“At work, at home”

As I began a new role with WorkSafeNB, alongside ongoing work in Emergency Care, I thought that perhaps it was timely to reflect on some of the best ways that we can all improve our health and the health of our patients, whether at work, or at home. Too often, we equate our health with how we feel, what pills we take, or how often we see a nurse or doctor. We all have a much greater influence and control over the quiet processes underpinning our physical and mental health than we are aware of.

How can we, as a society, achieve mindfulness that while some parts of our bodies (neurons) are as old as we are, others (skin, lungs, liver and even our heart) are replaced over time, cell by cell? That the food we eat is not just fuel for our bodies, but also supplies the building blocks – the replacement parts for our organs? To consider that when we drink that bottle of sugary pop to wash down the nachos or pizza, we should not be surprised if the body we build, over time, reflects those choices. If we sit all day, every day, and then suddenly need to run to catch a bus, or climb a flight of stairs, is it surprising that our leg muscles cry out in protest, and our heart pounds to alert us to its stress?

I believe that 2017 is as good a year as any for us as a society, and as individuals, to make some changes, so that in 2018, 2028 and beyond, we have a little bit more health, and a little less “health care” in our lives. How does that relate to work? Let’s look at a few scenarios: working, being unemployed, disability, going back to work and time spent at home.

Working: In general, going to work is good for us. Working is the most common way to make a living and attain financial independence. We know that long spells without work are harmful to physical and mental health. Earning enough money to eat well, to afford leisure, to reduce stress around meeting payments is likely to benefit our health. Work also meets many psychosocial needs including identity and providing a purpose in life.

However, many jobs pose both physical and psychological hazards that can risk health. These might include the dangers associated with construction, operating machinery or performing repetitive tasks, or may simply be the amount of sitting down at work. People who sit for prolonged periods of time have a higher risk of dying from all causes — even those who exercise regularly.

Unemployment: There is a strong association between not working and being in poor health. Unemployed people die earlier, have more physical and mental health issues, and use medical resources more frequently.

Disability: Injured and ill workers need the time and medical interventions provided to them by workers’ compensation, or other insurance, to recover from their injury or illness. However, they too will suffer the ill effects of being off work for extended periods of time.

Going back to work: For the most part, the negative effects of not working can be reversed by going back to work. Disabled and sick individuals should be encouraged and supported to return to some form of work as soon as possible, when their health condition permits. Again, this helps to promote recovery and rehabilitation; leads to better physical and mental health outcomes; improves their economic position and improves quality of life overall.

At home: Many of the factors that influence health in the workplace also apply at home and in all other settings. Better food, less sitting, more exercise, more relaxation, and active community engagement all improve our health and wellbeing.

We all know these things to be true. Physicians and politicians talk about educating the public. And yet rates of obesity, diabetes, high blood pressure, mental health issues and many other chronic illnesses continue to increase. So, while we must continue to promote healthy choices, it is clear that education and information are not very effective without systemic change.

Over the past century, major health improvements and increased life expectancy came about because of clean water and rapid declines in infectious disease, including immunization policy, as well as broad economic growth, rising living standards, and improved nutritional status. Much of this change has been at a societal level, rather than individual – in other words, ordinary people didn’t really need to make any special effort to benefit from these things. More recent smaller gains have resulted from advances in treatment of cardiovascular disease and control of its risk factors, such as smoking.

Frieden’s “Health Impact Pyramid” clearly shows that if we want to improve health, the most effective and straightforward means is through improving socio-economic factors. However, the next level of action is challenging. “Changing the context to make individuals’ default decisions healthy” may sound to some a little too much like the “nanny state” or “big brother.” But does true independent individual choice exist? We tend to eat similar foods to those around us – think of the difference you notice when you travel to another culture. The milk we drink, the bread we eat – as individuals, we do not control the ingredients. We have similar habits to those around us – think social media, cars we drive, holidays we celebrate. These choices all contain elements that are beyond our control, yet they influence our health every day. Individual choices will move in a healthier direction when government, industry and community leadership come together to establish a healthier environment.

I will sign off with my suggested prescriptions for 2017. These are all achievable, without a major amount of effort, at minimal cost, but with major potential benefit:

Prescription for Workers:

Engage in your job. Remain as physically active as possible at work – stand rather than sit, for periods of time; use the stairs rather than the elevator. Eat well – pack a salad for lunch; don’t bring unhealthy sugary snacks to work. Take regular breaks, each day, each week, and use your vacation to renew body and mind. Safety – always take full safety precautions; never operate dangerous machinery when fatigued, distracted or intoxicated; report any dangers you discover.

Prescription for Employers:

Engage your workers. Provide opportunity for physical activity. Facilitate options for healthy eating. Schedule workers appropriately, allowing adequate rest periods. Provide support for stressed, sick, or injured workers. And of course, always provide a safe work environment, cultivating a safety culture where workers are comfortable discussing dangers and precautions.

Prescription for Decision Makers (Government, Healthcare Providers, Industry, etc.):

Continue to work towards full employment. Promote exercise, and make it easier for all to exercise safely – with walking paths, cycle lanes and paths, safe crosswalks. Encourage a better general diet – create incentives for healthy choices. Encourage and incentivize the healthcare sector to make cost effective choices for treatment and investigation. Prioritize health and prevention of disease when making policy decisions – factor in long term investment and cost savings over short term gains. Help create a healthy, safe culture for all.

Prescription for All of us at Home:

Let’s think about what food we buy – we are likely to eat it! We are what we eat (and drink) – it is not just fuel. Don’t drink sugary beverages – they will damage our livers and increase our chance of diabetes and obesity. Don’t smoke – it kills – and help is available to stop. Stand up, walk around, then walk some more. There are 24 hours in a day – why not spend at least half an hour exercising? Spend some time with friends and family, and spend some time alone, thinking.

Here’s to a healthier 2017, at work, and at home.

Dr. Paul Atkinson MB MA FRCPC
Professor and Research Program Director
Emergency Medicine
Dalhousie University
Saint John Regional Hospital
Saint John, NB E2L 4L2Chair, Department of Emergency Medicine Research Committee,
Dalhousie University in New Brunswick

Chief Medical Officer, WorkSafeNB

Senior Editor, Canadian Journal of Emergency Medicine

paul.atkinson@dal.ca

@Eccucourse

Dr Paul Atkinson

 

For original article in OPUS MD and French version see below.

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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.

 

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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)

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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

 

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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

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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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RCP – Nar’ pump, mo’ problems

Nar’ pump, mo’ problems, a case on cardiogenic shock

Resident Clinical Pearl (RCP) – June 2017

Mandy Peach, R2 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed/Edited by Dr. David Lewis and Dr. Kavish Chandra

It’s 11 pm, you’re doing the overnight shift and EMS calls in to report a patient with an ETA of 3 minutes: “80 yo female, found on floor in apartment by husband after reportedly feeling unwell for 2 days. Decreased LOC but arousable and responding appropriately. BP 82/36, HR 120, RR 22, Afebrile, oxygen sat 86% on 6L nasal cannula.”

You hear the vitals, and many differentials run through your mind – PE, sepsis, hemorrhage, tamponade. Your main concerns are: this person needs more airway support and they are in shock, and when you think shock you think ‘fluids’.

EMS rolls in with your patient and she looks awful – pale, mottled extremities and drowsy. She is being re-assessed, RT is present to switch to a face mask, IV access is being established and you’re about to pound her with fluids when you are handed her ECG:

1https://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/

This lady clearly is having an inferior STEMI – there is marked ST elevation in II, III and aVF with early Q wave formation.

 

Take home point #1: In any Inferior STEMI, you must suspect RV involvement

Look for ST elevation in V1 and depression in V2, or ST elevation in lead III > lead II. If these are present – get a 15 lead ECG.1

On closer look at our patient’s ECG there is ST elevation in V1-V2 and the elevation in lead III is indeed larger than lead II. You order the 15 lead.

2 https://lifeinthefastlane.com/ecg-library/right-ventricular-infarction/

Look for ST elevation in right sided leads V3-V6, but the money is on V4R – ST elevation in this lead has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% for RV infarction2. Our patient does have RV infarction seen by ST elevation in V4R.

 

Take home point #2: RV involvement is associated with increased risk of cardiogenic shock and death with a mortality of 50% within the first 48 hours3. If there is RV involvement, giving nitroglycerin for chest pain is CONTRAINDICATED

Due to a poorly functioning RV, patients are pre-load sensitive2. If you decrease the pre-load then they have even less to pump, further worsening the hypotension.

So we have diagnosed this lady with cardiogenic shock secondary to AMI (the most common cause of cardiac related shock) and we determined she has RV involvement. We know we can’t give her nitroglycerin. Let’s reassess her status – the basic ABC’s.

Airway & Breathing – the RT has since advanced her to a non-rebreather with a sat level in the high 80’s. You suggest trying Optiflow or BiPAP as a temporizing measure – this lady is going to need to be intubated.

 

Take home point #3: Positive pressure ventilation requires a stable, cooperative patient – which is often not the case in cardiogenic shock

Positive pressure can decrease pre-load and potentially worsen hypotension3. It is a temporizing measure only. The majority will require endotracheal intubation to maintain their saturation as their work of breathing is a large expenditure of energy.

You successfully complete a RSI and the saturation improves to 94-98%.

Circulation – Repeat BP is 82/36. You complete a cardiac point-of-care-ultrasound (PoCUS) and see poor contractility, but no pericardial effusion or large clots suggesting chordae or papillary rupture. IVC is > 50% collapsible.

 

Take home point #4: On PoCUS, heart failure caused by acute ischemia will show a large RV and small LV secondary to low filling pressures, which is best seen on the apical 4 chamber view3

Your patient continues to be hypotensive – you give a small 500 cc bolus; you don’t want to overload a poorly pumping heart with fluid it can’t handle. However you anticipate that this will not be enough to improve her BP, and as she continues to be hypotensive her myocardial ischemia worsens, which subsequently worsens her pump dysfunction in a vicious cycle. She needs pressure support.

 

Take home point #5: Cardiogenic shock requires vasopressor support

If systolic BP > 90: Start with dobutamine for inotropy. Double up on agents – likely will need to add a vasoconstrictor. Dopamine is usually the next to add.

If systolic BP < 90: Can still use dobutamine, but need to add norepinephrine for vasoconstriction. Dopamine alone will worsen BP as it is a vasodilator.

3Tintinalli’s Comprehensive Guide to Emergency Medicine.

You start dobutamine and dopamine peripherally with the intention of obtaining central venous assess once stabilized.

In the meantime, cardiac labs and portable CXR are pending, you treat this patient as any other STEMI in terms of dual anti-platelet and anti-coagulation loading.

 

Take home point #6: Do not give beta blockers

Do not give beta blockers in RV infarcts as high risk of bradycardia and AV block due to ischemia of the AV nodal artery3.

You consult cardiology to activate the cath lab.

 

Take home point #7: Early revascularization in ischemic related cardiogenic shock is key

Early revascularization has a long term mortality benefit, preferably if done within 6 hours4.  Catheterization or CABG is the preferred method over thrombolytic therapy.

You consult cardiology to activate the cath lab.

Back to our patient –

This lady did go on to the cath lab and had stenting of her RCA, however her infarct likely occurred > 48 hours before presentation. Unfortunately, despite aggressive vasopressor therapy and revascularization, she coded immediately after the procedure and resuscitation attempts were unsuccessful, emphasizing the poor prognosis associated with ischemia related cardiogenic shock.

 

Bottom line for cardiogenic shock: fluid bolus 500 cc 0.9% NaCl, vasopressor support and RSI. Early revascularization is key – catheterization is preferred. Despite these interventions, the diagnosis portends a poor prognosis.

 

References

  1. Inferior STEMI – Life in the Fast Lane https://lifeinthefastlane.com/ecg-library/basics/inferior-stemi/
  2. Right Ventricular Infarction – Life in the Fast Lane https://lifeinthefastlane.com/ecg-library/right-ventricular-infarction/
  3. Tintinalli, JE. (2016). Cardiogenic Shock (8th ed.) Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (pages 349-352). New York: McGraw-Hill.
  4. Cardiogenic Shock – Literature Summary – Life in the Fast Lane https://lifeinthefastlane.com/ccc/cardiogenic-shock-literature-summaries/

 

This post was copyedited by Kavish Chandra @kavishpchandra

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RCP – The pee or not the pee: so many questions!

The pee or not the pee: so many questions!

Resident Clinical Pearl (RCP) – May 2017

Jacqueline MacKay, R3 FMEM, Dalhousie University, Saint John, New Brunswick

 

The case: 

A 16-month old girl with a history of fever of 39 degrees and slightly decreased oral intake for three days. She has no other symptoms of note and is a healthy, fully immunized child. Her vital signs are stable and her temperature is 37.9 after having some Advil at triage. After a careful head-to-toe examination, you note that she looks extremely well and you aren’t able identify a source for the infection.

 

Question:

Could this be a UTI? What investigations would be appropriate?

 


The overall prevalence of UTI in febrile infants age 2-24 months who have no apparent source for fever is 5%. There are some groups with higher than average risk of UTI and these groups can be identified. Additionally, the presence of another source of infection (based on clinical history and physical exam) reduces the likelihood of UTI by half.


 

Individual Risk Factors: Girls Individual Risk Factors: Boys

Caucasian race

Age < 12 months

Temperature 39 degrees or greater

Fever for 2 or more days

Absence of another source of infection

Nonblack race

Temperature 39 degrees or greater

Fever for 24 hours or more

Absence of another source of infection

 


 

In girls age 2-24 months:

  • 1 risk factor: probability of UTI 1% or less
  • 2 risk factors: probability of UTI 2% or less

 

In boys age 2-24months:

  • uncircumcised: probability of UTI exceeds 1% even in the absence of other risk factors
  • circumcised with 2 risk factors: probability of UTI 1% or less
  • circumcised with 3 risk factors: probability of UTI 2% or less

 

The probability of UTI increases with the addition of more risk factors, and some of the factors (such as fever duration) may change during the course of the illness, increasing the probability of UTI.

 

Approximately half of clinicians consider a more than 1% risk of UTI sufficient for further investigation and treatment if UTI is found, to prevent spread of infection and renal scarring.

 


 

Recommendations:

  1. If the clinician determines the febrile infant to have a low (<1%) likelihood of UTI, then clinical followup monitoring without testing is sufficient.
  2. If the clinician determines that the febrile infant is not in a low risk group (>1% risk) then there are two options: obtain a urine specimen through catheterization or suprapubic aspirate for urinalysis and culture; or to obtain a urine specimen through the most convenient means and perform a urinalysis. If the urinalysis suggests UTI (positive leukocyte esterase or nitrites, or microscopic bacteria or leukocytes), then a urine specimen should be obtained through catheterization or suprapubic aspirate.
  3. Consider SPA

RCP – Suprapubic Aspiration PoCUS

 


 

Caveats:

  1. A negative urinalysis does NOT rule out UTI with certainty in children; however it is reasonable to monitor the clinical course without initiating antibiotics.
  2. Urine from a specimen bag CANNOT be used for culture to document UTI due to high risk of contamination.

 


 

Case conclusion:

A bag specimen was obtained for urinalysis, which was negative. After discussion with the parents, no antibiotics were prescribed and close followup was available. The child’s fever resolved within 24 hours. The urine culture was also subsequently negative.

 


Reference:

American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management; Roberts KB. Urinary tract infection: Clinical practice guideline for diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128(

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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

 

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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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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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SHoC blog from @CanadiEM

Social media site @CanadiEM recently featured the @CJEMonline @IFEM2 #SHoC Consensus Protocol, featuring authors from @SJRHEM among others.

So why do we need another ultrasound protocol in emergency medicine? RUSHing from the original FAST scan, playing the ACES, FOCUSing on the CAUSE and meeting our FATE, it may seem SHoCking that many of these scanning protocols are not based on disease incidence or data on their impact, but rather on expert opinion. The Sonography in Hypotension (SHoC) protocols were developed by an international group of critical care and emergency physicians, using a Delphi consensus process, based upon the actual incidence of sonographic pathology detected in previously published international prospective studies [Milne; Gaspari]. The protocols are formulated to help the clinician utilize ultrasound to confirm or exclude common causes, and guides them to consider core, supplementary and additional views, depending upon the likely cause specific to the case.

Why would I take the time to scan the aorta of a 22 year old female with hypotension, when looking for pelvic free fluid might be more appropriate? Why would I not look for lung sliding, or B lines in a breathless shocked patient? Consideration of the shock category by addressing the “4 Fs” (fluid, form, function, and filling) will provide a sense of the best initial therapy and should help guide other investigations. Differentiating cardiogenic shock (a poorly contracting, enlarged heart, widespread lung B lines, and an engorged IVC) in an elderly hypotensive breathless patient, from sepsis (a vigorously contracting, normally sized or small heart, focal or no B lines, and an empty IVC) will change the initial resuscitation plan dramatically. Differentiating cardiac tamponade from tension pneumothorax in apparent obstructive shock or cardiac arrest will lead to dramatically differing interventions.

SHoC guides the clinician towards the more likely positive findings found in hypotensive patients and during cardiac arrest, while providing flexibility to tailor other windows to the questions the clinician needs to answer. One side does not fit all. That is hardly SHoCing news. Prospective validation of ultrasound protocols is necessary, and I look forward to future analysis of the effectiveness of these protocols.

References

Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an inter- national consensus conference. J Trauma 1999;46:466-72.

Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography. 2010 Dec 31;23(12):1225-30.

Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: cardiac arrest ultra-sound exam – a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206

Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26:87–91

Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in Shock in the evaluation of the critically lll. Emerg Med Clin North Am 2010;28:29 – 56

Jensen MB, Sloth E, Larsen KM, Schmidt MB: Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol. 2004, 21: 700-707.

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Dec 31;109:33-9.

Milne J, Atkinson P, Lewis D, et al. (April 08, 2016) Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol. Cureus 8(4): e564. doi:10.7759/cureus.564

Sonography in Hypotension and Cardiac Arrest: The SHoC Consensus Statement

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CAEP Definition of an Emergency Physician and the Importance of Emergency Medicine Certification

CAEP Definition of an Emergency Physician

An emergency physician is a physician who is engaged in the practice of emergency medicine and demonstrates the specific set of required competencies that define this field of medical practice. The accepted route to demonstration of competence in medicine in Canada is through certification by a recognized certifying body.*

CAEP recognizes that historically many of its members are physicians who have practiced emergency medicine without formal training and certification. Many have been, and continue to be key contributors to developing emergency medicine and staffing emergency departments in Canada. CAEP acknowledges the contributions of these valued physicians and recognizes them as emergency physicians. It is CAEP’s vision going forward that physicians entering emergency practise will demonstrate their competencies by obtaining certification.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency Physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

CAEP Statement on the Importance of Emergency Medicine Certification in Canada

It is CAEP’s vision, that by 2020 all emergency physicians in Canada will be certified in emergency medicine by a recognized certifying body.*

Toward that vision, provincial governments and Faculties of Medicine must urgently allocate resources to increase the numbers of emergency medicine postgraduate positions in recognized training programs so the Colleges are able to address the gap in human resources and training. Furthermore, physicians who have historically practiced emergency medicine without certification must be supported in their efforts to become certified. CAEP is committed to facilitate this process by cataloguing and nationally coordinating practice- and practitioner-friendly educational continuing professional development programs designed to assist non-certified physicians to be successful in their efforts.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

We have also published on this topic, highlighting the need for more resident positions in New Brunswick and PEI. Read our paper here.

 

Read more from CAEP here.

 

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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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