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Back to Basics 2011 Dr. Brian Weitzman Department of Emergency Medicine Ottawa Hospital Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Review of 14 Common Emergency Medicine Topics • April 6 – – – – – – Acute Abdominal Pain Acute Dyspnea Hypotension/Shock Syncope Coma Cardiac Arrest Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Emergency Medicine Topics April 7 • • • • • • • Malignant Hypertension Animal Bites Burns Near-drowning Hypothermia Poisoning Urticaria/Anaphylaxis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Abdominal Pain MCC Objectives 1. Common causes of pain – – 2. 3. 4. 5. 6. 7. 8. intra and extra abdominal, metabolic Localized vs diffuse 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/surgery Manage common causes of abdominal pain Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Neurologic Basis of Abdominal Pain • Visceral • Somatic • Referred Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 Referred Pain • What is it? • What are some examples? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Differential Diagnosis • Diffuse vs Localized Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Diffuse Abdominal Pain • • • • • • • Peritonitis AAA Ischemic Bowel Sickle cell Gastroenteritis Diabetes Perforated viscus Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Causes of Abd Pain - Localized Upper Abdominal Lower Abdominal Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Localized Abdominal Pain Colic/Cholecystitis Gastritis,GERD/PUD Hepatitis / Hepatic Abscess Pancreatitis Pneumonia / Pleurisy MI Biliary Appendicitis Mesenteric lymphadenitis Splenic Infarction Splenic Rupture Pneumonia Inflammatory bowel disease Diverticulitis Ectopic Ovarian(torsion or cystA) Salpingitis/PID Renal Stones/UTI Testicular torsion Incarcerated Hernia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 High Yield Questions Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 Physical Examination Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Physical Examination • MCC objectives: understand signs of peritonitis • Guarding • Rebound Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Risk Factors for Acute Disease • • • • • 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 April 2011 Initial Stabilization Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 1-2of Emergency mg Medicine Copyright: Dr. Brian Weitzman, Department University of Ottawa April 2011 Nausea/Vomiting: ER Tx Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Nausea/Vomiting: ER Tx • Ondansetron (Zofran) : iv 4-8 mg – very useful in patients with refractory vomiting – No longer expensive! • Gravol: po/pr/im/iv 25-50 mg – beware of anticholinergic side effects – sedating, may cause confusion • Maxeran/prochlorperazine (Stemetil): 10 mg iv – beware of possible EPS – less sedating; may help with pain control • Domperidone: po/iv – especially useful with diabetic gastroparesis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Investigations Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Investigations Imaging ultrasound CT scan plain Xrays Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 What is the cause of this 45 y.o. man’s LLQ pain? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 What is the cause of this man’s pain? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Why is this woman vomiting? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 • Central location, plica circularis (valvulae coniventes) • Small bowel obstruction central, stack coins, Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Why is this woman vomiting? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Large bowel, haustra, air LLQ Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 What is the cause of this man’s abdominal pain? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 What is the cause of this man’s abdominal pain? • Free air Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Summary: Common Causes of Abdominal Pain MCC Categorization • Is it diffuse or localized? • Do they need immediate referral or surgery? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Acute Dyspnea (minutes to hours) MCC Objectives • 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 April 2011 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 April 2011 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 April 2011 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 April 2011 • 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 April 2011 Most Common Causes of Acute Dyspnea • • • • • • COPD Asthma CHF PE Pneumonia Pneumothorax Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Acute Dyspnea-Respiratory Causes • Interstitium 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 April 2011 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 April 2011 • 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 April 2011 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 April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 5 Reasons to Intubate • • • • • Protection Creation Oxygenation Ventilation Pulmonary toilet Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Circulation • • • • Pulse, BP, Heart sounds ? Muffled JVP Edema Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Rapid Assessment • • • • • • • Does this person need immediate treatment? Ventolin Nitroglycerin ASA Furosemide BiPap Needle decompression Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 History-What are the key questions? • • • • 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 April 2011 Labs/Investigations • • • • • ABG CBC, Lytes, Cardiac enzymes D dimer ECG Pulmonary Function Tests Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Imaging • • • • CXR VQ Helical CT Pulmonary angiogram Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 COPD hyperlucent 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 April 2011 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 • • • • Steroids ex. Solumedrol 125 mg IV Theophylline: poor bronchodilator Antibiotics BiPap Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 LLL pneumonia diaphragm obscured lat confirms post location Copyright: Dr. Brian Weitzman, Department of Emergency Medicine 58yr female: weakness, cough, SOB University of Ottawa April 2011 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 April 2011 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 April 2011 Principles of Management Pulmonary Edema • • • • • • 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 April 2011 A 25 year old with dyspnea Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Pneumothorax Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Hyperventilation Syndrome • Must rule out organic causes – PE, myocardial ischemia • ABG: pH 7.30 CO2 25 HCO3 24 O2 100 • Avoid rebreathing from paper bags • Treatment: reassurance, mild anxiolytic ex. Lorazepam 1 mg Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 75 y.o. with a history of CHF comes in drowsy, gasping for air. : • • • • pH pC02 HCO3 P02 7.15 70 30 60 • Acute or Chronic Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 75 y.o. with a history of CHF comes in drowsy, gasping for air. : • • • • pH pC02 HCO3 P02 7.15 70 30 60 • Acute Respiratory Acidosis – pC02 increase by 10 decreases pH by .08 – HC03 increases 1 meq/l per 10 C02 rise Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 75. y.o. with COPD and dyspnea x 2 days • • • • pH pC02 HC03 p02` 7.28 80 40 65 • Acute or Chronic Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 75. y.o. with COPD and dyspnea x 2 days • • • • pH pC02 HC03 p02` 7.28 80 40 65 • Chronic Respiratory Acidosis – C02 rise by 10 decrease pH by .03 – HC03 rises by 4 per 10 mmHg C02 rise Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 25 y.o. diabetic, vomiting x 2 days, looks dyspneic • • • • pH HC03 pC02 P02 7.10 10 18 95 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 25 y.o. diabetic, vomiting x 2 days, looks dyspneic • • • • pH HC03 pC02 P02 7.10 10 18 95 • C02 decreases 1.2 per 1 HCO3 decrease • Change of HC03 of 10 changes pH by 0.15 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Guidelines for ABG • 10 mmHg change in C02 changes pH .08 opposite direction • C02 decreases by 1 for every 1 decrease in HC03 • Change HCO3 of 10 changes pH 0.15 same direction Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Our 55 year old woman in distress… Pericarditis or Acute Inferior MI Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Acute Inferior MI Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Syncope Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Syncope-MCC Objectives • • • • • • • 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 April 2011 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 likelihood 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 • 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 April 2011 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 April 2011 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 April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Review of Systems • • • • • 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 April 2011 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 April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Vasovagal Faint • Common (20% all syncope) • Increased parasympathetic tone • Bradycardia, hypotension Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Vasovagal Faint -Predisposing Factors • • • • • • • • 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 April 2011 Vasovagal Faint Symptoms 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 Our 73 y.o. man who collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430. • Sick sinus syndrome: need pacer Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 An 80 y.o. man complains of recurrent syncope What is his diagnosis and treatment? • Third degree Heart Block Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 65 y.o. man on diuretics has recurrent syncope Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Torsades de Pointes Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 ? Break Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Coma Coma Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 What is Coma? • MCC Defintion: • state of pathologic unconsciousness (unarousable) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Isodense Subdural Hematoma Enhanced CT Head Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 • • • • • • • • • • • 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 April 2011 What is your initial approach with this comatose patient? • • • • • • • • • 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 April 2011 Level of Consciousness • AVPU – Awake, verbal, pain , unresponsive • Glasgow Coma Scale Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Physical Exam • HEENT: – Battle’s sign, hemotympanum. – Breath odour • Ex. Acetone = DKA Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Physical Exam Pupils Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Physical Exam • Corneal Reflex – Sensory CN 5, and Blink is CN 7 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 Labs ? • • • • • • • 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 April 2011 Diagnostic Tests/Imaging • • • • • CXR CT Head LP ECG EEG Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 Uncal Herniation Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 • 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 April 2011 • 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 April 2011 Restraining People 1) Is the patient competent to decide for them self? 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 illness Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Valid Consent • • • • Relate to treatment Informed Voluntary Can’t misrepresent or be fraudulent Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Substitute Decision Making Highest of Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 What Is Shock • Tissue hypoperfusion or tissue hypoxia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Shock • Catecholamine surge • Vasoconstriction, increased CO • Renin-angiotensin, vasopressin – Salt and water retention Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Shock What are the causes? Obstructive Obstructive Cardiac Hypovolemic Distributive Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 • 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 April 2011 • 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 April 2011 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 April 2011 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 April 2011 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 April 2011 A 75 y.o. comes in confused x 2 days, lethargic • BP 80/50 P. 130 T 38 RR 25 02 85% • What is his diagnosis? • What would you do? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Septic Shock • Fluids: normal saline 1-2 litres • Oxygen • Treat the infection: – Antibiotics: broad spectrum – 3rd generation cephalosporins – Pip-tazo • BP support: inotropes: dopamine Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 39 y.o. man arrives in the ED having been stung by a bee 30 minutes ago. He has hives, facial and tongue swelling and is dyspneic. • What will you do? • BP 70/50 P. 140 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Anaphylaxis • 100 % oxygen • bolus 1-2 litres normal saline • epinephrine 0.3 mg IM q5min • or 5-15 microgm/min IV with shock • • • • benadryl 50 mg IV ranitidine 50 mg IV solumedrol 125 mg IV Glucagon 1mg IV if on beta blockers Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Cardiac Arrest - Causes • Non Cardiac – – – – Tamponade PE Tension Trauma Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 72 y.o. man clutches his chest and collapses in the ED • Why did he collapse? • What are you going to do ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Sudden Cardiac Arrest • electrical accident due to ischemia or reperfusion • 80% ventricular fibrillation or ventricular tachycardia • 20 % asystole pulseless electrical activity Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Mechanism of Fibrillation • ischemia: slows conduction • adjacent myocardium in various phases of excitation and recovery • multiple depolarizing reentrant wave fronts Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Ventricular Fibrillation (V. fib.) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Ventricular Tachycardia (V. tach) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Survival from Sudden Cardiac Arrest • function of time – Witnessed: 90% • survival decreases by 10% /min • With CPR: Survival decreases by 4%/min Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Cardiac Arrest • What are the key actions that are required to improve survival from cardiac arrest? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Chain of Survival Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Major Changes of BLS • Change in CPR sequence to : –C-A-B rather than A-B-C... • Begin with chest compressions !!! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Major Changes of BLS • Trained Layperson or Health Care Provider – 30 compressions, 2 breaths • Untrained layperson – Compression only CPR acceptable – ‘Hands Only’ CPR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Major Changes of BLS • Elimination of : “Look, Listen & Feel” for breathing... • …except for hypoxic arrest • Pulse check for Health Care Providers < 10 sec. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Chest Compressions • Most compressions inadequate • Return of cardiac activity related to adequate CPR • Too many pauses in CPR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Why the change to CAB? • Beginning with airway significantly delays compressions • Most cardiac arrest victims have oxygenated blood • Survival related to adequate chest compressions Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 High Quality CPR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 High Quality C.P.R. • Compression : Ventilation ratio (30 : 2) – Until advanced airway • Minimize interruptions in CPR • Push Hard & Fast : 2 inches / 100/ min. • Full chest recoil-lift hands off chest Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Airway Management • BVM (Bag-Valve-Mask) – Avoid hyperventilation! – 8 – 10 breaths / min. interposed with CPR • Secure Airway & Confirm Placement – No need to pause compressions! • Supraglottic Airway Device • (LMA / King LT / Combitube) • Endotracheal Intubation (ETT) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Exhaled CO2 Detectors • 100% sensitivity and 100% specificity in identifying correct endotracheal tube placement. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Airway & Adjuncts • Role of cricoid pressure during cardiac arrest has not been studied. • Routine use of cricoid pressure in cardiac arrest is not recommended. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Supraglottic Airways • LMA King LT Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 What are the only things that should interrupt CPR? • • • • Rhythm and pulse check Ventilation (if advanced airway not present) Advanced airway and intubation Defibrillation Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A patient you are talking to suddenly becomes unresponsive Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 The crash cart arrives, 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 April 2011 Would you: A) Do 2 minutes of CPR then defibrillate B) Defibrillate immediately What if the patient had an unwitnessed arrest? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 New CPR Guidelines • Even with unwitnessed arrest…. • Once V fib is recognized…shock ASAP Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Shock Protocol • Optimal energy level for defibrillation unknown. • Shorten interval between compressions and shocking – improves shock success. • After shock delivery, resume CPR immediately – Don’t delay chest compressions for rhythm or pulse check Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 How many times do you defibrillate? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 No Change in Recommendations • 1 shock then resume CPR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 If you can’t get an IV, what other route can you give drugs? • Intraosseus • Endotrachael: (not a good route) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Intraosseous Access Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Your patient is still in this rhythm ! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Cardiac Arrest Medications No Significant Change in New Guidelines • Vasopressors – Epinephrine • 1 mg q3-5 min – Vasopressin • 40 units • May replace 1st or 2nd dose of epinephrine Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Cardiac Arrest Medications No Significant Change in New Guidelines • Antiarrythmics • Don’t revert v fib. • Work by preventing V.Fib, – – – – Amiodarone – Procainamide Lidocaine Magnesium Sulfate Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Amiodarone • First line antidysrhymthmic • 300 mg IV bolus • May give 2nd dose: 150 mg Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Lidocaine • 1.5 mg/kg • Repeat x 1 prn. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 • 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 April 2011 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 April 2011 ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 69 y.o. patient you are assessing for chest pain suddenly complains 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 April 2011 After verifying the patient’s pulse, would you ? A) Give lidocaine 100 mg B) give amiodarone 150 mg IV C) sedate and cardiovert D) Adenosine 6 mg IV E) need more info Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 BP 110/60, no SOB, no chest pain A) Give lidocaine 100 mg B) give amiodarone 150 mg IV C) sedate and cardiovert D) Adenosine 6 mg IV Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Adenosine • recommended as a safe and potentially effective therapy in wide-complex tachycardia – – – – stable undifferentiated regular monomorphic wide-complex tachycardia. • Level 11b: Observational retrospective studies – Critical Care Medicine –Copyright: Marill, KA SeptDepartment 2009of Emergency Medicine Dr. Brian Weitzman, University of Ottawa April 2011 Which medications are useful for terminating monomorphic VT • Lidocaine: 6 studies (8-30% effective) • Procainamide: few studies – 30% effective • Amiodarone: small case reports only • 30% Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 Ventricular Tachycardia-Summary • If stable: can try drugs but cardioversion best choice • If unstable: cardiovert (synchronized) • If pulseless: defibrillate • Drugs rarely effective Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 An 80 y.o. patient recovering from oral surgery was found unresponsive 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 April 2011 Asystole Witnessed Arrest ? Yes No CPR - Intubate - IV access Confirmation in 2 leads ACLS futile? Possible causes Hypoxia Hyperkalemia Hypokalemia Acidosis Drug overdoses Hypothermia Epinephrine 1 mg IV q 3 - 5 min (consider 1 dose Vasopressin 40 IU IV may replace 1st or 2nd dose epinephrine) Consider termination of efforts Atropine no longer recommended Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 65 y.o. man with an extensive cardiac history collapses in the ED. He has no pulse. He has the following rhythm Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 PEA • Treatment: • Find and treat cause • (Is there a shockable rhythm?) • Epinephrine 1 mg IV • (no longer atropine) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 PEA • Consider causes: – 5 H’s : – hypovolemia, hypoxia, H ion, hyper/hypo K, – 5 T’s: – tamponade, tension pneumo, thrombosiscoronary or pulmonary, tablets OD Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 You are working on your 49 y.o. patient when their heart rate suddenly jumps from 115 to 200. What is this? A) Atrial fibrillation B) Atrial flutter C) Ventricular tachycardia D) A-V nodal re-entrant tachycardia E) Sinus tachycardia What will you do? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 A 75 year old woman complains of dizziness. A) NSR B) Second degree HB type 1 C) Second degree HB type 2 D) Third degree HB What are the treatment options if: 1) her BP is 120/80 and she looks well 2) her pulse was 45, BP 70/30 and she looks ill Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Second degree HB type ll • Dysfunctional His Purkinje system can lead to complete heart block • If stable, send to monitored bed, and arrange permanent transvenous pacer • If unstable: external pacing, or dopamine or epinephrine infusion. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 70 yo woman complains of dizziness x 3 days What is this rhythm? A) NSR B) Second degree HB type 1 C) Second degree HB type 2 D) Third degree HB Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 A 70 yo woman complains of dizziness x 3 days What is this rhythm? A) NSR B) Second degree HB type 1 C) Second degree HB type 2 D) Third degree HB Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 Bradycardia When to Treat ? • Symptomatic: chest pain, SOB, hypotension • Therapy: – – – – atropine 0.5-1 mg (max total 3 mg) transcutaneous pacemaker OR dopamine 5-20 microgm/kg/min OR epinephrine 2-10 microgm/min Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 Myocardial Infarction What can you do? • MONA – – – – ASA 160 mg chew oxygen nitrates sublingual or IV morphine 2-3 mg prn Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Myocardial Infarction What can you do? • • • • Antiplatelets: clopidogrel 600 mg Heparin Thrombolytics < 30 mins Primary PTCA <90 mins – Percutaneous transluminal coronary angioplasty Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 Myocardial Infarction STEMI • Thrombolytics – door – needle : < 30 min. • Primary PTCA – Door-Balloon : < 90 min. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 CPR and ACLS Purpose: treatment of sudden unexpected death. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 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 April 2011 ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2011