massive hemoptysis showed promise but this was not an ED study

Pediatric IV Cannulation Tips and Tricks

• Decide on the necessity and urgency – ask yourself if the IV needs to be placed now or can you delay while the child drinks or sucks on a popsicle and settles down
• Optimize in advance – consider topical analgesic such as EMLA, get all your equipment in advance, assess all limbs before committing to one location, gather the staff you’ll need
• Have a good look with your eyes +/- POCUS – the vein running across the proximal half of the 4th metacarpal joining with the vein running between the 4th and 5th metacarpal is likely to have a higher success rate than antecubital in the pediatric population; consider also the great saphenous vein at the ankle and the palmar aspect of the wrist
• Go low, go slow – use an angle that is almost flat along the skin and advance slowly
• Secure the IV as if your life depends on it with steristrips, tegaderm, 1 or 2 limb immobilization boards and bandaging

None of the authors have any conflicts of interest to declare