EMGuidewire's Podcast

Join the EMGuideWire team as they explore the use of Point-of-Care Ultrasound for the evaluation of patients with possible COVID-19 infection. Dr. Patrick Lam, from the Carolinas Medical Center Department of Emergency Medicine Department Division of Ultrasound, will guide us on the techniques and pro-tips for this application.

Join EMGuideWire team as they listen in to EM Residency Conference at Carolinas Medical Center (in Charlotte, NC) and learn from Emily MacNeill, MD as she discusses "What Happens When a Disease Management System Crashes into a Public Health Crisis."

Join the EMGuideWire team as they learn from one of the world's foremost experts in neurologic emergencies, Dr. Andrew Asimos. This episode will address the Neurologic Manifestations and Complications of the COVID-19 Infection.

Join the EMGuideWire team as they listen to Dr. Geib discuss how to recognize and manage Hydroxychloroquine toxicity, which may become more prevalent during the current COVID-19 pandemic.

Join the EMGuideWire team as they learn from Critical Care fellow, Dr. Russell Trigonis while he addresses the important aspects of managing ARDS in patients with COVID-19 infections.

OB Trauma Core Concepts

• Physiologic changes of pregnancy: physiologic anemia, decreased SVR, increased HR, increased RR, and pelvic vessel engorgement
• Traumatic complications: placental abruption, preterm labor (PTL), uterine rupture, and pelvic fx
• Abruption triad = abd pain, large for dates uterus, vaginal bleeding
• Perform cervical check to eval for PTL
• Obtain Type and Screen and KB test
• Give Rhogam if mom is Rh neg. 50 mcg if 12 wks
• Check fetal HR after E-FAST, nml is 120-160

-Travis Barlock

Join the EMGuideWire Crew from CMC EM Residency Program as they discuss Ludwig's Angina and the management Priorities!!!

BACKGROUND

• Angina = "Strangling"
• Bilateral infection of submental, submandibular, and sublingual spaces
• 70-85% of cases arise from odontogenic source
  • Periapical abscesses of mandibular molars
  • Piercings (frenulum)
  • URI more common cause in children

• Source of infection often polymicrobial
  • Most commonly viridans; also Staphylococcus and Bacteroides species
• Patients usually 20-60 years-old; more common in males1
• Mortality in treated Ludwig's Angina = 8%7
• ***Airway compromise = leading cause of death8

Who Is At Risk?

• Diabetes mellitus
• Chronic alcohol abuse
• IVDA
• HIV/AIDS
• Malnutrition
• Poor oral hygiene
• Smokers

Anatomy & Pathophysiology

• Mylohyoid subdivides submandibular space:
  • Sublingual space
  • Submaxillary (submylohyoid) space
• Infection extends posteriorly and superiorly, elevating tongue against hypopharynx
• If left untreated, can extend inferiorly to retropharyngeal space and into superior mediastinum3

Clinical Signs & Symptoms

• Dysphagia
• Odynophagia
• Trismus
• Edema of upper midline neck and floor of mouth
  • Raised tongue
• "Woody" or brawny texture to floor of mouth with visible swelling and erythema

Late Findings

• Drooling
• Tongue protrusion
• Trismus
• Dysphonia
• Cyanosis
• Acute laryngospasm
• Stridor
• Patients may demonstrate signs of systemic toxicity → fever, tachycardia, and hypotension

How Do I Make the Diagnosis?

• Clinically!
• Consider CT head/neck
  • Can help evaluate extent of infection if clinical situation persists
• CBC
• Chemistry
• Lactate
• Blood Cultures

Management

• Emergent ENT/OMFS consult for I&D in OR and extraction of dentition if source is dental abscess
• Airway Management
  • Intubation will be VERY difficult due to trismus and posterior pharyngeal extension
  • Ideal situation = awake fiberoptic intubation in OR
• ALWAYS have a surgical airway ready as your back up plan
• Blind insertion devices (e.g. intubating LMA) are NOT recommended

Management - Antibiotics

• Must cover typical polymicrobial oral flora
• Immunocompetent
  • 3rd-generation Cephalosporin + (Clindamycin or Metronidazole)
  • Ampicillin/Sulbactam
  • Penicillin G + Metronidazole
  • Clindamycin (allergic to penicillin)
• Immunocompromised → *Need MRSA and GNR coverage!3
  • Cefepime + Metronidazole
  • Meropenem
  • Piperacillin-tazobactam
  • Add Vancomycin if concern for MRSA risk factors

• Steroids
  • Dexamethasone 10 mg IV
    • Thought to chemically decompress for airway protection and increase antibiotic penetration6
  • Nebulized epinephrine
  • Resuscitation and pain control

Complications

• Intracranial infections (e.g. CST, brain abscess)
• IJ thrombophlebitis (Lemirre's Syndrome)
• Mediastinitis
• Mandibular osteomyelitis
• Empyema

Pearls

Three characteristics of Ludwig's angina can be remembered as the 3 Fs:

• Feared
• Often Fatal
• Rarely Fluctuant
• ABCs—Sit upright
• Early notification of ENT/OMFS and anesthesia to facilitate definitive airway management
• Arrange for the patient to be admitted to ICU

Priorities!!!

• Secure the airway EARLY!
  • Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway
• Prevent the development of septic shock and multi-organ failure — give antibiotics early

References

1. Lin HW, O'Neil A, Cunningham MJ. Ludwig's Angina in the Pediatric Population. Clin Pediatr (Phila) 2009;48:583-7.
2. Baez-Pravia, Orville V. et al. "Should We Consider IgG Hypogammaglobulinemia a Risk Factor for Severe Complications of Ludwig Angina?: A Case Report and Review of the Literature." Medicine. 2017;96(47):e8708.
3. Pandey M, Kaur M, Sanwal M, Jain A, Sinha SK. Ludwig's Angina in children anesthesiologist's nightmare: Case series and review of literature. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):406-409.
4. Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig's Angina Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73.
5. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110: 1051, 2001.
6. Saifeldeen K, R Evans. Ludwig's Angina. Emerg Med J 2004; 21: 242-243
7. Nanda N, Zalzal HG, Borah Gl. Negative-Pressure Wound Therapy for Ludwig's Angina: A Case Series.Plast Reconstr Surg Glob Open2017 Nov 7;5(11):e1561.
8. Pak S, Cha D, Meyer C, Dee C, Fershko A.Ludwig's Angina. Cureus. 2017 Aug 21;9(8):e1588.

Join the EMGuideWire team as they discuss Superior Vena Cava Syndrome!

Shownotes:

Definition:

• Any condition leading to obstruction of blood flow through the SVC

Pathophysiology:

• Pathology in adjacent anatomy (lung, lymph node, thymus, mediastinum) or within the SVC itself obstructs venous return to the right atrium. As the SVC is compressed, venous collaterals form alternative pathways returning blood to the right atrium which can dilate over several weeks. As a result, upper body venous pressure increases, which in extreme cases lead to airway congestion and venous cerebrovascular congestion and edema. Hemomdynamic compromise is most often by direct compression of the heart, not from SVC obstruction.

Risk factors:

• Indwelling device through the SVC (Central line, dialysis catheter, pacemaker)
• Lung cancer
• Lymphoma
• Thymoma

Presentation:

• Signs – plethoric appearance, dilated neck and chest veins, swollen face/neck/chest
• Symptoms – congestive symptoms (head fullness, swelling), cardiopulmonary symptoms (chest pain, dyspnea, stridor, hoarseness), and neurologic symptoms (headache, confusion, obtundation, visual disturbances)

Work-up:

• Is the patient unstalbe? Do they have severe SVC?
  • If yes, secure airway, support breathing, support circulation
  • Consult vascular/cardiothoracic surgery
• If patient is stable, then:
  • Confirm diagnosis and evaluate for malignant obstruction
    • CBC, CMP, PT/INR, CXR, CT chest w/contrast
  • Does the patient have a malignant obstruction or thrombosis?
    • Yes -> consult heme/onc and admit
    • No -> observe in ED

References:

García Mónaco R, Bertoni H, Pallota G, et al. Use of self-expanding vascular endoprostheses in superior vena cava syndrome. Eur J Cardiothorac Surg 2003; 24:208.

Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore) 2006; 85:37.

Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena caval obstruction. Is it a medical emergency? Am J Med 1981; 70:1169.

Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862.

October was Domestic Violence month and in an effort to help highlight this very important topic, join Drs. Salzman, Dragoo, and Richardson from Carolinas Emergency Medicine Residency while they discuss the very important presentation of Strangulation. This is not a mere gesture of power, it may be our last opportunity to save this patient's life!

Pearls

• Strangulation victims are 750% more likely to become a homicide victim.
• Strangulation is not choking. Call it what it is.
• External exam findings are often not present and do not rule out internal injury.
• History is key. Look for neck pain, dizziness, vision/hearing changes, dysphagia, and SOB.
• Most common internal injury is hyoid fracture.
• Suspect strangulation? Get CTA neck. Neuro findings? Get non-con CT head + MRI brain.

Summarized by Travis Barlock, MD PGY-1

Join the EMGuideWire crew as they discuss some tips and pearls on how to skillfully run a medical resuscitation.

Pearls

• Preparation is everything. Get your staff, and get your stuff!
• Call out names, be redundant, and say what you are thinking out loud.
• Don't go for the tube! Supraglottic airways are quicker and safer!
• High quality compressions are life saving.
• V-tach and V-fib are usually ischemic. PEA is usually non-cardiac.
• PEA? Is it Wide or Narrow? Narrow - think procedural. Wide - think chemical.
• Ultrasound is your friend. RV strain, pericardial tamponade, and pneumothorax can all be quickly found!
• Wide complex (but not V-tach) is hyperkalemia until proven otherwise. Provide Calcium Chloride (not gluconate).

Summarized by Travis Barlock, MD PGY-1