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

Posted on May 16, 2017 by David Lewis

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

Posted on April 12, 2017 by David Lewis

‘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

Posted on April 12, 2017 by David Lewis

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

Posted on March 14, 2017 by David Lewis

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
monotherapy
low dose
short course

Benzos- reserve for withdrawal
APs

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

Posted on March 14, 2017 by David Lewis

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:

Center for Mindfulness http://www.umassmed.edu/cfm/
Full Catastrophe Living – Jon Kabat-Zinn, PhD
- Guided meditations on CD
The Iris Center in Fredericton
Silent Retreat
Mindfulness Mondays (SJRH)

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ED Rounds – Sickle Cell Anemia

Posted on March 14, 2017 by David Lewis

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

Posted on January 15, 2017 by David Lewis

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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