M2E Too! Mellick's Multimedia EduBlog
E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.
By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.
Monday, October 3, 2016
Ankle dislocations are usually the result of high-energy trauma that cause plantar flexion of the ankle combined with an inversion or eversion stress. These dislocations are typically described according to the direction of displacement of the talus and foot in relation to the tibia. Consequently, dislocation may be upward, posterior, medial, lateral, posteromedial, or anterior.
Posterior dislocation of the talus is the most common form of ankle dislocation. Associated fractures are the rule rather than exception, and ligamentous disruption varies according to the type of dislocation. One of the most dramatic joint dislocations is the open, dislocated ankle. A principal concern, in addition to timely reduction, is the possibility of a neurovascular injury. Radiographs should not delay reduction in cases where vascular compromise or skin tenting is present. After reduction, reassessment of the neurovascular status, splinting, ankle elevation, and post-reduction radiography are accomplished.
The reduction procedure is accomplished with the patient lying supine. After procedural sedation and analgesia, the knee is flexed to 90 degrees. Distraction of the foot, followed by a gentle force reversing direction of the dislocation is sometimes all that is needed, though a more forceful maneuver may be needed. Many open ankle fractures and dislocations will not be reduced unless the injury mechanism is first recreated.
This important tenet of orthopedic surgery is frequently overlooked. When that happens, the joint dislocation reduction can be nearly impossible to accomplish. This video shows the initial failures of open ankle fractures and dislocation reductions by emergency medicine and orthopedic residents. Only after the operators regrouped and recreated the mechanism of injury were the open ankle dislocations successfully reduced.
Watch a video showing an ankle injury being recreated so that the open dislocation can be reduced.
Thursday, September 1, 2016
How could a Lyme disease lookalike rash and anaphylaxis to meat have anything in common? As I found out recently, they do. They both have a common vector, the Lone Star Tick, which is also known by its formal name, Amblyomma americanum, and is found predominately in the East, Southeast, and Southwest. It is an aggressive tick that loves humans.
In fact, all three growth stages (adult, nymph, and larva) are known to feed on humans. Besides the common signs of irritation that often accompany a tick bite, a rash similar to the rash of Lyme disease has been commonly described. This "bull's-eye" rash is often accompanied by systemic symptoms such as fatigue, fever, headache, muscle, and joint pains. Even though the rash looks almost identical to the erythema migrans of Lyme disease, it isn't caused by Borrelia burgdorferi. In fact, researchers still have not isolated out the etiology of STARI or Southern Tick-Associated Rash Illness.
Treatment with doxycycline seems to be associated with disappearance of the rash and relief of the associated signs and symptoms. Yet, whether to treat is still considered the prerogative of the physician.
The Lone Star Tick is also implicated in causing growing numbers of humans to develop a strange allergy to meat. More specifically, the allergy is to a carbohydrate present in mammalian meat called galactose-alpha-1,3-galactose, or Alpha-Gal for short. The reaction may be delayed for several hours after eating mammal meat, causing confusion and misdiagnosis. As with any anaphylaxis condition, it can be severe and life-threatening.
This is what I love about medicine: the never-ending list of new discoveries that occur on a daily basis.
Watch this video showing removal of a female Lone Star Tick from a child, and hear a discussion of STARI and Alpha-Gal.
Monday, August 1, 2016
Geographic location and seasonal variations often dictate the frequency of specific emergencies. I have been impressed over the years how often my geographic location would determine the type of injuries and emergencies that would show up in my emergency department.
My two years in Honolulu taught me a lot about illnesses and injuries associated with work and recreation in the Pacific Ocean. Seasonal variations also affect the types of emergencies we see. Fish hook removal injuries are a prime example. Already this spring and summer I have had a number of children present with fish hooks embedded in their flesh so it seems appropriate to review the various techniques described in textbooks and review articles for removing fish hooks. Some techniques are clearly more effective than others.
This is simply pushing down on the shank and pulling out the hook. It may work with barbless hooks, but isn't very successful for barbed ones.
String Pull Technique
This is actually a pretty effective technique, and it is reportedly not too painful if done quickly. The shank is again pushed down on the skin, and a string is tied around the bend of the hook. Take precautions not to cause injury to the operator from a flying hook, and then abruptly yank the hook free with the string. The potential for additional tissue injury, however, seems significant.
Needle Cover Barb Technique
This technique uses an 18-gauge needle to cover the barb of the hook. Ideally, the hook and needle are removed simultaneously. This technique is technically difficult, in my opinion, and it usually fails in my experience.
Advance and Cut Technique
This technique maneuvers the fish hook barb to puncture through the skin, where the exposed barb is cut off with the appropriate tool. The remaining fish hook is effortlessly backed out. The only downside to this procedure is that deeply buried hooks or hooks with a narrow gap between the shank and the barb are not easily maneuvered to create a new puncture hole in the skin. Nevertheless, it is an excellent technique when it works.
Scalpel Barb Release Technique
This procedure uses a #11 scalpel blade to release the tissues around the barb. This technique is probably effective except for the fact that the wound size is enlarged and additional tissue damage occurs. My main criticism is that we are using a sledge hammer when a mallet will work just as effectively.
Finally, we formally name a new technique called the Needle Barb Release Technique. It is similar to the Scalpel Barb Release Technique, but uses an 18-gauge needle instead of a scalpel. I am confident that this technique has inadvertently been used over the years when the Needle Barb Cover Technique was attempted, but we recently decided to name it. The bottom line is that the fish hook is easily removed with minimal additional tissue injury when an 18-gauge needle is used to free the tissues around the fish hook barb.Watch a video of the Needle Barb Release Technique
Monday, June 27, 2016
Multiple methods are touted for reducing anterior shoulder dislocations, and every emergency physician seems to have gravitated to one or two methods that he uses routinely. Why someone prefers one technique over another is not clear, but the factors for technique selection seem to be training, ease of application, and prior successful experiences.
Every reduction procedure will have some degree of applied rotation, torque, and traction, and pain is a common and unavoidable theme. Unfortunately, not all shoulder reductions are created equally. Variations in human anatomy, time duration of dislocation, and the actual location of the humeral head relative to the glenoid fossa will contribute to the reduction technique selection process. Consider the worst-case scenario of the intoxicated weight lifter who presents after dislocating his shoulder many hours earlier.
Our attempts to overcome the serious muscle spasm holding the humeral head in its newly found location involve rotational torque, traction force, leverage maneuvers, relaxation techniques, and medications. Unfortunately, some reductions will still require a visit to the operating room and general anesthesia. And some shoulder dislocations can be successfully reduced without pain and muscle-relaxing medications, but those are less frequent and are usually performed immediately after the dislocation event.
Some procedures are definitely more expedient than others and how busy the emergency department is at the time of presentation may determine the method. Those are the procedures that simply lets the patient reduce himself while you are seeing other patients. On the other hand, a procedure like the traction-countertraction technique requires procedural sedation, more than one operator, and prolonged force, and it ends up being an endurance contest between the patient and the clinicians. The Stimson technique comes to mind when I think of expedient shoulder reduction procedures. The patient lies prone with the affected extremity hanging off the edge of the bed with 10 to 15 pounds of weight attached while the emergency physician continues managing the emergency department.
But now the Davos Technique for anterior shoulder dislocation reductions enters the scene. The technique was described recently in The Journal of Emergency Medicine. (2016;50:656.) It is known as the Davos technique because the physicians who first described it worked at Davos hospital in Switzerland. In reality, this technique has been around for a while, and was first described in 1993. (Z Unfallchir Versicherungsmed 1993;Suppl 1:215; Helv Chir Acta 1993;60[1-2]:263.) Nevertheless, it has never gained traction until now, if you'll pardon the pun. The Davos technique has been described as a nontraumatic, patient-controlled, and auto-reduction technique that does not require the use of anesthesia. (J Orthop Trauma1997;11:399.) It is used only for anterior dislocations, and has a reported success rate of 60 to 90 percent. (J Emerg Med 2016;50:656; J Orthop Trauma1997;11:399.)
The reduction procedures steps are described as:
- Standard pain and muscle relaxation medications can be used for these patients.
- The patient sitting on the gurney holding the injured extremity with the other hand is asked to flex the ipsilateral knee as much as possible.
- The physician assists the patient to place both hands in front of the flexed knee.
- The hands are then tied together using an elastic band at the wrist joint, not the fingers. (This allows the patient to avoid crossing the fingers, possibly increasing muscle tension.)
- The elbows should be kept close to the thigh to assist muscle relaxation.
- The physician or nurse sits on the patient's foot and may help stabilize the wrists against the anterior tibia.
- The patient is instructed to lean his head back and to let his shoulders roll forward (shrug), extending and relaxing all the muscles. The neck extension exerts a constant traction on the injured shoulder, and the dislocation is reduced without any additional maneuvers.
- Once reduction occurs, the usual and standard post-reduction interventions, such as radiographs and sling application, are performed.
- I could not independently confirm the information, but this method has reportedly been used for more than 20 years by US Navy Seals and US Marine Corps Reconnaissance. When shoulder dislocations occur during fast boat recovery, they go to the back of the Zodiac or combat rubber reconnaissance craft to reduce the dislocated shoulder using this technique, among others. (Personal communication.)
I would rank shoulder reduction techniques from greatest to least use of required force in this order:
9. Traction-countertraction technique
8. Stimson technique
7. Milch technique
6. External rotation technique
5. Spaso technique
4. Fares technique
3. Scapular manipulation
2. Davos technique
1. Cunningham technique (Read an article about this method in the June 2011 issue of EMN at http://emn.online/1OkBjFn.)
Two of these techniques can potentially be accomplished while the emergency physician continues managing the emergency department. Of course, any medicated patient still requires an emergency nurse carefully monitoring the reduction. Nevertheless, traction forces are set in motion by the Stimson and Davos techniques and don't necessarily move along faster with the physician in the room. Even though the Davos technique requires someone sitting on the patient's foot and stabilizing the bound wrists, it probably doesn't have to be the physician. Nevertheless, for safety reasons a member of health care team, not a family member, should fulfill this role.
Watch a video of the Davos technique being performed.
Watch a second video showing 10 other ways to reduce a dislocated shoulder.
Thursday, June 2, 2016
I have serious issues with the current management recommendations for fingertip felons. I hate the thought of blindly "slicing and dicing" fingertips as treatment. I agree that fingertip abscesses should be drained, but I really question whether current approaches are the best. Thankfully, the really aggressive techniques of the past such as the through-and-through, hockey stick, or fish mouth incisions are no longer recommended. Currently, the unilateral longitudinal approach and the volar finger pad longitudinal approaches are recommended in textbooks. Unfortunately, even these recommendations are based purely on consensus and have almost no supporting evidence-based literature. The research is essentially nonexistent, and these treatment recommendations come from consensus opinions based on clinical experience. (J Hand Surg Am 2012;37:2603.)
It's possible, however, that even these incision and drainage techniques may be unnecessary in a large percentage of these infections. The problem is that ultrasound adapted to avoid near field acoustic distortion is not being used consistently. Documentation of an abscess clearly justifies an intervention. It's entirely possible, however, that a simple large bore needle aspiration of the abscess may be the only intervention needed in addition to appropriate oral antibiotics. I agree that these infections are a compartment syndrome of the finger pad. These fingertip infections are not your typical compartment syndrome, however.
The compartment of the fingertip is actually 15 to 20 small compartments, which means the normal, healthy finger pad is divided into multiple small compartments by 15 to 20 septa that extend from the periosteum to the skin. Consequently, the same 18-gauge needle used to aspirate an abscess can be redirected to decompress these tiny, engorged compartments. It's highly possible that we have accomplished a kinder and gentler compartment release if the fingertip is vigorously massaged after the needle decompression to express fluid from the compartments through the needle tracks.
My agenda for wanting to find something less invasive is because the fingertip is rich with sensory nerves and blood vessels. I could not find a study, but I strongly suspect that the residual morbidity of the current approach with the fingertip incision and drainage procedure is significant and includes finger pad instability, pain, and numbness. We must find a kinder and gentler, evidence-based approach to treating felons.
Watch a video demonstrating techniques for treating felons.