Download Back to Basics Emergency topics Dr Weizman 2010

Back to Basics
2010
Dr. Brian Weitzman
Department of Emergency Medicine
Ottawa Hospital
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Review of 14 Common Emergency
Medicine Topics
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Acute Abdominal Pain
Acute Dyspnea
Hypotension/Shock
Syncope
Coma
Cardiac Arrest
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Emergency Medicine Topics
April 1
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Malignant Hypertension
Animal Bites
Burns
Near-drowning
Hypothermia
Poisoning
Urticaria/Anaphylaxis
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Abdominal Pain
MCC Objectives
1.
Common causes of pain
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2.
3.
4.
5.
6.
7.
8.
9.
intra and extra abdominal, metabolic
Localized vs diffuse
Peritoneal signs vs no peritoneal signs
Neurologic basis of pain
Perform focused detailed hx
Focused examination: vitals, abd, rectal, pelvic GU
Interpret clinical and lab data
Management plan for pts with abd pain
Which patients need immediate attention and treatment
Manage common causes of abdominal pain
Unusual causes of pain in elderly and immunocompromised
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Neurologic Basis of Abdominal Pain
• Visceral
• Somatic
• Referred
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Visceral vs Somatic Abdominal Pain
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Where are these fibers located?
What stimulates them?
Where is pain perceived with stimulation?
What are associated symptoms or signs?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Visceral Abdominal Pain
• Stretch receptors in walls 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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Referred Pain
• What is it?
• What are some examples?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Examples of Referred Pain
• Shoulder pain with diaphragm stimulation
– C 3,4,5 stimulation
• Back pain with biliary colic, pancreatitis, or
PID
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Differential Diagnosis
Epigastric
DIFFUSE
Suprapubic
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Epigastric pain
Which have peritoneal signs?
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PUD
Gastritis
Pancreatitis
MI
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Epigastric pain
Which have peritoneal signs?
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PUD
Gastritis
Pancreatitis
MI
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Diffuse Abdominal Pain
Which have peritoneal signs?
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Peritonitis
AAA
Ischemic Bowel
Obstruction
Pancreatitis
Sickle cell
Gastroenteritis
Diabetes
Perforated viscus
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Diffuse Abdominal Pain
Which have peritoneal signs?
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Peritonitis
Ruptured AAA
Ischemic Bowel
Obstruction
Pancreatitis
Sickle cell
Gastroenteritis
Diabetes
Perforation
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Causes of Abd Pain - Localized


Epigastric
RUQ

LUQ
RLQ
LLQ
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Differential Diagnosis
Which has peritoneal signs?
Colic/Cholecystitis Gastritis,GERD/PUD
 Hepatitis / Hepatic Abscess Pancreatitis
 Pneumonia / Pleurisy
MI
Appendicitis
 Biliary
RUQ
RLQ
 Appendicitis


Splenic Infarction
 Splenic Rupture
 Splenic Aneurysm
Pneumonia
LUQ
LLQ
Inflammatory bowel disease
Diverticulitis
Ectopic
Ruptured Ovarian Cyst
Salpingitis/PID
Renal Stones/UTI
Testicular torsion
Psoas abscess
Incarcerated Hernia
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Differential Diagnosis
Which has peritoneal signs?
Colic/Cholecystitis Gastritis,GERD/PUD
 Hepatitis / Hepatic Abscess Pancreatitis
 Pneumonia / Pleurisy
MI
Appendicitis
 Biliary
RUQ
RLQ
 Appendicitis


Splenic Infarction
 Splenic Rupture
 Splenic Aneurysm
Pneumonia
LUQ
LLQ
Inflammatory bowel disease
Diverticulitis
Ectopic
Ruptured Ovarian Cyst
Salpingitis/PID
Renal Stones
Testicular torsion
Psoas abscess
Incarcerated Hernia
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
High Yield Questions
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
High Yield Questions
1. Age Advanced age means increased risk.
2. Which came first—pain or vomiting?
1. Pain first is worse (i.e., more likely to be caused by
surgical disease).
3. When did it start? Pain for < 48 hrs is worse.
4. Previous abdominal surgery? Consider obstruction.
5. Is the pain constant or intermittent? Constant pain is worse.
6. Previous hx of pain? A report of no prior episodes is worse.
7. Pregnant? consider ectopic.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
High Yield Questions cont’d
8. History of serious illness: cancer, diverticulosis,
pancreatitis, kidney failure, gallstones, or inflammatory
bowel disease? All are suggestive of more serious disease.
9. HIV? Consider occult infection or drug-related pancreatitis.
10. Alcohol? Consider pancreatitis, hepatitis, or cirrhosis.
11. Antibiotics or steroids? These may mask infection.
12. Did the pain start centrally and migrate to the right lower
quadrant? High specificity for appendicitis.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
High Yield Questions, cont’d
13. 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.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Physical Examination
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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!
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Risk Factors for Acute Disease
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Extremes of age
Abnormal vital signs
Severe pain of rapid onset
Signs of dehydration
Skin pallor and sweating
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Initial Stabilization
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Initial Stabilization
All 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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Pain: ER Management
• Is it OK to give a patient pain medications
before you determine their diagnosis?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
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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
1-2of Emergency
mg Medicine
Copyright:
Dr. Brian Weitzman, Department
University of Ottawa March 2010
Nausea/Vomiting: ER Tx
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Nausea/Vomiting: ER Tx
• Gravol: po/pr/im/iv
– beware of anticholinergic side effects
– sedating, may cause confusion
• Maxeran/prochlorperazine (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!
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Investigations
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Investigations
Most 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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Investigations
Imaging
ultrasound
CT scan
plain Xrays
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Why are the elderly more challenging to
diagnose and treat when they present
with abdominal pain?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Abdo Pain: Geriatrics
-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 -
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What are specific problems related to the
emergency room diagnosis and treatment of
abdominal pain in the geriatric population?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Influence of Aging on Abd Pain
Increased Risk in the Elderly
Resultant Disease
Atherosclerotic Disease
AAA, mesenteric ischemia,
ischemic colitis
Cholelithiasis
Cholecystitis, pancreatitis
Carcinoma
Large bowel obstruction,
intussuception
Immobility
Colonic volvulus
Medications
PUD, Pancreatitis
Prior Surgery
Small bowel obstruction
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
HIV and Abdominal Pain
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
HIV and Abdominal Pain
• Gastroenteritis: Salmonella, Shigella,
Camphlobacter, Giardia, CMV,
Cryptosporidium, Mycobacterium avium
• Cholecystitis with or without stones
• Biliary obstruction from neoplasm
• Esophagitis
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is the cause of this 45 y.o.
man’s LLQ pain?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is the cause of this 45 y.o.
man’s LLQ pain?
• Renal stone
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is the cause of this man’s pain?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Why is this woman vomiting?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• Central location, plica circularis (valvulae coniventes)
• Small bowel obstruction central, stack coins,
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Why is this woman vomiting?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Large bowel, haustra, air LLQ
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Sigmoid Volvulus
massive
bowel
dilation
single loop
“bent rubber
tube”
34yr female: cerebral palsy,
BM’s,
Copyright:no
Dr. Brian
Weitzman,abdo
Departmentdistension
of Emergency Medicine
University of Ottawa March 2010
What is the cause of this man’s
abdominal pain?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is the cause of this man’s
abdominal pain?
• Free air
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Summary: Approach to
Abdominal Pain in the ER
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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)
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Summary: Common Causes of
Abdominal Pain
MCC Categorization
• Is it diffuse or localized?
• Peritoneal signs?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Acute Dyspnea
MCC Objectives
• Understand physiology of respiration
• Differentiate dyspnea from hyperpnea,
tachypnea and hyperventilation
• Differentiate cardiac and pulmonary causes
• Focused efficient hx
• Interpret clinical and lab data
– Select and interpret heart and lung investigation (ECG<
ABG, lung imaging)
• Diagnose and manage acute dyspnea
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Definitions
• Dyspnea:
– sensation of shortness of breath
• Hyperpnea:
– increase in rate or depth of breathing
– Ex. Metabolic acidosis, ASA
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Definitions
• Tachypnea:
– rapid, shallowing breathing
• Hyperventilation:
– breathing in excess of metabolic needs of body
lowering C02
– Need to rule out organic disease
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• A 55 year old woman comes into the ED in
obvious respiratory distress. She is very
agitated, sitting forward, using her
accessory muscles.
What is her problem?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Most Common Causes of Acute
Dyspnea
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COPD
Asthma
CHF
PE
Pneumonia
Pneumothorax
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Acute Dyspnea-Cardiac Causes
1. Acute coronary syndrome
2. Myocardial dysfunction
1.
2.
3.
4.
Ischemic/hypertensive cardiomyopathy
Valvular dysfunction
Pulmonary edema
Dysrhythmia
3. Pericardial disease-tamponade
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Acute Dyspnea-Respiratory Causes
• Upper airway:
– FB, epiglottis, angioedema, trauma
• Bronchi:
– asthma, bronchitis/iolitis, tumor
• Alveoli:
– Pneumonia, emphysema, contusion, toxic inhalation,
ARDS
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Acute Dyspnea Misc. Causes
• CNS stimulation:
– head trauma, ASA, sepsis, mass lesion
• Decreased O2 carrying: anemia, CO, methem
• Metabolic acidosis
– MUDPILES
• Hyperthyroidism, Pregnancy, Psychogenic
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• Our 55 year old woman is still in respiratory
distress.
What will you do?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Rapid Assessment
• ABC’s : 5 vitals: P, RR, BP, T, 02 sat.
• O2, IV, Monitor, ECG
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Rapid Assessment-General
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Ability to speak
Mental status, agitation, confusion
Positioning
Cyanosis:
– Central: Hgb desats by 5 g. Not evident in
anemia
– Peripheral: mottled extremities
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Rapid Assessment
• Airway:
– Is the patient protecting it?
– Is the patient able to oxygenate and ventilate
adequately?
– Is there stridor
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Oxygen
• Nasal prongs max. 4-5l/min
– Increase FIO2 by 4%/L
• Venturi: up to 50%
• 02 reservoir: 90-95%
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
5 Reasons to Intubate
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Protection
Creation
Oxygenation
Ventilation
Pulmonary toilet
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Breathing
• Look, listen, feel, or IPPA
• Wheezes, rales, rubs, decreased air entry
• Is it adequate? O2 sat?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Circulation
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Pulse, BP,
Heart sounds ? Muffled
JVP
Edema
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Rapid Assessment
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Does this person need immediate treatment?
Ventolin
Nitroglycerin
ASA
Furosemide
BiPap
Needle decompression
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
History-What are the key questions?
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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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
History-What are the key questions?
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Medications, home 02
Allergies
What has helped in the past
Past medical history:
– Cardiac, pulmonary, recent surgery
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Labs/Investigations
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ABG
CBC, Lytes, Cardiac enzymes
D dimer
ECG
Pulmonary Function Tests
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Imaging
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CXR
VQ
Helical CT
Pulmonary angiogram
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
COPD
yperlucent
lung fields
increased
retrosternal
air
low set
diaphragm
increased AP
diameter
flat
diaphragm
vertical
heart
72yr female: chronic SOB, worse x few days
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Principles of Management
COPD
• 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
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Steroids ex. Solumedrol 125 mg IV
Theophylline: poor bronchodilator
Antibiotics
BiPap
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Status Asthmaticus
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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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Status Asthmaticus
Intubation
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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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
RML pneumonia
diaphragm
preserved
R heart
border
obscured
lat confirms
ant location
Copyright: Dr. Brian
Weitzman,ant
Department
ofcreps
Emergency Medicine
46yr male: chills, pleuritic
C/P,
R
University of Ottawa March 2010
LLL pneumonia
diaphragm
obscured
lat confirms
post location
Copyright: Dr. Brian Weitzman,
Department
of Emergency Medicine
58yr female: weakness,
cough,
SOB
University of Ottawa March 2010
Principles of Management
Pneumonia
• Oxygen to maintain 02 sat at 92-94%
• Antibiotics:
– Macrolides
– Fluroquinolones
– 2nd or 3rd generation cephalosporin
• Beta agonists and BiPap as required
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Pulmonary edema
increased
cephalic
blood flow
increased
periph blood
flow
alveolar
infiltrates
prominent
hilar vessels
Kerley B
lines
cardiomegaly
69yr male: past MI, SOB, orthopnea, PND
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Principles of Management
Pulmonary Edema
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Oxygen
BiPap
Nitroglycerin SL, IV
Furosemide 40-160 mg IV
Morphine 2-4 mg IV
ECG-rule out ACS
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A 25 year old with dyspnea
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Pneumothorax
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Principles of Management
Pneumothorax
• Tension: 14 gauge needle 2nd ICS, MCL
• 30 Fr chest tube
• Pigtail catheter
• Small spontaneous pneumothorax: @20%
– May observe, discharge, repeat CXR 24 hrs
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Ruptured Aorta
widened
superior
mediastinum
loss of aortic
knuckle
34yr male: MVC hit tree, unrestrained, c/o chest pain
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
An anxious woman
• Our 55 y.o. woman, recent mulitple
stressors, comes in to the ED,
hyperventilating. Feels short of breath and
thinks she is having an anxiety attack.
• What else will you do?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Our 55 year old woman in distress…
Pericarditis or Acute Inferior MI
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Acute Inferior MI
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Pregnancy and Dyspnea
•
•
•
•
Increased 02 consumption
Increased minute ventilation
Decreased resistance
Decreased FRC
• Increased risk: PE, Pulmonary edema
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Admission Criteria for Dyspnea
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•
•
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Abnormal vitals including 02 sat
Abnormal level of consciousness
Significant illness ex. Pneumonia
Patient fatigue
No improvement despite treatment
Home situation
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Syncope
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Syncope
• http://www.blogtelevis
ion.net/p/VideosWatch-aVideo___1,2,,59315.ht
ml
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Syncope-MCC Objectives
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Definition
Physiology
Distinguish from Seizure
Causes: serious or not, cardiac or not
Initial Management Plan
Hx, Px, Investigations
Who needs referral, pacing, fitness to drive
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is syncope?
• Sudden, transient loss of consciousness
• Rapid and complete recovery
• May have minor myoclonic jerks or muscle
twitching
• No postictal state
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What are the common causes of
syncope? (MCC)
• Cardiovascular (80%)
– Cardiac arrhythmia (20%)
– Decreased cardiac output
– Reflex/underfill (60%)
• Cerebrovascular (15%)
• Other
– metabolic
– psychiatric
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Cardiovascular Causes of Syncope
• Reflex/Underfill (60% of syncope)
– Vasovagal (common faint)
– orthostatic/postural ex. Blood loss
– Situational (micturition, cough, defecation)
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• Cerebrovascular Causes (15%)
– TIA
– vertibral basilar insufficiency
– high ICP
• Metabolic : hypoxia, low BS, drugs, alcohol
• Psychiatric: hyperventilation, panic
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Physiology
• Cerebral perfusion pressure= MAP-ICP
• MAP = CO x PVR
• CO= SV x HR
(peripheral vascular resistance)
(stroke volume)
• SV a function of preload, contractility,
afterload
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is your initial approach with
your patient with syncope?
•
•
•
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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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Review of Systems
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•
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volume status (eating, diarrhea, exercise)
recent blood loss
chest pain, palpitations, SOB,
any focal neurologic symptoms
pregnancy
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Physical Exam
•
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ABC
Orthostatic Vitals
HEENT: trauma, papilledema,
Resp/CVS: S3, AS murmur,
Abd: aorta, pulses, peritoneal, blood PR
Pelvic: bleeding, tenderness
Neurologic: focal findings
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Lab Investigations
• CBC
• Type and xmatch
– If suspect acute blood loss AAA, ectopic, GI bleed
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Lytes, BS, BUN, Cr
D dimer
Pregnancy Test
ECG
CT Head if suspect cerebrovascular cause
Holter
EEG
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Vasovagal Faint
• Common (20% all syncope)
• Increased parasympathetic tone
• Bradycardia, hypotension
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Vasovagal Faint -Predisposing
Factors
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Fatigue
Hunger
Alcohol
Heat
Strong smells
Noxious stimuli
Medical conditions anemia, dehydration
Valsalva (trumpet player)
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Vasovagal Faint
Symptoms and signs
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Warm, sweaty
Weak
Nausea
Confused
Unprotected fall
Eye rolling, myoclonic jerks,
Resolves in 1-2 min
Rarely tongue biting or incontinence
Not confused afterward
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Cardiac Syncope
• 20% all syncope
• Serious prognosis
• Exertional syncope
– Outflow obstruction AS, IHSS
• Ischemia/MI
• Conduction disorders
• dysrhythmias
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Orthostatic
• Decrease in systolic BP by 20-30 or
increase in pulse by 20-30 on standing
• Supine
• Meds -antihypertensives
• Blood loss, dehydration
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
San Francisco Syncope Rule
98% sensitive and 59% specific for predicting
serious outcome
• Patient requires admission with any of:
•
•
•
•
•
C
H
E
S
S
CHF history
Hematocrit < 30
ECG abnormal
SOB
Systolic < 90
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
An 80 y.o. man complains of
recurrent syncope
What is his diagnosis and treatment?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A 65 y.o. man on diuretics has
recurrent syncope
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Torsades de Pointes
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Treatment of Torsades
•
•
•
•
Correct electrolytes
Magnesium 2 gm over 20 min
Isoproterenol 2-20 mcg/min
Overdrive pacing
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Cardiac Pacing
When is it required?
•
•
•
•
3rd degree (complete HB)
2nd degree type ll
Sick sinus syndrome
Symptomatic bi or trifasicular blocks
– Ex. RBBB + LAH + 1st degree HB
• Symptomatic bradycardia
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Fitness to Drive
• Single episode of syncope that is easily
explained ie. Simple faint dosen’t need
reporting
• Recurrent episodes or suspected cardiac
cause is more serious, needs to be reported
and the patient shouldn’t drive til a cause is
determined and treated.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
?
Break
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Coma
Coma
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
MCC Objectives
• Definition and 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)
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is Coma?
• MCC Defintion:
• state of pathologic unconsciousness
(unarousable)
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
An 80 y.o. man is comatose 2 weeks
after falling down stairs?
Why is this patient comatose?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Isodense Subdural Hematoma
Enhanced CT Head
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A diabetic patient present in a coma and is
found to have a BS of 1.5
Why are they in a coma?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A 45 y.o. ‘street’ person is brought
in to the ED in a coma. What are the
causes?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Causes of Coma
• Structural
– Bleed, CVA, CNS infection,
• Metabolic (medical)
– A,E,I, O, U, TIPS
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
•
•
•
•
•
•
•
•
•
•
•
A 45 y.o. ‘street’ person is brought
in to the ED in a coma. What are the
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)
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What is your initial approach with
this comatose patient?
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•
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•
A-airway protection (and c spine)
B-breathing O2 sat
C-5 vitals (pulse, BP, temp)
D-dextrose Glucoscan
Thiamine (if giving glucose)
Naloxone
IV, ECG monitor, foley, labs
Hx, Px
Determine level of consciousness
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Level of Consciousness
• AVPU
– Awake, verbal, pain , unresponsive
• Glasgow Coma Scale
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
GCS
Best 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 = coma
1. No motor response.
2. Extension to pain.
3. Flexion to pain.
4. Withdrawal from pain.
5. Localising pain.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
6. Obeys Commands
University of Ottawa March 2010
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,
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Signs and Symptoms of
Increased ICP
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•
•
•
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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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Respirations
• Cheyne stokes
– Fast alternating with slow breathing
• Brain lesions, acidosis
• Apneustic
– Pauses in inspiration
• Pons lesions, CNS infection, hypoxia
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Physical Exam
• HEENT:
– Battle’s sign, hemotympanum.
– Breath odour
• Ex. Acetone = DKA
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Pupils
• Fixed dilated pupils ominous
• Dead, central herniation, hypoxic injury
• Small pinpoint pupils
– Lesion in pons (ischemic or bleed
– Opiate OD
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Physical Exam
Pupils
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Physical Exam
• Corneal Reflex
– Sensory CN 5, and Blink is CN 7
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Extraocular Movements
• Helps determine brainstem function in coma
• Doll’s eyes
– Eyes move in opposite direction to head
movement
– indicates functioning brainstem
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Oculocephalic Reflex
Ensure 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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Oculovestibular Reflex
Cold Calorics
• Check eardrum
• 50 cc iced saline
• Awake person:
– COWS
– Nytagmus away from cold
– Driving a car, cerebral cortex keeps you on the
road
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Oculovestibular Reflex
Cold Calorics
• Comatose patient, intact brainstem
– Eyes deviate to cold side
– Hey who’s putting ice in my ear
• Comatose patient, nonfunctioning brainstem
– No reaction
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Physical Exam cont.
•
•
•
•
Disc
Nuchal rigidity
Resp/CVS/Abd/Extrem
Neuro:
level of consciousness, CN, Motor, Sensory,
DTR
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Motor Exam
• Decerebrate posture
– Extends elbow with internal rotation
– Lesions or metabolic effect in midbrain
• Flaccidity
– Ominous sign
– Toxin/OD
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Labs ?
•
•
•
•
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•
CBC,
Lytes, Bun Cr, BS
LFT, Ca, Mg,
ABG
Alcohol, Osmolality
Tox screen
CO level
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Diagnostic Tests/Imaging
•
•
•
•
•
CXR
CT Head
LP
ECG
EEG
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Uncal Herniation
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Summary COMA
• ABC, Vitals, O2, CO2, BS, Naloxone
• Metabolic vs Structural
• Key to Exam
–
–
–
–
Respiration
Pupils
EOM
Motor response
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• 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.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• Your options:
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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 Form 1
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Competence / Capable
• Understands medical issue
• Understands treatment proposed
• Understands consequences of accepting or
refusing treatment
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Valid Consent
•
•
•
•
Relate to treatment
Informed
Voluntary
Can’t misrepresent or be fraudulent
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Substitute Decision Making
Highest of
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Hypotension Shock – MCC
Objectives
•
•
•
•
•
•
•
Causes
History
Examine
Diagnose
Labs
Management strategy
Physiology of cell/tissue hypoxia
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
What Is Shock
• Tissue hypoperfusion or tissue hypoxia
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Shock
• Catecholamine surge
• Vasoconstriction, increased CO
• Renin-angiotensin, vasopressin
– Salt and water retention
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Shock What are the causes?
Obstructive
Obstructive
Cardiac
Hypovolemic
Distributive
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• Obstructive Shock
– PE, tamponade, tension pneumothorax
• Cardiac
– Pump failure: MI, ruptured cordae or septum
• Contutsion, aortic value dysfunction
– Dysrhythmia
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• Hypovolemic
– Blood Loss
• Trauma, AAA, aneurysm, GI bleed, ectopic
– Dehydration
• Gastro, DKA, Burns
• Distributive
– Sepsis –most common
– adrenal, neurogenic, anaphylactic
– Toxins (cyanide), CO, acidosis
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Labs
•
•
•
•
•
•
BS
CBC, lytes, liver/renal function
Lipase, fibrinogen, fibrin split products,
Cardiac enzymes, ABG, ECG, urine,
Tox screen
Stool OB
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Treatment
• Know specific treatment of each type of
shock
•
•
•
•
MI
Tension
Sepsis
GI bleed
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Cardiac Arrest – MCC Objectives
• Causes
– Cardiac and noncardiac
•
•
•
•
•
Hx
Recognize impending and actual cardiac arrest
Investigations
Management plan
Communicate
– DNR
– Death
• Ethics
– Understand consent, capacity to consent
– Providing care where no consent is available
– Use resources carefully, resolving disputes for resources
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Cardiac Arrest - Causes
• Cardiac
– Coronary artery
– Conduction
• Metabolic: hypo Ca, Mg, K, anorexia
• Brady or tachydysrhythmia
– Myocardium
• Hereditary: cardiomyopathy
• Acquired: LVH, Valve disease, myocarditis
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Cardiac Arrest - Causes
• Non Cardiac
–
–
–
–
Tamponade
PE
Tension
Trauma
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Sudden Cardiac Arrest
• electrical accident
80% due to VF or VT
• most due to ischemia or reperfusion
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Chain of Survival
• early access
• early CPR
• early defibrillation
• early advanced care
• airway and drug
therapy
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A patient, who has been complaining
of chest pain, collapses while you
are talking to them
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
You grab the paddles and have a
quick-look
Is this
A) Normal sinus rhythm
B) Ventricular tachycardia
C) Ventricular fibrillation
D) Can I call a friend?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Route of Drug Administration
• IV
• IO
• ETT
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Drugs and VF
• Sympathomimetic:
–Epinephrine 1 mg
–Vasopression 40 units
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Drugs and VF
• Antidysrhythmics:
–Amiodarone 300 mg IV
• Repeat once 150 mg
–Lidocaine 1.5 mg/kg
–Magnesium 2-4 gm
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• 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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Therapeutic Hypothermia for Cardiac Arrest
ILCOR 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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
All reasonable options
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Wide-Complex Tachycardia
• DDX:
– VT
85-95%
– SVT with BBB or accessory pathway (5-15%)
• Treat all wide complex tach as if it is VT
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Epidemiology
• 80-85% of wide complex tachycardias
are VT
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Which medications are useful for
terminating monomorphic VT
• Medications are at best 30-50% effective in
terminating VT
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Procainamide in V. Tach
• 20-30 mg/min up to 17mg/kg
• stop bolus when:
–
–
–
–
v. tach terminates
hypotension
QRS widens
max dose given
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Ventricular Tachycardia
• Do not give multiple antidysrhythmics if
one has failed (pro-arrhythmic effects)
• pick one antidysrhythmic, if it fails, go to
electrical cardioversion.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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!!
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Asystole
• Uniformly bad outcome if arrest
unwitnessed
• Consider CPR, causes (hypoxia, K,
acidosis, OD, hypothermia’
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Asystole
• Epinephrine 1 mg IV – q5min
• Atropine 1 mg IV max. 3 mg
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A 65 y.o. man collapses in the waiting
room of a busy emergency department
He has the following rhythm
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
PEA
• Treatment:
• Find and treat cause (is there a shockable
rhythm)
• Epinephrine 1 mg IV
• Atropine 1 mg IV (if bradycardic)
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A 49 y.o. woman develops palpitations while you are
talking with her
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Is this
•
•
•
•
•
A) sinus tach
B) Ventricular tach
C) AV node re-entrant tach
D) A flutter
E) Atrial fib
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
SVT
STABLE
UNSTABLE
CARDIOVERSION
VAGAL MANOEUVRES
OR
Verapamil 2.5 – 5 MG I.V. over 2 min (Class I)
(or Diltiazem 20 mg IV over 2 min) (Class I
Adenosine 6 mg IV (Class I)
RAPID PUSH
(IF B.P. NORMAL)
Verapamil 5 – 10 MG I.V.
Diltiazem 25 mg IV
Adenosine 12 MG I.V.
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Tachydysrhymias
• Enhanced Automaticity
– Sinus tach
– Junctional tach
– Atrial tach
• Re-entrant circuit
– VT, AVnRT, Flutter, Fib, VF
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Cardioversion
• You can only shock a re-entrant circuit
• Should be > 150
– Ex A. fib 120 , shouldn’t get the person in
trouble
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
• Sinus tach: not usually > 150
• A flutter: around 150,
• A fib: very irregular
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Would 1 mg of epinephrine be
appropriate if her BP was 60/40
A) Agree
B) Disagree
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Steps to determine the degree of AV
heart block
1) Are there more P’s than QRS’s, or are the P’s not
connected to the QRS.
–
If yes, then it is either a 2nd or 3rd degree HB.
2) Are the PR intervals changing
-if yes, it is either 2nd type l, or 3rd degree
-if not, it is 2nd type ll
3) Are the RR intervals constant
-if yes, then it is 3rd degree (or 2:1 2nd degree)
-if no, then it is 2nd degree, type l
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Bradycardia
When to Treat ?
• Symptomatic: chest pain, SOB, hypotension
• Therapy:
–
–
–
–
atropine
transcutaneous pacemaker
dopamine 5-20 microgm/kg/min
epinephrine 2-10 microgm/min
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
A 72 year old man complains of
persistant retrosternal chest
heaviness
What is your management ?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Is this patient a candidate for PCI or a
thrombolytic?
A) Agree
B) Disagree
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
CPR and ACLS
Purpose: treatment of sudden
unexpected death.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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 Interventions
CMAJ Dec 1, 1995
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
When to Discontinue CPR
• Judgement that patient is unresuscitatable
• Variables:
– down time, rhythm, age, premorbid conditions
– advance directives
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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.
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Sudden Unexpected Death
• 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 ?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Sudden Unexpected Death
• 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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
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
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Summary CPR
• Push hard, push fast, don’t interrupt
• Don’t overventilate
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Summary
Cardiac arrest:
Is there a shockable rhythm.
Don’t delay defibrillation
consider drugs
Tachydysrhythmia:
unstable-cardiovert
stable-can use medications
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
Summary
• Bradydysrhythmia
– Does it need immediate treatment
– Can it deteriorate
– Does it need long term pacing
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010
?
Copyright: Dr. Brian Weitzman, Department of Emergency Medicine
University of Ottawa March 2010