Tuesday, February 24, 2015

Scorpion Envenomation (Podcast)


This week, we are going to discuss another overlooked issue - "Scorpion Envenomation"
Fortunately, I did initial two years of my EM training at Christian Medical College, Vellore, Tamil Nadu where we used to get quite a bit of patients with Scorpion Sting/Envenomation.

Back in Vellore, whenever we used to talk about this issue, there was one name which always came up - "Dr. Himmatrao Bawaskar". He has done a ton of research on this and came up with an antidote for scorpion sting dropping the mortality down to <1% from 30%. His first individual paper titled “Diagnostic cardiac premonitory signs and symptoms of red scorpion sting” was published in The Lancet in 1982. 

It was in 1984, when he treated 126 patients with Prazosin; all of them survived. In 1986, in his paper in The Lancet - he put forward for the first time Prazosin as a physiological antidote for scorpion stings.

His work got recognition internationally as Prazosin's success was duplicated all over the world. This episode was not possible without mentioning about his exemplary work in this field. 

A message from Dr. Bawaskar,
We owe our learning, earning, and satisfaction to our ancestors (scientists) who blessed us with their research which gave us direction. It is our moral duty to repay them by engaging ourselves in, contributing to and publishing the research for the benefit of our future generations. This can be done only by performing our honest, sincere, and dedicated duty every single day. Never neglect what the patient or his relatives have to say since they are the sole reason of your existence as a doctor.”

I have focused on species found around Southern India.
This a really short one, just about 8 minutes. Check out the show notes.


Monday, February 16, 2015

HyperK - Get the ECG

Hello friends

This week we are gonna talk about something which we come across in the ED almost everyday.

We all learned to look for the ECG changes for hyperK and also how the changes correlate with the levels of potassium.

K levels        ECG changes

5.5 - 6.5       Tall tented T waves
6.5 - 7.5       Loss of P waves
7.5 - 8.5       Widening QRS
> 8.5            Sine Wave pattern, Ventricular Arrythmias

Well, Don't waste your time in memorising these changes and the corresponding potassium levels. Patients don't read textbooks and they don't follow this textbook pattern of ECG changes.

A potassium of 8 may not produce any ECG changes and at the same time Ventricular Fibrillation can be the first ECG change in hyperK. So if they have elevated K which concerns you, just go ahead and give them some calcium regardless of ECG changes. And if they have ECG changes with hyperK, be more aggressive with the correction.

HyperK often comes up with strange rhthyms and I learned this pearl from the EKG Guru "Amal Mattu" --> "Any bizarre EKG changes, think hyperKalemia and try some calcium". Lets hear it from the EKG GOD himself.

Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008 Dec;36(12):3246-51.

Tuesday, February 10, 2015

Penile Fracture : Is it possible?

Yes, Penile trauma can lead to PENILE FRACTURE. This is a rare injury, but as Emergency Physicians we need to know about this (presentation/Investigations and Rx) to liaise with the Urologists. Lets see how it presents and what we need to look for:

Fracture of the penis is a surgical emergency that results from blunt trauma to the erect penis.
When flaccid, the penis can withstand a certain amount of stress due to the thick tunica albuginea. However, when the penis is erect, the tunica albuginea stretches over the engorged corpora cavernosa, making it vulnerable to rupture when placed under significant strain. Unfortunately, medical care is often delayed, due to the embarrassing nature of the condition.

The majority of penile fractures result from vigorous vaginal intercourse, can also occur following manipulation of the penis during masturbation, and rarely, following trauma.

Classical history - i.e. vigorous sexual intercouse which is interrupted by sudden pain in the penis, often in association with a popping sound; this is followed by immediate detumescence, and swelling and bruising of the penis. Urinary symptoms such as dysuria, poor stream, urinary retention and meatal bleeding, may be seen if the injury involves the penile urethra.

On examination, an ‘egg-plant deformity’ of the penis is typically seen due to the combination of swelling of the penis, and bruising and deviation to the side opposite to the tear. The bruising is often contained within Buck’s fascia and therefore appears localised to the penile shaft. If the fascia has also been damaged, blood may track down into the scrotum, supra pubic area or the perineum.

On palpation, a hematoma may be located over the site of the tear, or the tear may be palpable as a defect; the 'rolling sign' (where the penile skin can be rolled above a firm immobile hematoma on the shaft) may also be present.

The diagnosis of penile fracture is mainly clinical. Investigations are warranted only if the clinical features are equivocal, if signs and symptoms suggestive of urethral injury are present, or if the patient presents late. Bilateral tears also warrant investigations, as the chance of urethral injury is much higher in these patients.

In such individuals, retrograde urethrography, cavernosography, ultrasonography and magnetic resonance imaging (MRI) may prove to be of use.

Retrograde urethrography is quick and inexpensive, and can easily identify urethral tears; however, current evidence does not support its routine use in all patients with penile fracture.

The technique of penile cavernosography involves injection of contrast medium into the corpora cavernosa by direct injection. A series of fluoroscopic images is subsequently obtained, with the presence of contrast leakage across the tunica albuginea being confirmatory of the condition; this will also help localize the exact location of the tear. Note that the procedure is not without complications; priapism, allergic reactions and fibrosis of the corpus cavernosa have been observed.

Ultrasound imaging is less informative but may prove advantageous in pediatric patients; while MRI has the ability to visualize the anatomy clearly, the time and cost may be an issue.

From the ED Management perspective, we need to give them adequate analgesia (Meds, Cold Compression) and get Urology ASAP. Most authorities agree that urgent surgical exploration and repair is the first-line treatment in these patients. Overall, surgical repair has an excellent outcome.

Complications: permanent penile deviation due to fibrosis, fistulae formation between the urethra and skin or the corpora cavernosa, urethral strictures, painful erections, and erectile dysfunction.

Conservative measures such as ice packs, foley catheterization and anti-inflammatory agents have been used in the past, success rates were low, and complication rates high. Now, these are only used as an adjunct to surgery.

Take home:
1. Penile fracture is a clinical diagnosis (Investigate only if C/F equivocal, suspected uretheral injury, delayed presentation)
2. The presence of associated urinary symptoms should raise strong suspicion of urethral injury.
3. Urgent surgical exploration and repair is the cornerstone of management.

1. EKE N.. Fracture of the penis. Br J Surg [online] 2002 May, 89(5):555-565 [viewed 20 June 2014] Available from: doi:10.1046/j.1365-2168.2002.02075.x
2. JACK GS, GARRAWAY I, REZNICHEK R, RAJFER J. Current Treatment Options for Penile Fractures Rev Urol [online] 2004, 6(3):114-120 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472832
3. MURRAY KATIE S., GILBERT MICHAEL, RICCI LAWRENCE R., KHARE NARENDRA, BROGHAMMER JOSHUA. Penile fracture and magnetic resonance imaging. Int. braz j urol. [online] 2012 April, 38(2):287-288 [viewed 20 June 2014] Available from: doi:10.1590/S1677-55382012000200019

4. Amer, Tarik, et al. "Penile Fracture: A Meta-Analysis." Urologia internationalis96.3 (2016): 315-329.

Wednesday, February 4, 2015

Snake Envenomation (Podcast)

Hello friends,

This week, we are going to discuss a problem which is a major public health issue especially in and around SE Asia. It affects thousands of people but treatment protocols are not in place. This podcast will give you information which you need at the bedside when you come across these critically ill victims.

This information presented here comes from the national snakebite protocol (India) and WHO guidelines for snake bites in SE Asia. Checkout the show notes and listen to the podcast.