>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

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