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

 


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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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ED Rounds – EM Teaching Techniques – Dr James French

EM Teaching Techniques

Presented by Dr James French

 


Read the RSI Drugs Summary first – LINK

1. We are going to have a flipped classroom discussion about RSI drug doses. Flipped classroom sessions require you do a little work beforehand. Please find attached a brief summary of RSI drug doses and a podcast with slides to use. It wont take long. http://sjrhem.ca/sjrhem-podcast-rsi-drugs-basics/

2. We are going to do a deliberate practice session using micro skills on laryngoscopy (which should be fun) to illustrate how microskills and deliberate practice works…..

3. We will then have a discussion around performance and behaviour as a stand alone competence….

4. And then how this all ties into simulation….


 

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ED Rounds – EM and Hand Surgery – Dr Don Lalonde

EM and Hand Surgery

Presented by Dr. Don Lalonde

An excellent double presentation by Dr Don Lalonde, who wanted to start his presentation by thanking the ED staff (Physicians and Nurses) for all their help over the last few years. A selection of relevant papers from his numerous publications are included at the end of this report.

 


 Digital Block

“Wide awake local anaesthetic no tourniquet”

Epinephrine in the finger is safe (see references attached below)
Phentolamine reversal – starts at 5mins completely reverse at an 1hr (dose is 1mg). Although rarely required.
Cause of the myth – (born before 1950) – Procaine was responsible (ph 3.6 – became more acidic on shelf – down to 1.0)

SIMPLE Block

Single subcut
Injection
Middle
Prox Phal
Lidocaine
Epinephrine
In the fat not in flexor sheath
Don’t stick needle in nerve. Near nerve not in it….
Use 27 needle or 30G
Use 2cc syringe
60sec less painful than 2sec – therefore go slow
Push skin into needle rather than vice versa (sensory noise)
Get through dermis
But doesn’t get dorsum of finger
So 2nd needle injection required
Lidocaine with Epinephrine = 10hrs
Lidocaine without Epinephrine = 5hrs
Bupivicaine – pain returns at 15hrs, pressure touch 30hrs
But not cardiac friendly
Can rescue with Intralipid

Median nerve Block

10ml better than 5ml
But takes 1 hr to get finger numb
Wait a minimum of 40mins
Therefore tumescent local anesthesia may be better for us

How to stop causing Pain

Let every patient teach you- get them to score you
Ask them to tell you when the needle pain has stopped
Then again if they feel any new pain (drop shot for each pain – hole-in-one, eagle, birdie, par, bogie)
Wheelock study – no difference between dorsum or palm for pain of injection

Hole-in-one block

  • Slow
  • 5 mins to get hole in one
  • Need enough volume
  • Need to see or feel
  • 27g needle will force you to slow down – use 10 cc
  • pH
    • add 1cc Bicarb 8.4% ph 4.2 becomes 7.4
  • No alcohol prep (causes pain)
  • Push skin into needle rather than vice versa (sensory noise)
  • Don’t wobble
  • 2 hand technique
  • Thumb on plunger
  • Go perpendicular (90 deg)
  • Dont inject in dermis (If inject in dermis will see peau d’orange)
  • 2cc under skin, then wait
  • inject LA before advancing needle
  • “Blow slow before you go”
  • Feel where is the LA going
  • Needs to be 2 cm below where its going
  • If pink , not worked
  • Wait at least 30mins for block to work
Dose
7mg per kg old safe dose (1% Lidocaine plus 1:100000 Epinephrine)
therefore – for most adults – 50cc is safe
And can dilute down to 0.5% or even 0.25% (by using N/Saline)
Same LA effect, bigger volume can be used
May need to add more bicarb

Note –

1:1000 Epinephrine (e.g EpiPen) – will result in white digit for over 24hrs
Therefore should treat accidental epinephrine injections – ischemic re-perfusion pain, and ischemic neuropraxia  – so use phentolamine

For Lacerations

Inject directly into fat, through wound
Then slow – as above
Non sterile gloves okay for suturing injury lacerations

Tibial hematoma

60-80 cc with diluted 1/2 strength 1%lido
Blow the crap out of it

Wounds

Don’t let exposed bone, joint tendon ‘dry and die’
Daily wash with clean bottle water
Vaseline cover to prevent drying
Must get vaseline off between wash and new vas

Finger tips

Secondary intent
Vaseline
wash with water
vaseline on Coban
Fingertip flap surgery can be problematic
Flaps cause log term problems, insensate, bulky etc
Although 2nd intent maybe slower initially, better in long run
Not if it crosses a joint

Fractures

Metacarpal fracture – Only need ORIF if scissoring
for stable MC fracture
Splint – removable
?buddy taping
Patient info – “Don’t do anything that hurts”
Boxers
Immobilisation
No diff between flexed or extended

Tendon injuries

Please close the skin over injury then refer

Papers

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ED Rounds – September 2016

Report by Kraig Worrall

DMNB Clinical Clerk Med3

 


 

Pre-oxygenation for Intubation – Dr Jay Mekwan

Oxygenation is essential in the management of critically ill patients. Intubation in the emergency department is a critical skill in improving patient outcomes. When indicated, intubation should be performed by skilled personnel to minimize hypoxia. Desaturation in the peri-intubation period can happen quickly – particularly in pediatric, bariatric and critically ill patients. Today in rounds, Dr. Mekwan reviewed recent evidence in the realm of pre-oxygenation. Bag Valve Mask (BVM) pre-oxygenation alone outperforms: (1) BMV with concurrent nasal cannula, (2) non-rebreather mask, and (3) non-rebreather mask with concurrent nasal cannula. Using a nasal cannula together with BMV compromises the mask seal, which leads to inferior pre-oxygenation performance. A nasal cannula should be applied after BMV and before intubation and remain in place during the intubation process. Discussion in rounds centered around strategies to improve peri-intubation O­2 saturations, and ultimately improve outcomes in the Saint John Emergency Department. Finally, the use of ketamine in rapid sequence intubation was also discussed.

 

Reference:

http://www.sciencedirect.com/science/article/pii/S0196064411016672

 


 

Blunt chest trauma – Dr. Andrew Lohoar

Although blunt chest traumas can present to the emergency department from a variety of etiologies, motor vehicle collisions and falls account for the majority of cases. This statistic holds true in Saint John, for which Dr. Lohoar presented some recent data (see slides). Several important conditions arising from blunt chest trauma were discussed, including lung contusion, hemothorax (HTX), cardiac tamponade and pneumothorax (PTX). In particular, discussion was centered around decisions surrounding chest tube placement for PTX and HTX. Emergency chest tube insertion is the definitive initial management for either of these potentially deadly presentations. The decision to place a chest tube in a hemodynamically stable patient with radiological evidence of PTX following blunt trauma is influenced by a number of factors. Today in rounds, we discussed how experience is paramount to successful chest tube placement. The balance between practitioner experience and patient’s need for urgent decompression must be considered. Complications from improperly placed chest tube can contribute significant morbidity. Initial observation of an otherwise stable patient can certainly be the right choice for emergency room staff with limited chest tube experience. The same can be true for patients requiring hospital transfer.

Additional teaching points included: the use of POCUS as part of the primary survey, the role of CT and CT-decision rules, the disposition of blunt chest trauma patients, and, finally, strategies to reduce complications when placing chest tubes.

 


 

Managing violent patients – Dr. Jo-Ann Talbot

For many patients, emergency departments are the gateway into medical care. This includes violent patients, who, despite their behaviour, are sick and in need of care. This presentation, by Dr. Talbot, described strategies for managing violent patients. Strategies when faced with a violent patient include; (1) Calling for help, (2) controlling the scene, (3) de-escalating the situation. Fundamental to de-escalation is recognizing signs of an impending crisis. As with other aspects of medicine, prevention is better than reaction. Recognizing a patient’s needs can prevent a violent episode, for example, a simple gesture of food, nicotine replacement, or medication can calm a tense situation, develop a therapeutic trust with the patient, and prevent physical violence.

When a situation moves beyond prevention, physical and chemical restraints become viable options to reduce harm to the patient, staff, and assets. When physical restraints are used, it requires a team of 5 trained individuals. If possible, the treating physician should not participate in restraining the patient, as this can be deleterious to the therapeutic relationship. Agents, dosing, and strategies for chemical restraint are reviewed in the attached presentation.

Finally, Dr. Talbot emphasized the need for a centre/region-wide protocol for violence in the ED that is understood and implemented by all staff.

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