Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Alex Chan, edited by Anton Helman
Cite this podcast as: Helman, A. Swaminathan, A. Reid, S. Petrosoniak, A. Toth,, P. Khatib, N. Wallace, J. Poyner, M. EM Quick Hits 49 – Stroke Management Update, Intussusception, 5 Penetrating Trauma Tips, Foreign Body Hack, Radiation Risk, Emergency Fund. June, 2023. https://emergencymedicinecases.com/em-quick-hits-june-2023/. Accessed September 25, 2023.
The eligibility criteria of endovascular therapy for large vessel strokes may be expanding in the future
Current guidelines indicate endovascular therapy (EVT) for large vessel occlusion strokes occurring within 24 hours of presentation with neuroimaging demonstrating a small ischemic core with a viable penumbra
The ANGEL-ASPECT and SELECT2 RCTs published in 2023 suggested that patients presenting with large infarcted cores receiving EVT were found to have superior neurologic outcomes compared to medical management alone
In the SELECT Late retrospective study, there additionally appeared to be a benefit of neurologic outcomes for patients receiving EVT despite presenting with large vessel strokes beyond 24 hours of “last known well”
Although the mentioned studies suggest benefit for EVT beyond our current eligibility criteria, further studies are needed before applying the evidence to clinical practices as SELECT was a retrospective study and biases and limitations were present
Kelley-Quon LI, et al. Management of intussusception in children: A systematic review. J Pediatr Surg. 2021 Mar;56(3):587-596.
Lin-Martore M, et al. Diagnostic accuracy of point-of-care ultrasonography for intussusception in children: A systematic review and meta-analysis. Am J Emerg Med. 2022 Aug;58:255-264.
Nguyen PN, et al. Common Conditions II: Acute Appendicitis, Intussusception, and Gastrointestinal Bleeding. Surg Clin North Am. 2022 Oct;102(5):797-808.
Litz CN, et al. Outpatient management of intussusception: a systematic review and meta-analysis. Pediatr Surg. 2019 Jul;54(7):1316-1323.
Gray MP, Li SH, Hoffmann RG, et al. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014 Jul;134(2): 110-9.
5 Tips for the management of penetrating trauma in community hospitals
Call for 2 units of uncrossed packed red blood cells as soon as you are made aware of an incoming penetrating trauma patient
Once the patient arrives, immediately sit the patient upright and raise their arms to inspect for axillary and posterior thoracic wounds
Prioritize PoCUS of the pericardium to identify pericardial effusion, followed by the lung to identify pneumothorax, before an abdominal FAST exam
Make metallic markers on each wound with staples, as this will allow you to have a better understanding of the trajectory of the penetrating trauma(s) on CT
The bullet rule for gun shot wounds: the sum of the number of bullet wounds and actual bullets seen on imaging should always be an even number; an odd number implies that you are either missing wounds, or bullets!
When imaging, ensure to image all of the chest, abdomen, and pelvis for any thoracolumbar penetrating trauma
Call your regional trauma centre earlyto have them involved in the management
Starnes BW, Andersen CA, Bard MR, et al. Management of penetrating cardiac injuries: a statement of the Society of Thoracic Surgeons. J Thorac Cardiovasc Surg. 2017;153(4):e77-e90.
Inaba K, Aksoy H, Seamon MJ, et al. Multicenter evaluation of temporary intravascular shunt use in vascular trauma. JAMA Surg. 2020;155(4):e195239.
Shiroff AM, Gale SC, Martin ND, et al. Penetrating cardiac injury: a population-based analysis. J Trauma Acute Care Surg. 2014;76(1):226-231.
Hirshberg A, Wall MJ Jr, Mattox KL. Planned reoperation for trauma: a two-year experience with 124 consecutive patients. J Trauma. 1994;37(3):365-369.
Slit lamp skin foreign body removal hack (Best of University of Toronto EM)
For patients whom you suspect foreign bodies that are difficult to see clearly with the naked eye, the slit lamp can be a helpful tool to explore wounds and remove foreign bodies under greater magnification
An assistant may be required to stabilize the patient’s hand or foot in ideal position on the slit lamp
A 25 gauge needle that is recommended for corneal foreign bodies may be helpful for foreign body removal of the skin as well
Magnified skin foreign body under slit lamp examination with 25 gauge needle for removal
The downstream risks of CT radiation are under-appreciated in practice
Up to 2% of all cancers in the United States are estimated to be iatrogenic and caused by radiation associated with use of CT scans, and the use of CT scans has risen considerably over the last 3 decades
https://www.xrayrisk.com/ is a useful tool that can provide individualized cancer risk statistics for patients by age, gender and type of CT scan, and can aid in shared decision making
Clinicians should weigh the risk-benefit ratio of clinical imaging and weigh factors such as age, presentation, and patient preferences when ordering medical imaging
Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013 Aug;167(8):700-707.
Mathews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013 May 21;346:f2360.
Smith-Bindman R, Miglioretti DL, Johnson E, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA. 2012 Jun 13;307(22):2400-2409.
Berrington de González A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009 Dec 14;169(22):2071-2077.
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.