The Emergent Evaluation and Treatment of Hand and Wrist Injuries: An Update

Injury patterns of the hand and wrist can be complex and challenging for the emergency physician to diagnose and treat. The ability of the hand to perform delicate maneuvers requires a very intricate interplay of bones, ligaments, and tendons. Unfortunately, due to the omnipresence of the hand, the hand and wrist are commonly injured. These injuries can be debilitating if not treated correctly and can be both time-consuming and fraught with medicolegal risk. This article provides the necessary knowledge to diagnose and treat common hand and wrist injuries encountered in the emergency department.

The neurology literature 2016

Emergency neurology is a complex and rapidly changing field. Its evolution can be attributed in part to increased imaging options, debates about optimal treatment, and simply the growth of emergency medicine as a specialty. Every year, a number of articles published in emergency medicine or other specialty journals should become familiar to the emergency physician. This review summarizes neurology articles published in 2016, which the authors consider crucial to the practice of emergency medicine. The articles are categorized according to disease process, with the understanding that there can be significant overlap among articles.

Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a neurological emergency with high risk of neurological decline and death. Although the presentation of a thunderclap headache or the worst headache of a patient's life easily triggers the evaluation for SAH, subtle presentations are still missed. The gold standard for diagnostic evaluation of SAH remains noncontrast head computed tomography (CT) followed by lumbar puncture if the CT is negative for SAH. Management of patients with SAH follows standard resuscitation of critically ill patients with the emphasis on reducing risks of rebleeding and avoiding secondary brain injuries.

Influenza in the Emergency Department: Vaccination, Diagnosis, and Treatment: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee

BACKGROUND

Influenza is an acute respiratory virus that results in significant worldwide morbidity and mortality each year. As emergency physicians, we are often the first to encounter patients with seasonal influenza. It is therefore critical that we draw on the most recent and relevant research when we make clinical decisions regarding the diagnosis, treatment, and prophylaxis of this disease.

METHODS

A MEDLINE literature search from August 2009 to August 2015 was performed using the keywords influenza vaccination efficacy AND systematic, influenza AND rapid antigen testing, and Oseltamivir AND systematic, while limiting the search to human studies written in the English language. General review articles and case reports were omitted. Each of the selected articles then underwent a structured review.

RESULTS

We identified 163 articles through our literature search, of which 68 were found to be relevant to our clinical questions. These studies then underwent a rigorous review from which recommendations were given.

CONCLUSIONS

Influenza vaccine efficacy continues to range between 40% and 80%. Vaccination has the potential to decrease disease severity and is recommended for individuals older than 6 months of age. If resources permit, vaccination can be offered to patients presenting to the emergency department. Rapid antigen detection for influenza is a simple bedside test with high specificity, but generally low sensitivity. If a patient presents with a syndrome consistent with influenza and has negative rapid antigen detection, they should either receive a confirmatory reverse transcriptase polymerase chain reaction or be treated as if they have influenza. Treatment with neuraminidase inhibitors can decrease the duration of influenza and is recommended in hospitalized patients, or in those with high risk of complications.

Implementation of a team-based physician staffing model at an academic emergency department

Introduction

There is scant literature regarding the optimal resident physician staffing model of academic emergency departments (ED) that maximizes learning opportunities. A department of emergency medicine at a large inner-city academic hospital initiated a team-based staffing model. Its pre-interventional staffing model consisted of residents and attending physicians being separately assigned patients, resulting in residents working with two different faculty providers in the same shift. This study aimed to determine if the post-interventional team-based system, in which residents were paired with a single attending on each shift, would result in improved residents’ learning and clinical experiences as manifested by resident evaluations and the number of patients seen.

Methods

This retrospective before-and-after study at an academic ED with an annual volume of 52,000 patients examined the mean differences in five-point Likert-scale evaluations completed by residents assessing their ED rotation experiences in both the original and team-based staffing models. The residents were queried on their perceptions of feeling part of the team, decision-making autonomy, clinical experience, amount of supervision, quality of teaching, and overall rotational experience. We also analyzed the number of patients seen per hour by residents. Paired sample t-tests were performed. Residents who were in the program in the year preceding and proceeding the intervention were eligible for inclusion.

Results

34 of 38 eligible residents were included (4 excluded for lack of evaluations in either the pre- or post-intervention period). There was a statistically significant improvement in resident perception of the quality and amount of teaching, 4.03 to 4.27 (mean difference=0.24, p=0.03). There were non-statistically significant trends toward improved mean scores for all other queries. Residents also saw more patients following the initiation of the team-based model, 1.24 to 1.56 patients per hour (mean difference=0.32, p=0.0005).

Conclusion

Adopting a team-based physician staffing model is associated with improved resident perceptions of quality and amount of teaching. Residents also experience a greater number of patient evaluations in a team-based model.

Levosimendan does not improve survival time in a rat model of verapamil toxicity

OBJECTIVE

Calcium channel blocker (CCB) toxicity, in particular that induced by verapamil and diltiazem, presents clinical challenges with no true antidote. Levosimendan, a calcium sensitizer, improves cardiac contractility in patients with heart failure. We tested the hypothesis that calcium channel sensitization will prolong survival in a rat model of severe verapamil poisoning.

METHODS

This was a blinded, randomized, controlled animal study. Wistar rats (mean weight, 371 +/- 50 g) were used. Verapamil (2.5 mg/ml) was infused at a rate of 37.5 mg/kg per hour. Bolus doses of levosimendan (5 microg/mL) were given at 0 min (12 microg/kg) and 5 min (18 microg/kg); saline control was of equal volume. The rats were intubated and maintained under general anesthesia with isoflurane. Electrocardiographic activity and core temperature were monitored during the poisoning and treatment phases. Each rat underwent femoral vein cannulation and was then randomized, in blinded fashion, to receive either levosimendan or an equal volume of saline at 0 and 5 minutes. Death, defined as 1 minute of asystole, was used as the primary endpoint.

RESULTS

Rats treated with levosimendan died before the control group (7.37 +/- 0.7 min [n=7] vs. 16.4 +/- 4.2 [n=7] [ p=.053]). All animals experienced bradycardia prior to asystole.

DISCUSSION

Although levosimendan has the ability to sensitize and enhance binding of troponin C to Ca2+, this study did not show an improvement in survival time in the setting of verapamil toxicity. This may be attributed to levosimendan's inhibition of phosphodiesterase, which possibly exacerbated the CCB-induced hypotension.

CONCLUSION

In this rat model, levosimendan as a solitary antidotal treatment for verapamil toxicity was not beneficial.

′Sure closure′-skin stretching system, our clinical experience

Objective: In clinical practice of reconstructive surgery one of the problems one routinely comes across is skin and soft tissue defects, which require coverage. Coverage of such wounds requires primary/secondary closure, skin grafting or flaps. The objective of our clinical series was to assess the efficacy of sure closure skin stretching system for closure of defects which otherwise would have required major flap cover or skin grafting.

Methods: Our series included five patients with different causes and types of wound defects namely:

1. Post-traumatic soft tissue defect on dorsum of hand.

2. Post fasciotomy wound on leg (anterolateral aspect).

3. Abdominal wound dehiscence following surgery for enterocutaneous fistula.

4. Leg soft tissue defect following dehiscence of fasciocutaneous flap.

5. Secondary defect following harvesting a lateral arm/forearm free flap.

The device was applied to skin edges after preparing the wound under local anesthesia and the skin edges were brought together by turning the skin-stretching knob. After adequate approximation of the edges of the wound it was sutured by conventional suturing techniques.

Results: All the wounds could be successfully closed using the skin stretching system in our series. The time taken for the closure ranged from 2 to 48 h.

Conclusions: Sure closure skin stretching system is an effective device for closing some of the skin defects which otherwise would have required skin flaps or grafts. In all the patients wound closure could be achieved by this method and was carried out under local anesthesia. Use of this technique is simple and helps to reduce the morbidity and cost of treatment by allowing the reconstructive surgeon to avoid using major flaps or grafts.

Inhibition of antigen-induced acute bronchoconstriction, airway hyperresponsiveness, and mast cell degranulation by a nonanticoagulant heparin: comparison with a low molecular weight heparin

Inhaled heparin prevents antigen-induced bronchoconstriction and inhibits anti-IgE-mediated mast-cell degranulation. We hypothesized that the antiallergic action of heparin may be dependent on molecular weight and related to its nonanticoagulant properties. Therefore, in the present investigation we studied the effects of a nonanticoagulant fraction of heparin (LA-heparin) on antigen-induced bronchoconstriction, airway hyperresponsiveness (AHR), and mast-cell degranulation, and compared its antiallergic activity with that of a low molecular weight heparin (LMW-heparin, fragmin). Specific lung resistance (SRL) was measured in 15 sheep before, immediately after, and serially for as long as 2 h after airway challenge with Ascaris suum antigen, without and after pretreatment with inhaled fractionated heparins at doses of 2.5 and 5 mg/kg. Airway responsiveness was estimated before, and 2 h after antigen as the cumulative provocating dose (PD400) of carbachol in breath units, which increased SRL by 400% (one breath unit was defined as one breath of 1% carbachol solution). LA-heparin caused a dose-dependent inhibition of antigen-induced bronchoconstriction, and a 5-mg/kg nebulized dose caused a 67% inhibition of allergic bronchoconstriction, whereas a 2.5-mg/kg dose was ineffective (20% inhibition). Inhaled fragmin was more potent than LA-heparin, as shown by 84% (2.5 mg/kg) and 82% (5 mg/kg) inhibition of allergic bronchoconstriction. Fragmin (5 mg/kg) also attenuated the postantigen AHR, whereas LA-heparin was ineffective. In vitro, preincubation with both LA-heparin and fragmin inhibited the anti-IgE-induced degranulation of rat peritoneal mast-cells in a dose-dependent fashion. LA-heparin was fourfold more potent than fragmin, with IC50 of 80 and 320 microg/ml, respectively. These data suggest that: (1) fractionated heparins attenuate antigen-induced acute bronchoconstriction, (2) nonanticoagulant fractions mediate the antiallergic activity of inhaled heparin, and (3) antiallergic activity of nonanticoagulant heparin and LMW-heparin may be related to prevention of mast-cell degranulation.

Protective effect of heparin on immunologically induced tracheal smooth muscle contraction in vitro

Our previous studies have shown that heparin, a competitive inhibitor of inositol triphosphate receptors, inhibits airway anaphylaxis in vivo. In the present study, we tested the hypothesis that heparin blocks immunologically induced tracheal smooth muscle (TSM) contraction in vitro. TSM was obtained from sheep allergic to Ascaris suum antigen, and was suspended in an organ bath containing oxygenated (95% O2, 5% CO2) Krebs-Henseleit buffer at 39 degrees C. After an equilibration period, the tissues were treated with heparin dissolved in 10 microliters DMSO, at concentrations of 1, 10, or 100 U/ml (final concentration in the bath). Two types of controls were used: vehicle (10 microliters DMSO)-treated tissues and tissues treated with the anti-asthmatic nedocromil sodium (10(-5) M). After 30 min pretreatment, tissues were challenged with 10, 30 and 100 microliters of antigen. Contractions induced by antigen were expressed as percentage of the contraction elicited by the maximum effective concentration of acetylcholine (ACh, 10(-2) M). Antigen produced dose-dependent increases in tension, which were blocked by heparin and nedocromil sodium; maximal inhibition was 43 and 52%, respectively. Neither heparin nor nedocromil sodium affected the dose-response curve or the maximum response to Ach. The addition of the heparin preservative (benzyl alcohol) did not reverse ACh-induced contractions, or inhibit antigen-induced contractile responses. These results suggest that heparin blocks immunologically induced TSM contraction, without affecting the contractile response to the airway smooth muscle agonist, ACh. This action of heparin is similar to that of the anti-asthmatic nedocromil sodium and may be related to inhibition of mast cell mediator release.

Mohan's urethral valvotome: a new instrument

Electrothermic fulguration of posterior urethral valves with a resectoscope is difficult in newborns, especially in small for gestation date and premature newborns because of a small caliber urethra. This difficulty has prompted the innovation of the valvotome described. The outer diameter of the valvotome is 3 mm. and it can be easily introduced without stretching the urethra. This instrument has been used successfully in 8 patients to date. Patient age ranged from 3 days to 3 1/2 years with varying degrees of hydronephrosis and hydroureter. All patients have a good urinary stream with regression of the hydronephrosis and hydroureter.