>EM Reflections – November 2019

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 


Discussion Topics

  1. Popliteal Artery Thrombus

    • Closed loop communication is key to avoid possible poor outcomes with follow up
    • Relying on other specialties to arrange follow up with ED patients can result in error. Direct contact with specialty to arrange urgent follow up is the best approach
    • Also make sure patient is aware of plan
  1. Vertebral Artery Dissection / Thrombus

    • A thorough neurological exam and documentation is essential for vertigo presentation
    • Can’t walk, Can’t go home
  2. Elderly Delirium / Dementia with Sepsis

    • Majority of delirious patients are quiet and withdrawn, not hyperactive
    • For patients with dementia , get baseline functioning from family if possible

Popliteal Artery Thrombus

The full differential diagnosis should be considered in possible cases of DVT including Baker’s cyst, cellulitis, lymphedema, chronic venous insufficiency, superficial thrombophlebitis, popliteal venous or arterial aneurysm, peripheral vascular disease, enlarged lymph nodes compressing the veins, heterotopic ossification, hematoma, and muscle tears.

 

Ultrasound for Lower Extremity Deep Venous Thrombosis
Multidisciplinary Recommendations From the Society of Radiologists in Ultrasound Consensus Conference

It’s Not All Deep Vein Thrombosis: Sonography of the Painful Lower Extremity With Multimodality Correlation

 

Consultations and Referals

One of the most common ways for doctors to collaborate is through referral and consultation. Poor communication between referring physicians and consultants can lead to disruptions in care, delayed diagnoses, unnecessary testing, iatrogenic complications, and frustrated physicians and patients. Improving the referral-consultation process is one of the most effective ways of providing safer care and reducing the risk of medical-legal difficulties.

  • What is the question I want answered?
  • Who has the specialized knowledge and skill to answer it?
  • How urgent is the clinical situation?
  • Do I need advice from the consultant or would a transfer of care to the consultant be more appropriate in the specific circumstances?
  • Have all the appropriate steps been taken to this point?
  • Has the patient consented to the referral?

CMPA Guidance on Referrals

 

 


Vertebral Artery Dissection / Thrombus

See these SJRHEM Reflections post on the same subject:

EM Reflections – March 2017

EM Reflections – May 2019

 

and this post on the HINTS exam:

HINTS exam in Acute Vestibular Syndrome

 

 

 

 


Elderly Delirium / Dementia with Sepsis

The fluctuating presentation of delirium makes it difficult to recognize but we should be attentive to certain hallmarks, including alterations in attention and awareness and acute changes in cognition.  These can be associated with hallucinations or other perceptual disturbances.  Collateral information and family input can be critical in detecting changes from baseline function and cognition.  The more acute temporal course of delirium is important to distinguish from underlying dementia, which is itself one of the most important risk factors for delirium.  The most common presentation, the hypoactive form, is a quiet, subdued, withdrawn state.

The Seriousness of Deliriousness: Delirium in the ED

 

See this SJRHEM Rounds

ED Rounds – Delirium in the ED

 

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