EM Quick Hits 33 Polytrauma Tips & Tricks, Toxic Megacolon, ECG in PE, Patch Calls, CT Before LP, Nebulized Ketamine

Topics in this EM Quick Hits podcast

Anand Swaminathan on tips and tricks in polytrauma (0:38)

Rohit Mohindra on diagnosis and management of toxic megacolon (7:31)

Jesse McLaren on ECG in pulmonary embolism (12:53)

Victoria Myers & Morgan Hillier on approach to the patch call (19:19)

Brit Long on when to do a CT head before LP (28:00)

Salim Rezaie on ketaBAN study (34:57)



Podcast production, editing and sound design by Anton Helman

Podcast content by Anand Swaminathan, Rohit Mohindra, Jesse McLaren, Victoria Myers, Morgan Hillier, Brit Liong and Salim Rezaie

Written summary & blog post by Kate Dillon, Anton Helman and Brit Long

Cite this podcast as: Helman, A., Swaminathan, A., Mohindra, R., McLaren, J., Myers, V. Hillier, M. EM Quick  Hits 33 - Polytrauma Tips & Tricks, Toxic Megacolon, ECG in PE, Patch Calls, CT Before LP, Nebulized Ketamine. Emergency Medicine Cases. October, 2021. https://emergencymedicinecases.com/em-quick-hits-october-2021/. Accessed [date].

Tips and tricks to make your trauma care a bit smoother



* To secure a chest tube to the chest wall quickly and easily, use the ETT holder as a temporary measure



Source: Vanessa Cardy, Twitter



* If the FAST is negative and you still suspect intra-abdominal bleeding, but the patient cannot get to the CT scanner for whatever reason, scrutinize the tip of the liver and the left and right sub-diaphragmatic spaces as blood will often be seen first on PoCUS in these areas, especially if the patient is placed into Trendelenburg



Fluid in the subdiaphragmatic space. Source: Radiologykey.com



* Place a pelvic binder on the stretcher before the patient arrives and and secure it on the patient ASAP, before imaging, if they are hemodynamically unstable without an obvious cause; but don't forget to shoot a pelvic x-ray soon thereafter in case the binder has not fully reduced the fracture

* On the initial CXR do not forget to look at the bones/joints as well as the thorax as an unexpected shoulder dislocation for example, should ideally be reduced before the patient goes to the O.R. for another reason

* For patients who receive ketamine during their trauma resuscitation, consider starting a ketamine drip or adding a benzodiazepine (if they are hemodynamically stable) to avoid an emergence reaction from the ketamine during transport



Toxic megacolon: A tricky diagnosis



* Definition: acute colonic dilatation >6cm involving at least the transverse colon, with signs of systemic illness

* Common etiologies: IBD, C.Difficile colitis, CMV or parasite infections, ischemic colitis, lymphoma

* Risk Factors: age >40, anticholinergic or narcotic medication use, electrolyte abnormalities, barium enemas or recent colonoscopy

* Presentation: abdominal pain (not typically peritonitic early on), distension, bloody diarrhea, metabolic acidosis/alkalosis, electrolyte disturbances, elevated WBC (Note: steroids can mask symptoms)

* Management: treat underlying cause, IV fluids, antibiotics, pressors as needed, steroids (only after consultation with specialist service)

* Indications for Surgery: necrosis, perforation, ischemia, abdominal compartment syndrome, end organ injury or worsening clinical status



=>Bottom line: the triad of bloody diarrhea, belly pain and distention in someone with a colitis history of any kind, especially if they’ve had a recent colonoscopy,