EM Reflections – March 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Abdominal Aortic Aneurysm – Size matters, but it isn’t everything

CME QUIZ

 

 


Abdominal Aortic Aneurysm – Which patients require urgent consult / transfer ?

AAA is a disease of older age. The prevalence of AAA among men aged 65 to 80 is 4 to 6 times higher than in women of the same age. The Canadian Task Force on Preventative Healthcare have recently (2017) made the following recommendations on screening:

Recommendation 1: We recommend one-time screening with ultrasound for AAA for men aged 65 to 80. (Weak recommendation; moderate quality of evidence)

Recommendation 2: We recommend not screening men older than 80 years of age for AAA. (Weak recommendation; low quality of evidence)

Recommendation 3: We recommend not screening women for AAA. (Strong recommendation; very low quality of evidence)

 

Emergency Physicians are trained to recognize the signs and symptoms of ruptured AAA (hypotension, tachycardia, pulsatile abdominal mass, back pain) and are always on the lookout for those curveball presentations e.g renal colic mimic, syncope, sciatica etc.

With the organization of centralized vascular services predominating in the majority of developed national health systems, patients with ruptured AAAs are now being transferred for specialist care. Recent evidence from the UK suggests that this practice is safe with no observed increased mortality or length of stay. and other studies have shown a benefit, with reduced mortality post service-centralization.

While there maybe benefits of centralization for patients, vascular surgeons and health economies, the initial management of the patient with AAA disease can be increasingly challenging for the Emergency Physician, especially if they are located in a peripheral hospital.

Let us consider a few scenarios:

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with severe back pain and hypotension. Point of Care Ultrasound (PoCUS) confirms the diagnosis of a 7.5cm AAA.

This scenario is relatively straightforward. The patient is judiciously resuscitated (avoiding aggressive fluid infusion), and transferred, after discussion with on-call vascular surgery, as quickly as possible directly to the receiving hospital’s vascular OR.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They are known to have a 3.7cm AAA (last surveillance scan 6 months ago). PoCUS confirms the presence of an AAA measuring approx. 3.7cm. Urinalysis is negative.

This scenario is also relatively straightforward. While the cause of the flank pain has not been determined, the risk of AAA rupture is highly improbable. For men with an AAA of 4.0 cm or smaller, it takes more than 3.5 years to have a risk of rupture greater than 1%. Given the stable vital signs, low pain score and lack of significant change in AAA size, this patient can be safely worked-up initially at the peripheral hospital pending transfer for abdominal CT if diagnosis remains unclear or symptoms change.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They have no past medical history. PoCUS confirms the presence of a new 4.7cm AAA.  

This scenario starts to become more challenging. Is the AAA leaking? Is the AAA rapidly expanding? Has PoCUS accurately measured the AAA size, Is the AAA causing the symptoms or is there another diagnosis? While this AAA is still below the elective repair size (5.5cm), the rate of growth is not know (and this is important), 4.7cm AAAs do occasionally rupture and rapidly expanding AAA’s can cause pain (the phenomena is more common in inflammatory and mycotic aetiologies). In this scenario the safest approach would be to organize transfer for an urgent CT and to arrange for Vascular Surgey consult immediately thereafter.

 

 

Salmonella aortitis may appear after a febrile gastroenteritis. The common location of primary aortitis and aneurysm formation is at the posterior wall of the suprarenal or supraceliac aorta – . 2010; 3(1): 7–15.

 

Aortitis is the all-encompassing term ascribed to inflammation of the aorta. The most common causes of aortitis are the large-vessel vasculitides including GCA and Takayasu arteritis. The majority of cases of aortitis are non-infectious, however an infectious cause must always be considered, as treatment for infectious and non-infectious aortitis is significantly different.

This article provides a detailed summary of the diagnosis and management of Aortitis

 


CME QUIZ

EM Reflections - March 2018 - CME Quiz

EM Reflections – March 2018 – CME Quiz

Continue Reading

EM Reflections – February 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Pleuritic Chest Pain – Don’t forget the Abdomen

Headache – Not always Migraine

Epistaxis – Posterior Bleed

CME QUIZ

 


Pleuritic Chest Pain – Don’t forget the Abdomen

The commonest causes of pleuritic chest pain (pleurisy) presenting to the ED include:

  • Pulmonary embolus
  • Pneumonia
  • Pericarditis
  • Myocardial infarct
  • Pneumothorax

Once these have been ruled out consider the following differential diagnosis:

ref: American Family Physician (May 2007)

 

Another differential to consider is:

Perforated peptic ulcer

This can result in localized sub-diaphragmatic peritonitis that can result in pleuritic chest pain

 

Tips:

  • If a CT Chest has been performed – look for free air under the diaphragm
  • Always document an abdominal exam when assessing a patient with pleuritic chest pain
  • Although radiologists are highly skilled, like any physician, they are not infallible. Conservative estimates suggest an error rate of 4%. See this excellent article: The Epidemiology of Error in Radiology and Strategies for Error Reduction
  • Wherever possible physicians should always review the images from CT and X-Ray prior to reading the formal radiology report.

Arrows depicting free air on erect CXR – note the double stomach bubble sign on the left

Free air seen on lower slice of CT Chest. Easily mistaken for bowel

 

 


Headache – Not always migraine

The commonest cause of headache presenting to the ED is migraine

The features of migraine headache are well documented in this article – The diagnosis and treatment of chronic migraine

 

The differential diagnosis for patients presenting with headache is large. This excellent website (https://ddxof.com/) provides algorithms to help consider the differential diagnosis in the cardinal EM presentations.

From: DDxof.com

 

Another differential to consider is:

Anemia

Sub-acute onset anemia secondary to chronic blood loss e.g menorrhagia, chronic GI bleed, etc can present with fatigue, visual disturbance and headache.

Tips:

  • Patients who present to ED with a new headache (no previous hx of primary headache syndrome or change in symptoms) should have baseline investigations including CBC and Glucose.
  • Always review the paramedic and triage notes for supplementary information and the presence of additional symptoms that may broaden or narrow the differential.
  • Patient ethnicity and skin colour may mask the presence of anemia.

 

 

 

 


Epistaxis – Posterior Bleed

Posterior epistaxis is a difficult condition to manage and is associated with a number of acute and serious complications. In this study, 3.7% required intubation.

The #FOAM Blog post provides an excellent outline to the management of posterior epistaxis – EMDocs.net

The Emergency Department Management of Posterior Epistaxis

 

Posterior Nasal Packing – video

 

 

Tips:

  • All cases of major bleeding, including epistaxis should be initially managed in the highest acuity areas of the ED. Patients can then be rapidly stepped down and relocated to lower acuity areas if determined to be lower risk after initial assessment.
  • Consider using a suction device to aid intubation in cases of massive obscuring oro/naso-pharynx haemorrhage.

PulmCrit: Large-bore suction for intubation: strategies & devices

 


 

 

CME QUIZ

EM Reflections - Feb 18 - CME Quiz

EM Reflections – Nov 17 – CME Quiz

Continue Reading

Great ideas and making things better

I heard Dr. Dylan Blacquiere speaking on the radio while driving home after one of those busy D2 shifts on Friday, and it really cheered me up to hear him describe how we all in Saint John are leading the way in managing acute stroke care. http://www.cbc.ca/player/play/1152508483846
From EMS, through Emergency Medicine, diagnostic and intervention radiology, internal medicine and neurology, Saint John Regional Hospital (probably more appropriately Saint John University Hospital) provides a world class service for stroke patients in New Brunswick.
This got me thinking about many of the other innovations and ideas that we continue to push forward locally, especially relating to emergency medicine, and how important it is not to let ourselves become disillusioned by busy shifts, perceived administrative inertia, perceived injustices, crowding and many of the negatives we face, and will likely continue to face for sometime.
To name but a few, we can be proud of the integrated STEMI program we have from EMS to Cath Lab, the Point of Care Ultrasound program that leads in this nationally and beyond, the new Trauma Team leadership program, the patient wellness initiatives such as the photography competition corridor that make things just a little brighter for patients, the regionally dominant and growing simulation program, the regional and local nursing education programs, the nationally unique and hugely popular 3 year EM residency program, the impact of our faculty on medical education at DMNB, the leading clinical care provided by a certified faculty of emergency physicians, our website, our multidisciplinary M&M and quality programs, many of the research initiatives underway including development of an ECMO/ECPR program with the NB Heart Centre, improving detection of domestic violence, innovations around tackling crowding, preventing staff burnout, better radiology requesting, encouraging exercise prescriptions, and much more.
I was particularly impressed how Dylan explained the integrative approach that was required to improve stroke care, and how that was achieved here. There are many other areas that we can also improve, innovate and lead in. Every day we see ways to make things better.
I hope that at this point in our department’s journey, we can continue to make the changes that matter, for patients, our departmental staff, physicians, nurses and support staff alike.
I encourage all of us to think of one area we can improve, to plan for change and for us all to support each other to achieve those improvements. Some of our residents are embarking on very interesting projects, such as designing early pregnancy clinic frameworks, models to improve performance under stress, and simulating EMS ECPR algorithms – all new innovations, not just chart reviews of what we are already doing. I encourage us all to support them, and others with these projects, and to begin to create innovation priorities for the department.
Continue Reading

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

 

 

Continue Reading

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.

 

Continue Reading

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

 

 

 

Continue Reading

EM Reflections – January 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:


1. Presenting Complaint: Abdominal Pain – Might not be due to Abdominal pathology

Keep in mind other life threatening causes of abd pain not in the abd. ( ie Aortic Dissection, PE, ACS, Pneumonia).

ECG on all pts who present with pain between chin and umbilicus.

 

 


 

2. Presenting Complaint: Back Pain – Careful with diagnosis of MSK Back Pain

Careful review of vital signs (current and recorded – including EMS). Persistent hypotension or even an episode of recorded hypotension should warrant further evaluation to rule out other more serious diagnoses (AAA, Pancreatitis, bowel perf, hemorrhage etc). (see article pdf below). PoCUS for AAA is highly sensitive and specific and should be considered in all patients >60 who present with back pain, syncope, transient hypotension etc. Although this study found that Routine Screening for Asymptomatic Abdominal Aortic Aneurysm in High-risk Patients Is Not Recommended in Emergency Departments That Are Frequently Crowded

 

Midline Abdomen, Transverse PoCUS view of the Abdominal Aorta – Spot the abnormality?

 


 

3. Can you reliably differentiate Cardiac Chest pain from Non Cardiac Chest pain by history alone?

Whilst the history is very important in the assessment of a patient with chest pain, it cannot reliably exclude Cardiac Chest Pain. Neither can examination (chest wall tenderness etc). All patients who present to ED with chest pain should have an ECG.

Link to a good article on Non Cardiac Chest Pain here.

 

 


 

Download (PDF, 179KB)

 


 

Download (PDF, 445KB)

 

Continue Reading

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

PURPOSE:

To assess and address dehydration and initiate treatment to prevent further clinical decline in children >6m with vomiting +/- diarrhea triaged CTAS 3,4,5


The hydration guidelines will be implemented in Triage level 3, 4 and 5 children who are greater than 6 months old presenting with a history of vomiting and/ or diarrhea with no abdominal pain other than expected cramping.

See the Guideline Here

 

 

Continue Reading

EM Reflections – December 2016

Thanks to Dr Joanna Middleton for this summary

Edited by Dr David Lewis

Top tips from this month:


Inotropes in Cardiogenic Shock

1)  Time-to-revascularization is one of the primary determinants of survival in patients with cardiogenic shock secondary to ACS so early consultation with cardiology is needed. Vasopressors and inotropes are a bridge to revascularization.

CAEP 2015 guidelines

Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?

– Recommendation: Cardiogenic shock patients in the ED should receive norepinephrine as the first- line vasopressor. (Strong)

– Recommendation: Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary. (Conditional)


Labs alert

2)  Remember to repeat hemolyzed lab values (especially potassium levels)

what-are-the-causes


Dyspnoea in Pregnancy

3) Asthma in pregnancy – include other pregnancy related causes of SOB (PE, cardiomyopathy, pre-eclampsia etc) in pregnant patients who present with an asthma exacerbation.


SJRH Obstetric Pathway

4)  Pregnant patients – who goes directly to L and D?  Who gets seen in the ED?  See Dr. Sanderson’s suggestions below.

In general, the current triage process for pregnant patients presenting to the ED at > 20 weeks gestation has been working well:

–          Pregnant patients > 20 weeks gestation who have a presenting complaint that may involve a condition relevant to the pregnancy are triaged directly to the Labour and Birth Unit (eg. Abdominal pain, vaginal discharge, vaginal bleeding)

–          Pregnant patients that have a clearly non-pregnancy-related condition, with no apparent risk to the pregnancy, are managed in the ED (eg. Lacerations and minor injuries). Consultation with the Obstetrician on call is available if there are any questions.

–          Pregnant patients with an acute condition with an immediate risk to the maternal health are assessed and managed for that condition in the ED, with urgent consultation to the Obstetrician on call for input regarding any relevant concerns for the pregnancy, including fetal surveillance (eg. Cardiac arrhythmia, acute respiratory compromise, and multiple trauma need to be assessed and managed in the ED as there are not the facilities or the expertise to safely deal with these conditions in the Labour and Birth Unit)

5)  Reminder that Labor and Delivery are able to bring fetal monitor to the ED to assess fetal status.


Posterior Circulation Strokes

arteries_beneath_brain_gray_closer

6)  Review of posterior circulation strokes – I have attached a good review article (BMJ 2014;348:g3175 ).

SUMMARY POINTS

Posterior circulation stroke accounts for 20-25% (range 17-40%) of ischaemic strokes

Posterior circulation transient ischaemic attacks may include brief or minor brainstem symptoms and are more difficult to diagnose than anterior circulation ischaemia

Specialist assessment and administration of intravenous tissue plasminogen activator are delayed in posterior circulation stroke compared with anterior circulation stroke

The risk of recurrent stroke after posterior circulation stroke is at least as high as for anterior circulation stroke, and vertebrobasilar stenosis increases the risk threefold

Acute neurosurgical input may be needed in patients with hydrocephalus or raised intracranial pressure

Basilar occlusion is associated with high mortality or severe disability, especially if blood flow is not restored in the vessel; if symptoms such as acute coma, dysarthria, dysphagia, quadriparesis, pupillary and oculomotor abnormalities are detected, urgently seek the input of a stroke specialist


Ordering CT Angio

vein_of_galen_ax_direct_av_arrow

7)  Reminder to request CTA for patients with persistent neurological deficits suggestive of CVA.


Thanks

Joanna

Download (PDF, 447KB)

Download (PDF, 1.27MB)

Continue Reading

EM Reflections – October 2016

Thanks to Dr Joanna Middleton for this summary

Edited by Dr David Lewis

 


1)  A fracture of the ulna should raise suspicion for a radial head dislocation (i.e. -Monteggia) – these can be subtle.  Proper elbow x-ray films assist in the diagnosis –  look at the radiocapitellar line to r/o radial head dislocation.

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Monteggia_fracturedislocations_Emergency_Department_setting/

figure-1_1372210_monteggia-type-1_ulna-shaft_lat


2)  The posterior interosseous nerve is the most common neuropraxia seen with a Monteggia fracture-dislocation  The PIN is a branch of the radial nerve and is the motor supply to most of the extensor muscles (thumb and wrist extension).

22_thompson_aprch_06_540n


3)  A lactate >4 is a red flag and is associated with higher mortality, particularly if the lactate does not rapidly clear.

http://sinaiem.org/10278-2/

Prognostication: Lactate predicts badness and whether your treatment for badness is working.

capture-1024x346


4)  Crohn’s patients are at risk for intrabdominal abscess, in particular, psoas abscess.  Consider this diagnosis in Crohn’s patients who present with hip pain, particularly if their pain is increased by hip extension

42475ed112f1ca5e40e2cec9e3ffdc7b-1

 

images


5)  EtOH and head injury….low threshold for CT, particularly if there are any focal neurological findings.

iv-fluids-for-alcohol-intoxication


 

6)  EMS records are not always available when we initially see a patient but they often have helpful information.  It is worthwhile to have a look at them, particularly if the history from the patient is vague.

hi-kw-ems

Continue Reading

SJRHEM Photo Contest 2016

We are very excited to announce the 2016 SJRHEM Photo Contest. This photography competition is open to all personel who work in the Saint John Regional Emergency Department in any role including clinical, admin, support, volunteers etc.

The themes of this competition mirror our mission statement and now include a new ‘open’ category:

CARING, RESPECT, INTEGRITY AND FAIRNESS

WHILE WORKING AS A PROGRAM TO ACHIEVE EXCELLENCE

Our aim is to improve the look and feel of our facility, for both staff and patients, by decorating the walls and corridors with high quality, thought inspiring photographic artwork that reflect the themes above.

CARING

Genuine concern for the well-being of others

caring


RESPECT

The dignity of all people

respect


INTEGRITY

Honest with strong moral principles

Dalai_Lama_1430_Luca_Galuzzi_2007crop


FAIRNESS

Making judgments that are free from discrimination

fairness


New OPEN CATEGORY

Landscapes, Architecture, People, Animals etc

2014-03-26 08.46.27

There will be a winner for each category and an overall winner. All will receive a framed print of their winning photo. The overall winner will be awarded the “Winner of the SJRHEM Photo Contest 2016” award.

The closing date for applications is October 10th 2016.

Click Here for More Information (Rules, Entry Forms etc)

Each entry must be accompanied by a separate application form and necessary consent forms.

Each entry must be emailed to :admin@sjrhem.ca  (subject: photo contest) or via online entry below

Continue Reading

EM Reflections – May 2016

Presented by Dr Paul Page

Edited by Dr David Lewis

 

Top Tips this month:


Trauma

Reminder to use the NB Trauma – Transfer Protocols

Lower GI Bleed in the Elderly

Because of the broad differential diagnosis for hematochezia, taking a careful medical and surgical history is mandatory to guide the subsequent evaluation. Based on its favorable safety profile, as well as diagnostic and therapeutic capabilities, colonoscopy is the preferred modality for managing patients with severe hematochezia and suspected colonic hemorrhage. Urgent colonoscopy has been reported to increase the diagnostic yield and treatment of bleeding stigmata, as well as reduce the rebleeding rate. While most cases of colonic bleeding can be diagnosed endoscopically and treated appropriately, physicians should be able to recognize the situations when alternatives such as radionuclide imaging, angiographic, or surgical management are indicated.

Colles Fracture

CAST vs Slab
Some debate as to whether a full cast or backslab splint is required after MUA of displaced Colles fracture.
Link to – A practical guide to the application of backslabs, splints, CAM boots and Darco shoes for your paediatric and adult patients.The videos are designed to show you how to do each backslab when required, indications are listed but those that are not are usually discussed with orthopaedics (protocols may vary at different sites). In addition you can follow the links at the bottom for additional tips and videos.
Continue Reading