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High‐risk Cases in Emergency Medicine: Part 2

Kevin M. Klauer, DO, EJD, FACEP

Chief Medical Officer, EMP, Ltd.

Medical Editor‐in‐Chief, ACEP Now

Speaker, ACEP Council

Asst. Clinical Professor, MSU College of Osteopathic Medicine

The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.

Wednesday, November 12th, 2014

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SpeakerDr. Kevin Klauer is the Director of the Center for Emergency Medical Education and the Chief Medical Officer for Emergency Medicine Physicians, Ltd., based in Canton, Ohio.  He also is the Director of EMP’s Patient Safety Organization.  He serves on the Board of Directors for Physicians Specialty Limited Risk Retention Group. He is an Assistant Clinical Professor at Michigan State University College of Osteopathic Medicine.   He has received the EMRA Robert Dougherty ACEP/EMF Teaching Fellowship and also the ACEP's National Emergency Medicine Faculty Teaching Award. He was most recently recognized by the Ohio Chapter ACEP with the Bill Hall Award for service.  Dr. Klauer is the co‐author of two risk management books: Emergency Medicine Bouncebacks: Medical and Legal and Risk Management and the Emergency Department: Executive Leadership for Protecting Patients and Hospitals.

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1. Discuss strategies to identify high-risk features of clinical entities in emergency medicine.

2. Develop strategies to improve patient safety.

3. Review ways to reduce professional liability in the practice of emergency medicine.

Learning Objectives

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High Risk Entities

Hyponatremia is expensive

Sepsis is a chronic disease

Methotrexate

Don’t Forgot the Rhogam 

“Eye” Would Hate to Miss This One! 

“SEA” of Neuro Disasters

Hyponatremia

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Clinical approach to hyponatremia shown as a flow diagram after initial presentation.

Tzamaloukas A et al. ahaoa 2013;2:-

©2013 by Lippincott Williams & Wilkins

Computed tomographic imaging brain slice from index patient showing myelinolysis in pons (white arrow).

Tzamaloukas A et al. ahaoa 2013;2:-

©2013 by Lippincott Williams & Wilkins

Medical Legal Case

• 42 y/o female

• Found unresponsive by family (no trauma)“Snoring loudly”

• July 10, 2009:  23:00

• Intermittent N & V for 1 week

• PMHx:  hypertension, pancreatitis, and anxiety 

• Meds:  Lorazepam, Promethazine, and Benicar 

• Seizures:  1 upon EMS arrival and 2 in ED

•

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Medical Legal Case

• 124 P, 122/70 BP, 13 R, and 96 % O2 Sat 

• Exam:  23:55

• GCS = 10

• 0012:  60 second tonic/clonic seizure

• Tx:  Ativan 1mg IVP

• Diagnostics:  CT Neg

Medical Legal Case

• Treatment

0100: 1st Liter of NS completed

0145:  BP 84/54:  2nd Liter bolus ordered

Central line initiated

• Consultation:  Intensivist 0210

Admit to ICU

3% Hypertonic Saline at 80ml/hr

K+ 60 meq over 6 hours 

Medical Legal Case

• Q 4 hr BMP order changed be intensivist to wait for K+  to be completed

• Next BMP 0945

• Na+:  125

• 24 hours later:  Unresponsive

• 8 days later:  MRI:  CPM

• 10 days later:  Trach and moved to long term care facility

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Medical Legal Case

• Q 4 hr BMP order changed be intensivist to wait for K+  to be completed

• Next BMP 0945

• Na+:  125

• 24 hours later:  Unresponsive

• 8 days later:  MRI:  CPM

• 10 days later:  Trach and moved to long term care facility

Medical Legal Case

Died August 22, 2009

Lawsuit filed:  September 23, 2012

Mediation:  Settlement

1. Undisclosed for the Intensivist

2. $60,000 for the EP

Take Home

• Slow Correction

• Hypertonic Saline in Consultation

• Frequent rechecks

• 10‐15 mEq/L/24 hours and less than 18 mEq/L/48 hours

• CPM may occur on either side of the equation

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Sepsis

Sepsis

Winters BD, et al. Long‐term mortality and quality of life in sepsis: a systematic review. Crit Care Med. 2010 May;38(5):1276‐83.

• Ongoing Mortality up to 2 Yrs

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975 with SepsisMortality Rates

Hospital:  8.9%1 yr:  23% v. 1%2 yr:  28.8% v. 2.6%5 yr:  43.8% v.  8.3%

750,000 Hospitalizations570,000 ED visits200,000 Deaths$16.7 Billion

Limitations and Liability

• Death

• ARDS

• MODS

• Renal Failure

• Hepatic failure

• Encephalopathy

• DIC

• Purpura Fulminans

• Septic Emboli

• Endocarditis

• Cavernous sinus thrombosis

• Limb/Digital amputations

Limitations and Liability

• Death

• ARDS

• MODS

• Renal Failure

• Hepatic failure

• Encephalopathy

• DIC

• Purpura Fulminans

• Septic Emboli

• Endocarditis

• Cavernous sinus thrombosis

• Limb/Digital amputations

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Outrage!

Outrage!

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Daniels R. Surviving the first hours in sepsis: getting the basics right

(an intensivist’s perspective); J Antimicrob Chemother 2011; 66 Suppl 2: ii11–ii23 (US 

National Library of Medicine)

Sankoff JD. Validation of the Mortality in Emergency Department Sepsis (MEDS) score in patients with the systemic inflammatory response syndrome

(SIRS). Crit Care Med. 2008 Feb;36(2):421-6.

• MEDS Score predicts 28 day mortality in admitted Pts with SIRS

• Terminal illness, Tachypnea or Hypoxemia, Septic shock, PLT < 150K, Bands > 5%, Age > 65 yrs, pneumonia, Nursing home, AMS

• very low (0.6%), low (5%), moderate (19%), high (32%), and very high (40%)

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Carpenter C. J Emerg Med. 2009 Oct;37(3):319-27. Epub 2009 May 8.Valid: Less accurate in severe sepsis

Surviving Sepsis Campaign: InternationalGuidelines for Management of Severe Sepsis

and Septic Shock: 2012“A strong recommendation does not automatically imply

standard of care. For example, the strong recommendation

for administering antibiotics within 1 hr of the diagnosis

of severe sepsis, as well as the recommendation for achieving a central venous pressure (CVP) of 8 mm Hg and a central venous oxygen saturation (Scvo2) of 70% in the first 6 hrs of resuscitation of sepsis‐induced tissue hypoperfusion, although deemed desirable, are not yet standards of care as verified by practice data.”

• 31 U.S. EDs

• 2 or more SIRS + Refractory HYN or Lactate >4

• 3 Groups for 6 hours of resuscitation

EGDT, Sepsis Protocol, Usual

• 1,341 Pts (well matched at baseline)

Systemic Inflammatory Response Syndrome

At least 2 of the following:A temperature over 38.3C or less than 36.0CA heart rate over 90A respiratory rate over 20A WBC count less than 4,000 or over 12,000Acutely alerted mental statusHyperglycemia in non‐diabetic patients

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• 31 U.S. EDs

• 2 or more SIRS + Refractory HYN or Lactate >4

• 3 Groups for 6 hours of resuscitation

EGDT, Sepsis Protocol, Usual

• 1,341 Pts (well matched at baseline)

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Mortality20.1%18.2%18.9%No diff:90 Day/1 Yr Organ Support

Medical Legal Case

• 3 y/o female presented at 13:00

• CC:  Cough, earache, bruising and fever

Ill for 2 days

Rash started today

• Initial Eval (PA) in FT:  16:10

• Transferred to ED & EP:  18:02

Medical Legal Case

• Exam

• Physician findings

“Slight Jaundice”

“Purpura cheeks, earlobes, buttocks, thorax and lower extremities”

“Crying but easily consolable”

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Medical Legal Case

• Exam

• Physician findings

“Slight Jaundice”

“Purpura cheeks, earlobes, buttocks, thorax and lower extremities”

“Crying but easily consolable”

Medical Legal Case

• DiagnosticsWBC:  3.1; PLT 50K; INR: 4.8; LFTs 

IVF

Acetaminophen

Ceftriaxone 1 gm:  18:52

• DDX:  ITP, HSP, EB ….

• Disposition:  Transfer to Tertiary Referral Center:  2102 report; 2238 OTD

Medical Legal Case

• Outcome

• Streptococcus A sepsis

• 4 limb amputation

• Multimillion $ settlement

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Sepsis Solutions

1. Early Identification

2. Early Patient Education (natural course)

3. Document the consideration and discussion

4. Discussion about outcomes

5. Consent for vasopressors

Methotrexate

Kurt T. Barnhart. Ectopic Pregnancy. N Engl J Med 2009; 361:379‐387July 23, 2009

• Heterotopic pregnancy

1 in 4,000

1 in 100 with in vitro fertilization

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Surgical Management of Ectopic PregnancyA Jazayeri. eMedicine, Jan 7, 2008

• 1. No evidence of rupture or hemoperitoneum• 2. Hemodynamically stable• 3. < 8 weeks gestation• 4. B-HCG <5,000 (3000 –15,000 reported in

various sources)• 5. Adnexal mass < 4 cm (2 cm –5 cm reported in

various sources)• 6. No fetal cardiac activity• 7. Confirmed ectopic, not requiring surgical

confirmation

Methotrexate

Case History

• 30 y.o. female

• 7 weeks with vag bleeding and cramping.

• BHCG: 9,500

• US: Small amt of non specific endometrial fluid.

• OB consulted, saw patient, and gave methotrexate.

Follow Up

• Two days later patient seen at another facility

• US showed ~ 6 week IUP with fetal pole.• Next US, three days later showed fetal HR

around 70/min. • 1 week: HCG declining, Fetal demise and

D&C performed.• Lawsuit Filed: Numerous defendants

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Rh Isoimmunization

• Walker v. Rinck, 604 N.E.2d 591 (Ind. 1992).

“physician owes a duty to future children of an Rh‐negative woman who gives birth to an Rh‐positive child.”

RhoGAM• RhoGAM = IgG anti-D antibodies

• Destroy Rh+ fetal red cells in the maternal circulation

• If RhoGAM not given, mother develops antibodies to Rh+ fetal blood which cross the placenta and cause a hemolytic anemia in the fetus, splenomegaly, erythroblastosis, death

• Indications: Rh- and abortion (any type), abruption, ectopic, antepartum hemorrhage, trauma (even relatively minor)

• Dose: 50 mcg if <12 weeks, 300 mcg if >12 weeks

Anti-D administration after spontaneous miscarriage for preventing Rhesus alloimmunisation.

Cochrane Database Syst Rev. 2013 Mar 28;3:CD009617

• Rh-neg: Following spont AB• 1 RCT: 48 women• 8-24 weeks• 19/29• Small sample size• No difference

Maternal sensitizationRh alloimmunization in subsequent pregnancies

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Medical Legal Case

• CC: “Vaginal bleeding”

• HPI:  8 weeks pregnant; 2 days; No clots

• PE:  BP 112/70, pulse 72

25 y/o

No CVAT or LBP

Pelvic:  Os Closed, Mod amount of BRB, No CMT

• No Tissue

Medical Legal Case

• Diagnostics

Hgb:  13.7

Quant:  28,543

Pelvic US:  8 wk viable twin!

• Consult

Phone with the Ob/Gyn

• Clinical Impression:  “Threatened miscarriage”

• Disposition:  Discharge

Outcome

• Twin GirlsTwin 1 died

Twin 2: Hydrops fetalis, Anemia, Kernicterus, Hearing impaired and learning disabilities(?)

• Claims:  Rh IsoimmunizationWrongful death

Injury of twin 2

Mother’s concerns about future pregnancies

Father’s loss of consortium

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Outcome

• Demand $800,000

• Settlement for $425,000

“Eye” Would Hate to Miss This One!

Medical Legal Case

• CC:  “Hit in the left eye with a piece of plastic”• HPI:  21 y/o male patient

Accidentally hit in eye with a small plastic object2 hours prior to arrivalBlurred vision after rubbing his eye since the injury

• PE:  Vital signs NLInjected and swollen“Pupils, equal, round and reactive to light”Fundoscopic exam NLVA:  NL in right eye; unable to decipher anything on the chart due to rubbing the eye

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Medical Legal Case

• Diagnostics

Slit Lamp Exam

• 2mm corneal abrasion near the left pupil

• Clinical Impression:  Corneal Abrasion

• Disposition:  Discharge with 3 day follow up

• Gentamicin drops

Outcome

• RN triage note

“Working on his car when foreign material (metal or plastic) shot into his eye.”

• Follow up 3 days later

• Dx:  Globe perforation and Retinal detachment

• Permanent visual loss

Outcome

• A case for excess limits?

• Settlement:  $800,000

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Corneal Lacerations• Anterior chamber perforation

• Teardrop shaped pupil

• Flat anterior chamber

• Black iris pigment may be at the wound edge

• Seidel test: fluorescein on eye is washed away by leaking aqueous humor = corneal perforation

• Tonometry contraindicated / No patch (but put eye

shield on / Avoid eye movements) may extrude

vitreous with eye muscle contractions

• Urgent referral / consultation

Corneal Lacerations

Corneal Laceration

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Corneal Laceration 

Med‐Challenger • EM

Globe Rupture• Most have associated hyphemas

• “Tear drop” pupil points to rupture site

• Flat anterior chamber (due to lowered

pressure)

• No pressure on eye - use shield

• No contact tonometry

• IV antibiotics / analgesia / tetanus / CT-MRI

Globe RupturePathology

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“SEA” of Neuro Disasters

Medical Legal Case

• CC:  Back pain, numbness and abdominal pain

• 26 y/o Male 

• Rt lower back pain for 1wk

• Seen at different ED twice in past 24 hours

Dx:  “Sciatica”

• Numbness from knees down4 hours prior to arrival

• PMHx:  IDDM, Schizophrenia, ADD

Medical Legal Case

• Physical Examination

• VS:  T 101.6, HR 105, RR 20, BP 136/80

• Abdomen:  Soft and Non tender

• T8‐L1 paraspinal tenderness near ML

• Distal sensation NL

• “Can’t move legs secondary to severe pain”

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Medical Legal Case

• Diagnostics

• WBC:  13.9 with 11% bands

• UA Neg

• Abd CT:  Paravertebral ST swelling T7‐L2 (no discitis)

• Chest XR:  NAD

• Antibiotics:  Vanco & Nafcillin

• Consult:  NSGY:  Stop antibiotics due to Cxs

Medical Legal Case

• Patient to be transferred• Dx:  Acute discitis• “The patient is schizophrenic, not convinced that the patient can’t move his legs.”

• Transferred at 0010 (original arrival 1645)• T‐L MRI ordered:  Canceled by radiology

Needs Plain Skull, Abd and Chest XR

• Performed at 0445• 1247:  Negative (but Thoracic portion not performed)• Reordered:  1300• Results:  Posterior Epidural Collection T4‐T12• Taken to OR

Medical Legal Case

• Outcome

Paraplegic

Discharged to skilled nursing/rehabilitation

• Hospital Settlement (undisclosed)

• Initial EP

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Medical Legal Case

• Outcome

Paraplegic

Discharged to skilled nursing/rehabilitation

• Hospital Settlement (undisclosed)

• Initial EP

$900,000

Davis DP. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain.J Neurosurg Spine. 2011 Jun;14(6):765‐70. Epub 2011 Mar 18.

• Risk factor assessment

• ESR v. CRP

ESR outperformed CRP:  100%/67%

• Imaging

• Control period v. Study period

Delays 83.6% v. 9.7%

Deficits 81.8% v. 19.4%

Davis DP. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain.J Neurosurg Spine. 2011 Jun;14(6):765‐70. Epub 2011 Mar 18.

• Risk factor assessment

• ESR v. CRP

ESR outperformed CRP:  100%/67%

• Imaging

• Control period v. Study period

Delays 83.6% v. 9.7%

Deficits 81.8% v. 19.4%

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Recommendations

1. Sodium correction:  10‐15 mEq/L/24 hours and less than 18 mEq/L/48 hours.

2. Alert patients about the dangers of vasopressors and obtain informed consent.

3. Methotrexate can be dangerous.  Follow the inclusion/exclusion criteria and consult Ob/Gyn.

4. 24 hour follow for all eye injuries.5. Don’t forget the RhoGam!6. Consider SEA in all patients with new back pain and 

new neuro deficits or risk factors with a positive ESR.

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This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials does not create an attorney‐client relationship with the presenter(s). You should not take any 

action based upon any information in this presentation without first consulting legal counsel familiar with your particular circumstances.

Thank you for attending!

Questions?