>EM Reflections – September 2019

Thanks to Dr Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


Discussion Topics

  1. Refractory Hypotension / Sepsis – ‘ringing the changes

  2. Hypertensive Urgency / Emergency – “I was sent to the ER by the pharmacy checkout assistant

  3. Investigation Reports / Systems / Adverse Events


Refractory Hypotension / Sepsis

 

This interesting historical perspective from NPR makes an interesting read on the origins of Normal Saline

As it turns out, normal saline isn’t very normal at all. The average sodium level in a healthy patient is about 140 (as measured in something called milliequivalents per liter). For chloride, it’s about 100. But the concentration of both sodium and chloride in normal saline is 154. That’s pretty abnormal—especially the chloride.

Sidney Ringer (click for biography)

 

 “Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline.” Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adultsN Engl J Med. 2018;378:829-839.

Data Suggests Lactated Ringer’s Is Better than Normal Saline – ACEP Now

PulmCrit- Get SMART: Nine reasons to quit using normal saline for resuscitation

Take Home

  • Re-consider cause of hypotension in patients not responding to IV fluid resuscitation.
  • High mortality for elderly patients presenting to ED with hypotension.
  • Early switch to Ringers Lactate for IV fluids if needed for large volume resuscitation in sepsis.
  • If a British doc asks for Hartman’s, use Ringer’s… it’s the same.

 


 

Hypertensive Urgency / Emergency

Although elevated blood pressures can be alarming to the patient, hypertensive urgency usually develops over days to weeks. In this setting, it is not necessary to lower blood pressure acutely. A rapid decrease in blood pressure can actually cause symptomatic hypotension, resulting in hypoperfusion to the brain

RxFiles.ca summary pdf

How should I manage patients who present with a hypertensive urgency — i.e. BP > 180/120 mm Hg without impending or progressive end-organ damage (e.g. patient with headache, shortness or breath or epistaxis)?

  • For patients with hypertensive urgencies
    • Optimize (or restart) their current treatment regimens
    • Consider oral short-acting agents (e.g. captopril, labetalol, clonidine)
    • Do not treat aggressively with intravenous drugs or oral loading
    • Ensure that the patient has a follow-up appointment within a few days

How should I manage patients who present with a hypertensive emergency — i.e. BP > 180/120 mm Hg and impending or progressive end-organ damage (e.g. neurologic, cardiovascular, eclampsia)?

  • Reduce BP immediately with intravenous drugs, and monitor BP continuously in an intensive care setting.
  • Consider using the following drugs:
    • Vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, nitroglycerin, enalaprilat, hydralazine
    • Adrenergic blockers: labetalol, esmolol, phentolamine
  • Do not use short-acting nifedipine (lowers BP fast enough to provoke ischemia).
  • Aim for 25% reduction of the mean arterial blood pressure within minutes to 1 hour o Then if the patient is stable, reduce BP to 160/100-110 mm Hg over 2-6 hours and normalize within 24-48 hours.
  • Exceptions include stroke (unless BP is lowered to allow thrombolytic agents to be used) and dissecting aortic aneurysm (target systolic BP is < 100 mm Hg if possible).

from GAC Guidelines

Episode 40: Asymptomatic Hypertension

 

Take Home

  • Most patients with elevated BP (greater than 180/110) that are asymptomatic can safely follow up with Family Doctor.
  • True hypertensive emergencies are infrequent.
  • If mild symptoms consider starting antihypertensives in ED if unsure about follow up.
  • No good evidence that starting in antihypertensives ED for patients that can access their Family Doctor within next few days improves outcomes.

 


 

Radiology Reports / Systems / Adverse Events

 

Failure to follow up on radiology studies has become a frequent claim against both EPs and radiologists, according to Darien Cohen, MD, JD, an attending physician at Presence Resurrection Medical Center and clinical assistant professor in the Department of Emergency Medicine at University of Illinois, both in Chicago.

  • ED policies should ensure that all radiology alerts are available in a single location, and it must be clear who is responsible for follow-up.
  • Follow-up must be clearly documented in the medical record.
  • Any incidental finding mentioned on the radiology report should be communicated to the patient, and this communication must be clearly documented in the medical record.

 

Adverse Events Related to Emergency Department Care: A Systematic Review

A greater proportion of AE were preventable among the discharged population (71.4%; n = 15) than among the admitted population (40.9%; n = 9). Among discharged patients, management issues (47.6%; n = 10), diagnostic issues (33.3%; n = 7), and unsafe dispositions decisions (19%; n = 4) were the most common causes of AE

 

Safeguards in the system of care are like slices of cheese with holes representing possible failure points. See the Swiss Cheese Model at CMPA.ca

 

WTBS 9 – EM Quality Assurance Part One: Improving Follow up from the ED

 

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