New SJRHEM Dalhousie Course – Debriefing Skills for Simulation – The Basics

New SJRHEM Dalhousie Course – Debriefing Skills for Simulation – The Basics

When Is It?

8th-9th February 2018

Who is this for?

If you are interested in using simulation for education in healthcare, then this is for you! We aim to give you the basic skills needed to start debriefing in your own institution. This is a practical course with lots of opportunities to debrief.

 

 

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RCP – Dental Block, ER Doc

Another Solution for Dental Pain when “NSAIDs do nothing for me Doc!

Resident Clinical Pearl (RCP) – Guest Resident Edition

Peter Leighton,  R3 FMEM 2+1, Dalhousie University, Halifax

Reviewed by Dr. David Lewis

 

Dental pain is a common problem encountered in the Emergency Department (ED), yet physicians in the ED often have no to little education regarding management of dental pain. Depending on where you read, dental pain complaints account for 1-5% of emergency department visits. A common approach consists of looking for infection and providing a prescription for antibiotics and NSAIDs along with recommendation to follow up with a dentist. Although, there is good evidence for NSAIDs in dental pain, some patients find that it does not help enough with their pain or they have contraindications to NSAIDs. This often leads to the prescription of opioids for dental pain. Given the recent opioid crisis in Canada, there has been a search for other forms of management of toothache/dental pain in the ED. Insert the dental block! It’s fast, easy, and provides good pain relief, while providing a chance for patients to book an appointment to see their dentist the following day. There has been some evidence that this method achieves good pain control for the patient and may help lower opioid prescriptions in the ED for dental pain.

There are essentially 2 blocks you will need to know:

  • The Inferior Alveolar Nerve Block (Mandibular teeth)
  • Supraperiosteal Infiltrations (Maxillary teeth)

Indications

  • Dental abscess
  • Toothache
  • Pulpitis
  • Root impaction
  • Dry socket
  • Post-extraction pain
  • Trauma – lacerations, fractures

Contraindications

  • Allergy to local anesthetic
  • Distortion of landmark
  • Uncooperative patient
  • Injecting through infected tissue – may cause bacteremia
  • Cardiac congenital abnormalities and mechanical valves – require prophylaxis for endocarditis
  • Coagulopathy

What you will need

  • Syringe
  • Needle – 25-27 gauge and 1.5 inch
  • Lidocaine with epinephrine (max dose 7 mg/kg)
  • Bupivicaine +/- epinephrine (max dose 2 mg/kg)
  • Non-sterile gloves
  • Suction and light source may be required

 

The combination of Lidocaine and Bupivicaine allow the mix of immediate analgesia from the Lidocaine and prolonged duration of action by the Bupivicaine. The addition of Epinephine will also increase duration of effect. This combination should provide approximately 8 or more hours of anesthetic effect.

 

Technique:

Supraperiosteal Infiltration

Pull out patient’s cheek laterally to have a good view of the patient’s tooth and gingiva. Insert needle into the mucobuccal fold just above the apex of the tooth to be anesthetized. Keep the needle parallel to the tooth and insert it a few millimeters until needle tip is above the apex of the tooth. If bone is contracted, withdraw 1-2mm and aspirate. If no blood is aspirated then inject 1-2 ml of anesthetic. If blood is aspirated then withdraw and reposition.

 

From: www.ebmedicine.net – click here for full article

 


 

Inferior Alveolar Nerve Block

Place your thumb in the coronoid (mandibular) notch of the patient and extend the patient’s cheek out laterally so you can see the patient’s pterygomandibular raphe. Place your syringe in the opposite corner of the mouth and with your needle at the middle level of the raphe, aim just lateral to the raphe. Insert your needle approx. 2-2.5cm until you hit bone. Pull back a millimeter and aspirate twice. If any blood on aspiration, withdraw and reposition more laterally. If no blood with aspiration then inject 1-2ml of anesthetic.

 

From: Jason Kim’s Blog – click here for full article

 

 

From: www.ebmedicine.net – click here for full article

 


 

Videos:

Please see the dentistry videos below to review anatomical landmarks of both techniques:

 

Supraperiosteal technique

 

Inferior Alveolar Block

 


 

References

 

  1. Complications, diagnosis, and treatment of odontogenic infections [Internet]; c2017 [cited 2017 November 10]. Available from: https://www.uptodate.com/contents/complications-diagnosis-and-treatment-of-odontogenic-infections?source=search_result&search=dental%20pain&selectedTitle=1~150.
  2. Fixing Faces Painlessly: Facial Anesthesia In Emergency Medicine [Internet]; c2017 [cited 2017 November 12]. Available from: https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=207&seg_id=4229
  3. Fox TR, Li J, Stevens S, Tippie T. A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Annals of Emergency Medicine 2013;62(3):237-40.
  4. IA with a Short Needle [Internet]; c2015 [cited 2017 November 10]. Available from: https://www.youtube.com/watch?v=1Mf3f0XmsqI.
  5. 5. Local Infiltration [Internet]; c2014 [cited 2015 November 10]. Available from: https://www.youtube.com/watch?v=Y2NSuxd7j_g.
  6. How I learned to love dental blocks [Internet]; c2014 [cited 2017 November 10]. Available from: http://www.clinicaladvisor.com/the-waiting-room/dental-blocks-useful-in-emergency-medicine/article/382951/.
  7. M2E Too! Mellick’s Multimedia EduBlog [Internet]; c2014 [cited 2017 November 10]. Available from: http://journals.lww.com/em-news/blog/M2E/pages/post.aspx?PostID=32.
  8. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice. J Am Dent Assoc 2013 Aug;144(8):898-908.
  9. Okunseri C, Dionne RA, Gordon SM, Okunseri E, Szabo A. Prescription of opioid analgesics for nontraumatic dental conditions in emergency departments. Drug Alcohol Depend 2015 Nov 1;156:261-6.
  10. Patel NA, Afshar S. Addressing the high rate of opioid prescriptions for dental pain in the emergency department. Am J Emerg Med 2017 Jul 3.
  11. Oral Nerve Block [Internet]; c2016 [cited 2017 November 10]. Available from: https://emedicine.medscape.com/article/82850-overview#a1.
  12. Dental Pain in the ED: Big Solution in a Small Package [Internet]; c2005 [cited 2017 November 10]. Available from: http://journals.lww.com/em-news/Fulltext/2005/06000/Dental_Pain_in_the_ED__Big_Solution_in_a_Small.12.aspx.

 

 

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SJRHEM Journal Club Report Oct 2017

SJRHEM Journal Club Report Oct 2017

Allyson Cornelis, R1 iFMEM

Hosted by Dr Andrew Lohoar


Abstract:

Idarucizumab for Dabigatran Reversal — Full Cohort Analysis

Charles V. Pollack, Jr., M.D., Paul A. Reilly, Ph.D., Joanne van Ryn, Ph.D., John W. Eikelboom, M.B., B.S., Stephan Glund, Ph.D., Richard A. Bernstein, M.D., Ph.D., Robert Dubiel, Pharm.D., Menno V. Huisman, M.D., Ph.D., Elaine M. Hylek, M.D., Chak-Wah Kam, M.D., Pieter W. Kamphuisen, M.D., Ph.D., Jörg Kreuzer, M.D., Jerrold H. Levy, M.D., Gordon Royle, M.D., Frank W. Sellke, M.D., Joachim Stangier, Ph.D., Thorsten Steiner, M.D., Peter Verhamme, M.D., Bushi Wang, Ph.D., Laura Young, M.D., and Jeffrey I. Weitz, M.D.

N Engl J Med 2017; 377:431-441August 3, 2017DOI: 10.1056/NEJMoa1707278

 

BACKGROUND
Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran.

METHODS
We performed a multicenter, prospective, open-label study to determine whether 5 g of intravenous idarucizumab would be able to reverse the anticoagulant effect of dabigatran in patients who had uncontrolled bleeding (group A) or were about to undergo an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the diluted thrombin time or ecarin clotting time. Secondary end points included the restoration of hemostasis and safety measures.

RESULTS
A total of 503 patients were enrolled: 301 in group A, and 202 in group B. The median maximum percentage reversal of dabigatran was 100% (95% confidence interval, 100 to 100), on the basis of either the diluted thrombin time or the ecarin clotting time. In group A, 137 patients (45.5%) presented with gastrointestinal bleeding and 98 (32.6%) presented with intracranial hemorrhage; among the patients who could be assessed, the median time to the cessation of bleeding was 2.5 hours. In group B, the median time to the initiation of the intended procedure was 1.6 hours; periprocedural hemostasis was assessed as normal in 93.4% of the patients, mildly abnormal in 5.1%, and moderately abnormal in 1.5%. At 90 days, thrombotic events had occurred in 6.3% of the patients in group A and in 7.4% in group B, and the mortality rate was 18.8% and 18.9%, respectively. There were no serious adverse safety signals.

CONCLUSIONS
In emergency situations, idarucizumab rapidly, durably, and safely reversed the anticoagulant effect of dabigatran. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.)

 

http://www.nejm.org/doi/full/10.1056/NEJMoa1707278

 


SJRHEM Journal Club Report

 

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EM Reflections – October 2017

Thanks to Dr Joanna Middleton for leading the discussion this month

Edited by Dr David Lewis

Top tips from this month’s rounds:

  1. Imaging reports can underestimate the clinical impact of an incidental finding

  2. Neuro ICU in the Emergency Department?

 


Imaging reports can underestimate the clinical impact of an incidental finding

Not all benign conditions have a benign outcome. A CT report will occasionally underestimate the clinical impact of an incidental finding. Its always worth reviewing the images yourself.

For example – a report might read – “No acute bleed or infarct, incidental finding of frontal bone fibrous dysplasia” –  may sound innocuous and unrelated to the patient’s headache, until you review the scans yourself:

 

Fibrous dysplasia is a benign condition which can present with new craniofacial asymmetry. Whilst the condition itself may be benign, the location and speed of growth can result in symptoms, especially headache and even cranial nerve compression.

Clinical Guidelines for managing craniofacial fibrous dysplasia

 


Neuro ICU in the Emergency Department?

 

Management of Intracranial Hemorrhage in the Emergency Department can be complex. The diagnosis is usually straightforward with CT (providing it has been considered as a possibility – subarachnoid hemorrhage can present with syncope alone) and the broad category of bleed determined by the history, patient age, CT appearance, etc.

ED Management will depend on the category of bleed (Primary ICH, Subdural, Epidural, Traumatic SAH, Spontaneous SAH).

From ALIEM.com, click here for the full article

 

Initial management of intracranial hemorrhage can be simplified / summarized as follows:

Airway – ET Intubation if GCS < 9

Breathing – Ventilate if GCS < 9 (SaO2 >94%, ETCO2 35-45 mmHg)

Circulation

  1. Stop the bleeding
    1. Neurosurgery (see here for indications)
    2. Reverse anticoagulation
    3. ?Tranexamic acid
  2. Maintain an adequate cerebral perfusion pressure (CPP) to ensure adequate tissue oxygenation
    1. CPP = Mean Arterial Pressure (MAP) – Intracranial Pressure (ICP)
      1. Seems simple enough? – ensure the patient’s blood pressure is high enough to overcome the ICP
    2. However, the optimal CPP following acute brain injury is not known (general consensus suggest 50-70 mmHg)
      1. In the normal brain CPP is maintained by autoregualtion
      2. Autoregulation is less effective after brain injury
      3. If the CPP is too low brain hypoxia occurs
      4. If the CPP is too high there may be a risk of hematoma expansion
    3. However, it’s not easy to measure the ICP
      1. Methods of non-invasive ICP estimation:
        1. Level of consciousness
        2. Papilledema
        3. CT appearances
        4. Transcranial doppler
        5. Sonographic Optic Nerve Sheath Diameter
        6. Lots of others
        7. None of these are perfect
      2. Invasive ICP measurement
        1. External Ventricular Drain – Neurosurgical procedure
        2. Setting up the EVD and measuring ICP requires experienced nursing staff (see below)
    4. Even measuring the MAP is not without its own problems in the ED
      1. MAP = (Systolic BP + 2(Diastolic BP))/3
      2. However non invasive measurement of MAP (based on SBP and DBP peripheral sphygmomanometry) is not accurate.
      3. An accurate measurement of MAP requires invasive monitoring via an arterial line.
    5. Assuming that we are able to accurately measure ICP and MAP, there is then the question of how to adjust these values reliably via therapeutic interventions.
      1. ICP Management (Normal = 0-15, Goal < 20)
        1. Patient position, head up
        2. Sedation and paralysis, if patient aggitated
        3. Mannitol – potential risk of acute kidney failure in prolonged use
        4. Hyperventilation – will also reduce cerebral blood flow – so PaCO2 no lower than 35 mmHg
        5. CSF Drainage : 
        6. Hypothermia
      2. MAP Management
        1. IV Fluid (crystalloid vs colloid?)
        2. Diuretics / Antihypertensives vs Inotropes
        3. A very detailed guide to blood pressure management in stroke can be viewed here: BP-Stroke


I suspect that most emergency physicians/nurses are wondering whether this level of care falls within their remit. In most hospitals the answer will be NO, these cases are stabilised and managed in an Intensive Care Unit. However, there are occasions when this level of care is required prior to transfer to another unit/hospital, in which case it is likely that the care will be directed by the local neurosurgeon / neurointensivist and the receiving specialists.


EVD Drainage System and ICP Monitoring

 

Suggest ICP Protocol from Vancouver General ICU

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CME QUIZ

 

ED Reflections - CME Quiz - Oct 2017

ED Reflections – CME Quiz – Oct 2017

 


 


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New SJRHEM Course – Debriefing Skills for Simulation – The Basics

New SJRHEM Course – Debriefing Skills for Simulation – The Basics

Who is this for?

If you are interested in using simulation for education in healthcare, then this is for you! We aim to give you the basic skills needed to start debriefing in your own institution. This is a practical course with lots of opportunities to debrief.

 

Download (PDF, 254KB)

 

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SJRHEM Research Report – September 2017

 

Summer 2017 has been productive for the Horizon / Dal NB emergency medicine research team. We are pleased that there continues to be a high level engagement from our department and from colleagues in other departments in the projects. A big thanks to Jackie, James and others listed below for all their hard work. We are also honoured to have had an opportunity to publish with some big names in emergency medicine including Jerry Hoffman, Scot Weingart, Simon Carley and others.

Please do not hesitate to ask Jackie, James or me about getting involved as a topic expert or team member in a 2017/18 project. Contact Chris Vaillancourt, Cheri Adams, David Lewis, Jay Mekwan, Jo Ann Talbot, Mike Howlett, or anyone else listed below to chat about what is involved and their experience.

We are looking forward to our annual research rounds in November.


Presentations

We had a successful CAEP in June, with 15 abstract presentations – these can be seen here https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/issue/DE69CB0B8806C073C42126337B1A814F

and here http://sjrhem.ca/?s=CAEP17

 


Publications and manuscript submissions:

Published

Mackay J, Atkinson P, Palmer E, et al. (June 23, 2017) Alternate Access to Care: A Cross Sectional Survey of Low Acuity Emergency Department Patients. Cureus 9(6): e1385. doi:10.7759/cureus.1385

Hayre J, Rouse C, French J, Sealy B, Fraser J, Erdogan M, Watson I, Chisholm A, Benjamin S, Green R, Atkinson P. A traumatic tale of two cities: a comparison of outcomes for adults with major trauma who present to differing trauma centres in neighbouring Canadian provinces. CJEM. 2017 Jul 13:1-9. doi: 10.1017/cem.2017.352.

Massaro PA, Kanji A, Atkinson P, Pawsey R, Whelan T. Is computed tomography-defined obstruction a predictor of urological intervention in emergency department patients presenting with renal colic? Canadian Urological Association Journal. 2017;11(3-4):88-92. doi:10.5489/cuaj.4143.

Featured in September CJEM (in 2 weeks): Jacqueline Fraser, Paul Atkinson, Audra Gedmintas, Michael Howlett , Rose McCloskey, James French. A comparative study of patient characteristics, opinions, and outcomes, for patients who leave the emergency department before medical assessment. Canadian Journal of Emergency Medicine. Vol. 19, No. 5. Sept 2017.

At work, at home. Opus MD. NBMS 2017. https://goo.gl/2kvjvX

Accepted for publication

Geoffrey J. Hoffman, PhD, Jerome R. Hoffman, MA MD,  Michael Howlett MD, Paul Atkinson MB MA. CoPayment. Medical Insurance is for non-routine events. CJEM.

Paul Atkinson MB MA, Eddy Lang MDCM, Meaghan Mackenzie BSc, Rashi Hirandani BSc, Rebecca Lys MSc, Megan Laupacis BScH , Heather Murray MD, MSc. The Choosing Wisely campaign will not impact physician behaviour and choices. CJEM

Peter Cameron, Simon Carley, Scott Weingart, Paul Atkinson. Social media has created emergency medicine celebrities who now influence practice more than published evidence. CJEM

Jim Ducharme, Sam Campbell, Paul Atkinson. Burnout is inevitable in clinical emergency medicine practice. CJEM

Submitted for publication

Mazurek A, Atkinson P, Hubacek J, Lutchmedial S. Is there a relationship between frequency of presentation and quality of care for ST-Segment Elevation Myocardial Infarction?

Canadian Journal of Cardiology.

Sebastian de Haan, MBChB; Hein Lamprecht, MBChB; Michael K Howlett MD, MHSA; Anil Adisesh MBChB, MSc, MD; Paul R Atkinson MB BCh BAO MA. A Comparison of Work Stressors in Higher and Lower Resourced Emergency Medicine Health Settings: An International Survey. CJEM.

Hein H Lamprecht MBChB; Paul R Atkinson MB BCh BAO MA,; Richard Hoppmann MD; Gustav Lemke MBChB MMed; Daniel van Hoving MBChB MMed MSc; Lee A Wallis MBChB MD; Thinus F Kruger MBChB MMed MD DSc.  Poor return on investment: Investigating barriers causing low credentialing yields in a low-resourced clinical ultrasound training program. CJEM.

Hein H Lamprecht MBChB; Paul R Atkinson MB BCh BAO MA ; Richard Hoppmann MD; Lee A Wallis MBChB MD, Thinus F Kruger MBChB MMed MD DSc. Clinical Ultrasound Credentialing Outcomes: A Systematic Review and Critical Analysis. CJEM.

K McGivery, P Atkinson, D Lewis, L Taylor, J Fraser et al. Emergency Department Ultrasound for the detection of B lines in the Early Diagnosis of Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis. CJEM

D McLean, L Hewitson, D Lewis, J Fraser, P Atkinson, J Mekwan, J French, G Verheul. ULTRASIM: ULtrasound in TRAuma SIMulation. CJEM

Rouse C, Hayre J, French J, Sealy B, Fraser J, Erdogan M, Watson I, Chisholm A, Benjamin S, Green R, Atkinson P. A Traumatic Tale of Two Cities: Does EMS level of care and transportation model affect survival in trauma patients at level 1 trauma centres in two neighbouring Canadian provinces? Emergency Medicine Journal.


Current Projects

We continue to recruit for CRASH3 – please consider any adult patient who presents with an isolate head injury within 3 hours of injury for inclusion.

Thank you for your continued support for the Burnout (Critical Dynamics and Crucial Conversations) project which is ongoing.

The epinephrine auto-injector education project is progressing well.

We are finalizing data analysis on SHoC-ED1 and SHoC-ED2 studies and hope to submit for publication in the fall.

We are preparing manuscripts for publication on several completed projects including Head CT at night, Intimate Partner Violence in the ED, Exercise prescription in the ED, Choosing Wisely (Low Back Pain Imaging), COPD management, Crowding Scores,


New Projects underway

Following the success at the Dragon’s Den in the spring of 2017, we have received REB approval for our ECPR (ED-ECMO) project and have begun phase 1. Phase 2 will involve in-situ simulation – coming up this fall.

The Sonography in Hypotension and Cardiac Arrest Series  continues with 2 systematic reviews – – PoCUS in Hypotension. A systematic Review and Meta-Analysis and Echo in Life Support – A systematic Review and Meta-Analysis


Proposed new projects and a chance to get involved

There are opportunities to supervise or co-supervise a resident of medical student project starting this fall.

Potential topic areas include:

First trimester bleeding, low back pain in the ED, age-adjusted D-Dimer in DVT, predictive markers in shock, Informatics – admission predictors and more.


Find out more about these projects and more at http://sjrhem.ca/programs/research/

 

Regards,

Paul

on behalf of the research team

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EM Reflections – September 2017

Thanks to Dr Paul Page for leading the discussion

Edited by Dr David Lewis

Top tips from this month’s rounds:

  1. Non-specific Abdo pain – Appendicitis is always high on the differential 

  2. Intoxicated patients are at high risk for Head Injury

  3. Acute Heart Failure has a higher mortality than acute NSTEMI

  4. Enhancing Morbidity and Mortality Rounds Quality


Non-specific Abdo pain – Appendicitis is always high on the differential 

Does a normal white count exclude appendicitis?No – Clinicians should be wary of reliance on either elevated temperature or total WBC count as an indicator of the presence of appendicitis. The ROC curve suggests there is no value of total WBC count or temperature that has sufficient sensitivity and specificity to be of clinical value in the diagnosis of appendicitis. Acad Emerg Med. 2004 Oct;11(10):1021-7.Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis.

Does a normal CRP exclude appendicitis?No – Acad Emerg Med. 2015 Sep;22(9):1015-24. doi: 10.1111/acem.12746. Epub 2015 Aug 20. Accuracy of White Blood Cell Count and C-reactive Protein Levels Related to Duration of Symptoms in Patients Suspected of Acute Appendicitis.

 

A useful review on the diagnosis of appendicitis – JAMA. 2007 Jul 25; 298(4): 438–451. Does This Child Have Appendicitis?

 

Summary of Accuracy of Symptoms

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Summary of Accuracy of Signs

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Finally – Don’t forget Emergency Physicians can learn how to use Point of Care Ultrasound (PoCUS – ?Appendicitis) which can significantly improve diagnostic accuracy in experienced hands. Experience comes with practice.

J Med Radiat Sci. 2016 Mar; 63(1): 59–66. Published online 2016 Jan 20. doi:  10.1002/jmrs.154
Ultrasound of paediatric appendicitis and its secondary sonographic signs: providing a more meaningful finding

See SJRHEM PoCUS Quick Reference

PoCUS – Measurements and Quick Reference

 


Intoxicated patients are at high risk for Head Injury

Intoxicated patients with minor head injury are at significant risk for intracranial injury, with 8% of intoxicated patients in our cohort suffering clinically important intracranial injuries. The Canadian CT Head Rule and National Emergency X-Radiography Utilization Study criteria did not have adequate sensitivity for detecting clinically significant intracranial injuries in a cohort of intoxicated patients.

ACADEMIC EMERGENCY MEDICINE 2013; 20:754–760. Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

Canadian CT Head Rule not applicable to intoxicated patients (GCS<13)

Download (PDF, 76KB)

 

 

CMPA provide useful guidance on the duties expected in the management of intoxicated ED patients.

 

All intoxicated patients, even the so called ‘frequent fliers’ require a full assessment, including history (from 3rd parties if available), full examination (especially neurological), blood glucose level, neurological observations, and this assessment should be carefully documented.

 

Can we defer CT imaging for intoxicated patients presenting with possible brain injury?

This study suggests that deferring CT imaging while monitoring improving clinical status in alcohol-intoxicated patients with AMS and possible ICH is a safe ED practice. This practice follows the individual emergency physician’s comfort in waiting and will vary from one physician to another.

http://www.sciencedirect.com/science/article/pii/S0735675716306805

 

Download (PDF, 172KB)

 

 


Acute Heart Failure has a higher mortality than acute NSTEMI

Cardiac markers are routinely used to exclude NSTEMI in patient presenting with chest pain. However the diagnosis of acute heart failure (AHF) is mainly clinical, including CXR, ECG, PoCUS.

Ultrasound B Lines and Heart Failure

 

There is good evidence that BNP can be helpful in ruling out AHF – BMJ 2015;350:h910

Recommended Link – Emergency Medicine Cardiac Research and Education Group

Download (PDF, 1.32MB)

 

 

Emergency Treatment of Acute Congestive Heart Failure

Most recent recommendations from Canadian Cardiovascular Society (2012)

  • 1 – We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation > 90% (Strong Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places relatively higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on long-term clinical usage of supplemental oxygen without supportive data.

  • 2 – We recommend CPAP or BIPAP not be used routinely (Strong Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP might be appropriate for patients with persistent hypoxia and pulmonary edema.

  • 3 – We recommend intravenous diuretics be given as first-line therapy for patients with congestion (Strong Recommendation, Moderate-Quality Evidence).
  • 4 – We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (eg, twice daily) or as a continuous infusion (Strong Recommendation, Moderate-Quality Evidence).
  • 5 – We recommend the following intravenous vasodilators, titrated to systolic BP (SBP) > 100 mm Hg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mm Hg):
    • i

      Nitroglycerin (Strong Recommendation, Moderate-Quality Evidence);

    • ii

      Nesiritide (Weak Recommendation, High-Quality Evidence);

    • iii

      Nitroprusside (Weak Recommendation, Low-Quality Evidence).

Values and preferences. This recommendation places a high value on the relief of the symptom of dyspnea and less value on the lack of efficacy of vasodilators or diuretics to reduce hospitalization or mortality.

  • 6 – We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine, or milrinone (Strong Recommendation, High-Quality Evidence).

Values and preferences. This recommendation for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short term hemodynamic effects of inotropes.

  • 7 – We recommend continuation of chronic β-blocker therapy with AHF, unless the patient is symptomatic from hypotension or bradycardia (Strong Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places higher value on the RCT evidence of efficacy and safety to continue β-blockers, the ability of clinicians to use clinical judgement and lesser value on observational evidence for patients with AHF.

  • 8 – We recommend tolvaptan be considered for patients with symptomatic or severe hyponatremia (< 130 mmol/L) and persistent congestion despite standard therapy, to correct hyponatremia and the related symptoms (Weak Recommendation, Moderate-Quality Evidence).

Values and preferences. This recommendation places higher value on the correction of symptoms and complications related to hyponatremia and lesser value on the lack of efficacy of vasopressin antagonists to reduce HF-related hospitalizations or mortality.

 

Emergency Medicine Cases – Episode 4: Acute Congestive Heart Failure 

In Summary

  • AHF is a serious life-threatening condition in its own right, excluding NSTEMI does not change that. Appropriate management and disposition (almost always admission) is required.
  • Oxygen and intravenous Diuretics are the first-line  treatment
  • Nitrates are recommended in the relief of dyspnea in hemodynamically stable patients (SBP > 100 mm Hg)

 


Enhancing Morbidity and Mortality Rounds Quality

The Ottawa M&M Model

CalderMM-Rounds-Guide-2012

 

 

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Medical Student Clinical Pearl – Reversal of Anticoagulation in the Emergency Department

Reversal of Anticoagulation for Bleeding Complications in the ED


Tess Robart, Med 1

Dalhousie Medicine New Brunswick, Class of 2020

Reviewed by: Dr David Lewis and Liam Walsh (SJRH Pharmacy)


Clinical Question:

Emergency Departments frequently encounter patients on anticoagulant therapy. How are we currently managing anticoagulation reversal in our ED? How do we approach reversal, considering urgency in the face of major bleeding complications or prior to emergency surgery?

Background:

As result of the narrow therapeutic window of many anticoagulants, treatment presents a significant risk for life-threatening bleeds. Major bleeding involving the gastrointestinal, urinary tract, and soft tissue occurs in up to 6.5% of patients on anticoagulant therapy. The incidence of fatal bleeding is approximately 1% each year (1). Standard therapy for the control of coagulopathy related bleeding has traditionally required the use of available blood products, reversal of drug-induced anticoagulation, and recombinant activated factor VII (rFVIIa). The introduction of new direct oral anticoagulants (DOACs), dabigatran, apixaban and rivaroxaban presents the need for a new realm of antidotes and reversal agents.



Indications for Reversal:

Emergency physicians should consider reversal of anticoagulation for patients presenting with bleeding in the case of anticoagulant use, antiplatelet use, trauma, intracranial hemorrhage, stroke, and bleeding of the gastrointestinal tract, deep muscles, retro-ocular region, or joint spaces (2,3). The severity of each hemorrhage should be considered, reversing in cases of shock or if the patient requires blood transfusions because of excessive bleeding (2).

Patients should also undergo reversal of anticoagulation if urgent or emergent surgery is necessary (4).

For most medical conditions requiring anticoagulation, the target international normalized ratio (INR) is 2.0 to 3.0 (5). Notable exceptions to this rule are patients with mechanical heart valves, and antiphospholipid antibody syndrome. These patients require more intense anticoagulation, with target INR values between 2.5-3.5 (5).

The following laboratory assays should be considered, and repeated as clinically indicated (2):

  • PT/INR
  • aPTT
  • TT (thrombin time)
  • Basic Metabolic Panel
  • CBC

Initial assessment should address the following from a patient history (2):

  • How severe is the bleed, and where is it located?
  • Is the patient actively bleeding now?
  • Which agent is the patient receiving?
  • When was the last dose of anticoagulant administered?
  • Could the patient have taken an unintentional or intentional overdose of anticoagulant?
  • Does the patient have any history of renal or hepatic disease?
  • Is the patient taking other medications that would affect hemostasis?
  • Does the patient have any other comorbidities that would contribute to bleeding risk?

See this article for more details on the management of anticoagulation reversal in the face of major bleeding

It is important to note that not all coagulopathies will be anticoagulant drug induced. After all drug-induced causes have been ruled out, it is appropriate to follow previously established protocols (ie. transfusion protocol).


Table 1: Common Anticoagulants and Drug Reversal Considerations 


Table 2: Anticoagulant Reversal Agents (5)

 


Bottom Line: 

 

Anticoagulation leading to clinically significant bleeding is an issue commonly encountered in the emergency department. Therapies designed to combat and reverse anticoagulation are constantly changing in response to new anticoagulant medications. Emergency physicians must be well versed around anticoagulants commonly used, and recognize the antidotes used to treat their overuse in urgent and emergent situations.

 

 


References:

 

  1. Leissinger C.A., Blatt P.M., Hoots W.K., et al. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: A review of the literature. Am J Hematol. 2008;83:137-43.
  2. Garcia D.A., Crowther M. (2017) Management of bleeding in patients receiving direct oral anticoagulants. Retrieved from https://www.uptodate.com/contents/management-of-bleeding-in-patients-receiving-direct-oral-anticoagulants?source=search_result&search=reversal%20of%20anticoagulation&selectedTitle=1~150
  3. UC Davis Health Centre. Reversal of Anticoagulants at UCDMC. Retrieved from Reversal of Anticoagulants at UCDMC – UC Davis Health
  4. Vigue B. Bench-to-bedside review: Optimising emergency reversal of vitamin K antagonists in severe haemorrhage–from theory to practice. Crit Care. 2009;13:209.
  5. Mathew, A. E, Kumar, A. (2010) Focus On: Reversal of Anticoagulation. American College of Emergency Physicians. Retrieved from https://www.acep.org/Clinical—Practice-Management/Focus-On–Reversal-of-Anticoagulation/
  6. Brooks J.C., Noncardiogenic pulmonary edema immediately following rapid protamine administration. Ann Pharmacotherap1999;33(9):927-30.
  7. National Advisory Committee on Blood and Blood Products. Recommendations for Use of Prothrombin Complex Concentrates in Canada. May 16, 2014. http://www.nacblood.ca/resources/guidelines/PCC-Recommendations-Final-2014-05-16.pdf
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