ED Rounds – Sexual Assault and the SJRH SANE Program

Sexually Assault and the SJRH SANE Program

ED Rounds Presentation by Dr. Robin Clouston and Maureen Hanlon RN, SANE Co-ordinator


The Sexually Assaulted Patient – Evaluation & Management in the Emergency Department

Dr. Robin Clouston

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The Saint John SANE Program

Maureen Hanlon RN, SANE Co-ordinator

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ED Rounds – Oral Rehydration in Children

Pediatric Dehydration and Oral Rehydration

ED Rounds Presentation by: Dr Paul Page


 

  • Volume Depletion (hypovolemia): refers to any condition in which the effective circulating volume is reduced. It can be produced by salt and water loss (as with vomiting, diarrhea, diuretics, bleeding, or third space sequestration) or by water loss alone (as with insensible water losses or diabetes insipidus).
  • Dehydration -refers to water loss alone. The clinical manifestation of dehydration is often hypernatremia. The elevation in serum sodium concentration, and therefore serum osmolality, pulls water out of the cells into the extracellular fluid.

American Family Physician article (2009) – Diagnosis and Management of Dehydration in Children


 


SJRHEM Guideline

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

 


View/Download Full Presentation below:

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ED Rounds – Ortho Clinic Pathway

ED Rounds – Ortho Clinic Pathway

ED Rounds Presentation by Dr Paul Keyes

 


 

A personal perspective on system review and pathway re-engineering…

 


Rationalization of Process

  • —Every consult is entered by ERP into I3 and printed to accompany copy or ED chart and is placed in clinic book, with a patient sticker placed on clinic appointment sheet.
  • —Non-urgent consults are faxed to orthopedic surgeons offices for triage and cue placement with all other primary care referrals
  • —If subspecialty specific consult requested, then this is faxed to the orthopod of choice’s office. If urgent, then the orthopod on call will sort/laterally refer consult in clinic that week

Outcomes

  • —Collaborative approach ED and ortho
  • —Single process for all orthopedic referrals
  • —Identical sorting of: In ED, Clinic, Ortho office/subspecialty referrals
  • —Legible, billable consults
  • —Timely and appropriate consultations/assessments
  • —Orthopod flexibility as to site of consultation/clinic
  • —Appropriate chain of responsibility from Consult to consultant evaluation

 

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ED Rounds – How Big Are Your Stones

‘How big are your stones….David?’

A Renal Colic Presentation by Brian Ramrattan

 


 


 

 


 

Passing a Stone?

  • <5mm likely to pass without intervention
  • >10mm unlikely to pass without intervention
  • Increased intervention requirements with larger stones
  • Likelihood of stone passing also affected by position
    • Stones at the vesicoureteric junction more likely to be passed than those in the proximal ureter

 


 

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ED Rounds – Early Pregnancy

Pregnancy of Unknown Location & Early Pregnancy Loss

Presented by: Dr Robin Clouston

 


 

  • Ruling out ectopic pregnancy is a critical issue in evaluation of the symptomatic patient in early pregnancy
  • In women presenting to ED with abdominal pain or pv bleeding, prevalence of ectopic as high as 13%
  • Well known sequelae of missed ectopic
    • Rupture, tubal infertility, possible death
  • Sequelae of false positive diagnosis of ectopic
    • Termination of viable, desired pregnancy

 


Sonographic findings in Ectopic

  • Adnexal mass
    • Simple adnexal cyst – low probability ectopic if < 3mm (5%)
    • Complex adnexal mass – high probability ectopic (90%)
    • Most common location: ampullary or isthmic portion of fallopian tube (95% of ectopics)
  • Isolated free fluid in the pelvis
    • Rarely the only sonographic finding
  • Pseudogestational sac – seen in at most 10% ectopic
  • Normal scan – 15 to 25%

Utility of US with low βHCG

  • ACEP recommends:

“Proceed to transvaginal ultrasonogaphy in symptomatic patients with βHCG less than 1000.”

  • Comprehensive transvaginal ultrasonography has a moderate sensitivity to detect IUP with βHCG < 1000
    • 40 to 67% sensitive
  • For patients whose final diagnosis is ectopic:
    • When βHCG < 1000, TVUS had 86 to 92% sensitivity to detect findings suggestive of ectopic

Safety of Discharge

  • NJEM 2013:3
    • there is limited risk in taking a few extra days to make a definitive diagnosis in a woman with a pregnancy of unknown location who has no signs or symptoms of rupture and no ultrasonographic evidence of ectopic pregnancy.
  • Progression of hCG values over a period of 48 hours provides valuable information:13
    • If failure to fall by 15%
    • And failure to rise by 55%
    • …most likely diagnosis is ectopic pregnancy

Morin L et al. Ultrasound Evaluation of First Trimester Complications of Pregnancy. J Obstet Gynaecol Can 2016;38(10):982-988

 

 


 

A reasonable approach

In the pregnant patient with vaginal bleeding and / or abdominal pain:

  • Always perform bedside US to establish ?definitive IUP
  • Do not rule out ectopic pregnancy in patients with empty uterus and βHCG < 1000
  • Do obtain a comprehensive TVUS when bedside US does not confirm IUP regardless of βHCG

In the pregnant patient with vaginal bleeding and / or abdominal pain:

  • When TVUS is delayed or remains non-diagnostic, involve obstetrician to aid in risk stratification and management
  • Reliable, hemodynamically stable patients may be discharged with follow up
  • Expedited TVUS (next day)
  • Repeat βHCG in 48h

 


 

Take Home Points

  • Do obtain a comprehensive TVUS when bedside US does not confirm IUP regardless of βHCG
  • Do not rule out ectopic pregnancy in patients with empty uterus and βHCG < 1000
    • Clinical judgment: safe discharge planning vs admission
    • Low threshold to involve Obs-Gyn for these cases
  • Early pregnancy loss is diagnosed by US when:
    • CRL >/= 7mm with no FRH
    • Mean sac diameter >/= 25mm and no embryo
  • Expectant, medical and surgical management are equally effective and safe in treatment of EPL
    • Patient preference may guide decision making

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ED Rounds – Delirium in the ED

Delirium in the ED: How can we help?

Presented by: Dr Cherie-Lee Adams

 


Incidence of Delirium

  • 40% admitted patients >65yo
  • 10-20% on admission
  • 5-10% more during admission

Increased Risk of Delirium:

  • Male
  • >60yo, more prevalent >80yo
  • Hearing/visual impairment
  • Dementia
  • Depression
  • Functional dependence
  • Polypharmacy
  • Major medical/surgical illness


DSM-V Criteria

  • A) Disturbance in attention and awareness
  • B) Disturbance is ACUTE
  • C) Concurrent cognitive impairment
  • D) Not evolving dementia, nor coma
  • E) Can be explained by Hx/Px/Ix

 


 

Non – Pharmacological Approach

  • Nutritional support
  • Optimize hearing/sight
  • Maximize day/night/date/time cues
  • Minimize pain
  • Rehabilitate- ambulate, encourage self-care
  • Avoid restraints

Pharmacological Options

  • Treat only if distress/agitated/safety concern
      • don’t treat hypoactive delirium, wandering, or prophylactically
  • monotherapy
  • low dose
  • short course
  • Benzos- reserve for withdrawal
  • APs
        • Haldol 0.25-0.5mg
        • risperidone 0.25mg od-bid
        • olanzapine 1.25-2.5mg/d
        • quetiapine 12.5-50mg/d

 

Take Home Points

  • Delirium is common, esp in elderly
  • Significant morbidity/mortality associated
  • Brief screening with DTS/bCAM works
  • Intervention focus on limiting pathology, normalizing activities, minimizing drugs
  • Low dose APs for short period for agitation

 


 

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ED Rounds – Compassion Fatigue and Burnout – Dr Jenn Hannigan

Preventing Compassion Fatigue and Burnout

Presented by: Dr Jenn Hannigan MD CCFP(PM)

 

The practice of medicine is:

an art, not a trade;

a calling not a business;

a calling in which your heart will be exercised equally with your head.

-Sir William Osler


Compassion Fatigue:

  • “the cost of caring”
  • Secondary or vicarious traumatization
  • Symptoms parallel to PTSD
    • Hyperarousal (poor sleep, irritability)
    • Avoidance (“not wanting to go there”)
    • Re-experiencing (intrusive thoughts/dreams when triggered)

Burnout:

  • Emotional exhaustion
  • Reduced personal accomplishment and commitment to the profession
  • Depersonalization
    • A negative attitude towards patients
    • Personal detachment
    • Loss of ideals

 

How can we mitigate burnout:

  • Mindfulness Meditation
  • Reflective Writing
  • Adequate supervision and mentoring
  • Sustainable workload
  • Promotion of feelings of choice and control
  • Appropriate recognition and reward
  • Supportive work community
  • Promotion of fairness and justice in the workplace

 

Between stimulus and response there is a space.

In that space is our power to choose our response.

In our response lies our growth and our freedom.

  -Viktor Frankl


 

 


Getting Started with Meditation:

 


 

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ED Rounds – Sickle Cell Anemia

Sickle Cell Disease

Presented by: Dr Paul Vanhoutte

 

As we welcome new families to New Brunswick from the Middle East and Africa, we are likely to see an increased incidence of sickle cell emergencies.  Needs assessments in Canada have shown that Emergencies Physicians outside of the major urban centres lack experience and knowledge in dealing with this disease.

 

 

Global distribution of the sickle cell gene – from: http://www.nature.com/articles/ncomms1104

Emergency Presentations

  • Acute painful episodes
  • Acute anemic crisis
  • Acute aplastic crisis
  • Acute chest syndrome
  • Infection
  • Splenic sequestration
  • Cerebrovascular events
  • Avascular necrosis
  • Renal complications
  • Hepatobiliary complications
  • Ophthalmic complications
  • Priapism

 

A recent article and podcast in EM Cases provides a great outline on  – Emergency Management of Sickle Cell Disease

 

Take Home Points

  • Treat sickle – acute painful episodes with opiate analgesia.
  • Normal vital signs do not exclude sickle – acute painful crisis.
  • High index of suspicion for associated sepsis ( meningitis, septic arthritis, osteomyelitis, pneumonia, pyelonephritis)especially if they have a fever
  • Check renal function before prescribing NSAIDS
  • Supplemental Oxygen only if hypoxic (<92%)
  • IV fluids only required if hypotensive/ hypovolemic

 

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ED Rounds – Lyme Disease – Dr Paul Frankish

Lyme Disease: Update and recent controversies

Presented by Dr Paul Frankish

 

 


 Link to NB Health Lyme Disease Information


Transmission

  • Borrelia burgdorferi
  • Tick-borne spirochetal bacteria
  • Ixodes scapularis and Ixodes pacificus
  • Field mice, birds and white-tailed deer

Discovered in Lyme, Connecticut  by Dr. Burgdorfer, investigating an abnormal cluster of juvenile RA. Other common tick-borne illnesses are transmitted through the lone star tick (Amblyomma americanum) and the American dog tick (Dermacentor variabilis) that transmit ehrlichiosis and Rocky Mountain spotted fever, respectively.  The ticks serve as the vector between the animal population and humans.  Deer are the preferred host for ticks, and the tick population is highest when deer are present, but the actually pick up the Borrelia from small mammals mostly.


Identification

A) is an Argasid (soft tick, Ornithodoros turicata)

B) has a scutum, long body butshort mouth parts (dog tick, Dermacentor variabilis)

C) is Ixodes scapularis(!)

D) has a scutum, but has a short and stout body – it also has a “lone star” on its body (lone star tick, Amblyomma americanum)


Erythema Migrans Pearls

  • Often just a macule with no central clearing (20-30%)
  • Classically 1-2 weeks from time of tick bite, but anywhere from 3-30 days
  • Some patients may either not have it or notice it
  • May have multiple lesions
  • Rashes within 2 days are usually an immune reaction to tick saliva


Clinical Pearls

  • Always take clinical context into consideration
  • If IgM positive and IgG negative greater than 4 weeks since infection, likely false positive
  • Do not use the test in the setting of EM rash
  • Consider testing if all satisfied:
    • Lyme endemic area
    • Risks for exposure
    • Any features of disseminated or late disease

Testing


Prophylaxis

  • Common ED presentation
  • If attached less than 36 hrs or not Ixodes scapularis, then risk is very low
  • Criteria for prophylaxis (need all)3:
    • Ixodes scapularis
    • Attached longer than 36 hrs
    • Prophylaxis within 72 hrs of removal
    • Greater than 20% local tick infection rate
  • Single dose of Doxycycline 200 mg or 4mg/kg for children greater than 8 years old
  • Children < 8yrs
    • Not sufficient evidence to recommend any other regimes
    • A “watch and wait” approach is recommended in these cases

Full Presentation with Notes

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NB Health Lyme Disease Update Jan 2017

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