SJRHEM @Whistler CAEP 2017

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ED Rounds – Oral Rehydration in Children

Pediatric Dehydration and Oral Rehydration

ED Rounds Presentation by: Dr Paul Page


 

  • Volume Depletion (hypovolemia): refers to any condition in which the effective circulating volume is reduced. It can be produced by salt and water loss (as with vomiting, diarrhea, diuretics, bleeding, or third space sequestration) or by water loss alone (as with insensible water losses or diabetes insipidus).
  • Dehydration -refers to water loss alone. The clinical manifestation of dehydration is often hypernatremia. The elevation in serum sodium concentration, and therefore serum osmolality, pulls water out of the cells into the extracellular fluid.

American Family Physician article (2009) – Diagnosis and Management of Dehydration in Children


 


SJRHEM Guideline

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

 


View/Download Full Presentation below:

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ED Rounds – Ortho Clinic Pathway

ED Rounds – Ortho Clinic Pathway

ED Rounds Presentation by Dr Paul Keyes

 


 

A personal perspective on system review and pathway re-engineering…

 


Rationalization of Process

  • —Every consult is entered by ERP into I3 and printed to accompany copy or ED chart and is placed in clinic book, with a patient sticker placed on clinic appointment sheet.
  • —Non-urgent consults are faxed to orthopedic surgeons offices for triage and cue placement with all other primary care referrals
  • —If subspecialty specific consult requested, then this is faxed to the orthopod of choice’s office. If urgent, then the orthopod on call will sort/laterally refer consult in clinic that week

Outcomes

  • —Collaborative approach ED and ortho
  • —Single process for all orthopedic referrals
  • —Identical sorting of: In ED, Clinic, Ortho office/subspecialty referrals
  • —Legible, billable consults
  • —Timely and appropriate consultations/assessments
  • —Orthopod flexibility as to site of consultation/clinic
  • —Appropriate chain of responsibility from Consult to consultant evaluation

 

Download (PDF, 3.8MB)

 

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EM Reflections – May 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

 

Top tips from this month’s rounds:

  1. DVT – Anticoagulation Bridging… when is it needed?
  2. Anticoagulated elderly patient with minor trauma. Can we rely on a recent INR?
  3. Abdominal pain in an elderly patient. Does a nonspecific exam and normal vitals exclude serious illness?

 


DVT – Anticoagulation Bridging… when is it needed?

Consider the type of anticoagulation best suited for your patient. Remember warfarin needs bridging until therapeutic INR is achieved.  Ensure that patients discharged after hours have a robust plan for follow up and enough supply until follow up occurs.

Outpatient Management of Anticoagulation Therapy – American Family Physician 2013

 

For Warfarin therapy in DVT, Thrombosis Canada recommends:

Full-dose low molecular weight heparin (LMWH) overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.

 

Bridging is not required when prescribing a Direct Oral Anticoagulant (DOAC) e.g Apixaban or Rivaroxaban.

 

Thrombosis Canada tool to support decision making for Anticoagulation therapy in DVT

Management of DVT:

General measures:
Unless compression ultrasound (CUS) is rapidly available, patients with moderate-to-high suspicion of DVT (except those with a high risk of bleeding) should start anticoagulant therapy before the diagnosis is confirmed.  Imaging confirmation should be obtained as soon as possible.
Outpatient management is preferred over hospital-based treatment unless there is an additional indication for hospitalization.
Initial treatment should have an immediate anticoagulant effect. Therefore, warfarin monotherapy is not appropriate initially.

Treatment Regimens:

Depending on the clinical presentation, one of following regimens should be used for the initial 3 months:

  • Full-dose low molecular weight heparin (LMWH) overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.
  • Full-dose IV heparin overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.
  • Apixaban 10 mg PO BID for 1 week before reducing dose to 5 mg PO BID.
  • Rivaroxaban 15 mg PO BID for 3 weeks before reducing dose to 20 mg PO once daily.
  • Full-dose SC LMWH or IV heparin for at least 5-10 days before switching to dabigatran 150 mg PO BID or to edoxaban 60 mg PO once daily.
  • Full-dose LMWH alone without switching to an oral anticoagulant.
  • Full-dose LMWH for the 1st month or so before switching to a DOAC or warfarin.

 


Anticoagulated elderly patient with minor trauma. Can we rely on a recent INR?

 

Elderly patients on warfarin presenting with minor trauma are commonly seen in the ED.  Many will have been on warfarin for a prolonged period and will have stable INRs. However we can not rely on a previous INR level when assessing the current presentation. Consider the following rational:

  • Why did the patient fall?
  • Do they have a concomitant illness?
  • Are they compliant with their medication?
  • Have they been prescribed or are you considering prescribing new medication that may interact with warfarin?

Clinically Significant Drug Interactions

Anticoagulated patients frequently re-attend the ED with complications of bleeding after discharge following minor injury e.g enlarging hematoma, blood soaked dressings, missed internal bleeding, mobility failure. Consider whether admission for observation may be more appropriate than discharge in this group of patients. For those discharge ensure that they have close support and clear advice on when to return.

Practical tips for warfarin dosing and monitoring – Cleveland Clinic Journal

 

See this recent Medical Student Pearl on Reversal of Anticoagulation in the ED

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

 


 

Abdominal pain in an elderly patient. Does a nonspecific exam and normal vitals exclude serious illness?

Elderly patients presenting to the ED with acute abdominal pain should be considered extremely high risk. Published series have reported mortality rates approaching 10% (https://www.ncbi.nlm.nih.gov/pubmed/7091511)

Presentations can be delayed, physical exam can be innocuous, lab results can be misleading. The risk of serious pathology is much greater and the outcome of delayed diagnosis can be significant.

Abdominal emergencies in the geriatric patient – Int J Emerg Med. 2014; 7: 43.

 

 

An excellent post from ALIEM – 10 Tips for Approaching Abdominal Pain in the Elderly

After seeing your fifth young patient of the day with chronic pelvic pain, constipation, and irritable bowel syndrome, it is easy to be lulled into the mindset that abdominal pain is nothing to worry about. Not so with the elderly. These 10 tips will help focus your approach to atraumatic abdominal pain in older adults and explain why presentations are frequently subtle and diagnoses challenging.

 

Erect CXR – Abdominal Series – Free air under diaphragm in perforated bowel

 

Bottom Line –

Elderly patients with abdominal pain are at a much greater risk of serious pathology and require an extremely thorough assessment before (if ever) discharging with a rule-out diagnosis e.g constipation, gastro, abdo pain NYD etc.

 

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PoCUS – Measurements and Quick Reference

Developed by Dr. Heather Flemming as part of her PG PoCUS Elective at SJRHEM.

A useful Point of Care Ultrasound (PoCUS) guide to common normal values, measurements, pathological values and quick reference tips. A pdf version is also provided in this post which can be downloaded, printed and attached to your ultrasound machine for easy access.

 

 

 


 


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SJRHEM Physicians win SJRH Foundation Dragons Den and Audience Choice Awards

Congratulations to Paul Atkinson, Michael Howlett, Jay Mekwan, Mark Tutschka and Bill O’Reilly for taking the SJRH Foundation Dragons Den top prize of $75,000 for their Cardiac Arrest ECMO project. James French, Tushar Pishe and Ian Watson won the Audience Choice award for their Trauma Simulation project. A great performance by SJRHEM Physicians!

 

 

The Dragons

Scott McCain, Dr. David Elias, Derek Pannell

Click here for video

 

The Teams

Team: Dr. Paul Atkinson, Dr. Michael Howlett, Dr. Mark Tutschka, Dr. Jay Mekwan, and Mr. Bill O’Reilly. Department of Emergency Medicine

Despite modern advances in CPR and resuscitation, the average survival rate for adults suffering a cardiac arrest outside of hospital is 4 out of every 100. Right now, if defibrillation does not work immediately, there is little hope of survival. We in Emergency and Critical Care Medicine want to investigate the use of new technology called ECMO and how it could help with untimely death. ECMO (Extra-corporeal membrane oxygenation) is essentially cardiac bypass in a box – portable and potentially available outside the Heart Centre in places such as the Emergency Department. Using it during CPR (ECPR) keeps a persons vital organs such as their brain supplied with blood and oxygen until we can treat the cause of their cardiac arrest. In some European countries, this technology is now available in specialized ambulances. Although extremely expensive, and with the potential to impact other services, this technology has the potential to allow many more patients to survive cardiac arrest. We wish to see if introducing ECPR is feasible in New Brunswick. The $75,000 would cover the two of the four stages needed to fully implement ECPR.

 

Team: Dr. James French, Dr. Tushar Pishe, Ian Watson. New Brunswick Trauma Program

We offer lots of education to health-care providers already, but we know that a really important element in saving the life of a critically injured patient is providing healthcare professionals with the chance to practice in advance of an emergency – just as pilots do in cockpit simulators. Physicians, nurses and other professionals working in emergency departments see critically injured patients infrequently. When they do, they need to be able to immediately work as a team to save a life, and to ensure rapid, safe transfer to a major trauma centre like the Saint John Regional Hospital. The Mobile Simulation initiative of the New Brunswick Trauma Program brings education by simulation to these smaller centres – bringing the equipment and the expertise to work with local teams, in their local environments, to make sure that the public gets the very best care possible, regardless of where or when a major injury occurs. $75,000 would allow us to purchase an advanced human simulator – essentially, a robotic patient who blinks, moans and breathes just like a real person.”

 

Team: Dr. Sohrab Lutchmedial and Dr. Ansar Hassan. Department of Cardiology

Our project’s goal is to bank a cash of tissues for medical research while introducing two cutting edge medical techniques. The first we call chemical fingerprinting, where we process blood using nanotechnology to reveal each person’s unique biochemical signature. This allows us to know if drugs are working or perform enhanced diagnosis. The second is called pharmacogenomic screening, where specific gene panels let us quickly determine whether a patient is better suited for certain drugs or medical procedures. Our project will leapfrog our medical approaches about 10 years into the future, where treatments are tailored to an individual patient. Not all solutions can be imported to New Brunswick and be as effective as those created and developed at home. Therefore, we will create a unique New Brunswick reference library of medical information to improve how we treat the specific and unique features of our New Brunswick population. This $75,000 will support a full-time BioBank Analyst and cover part of the expenses for the first 500 patients investing in the New Brunswick BioBank Project. We plan to grow that investment, commercialize some of the reagents we have developed and eventually become a major medical solutions exporter.

 

Team: Dr. Neil Manson and Dr. Robert Stevenson. Department of Orthopedics

For our project, we will be doing a study that merges the cardiac rehabilitation program with our pre-operative spine surgery patients who have multiple cardiac risk factors. This is a great project because it is simultaneously caring for patients and validating the research. In the short-term, the patients enrolled in the study are getting superior care, and will gain direct benefits in terms of surgical benefit when it comes time for their operation. In the long-term, were validating a program that could change the way we prepare our patients for spine surgery on a larger scale, and showcasing New Brunswick as a province that does ground-breaking research that addresses issues directly within our health-care system. The $75,000 would support the entire study, including the purchase of equipment, paying staff and independent reviewers. “Our goal with this money, is to take care of our patients right now, but also prove that the program works, so we can develop a long-term, self-sustained program for all of our patients who need it.

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RCP – Gravidology for the Emergency Physician

Gravidology for the Emergency Physician

Resident Clinical Pearl – April 2017

Luke Taylor, PGY1 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

 

Many adaptations take place in the gravid female, the end goal of each being to provide optimal growth for the fetus, as well as to protect the mother from the potential risks of labour and delivery. It is very important to understand these changes when assessing an unwell pregnant patient in the ED.


Vital Signs:

 

BP: Blood pressure falls earlier in pregnancy with nadir in second trimester (mean ~105/60 mmHg). In the third trimester BP increases and may reach pre pregnancy levels at term. BP is related to a reduction in SVR and multiple hormonal influences that are not fully understood.

 

HR: CO=HRxSV. The increase in CO is attributed mainly to the increase in circulating volume (30-50% above baseline). HR increases by 15-20 beats/min over non pregnant females.

*Supine position in the gravid female can lower CO by 20-30% due to a reduction in venous return which reduces stroke volume.

 

RR: State of relative hyperventilation. NO change in RR, however there is an increase in tidal volume resulting in a 50% increase in minute ventilation. Increased O2 consumption and demand with hypersensitivity to chances in CO2.

*60-70% of women experience a sensation of dyspnea during pregnancy

 

 


Diagnostic Imaging and ECG:

 

Must ensure imaging is necessary for management and explain risks well.

** 1 rad increases the risk of childhood malignancy by 1.5-2x above baseline.

 

CXR: Minimal changes to CXR in normal pregnancy but may have; prominence of the pulmonary vasculature and elevation of the diaphragm.

 

PoCUS: FAST doesn’t perform well in pregnant patient. Small amount of physiologic free fluid in the pelvis (posterior, lower portion of uterus), all else should be considered pathologic. Physiologic hydronephrosis and hydroureter (mostly R-sided).

 

CT-A: When required to r/o PE, capable of being completed at very low rad (below teratogen cut off, CT of 1-3rad is under the teratogenic cutoff of 5-10rad = 10,000 cxr or 10x CT chest

 

ECG: Various changes occur, may include ST and T wave changes, and presence of Q waves. The heart is rotated toward the left, resulting in a 15 to 20º left axis deviation. Marked variation in chamber volumes, especially left atrial enlargement. This can lead to stretching of the cardiac conduction pathways and predisposes to alterations in cardiac rhythm.

 

 


Routine Laboratory Tests:

 

CBC: Physiologic Anemia – Increased retention of Na and H2O (6-8L) leading to volume expansion combined with a slightly smaller increase in red cell mass.

Leukocytosis – Due to physiologic stress from the pregnancy itself, creates a new reference range from 9000, to as high as 25000 in healthy pregnant females (often predominately neutrophils)

 

PTT: Various processes result in 20% reduction of PTT and a hypercoagulable state (also helps to protect from hemorrhage during labour).

 

Urinalysis: Very common to have 1-3+ leukocytes, presence of blood, as well as ketones on point of care testing. Not considered pathologic unless Nitrite positive.

 

Creatinine: Pre-eclamptic patients may have a creatinine in the normal range, but have a drastic reduction in GFR (40%).

 

B-HCG: Every female of childbearing years should be considered to: Be pregnant, RH-, and have an ectopic until proven otherwise. Draw a beta HCG on every critically ill or injured women of childbearing years regardless of reported LMP.

 


ACLS:

 

Remember, most features are the same as when resuscitating a non-pregnant patient.

Some things to remember:

 

Higher risk of aspiration – Progesterone relaxes gastroesophageal sphincters and prolongs transit times throughout the intestinal tract. = Careful bag mask ventilation, do not overdo it.

Left uterine displacement (LUD)– While patient supine to provide best chest compressions possible

Medications and Dosages– Remain the same in pregnancy, vasopressors like epinephrine should still be used despite effect on uterus perfusion

Defibrillation OK-  Fetus is not effected by defibrillation, low risk of arc if fetal monitors in place, do not delay.

Four minute rule– For patients whose uterus is at or above the umbilicus, prepare for cesarean delivery if no ROSC by 4mins. ** In a case series of 38 perimortem cesarean delivery (PMCDs), 12 of 20 women for whom maternal outcome was recorded had ROSC immediately after delivery.

Etiology:  Must continue to think broadly, however common reasons for maternal cardiac arrest are: bleeding, heart failure, amniotic fluid embolism (AFE), and sepsis. Common maternal conditions that can lead to cardiac arrest are: preeclampsia/eclampsia, cerebrovascular events, complications from anesthesia, and thrombosis/thromboembolism.

 


REFERENCES

Cardiac Arrest in Pregnancy – A Scientific Statement From the American Heart Association

Up To Date – Respiratory Tract Changes in Pregnancy

Merk Manual – Physiology of Preganacy

https://radiopaedia.org/cases/chest-x-ray-in-normal-pregnancy

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ED Rounds – How Big Are Your Stones

‘How big are your stones….David?’

A Renal Colic Presentation by Brian Ramrattan

 


 


 

 


 

Passing a Stone?

  • <5mm likely to pass without intervention
  • >10mm unlikely to pass without intervention
  • Increased intervention requirements with larger stones
  • Likelihood of stone passing also affected by position
    • Stones at the vesicoureteric junction more likely to be passed than those in the proximal ureter

 


 

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ED Rounds – Early Pregnancy

Pregnancy of Unknown Location & Early Pregnancy Loss

Presented by: Dr Robin Clouston

 


 

  • Ruling out ectopic pregnancy is a critical issue in evaluation of the symptomatic patient in early pregnancy
  • In women presenting to ED with abdominal pain or pv bleeding, prevalence of ectopic as high as 13%
  • Well known sequelae of missed ectopic
    • Rupture, tubal infertility, possible death
  • Sequelae of false positive diagnosis of ectopic
    • Termination of viable, desired pregnancy

 


Sonographic findings in Ectopic

  • Adnexal mass
    • Simple adnexal cyst – low probability ectopic if < 3mm (5%)
    • Complex adnexal mass – high probability ectopic (90%)
    • Most common location: ampullary or isthmic portion of fallopian tube (95% of ectopics)
  • Isolated free fluid in the pelvis
    • Rarely the only sonographic finding
  • Pseudogestational sac – seen in at most 10% ectopic
  • Normal scan – 15 to 25%

Utility of US with low βHCG

  • ACEP recommends:

“Proceed to transvaginal ultrasonogaphy in symptomatic patients with βHCG less than 1000.”

  • Comprehensive transvaginal ultrasonography has a moderate sensitivity to detect IUP with βHCG < 1000
    • 40 to 67% sensitive
  • For patients whose final diagnosis is ectopic:
    • When βHCG < 1000, TVUS had 86 to 92% sensitivity to detect findings suggestive of ectopic

Safety of Discharge

  • NJEM 2013:3
    • there is limited risk in taking a few extra days to make a definitive diagnosis in a woman with a pregnancy of unknown location who has no signs or symptoms of rupture and no ultrasonographic evidence of ectopic pregnancy.
  • Progression of hCG values over a period of 48 hours provides valuable information:13
    • If failure to fall by 15%
    • And failure to rise by 55%
    • …most likely diagnosis is ectopic pregnancy

Morin L et al. Ultrasound Evaluation of First Trimester Complications of Pregnancy. J Obstet Gynaecol Can 2016;38(10):982-988

 

 


 

A reasonable approach

In the pregnant patient with vaginal bleeding and / or abdominal pain:

  • Always perform bedside US to establish ?definitive IUP
  • Do not rule out ectopic pregnancy in patients with empty uterus and βHCG < 1000
  • Do obtain a comprehensive TVUS when bedside US does not confirm IUP regardless of βHCG

In the pregnant patient with vaginal bleeding and / or abdominal pain:

  • When TVUS is delayed or remains non-diagnostic, involve obstetrician to aid in risk stratification and management
  • Reliable, hemodynamically stable patients may be discharged with follow up
  • Expedited TVUS (next day)
  • Repeat βHCG in 48h

 


 

Take Home Points

  • Do obtain a comprehensive TVUS when bedside US does not confirm IUP regardless of βHCG
  • Do not rule out ectopic pregnancy in patients with empty uterus and βHCG < 1000
    • Clinical judgment: safe discharge planning vs admission
    • Low threshold to involve Obs-Gyn for these cases
  • Early pregnancy loss is diagnosed by US when:
    • CRL >/= 7mm with no FRH
    • Mean sac diameter >/= 25mm and no embryo
  • Expectant, medical and surgical management are equally effective and safe in treatment of EPL
    • Patient preference may guide decision making

Download (PDF, 1.92MB)

 


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EM Reflections – April 2017

Thanks to Dr. Joanna Middleton for her summary

Edited by Dr David Lewis

 

Top tips from this month’s rounds:


Syncopal/Pre-Syncopal Episode – Usually benign, but sometimes serious…….

Red flag symptoms of potentially life-threatening causes of syncope are syncope with exercise, chest pain, dyspnea, severe headachepalpitations, back pain, hematemesis / melena before the syncopal episode. Palpitations before loss of consciousness are a significant predictor of a cardiac cause of syncope. Focal neurologic deficits, diplopia, ataxia, or dysarthria after the syncopal episode.

 

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society


Syncope Risk Scores

San Francisco Syncope Rule

Canadian Syncope Risk Score


ECG in Syncope

CanadiEM – Medical Concept – ECGs in Syncope

Download (PDF, 2.02MB)

 


Subarachnoid hemorrhage can present with syncope…

  • 97% – sudden, severe headache – “worst”
  • 53% – syncope
  • 77% – N/V
  • 35% – meningismus

How To Be A Clinical Rock Star Managing Subarachnoid Hemorrhage

 


 

Abdominal Aorta – Aneurysm vs Dissection

Only 2% of all aortic dissections originate from abdominal aorta. Almost all aortic dissections originate in the thoracic aorta.

The majority of abdominal aortic aneurysms are infrarenal

AAA – A comprehensive review

Download (PDF, 516KB)

 


Management of the Unruptured AAA

  • Symptomatic or asymptomatic
  • How can an unruptured AAA be symptomatic???
    • (rapid expansion of the aortic wall, ischemia from blocking off blood vessels, compression of other structures etc)
  • Symptomatic – admit for repair, regardless aneurysm diameter
  • Asymptomatic
    • <5.5cm – likely outpatient
    • “Very large aneurysm” (>6cm) – likely admit for repair

 

Transfers to and from Major Emergency Departments

  • Emergency transfers from referring sites for diagnostic imaging are potentially high risk
  • Adverse events have been reported in the medical literature for this group of patients
  • A detailed handover between referral and receiving site will reduce risk
  • Patient stability must be assessed prior to transfer, on arrival at receiving site and prior to return to referral site.
  • The results of the diagnostic imaging should be taken into context with the patient’s condition prior to release for return to referral site.

Download (PDF, 293KB)

 


 

Hyponatremia – How low is too low?

 

  • All patients with severe (< 120)
  • Any patient that is symptomatic from the hyponatremia

LIFL – Hyponatremia – Diagnosis and Management

 

For the budding critical care physiologist – Deranged Physiology – Hyponatremia

 

 

 

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Allscripts (i3) Documents Filter

New Documents Filter for New Physicians All new physicians getting access to Allscripts will have a new filter available to them by default on their documents tab that pulls in just physician documents to make it easier to find those key documents (such as Operative Records, Discharge Summaries, etc).

For existing physicians, here is how to create a filter to help you to find Physician documents:

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