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)
Subscribe: Apple Podcasts | Google Podcasts
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].
- 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.
- Abedin MJ, Sayeed AA, Basher A, Maude RJ, Hoque G, Faiz MA. Open-label randomized clinical trial of atropine bolus injection versus incremental boluses plus infusion for organophosphate poisoning in Bangladesh. J Med Toxicol. 2012;8(2):108-17.
- Eddleston M, Dawson A, Karalliedde L, et al. Early management after self-poisoning with an organophosphorus or carbamate pesticide – a treatment protocol for junior doctors. Crit Care. 2004;8(6):R391-7.
- Eddleston, M et al. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371(9631):2170..
- UN General Assembly. Report of the Special Rapporteur on the right to food. (https://documents-dds-ny.un.org/doc/UNDOC/GEN/G17/017/85/PDF/G1701785.pdf?OpenElement)
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
- Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (N Y). 2014;9(1):16-23.
- Day CS. Fractures of the metacarpals and phalanges. Wolfe SW, Hotchkiss RN, Pederson WC, et al, eds. Green’s Operative Hand Surgery. 7th ed. Philadelphia: Elsevier; 2017. Vol 1: 231-77.
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
- 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
- Martin et al. Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018;85: 1007–1015.
- Baron et al. Accuracy of Computed Tomography in Diagnosis of Intra-abdominal Injuries in Stable Patients With Anterior Abdominal Stab Wounds: A Systematic Review and Meta-analysis. Acad Emerg Med 2018 Jul;25(7):744-757.
- Yucel et al. Evaluation of diaphragm in penetrating left thoracoabdominal stab injuries: The role of multi-slice computed tomography. Injury 2015 Sep;46(9):1734-7.
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 EM Morsels: Post-Tonsillectomy Hemorrhage
EM PharmD Blog: A Breath of Fresh Air: Nebulized TXA for Hemoptysis
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-postpartum hemorrhage (WOMAN): an international randomized, double-blind, placebo-controlled trial. Lancet 2017.
CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet 2010; 376: 23-32.
Wand O et al. Inhaled tranexamic acid for hemoptysis treatment: a randomized controlled trial. Chest 2018.
Schwarz W et al. Nebulized tranexamic acid use for pediatric secondary post-tonsillectomy hemorrhage. Ann Emerg Med 2018.
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
Goldstein, H. Twelve Tips to placing a well secured Peripheral IV Cannula, Don’t Forget the Bubbles, 2016. Available at: http://doi.org/10.31440/DFTB.7939.
Top Tricks for Little Pricks, Songs or Stories, August 2015. Available at: https://songsorstories.com/2015/08/15/top-tricks-for-little-pricks/
Royal Children’s Hospital Melbourne on peripheral IV access
None of the authors have any conflicts of interest to declare
Hi Dr. Austin,
Thanks for the primer on Organophosphate toxicity, very cool stuff. I just wanted to point out to the readers that while Atropine is a great agent for temporizing patients with exposure to Organophosphates it’s not truly an antidote. It will “dry them out” a bit and does help with symptomatic bradycardia but being an anti-muscarinic primarily it does little to offset the nicotinic receptor stimulation.
Pralidoxime (2PAM) should be the first line for most providers (if they have it) and if they don’t there should be a stockpile close to every major city that can be accessed through provincial and federal resources (kept for nerve agent attacks).
The major issue with the Organophosphate exposures is “aging” or the irreversible damage to acetylcholinesterase. If Pralidoxime isn’t administered before this aging occurs, the patient will require a long ICU stay and likely more Atropine than your pharmacy has while their body replenishes its supply of the critical enzyme to clear the excess acetylcholine.
While the patient may seem to improve symptomatically with high doses of atropine (think 3X the ACLS doses) they’re just ticking away to their “aging” limit and a much worse prognosis.
While aging times vary for all organophosphates and carbamates, from less than 5 minutes for Sarin gas to more than an hour for some of the stable pesticides, they will all irreversibly age if Pralidoxime isn’t administered along with Atropine.
These Quick Hits are next-level.
Thanks for your comment and touching on the issue of aging with organophosphorus compounds.
As I mentioned in the EM Quick Hit, atropine should be the first drug that emergency providers are reaching for when we are managing these patients.
Pralidoxime should be given as well, however the evidence of benefit remains elusive. Of the published clinical studies some have shown improved clinical outcomes (DOI: 10.1016/S0140-6736(06)69862-0), but others haven’t (DOI: 10.1371/journal.pmed.1000104).
Here’s a great review article that discusses some issues with pralidoxime and the literature surrounding it:
Also, here’s a link to the 2011 Cochrane Review on oximes for OP pesticide poisoning. The authors concluded that the current evidence is lacking to determine if pralidoxime is beneficial (or harmful).
Hi good informative quick hits just want to find out what’s the role of magnesium sulfate in organophosphate poisoning.