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.

 

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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

Download (PDF, 124KB)

Summary of Accuracy of Signs

Download (PDF, 117KB)

 

 

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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