VOTW: HAND me the probe and let me FLEX my POCUS skills!

HPI: 44 year old male with no PMH presenting to the ED for worsening left 3rd finger pain and swelling after sustaining trauma and laceration to affected area 9 days ago. The team's differential included finger cellulitis, abscess, flexor tenosynovitis, and underlying fracture.

The patient’s hand was placed in a water bath and the following images were obtained using the linear probe:

POCUS evaluation of flexor tenosynovitis

1. Use a water barrier between probe and fingers to improve image quality(ex: plastic basin, emesis bag, glove filled with water, bag of NS/LR).

2. Use the linear probe on the flexor side of the fingers.

3. Evaluate the flexor tendon which overlies the bone. Look for fluid (anechoic) within the flexor tendon sheath surrounding the flexor tendon. Remember, tendons are anisotropic which means they can appear hyperechoic or hypoechoic depending on the angle of your probe. Hypoechoic areas can be confused for edema so it is important to fan through the entire tendon. If the area of concern remains consistently hypoechoic, that is more concerning for fluid/edema.

4. The tendon may also appear thicker compared to fingers. If you apply color doppler, you may see surrounding hyperemia.

5. You can scan an unaffected finger also for real time comparison on what “normal” should look like.

Case conclusion: After this bedside POCUS, orthopedics team was consulted for concern for flexor tenosynovitis!

Learn more about POCUS findings for flexor tenosynovitis here:

1. https://coreultrasound.com/fts/

2. https://www.ultrasoundgel.org/posts/q08ayJgg3rmHtiQgs9n82w

POTD: Putting a pause on "GCS less than 8 - intubate"

Hello all and welcome to my final Trauma Tuesday POTD!

Today we'll be discussing something that many of us were taught in medical school about trauma - "GCS less than 8 - intubate". This phrase has also been said about patients who are altered for other reasons - infection, tox, etc.

The thought process behind this is that patients who have a low GCS are at risk for aspiration, and we should secure the airway to prevent this. In trauma, it's thought that patients with low GCS have severe enough brain injury that they are at risk for depressed respirations, and intubation is done to prevent this. 

Is GCS < 8 associated with decreased airway reflexes?

A study showed that 22% of patients with GCS of 15 had absent gag reflexes, 37% in GCS of 9-14, and 63% in patients with GCS < 8. So, it does appear that lower GCS has a higher percentage of absent gag reflexes, but 22% of patients with a GCS of 15 is a pretty high number to be solely using GCS as our measure. 

Is it associated with more aspiration events?

A prospective study of 73 ED patients showed that none of the patients with a GCS <8 aspirated or required intubation. Actually, the only patient who required intubation in that study had a GCS of 12. 

However, there have not been any RCTs studying this. A systematic review on this topic showed that there isn't enough evidence to draw a conclusion. 

Decreased GCS can be due to a temporary cause, such as alcohol intoxication, as we often see. How often are we intubating someone for alcohol intox? Not frequently. So, it's important that we consider the full clinical picture before jumping to intubation. 

In conclusion - when we need a quick and dirty guide, GCS < 8 is generally the cutoff that's used for us to consider intubation. However, it's important to consider the whole clinical picture and make sure the patient is not getting intubated unnecessarily and suffering the potential side effects of intubation. Also, conversely, GCS > 8 doesn't always mean that the patient is protecting their airway!

References:

Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-455. doi:10.1016/j.jemermed.2008.11.026

Orso D, Vetrugno L, Federici N, D'Andrea N, Bove T. Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review. Scand J Trauma Resusc Emerg Med. 2020;28(1):116. Published 2020 Dec 10. doi:10.1186/s13049-020-00814-w

Ribeiro SCDC. Decreased Glasgow Coma Scale score in medical patients as an indicator for intubation in the Emergency Department: Why are we doing it?. Clinics (Sao Paulo). 2021;76:e2282. Published 2021 Mar 8. doi:10.6061/clinics/2021/e2282

Freund Y, Viglino D, Cachanado M, et al. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023;330(23):2267-2274. doi:10.1001/jama.2023.24391

POTD: De-escalating the agitated patient

Today's POTD will be on de-escalating the agitated patient in the emergency department. We frequently encounter patients who are agitated for a variety of reasons, so let's talk about how we can provide the best possible outcomes for the staff and for the patient in these situations. 

When approaching an agitated patient, approach with 4 main objectives:

1) Ensure safety of patient, staff, and others in the area

2) Help the patient manage their emotions and distress and maintain or regain control of their behavior

3) Avoid use of restraints if possible

4) Avoid coercive interventions that escalate agitation

Really, the biggest thing is maintaining patient and staff safety. Make a quick assessment as to whether this patient is mildly, moderately, or severely agitated. 

If your patient is mildly or moderately agitated, verbal de-escalation should typically be your first go-to. Physical and chemical restraints have both been found to increase length of stay and are associated with higher likelihood of psychiatric admission, so if verbal de-escalation is a safe option in your patient encounter, it should be attempted first. 

Guidelines for verbal de-escalation

Richmond et al. (2012) published ten domains for de-escalation that I find to be helpful. They are summarized in this table:

1: Respect personal space

Maintain at least 2 arms' length of distance between you and the patient. Also, make sure you know where the exits are, and make sure the patient is not positioned between you and the closest exit. 

2: Do not be provocative

Pay attention to your body language. Be calm and avoid clenching your fists or concealing your hands. 

3: Establish verbal contact
Have one main point of contact for the patient to avoid confusion and further agitation.

4: Be concise

Try to keep the information you're conveying simple, as agitated patients may not be able to process complex information quickly.

5: Identify wants and feelings

Use open-ended statements to understand what it is that the patient wishes to get out of the encounter.

6: Listen closely to what the patient is saying

Use active listening to understand what the patient is saying.

7: Agree or agree to disagree

Find something about the patient's position to agree with - even if you don't agree with their whole statement. 

8: Lay down the law and set clear limits

The patient should know about acceptable and unacceptable behaviors, and boundaries should be clearly set.

9: Offer choices and optimism

The ability to choose can empower a patient.

10: Debrief the patient and staff

Have a discussion amongst the staff about what the plan is if the patient continues to be agitated or escalates their behavior. Also, discuss with the patient and family why certain measures were necessary. 

If verbal de-escalation doesn't work or is not safe to attempt:

Physical or chemical restraints can be used. Physical restraints should never be used on their own without chemical sedation. 

I won't go into all the nitty gritty about physical/chemical restraints in this POTD, but generally, if you're having to sedate the patient or physically restrain them, make sure the patient is somewhere visible to a staff member at all times and their ABCs are being monitored. 

Finally, know your resources!

Luckily for us, we have an on-site ED psychiatry team, mental health workers, and security who are all trained in how to manage an agitated patient, so if you ever find yourself in a potentially unsafe situation, know your resources and don't go into it alone. 

References:

Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. doi:10.5811/westjem.2011.9.6864

https://www.crisisprevention.com/blog/general/de-escalation-tips/

https://www.crisisprevention.com/en-GB/blog/general/cpi-top-10-de-escalation-tips/

https://litfl.com/de-escalation/

https://emergencymedicinecases.com/emergency-management-agitated-patient/