Download The Written Summary of the EM:RAP Monthly Audio Program

The Written Summary of the EM:RAP Monthly Audio Program
August 2014: Volume 14, Issue 8
Editor-in-Chief: Mel Herbert, MD
Executive Editor: Paul Jhun, MD
Associate Editor: Marlowe Majoewsky, MD
www.emrap.org
Notes from the Community:
Bronchiolitis: Part 2
oxygen, 6% were subsequently admitted. There were no
ICU admissions or need for advanced airway intervention
in any of the patients.
Rob Orman MD and Andy Sloas MD
u
u
Occasionally, the bronchiolitis patient will look well but
remain hypoxic after intervention. They are tolerating POs,
breathing comfortably, and not tachypneic, but the lung exam
remains with crackles and wheezes and the pulse oximetry
reads 85%. Can you discharge these patients with
home oxygen therapy via nasal cannula? It makes sense.
However, this is not feasible for most emergency departments.
The oxygen saturation curve doesn’t fall off until 85%. Patients
with an oxygen saturation of 90% that drops to 88-89% while
sleeping can probably be sent home.
•Sandweiss DR et al. Decreasing hospital length of stay
for bronchiolitis by using an observation unit and home
oxygen therapy. JAMA Pediatr. 2013 May;167(5):422-8.
PMID: 23479000.
•Halstead S et al. Discharged on supplemental oxygen from
an emergency department in patients with bronchiolitis.
Pediatrics. 2012 Mar;129(3):e605-10. PMID: 22331343.
This was a retrospective chart review looking at admission,
bouncebacks, and need for intervention in patients after
initiation of a home O2 protocol. The study included 419
children with bronchiolitis: 57% of the patients were
discharged on room air; 28% were admitted; 15% were
discharged on home oxygen. The children discharged with
home oxygen were classified as uncomplicated bronchiolitis:
a lower respiratory tract infection with wheezes/crackles in
an otherwise healthy patient without underlying medical
cardiopulmonary disease. Hypoxia was defined as pulse
oximetry on room air of <88%.
°Of the patients discharged on room air, 4% were subse-
°The
overall admission rates for bronchiolitis dropped
from 40% to 31%.
•These studies came to the same conclusion: if you send
most of these otherwise well-appearing kids home, they
don’t come back. However, this probably means that they
don’t need the home oxygen.
u
What does the literature say?
•Tie SW et al. Home oxygen for children with acute
bronchiolitis. Arch Dis Child. 2009 Aug;94(8)641-3.
PMID: 18927148. This was a prospective study. This included
children with moderate disease that got suctioned, received
a bronchodilator or saline nebulizer and looked well aside
from hypoxia. They had a very low bounceback rate.
Is there a subset of patients at risk of apnea? Children
that were full-term and younger than 1 month were at risk of
apnea. Also, children born premature and younger than 48
weeks post conception had an equal risk of apnea. These two
groups should probably be admitted for observation. Also,
admission is recommended if the patient’s parents or physician
have witnessed a prior period of apnea.
•Willwerth, BM et al. Identifying hospitalized infants who
have bronchiolitis and are at high risk for apnea. Ann
Emerg Med. 2006 Oct;48(4):441-7. PMID: 16997681.
•Consider admission in any child who has some nonfunctioning system (for example: a kid with cystic fibrosis,
congenital heart defect, MRCP, etc.). These children do
not do well and have limited functional reserves. They may
return in arrest without indicating impending badness.
u
Utility of RSV testing. RSV tests are not necessary to make
this clinical diagnosis. If you are wrong, they have a cold. If the
child looks awful, you are going to do a lumbar puncture on
them regardless.
• However, they may be useful in children between 2-3 months
of age with a fever without source and you are trying to avoid
a lumbar puncture. This patient population may benefit from
transfer to a pediatric facility regardless as they are at higher
risk for apnea.
• If the RSV is positive, these patients are at extremely low risk
for a serious bacterial infection. Levine DA et al. Risk of
serious bacterial infection in young febrile infants with
respiratory syncytial virus infections. Pediatrics. 2004
Jun;113(6):1728-34. PMID: 15173498.
quently admitted. Of the patients discharged home with
EM:RAP Written Summary August 2014: Volume 14, Issue 8
1
The Written Summary of the
• The inpatient team will often request RSV swabs to determine
location when admitted. However, it is a clinical diagnosis
and these patients should be separated from immunocompromised patients just based on their symptoms.
u
Cardiology Corner:
A Common Sense PEA Algorithm
Amal Mattu MD and Rob Orman MD
Case #1
Criteria for admission. There are clinical scores available.
The Wang score is commonly used but does not include oxygen
saturation. Rather than using a scoring system, you can ask
yourself several questions:
•What is their work of breathing? If the patient has retractions (abdominal, supraclavicular, substernal), then they
should probably be admitted. A respiratory rate over 40 may
need admission. A patient with an oxygen saturation of 90%
while awake is probably safe to go home. Sloas will send
home anything over 85% saturation while sleeping because
that is where the saturation curve begins to fall off.
•How do they feed? It is ok if they normally take 4 ounces
but are now taking 1-2 ounces, as long as they are feeding
more frequently. Advise the parents that they are going to
have to feed the child more frequently every 3-4 hours, like a
newborn. Parents should feed more frequently over the next
4-5 days. The disease course runs approximately 14 days.
u
Monthly Audio Program
The patient has no pulses but good cardiac activity on
ultrasound with a rate of 90 on the monitor. The blood
pressure is 50. Is this considered PEA? Do you start CPR?
Do you give pressors? Technically this is PEA with electrical
activity and no pulse. However, there is evidence that ED
providers are not perfect at detecting a pulse in patients
with decreased perfusion and borderline cardiac activity.
u
Unlike asystole or ventricular fibrillation/tachycardia,
where we know what to do, PEA is less clear. ACLS has
tried to simplify things. Unfortunately, there is no single course
of therapy for PEA that is appropriate, which can lead to
problems.
u
A history of PEA. PEA used to be called EMD or electromechanical dissociation. They realized that you could have
electrical activity on the monitor but not have a pulse. It was
thought that if there was no pulse, it signified that the heart
was completely disorganized and not producing any organized
activity. With the advent of ultrasound, they saw organized cardiac activity but no pulse. The term was changed to pulseless electrical activity. This meant that the patient had
cardiac activity detectable on the monitor but no pulse.
The electrical activity on the monitor must be a rhythm that
would normally have a pulse. Ventricular fibrillation without
a pulse is not PEA. A heart rate of 20 with no pulse is extreme
bradycardia or an agonal rhythm.
u
Most patients in PEA likely have organized activity, but
the blood pressure is so low that we don’t feel a pulse.
u
The ACLS guidelines recommend initiating compressions. However, in discussions with several of the critical care
experts (Scott Weingart, Haney Mallemat, etc.), many of them
would not initiate chest compressions in the patient scenario
above. There is a concern that chest compressions may cause
more harm than good in a beating heart. However, we do chest
compressions in neonates and infants with organized cardiac
activity as part of the PALS algorithm. Chest compressions may
be the only way to produce a reasonable blood pressure.
u
Fluids are important. The most common overall cause of
PEA is hypovolemia.
u
It can be difficult to remember the Hs and Ts. Hypovolemia, hypokalemia or hyperkalemia, hypoxia, hypothermia and
acidosis (hydrogen ion). Some include hypoglycemia although
this is extremely rare as an etiology of PEA arrest. Toxins, tamponade, tension pneumothorax, thrombosis (massive MI or
What is the deal with urine testing in patients with
bronchiolitis? This came from two studies.
•Kuppermann N et al. Risks for bacteremia and urinary
tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med. 1997 Dec;151(12):1207-14.
PMID: 9412595. He found a 2% prevalence of urinary tract
infection with concomitant RSV.
•Levine DA et al. Risk of serious bacterial infection in
young febrile infants with respiratory syncytial virus
infections. Pediatrics. 2004 Jun;113(6):1728-34.
PMID: 15173498. Found a similar rate.
•However, this is similar to the baseline rate of culturepositive urine in asymptomatic children under the age of
3 years, randomly selected for testing. You don’t need to
check the urine in febrile children with bronchiolitis.
2
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
Monthly Audio Program
PEA Evaluation
Narrow QRS = Mechanical (RV) Problem
Wide QRS = Metabolic (LV) Problem
• Cardiac tamponade
• Severe hyperkalemia
• Tension pneumothorax
• Sodium-channel blocker toxicity
• Mechanical hyperinflation
• Agonal rhythm
• Pulmonary embolism
• Acute MI with pump failure
• Severe hypovolemia
Bedside US: LV hypokinetic or akinetic
• Acute MI with myocardial rupture
Management: Pharmacologic management with IV calcium chloride
Bedside US: LV hyperdynamic
and IV sodium bicarbonate boluses
Management: Wide open fluids plus treatment of underlying pathology
• Cardiac tamponade ➡ pericardiocentesis
• Tension pneumothorax ➡ needle decompression
• Mechanical hyperinflation ➡ ventilator management
• Pulmonary embolism ➡ thrombolysis
massive PE) and trauma. Some have proposed an easier
algorithm.
u
Littmann L et al. A simplified and structured teaching tool
for the evaluation and management of pulseless electrical
activity. Med Princ Pract. 2014;23(1):1-6. PMID: 23949188.
•They compiled a simple and practical approach to
PEA that focuses on the causes that have the highest
likelihood and relevance to us in the ED. They removed
some of the rare causes. It does not apply to trauma.
•They separated the different causes of PEA based on
whether the cardiac monitor shows narrow or wide
QRS complexes. They added an echocardiogram. If you
look at the QRS complex and an echo, you should be able to
identify the cause.
•If you have a narrow complex PEA, it is usually
due to a mechanical problem that causes right
ventricular inflow or outflow problems such as
hypovolemia, hyperinflation of chest like in COPD patients,
tension pneumothorax, cardiac tamponade and acute MI
with rupture. What can lead to outflow problems? Pulmonary
embolism. How can you tell the difference between
these? Grab the ultrasound and take a look. You can
diagnose tamponade, pneumothorax, and hypovolemia (e.g.
IVC collapse). You should see a hyperdynamic heart.
•If you have a wide complex PEA, it is usually metabolic or tox problems. Examples of metabolic problems
include severe acidosis and severe hyperkalemia. Overdose.
Massive MI can lead to severe pump failure. These patients
usually will have a hypokinetic left ventricle or standstill.
•What did they leave out? Hypothermia. Hypokalemia.
Hypoglycemia. Hypoxia. However, a review of the literature
showed that hypoglycemia and hypokalemia are not likely to
present in PEA.
•This method is not comprehensive but it is practical.
•Treatment strategies can also be divided into wide
and narrow complex rhythms.
• If it is a narrow complex rhythm, hydrate the patient aggressively and look for the underlying cause. In these patients
with mechanical obstruction, aggressive mechanical
ventilation or chest compressions can be harmful.
You don’t need to empirically give bicarb or calcium in these
patients.
• If it is a wide complex PEA rhythm, they recommend empiric
treatment with calcium and bicarb. This makes sense because
so many of these patients are severely hyperkalemic or acidotic.
Critical Care Mailbag:
Sepsis: Blood Pressure Targets,
ProCESS and Albumin
Scott Weingart MD and Rob Orman MD
u
ProCESS Investigators et al. A randomized trial of protocolbased care for early septic shock. N Engl J Med. 2014 May
1;370(18):1683-93. PMID: 24635773.
•This trial looked at the original Rivers protocol and
asked if the findings were generalizable and if all
aspects of the protocol were necessary.
August 2014: Volume 14, Issue 8 | www.emrap.org
3
The Written Summary of the
• This study included 1341 patients at 31 emergency departments. A third of the patients received protocol-based early
goal directed therapy, a third received protocol-based standard therapy and the remainder received usual care.
• The early goal directed therapy group received placement of
a central venous catheter to monitor pressure/ScvO2 and IV
fluids, vasopressors, dobutamine, or packed red blood cell
transfusion as indicated. They had specified amounts and
timing of IV fluids, and thresholds for vasopressor use.
•The standard therapy group had peripheral access with
placement of a central line only if peripheral access was insufficient. These patients received fluids and vasopressors to
reach goals for systolic blood pressure and shock index. The
team leader decided when the patient had received enough
fluid hydration.
• The third group had no protocol or prompts.
•Although these were a heterogeneous group of centers, they were all academic centers capable of running a study of this magnitude. This is not necessarily
generalizable to the tiny community ED.
•What did they find? There were no statistically significant
differences amongst these groups in terms of the primary
outcome, which was death within 60 days.
•This is confirming what many facilities are currently
doing: avoiding central line placement until the
patient is vasopressor dependent. This saves the patient
from a potentially risky procedure that exposes them to
infection and is time-consuming.
u
u
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4
How much fluid did the patients in the usual care group
receive? On average 4.4 liters. This is a lot more than the 2
liters that most give. The early goal directed therapy group received 4.5 liters of fluid. The group that received the highest
amount of fluid (4.9 liters) was the hybrid protocol.
If you have a patient who satisfies severe sepsis by labs
but has a normal lactate and is normotensive, does the
Surviving Sepsis Campaign mandate that they receive a
30cc/kg bolus within 3 hours? The most recent recommendations complicate the definitions of sepsis and severe sepsis.
In the recommendations, it requires persistent hypotension or
a lactate greater than or equal to 4 mmol/L to be considered severe sepsis. However, they include a table defining severe sepsis
as various lab abnormalities. There is not a clear answer.
Take-home points. The usual care group received much
more fluid than usual, more than 50% percent had central
lines, and 44% received vasopressors. All three groups also
received early antibiotics. The usual care group still received
very aggressive resuscitation. Aggressive pragmatic care is
as good as early goal directed therapy.
Monthly Audio Program
u
Ricard JD et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial.
Crit Care Med. 2013 Sep;41(9):2108-15. PMID: 23782969.
•This was a randomized controlled trial of central
versus peripheral venous access. They recommended
using central access due to an increased rate of adverse
events with peripheral lines. However, if you look at the
adverse events, they were not life-threatening and included
complications such as failure of peripheral access requiring
placement of a central line. This was a large trial including
263 randomized patients.
u
If you want to initiate pressors via peripheral access in
the ED, this is probably ok with some provisos:
•You need to a have a protocol in place to look at the
arm. If you are going to do this, you need to have a nursing protocol with frequent reassessment by nursing staff to
rule out extravasation. If extravasation is caught early, it is
unlikely to result in serious complications. Problems arise
when the extravasation remains undetected and the patient
develops compartment syndrome or another complication.
•You should probably have a protocol in place to address extravasation. Weingart recommends administration of phentolamine or another antidote. Consultation with
plastics possibly.
u
Asfar P et al. High versus low blood-pressure target in patients
with septic shock. N Engl J Med. 2014 Apr 24;370(17):1583-93.
PMID: 24635770.
•The study included 776 patients with septic shock. Half had a
target mean arterial pressure of 80-85 mm Hg or 65-70 mm Hg.
•They found no difference in mortality.
u
Caironi P et al. Albumin replacement in patients with severe
sepsis or septic shock. N Engl J Med. 2014 Apr 10;370(15):
1412-21. PMID: 24635772.
•This was a large study including 1818 patients with severe
sepsis. They were randomized to receive either 20% albumin
and crystalloid solution, or crystalloid solution alone.
•They found no difference in mortality, organ dysfunction, length of hospital stay, or length of ICU stay.
u
The SAFE trial. Finfer S et al. A comparison of albumin and
saline for fluid resuscitation in the intensive care unit. N
Engl J Med. 2004 May 27;350(22):2247-56. PMID: 15163774.
•This study showed no benefit to albumin versus crystalloid but subgroup analysis hinted at a potential
benefit in septic patients. The albumin used in this study
was a higher concentration than the concentration usually
used as a substitute for fluid. The albumin concentration was
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
Monthly Audio Program
higher to improve oncotic pressure in the blood and resuscitate the glycocalyx.
•The glycocalyx is a thin layer, initially thought inert,
that may play a key role in vascular integrity and
function. This may be important in sepsis syndromes and
capillary leakage.
u
Take-home point. There does not appear to be benefit to giving albumin. If you aren’t using it now, don’t go looking for it.
u
Normal saline versus lactated ringers. Normal saline is
very non-physiologic and makes the body acidotic. There is
some increasing evidence that this can result in injury to the
kidneys and affect the inflammatory cascade. There has been a
move toward more balanced fluids like Plasma-Lyte or Lactated
Ringers or Hartmann’s solution. There is no definitive data.
Plasma-Lyte is more expensive than normal saline. It is similar
to Lactated Ringers and probably as close as you can get to
plasma. It has normal sodium compared to the slight hyponatremia of Lactated Ringers. It doesn’t have lactate. Weingart will
usually give a liter of Plasma-Lyte after the patient has received
1-2 liters of normal saline.
backboard. Haut ER et al. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010
Jan;68(1):115-20. PMID: 20065766.
3.Spinal precautions can be maintained by application of
a rigid cervical collar and securing the patient to an EMS
stretcher and not a backboard. This may be most appropriate for patients found ambulatory at the scene and patients
transported for a protracted time.
u
Anyone who meets the following criteria does not require immobilization with a backboard: GCS 15; no spinal
tenderness to palpation or anatomic abnormality; no neuro complaints or exam findings; no distracting injury; no intoxication.
u
Patients should be removed from backboards as soon
as possible.
u
Spinal protection is not synonymous with a long backboard. The backboard is a good tool for extrication because it
allows the patient to remain flat despite multiple people moving them. However, once they are on the cot, they are on a flat
surface and this is able to provide support for the spine without
the negative effects of a hard backboard.
u
There is a new emphasis on self-extrication. Patients with
a positive spinal assessment will have a C-collar applied. If they
are able, they can ambulate to the cot on their own power or
with assistance but will not be placed on a backboard. There is
no need for the standing takedown.
u
Where is the evidence?
Back of the Bus:
The End of the Backboard?
Darren Braude MD and Chelsea White MD
u
Do backboards help or harm?
u
There are multiple downsides. Pain, unnecessary imaging
(is their back pain due to the board or injury?), respiratory
compromise and pressure sores. Many EMS systems are
moving away from backboards. This goes against decades of
dogma and inertia.
u
Selective immobilization. We no longer immobilize every trauma patient but there are more developments to come. It is no longer about whom we immobilize, but rather how we immobilize.
u
White CC 4th et al. EMS spinal precautions and the use
of the long backboard – resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on
Trauma. Prehosp Emerg Care. 2014 Apr-Jun;18(2):306-14.
PMID: 24559236.
•Engsberg JR et al. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. PMID: 23079144.
• Used a system of multiple high speed infrared motion analysis
cameras and sensors to detect motion of the cervical spine
during four different extrication techniques: 1) unassisted
and unprotected; 2) unassisted and protected with a cervical
collar; 3) assisted and protected with a cervical collar; and
4) assisted and protected with a cervical collar and Kendrick
Extrication Device. They found self-extrication with a C-collar
resulted in less movement of the spine.
u
Who should we immobilize?
1.Utilization of spinal backboards for spinal immobilization
during transport should be judicious so that the benefits
outweigh the risks.
•Is the mechanism of injury sufficient to result in
spinal cord injury? This may be difficult to assess. A fall
from standing in a healthy middle aged male is less like to
result in injury than a fall from standing by a nursing home
resident. There is a degree of discretion for the provider. If
the mechanism is concerning for spinal cord injury, continue
to perform spinal assessment.
2.Patients with penetrating trauma to the head, neck or torso
without evidence of spinal injury such as obvious paralysis
or focal neurologic deficit should not be immobilized on a
•Much of this derived from NEXUS and the Canadian
C-spine rules. A positive spinal assessment includes any
of the following: pain, tenderness or deformity in the poste-
u
There are three major points.
August 2014: Volume 14, Issue 8 | www.emrap.org
5
The Written Summary of the
Monthly Audio Program
ception. 2011 Oct;84(4):363-7. PMID: 21920190. This study
looked at trials involving Ella (ulipristal acetate) versus Plan B.
During review of the data they found that patients with a BMI
greater than 25 had no efficacy from Plan B. The risk of pregnancy was 3 times higher in obese women and higher with levonorgestrel than ulipristal. These medications were less effective
if intercourse was near the predicted time period of ovulation.
The paper recommends women near ovulation should
be offered a copper intrauterine device and women with
a BMI greater than 25 be offered an IUD and ulipristal.
rior midline over any vertebra, an unexplained neurologic
deficit, or unreliable spinal exam. Examples of unreliability:
altered mental status, intoxicated with alcohol or drugs, or a
painful distracting injury (usually described as a long bone
fracture proximal to the wrist or ankles). Young patients
who are unable to alert you to pain. Language barriers.
•If the spinal assessment is negative, transport the
patient in a position of comfort and place a c-collar
if he/she is over age 65 years. Age greater than 65 is
considered high risk criteria by the Canadian C-spine rules.
•If there is a positive spinal assessment, place a C-collar. If the patient is ambulatory or can safely self-extricate,
assist him/her to the cot. There is no need for a backboard
takedown. If the patient is not ambulatory or extrication is
required, use a rigid extrication device such as backboard to
get him/her to the cot. Once the patient is transported to the
cot, remove the backboard. If the patient requires additional
stabilization, you can use a head block. The patient may be
secured to the cot with seatbelts.
•There is a caveat for continued immobilization if removal of the backboard will interfere with a device or
intervention, such as CPR or intubation.
u
This is a problem as Plan B is now available over the
counter and many women do not consult with a pharmacist prior to using it.
u
In optimal conditions, Plan B is thought to decrease the chance
of pregnancy by about 85%. These agents inhibit the egg from
ovulation and to some extent can decrease implantation. You
can only get pregnant within about 24 hours of egg release but
sperm can stay alive for 5 days. Plan B is most efficacious when
given in the first 72 hours. Ulipristal acetate is effective for the
5 day duration and is probably the better choice.
u
The American College of Obstetrics and Gynecology
recommend Plan B and its generics, ulipristal acetate
(available only via prescription), and copper IUDs.
Giving larger doses of regular oral contraceptives is less
efficacious than these three options. Women are candidates
if they have had unprotected or inadequately protected sexual
intercourse and do not desire pregnancy. Pregnancy test is not
needed before giving emergency contraceptives.
u
If a patient has an actual body weight greater than 165 lbs.,
they should not use Plan B.
u
The morning-after contraceptives all have side effects of nausea
and vomiting, and patients should be given anti-emetics. These
medications do not appear to be dangerous to pregnancy. They
are not mifepristone. Mifepristone is less effective than Plan B.
u
Plan B contains 1.5 mg of levonorgestrel. This contains
only progestin. Another option is to take two 0.75mg doses of
levonorgestrel 12 hours apart.
u
Ulipristal acetate (Ella) is a selective progesterone
receptor modulator. There is some evidence that it is more
effective than levonorgestrel for emergency contraception.
It can be used up to 120 hours post intercourse. The dose is
30mg up to 5 days from intercourse. However, it is not available
over the counter.
u
Copper IUDs are very effective at preventing pregnancy
after intercourse within 5 days. There are no head-to-head
studies with oral contraceptives. However, the Mirena IUD (the
levonorgestrel releasing IUD) is not effective as emergency
contraception.
• Appropriate candidates for spinal immobilization may include
those with blunt trauma and: altered level of consciousness,
intoxication, spinal pain or tenderness, neurologic complaint,
anatomic deformity of the spine, high energy mechanism,
inability to communicate, or distracting injury.
u
This may result in fewer x-rays as patients often develop pain
due to the backboard.
u
If you are not using a backboard, how can you transport
patients from the EMS stretcher to the ED stretcher to
CT? Very carefully. Some use slide boards but be careful as
these are sometimes left under patients for hours.
u
What are your thoughts? Tell us.
Toxicology Sessions:
Plan B and Emergency Contraception
Sean Nordt MD and Stuart Swadron MD
u
There is a concern that the Plan B contraceptive may not
be very effective in patients who are obese.
u
Plan B is a single tablet of levonorgestrel that is available over
the counter. Patients may use this if they have had intercourse
and are concerned they are at risk of pregnancy.
u
6
Glasier A et al. Can we identify women at risk of pregnancy
despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contra-
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
Monthly Audio Program
The LIN Sessions:
Medical Photography
out because it is too close to the image. If you want to show
texture or raised skin lesions, placing lighting at a 30-40 degree
angle from the camera can help add depth. If you are still having a difficult time getting good lighting, you can try the HDR
or high dynamic range setting of smartphone cameras. The
technology is rapidly improving. The camera captures multiple
shots of the same image at different exposures and combines
them in a photograph more representative of true colors and
exposure. Photoshop and other editing programs can only fix
so much and poor lighting is notoriously difficult to salvage.
Michelle Lin MD
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How to make your medical pictures of cool rashes,
foreign bodies, etc., look just like the pros.
u
You have about 10 seconds to get a picture on your
smartphone camera. What can you do to take the photo
from good to great?
u
#1. Be in focus. Sometimes you can’t really tell that pictures
are slightly out of focus on your device due to the small screen.
Just in case, take a few extra photos using two hands to stabilize
the camera and minimize movement. If the object of interest is
not in the exact center of the frame, the autofocus may focus on
the background instead of the foreground. Manually reposition
where you want the autofocus to set. You may do this by touching the area of the screen you want to autofocus. If you are
still having trouble, you may be too close to the image. Move a
few inches away from the image. Smartphones have notoriously
poor macro shooting capabilities. You can crop the image later
for a close-up. Sharp focus should be your first priority.
u
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#2. Minimize cognitive distractions in the shooting field.
Don’t forget about the rest of the surrounding area such as
equipment, oxygen tubing, bloody gauze, or hair. Remove these
from the frame or reposition the patient to keep these from the
shot. Pay attention to the entirety of the photo.
#3. Avoid patient identifiers. For example, jewelry, unique
clothing logos, tattoos, or patient ID wrist band. It is important
to remove these items or reposition the patient. Look at every
corner of your captured photo.
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#4. Control the background. Remove a wrinkled, bloody
sheet. Try to get a clean sheet or a surgical towel to serve as the
background. Make sure the towel extends beyond edges of your
frame. Blue, black and white backgrounds work best.
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#5. Frame the image with a reference shot. It can be difficult to identify which part of the body you are photographing.
Reference shots may be necessary. Shoot a zoomed out view
of what you are looking at. For example, if you are shooting a
thigh abscess, include a photo of both thighs and the knees.
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#6. Minimize perspective distortion. Be traditional. Images may be distorted when taken from a non-perpendicular
angle, especially of the face. Be careful you aren’t casting a
shadow over the subject when leaning over. You may need to
reposition yourself or the subject to minimize shadowing.
#7. Optimize lighting. This is very important. You will need
to do some experimenting by shining different light sources on
the object at different distances. You are trying to strike a balance between an underexposed and overexposed image. Using
the smartphone’s internal flash can cause the images to white
u
#8. Provide scale. You can pair photos with reference shots
or place standard images within the same shot as your object.
You can include a scale or a commonly identifiable object such
as a penny or pen next to the image.
u
#9. Think like a radiologist taking x-rays. Take images
from different perspectives. Try to shoot images from an AP and
lateral perspective.
u
#10. Signed consent. Most patients are more than happy to
help in teaching future physicians as long as they are not identifiable. Many patients are amateur photographers and will try
to help with lighting and zoom. Loose leaf paper consent forms
can easily be lost. Lin keeps a photo of the signed consent form
along with the photos.
Paper Chase 1:
ACEP on First Time Seizures
Sanjay Arora MD and Michael Menchine MD
u
American College of Emergency Physicians Clinical
Policies Subcommittee (Writing Committee) on Seizures
et al. Clinical policy: Critical issues in the evaluation
and management of adult patients presenting to the
emergency department with seizures. Ann Emerg Med. 2014
Apr;63(4):437-47. e15. PMID: 24655445.
u
These clinical guidelines are made from the best available
literature and expert opinion. They attempted to answer four
questions:
u
1) Should you give anti-epileptic medications in patients with first-time tonic-clonic seizure, who have returned to baseline by the time of your evaluation in the
emergency department?
• There are two types of seizures: provoked seizures and unprovoked seizures.
° Provoked seizures are due to a very specific cause such
as an electrolyte abnormality, head trauma, alcohol
withdrawal, or hemorrhage.
° Unprovoked seizures are idiopathic or due to an underlying
pathology.
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• For provoked seizures, we should treat the underlying cause.
We do not need to give antiepileptic medications if
they have returned to their baseline. You do not need
to give them one dose of a benzodiazepine to prevent them
from seizing in the ED. This is likely to make them sleepy and
delay their discharge. You do not need to start phenytoin.
Although, you may consider starting a medication if directed
by your consulting neurologist.
u
• No. You may discharge the patient. This applies to patients with a first time seizure who have had a negative workup for provoked causes in the ED (for example, head CT
and labs). Only a third of these patients will go on to have
a second seizure in their lifetime. Mandatory reporting to
the department of motor vehicles varies by states. Patients
should be referred for follow-up.
3) Does the route of administration matter when
loading antiepileptic drugs in a patient with a known
seizure history and medication noncompliance?
•There no evidence that the route of administration differs.
You should make your decision based on patient preference,
available resources, and what your preference is.
• Phenytoin can be administered in several ways. Fosphenytoin
can be given faster but needs to be metabolized, so time until
efficacy is still similar to phenytoin. Oral loading may be
given. One strategy is to give 400mg PO, observe the patient
for a few hours and give a second 400 mg PO dose, with
plans for a repeat dose of 300-400mg after discharge. There
is no recommended strategy for loading orally.
u
4) What is the second line medication in patients with
status epilepticus after benzodiazepines have failed?
• About 5% of adults with epilepsy will have status epilepticus
within their lives. There are a few studies showing that
valproate is a little better than phenytoin in these patients.
However, any of these medications may be used with
equivalent efficacy: phenytoin, fosphenytoin, valproate (this
has the advantage of less hypotension than phenytoin),
levetiracetam, and propofol. Barbiturates are starting to fall
out of favor, due to the risk of respiratory depression and
subsequent intubation.
•There is no one preferred agent that you should go to
after a patient fails benzodiazepines.
8
Paper Chase 2:
ProCESS Trial
Sanjay Arora MD and Michael Menchine MD
u
ProCESS Investigators et al. A randomized trial of protocolbased care for early septic shock. N Engl J Med. 2014 May
1;370(18):1683-93. PMID: 24635773.
u
This examined early goal directed therapy versus a less
aggressive sepsis resuscitation protocol, and a third arm which
was usual care. They found similar mortality among all
groups, regardless of intervention.
u
Sepsis is a significant public health concern. Somewhere
between 750,000 and one million severe sepsis cases annually
and the mortality rate is high. In 2001, Manny Rivers proposed
that early goal directed therapy was highly effective in treating
sepsis. It reduced mortality from 46% to 30% in the EGDT. This
was a number needed to treat of 7.
u
What is EGDT? This was a very aggressive strategy that used
large amount of fluids, blood products and vasopressors, including dobutamine. Patients were often intubated. There were
very frequent reassessments. Central venous monitoring of
SCVO2 was described as a key component of resuscitation, but
this was very controversial.
u
The protocol-based therapy basically advocated aggressive fluid
resuscitation and transfusion, only if the hemoglobin is below
7.5 g/dL. EGDT recommended transfusion for a SCVO2 <70%.
u
In the standard therapy group, the investigators were told to
give fluids until the volume status is restored but it was left up
to the discretion of the investigator.
u
This study was conducted at 31 institutions around the United
States. Subjects were eligible if they had refractory hypotension
or serum lactate greater than 4 mmol/L and SIRS. This was a
large study (5 times bigger than the Rivers study). The primary
outcome was in-hospital death and death from any cause at 90
days. These were not statistically significant across the groups. 60
day mortality was 21% in the EGDT group, 18% in the protocolbased standard-therapy group, and 19% in the usual care group.
u
The resuscitative effort was intense in all three groups.
By 72 hours, patients in the EGDT group had received on average 8.2 liters of fluid and the protocol standard therapy group
received 7.2 liters. At 72 hours, the usual group had received
only 500cc of fluid less than those in the more aggressive groups.
u
The rate of blood transfusion was also similar in all the
groups: 27% in EGDT and 22% in the usual care group. Pressors were used more in the EGDT group: 60% versus 54%.
u
There were some notable differences. Dobutamine was
used less commonly when it was not mandated (9.3% and
2.0%). Central venous catheterization was performed 94% of
2) Do patients with first time seizures need to be admitted?
•One study found only 9% of patients referred to a clinic
within 6 weeks of first seizure had recurrence while awaiting follow-up. Breen DP et al. Epidemiology, clinical
characteristics, and management of adults referred to a
teaching hospital first seizure clinic. Postgrad Md J. 2005
Nov;81(961):725-8. PMID: 16272236.
u
Monthly Audio Program
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
the time in the EGDT group but only about 50% of the time in
the standard therapy or usual care groups.
u
What does this mean? An aggressive approach is correct. However, there appears to be no added value to
central venous catheterization. Because there was no difference in the groups, there is a risk that people will assume that
it doesn’t matter what you do. However, the usual care group still
received very aggressive care.
Monthly Audio Program
u
u
Paper Chase 3:
Video vs. Direct Laryngoscopy –
One More Time!
Sanjay Arora MD and Michael Menchine MD
u
u
De Jong A et al. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit:
a systematic review and meta-analysis. Intensive Care Med.
2014 May;40(5):629-39. PMID: 24556912.
It is important for us to know about new airway devices. If you
haven’t used a bougie before, do one on your next intubation,
especially if it is looks like an easy one.
u
Extraglottic devices include the LMA, King Tube, and Combitube. You should know how to use these devices.
u
This study looks at video laryngoscopes. These function
and look similar to the MAC blade. However, you don’t need to
sweep the tongue and there is very little lift.
•The optics are set back in these devices to minimize the
amount of secretions that are in front of the camera lens.
Examples include the Glidescope, Pentax, King Vision, McGrath, and CMAC. The CMAC is different than the others as it
is the only one that can be converted to direct laryngoscopy.
These may differ in the monitor location, attachment site of
the blade, and single-use versus multiple-use. Some have a
camera and others are optical scopes.
• The optical scopes use a series of mirrors and lenses to evaluate the cords. The image quality is not as good with these but
they are much cheaper. They are also portable and do not
need to be plugged in. These include the Truview and Airtraq.
u
Should these devices be the first line in the ED? There
are multiple studies on this topic and they all say the same
thing: whatever device the author is studying seems to be better
than the other devices.
u
This study is a meta-analysis of 9 trials with 2,133 intubated patients. There was a fairly even split with 1,067 intubated with direct laryngoscopy (DL) and 1,066 with video
laryngoscopy. Some studies were randomized controlled trials,
others were before and after studies due a shift at the institution, and some were observational studies.
The take-home point: using one of the video laryngoscopy
devices reduced the risk of esophageal intubation with a better
first-pass success rate (odds ratio 2.07). This odds ratio
does not mean that you are twice as likely to get a first-pass
intubation. We are good with DL and video scopes. There was
no statistically significant difference found in bad outcomes
(severe hypoxemia, cardiovascular collapse, or airway injury).
We can’t say goodbye to direct laryngoscopy yet. Video
laryngoscopy is not available in all facilities. However, there is
value in using these video technologies, especially when you
are serious about maintaining in-line stabilization. Patients
rarely have to be repositioned when using the video scopes,
unlike with direct laryngoscopy, where about 80% require
manipulation of the airway. This is a good back-up in patients
with anticipated difficult airways.
Paper Chase 4:
Is There a Decision Instrument
for Renal Colic?
Sanjay Arora MD and Michael Menchine MD
u
Moore CL et al. Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone – the STONE
score: retrospective and prospective observational cohort
studies. BMJ. 2014 Mar 26;348:g2191. PMID: 24671981.
u
This study looks for a decision support aid that helps physicians place patients with suspected stone into low, moderate, or
high risk categories (10%, 50%, and 90%). They determined
a scoring scheme that includes gender, race, duration of pain,
nausea/vomiting, and hematuria.
u
Kidney stones affect 10% of the population in the US at some
point during their lives. They are responsible for 2 million visits
to the ED annually. This leads to a large number of CT scans.
Most of the literature has not found that CT scans or ultrasounds influence the decision to admit the patient or perform a
procedure. Most stones are small and pass spontaneously.
u
CT scans are expensive, take time to perform and expose patients to radiation. There are alternative diagnoses which may
be seen on CT scan however.
u
The authors of this study attempted to create a scoring
scheme that could identify patients at very high risk of
stones without having to scan them. They retrospectively
reviewed 1040 cases of patients getting CT scans for suspected
stone. The study was performed at two sites in the Yale health
system. They identified variables placing patients in the different
risk categories and then validated the variables prospectively.
u
This study excluded patients with prior stones and instrumentation.
u
What did they find? They found about 50% of the patients
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Monthly Audio Program
receiving the CT stone protocol had a stone. Only 2.9% had
another important alternative diagnosis found on CT. Only
0.3% of the patients in the derivation cohort who were
deemed high probability for a stone had an alternative
diagnosis.
u
In the validation phase, 491 patients received the stone
protocol. About 15% of patients were in the low risk category
and only about 10% had a stone. 50% were moderate risk and
about 50% had a stone. 37% were high risk and 89% of these
had a stone. Unfortunately, in the validation protocol, 1.6% of
patients in the high risk group had something important that
was not a stone, such as diverticulitis, appendicitis, and AAA.
u
The criteria predictive of high risk of kidney stone
were: male gender, pain for less than 6 hours, nonblack race, vomiting, and hematuria. All five of these variables place patients into the high risk category. It was validated
in the same study population, so it may be less applicable to a
population with different racial composition.
u
This should help inform your assessment of the risk of stone
versus another alternative diagnosis. In patients who are high
risk you can consider not imaging or using the least invasive
modality such as low radiation CT or ultrasound.
u
Limitations. This was single site. One needs to balance the 90%
likelihood of stone in the high risk group with a miss rate of
1.6%.
Paper Chase 5:
Does Codeine/APAP actually work?
week. The patients were not given standardized drugs while in
the emergency department. They sent the patients home with
specific instructions on how to take their medications and the
patient, doctor and pharmacist were all unaware of what the
patient was receiving. The study is very well done.
u
The patients were contacted at 24 hours and asked to
report their pain scores. They wanted to know the pain level
experienced two hours after taking the medication. If the patient had taken pain medication more than 2 hours prior to the
time of contact, they were asked to estimate their pain score at
2 hours post meds. This leads to problems due to recall.
u
240 patients were randomized. Most of these patients were
strains/sprains and only about 20% were fractures. 12 (10%)
patients in each group didn’t take the medication or follow instructions and were excluded. None of the other patients were
lost to follow-up.
u
The mean pain scores were 7.6 out of a 11 point scale 2 hours
before their pain medication and decreased to 3.9 (hydrocodone/acetaminophen) and 3.5 (codeine/acetaminophen) two
hours post medication. This was essentially the same. They
found satisfaction was a little higher in the hydrocodone/acetaminophen group (83%) versus the codeine/acetaminophen
group (71%). Negative effects were the same in the two groups.
u
They concluded that if hydrocodone/acetaminophen
becomes a Schedule 2 drug and we see a rise in use of
codeine/acetaminophen, it seems to work as well.
u
This study does not mimic real world conditions. Patients were
regimented to 1 pill every 4 hours and didn’t have the option
to adjust their medication as needed. These weren’t patients
with severe pain. Hydrocodone/acetaminophen may be more
potency than most people need. We need to pick the right drugs
for the right patient.
Sanjay Arora MD and Michael Menchine MD
u
u
u
10
Chang AK et al. Randomized clinical trial of hydrocodone/
acetaminophen versus codeine/acetaminophen in the
treatment of acute extremity pain after emergency department discharge. Acad Emerg Med. 2014 Mar;21(3):227-35.
PMID: 24628747.
Pain is a common presenting complaint in the ED. About
1/3 of patients presenting with complaints of pain receive a prescription for an opiate. The typical choices are hydrocodone/
acetaminophen, oxycodone/acetaminophen and codeine/acetaminophen. Hydrocodone/acetaminophen is the most commonly prescribed. Opiate prescriptions from the ED remain
controversial. There has been some discussion about hydrocodone/acetaminophen moving to a Schedule 2 classification.
The authors of this study compared effectiveness of
hydrocodone/acetaminophen with codeine/acetaminophen, which is likely to remain a Schedule 3 drug. They
performed a prospective, randomized, double-blinded, placebo-controlled trial looking at adults with acute extremity pain
with an expected course of outpatient analgesia less than one
Paper Chase 6:
When a Non-diagnostic EKG
Becomes a STEMI
Sanjay Arora MD and Michael Menchine MD
u
Riley RF et al. Diagnostic time course, treatment, and inhospital outcomes for patients with ST-segment elevation
myocardial infarction presenting with nondiagnostic initial electrocardiogram: a report from the American Heart
Association Mission: Lifeline program. Am Heart J. 2013
Jan;165(1_:50-6. PMID: 23237133.
u
This is a registry study looking at the proportion of STEMI
patients that did not have a diagnostic EKG at the time of
presentation. STEMI is a huge issue in emergency medicine.
They are deadly and we are under a huge amount of scrutiny
by administrators. Missed diagnosis is a huge problem in terms
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
of malpractice and payouts. There have been some studies
showing that acute MI may not be present on the initial EKG.
Older studies have shown that approximately 15% of patients
diagnosed with STEMI did not have it on initial EKG. However,
these studies did not describe when these became evident.
u
This study included 41,560 patients from 600 hospitals
between 2007-2010 diagnosed with STEMI. What
percentage of STEMIs present without a diagnostic initial EKG?
When does the EKG change? Does the delay in diagnosis cause
good or bad outcomes?
u
Patients were excluded if they had a left bundle branch
block, as well as a time to EKG of greater than 6 hours.
u
Of the more than 41,000 patients with STEMI, 4566
(11%) had initial nondiagnostic EKGs.
u
Analysis of both case and controls shows that they were similar
in terms of age. Approximately 40% in each group were
smokers. About 20% had a previous MI. Patients presenting
without STEMI on arrival were a little more likely to have CHF.
55% overall had an initially negative troponin.
u
u
u
u
About 1/3 converted from a non-diagnostic EKG to a
STEMI by 30 minutes. By 45 minutes, 50% had converted to
STEMI. By 90 minutes, about 75% had converted to STEMI. The
time until conversion for the remaining 25% ranged widely.
Treatments. Treatment was similar for the two groups: most
received PCI. Only 2% received thrombolytics. Door to balloon
time frequently exceeded the 90 minute limit in the group with
delayed conversion of STEMI. Adjusted mortality was 5.8%
in patients with STEMI on arrival EKG compared to 6.5% in
patients with delayed conversion to STEMI.
Limitations. We don’t know what prompted the follow-up EKG
in these patients. It is unclear if their symptoms changed and if
it was obvious or due to routine protocol.
Take-home points. When a patient presents and you are
suspicious for STEMI but the initial EKG is non-diagnostic, get
several EKGs. Look for clinical signs of deterioration. About
10% of patients with STEMI will have an initial EKG that is nondiagnostic. Most will convert within the first 45 minutes.
Monthly Audio Program
HIPPOEM Reviews:
CHF Update
Mel Herbert MD
Case #2
A 70 year old patient with a history of diabetes
and acute coronary syndrome presents with acute
shortness of breath. She appears gray in color and
is significantly hypertensive. She is in florid pulmonary
edema and not doing well. An EKG does not show STEMI.
She does not have any murmurs concerning for a surgical
cause of pulmonary edema. What do you do for this
patient?
u
Step 1. IV, O2, monitor, advanced airway equipment and defibrillator to the bedside. Patients who look like they are going
to die frequently commit the act in front of you. Vascular access
was difficult in this patient so an IO was placed.
u
Look at the blood pressure. There are two types of CHF of
pulmonary edema: with a good blood pressure or bad blood
pressure. Cardiogenic shock will be discussed another time.
u
The patient has a good blood pressure but is really
sick. Start nitrates. Give the nitrates sublingually initially
while getting set up. 400mcg is administered sublingually and
about 50-100mcg/minute is absorbed.
u
When you get IV access, start an IV drip. Don’t start out
wimpy. If you have been giving sublingual nitro and they have
been tolerating it, start at 100mcg/min IV and titrate it up fast.
The FDA-approved high dose is 650mcg/min. It is unclear if
there is much additional benefit at doses higher than 300400mcg/min.
u
BiPAP. This reduces the work of breathing, opens alveoli, and
may increase the intrathoracic pressure and decrease venous
return. It works. It is unclear if it reduces mortality. It probably
reduces the length of the ICU stay. It reduces intubation. Is there
is a difference between BiPAP and CPAP? A difference hasn’t
been shown in systematic reviews.
u
Once you have done nitrates and BiPAP, some would argue that you are done.
u
Furosemide is controversial. It has the potential to put
patients into renal failure and increases their length of stay
and mortality. The cardiologists love it. If you are going to give
it, give a small dose. There is very little evidence to support
furosemide drips.
u
Morphine is out. If these patients are really anxious because
they are about to die, there are probably better agents than morphine to use. Be careful with anxiolytics. You will get blamed
when you give them a benzo right before they stop breathing.
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The Written Summary of the
u
Nesiritide is not recommended. It is associated with death.
u
ACE inhibitors are controversial. Some recommend adding
ACE inhibitors along with nitrates and others recommend ACE
inhibitors instead of nitrates. Enalapril at a dose of 1.25mg IV
or captopril 25mg sublingually. There aren’t large studies. This
is a very regional treatment. It appears to be safe. It appears to
work. It has more effect on afterload than nitrates. Why not give
it a shot if you are losing the battle?
u
ACE receptor blockers. There is no good evidence supporting use in the acute setting.
u
What if the blood pressure remains elevated? In the
past nitroprusside was used. However, this has the potential to
dump the blood pressure. It is a very powerful afterload reducer. Many will still use it in this situation despite the risk.
u
Ultrafiltration versus dialysis. Ultrafiltration has been compared against high dose diuretics for sick patients with congestive heart failure and found to be superior. Ultrafiltration
devices are different than dialysis.
Monthly Audio Program
u
Even if you do have patients who are truly volume overloaded, the same principles apply. They have missed dialysis, have missed doses of diuretics, or have been eating a high
salt diet. If you redistribute the fluid out of the lungs and into
the body, the hypoxia resolves. Tachycardia, tachypnea, hypertension, diaphoresis, and anxiety all improve.
u
How do you do this? #1. Decrease preload. #2. Decrease
afterload. This makes it easier for the heart to pump blood in a
forward direction and helps empty the lungs of fluid.
u
When patients present in florid pulmonary edema, they
have tons of catecholamines and are extremely clamped
down. The afterload increases and the patients are very hypertensive. The heart has a difficult time pumping in a forward
direction. How do you fix this? Decrease the resistance against
which the heart has to pump. Make the hose bigger.
u
Diuresis can come later. Diuretics don’t often work initially.
Why? Many of these patients are not volume overloaded to begin
with. They are very clamped down. Most patients in pulmonary
edema are not perfusing their kidneys well (this has been estimated at 20% of normal renal blood flow). The furosemide
sits in the central circulation until the afterload decreases and
perfusion to the kidneys increase. This can take several hours if
you don’t focus on early afterload reduction.
u
How do you decrease preload? Nitroglycerin. Most of these
patients have a dry mouth from tachypnea. Put a drop of water
under the tongue with the nitroglycerin or use the nitroglycerin
spray. Be aggressive. Sublingual nitroglycerin administered every 3 to 4 minutes provides a good dose of nitroglycerin. Most
of the dose is absorbed (about 75%). A dose of 400mcg administered every 5 minutes is equivalent to an IV drip of 60mcg/
minute. Every 3 minutes is equivalent to a dose of 100mcg/min.
When you transition to IV, start at 60-100mcg/min. Do not be
afraid to start a high nitroglycerin drip for pulmonary edema. If
they drop their pressure, turn it off and it will be gone in a few
minutes. Some European authors discuss nitroglycerin drips at
doses of 400 of 500mcg/min. This will also decrease the afterload. ED staff are often very resistant to such high doses. You
are titrating for afterload reduction, not pain.
Scott Weingart MD
u There are three varieties of pulmonary edema patients
presenting to the ED.
1)The cardiogenic shock patient. Their lungs are filled
with fluid and they look like crap. They need to be intubated.
The blood pressure is 60/40.
2)The patient with some peripheral edema and bibasilar crackles. They look a little off from baseline but
aren’t that bad.
3)The “SCAPE” group. What is this? Sympathetic surge,
crashing, and pulmonary edema. They have tons of norepinephrine and epinephrine coursing through their system,
leading to hypertension and tachycardia. This makes them
vasoconstricted. They look like they are going to die.
u
The literature doesn’t really specify between the last
two categories. They try to apply therapies for the sympathetic
surge and crashing patient to regular patients and say there is
no mortality benefit.
Amal Mattu MD
u Most patients presenting to the ED with cardiogenic
pulmonary edema are often not fluid overloaded. This
is in complete contradiction to what we learned in medical
school. There are studies that indicate that 50% or more of patients we see with cardiogenic pulmonary edema are not fluid
overloaded but rather have fluid in the wrong place. They are
total body euvolemic or hypovolemic but the fluid has shifted
into the lungs.
u
12
Scott Weingart MD
u Weingart places patients on 400mcg/min nitroglycerin
for two minutes. Then he decreases to a dose of 100 or
150mcg/min and titrates back up as needed.
u
Why nitroglycerin? It is dependable and predictable. When
the patient begins improving, the blood pressure will plummet.
If you turn the nitroglycerin off, it will respond rapidly.
u
Nitroprusside is best avoided as it can drop the blood
pressure to nothing. This is an unpredictable agent.
Our focus should not be just on diuresis; our job is
fluid redistribution.
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
Monthly Audio Program
Rob Orman MD
u Orman gives a dose of sublingual nitroglycerin and
then starts the nitroglycerin dose at 50mcg/min. He continues the nitroglycerin and lets the BiPAP work.
Amal Mattu MD
u Early and aggressive use of CPAP and BiPAP will decrease
intubation rates, decrease hospital and ICU length of
stay, decrease costs, and possibly decrease mortality. It
buys you time until your medications start working. Don’t wait
until the patient is crashing to start it. CPAP and BiPAP decrease
preload and afterload by themselves.
Scott Weingart MD
u These patients should be placed on CPAP as soon as
they are transferred to the gurney. CPAP can be titrated
from 5 to 10 to 15. Above 15, CPAP has the potential to open
their lower esophageal sphincter. CPAP decreases afterload.
Al Sacchetti MD
u Sacchetti uses BiPAP in patients with moderate CHF exacerbation, in addition to those in extremis. It makes
them feel better and there are multiple physiologic benefits.
u
You need to use the BiPAP correctly. Most people like to
start them low and then titrate up the pressures. This is like
controlled suffocation. Sacchetti starts out at 20/15 and 100%
oxygen. Lower pressures with a wider spread are fine for COPD
patients but patients with CHF and pulmonary edema should be
started higher initially.
Amal Mattu MD
u Mattu is a proponent of ACE inhibitors. When you give it,
you need to make sure the other people around you understand
that you are giving it for afterload reduction. IV enalapril at
1.25mg or sublingual captopril at 25 mg. This is a one-time
dose for acute afterload reduction. Studies estimate that improvement in afterload occurs within 15 minutes. The diuretics
can now start working.
u
u
Mattu and Sacchetti used to frequently receive patients
who had missed their dialysis. They gave a dose of sublingual nitroglycerin and sublingual captopril, and started the
patients on BiPAP while they were trying to establish IV access.
The patients started improving within 15 minutes.
requirement drops from 300mcg/min to 10-20mcg/min, you
have improved the catecholamine surge. At that point, if you
feel the patient is volume overloaded, give furosemide. If the
patient seems volume depleted, he/she may need some fluids.
u
Rob Orman MD
u Orman likes IV enalapril to reduce afterload. There is
weak evidence to support this. He uses 1.25mg of IV enalapril
with a combination of IV nitrates and BiPAP.
u
Scott Weingart MD
u Weingart does not use diuretics or ACE inhibitors initially. After the patient starts improving and the nitroglycerin
Furosemide. In florid pulmonary edema, renal perfusion is
going to be decreased. No matter how much furosemide you
give, it won’t work until the patient is stabilized by your other
interventions. The patient may not be volume overloaded.
Orman usually will give 20mg of furosemide after the patient is
stabilized.
Amal Mattu MD
u Furosemide is a good preload reducer, but not in acute
pulmonary edema. There is no rush to give it. It won’t work
quickly. Give it after you reduce afterload.
u
Morphine doesn’t work to reduce preload. It increases
intubation rates and ICU length of stay, and may be associated
with increased mortality.
Medical Legal 101:
Insurance
Mike Weinstock MD, Ed Boudreau MD and Jeanie Taylor
u
What does the insurance company do when they receive notification of a claim? They analyze the content of
the claim. They prefer to know about the incident at the time of
occurrence and prior to filing a claim. This helps with strategies to intercede before a suit is filed. They separate risk from
claims so that physicians may talk to risk management before it
becomes a claim. They encourage early reporting.
u
There is evidence that early disclosure reduces claims.
There is a lot of hesitation but many physicians are aware of this
and interested.
u
They try to understand practice patterns of their policy
holders.
u
The insurance company does not make the decision
whether or not to defend the case in trial. This is not a
decision that happens in an afternoon. The decision is made
after many discussions with the physician involved and the leadership of the group, the claims committee, and claims manage-
If you want to use nitroglycerin, he recommends 100 to
150 mcg/min for afterload reduction.
Al Sacchetti MD
uSacchetti has seen so many dialysis patients with poor access
that he has become very comfortable at managing pulmonary
edema with sublingual nitroglycerin and captopril.
ACE inhibitors won’t do much for patients in the midst
of their sympathetic surge. These add complexity. If Weingart is unable to wean patients from the nitroglycerin drip, he
will give an ACE inhibitor, which may be able to take them off
the drip and send them to a lower acuity setting.
August 2014: Volume 14, Issue 8 | www.emrap.org
13
The Written Summary of the
u
Monthly Audio Program
ment team. The policy is with the group and not the individual
physician. Earning potential of the patient can affect settlement
and verdict amount.
u
Who can you talk to? It should be as limited as possible. This
can be difficult because this is one of the most upsetting events
a physician can experience.
This can be very difficult for the physician involved. They
assign a more senior physician in the group to be a mentor to
the affected physician.
u
How is an attorney selected? The physician has the
opportunity to participate in the selection process. The group
can recommend a preferred attorney, but the insurance
company also maintains a panel of attorneys they are
comfortable working with.
u
What are the rough estimates for defense attorney fees?
It usually costs a minimum of $250,000 to take a case to trial.
This does not include an indemnity payment.
u
The process of determining a settlement varies based
on case and jurisdiction. Excess policy verdicts are often
settled based on policy limits. The plaintiff’s attorneys do not
want to spend the resources to chase the defendant’s asset pool.
u
The attorneys will usually discuss with the physician
prior to settlement. However, the group has the final say.
u
What can you do to mitigate lawsuit? Reduce the variation
in your practice. Step back and look at the probability of a bad
disease prior to discharging the patient. Be nice.
Case #3
40 year old female with a history of hypertension and
chest pain thought to be due to bronchospasm. She was
discharged home but died the next day.
14
u
The physician hears about the bounceback and calls
risk management. Most important is to find out how the physician is doing and make sure the physician gets the support he/
she needs.
u
The physician gets the letter in the mail. This triggers
a process of management. The insurance company begins to
gather data.
EM:RAP Written Summary | www.emrap.org
The Written Summary of the
Monthly Audio Program
NOTES
August 2014: Volume 14, Issue 8 | www.emrap.org
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The Written Summary of the
Monthly Audio Program
NOTES
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EM:RAP Written Summary | www.emrap.org