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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Monday, August 1, 2016

We are going to get up close and personal this month to talk about hemorrhoids. You should be familiar with these painful offenders because half to two-thirds of people between 45 and 65 will suffer from their cruelty. (Am Surg 2009;75[8]:635.) Patients may seek emergency department care if they experience bleeding or severe pain from hemorrhoids.

Hemorrhoids are highly vascular structures that are round or oval in shape. They arise from the rectal and anal canal, and sometimes appear around the anus itself. It is important to note that hemorrhoids do not have arteries and veins but special blood vessels called sinusoids, connective tissue, and smooth muscle. (Beck, DE, et al. The ASCRS Textbook of Colon and Rectal Surgery, Second Edition. New York, NY: Springer New York, 2015, p. 175.) Hemorrhoids at times can exist within the anal canal and be completely painless because sensory innervation to the rectum is primarily visceral. (Roberts JR, Hedges JR, et al. Clinical Procedures in Emergency Medicine. Elsevier, Philadelphia, PA, 2015, p. 880.)

Hemorrhoids protrude around the anus and swell, causing significant pain, when they become inflamed or irritated. The straining from constipation and poor diet choices may be the main cause of hemorrhoids, although lack of exercise, aging, pregnancy, and hereditary may also contribute to their formation. Very rarely are hemorrhoids cancerous. Fissures or tears in the skin around the rectum may occasionally accompany hemorrhoids.

Not all external hemorrhoids contain clots; some are just swollen and irritated and not amenable to incision. Some hemorrhoids are swollen, soft, and compressible, and may be tender. If the hemorrhoid is not tense or a clot is not palpated, topical corticosteroids and sitz baths are the best intervention.

Thrombosed external hemorrhoids are readily drained in the ED. Surgical intervention for internal hemorrhoids is not an outpatient procedure and usually is a last resort. Hemorrhoid surgery can be a difficult procedure for many to endure, and patients who suffer from long-term hemorrhoid complaints may benefit from a visit to a colorectal surgeon. A colonoscopy or sigmoidoscopy may assist in ruling out more complicated or serious diagnoses.

​Anatomy Review
Hemorrhoids are veins in the rectum. They are normal vascular structures in the anal canal, arising from a channel of arteriovenous connective tissues that drain into the superior and inferior hemorrhoidal veins. They are located in the submucosal layer in the lower rectum and may be external, internal, or mixed based on their location relative to the dentate line. External hemorrhoids are located distal to the dentate line; internal ones are located proximal. Hemorrhoidal bleeding is characterized by the painless passage of bright red blood from the rectum with a bowel movement. Painful defecation is not associated with hemorrhoids unless they are thrombosed. Acute onset of perianal pain with perianal swelling suggests the presence of a thrombosed hemorrhoid.

​Presentation
Hemorrhoids can produce bleeding with a bowel movement, itching, pain, feces leakage, difficulty cleaning after a bowel movement, or tissue bulging around the anus. Patients may be able to see or feel hemorrhoids, or they may be hidden from view inside the rectum. Hemorrhoids are classified as internal or external; internal ones are best treated by medication and a surgeon, but acutely thrombosed external hemorrhoids are fair game for drainage in the ED or clinic. Neither type of hemorrhoid is painful unless complications develop.

Both internal and external hemorrhoids can develop clots in the vessels. A thrombosed hemorrhoid is extremely tender to palpation, and a thrombus may be palpable within the tense hemorrhoid. Internal hemorrhoids can also contain a clot, but more likely prolapse outside the rectum, causing significant pain and increased bleeding. Prolapsed internal hemorrhoids appear as dark pink, glistening, and tender masses at the anal margin. Thrombosed internal hemorrhoids can cause pain but to a lesser degree than external hemorrhoids. An exception is when internal hemorrhoids become prolapsed and strangulated, and develop gangrenous changes from the associated lack of blood supply.

External hemorrhoids are not typically graded, but internal hemorrhoids are according to the degree to which they prolapse from the anal canal. Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not prolapse below the dentate line. Grade II hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade III hemorrhoids prolapse out of the anal canal with defecation or straining, and require manual reduction. Grade IV hemorrhoids are irreducible and may strangulate, and urgent surgery is required for grade IV internal hemorrhoids, though rubber band ligation is the most widely used procedure for other grades. Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Banding is successful in approximately 70 to 80 percent of patients. (Roberts & Hedges, 2015.)

This current discussion concerns diagnosis and treatment of thrombosed external hemorrhoids only. These are covered by modified squamous epithelium (anoderm), which contains numerous somatic pain receptors, making external hemorrhoids extremely painful with thrombosis. Thrombosed external hemorrhoids are acutely tender and have a purplish hue, and occasionally a partially extruded clot can be seen. Patients present with acute onset of perianal pain and a palpable perianal "lump" from thrombosis. Thromboses of external hemorrhoids may be associated with excruciating pain as the overlying perianal skin is highly innervated and becomes distended and inflamed. Importantly, not all swollen external hemorrhoids contain an organized extractable clot, and incision of a swollen hemorrhoid is of no value unless a clot is present. A clotted hemorrhoid is generally very firm and discolored from the underlying clot.

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Typical appearance of external hemorrhoids. Note the partially extruded clot from one thrombosed hemorrhoid. The other hemorrhoids are swollen, but are soft and do not contain a clot. Incision of non-thrombosed hemorrhoids should be avoided. They are treated with frequent sitz baths and topical corticosteroid ointments. (Photo by Martha Roberts.)


The ED is a place people will visit for this ailment, and you need to be ready. Hemorrhoids aren't just for grandmas and grownups but also occur in children and athletes. In fact, George Brett, one of baseball's Hall-of-Fame inductees, had to stop playing in the 1980 World Series because of hemorrhoid pain. Glenn Beck, a well known talk show host, took his treatment of hemorrhoids to the next level in 2008 by having surgery and speaking out about his case. He stated that the pain medications (opioids) only made his hemorrhoids worse and affected his mental state. (http://cnn.it/29iIAvV.) Stories like this give rise to concerns of pain control complications and addiction. ED interventions can help patients be well and learn about nonopioid treatments.

Now that you know a little bit more about hemorrhoids and their mercilessness, we are going to highlight some ways you can treat painful, thrombosed external hemorrhoids. Remember, internal hemorrhoids are not treated by minor surgery in the ED. We are also going to remind you that your craft requires compassion and that treatment should be carefully completed.

The Procedure

  • Identification of thrombosed external hemorrhoids and differentiation from prolapsed internal hemorrhoids
  • Sedation/pain control techniques, usually parenteral opioids
  • Cleaning of area and application of topical LET or EMLA cream
  • Taping technique and setup
  • Injection of anesthesia used during the procedure
  • Removal of thrombosis and drainage with incision
  • Follow-up care and treatments

hem 3.jpg
Multiple external hemorrhoids. Not all visible hemorrhoids contain a thrombosis. A clot produces a firm palpable mass. If a clot is not palpated, do not incise. Note partially extruded clot in one hemorrhoid. (Photo by Martha Roberts.)


The Pause
How do we identify thrombosed external hemorrhoids and when do we need to intervene? A thrombosed hemorrhoid will be protruding from the anal canal around the anus. The hemorrhoid itself will appear dark blue or purple, and appear quite swollen. The hemorrhoid appears this color because of the collection of blood clots inside the hemorrhoid itself. This can cause significant pain, and incision and drainage may help with relief. Thrombosed external hemorrhoids that are not drained most likely will spontaneously rupture in one to three weeks and leave a skin tag behind. Sitz baths two to three times a day are often curative if a patient declines drainage in the ED.

The Approach

  • Provide an area of privacy for comfort. Professionalism, kindness, and caring are key to successful treatment.
  • Positioning this patient is variable. There are several ways to position the patient including prone, left lateral decubitus, or Sims knee-shoulder position. Our position of choice will be prone. Patients with breathing complications, obesity, claustrophobia, or anxiety may not be good candidates for this procedure.
  • A digital rectal exam should be completed with guaiac testing if indicated. Anoscope may not be needed for severely thrombosed hemorrhoids and too painful to complete.
  • A CBC and 500 mL bolus may be ordered if the patient reports copious bleeding.
  • Obtain IV access and administer sedation/pain control. IV opioids are best, providing some relaxation/sedation as well as analgesia. IV fentanyl, hydromorphone, and morphine are suitable options. Use appropriate dosing. Be sure to monitor the patient's airway during the procedure with end-tidal CO2 and oxygen saturation. Do not forget to document appropriately.
  • Clean the area well with soap and water and Betadine.
  • Apply LET, a combination of lidocaine (2%), epinephrine (0.1%), and tetracaine (0.5%), and wait 20 minutes. EMLA cream is also suitable, but can take up to one hour to work.
  • Ask the nurse, technician, or another provider to assist with initial investigating and setup.
  • Use 2-inch tape to tape the buttock apart. This will allow for free use of both hands and full exposure.
  • Locate the thrombosed hemorrhoid and prepare for analgesic injection.
  • Obtain a 25-gauge needle and 10 mL syringe for medication injection.
  • Obtain a suture kit and 11-blade scalpel for incision and drainage.
  • Use a single injection of buffered long-acting bupivicane (NOT LIDOCAINE) with epinephrine. Buffer the injection with sodium bicarbonate.
  • Infiltrate the thrombosed hemorrhoid just under the skin and over the dome of the hemorrhoid. Avoid deep injection, and inject slowly.
  • If full pain control is not achieved, you may advance the needle slightly and inject more analgesia.
  • Make an elliptical incision around the clot and direct it radially from the anal orifice. An elliptical incision should be made as opposed to a simple cut because premature closing of the incision may prevent clots from dissolving.
  • Squeeze the hemorrhoid with your fingertips to express clots.
  • Forceps may be used to remove residual clots.
  • Do not pack the hemorrhoids. Apply pressure to the site to control bleeding. Use a folded gauze to pad over the operative site and tape the buttock closed to hold it in place. Gelfoam may be used to help control bleeding.
  • Home care: Have the patient soak in a few inches of water in warm tub bid for the next two to three days. NSAIDs are first-line treatment for pain and inflammation. Wash (shower is best) the anal area after every bowel movement with soap and water. Post-operative opioids are relatively safe in small amounts with stool softener and increased fluids. Fiber regimen should be added after healing.
  • Antibiotics are not indicated.
  • Warn patients of residual skin tags and that scant bleeding is OK.
  • Plan colorectal follow-up care.

 

Contraindications and Cautions

  • Thrombosed external hemorrhoids are most effectively drained less than 48 hours after onset. Prolapsed/thrombosed internal hemorrhoids are not amenable to ED surgical drainage.
  • Consider surgical consult for prolapsed internal hemorrhoids, multiple external hemorrhoids, or severe bleeding.
  • You should not complete this procedure on patients who are obese, who have breathing disorders or airway compromise, bleeding disorders, seriously systemic illness, rectal abscess, or who are hemodynamically unstable.
  • Patients using aspirin, Plavix, warfarin, or other anticoagulants should be approached with caution and possibly referred to a colorectal surgeon, although it is not an absolute contraindication.
  • A post-thrombectomy flexible sigmoidoscopy or colonoscopy based on the presence of associated symptoms and risk factors for colorectal cancer should be considered in patients over 40.
  • Have the patient increase his fluid intake. Steroid creams should not be applied until the incision has healed, and then should be applied twice a day for no more than seven days.

Supportive Treatments and Prophylaxis
Topical analgesics can be used postoperatively. Topical corticosteroids and astringents can control itching and irritation. Avoiding constipation and straining with stool bulking agents and softeners are the best ways to prevent recurrence.

Drugs Used for Hemorrhoids

  • Benzocaine 5-20% rectal ointment or other topical analgesic
  • Astringents such as witch hazel (Tucks, Preparation H pads) zinc oxide (Desitin)
  • Bulk-forming laxatives (oral): methylcellulose (Citrucel), polycarbophil (FiberCon), psyllium (Metamucil), wheat dextrin (Benefiber)
  • Corticosteriods (topical): hydrocortisone rectal creams 1 to 2.5% (Anusol-HC, Preparation H, Proctosol-HC); hydrocortisone rectal suppository 25 to 30 mg (Anusol-HC)
  • Stool softeners: ducosate sodium (Colace)

Tip of the Week: Antispasmodic Agents
Several types of agents can be useful for reducing anal sphincter spasm. A small series suggested that topical 0.5% nitroglycerin ointment may provide temporary analgesia by reducing internal anal sphincter spasm. (Dis Colon Rectum 1995;38[5]:453.)


Watch a video of hemorrhoid treatment in the ED​.

hem 2.jpg 


Saturday, July 2, 2016

Ultrasound may seem intimidating at first, but it is not a procedure out of your reach. Those of you still feeling shy about it should just play with it to increase your comfort level. It's OK to be early for a shift or to stay late figuring out the machine. Try using ultrasound on patients who will allow it and scribes who don't say no. It can't hurt, and it will make you a better and more knowledgeable provider.

We all know an "official" ultrasound is needed to confirm a suspected DVT, but what if you just need to know right away? Picture this: You are starting an overnight shift and are already 10 patients deep. Your 55-year-old patient with leg pain and unilateral leg swelling is waiting for an ultrasound, and it's going to be awhile. Your plan is to do some basic labs and obtain the official ultrasound to rule out a DVT. The patient has a few risk factors for DVT and a story to match. Why not test your bedside skills and see what you can see?

Bedside ultrasound for DVT is a great way to plan your night and your patient's future. You begin to ask yourself if you need to transfer this patient, probably let him go home, or admit him to the hospital. It's nice to know where your ducks are, so throwing the ultrasound on patients to make a decision from the get-go is imperative. Then you can order that official test. Why can't you do it, too? The good news is you can, and here is how.

The Procedure
Bedside ultrasound with linear probe to detect DVT in lower extremity
Collection of data, formal ultrasound, and admit/discharge plan

​The Pause
We want to draw your attention directly to our video. If you have been following our series on ultrasound, all you need to do is watch this and like magic, you have your answer. You can read the first four part of this ultrasound series on our website. (See box.)

Watch Dr. Amie Wood demonstrate using ultrasound for detecting DVT.

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Clinical Pearls and EBP
The best way to detect proximal lower extremity DVTs in the emergency department is to use a "modified 2-point compression technique that focuses on the highest probability areas, decreases the study time to less than 5 minutes, and provides similar sensitivity and specificity." (Acad Emerg Med 2000;7[2]:120.)

A "negative compression ultrasound study may safely delay the need for anticoagulation therapy" if a patient has a clinically suspected DVT. (BMJ 1998;316[7124]:17) Not only does bedside-provider ultrasound help determine the diagnosis and plan, the 2-point DVT compression examination has been "assessed in multiple randomized controlled studies and is well accepted when used properly with pretest probability assessments" (JAMA 2008;300(14):1653.) It's imperative you try it and expedite the care of your patient who need it most.

​Tip of the Week
Amie Woods, MD, a clinical ultrasound expert, has some tips if you decide to dabble in the artistry we call ultrasound. Dr. Woods suggests using the bedside ultrasound test to help make clinical decisions. Usually, following the common femoral vein to the mid thigh will give you the results you need. This can be a reasonable tool to diagnosis DVT if you can confirm the compressibility. It's important to note that this does not rule out superficial DVT. All superficial DVTs have the ability to form a true DVT and need formal outpatient follow-up or a repeat study. But this means it's possible for you to send patients home on high-dose aspirin therapy and schedule a repeat exam with a vascular surgeon. Formal studies are never a bad idea, but your steady hand can help predict the long-term outcome.

Suggested Reading

  • Crisp JG, Lovato LM, Jang TB. Compression Ultrasonography of the Lower Extremity with Portable Vascular Ultrasonography Can Accurately Detect Deep Venous Thrombosis in the Emergency Department. Ann Emerg Med 2010;56(6):601.
  • Frazee BW, Snoey ER, et al. Negative Emergency Department Compression Ultrasound Reliably Excludes Proximal Deep Vein Thrombosis. (Abstract 102.) Acad Emerg Med 1998;5(5):406.
  • Nunn KP, Thompson PK. Towards Evidence-Based Emergency Medicine: Best Bets from the Manchester Royal Infirmary. Using the Ultrasound Compression Test for Deep Vein Thrombosis Will Not Precipitate a Thromboembolic Event. Emerg Med J 2007;24(7):494.

Read the first four parts of this series:
Part 1: We Had You at Ultrasound
Part 2: Foreign Body Removal
Part 3: Eye Think It's the Retina
Part 4: Ultrasound-Guided IV Line Placement


Wednesday, June 8, 2016

​BY MARTHA ROBERTS, ACNP, CEN

This Father's Day, Emergency Medicine News would like to recognize a true leader in emergency medicine. James R. Roberts, MD, a distinguished professor and emergency physician, is one of the founding fathers of the specialty. Since 1972he directly assisted in building the profession, paving the way for thousands of individuals who now call the ED their home.

Dr. Roberts was one of the first emergency physicians in the country, and he has taught tens of thousands of students over the years including physicians, fellows, residents, nurse practitioners, physician assistants, and nurses. His expertise is recognized worldwide, and his procedure textbook, Clinical Procedures in Emergency Medicine, is a staple in every ED, not to mention the global reach of his EMN column. (http://emn.online/INFOCUS-JR.) Dr. Roberts' clinical work in the ED and his toxicology expertise have helped saved the lives of thousands of sick children and adults.

This video is a small collection of images highlighting some of his work in emergency medicine​. Many of these photos were captured during my first clinical rotation alongside Dr. Roberts and his team at Mercy Hospital of Philadelphia, where he was chairman for more than 20 years. It would be impossible to compile a video of all the photos he took of patients and procedures over the past decades, but these are some of the most memorable.

Not only has Dr. Roberts groomed students and new practitioners, he has also taught many, including me, the art of the profession. It's not often you find his kind of intelligence anywhere, but when you do, it is rarely in his modest form. He manages to effortlessly balance his great intellect with a great sense of humor and wit that makes practicing emergency medicine rewarding, interesting, and fun.

I am truly lucky to call him Dad. He taught me everything from my ABCs in grade school to the ABCs of ED patients. He is a truly unique and dedicated soul, but he is, above all else, a caring person. Not only is he highly educated, he practices with feeling, intuition, common sense, and passion. His modest mentorship and enthusiasm for emergency medicine is contagious, in a good way.

This fall during the American College of Emergency Physicians Scientific Assembly in Las Vegas, Dr. Roberts will receive the award for Outstanding Contribution in Education. In nominating him for that award, Anthony S. Mazzeo, MD, wrote, "He has educated physicians worldwide on the nuances of all aspects of EM, from the mundane to the exotic, all with the charisma and erudite vocabulary that is undeniably 'trademark Roberts'. … Dr. Roberts remains a humble, modest, dedicated, and hard-working educator who would clearly never seek the recognition of this award. However, those of us who have worked with Jim and learned from Jim over the years feel this recognition is undeniably warranted."

Happy Father's Day to all the fathers of emergency medicine, and Happy Father's Day to my Dad, James R. Roberts, MD.


Thursday, June 2, 2016

It's time to be fearless and embrace the true utility — and maybe implement a new policy in your ED — of ultrasound-guided intravenous (IV) line insertion.

ultrasound machine.jpg 

Many physicians, NPs, and PAs already know how to place US-guided IVs, but we can help teach those who don't. Provider teaching can be in the form of real-time IV placement or a short 60-minute procedural training course open to all those who are interested. You can even use our procedural videos to help get you started! (http://emn.online/Mar16PP.)

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We all know our difficult patient population includes prior IV drug abusers, obese patients, patients with chronic illnesses, and hypovolemia. Let's make the procedure less painful for them! No one is asking for our nurses to place central lines or diagnose a DVT using US, but basic understanding of US technology is not difficult and can be beneficial for the patient. A delay in establishing vascular access can result in a delay in the administration of a fluids and medications.

Patients frequently experience delays in diagnosis and initiation of treatment. Multiple attempts at attaining vascular access also result in frustration and a loss of productivity by the treating team. (Clin Pediatr [Phila] 2009;48[9]:895.) (Rauch, Dowd, Eldridge, Mace, & Schears, 2009). Nurses and technicians are more likely to establish a well-placed, working IV site once they can identify the veins and arteries on the screen. This could help speed up treatment for a patient who needs an 18 g needle for a CT scan to rule out a PE or a septic patient who needs resuscitation.

arm.JPG 

The Approach
n Ultrasound-guided intravenous line placement
n Using sterile approach

scan 2.jpg 

The Pause
Make sure this particular procedure is already approved for immediate use. The emergency medicine technicians (EMTs) can use the US machine to insert IV lines in most hospitals, but in other institutions, RNs are allowed to do this without an order. And still, some facilities allow only a physician or midlevel to run the procedure.

graph.JPG 

The Approach
n Inform patient of need for intravenous line.
n Alert nurse and EMT team or place order for IV line.
n Nursing or EMT team attempt standard IV insertion. A US-guided approach should be activated if IV placement cannot be obtained within two attempts. NOTE: Consider creating a standing order or policy for department to allow nurses to complete this activity on their own without waiting.
n Regardless of who is initiating line placement, obtain the following items: appropriate-sized catheter (18 g is suggested), chlorhexidine prep pad, tourniquet, IV line set up or start kit with NS flush, sterile towel, and marking pen. Also obtain the US machine with linear probe, sterile US gel packets, US probe sterile plastic cover, sterile gloves, and any other equipment (i.e., culture bottles or lab testing tubes).
n Obtain written or verbal consent for the procedure.
n Prepare for US-guided IV placement. First, use the linear probe to examine the arm without a tourniquet. Attempt to locate deep and superficial veins for IV cannulation. Consider deep brachial veins and move the probe slightly higher up the bicep to look for deeper veins.
n NOTE: Remember that arteries will be pulsating and veins will not. If you turn on the color indicator, arteries will also appear red and veins will appear blue.
n Continue to look for veins by pressing down on the probe. Veins should be easily compressible. Add the tourniquet. Continue your search.
n Once you have located the vein you wish to cannulate, use the marking pen to mark the site. Note the depth on the US machine so you know how far to advance your needle.
n This is where it gets a little tricky. If you are confident that you can stick the vein without continuous US guidance, you can clean and prep the site and then insert the needle. At this point, you will be finished with the procedure.

If you are unsure, then you need to take this a few steps farther:
n Clean the site with chlorhexidine.
n Add sterile gel to the site on the arm you plan to cannulate.
n Set up a sterile towel on side table, and drop your sterile needle onto it. You will use the towel later to wipe off any extra gel. It's good to be prepared.
n Don sterile gloves.
n Ask an assistant to open the US probe-cover packet. Grab it and ask the assistant to squeeze gel inside the sleeve of the US probe cover. Do not break sterility.
n Have your assistant place the linear probe into the sleeve as you expand it over the full length of the probe and cord. Do not break sterility.
n Place the sterile-covered probe onto the site you already examined.
n Relocate the vein using your landmarks and markings.
n Use the US-guided technique to watch your needle enter the skin and cannulate the appropriate vein.
n Complete IV setup once the vein has been properly cannulated and the outline setup has been connected.
n Clean off the arm with the towel to remove any extra gel or blood.
n Complete the procedure by securing the IV line, drawing labs or cultures (if indicated), and flush the line with NS. NOTE: We often suggest that providers draw a 10 mL syringe of blood during initial placement, which can be placed in your sterile field prior to starting the procedure.

​Major Cautions
n If your patient is a frequent flyer and you know a line will be tough, try to use the US technique immediately, before completing two blind sticks.
n Do not forget to remove the tourniquet when the procedure is complete.
n Do not break your sterile field. You are cannulating a deep vein, and the potential for artery cannulation is possible.
n Immediately remove the IV catheter, and add pressure to any site where arterial cannulation was inappropriately completed.
n Consider US of the upper extremity to rule out DVT if a patient returns to the ED with arm pain after a deep vein cannulation and signs of DVT.

​Tip of the Week
Feel free to ask your administration if you can create a policy for US-guided IV placement and explain why it is beneficial for patient care (pain control, expedited testing etc.) and nursing autonomy. Consider offering to teach a 60-minute lab on US-guided IV insertion.

​Educational Considerations
Using ultrasound for IV access requires training, and the literature is mixed. Physician training is incorporated into residency training with up to 16 hours of didactic and more than 100 ultrasound scans. It is suggested that "nursing and technician staff members train with at least one hour didactic with additional hands on training." (J Emerg Med 2006;31[4]:407.)

​Pearl
The Emergency Nurses Association's policy supports US-guided IV placement by physicians, nurses, and techs in the appropriate setting. Read more about it at http://bit.ly/1iy4taJ.

​Click here to watch a video of ultrasound-guided intravenous line insertion, and read the first three parts of this series:
Part 1: We Had You at Ultrasound
Part 2: Foreign Body Removal
Part 3: Eye Think It's the Retina

Watch this month's video​.

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Monday, May 2, 2016

Part 3 in a Series

The Problem: Unilateral, painless vision changes and floaters

Ocular ultrasound is a short and sweet procedure that could change your practice and greatly benefit your patients. It can actually be used to diagnose retinal detachment, which in the past required a referral to an ophthalmologist and often led to delayed therapy. Noninvasive and simple ultrasound techniques can be used on any patient of any age presenting with visual changes. The differential for visual changes with or without complete vision loss or blurry vision encompasses a daunting list. This is for you especially if retinal detachment is on your differential.

First, let's review the anatomy. Visual messages are sent from the retina through the optic nerve to the brain. Patients experience painless, unilateral vision loss, which may be permanent if for some reason the retina becomes detached, moves, or is pulled away from its normal position. Other problems, such as retinal tears or breaks, can cause brief vision loss and can lead to future complete detachment. ("Facts about Retinal Detachment," NIH, National Eye Institute; http://1.usa.gov/21P46bg.) Patients will complain of unilateral vision changes without other symptoms aside from blurry or cobweb vision or floaters (photopsia). Some say they even see black, which can be the last fatal phase of retinal detachment.


Ocular structures. Photo courtesy of CreativeCommons.com

Things you can see with ocular ultrasound:

  • Retinal detachment
  • Posterior vitreous detachment (PVD)
  • Vitreous hemorrhage
  • Lens dislocation
  • Choroid detachment
  • Intraocular foreign body
  • Globe rupture
  • Orbital fractures
  • Central retinal artery and central retinal vein occlusions​

The Possibilities: History taking

Ask your patient the following questions before performing your ultrasound-guided exam:

  • Are you nearsighted?
  • Have you had painless vision loss?
  • Have you had a prior retinal detachment?
  • Is there a family history of retinal detachment?
  • Have you had cataract surgery? Recent eye trauma?
  • Did it seem like a dark curtain came over your eye?
  • Do you have a history of uveitis, degenerative myopia, or other eye complications?
  • And most importantly, have you experienced an increase in the number of floaters, cobweb-like vision, or cloudy/flashy vision in one eye in the past few weeks or months?

If your patient said yes to any of these questions, it's time to break out the ultrasound machine and be prepared to look directly at the retina. Remember, a retinal detachment may occur at any age, although it is more common in those over 40 and Caucasian males. (http://1.usa.gov/21P46bg.)

The Procedure: Ocular ultrasound

  • Ultrasound-guided identification of retinal detachment using the linear probe
  • Identification of structures: Anterior (lens, cornea, iris, ciliary bodies) and posterior chambers (vitreous, retina, optic nerve sheath diameter [ONSD], optic disc)
  • Identification of normal retina vs. detachment
  • Prompt and appropriate follow-up with retinal specialist if defect found
  • Measurement of ONSD if concerned about elevated intracranial pressure

The Approach

  • Complete an excellent history and fundoscopic exam.
  • Obtain an ultrasound machine.
  • Put your patient in a supine position.
  • Engage linear probe (7.5 MHz or greater). Set the machine in B-mode and activate the "ocular" preset.
  • Place a clear Tegaderm over the patient's affected eye after he closes it. This will prevent the lubricating gel from getting into his eye. It also does not pull off eyebrows or eyelashes. Tell the patient this prior to application, and that it prevents any foreign bodies from entering the eye or causing eye irritation.
  • Smooth out any air bubbles in the Tegaderm.
  • Add lubricating gel over the Tegaderm.
  • Darken the lights in the room.
  • Be prepared to use the probe in the transverse plane. The indicator should be pointing toward the patient's ear (i.e., you are looking at the left eye, the probe is held in the transverse or horizontal position with the indicator pointing toward the left ear).
  • Gently place the linear probe over the Tegaderm and adjust your depth to see the entire globe: the anterior and posterior chambers and ONSD. Identify all structures.
  • Locate the retina and determine if detachment has occurred. You will see a white line flopping around and waving gingerly at you on the screen. It looks almost like a streamer.
  • Pull off the Tegraderm to reveal a dry, non-irritated eye and complete appropriate follow-up. Immediately call for assistance if there is a detachment, and refer to ophthalmology.
  • Note: If you wish to measure the ONSD, it should be <5 mm. The provider should be concerned about elevated intraocular pressure if it is >5 mm. Studies have shown these two ailments have a direct clinical correlation. Start in the transverse plane when you measure. Measure the width of the optic nerve sheath 3 mm posterior to the retina and then "rotate the transducer clockwise to measure the ONSD in the sagittal plane, perpendicular to your first measurement. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)
  • Compare both eyes.
  • Limit your examination of the eye(s) with the ultrasound and adhere to ALARA principle (as low as reasonably achievable).



Click here to watch a video of ocular ultrasound.
Special thanks to Amie Woods, MD, an emergency physician at INOVA Fairfax Hospital and an assistant clinical professor at George Washington University, for her help in making this video.


Pearls

This procedure may initially sound difficult and above your level of expertise, but once you see a retinal detachment on ultrasound, you will never forget it. Discovering a retinal detachment is as simple as turning on the machine, using your linear probe on the affected eye, and examining the globe and its structures.

The retina itself is usually a flat white thickened line, which lies securely among the tissues at the back of the eye. A normal globe itself will appear dark (the vitreous), and the retina will appear white.

A significant detachment will show the white retinal tissue flopping and waving around in the black area, close to its normal resting place. Sometimes, you may be able to identify PVDs or hemorrhages. PVDs are usually thinner and smoother than retinal detachments and are more mobile. Retinal detachments should also not extend to the ciliary bodies because of their anatomy while PVDs usually do. A retinal detachment should also not extend over the optic sheath. Retinal detachments will be thicker, white (hyperechoic) membrane-like structures with multiple folds and move with ocular movements. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)



Retinal detachment as seen on ultrasound ocular exam. Photo courtesy of Dr. Amie Woods, Inova Fairfax Hospital

 

Keep in mind, your patient may still have a retinal artery occlusion (RAO) or spasms even if the retina appears normal. These patients may present with similar complaints of vision loss or changes caused by clots or blocked retinal arteries. The retina is starved of oxygen and nutrients and essentially dies and causes these symptoms. RAO may occur in patients who are symptomatic and without retinal detachment or who have a history of atherosclerosis. Final exam tip: You may see macular edema on your fundoscopic exam if you suspect RAO. RAOs can be treated with lasers, blood thinners, and treatments used for atherosclerosis.

Our retinal partners use a freezing treatment called cryopexy to fix the retina with lasers. They basically fuse it back in place. The majority of retinal detachments are treated successfully if identified quickly by the emergency department provider. Remember, the retina is at high risk for complications and requires an ophthalmologist's care.

 

Cautions

  • Don't push too hard on the probe. You won't need to apply much pressure at all if you use enough gel.
  • Use the bridge of the patient's nose or his forehead to stabilize your hand.
  • Use a dark room.
  • Keep it clean. Use the Tegaderm approach.
  • Obtain a fundoscopic exam prior to the ultrasound exam.
  • Test the visual acuity.
  • Use the "freeze" button on the machine to hold your image on the screen so you can complete the identification and measurements of the globe's structures. This allows you to look longer and closer without leaving the probe directly on the patient's eye. It also allows you to measure the ONSD accurately.
  • If you suspect ruptured globe and see that while doing your exam, stop and call the specialist immediately. Refrain from using tense pressure on the orbit.
    o Warm lube? No way, this is not a fetus! Chilling the lube actually allows you to complete a better exam because it causes increased viscosity and "allows the gel to stack easily." (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)
  • Retinal detachment and PVD are difficult to distinguish, but patients may be more likely to say they see floaters as opposed to having vision loss if suffering from PVD.

Procedural Pause Overachievers

If you really want to impress your ophthalmology colleagues, you can also measure the blood flow to the retinal artery based on a very simple equation related to the diameter measurements and blood flow seen on the ultrasound exam. If you want to know more about this, check out this great Austrian study by Droner, et al. (Curr Eye Res 2002;25[6]:341; http://bit.ly/25snrDM.)​

BONUS VIDEO: Watch Dr. Amie Woods' TEDx talk, "This is What's Making Me a Better Doctor," for her experience with ultrasound and a patient with a life-threatening condition: http://bit.ly/1VucDAx.

 

About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner for Johns Hopkins Medicine at the Sibley Memorial Hospital in Washington, DC, an adjunct faculty associate and clinical instructor of nursing at the Malek School of Health Professions, Marymount University in Arlington, VA, and is Dr. Roberts’ daughter.

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