Pearl of the Day: Clavicle Fractures

Clavicle Fractures - clavicle articulates with sternum proximally and acromion distally - protects adjacent lung, brachial plexus, subclavian and brachial blood vessels - mid-portion of clavicle is thinnest and does not contain ligamentous or muscular attachments - signs/symptoms: swelling, deformity, tenderness overlying clavicle; arm is slumped inward and downward; limited ROM at shoulder - diagnosis: usually standard shoulder and clavicle X-rays, but may require 45-degree cephalad tilt view or CT - management: emergent orthopedic consult for open fractures, fractures with neurovascular injuries, fractures with persistent skin tenting

Middle Third Clavicle Fractures - most common - usually managed nonoperatively - risk factors for nonunion: initial shortening > 2 cm, comminuted fracture, displaced fracture > 100%, significant trauma, female, elderly - management: immobilization with either sling or figure-of-eight brace for 4 - 8 weeks - orthopedic follow up in 2 - 3 days: high risk of malunion, severely comminuted or displaced fractures, athletes, professional impact, cosmetic concerns - orthopedic follow up in 1 - 2 weeks for conservative treatment

Distal Clavicle Fractures - type I: fracture is distal to coracoclavicular ligaments with ligaments intact - type II: fracture is distal to coracoclavicular ligaments with disruption of ligaments -> causes upward displacement of proximal aspect of clavicle - type III: intra-articular fractures through acromioclavicular joint - management: types I and III can be managed conservatively with sling immobilization and follow up in 1 - 2 weeks; type II may require operative intervention

Proximal Third Clavicle Fractures - associated with high-mechanism injuries and associated with intrathoracic trauma - diagnosis: CT (also to identify additional injuries) - management: emergent consultation for posteriorly displaced fractures that compromise mediastinal structures; immobilization for all other proximal third fractures - orthopedic follow up in 1 - 2 weeks for conservative treatment

Resources Tintinalli's Emergency Medicine, 8th Edition

Pearl of the Day: Complications of Vascular Access for Hemodialysis

Complications of Vascular Access for Hemodialysis- more frequent with autologous vein, polytetrafluorethylene, or bovine carotid artery graft (as opposed to native artery or vein) - account for more inpatient hospital days than any other complication of hemodialysis

Thrombosis and Stenosis - most common causes of inadequate dialysis flow (<300 mL/min) - grafts have higher rate of stenosis than fistulas - signs: loss of bruit or thrill over access - treatment: angiographic clot removal or angioplasty within 24 hours; direct injection of alteplase can be considered for thrombosis

Vascular Access Infections - 2 - 5% of AV fistulas, 10% of grafts - etiology: Staphylococcus aureus (most common), Gram-negative bacteria - signs/symptoms: hypotension, fever, leukocytosis - may not have pain, erythema, swelling, or discharge from access site - after 6 months, approximately 1/2 of patients with dialysis catheter develop bacteremia - diagnosis: peripheral and catheter blood cultures drawn simultaneously -> catheter is confirmed source if colony count is 4 times higher in catheter culture than peripheral culture - treatment: vancomycin IV (drug of choice) +/- gentamicin (if Gram-negative organisms suspected); consider access removal if fever for > 2 - 3 days

Hemorrhage - rare - causes: aneurysms, anastosmosis rupture, overanticoagulation

Management of Hemorrhage 1. manual pressure to puncture sites for 5 - 10 min and observe for 1 - 2 hours if ceased 2. apply pressure for 10 min using absorbable gelatin sponges soaked in reconstituted thrombin or chemical thrombotic (e.g., transexamic acid) 3. protamine 0.01 mg per unit of heparin dispensed during dialysis - if dose is unknown, protamine 10 - 20 mg is sufficient to reverse typical dose of heparin (usually 1000 to 2000 U) 4. desmopressin acetate 0.3 mcg/kg IV can be used as adjunct in consultation with nephrologist or vascular surgeon 5. consider placing figure-8 suture 6. tourniquet proximal to vascular access while awaiting urgent vascular surgery consultation

Vascular Access Aneurysms - caused by repeated punctures - usually asymptomatic, possibly occasional pain or impingement neuropathy - rarely rupture

Vascular Access Pseudoaneurysms - from subcutaneous extravasation of blood from puncture sites - signs: bleeding, infection at access site - diagnosis: arterial Dopper ultrasound studies - treatment: surgery

Vascular Insufficiency - usually occurs in extremity distal to vascular access - due to shunting of arterial blood to venous side of access - "steal syndrome" - signs/symptoms: exercise pain, nonhealing ulcers, cool/pulseless digits - diagnosis: Doppler ultrasound or angiography - treatment: surgery

High-output Heart Failure - occurs when >20% of cardiac output is diverted through access - signs/symptoms: Branham sign (drop in heart rate after temporary access occlusion) - diagnosis: Doppler ultrasound to measure flow rate - treatment: surgical banding of access

Resources Tintinalli's Emergency Medicine, 8th Edition

Pearl of the Day: Empyema

Empyema Background - pleural space infection with pus, positive Gram stain/culture, or parapneumonic effusion - predisposing factors: aspiration pneumonia, respiratory disease impairing ciliary function, alcoholism, malignancy, immuncompromise

Causes and Common Organisms - pneumonia -> Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenza - lung abscess, esophageal rupture -> mixed oropharyngeal anaerobes - thoracotomy -> Gram-negative bacilli - immunocompromised pneumonia -> tuberculosis, fungal infections - chest trauma -> S. aureus, Gram-negative bacilli - contiguous abdominal infection -> Gram-negative bacilli, anaerobes

Signs/Symptoms - unresolving fever, cough, dyspnea, pleuritic chest pain, malaise - weight loss, night sweats, anemia - decreased tactile fremitus, friction rub, dullness to percussion

Diagnosis - diagnostic criteria: aspiration of grossly purulent material on thoracentesis and at least one of the following: thoracentesis fluid with positive Gram stain or culture, pleural fluid glucose < 40 mg/dL, pH < 7.1, or LDH > 1000 IU/L

Stages of Disease 1. Exudative: <48 hours, free-flowing pleural effusion amenable to chest tube drainage 2. Fibrinopurulent: fibrin strands form in pleural fluid -> loculations; chest tube drainage is unlikely 3. Organizational: several weeks later; extensive fibrosis with "pleural peel" that restricts lung expansion

Treatment - treat underlying cause - definitive treatment: drainage + antibiotics - respiratory or cardiac distress -> thoracentesis - recommended antibiotics: piperacillin/tazobactam 3.375 - 4.5 g IV q6h or imipenem 0.5 - 1 g IV q6h - may add vancomycin for increased risk of MRSA (e.g., patients recently hospitalized, invasive medical device, from long-term healthcare facility, in contact sports, live in unsanitary conditions) - exudative empyema -> chest tube thoracostomy with antibiotics +/- intrapleural fibrinolytic agents if in fibrinopurulent stage - loculated empyema -> video-assisted thoracoscopic surgery - organizational stage -> surgical removal of fibrous peel

Resources Tintinalli's Emergency Medicine, 8th Edition