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

 

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

 

 

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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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