Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008...

Copyright: Dr. Brian Weitzman, Department of Emergency MedicineUniversity of Ottawa April 2008

Emergency TopicsBack to Basics

2008

Dr. Brian WeitzmanDepartment of Emergency Medicine

Ottawa Hospital


Review of 14 Common Emergency Medicine Topics

• Acute Abdominal Pain

• Acute Dyspnea

• Hypotension/Shock

• Syncope

• Coma

• Cardiac Arrest


Emergency Medicine Topics continued

• Urticaria/Anaphylaxis

• Malignant Hypertension

• Animal Bites

• Burns

• Near-drowning

• Hypothermia

• Poisoning


Abdominal PainMCC Objectives

1. Common causes of pain– intra and extra abdominal, metabolic– Localized vs diffuse– Peritoneal signs vs no peritoneal signs

2. Neurologic basis of pain3. Perform focused detailed hx4. Focused examination: vitals, abd, rectal, pelvic GU5. Interpret clinical and lab data6. Management plan for pts with abd pain7. Which patients need immediate attention and treatment8. Manage common causes of abdominal pain9. Unusual causes of pain in elderly and immunocompromised


Case 1:

Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ.

What disease process is this typical for?

What causes the change in the pain pattern?

What other diseases must you consider?


Neurologic Basis of Abdominal Pain

• Visceral

• Somatic

• Referred


Visceral vs Somatic Abdominal Pain

• Where are these fibers located?

• What stimulates them?

• Where is pain perceived with stimulation?

• What are associated symptoms or signs?


Visceral Abdominal Pain

• Stretch receptors in walls and and capsules of hollow and solid organs

• Stimulated by distention, inflammation, or ischemia

• Unmylinated fibers return to both sides of the spinal cord at multiple levels

• Brain cannot localize source


Visceral Abdominal Pain

• Pain felt as crampy, dull, achy, poorly localized

• Associated with autonomic responses of palor, sweating, nausea, vomiting

• Patients often writhing around – Movement doesn’t alter pain


Somatic Abdominal Pain

• Receptors located in parietal peritoneum

• Returns to ipsilateral dorsal root ganglion at 1 dermatomal level

• Sharp, localized pain

• Causes tenderness, rebound, and guarding

• Patients lie still, movement increases pain


Referred Pain

• What is it?

• What are some examples?


Referred Pain

• Pain perceived in an area that is distant from the disease process

• Due to overlapping nerve innervations

• Ex. Shoulder pain with diaphragm stimulation


Examples of Referred Pain

• Shoulder pain with diaphragm stimulation– C 3,4,5 stimulation

• Back pain with biliary colic, pancreatitis, or PID


Differential Diagnosis

Suprapubic

Epigastric

DIFFUSE


Differential Diagnosis

Suprapubic

Epigastric

DIFFUSE

DIFFUSE PAIN Peritonitis Acute pancreatitis Sickle cell crisis Early appendicitis Gastroenteritis Dissecting/rupturing aneurysm Intestinal obstruct Diabetes

EPIGASTRIC Peptic ulcer disease Pancreatitis MI Gastritis

SUPRAPUBIC Cystitis PID Endometritis Endometriosis


MCC-Causes of Abd PainDiffuse

With peritoneal signs– Perforated viscus– AAA rupture– Small bowel infarction/obstruction– Bacterial peritonitis

No peritoneal signs– Gastroenteritis– Irritable bowel syndrome– Constipation– Metabolic disease


Causes of Abd Pain - Localized

RUQ LUQ

RLQ LLQ

Epigastric


Differential DiagnosisWhich has peritoneal signs?

Biliary Colic/Cholecystitis Hepatitis / Hepatic Abscess Pneumonia / PleurisyAppendicitis

Appendicitis

Splenic Infarction Splenic Rupture Splenic AneurysmPneumonia

RUQ LUQ

RLQ LLQInflammatory bowel disease Diverticulitis Ectopic Ruptured Ovarian CystSalpingitis/PID Renal Stones/UTI Testicular torsionPsoas abscessIncarcerated Hernia

Gastritis,GERD/PUD

Pancreatitis

MI


Differential DiagnosisWhich has peritoneal signs?

Biliary Colic/Cholecystitis Hepatitis / Hepatic Abscess Pneumonia / PleurisyAppendicitis

Appendicitis

Splenic Infarction Splenic Rupture Splenic AneurysmPneumonia

RUQ LUQ

RLQ LLQInflammatory bowel disease Diverticulitis Ectopic Ruptured Ovarian CystSalpingitis/PID Renal Stones Testicular torsionPsoas abscessIncarcerated Hernia

Gastritis,GERD/PUD

Pancreatitis

MI


Case 1:

Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ.


Case 1: Questions

1. What further history do you need from the patient?

2. What would you do in your physical exam?

3. What are you looking for on physical examination?

4. What initial stabilization is required?

5. What is your differential diagnosis?


History Onset / Duration Nature / Character / Severity Radiation Exacerbating / Relieving Factors Location Associated Symptoms

Nausea / Vomiting Diarrhea / Constipation / Flatus Fever Jaundice / other skin changes GU (dysuria, freq, urgency, hematuria…) Gyne (menses, contraception, STDs,,,)

PMHx Prior Surgery Medical Problems

Medications


High Yield Questions


High Yield Questions

1. How old are you? Advanced age means increased risk.

2. Which came first—pain or vomiting? Pain first is worse (i.e., more likely to be caused by surgical disease).

3. How long have you had the pain? Pain for < 48 hrs is worse.

4. Have you ever had abdominal surgery? Consider obstruction in patients who report previous abdominal surgery.

5. Is the pain constant or intermittent? Constant pain is worse.

6. Have you ever had this before? A report of no prior episodes is worse.

7. Are you pregnant? Test for pregnancy - consider ectopic.


High Yield Questions cont’d8. Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease? All are suggestive of more serious disease.

9. Do you have human immunodeficiency virus (HIV)? Consider occult infection or drug-related pancreatitis.

10. How much alcohol do you drink per day? Consider pancreatitis, hepatitis, or cirrhosis.

11. Are you taking antibiotics or steroids? These may mask infection.

12. Did the pain start centrally and migrate to the right lower quadrant? High specificity for appendicitis.


High Yield Questions, cont’d

13. Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation? Consider mesenteric ischemia and abdominal aneurysm.

Reference from:Colucciello SA, Lukens TW, Morgan DL: Emerg Med Pract 1:2, 1999.Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.


Physical Examination


Physical Examination

• Vitals

• General appearance: writhing/motionless, diaphoresis, skin, mental status

• Always do brief cardiac and respiratory exam

• Abdominal exam: inspect, auscultate, percuss, palpate

• Pelvic, genital and rectal exam in ALL patients with severe abdominal pain

• Assess pulses!

• Remember: very young and very old patients may present atypically - don’t get mislead by this!


Abdo Exam: Specifics• Always palpate from areas of least pain to areas with

maximal pain

• ?Organomegaly, ?ascites

• Guarding: voluntary vs. involuntary

• Bowel sounds: increased/decreased/absent

• Rectal exam: occult/frank blood, ?stool, ?pain, ?masses

• Pelvic exam: discharge, pain, masses

• Peritonitis

– suggested by: rigidity with severe tenderness, pain with percussion/deep breath/shaking bed, rebound


Risk Factors for Acute Disease

• Extremes of age

• Abnormal vital signs

• Severe pain of rapid onset

• Signs of dehydration

• Skin pallor and sweating


Initial Stabilization


Initial StabilizationAll patients with acute abdominal pain:

Assess vital signs

Oxygen

Cardiac Monitoring/12 lead ECG

Large bore IV (may need 2)

250-500 cc bolus of NS in elderly with low BP

500-1000 cc bolus in younger patients with low BP

Consider NG and Foley catheter

Brief initial examination : history and physical

Consider analgesics

??Do they need immediate surgical consultation?


Pain: ER Management

• Is it OK to give a patient pain medications before you determine their diagnosis?


Abdominal Pain: ER Management

• Anti-inflammatories (NSAIDs):– po/pr/iv; very effective, esp. for MSK pain

– ensure no allergy, renal disease, CHF, concurrent NSAIDs, active bleeding; recent hx of PUD is relative contraindication

– Ex. Ketorlac (Toradol) 30 mg IV

• Narcotics– sc/im/iv; wide range of doses, strengths

– care re: sedation, confusion, addiction, etc.

– very effective, esp. for visceral or undifferentiated pain

– Ex. Morphine 2.5-10 mg, hydromorphone 1-2 mg


Nausea/Vomiting: ER Tx


Nausea/Vomiting: ER Tx

• Gravol: po/pr/im/iv– beware of anticholinergic side effects

– sedating, may cause confusion

• Maxeran/Stemetil: iv– beware of possible EPS

– less sedating; may help with pain control

• Domperidone: po/iv– especially useful with diabetic gastroparesis

• Ondansetron: iv– very useful in patients with refractory vomiting

– expensive!


Investigations


InvestigationsMost patients with acute abdominal pain require:

- CBC, differential; may need type and cross-match

- electrolytes, BUN, creatinine

- liver enzymes, liver function tests

- amylase/lipase

- beta-hCG

- urinalysis; stool for OB

They may also need: ECG, cardiac enzymes, ABG, lactate


Investigations

Imaging

ultrasound

CT scan

plain Xrays


What are specific problems related to the emergency room diagnosis and treatment of abdominal pain in the geriatric population?


Abdo Pain: Geriatrics

Elderly patients present some unique challenges in diagnosis and treatment in the emergency room:

-presentations often atypical

-Fever and WBC elevation may not be present

-Guarding and rebound often not present with peritonitis

- more likely to have life-threatening disease

- often quite vague historians

- multiple other medical issues confound the current problem

- pain often causes confusion in elderly patients -


Influence of Aging on Abdominal Pain

Small bowel obstructionPrior Surgery

PUD, PancreatitisMedications

Colonic volvulusImmobility

Large bowel obstruction, intussuception

Carcinoma

Cholecystitis, pancreatitisCholelithiasis

AAA, mesenteric ischemia, ischemic colitis

Atherosclerotic Disease

Resultant DiseaseIncreased Risk in the Elderly


Geriatric Abdo Emergencies• Vascular catastrophies

– AAA - leak or rupture

– Aortic dissection

– Mesenteric ischemia

• Malignant disease– chronic wasting, anemia - less able to tolerate acute insult

– bowel obstruction, intussusception, infarction

• Appendicitis - often atypical presentation; presents after perforation, as sepsis/peritonitis

• Diverticulitis - may perforate, create fistulas, lead to abscess formation


HIV and Abdominal Pain


HIV and Abdominal Pain

• Gastroenteritis: Salmonella, Shigella, Camphlobacter, Giardia, CMV, Cryptosporidium, Mycobacterium avium

• Cholecystitis with or without stones

• Biliary obstruction from neoplasm

• Esophagitis


What is the cause of this 45 y.o. man’s LLQ pain?


What is the cause of this man’s pain?


Why is this woman vomiting?


What is the cause of this man’s abdominal pain?


Summary: Approach to Abdominal Pain in the ER

• Stabilize the patient, and refer early if unstable

• Careful, detailed history

• Focused physical examination

• Early, thorough work-up:– Appropriate laboratory investigation

– Diagnostic imaging where indicated

• Continuous reassessment

• Consider patient circumstances (age, pmhx, reliability, home situation)


Summary: Common Causes of Abdominal Pain

MCC Categorization• Diffuse

– peritoneal signs• Perforated viscus, AAA rupture, bowel ischemia

• Peritonitis

– No peritoneal signs• Gastroenteritis, irritable bowel, constipation

• Metabolic disease


Summary: Common Causes of Abdominal Pain

MCC Categorization• Localized

• Upper– Peritoneal signs: cholecystitis/cholangitis

• Pancreatitis, appendicitis

– No Peritoneal signs:• Epigastric: PUD/gastritis, GERD

• RUQ: biliary colic, hepatitis, abcess

• LUQ: splenic infarct/abcess


Common Causes of Abdominal PainMCC Categorization

• Localized• Lower

– Peritoneal Signs• Bowel: appendicitis, mesenteric lymphadenitis

– Diverticulitis, incarcerated hernia

• Genital: PID, ectopic, ovarian torsion/ruptured cyst

– No peritoneal signs• UTI, renal colic, inflammatory bowel disease, • Psoas abcess


?


Acute DyspneaMCC Objectives

• Differentiate dyspnea from hyperpnea, tachypnea and hyperventilation

• Differentiate Cardiac and pulmonary causes• Focused efficient hx• Interpret clinical and lab data

– Select and interpret lung imaging– Select and interpret heart and lung investigation (ECG<

ABG)

• Diagnose and manage acute dyspnea


What drives us to breath?

• Chemoreceptors in medulla, carotid and aortic bodies respond to increased CO2 or H+ ion or decreased 02.

• Stretch receptors from lungs

• Baroreceptors


Definitions

• Dyspnea:– sensation of shortness of breath

• Hyperpnea: – increase in rate or depth of breathing– Ex. Metabolic acidosis, ASA


Definitions

• Tachypnea: – rapid, shallowing breathing

• Hyperventilation: – breathing in excess of metabolic needs of body

lowering C02 – Need to rule out organic disease


• A 55 year old woman comes in shouting and screaming that she can’t breath.

• She is very agitated, sitting forward, using her accessory muscles.

What is her problem?


Most Common Causes of Acute Dyspnea

• COPD

• Asthma

• CHF

• PE

• Pneumonia

• Pneumothorax


Acute Dyspnea-Cardiac Causes

1. Acute coronary syndrome

2. Myocardial dysfunction1. Ischemic/hypertensive cardiomyopathy2. Valvular dysfunction3. Pulmonary edema4. Dysrhythmia

3. Pericardial disease-tamponade


Acute Dyspnea-Respiratory Causes• Upper airway:

– FB, epiglottis, angioedema, trauma

• Bronchi: – asthma, bronchitis/iolitis, tumor

• Alveoli: – Pneumonia, emphysema, contusion, toxic inhalation,

ARDS


Acute Dyspnea-Respiratory Causes

• Insterstitium and Vasculature:– PE, fibrosis

• Thoracic Cage/lung interface: – Pneumo/hemothorax, effusion

• Respiratory Muscles and Thorax– Rib #, flail, MS, Guillain Barre, Myasthenia


Acute Dyspnea Misc. Causes

• CNS stimulation: – head trauma, ASA, sepsis, mass lesion

• Decreased O2 carrying: anemia, CO, methem

• Metabolic acidosis– MUDPILES

• Hyperthyroidism, Pregnancy, Psychogenic



• She is sitting forward, gasping for air, appears cyanotic, using accessory muscles

What will you do?


Rapid Assessment

• ABC’s : 5 vitals: P, RR, BP, T, 02 sat.

• O2, IV, Monitor, ECG


Rapid Assessment-General

• Ability to speak

• Mental status, agitation, confusion

• Positioning

• Cyanosis: – Central: Hgb desats by 5 g. Not evident in

anemia– Peripheral: mottled extremities


Rapid Assessment

• Airway: – Is the patient protecting it?– Is the patient able to oxygenate and ventilate

adequately?– Is there stridor


Oxygen

• Nasal prongs max. 4-5l/min

• Venturi: up to 50%

• 02 reservoir: 90-95%


5 Reasons to Intubate

• Protection

• Creation

• Oxygenation

• Ventilation

• Pulmonary toilet


Breathing

• Look, listen, feel, or IPPA

• Wheezes, rales, rubs, decreased air entry

• Is it adequate? O2 sat?


Circulation

• Pulse, BP,

• Heart sounds ? Muffled

• JVP

• Edema


Rapid Assessment

• Does this person need immediate treatment?

• Ventolin

• Nitroglycerin

• ASA

• Furosemide

• BiPap

• Needle decompression


History-What are the key questions?

• Previous hx of similar event

• How long SOB

• Onset gradual or sudden

• What makes it better or worse

• Associated symptoms:– Chest pain, cough, fever, sputum, PND,

orthopnea, SOBOE


History-What are the key questions?

• Medications, home 02

• Allergies

• What has helped in the past

• Past medical history:– Cardiac, pulmonary, recent surgery


Labs/Investigations

• ABG

• CBC, Lytes, Cardiac enzymes

• D dimer

• ECG

• Pulmonary Function Tests


Imaging

• CXR

• VQ

• Helical CT

• Pulmonary angiogram


Principles of ManagementCOPD

• Oxygen – Titrate with 02 sat:– Monitor pC02, avoid loss of hypoxic drive

• Beta agonists and anticholinergics– Ventolin 1 cc in 2 cc atrovent or MDI

• Steroids ex. Solumedrol 125 mg IV• Theophylline: poor bronchodilator• Antibiotics• BiPap


Status Asthmaticus• 100 % oxygen• continuous ventolin in atrovent• solumedrol 125 mg IV• magnesium S04 2 gm over 2 min• isoproterenol 0.1-6.0 microg/kg/min • epinephrine 0.2 mg IV over 5 min then

1-20 microg/min• aminophylline 5 mg/kg over 30 min,

–then infusion 0.5 mg/kg/hr


Status AsthmaticusIntubation

• sedate with ketamine 1.5 mg/kg

• paralyze with succinylcholine, or vec

• permissive hypercarbia (hypoventilate)

• inhalation anesthetics (halothane)

• lung massage

• bilateral chest tubes if patient arrests


A 75 y.o. man with dyspnea


Principles of ManagementPneumonia

• Oxygen to maintain 02 sat at 92-94%

• Antibiotics:– Macrolides– Fluroquinolones– 2nd or 3rd generation cephalosporin

• Beta agonists and BiPap as required


A 79 yo woman with dyspnea


Principles of ManagementPulmonary Edema

• Oxygen

• BiPap

• Nitroglycerin sc, IV

• Furosemide 40-160 mg IV

• Morphine 2-4 mg IV

• ECG-rule out ACS


A 25 year old with dyspnea


Principles of ManagementPneumothorax

• Tension: 14 gauge needle 2nd ICS, MCL

• 30 Fr chest tube

• Pigtail catheter

• Small spontaneous pneumothorax: @20%– May observe, discharge, repeat CXR 24 hrs


Hyperventilation Syndrome

• Must rule out organic causes – PE, myocardial ischemia

• ABG: respiratory alkalosis and normal 02

• Avoid rebreathing from paper bags

• Treatment: reassurance, mild anxiolytic ex. Lorazepam 1 mg



• She is very agitated, sitting forward, using her accessory muscles.

What is her problem?


Pericarditis or Acute Inferior MI


Acute Inferior MI


Pregnancy and Dyspnea

• Increased 02 consumption

• Increased minute ventilation

• Decreased resistance

• Decreased FRC

• Increased risk: PE, Pulmonary edema


Admission Criteria for Dyspnea

• Abnormal vitals including 02 sat

• Abnormal level of consciousness

• Significant illness ex. Pneumonia

• Patient fatigue

• No improvement despite treatment

• Home situation


?


Syncope


Syncope

• http://www.blogtelevision.net/p/Videos-Watch-a-Video___1,2,,59315.html


Syncope-MCC Objectives

• Definition

• Physiology

• Distinguish from Seizure

• Causes: serious or not, cardiac or not

• Initial Management Plan

• Hx, Px, Investigations


Syncope

• A 73 y.o. man collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430. He awakes fully, and is brought to the Emergency Department by his wife.

• Is this a syncopal episode?• What are the causes of syncope?• What is the liklihood he had a cardiac cause of syncope?• What is your workup and management of this patient?


What is syncope?

• Sudden, transient loss of consciousness

• Rapid and complete recovery

• May have minor myoclonic jerks or muscle twitching

• No postictal state


How is a generalized seizure different than a syncopal episode?

• Aura (parasthesia, noises, light, vertigo)

• Tonic-clonic movements and loss of consciousness

• Post ictal confusion for minutes-hours

• Tongue biting

• Incontinence bowel or bladder


What are the common causes of syncope? (MCC)

• Cardiovascular (80%)– Cardiac arrhythmia (20%)– Decreased cardiac output– Reflex/underfill (60%)

• Cerebrovascular (15%)• Other

– metabolic– psychiatric


Cardiovascular Causes of Syncope

• Cardiac arrhythmia (20%)– Tachy or bradycardia

– Carotid sinus syndrome

• Decreased cardiac output– Inflow obstruction (to venous return) ex. PE

– Squeeze: Myocardial ischemia (decreased contractility)

– Outflow obstruction (Aortic stenosis, hypertrophic cardiomyopathy


Cardiovascular Causes of Syncope

• Reflex/Underfill (60% of syncope)– Vasovagal (common faint)– orthostatic/postural ex. Blood loss– Situational (micturition, cough, defecation)


• Cerebrovascular Causes (15%)– TIA– vertibral basilar insufficiency– high ICP

• Metabolic : hypoxia, low BS, drugs, alcohol

• Psychiatric: hyperventilation, panic


Physiology

• What happens in the brain to make us lose consciousness?

• injury or dysfunction of bilateral cerebral hemispheres or reticular activating system

• due to toxins, loss of nutrients (oxygen or glucose), or decrease cerebral blood flow


Physiology

• Cerebral perfusion pressure= MAP-ICP

• MAP = CO x PVR (peripheral vascular resistance)

• CO= SV x HR (stroke volume)

• SV a function of preload, contractility, afterload


What is your initial approach with your patient with syncope?

• Check ABC,s, • 5 vitals -postural• monitor, IV, ECG, blood tests• Bolus fluids if hypotensive 250-1000cc NS• glucosan• give thiamine if giving glucose• consider naloxone if patient not fully awake• history and physical


History• what happened (witnesses important)• what were you doing (ex. urination,

standing up quickly etc.)• prodrome (hot, sweaty, vomiting)• any tonic-clonic activity• postural or neck turning• recovery – long or short

– any confusion


Review of Systems

• volume status (eating, diarrhea, exercise)

• recent blood loss

• chest pain, palpitations, SOB,

• any focal neurologic symptoms

• pregancy


PMH

• previous history of syncope• ex. occasional episodes over the years vs

several episodes recently (more sinister)• cardiac disease or medications• bleeding disorders or PUD• diabetes• medications ex. antihypertensives often

cause orthostatic syncope


Physical Exam

• ABC

• Orthostatic Vitals

• HEENT: trauma, papilledema,

• Resp/CVS: S3, AS murmur,

• Abd: aorta, pulses, peritoneal, blood PR

• Pelvic: bleeding, tenderness

• Neurologic: focal findings


Lab Investigations• CBC• Type and xmatch

– If suspect acute blood loss AAA, ectopic, GI bleed• Lytes, BS, BUN, Cr• D dimer• Pregnancy Test• ECG• CT Head if suspect cerebrovascular cause• Holter• EEG


Vasovagal Faint

• Common (20% all syncope)

• Increased parasympathetic tone

• Bradycardia, hypotension


Vasovagal Faint -Predisposing Factors

• Fatigue• Hunger• Alcohol• Heat• Strong smells• Noxious stimuli• Medical conditions anemia, edehydration• Valsalva (trumpet player)


Vasovagal FaintSymptoms and signs

• Warm, sweaty• Weak• Nausea• Confused• Unprotected fall• Eye rolling, myoclonic jerks, • Resolves in 1-2 min• Rarely tongue biting or incontinence• Not confused afterward


Cardiac Syncope

• 20% all syncope

• Serious prognosis

• Exertional syncope– Outflow obstruction AS, IHSS

• Ischemia/MI

• Conduction disorders

• dysrhythmias


Orthostatic

• Decrease in systolic BP by 20-30 or increase in pulse by 20-30 on standing

• Supine

• Meds -antihypertensives

• Blood loss, dehydration


Syncope-When to Admit

• Uncertain diagnosis

• Elderly (more likely cardiac)

• Suspected cardiac etiology

• Abrupt onset with no prodrome (typical for dysrhythmia)

• Unstable vitals

• Blood loss


San Francisco Syncope Rule98% sensitive and 59% specific for predicting

serious outcome

• Patient requires admission with any of:

• C CHF history

• H Hematocrit < 30

• E ECG abnormal

• S SOB

• S Systolic < 90


Our 73 y.o. man who collapsed in the bathroom and had a 30 second episode of

unresponsiveness at 0430.

In the ED, he had another brief syncopal episode, following by sinus tachycardia

What is his problem?

What would you do?


An 80 y.o. man complains of recurrent syncope

What is his diagnosis and treatment?


A 65 y.o. man on diuretics has recurrent syncope


Torsades de Pointes


Treatment of Torsades

• Correct electrolytes

• Magnesium 2 gm over 20 min

• Isoproterenol 2-20 mcg/min

• Overdrive pacing


?


Coma

Coma


MCC Objectives

• Causes of coma• Clinical Assessment

– Know how to examine a patient in a coma– Differentiate coma due to abnormal brainstem vs cortical injury

• Investigation: appropriate lab and imaging• Management plan

– Who needs immediate treatment– Who needs specialized treatment

• Management of Incompetent Patients• Assess for suspected brain death (prior to referring for

definitive diagnosis)


What is Coma?

• Deepest level of a decreased level of consciousness

• Unresponsive, no useful speech

• Def’n: pt who is unarousable and unaware


An 80 y.o. man is comatose 2 weeks after falling down stairs?

Why is this patient comatose?


Isodense Subdural HematomaEnhanced CT Head


A diabetic patient present in a coma and is found to have a BS of 1.5

Why are they in a coma?


Coma

Can be induced by structural damage or chemically depressed

1) reticular activating system in brainstem, midbrain, or diencephalon (thalamic area)

• Ex. Pressure from a mass

• Toxins

2) Bilateral cerebral cortices– Ex. Toxins, hypoxia, hypoglycemia


A 45 y.o. ‘street’ person is brought in to the ED in a coma. What are the

reversible causes?• AEIOU TIPS• A - alcohol, anoxia• E – epilepsy, electrolytes (Na, Ca, Mg), encephalopathy (hepatic)• I - insulin (diabetes)• O - overdose• U - uremia, underdose (B12, thiamine)• • T- trauma, toxins, temperature, thyroid• I - infection• P - psychiatric• S - stroke (cardiovascular)


Causes of Coma

• Structural– Bleed, CVA, CNS infection,

• Metabolic (medical)– A,E,I, O, U, TIPS


What is your initial approach with this comatose patient?

• A-airway protection (and c spine)• B-breathing O2 sat • 5 vitals (pulse, BP, temp)• Glucoscan• Thiamine (if giving glucose)• Naloxone • IV, ECG monitor, foley, labs• Hx, Px• Determine level of consciousness


Level of Consciousness

• AVPU– Awake, verbal, pain , unresponsive

• Glasgow Coma Scale


GCSBest Eye Response. (4)

1. No eye opening. 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously.

Best Verbal Response. (5) 1. No verbal response 2. Incomprehensible sounds. 3. Inappropriate words. 4. Confused 5. Orientated

Best Motor Response. (6) 8 or less = coma1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localising pain. 6. Obeys Commands


History• What happened?• Symptoms: depression, Headache• Gradual or sudden LOC• Sudden = intracranial hemorrhage• Gradual more likely metabolic, could be

subdural • PMH: diabetes, thyroid, hypertension,

substance abuse, alcohol• Meds,


Physical Exam• Goal: Try and determine if a

structural lesion is present, or a metabolic cause.

How do structural lesions present differently than metabolic causes of coma?


Physical Exam• Structural lesions:

– Often have focal findings, abnormal pupils, evidence of increased ICP

• Metabolic causes:– No focal findings, pupils equal mid or small, no

evidence of increased ICP


Signs and Symptoms of Increased ICP

• Headache, N, V,

• Decreased LOC

• Abnormal posturing

• Abnormal respiratory pattern

• Abnormal cranial nerve findings

• Cushing Triad: late sign of high ICP)– high BP, bradycardia, and low RR = high ICP


Physical Exam• Vitals

• BP > 120 diastolic may cause encephalopathy

• Hypotension uncommon with intracranial pathology

• Temperature– Infection, CNS or otherwise– Neuroleptic malignant syndrome

• Altered mental status, muscle rigidity, and fever


Respirations

• Cheyne stokes– Fast alternating with slow breathing

• Brain lesions, acidosis

• Apneustic – Pauses in inspiration

• Pons lesions, CNS infection, hypoxia


Physical Exam

• HEENT:– Battle’s sign, hemotympanum.– Breath odour

• Ex. Acetone = DKA


Pupils• Metabolic:

– pupils usually react

• Structural: – may be unilateral dilatation Why?

• Uncal herniation presses on CN 111, • Lose Parasympathetic tone• Unapposed sympathetic stimulation

• 10% normal people have 1-2 mm difference


Pupils

• Fixed dilated pupils ominous• Dead, central herniation, hypoxic injury

• Small pinpoint pupils– Lesion in pons (ischemic or bleed– Opiate OD


Physical ExamPupils


Physical Exam

• Corneal Reflex

– Sensory CN 5, and Blink is CN 7


Extraocular Movements

• Helps determine brainstem function in coma

• Doll’s eyes– Eyes move in opposite direction to head

movement– indicates functioning brainstem


Oculocephalic ReflexEnsure C spine cleared

• Awake person: – eyes look forward, some nystagmus

• Comatose patient with brainstem function: Eyes deviate completely in opposite direction to head movement

• Comatose Patient with no brainstem function– Eyes follow head movement


Oculovestibular ReflexCold Calorics

• Check eardrum• 50 cc iced saline

• Awake person: – COWS– Nytagmus away from cold– Driving a car, cerebral cortex keeps you on the

road


Oculovestibular ReflexCold Calorics

• Comatose patient, intact brainstem– Eyes deviate to cold side– Hey who’s putting ice in my ear

• Comatose patient, nonfunctioning brainstem– No reaction


Physical Exam cont.

• Disc

• Nuchal rigidity

• Resp/CVS/Abd/Extrem

• Neuro:level of consciousness, CN, Motor, Sensory, DTR


Motor Exam

• Is there asymmetry in response to pain

• Evidence for seizures?

• Withdrawing: nearly awake pt

• Decorticate: – Abnormal flexion response. Flexes elbow,

wrist, and adducts shoulder– Cerebral cortex injury


Motor Exam

• Decerebrate posture– Extends elbow with internal rotation– Lesions or metabolic effect in midbrain

• Flaccidity– Ominous sign– Toxin/OD


Labs ?

• CBC,

• Lytes, Bun Cr, BS

• LFT, Ca, Mg,

• ABG

• Alcohol, Osmolality

• Tox screen

• CO level


Diagnostic Tests/Imaging

• CXR

• CT Head

• LP

• ECG

• EEG


Brain Death

• Irreverisble failure of clinical function of the whole brain

• Coma, apnea, loss of brain stem reflexes• Difficult to assess in 1st few hours• Ensure no hypothermia, barbituates• Better to use concept of cardiopulmonary

death, some brainstem reflexes may persist• Spinal cord reflexes may persist


Testing for Brain Death

• Brainstem reflexes• Doll’s eyes, Oculocephalic reflex• Cold water calorics• Gag, cough, corneal

• Apnea testing: off ventilator, allow pC02 to rise to 60 mmHg while supplying O2– Takes 8-10 minutes


A 25 y.o. woman presents in a coma. Pupils pinpoint. RR 8. No focal findings?

What will you do?

• ABC’s, vitals

• BS

• Naloxone 0.4-2 mg IV

• What if she is chronically taking narcotics?


A 30 y.o. man, hit on the head, awake alert with a unilateral fixed

dilated pupil?

Is he having uncal herniation?


A 30 y.o. man, hit on the head, comatose with a unilateral fixed

dilated pupil?

What would you do?

• Intubate, pC02 to 30 mmHg• Mannitol .5 gm/kg• CT Head• Stat Neurosurgery consult


Uncal Herniation


Summary COMA

• ABC, Vitals, O2, CO2, BS, Naloxone

• Metabolic vs Structural

• Key to Exam– Respiration– Pupils– EOM– Motor response


• A 25 y.o. man is seen in the ED, and is drunk. He is swearing and screaming, jumping out of bed and staggers when he walks holding onto a chair to keep him upright. He has no evidence of trauma and no focal findings.

• He says he knows his rights and he wants to leave.


• Do you:

A) be thankful that he wants to go and get security to escort him out

B) Face the wrath of the nurses and other patients and forcibly restrain him


Restraining People

1) Is the patient competent to decide for themself?

2) Is the patient suffering from a mental illness that allows us to restrain them. Ie Formable

1) Unable to care for self

2) At harm to self or others

3) In the past has shown evidence of the above when suffering from this mental illess


Competence / Capable

• Understands medical issue

• Understands treatment proposed

• Understands consequences of accepting or refusing treatment


Valid Consent

• Relate to treatment

• Informed

• Voluntary

• Can’t misrepresent or be fraudulent


Informed consent

• Information that a reasonable person would need to make a decision about the proposed treatement

• Risks, benefits, side-effects,

• Alternative course of action

• Consequences of not accepting treatment


Substitute Decision MakingHighest of


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Hypotension Shock – MCC Objectives

• Causes

• History

• Examine

• Diagnose

• Labs

• Management strategy

• Physiology of cell hypoxia


What Is Shock

• Tissue hypoperfusion or tissue hypoxia


Shock

• Catecholamine surge

• Vasoconstriction, increased CO

• Renin-angiotensin, vasopressin – Salt and water retention


Shock

• If persists– Lactic acid, decreased CO and vasodilation– Cell membrane ion dysfunction,– intracellular edema– Leakage of intracellular contents– Intracellular acidosis– Cell and organ death


Shock What are the causes?

Cardiac

Obstructive Obstructive

Hypovolemic

Distributive


• Obstructive Shock– PE, tamponade, tension pneumothorax

• Cardiac– Pump failure: MI, ruptured cordae or septum

• Contutsion, aortic value dysfunction

– Dysrhythmia


• Hypvolemic– Blood Loss

• Trauma, AAA, aneurysm, GI bleed, ectopic

– Dehydration• Gastro, DKA, Burns

• Distributive– Sepsis –most common– adrenal, neurogenic, anaphylactic– Toxins (cyanide), CO, acidosis


Initial Management

• ABC’s• Vitals• MAP = DBP + 1/3 PP (SBP-DBP)

– MAP <70 = shock (inadequate perfusion)

• IV How much?– Fill the patient up

• Two, 16 ga, 500-1000cc bolus• Cardiac shock: bolus 250 cc at a time


Hx and Px

• Ask questions and examine carefully to rule in or out all of the major causes of shock

• ABC approach

• Head to Toe Survey


Labs

• BS

• CBC, lytes, liver/renal function

• Lipase, fibrinogen, fibrin split products,

• Cardiac enzymes, ABG, ECG, urine,

• Tox screen

• Stool OB


Treatment

• Know specific treatment of each type of shock

• MI

• Tension

• Sepsis

• GI bleed


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Cardiac Arrest – MCC Objectives

• Causes– Cardiac and noncardiac

• Hx• Recognize impending and actual cardiac arrest• Investigations• Management plan• Communicate

– DNR– Death

• Ethics– Providing care where no consent is available


Cardiac Arrest - Causes

• Cardiac– Coronary artery– Conduction

• Metabolic: hypo Ca, Mg, K, anorexia

• Brady or tachydysrhythmia

– Myocardium• Hereditary: cardiomyopathy

• Acquired: LVH, Valve disease, myocarditis


Cardiac Arrest - Causes

• Non Cardiac– Tamponade– PE– Tension– Trauma


Sudden Cardiac Arrest• electrical accident

80% due to VF or VT

• most due to ischemia or reperfusion


Mechanism of Fibrillation• ischemia: slows conduction

• adjacent myocardium in various phases of excitation and recovery

• multiple depolarizing reentrant wave fronts


Survival from Sudden Cardiac Arrest

• function of time

– ICU, Emerg, Cardiac rehab 90%

• survival decreases by 10% /min• if defibrillation > 10 min : 5-10% survival


Chain of Survival

• early access

• early CPR

• early defibrillation

• early advanced care• airway and drug therapy


Public Access Defibrillation• trained nonmedical individuals acting

independantly with AED

• city-wide programs across Canada

ex. police, security, first aid volunteers, airlines, recreation centers, pools, arenas


A patient, who has been complaining of chest pain, collapses while you are talking to them


Is this

A) Normal sinus rhythm

B) Ventricular tachycardia

C) Ventricular fibrillation

D) Can I call a friend?

You grab the paddles and have a quick-look


After verifying no pulse, which is the most appropriate treatment?

A) begin CPR

B) give 1 mg epinephrine

C) give 300 mg amiodarone

D) defibrillate at 200j

E) give 100 mg lidocaine

F) pee in your pants


Route of Drug Administration

• IV

• IO

• ETT


Drugs and VF

• Sympathomimetic:–Epinephrine 1 mg

–Vasopression 40 units


Drugs and VF

• Antidysrhythmics:–Amiodarone 300 mg IV

• Repeat once 150 mg

–Lidocaine 1.5 mg/kg–Magnesium 2-4 gm


• The paramedics brings in a 56 y.o. man who arrested at home, was successfully defibrillated but remains comatose and intubated. BP. 100/70, P. 75 NSR

• What other treatment options are available to you to increase survival?


Therapeutic Hypothermia for Cardiac ArrestILCOR June 8, 2003 Circulation

• 2 studies NEJM 2002; 346: 549-563

• Cool to 32-34°C x 24 hrs

• Criteria:– adult patient prehospital cardiac (v.fib)

arrest .– Spontaneous circulation BP > 90– Patient remains comatose and intubated


You are asked to see a 69 y.o. man complaining of palpitations

Is this

A) Normal sinus rhythm

B) Ventricular tachycardia

C) Supraventricular tachycardia

D) I don’t know but it looks bad


BP 110/60, no SOB, no chest pain

A) Give procainamide 30 mg/min to 17 mg/kg

B) give amiodarone 150 mg IV

C) sedate and cardiovert

D) defibrillate

E) lidocaine 100 mg IV


Wide-Complex Tachycardia

• Your colleague says there is a 15% chance this could be SVT with a BBB or accessory pathway

• They recommend 2.5 mg of verapamil or 20 mg of diltiazem

A) agree B) disagree


How Certain Can We Be That Wide-Complex Tach is VT ?


Epidemiology

• 80-85% of wide complex tachycardias are VT


How is the past history helpful?

• Previous MI or structural disease– increases probability of VT

• Long history of recurrent tachydysrhythmia dating back to youth– suggests SVT with abberancy


Clues on Physical Exam

• About 25% of VT will have AV dissociation on ECG

• Variable JVP (cannon a waves), variable S1 definitive evidence of VT


Which medications are useful for terminating monomorphic VT

• Lidocaine: 6 studies (8-30% effective)

• Procainamide: 1 study: 60% effective

• Amiodarone: small studies -30%


Amiodarone in V. Tach

• 150 mg over 10 min

• may repeat up to 5-7mg/kg

• infusion: 1 mg/min for 1st 6 hours»then 0.5 mg/min


Procainamide in V. Tach

• 20-30 mg/min up to 17mg/kg

• stop bolus when: – v. tach terminates– hypotension– QRS widens– max dose given


Lidocaine in V. Tach

• 1.5 mg/kg bolus

• 2nd and 3rd dose: 0.75 mg/kg q 5 min

• Total maximum: 3 mg/kg


Ventricular Tachycardia

• Do not give multiple antidysrhythmics if one has failed (pro-arrhythmic effects)

• pick one antidysrhythmic, if it fails, go to electrical cardioversion.


An 80 y.o. patient was found unresponsive in their room by the

RN

• What is your management

• This is his rhythm on the monitor!!


Asystole

• Uniformly bad outcome if arrest unwitnessed

• Consider CPR, causes (hypoxia, K, acidosis, OD, hypothermia’


Asystole

• Epinephrine 1 mg IV – q5min

• Atropine 1 mg IV max. 3 mg

• Pacing no longer recommended


A 65 y.o. man collapses in the waiting room of a busy emergency department

He has the following rhythm


PEA

• Consider causes:– six H’s :– hypovolemia, hypoxia, H ion, hyper/hypo K,

hypoglycemia

– six T’s: – trauma, tamponade, tension pneumo,

thrombosis-coronary or pulmonary, tablets OD


PEA

• Treatment:

• Find and treat cause

• Epinephrine 1 mg IV

• Atropine 1 mg IV (if bradycardic)


A 49 y.o. woman develops palpitations while you are talking with her


SVT

• How often do you have to electrically cardiovert an unstable patient in SVT?


SVT

STABLE UNSTABLE CARDIOVERSION

VAGAL MANOEUVRES

ORVerapamil 2.5 – 5 MG I.V. over 2 min (Class I) Adenosine 6 mg IV (Class I)(or Diltiazem 20 mg IV over 2 min) (Class I

RAPID PUSH(IF B.P. NORMAL)

Verapamil 5 – 10 MG I.V. Adenosine 12 MG I.V.Diltiazem 25 mg IV

RAPID PUSH

Metoprolol 5 mg IV(Class I)Procainamide 30mg/min to 17/kg (Class IIa)Amiodorone 150 mg over 10 min (Class IIa)Digoxin 0.5 mg IV (Class IIa)

SYNCHRONIZED CARDIOVERSION


Your patient develops this rhythm

Pulse 40 BP 60/40

Is this

A)Normal sinus rhythm

B) Wenkeback -2nd degree Heart Block, type 1

C) Complete Heart Block


Would 1 mg of epinephrine be appropriate if her BP was 60/40

A) Agree

B) Disagree


BradycardiaWhen to Treat ?

• Symptomatic: chest pain, SOB, hypotension

• Therapy:– atropine – transcutaneous pacemaker– dopamine 5-20 microgm/kg/min– epinephrine 2-10 microgm/min


A 72 year old man complains of persistant retrosternal chest

heaviness

What is your management ?


Is this patient a candidate for a thrombolytic?

A) Agree B) Disagree


An 80 year old man is being treated in hospital for pneumonia.

He is found VSA at 0300. His rhythm shows asystole.

How long are you required to perform CPR for?


CPR and ACLS

Purpose: treatment of sudden unexpected death.


When Not To Initiate CPR• CPR is inappropriate and ineffective for

medical problems where death is neither sudden or unexpected

• don’t offer CPR as an option to patients or families if it is not medically indicated

• communicate openly

Joint Statement on Resuscitative InterventionsCMAJ Dec 1, 1995


When to Discontinue CPR

• Judgement that patient is unresuscitatable

• Variables: – down time, rhythm, age, premorbid conditions– advance directives


You have just finished a 45 minute unsuccessful resuscitation attempt on a

42 y.o. man. His wife is anxiously waiting.

How do you tell her that her husband has died?

How do you make it less stressful on the survivors when a sudden unexpected

death has occurred.


Sudden Unexpected Death

• Develop multidisciplinary approach• Develop intervention strategy

• Contacting Survivors– Avoid disclosure on the phone– meet family at a specific site

CMAJ 1993 149(10) 1445-1451



• Arrival of Survivors– met by RN, or Social Worker– updated regularly

Should the family be brought to the bedside

if the resuscitation attempt is ongoing ?



• Notificiation of Death– obtain all information prior to meeting– quiet room, have RN also there– sit next or across from closest relative– explain in lay terms sequence of events– use the words dead or died– express condolences– answer questions now or later


Sudden Unexpected Death• Grief Response

– private time

• Viewing Deceased– encourage family– clean patient and remove equipment if possible

• Conclusion– return valuables, address concerns– give family permission to leave


Summary CPR

• Push hard, push fast, don’t interrupt

• Effective rapid defibrillation

• Electricity is better, more effective

• Intubation is not an emergency

• Don’t overventilate


Summary

Cardiac arrest: Is there a shockable rhythm. Don’t delay defibrillationconsider drugs

Tachydysrhythmia: unstable-cardiovertstable-can use medications


Summary

• Bradydysrhythmia– Does it need immediate treatment– Can it deteriorate– Does it need long term pacing


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Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008...

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Transcript of Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008...