February 2016 Volume 16 Issue 2
Editor-in-Chief: Mel Herbert, MD Executive Editor: Stuart Swadron, MDAssociate Editor: Marlowe Majoewsky, MD Pharmacology Rounds:
Rob Orman MD and Anand Swaminathan MD
Tramadol and Death from NSAIDS
Rob Orman MD and Bryan Hayes PharmD
Take Home Points
Take Home Points
Intrascalene nerve blocks may result in phrenic nerve
dysfunction with unilateral diaphragmatic paralysis and
NSAIDs have the potential to increase the risk for heart
attack and stroke. Patients with pre-existing disease are
at increased risk.
We should start using the term massive PE without hypo-
tension rather than hemodynamically stable.
Naprosyn seems to be the safest of the NSAIDs.
Oxygen saturation of 85% is concerning for a large de-
Tramadol is a synthetic codeine analog and very weak mu
crease in the amount of oxygen bound to hemoglobin.
receptor agonist with an affinity 1/6000 of that of morphine.
Tramadol use may result in seizures, abuse and withdrawal.
A 70 year old female was brought in with a complaint of short- Do non-aspirin NSAIDS increase the risk of stroke or MI?
ness of breath. Respiratory rate was 28 and oxygen saturation Patients are asking about this. There were three COX-2 inhib- was 88% on room air. The patient presented three hours after itors marketed a while ago; celecoxib, valdecoxib and rofecox- a right shoulder arthroscopy. Surgery and shortness of breath? ib. The last two drugs were withdrawn from the market. There Should you do a d-dimer? CT angiogram? are randomized trials that show the COX-2 selective NSAIDS increase the risk for MI, stroke and thrombosis although they This was an outpatient procedure and not performed under
decrease the risk of gastrointestinal complications. The risk general anesthesia. The patient would be unlikely to form a
appears to extend to older NSAIDs that are more selective for blood clot in such a short period of time. However, the patient COX-2 such diclofenac and meloxicam. had received an intrascalene nerve block. Because of this data, regulatory agencies have concluded
that NSAIDs have the potential to increase the risk for heart
There are two major complications associated with intrasca-
attack and stroke.
lene nerve blocks; pneumothorax and unilateral phrenic nerve
Patients with pre-existing disease are most at risk for cardio- vascular disease or thrombosis. The patient likely had a transient phrenic nerve dysfunction There was a study published in Lancet in 2013 that found
causing unilateral diaphragmatic paralysis. This is not a big major vascular events were increased by about a third due
problem for young healthy patients who are able to compen- to coxibs. However, this was a small effect and chiefly due to
sate. However, it can be a problem in older patients with limited an increase in major coronary events. Ibuprofen also signifi- cantly increased major coronary events but not major vascular EKG was unremarkable. A chest x-ray showed an elevated right events. Compared to a placebo, if you had 1000 patients tak- hemidiaphragm. Don't send a D-dimer or do a CT angiogram in ing a coxib or diclofenac for a year, three more patients had a major vascular events, one of which was fatal. The patient was placed on oxygen and had improvement in Coxib and traditional NSAID Trialists' (CNT) Collaboration, symptoms and oxygen saturation. The block had been per- et al. Vascular and upper gastrointestinal effects of non-ste- formed with bupivacaine and was anticipated to last for 6-8 roidal anti-inflammatory drugs: meta-analysis of individual participant data from randomised trials. Lancet. 2013 Aug 31;382(9894):769-79. EMRAP Written Summary February 2016: Volume 16, Issue 2 This was followed by an FDA warning. Naprosyn seems to be the safest out of all of the medications. It did not seem to Pharmacology Rounds:
increase the risk of vascular deaths in the meta-analysis.
Antidepressants + NSAIDS = Bad?
Rob Orman MD and Bryan Hayes PharmD
Should patients stop taking non-aspirin NSAIDs? Is it a cu-
mulative risk? The increased risk of heart attack or stroke
Take Home Points
can occur as early as the first few weeks of using an NSAID. However, the risk is greater with longer use and higher doses. Although a study found an association between the use of
In general, patients with pre-existing heart disease or cardiac NSAIDs with antidepressants and increased risk of intra-
risk factors have a greater likelihood of heart attack follow- cranial hemorrhage, it does not show causation.
ing NSAIDs than patients without risk factors. Use NSAIDs in An undetectable serum acetaminophen level drawn over
lower doses and for shorter time periods.
an hour after the ingestion does not require additional
A 60 year old diabetic with a history of previous MI has
sprained their ankle. The patient does not want narcotics.
Acetaminophen levels drawn within one hour post inges-
Start the patient on acetaminophen first. If their pain is still tion are unreliable.
not controlled, the patient could take an NSAID for a few days. Naprosyn was associated with the lowest risk. If the If you have an acetaminophen level between 0 and 100ug/
patient still needed a stronger pain medication, lower dose mL drawn 1-4 hours post ingestion, you need to repeat
narcotics could be used. the level at four hours and plot it on the nomogram.
How does tramadol work? It has been used as an alternative to
Do NSAIDs + antidepressants increase the risk of intracranial
opiates but there is recent data suggesting that we should limit its use as well secondary to concerns about abuse and addic-tion potential. The FDA and DEA finally changed the schedule Shin, JY et al. Risk of intracranial haemorrhage in antidepres- of tramadol to a schedule 4 controlled substance - similar to a sant users with concurrent use of non-steroidal anti-inflam- hydrocodone product. There is a risk of addiction with this drug. matory drugs: nationwide propensity score matched study. Tramadol is a synthetic codeine analog. It is a very weak mu receptor agonist (the affinity is 1/6000th of morphine). It also This was a retrospective, nationwide, propensity score has norepinephrine and serotonin reuptake properties similar matched study conducted in Korea. They took patients that to the SNRIs. Some early studies show that it can be as effec- were on the two drugs together and matched them with pa- tive as morphine in the treatment of mild to moderate pain. tients who weren't. The main outcome measure was time to However, it is not very effective for severe or chronic pain. It first hospital admission with an intracranial hemorrhage with- has an active metabolite that adds to the analgesia property. in thirty days of drug use. They included 4 million patients in It has its side effects, although respiratory depression is less than with other opiates. Tramadol can cause seizures or exac- They found the 30 day risk of intracranial hemorrhage was
erbate seizures. higher for the combined use of antidepressants and NSAIDs
Can patient withdraw from tramadol? There is some data to
than for the use of antidepressants without NSAIDs. The
support that patients can withdraw from tramadol. Howev- hazard ratio was 1.6 with a statistically significant confidence er, it seems to be less severe than the withdrawal associated interval. They didn't find any meaningful differences between the different classes of antidepressant drugs. What is the abuse potential? Tramadol can be abused. In
They concluded that the combined use of antidepressants 2013, there were 6500 exposure calls to the Poison Center and NSAIDs was associated with a higher risk of ICH within related to tramadol. 4500 calls were in patients older than 13. 30 days of combining those drugs. There were 4 deaths and 200 major outcomes (for example, However, the data doesn't show causation. There is an issue
disability or ICU stays). This is probably an underestimate as of external validity as the study was published in a relatively many events go unreported. uniform population in Korea. The rate of intracranial hemor- Tramadol isn't great at relieving pain and there is still a risk of
rhage with the use of these drugs in isolation is unknown. dependence and abuse.
There is no biologically plausible mechanism to explain why
this combination is an issue. The study did not have a control
group of patients only on NSAIDs. Is the combination of med-ications or the use of an NSAID responsible? EMRAP Written Summary www.emrap.org The rate of intracranial hemorrhage in patients taking antide- repeated. If an acetaminophen level is drawn before four pressants was 1.6/1000 patient years. When antidepressants hours, a second level must be drawn at 4 hours unless the ac- were combined with NSAIDs, the risk rose to 4.1 hemorrhag- etaminophen concentration is undetectable more than hour es/1000 patient years. after ingestion. The current data supports waiting 4 hours to draw the level. If you are suspicious but the level won't be If you start 3000 men on an NSAID while on an antidepres- back until after 8 hours post ingestion, you can start the NAC sant, only 1 will have an avoidable ICH in the first 30 days. and discontinue it if ultimately unnecessary.
We need additional data before changing practice.
The utility of pre-4 hour acetaminophen levels in acute over-
dose. We rarely know the exact time intervals regarding inges-
Medical Myths:
tion. Labs and toxicology panels are often sent on patient arriv- The Loop Diuretic
al. What do you do with an elevated level obtained prior to four
Anand Swaminathan MD and Haney Mallemat MD
hours after ingestion?
Can acetaminophen concentrations of less than 100 mcg/
Take Home Points
mL obtained between 1-4 hours after an acute ingestion ac-
curately predict a non-toxic concentration at 4 hours? If the
There is no role for the administration of loop diuretics
acetaminophen level is drawn after an hour post ingestion, an early in the resuscitation of patients with acute pulmo-
undetectable level does not require additional work-up. A level nary edema.
obtained prior to an hour post ingestion is not always accurate.
Immediate care should include non-invasive positive

What if the level is moderately elevated?
pressure ventilation and nitroglycerin.
83 patients with a level of <100ug/mL between 1 and 4 Patients with end-stage renal disease may need dialysis.
hours post ingestion were included in a study. They found 2 cases that had a subtoxic level prior to 4 hours that was Furosemide isn't necessarily good for all patients with acute
toxic after repeat at 4 hours. This was a negative predic- pulmonary edema, especially at the beginning of care.
tive value of 98.8% with a false negative rate of 6.5%. They Acute pulmonary edema is a heterogenous disease. Much of our
concluded that a 6.5% miss rate is unacceptable.
understanding is based on a cardiorenal model of acute pulmo- Froberg, BA et al. Negative predictive value of acetaminophen nary edema from the 1940s. Decreased blood flow to the kidneys concentrations within four hours of ingestion. Acad Emerg leads to renal dysfunction. This causes retention of fluid and vol- Med. 2013 Oct;20(10):1072-5. ume overload. In this situation, loop diuretics make sense.
A second study reported in abstract form found that the However, about 50% of the patients we see with acute pul-
negative predictive value under an hour was 76%. This rose monary edema are euvolemic. They don't have extra fluid but
to 88% between 1-2 hours, 98% between 2-3 hours and their fluid is shifted to the wrong place. 99% between 3-4 hours. What is the neurohormonal activation model? Decreased
Douglas, DR et al. APAP levels within 4 hours: are they useful? stroke volume and cardiac output leads to the release of a Vet Human Toxicol 1994;36:350[abstract variety of substances such as norepinephrine (to increase the cardiac output and improve blood pressure and afterload) and If you have an acetaminophen level between 0 and 100ug/
renin-angiotensin-aldosterone (to improve salt retention from mL drawn 1-4 hours post ingestion, you need to repeat it at
the kidneys and increase vascular tone).
four hours and plot it on the nomogram.
Is there any evidence to support the neurohormonal activation
A study of 520 cases found that only 59% of patients had a second level drawn at 4 hours. While many patients with acute pulmonary edema have Seifert, SA et al. Acetaminophen concentrations prior to increased cardiac filling pressures, most did not have an in- 4 hours of ingestion: impact on diagnostic decision-mak- crease in their dry weight on presentation. How can you be ing treatment. Clin Toxicol (Phila). 2015;53(7):618-23. fluid overloaded if your dry weight is the same? Zile, MR et al. Transition from chronic compensated to acute decompensated Take-home points. The Rumack Matthew nomogram needs
heart failure: pathophysiological insights obtained from contin- to be utilized starting 4 hours after acute ingestion. Acet- uous monitoring of intracardiac pressures. Circulation 2008 Sep aminophen levels drawn prior to four hours can lead to un- necessary treatment, admissions and adverse effects if not February 2016: Volume 16, Issue 2 www.emrap.org Where does the fluid in the lungs come from? Probably the
splanchnic circulation. This is a huge reservoir of blood that can You want to start this as soon as the patient hits the door. rapidly release up to 800mL of blood into circulation in response to the release of neurohumoral mediators.
A study on high dose nitroglycerin found boluses up to 1 g of nitroglycerin did not result in many adverse events (only Loop diuretics are fairly harmless. We don't know who is vol-
1 patient or 3.4% developed symptomatic hypotension with ume overloaded and who is experiencing a shift of fluid, so
high dose nitroglycerin). Most don't usually give boluses this why not give everyone a dose? Furosemide can be harmful.
large, but some will give a bolus of 300-400mcg. Levy, P et al. Consider the patient presenting in severe respiratory distress;
Treatment of severe decompensated heart failure with high-dose diaphoretic, tripoding, B-lines and fluid overload on x-ray. This
intravenous nitroglycerin: a feasibility and outcome analysis. Ann patient is trying to stay alive. What is happening with their
Emerg Med. 2007 Aug;50(2):144-52. physiology? They have increased secretion of norepinephrine.
Nitroglycerin is recommended for all patients with acute
The blood flow is going to their heart, brain and diaphragm. pulmonary edema. It reduces their preload and causes ven-
They have vasoconstriction of the blood supply leading to other odilation. It takes the fluid away from the heart and improves organs such as the kidney. performance of the left and right ventricle).
Furosemide won't work in this situation due to vasocon-
Starting doses are 100mcg/min. If the patient's pressure
striction. We have been taught to increase the dose if there is
drops, you can turn off the drip and it is short-lived.
no response. This will result in large amounts of furosemide in the circulation. Once they start to vasodilate, the furosemide It also decreases afterload. These patients are clamped down
will affect the kidney and cause diuresis. Now you are taking with increase sympathetic tone and high blood pressure. The a patient who was euvolemic to start with and making them heart is trying to squeeze against this afterload.
hypovolemic. This increases length of stay in the hospital and How do you titrate the nitroglycerin? 50mcg at a time every
adverse complications. 10-15 minutes while you are standing at the bedside. What is the maximum dose? Until the blood pressure drops. You Furosemide decreases GFR, activates the renin-angioten-
are titrating to symptomatic relief. Some patients may start sin-aldosterone system, decreases cardiac output and in-
improving within 15-20 minutes.
creases afterload early after administration.
Marik, PE et al. Narrative review: the management of acute decompensated heart failure. J Intensive Care Med. 2012 Nov- These aren't used routinely but make sense. They reduce the
afterload and improve forward flow. ACE inhibitors also work on the kidney to vasodilate the afferent arteriole and allow This does not mean that you should never give furosemide to
improved perfusion. These are less studied in acute pulmo- patients with CHF. However, there are some other therapies
nary edema but there is some available evidence.
you should start first. If the patient looks volume overloaded, it
is ok to give them furosemide. Try to avoid front loading them Hamilton found that patients who received sublingual capto- with furosemide and doubling or tripling the dose. It doesn't pril in addition to standard therapy were more comfortable work and can harm the patient. and had a decrease in respiratory failure that was not statisti- cally significant. The NAP mnemonic.
Hamilton, RJ et al. Rapid improvement of acute pulmonary Non-invasive positive pressure ventilation.
edema with sublingual captopril. Acad Emerg Med. 1996 This is CPAP or BiPAP. There is some evidence suggesting
Mar;3(3):205-12. BiPAP is better for these patients. What does it do in acute Haude found that sublingual captopril improved cardiac index pulmonary edema? Decreases the patient's work of breath- and stroke volume versus nitroglycerin in a small study. ing. Stents open collapsed alveoli and leads to better gas exchange. It decreases afterload on the heart and supports Haude, M et al. Sublingual administration of captopril versus respiration. A number of papers have shown a reduction in nitroglycerin in patients with severe congestive heart failure. ICU admissions (92% to 38%) and intubations. Int J Cardiol. 1990 Jun;27(3):351-9. You need to start non-invasive ventilation as soon as the
If you are in place that has sublingual captopril, you can con-
patient hits the door or even by EMS in the field. Even if it
sider giving a small dose. If you are in a place that has enal-
doesn't stave off intubation, it will help you preoxygenate the aprilat, you can give that. Mallemat will give a small dose if the patients so the patients don't crash during RSI.
patient remains hypertensive despite high doses of nitroglyc-erin (250-300mcg/min).
EMRAP Written Summary www.emrap.org It can be molded and will hold its shape. If you are trying to Many patients with acute pulmonary edema have end stage
advance the bougie and it is going too anterior or posteriorly, renal disease. Most of these patients are volume overloaded.
remove it and change the bend. Furosemide won't be sufficient. These patients will need dialy-sis. Call your renal consultants early.
The bougie is an excellent adjunct to the video laryngoscopy
with hyperangulated blades where the epiglottis is often eas-
ily visualized on the screen but hard to reach with the endo-
tracheal tube. Mold the bougie into the shape of the blade you
Bougie Every Intubation
Reuben Strayer MD
The bougie gives you immediate feedback as to whether you
are in the trachea or esophagus. As you transmit the bougie
Take Home Points
through the cords, you often feel the coude tip slide over the The bougie is designed to pass through the vocal cords
tracheal rings. It will reach a stop point at the carina. If you are easily. The endotracheal tube is designed to be a conduit
able to advance the bougie past the 50cm mark, you are in the between the trachea and ventilator.
esophagus. Put a lot of lube on the tip. You can also lube the cuff of the tip. Practice using the bougie in situations where you don't
Don't take the laryngoscope out once the bougie is in the tra-
chea. This makes it harder to pass the endotracheal tube over
The bougie can also be placed through an intubating LMA
the bougie. Leave it in place until the endotracheal tube is in One of the scariest clinical scenarios is the anatomically diffi-
Sometimes the bougie may become caught at the laryngeal in-
cult airway, where despite your best attempts at laryngoscopy,
let and you can't advance it past the cords into the trachea. It
you still do not see cords. There has been an explosion of de-
may often be overcome by rotating the coude tip 180 degrees vices and maneuvers that makes this situation less likely; video so that it points posteriorly. This disengages the distal edge from laryngoscopy, hyperangulated blades, ear-to-sternal-notch po- whatever is blocking it and allows the bougie to proceed into sitioning, external laryngeal manipulation, etc.
the tracheal unimpeded. There is a device that has been arounds for decades and is sci-
The endotracheal tube can also get stuck on glottic structures
entifically proven to improve your intubation success rate in
as it is placed over the bougie. Pull the tube back a few centi-
difficult intubations. It is cheap, available and easy to use. It is
meters and rotate it, then re-advance. The tube will slide. the gum-elastic bougie.
If you are good with the bougie, you can intubate a Cor-
This is a 60 cm long, 5 mm wide, semi-rigid tube with the distal mack-Lehane Grade 3 view where you only see epiglottis and
tip bent at 30 degrees. It is a long flexible stylet that can be no glottic structures. You don't get good at using the bougie if
inserted into the trachea and an assistant can place an endotra- you only use it in a crisis. cheal tube over it. The bougie was invented over 50 years ago. It
Use a bougie for every intubation. Get good at using the bougie
is not routinely used in most emergency departments and this
in cases where you don't need it so you are ready for when you is a shame.
do need it. When you have done a few normal airways with the Endotracheal tubes are designed to be a conduit between
bougie, practice for grade 3 airways by getting the best view the trachea and the ventilator. They are not designed to pass
and then relaxing your lift on the laryngoscope so the epiglottis through the cords easily. The bougie is designed to be as easy as falls down and covers the glottis. This simulates a Grade 3 view. possible to pass through the cords. The literature unequivocally You can then attempt to intubate this with a bougie.
demonstrates that you are more likely to intubate successfully if The bougie can also be used through an intubating LMA or cri-
you use a bougie, especially in difficult intubating conditions. cothyrotomy. There are case reports of using the bougie to fa-
The bougie is a superior intubating device compared to a sty-
cilitate blind digital intubation if you need to intubate someone leted endotracheal tube for three reasons.
sitting upright in the seat of a recently smashed car. The bougie is half the diameter of the endotracheal tube. It has a deflected coude tip engineered to get you where you need to go. You can slide it under the epiglottis or nudge it over the interarytenoid notch. February 2016: Volume 16, Issue 2 www.emrap.org lation and followed them for 30 days. They found that the Atrial Fibrillation ADP – Part 1:
incidence of thrombotic events was higher than previously quoted and may start at 12 hours.
Rob Orman MD and Cameron Berg MD
However, most of the ED literature has shown lower rates of Take Home Points
thrombotic complications. Patients will have bad outcomes whether or not they are cardioverted. Atrial fibrillation is a An accelerated diagnostic pathway may be applied to
risk factor for strokes. Some believe the patients in the study adults presenting with new, symptomatic atrial fibrillation.
would have had complications whether or not they were car- Patients in atrial fibrillation less than 48 hours may be
cardioverted and discharged from the ED with a low risk
Weigner, MJ et al. Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting Patients with atrial fibrillation greater than 48 hours in du-
less than 48 hours. Ann Intern Med. 1997 Apr 15;126(8):615-20. ration may be rate controlled with metoprolol or diltiazem.
This study included 357 hospitalized patients converted to This pathway applies to adults who present with new, symp-
sinus rhythm within 48 hours after symptom onset. Some pa- tomatic atrial fibrillation. This includes patients with a recur-
tients converted spontaneously and others were cardiovert- rent abnormal rhythm. Ideally, these patients present with atrial ed. Only 3 patients had thromboembolic events after conver- fibrillation that is in isolation and is the cause of the symptoms. sion to sinus rhythm. All three of these patients were in their This is considered primary atrial fibrillation. Secondary atrial 80s and had converted spontaneously.
fibrillation occurs when the arrhythmia is the result of some underlying and predisposing medical condition such as alcohol von Besser, K et al. Is discharge to home after emergency depart- withdrawal, decompensated COPD, thyrotoxicosis or sepsis. ment cardioversion safe for the treatment of recent-onset atrial fibrillation? Ann Emerg Med. 2011 Dec;58(6):517-20. Overall, we tend to see more secondary atrial fibrillation. For
these patients, the goal should be to treat and stabilize the under- lying medical condition. If the atrial fibrillation persists, then you This was a best available evidence review that looked at five can consider some of the concepts in the diagnostic pathway. papers examining the safety of ED cardioversion. The authors' synopsis of the five reviewed papers was that most of the What is the first decision point? Have they had symptoms for
complications related to cardioversion come from procedural more than 48 hours or less than 48 hours? Cardioversion is
sedation. They found zero reported thromboembolic events thought to be safe if the patient has been in the rhythm for less post cardioversion after ED discharge with follow-up periods than 48 hours. If the patient has been in the rhythm for more ranging from 7 to 30 days. than 48 hours, some additional diagnostics are indicated before If the symptoms of atrial fibrillation have been going on for
longer than 48 hours, control the rate. If the symptoms are un-
This concept is controversial. Previous literature suggested
der 48 hours, the patient goes straight to cardioversion.
that thrombi were unlikely to form in the first 48 hours. This led to the hypothesis that cardioversion was safe in this win- Why not use pharmacologic attempts to cardiovert? This is a
dow. This is wrong. Clots do form within 48 hours. However, reasonable approach. Procainamide has been identified as safe all of the clinical data generated so far validates this practice. and effective by the Ottawa research group. Others have looked It indicates that while clots can form within 48 hours, patients at similar strategies with flecainide or ibutilide. About 50% of pa- treated within this window without obligatory pre-cardiover- tients receiving the drug will convert during their ED stay.
sion anticoagulation appear to be stable for discharge with a Stiell, IG et al. Association of the Ottawa Aggressive Proto- low risk of complications. col with rapid discharge of emergency department patients What about the literature suggesting the risk of thromboembolic
with recent-onset atrial fibrillation or flutter. CJEM. 2010 complications at 12 and 24 hours is higher than anticipated?
Nuotio, I et al. Time of cardioversion for acute atrial fibrillation and Procedural sedation and electrical cardioversion is likely safer, thromboembolic complications. JAMA. 2014 Au 13;312(6):647-9. easier and quicker than pharmacologic treatment. It requires little monitoring. The results are much faster. It is more effec-tive when compared head to head with drugs alone. They did surveillance on a population of patients who was discharged from the ED after cardioversion for atrial fibril- Whether you use electrical or pharmacologic cardioversion will depend on your practice environment and resource constraints. EMRAP Written Summary www.emrap.org What is the recommended starting energy level? There is no
solid evidence. Berg places the pads on the front and back and shocks them at 200J biphasic. 65-74 years old +1 Can you offer a watch-and-wait option? Some may offer the pa-
> 75 years old tient rate control with a plan to reassess in the morning. About 50% of patients will spontaneously convert back into sinus rhythm within 24 hours. Some rate control may help with certain Congestive Heart Failure History patients but this is controversial. Several cardiology studies have Hypertension History found a weird association between acute rate control and per- sistent atrial fibrillation. However, this data may be confounded Vascular Disease History by spectrum bias (i.e. sicker patients received rate control). Diabetes Mellitus History We are experts in sedating patients. Electrical cardioversion, when
delivered in a monitored ED environment is exceedingly safe.
What happens if the cardioversion is unsuccessful?
Atrial Fibrillation ADP: Part 2
These patients are given urgent rate control when needed. Rate Control and Anticoagulation
They are risk-stratified according to risk of thromboembolic Rob Orman MD and Cameron Berg MD
disease and anticoagulated as needed. Take Home Points
Most will use up to 3 or 4 successive shock attempts before terminating the effort. Berg's group found that approximately Patients may be rate controlled with metoprolol or diltiazem.
90% of patients will be successfully cardioverted using the Metoprolol is contraindicated in patients with asthma or
protocol. When it doesn't work, there is usually some second- COPD. Do not use if the patient is wheezing.
ary cause. For example, a patient with atrial fibrillation who didn't respond to cardioversion was later found to have a PE.
Diltiazem is contraindicated in patients with a low ejec-
What work-up is indicated in these patients? The one obligato-
ry test is an electrocardiogram. Everything else should be deter- Berg's group has collected data on 422 patients in their cohort.
mined based on their clinical risk factors and symptoms. Many They have had zero short term thrombotic events.
will get an electrolyte panel on these patients. You can consider hemoglobin or chest x-ray. You do not need to routinely get a Do patients with a heart rate greater than 160 get rate control
troponin. ACS is a very unlikely cause of acute atrial fibrillation. prior to cardioversion? No. They proceed directly to cardiover-
sion. There is an association between acute rate control and fail- Do patients need post-cardioversion anticoagulation to po-
ure to cardiovert and although this may not be valid, it doesn't tentially decrease the rate of thromboembolic events? There
make sense to complicate things. is no evidence that acute post-cardioversion anticoagulation for all-comers has an effect on thromboembolic risk. However, Get diagnostics if it makes sense (often, it doesn't). Consent,
patients receiving anticoagulation and completing short term sedate and cardiovert the patient. If the cardioversion fails, you follow-up were associated with good outcomes. can do rate control. Most patients don't need rate control.
Sicker patients at baseline are likely to experience complications.
What do you do with patients who have duration greater than
48 hours or the duration is unclear? If you don't know, err on
Berg recommends use of the CHA DS -VASc risk stratifica-
the side of rate control. Most of these patients will not arrive tion score with a cut-off of 2. Patients with a cutoff of 2 are
with therapeutic anticoagulation. If they do, you can enter them recommended to start anticoagulation. ED physicians are en- into the pathway. Understand that cardioversion is unlikely to couraged to initiate anticoagulation at the time of the ED visit. be effective if they are in the rhythm for a longer time. They recommend considering anticoagulation for a score of 1.
You can confirm therapeutic anticoagulation with warfarin by CHA DS -VASc – See Chart
checking the INR. You may be unable to do so if the patient is Modifed from Lip, GY et al. Refining clinical risk stratification for pre- taking a newer agent. You need to find out exactly how com- dicting stroke and thromboembolism in atrial fibrillation using a novel pliant they have been. Are they taking the medication cor- risk factor-based approach: the euro heart survey on atrial fibrillation. rectly? Rivaroxaban needs to be taken with food. Dabigatran Chest. 2010 Feb; 127(2):263-72. needs to be taken twice daily. If they deviate from appropriate dosing, don't cardiovert. February 2016: Volume 16, Issue 2 www.emrap.org A rate of less than 110 at rest is targeted for rate control. Berg
See Flow Chart – Next Page
recommends IV metoprolol. They give 5mg boluses with a maxi- Most patients with atrial fibrillation are admitted to the hospi-
mum of 15mg and assess responsiveness. Diltiazem is their sec- tal. However, most of these patients can probably be discharged
ond-line agent with a weight-based dose of 0.35mg/kg. This is often higher than the reflexive 10-20mg. For the patient who remains in atrial fibrillation, the heart rate This drug selection is controversial. There is some research
should be as near normal as possible (<110 bpm). The systolic available but no large randomized controlled trial. Berg views blood pressure should be greater than 90.
diltiazem as slightly more effective in terms of acute rate con-trol. However, metoprolol is a better baseline drug for main- The patient should be feeling well. How can you quantify tenance. It is easy to convert from IV to PO formulations; 5mg this? The Canadian Cardiology Atrial Fibrillation scoring sys- of IV metoprolol is equivalent to 25 mg of PO metoprolol. Metoprolol has less impact on ejection fraction which may be See "Canadian Cardiovascular Society SAF Scale" Below
safer in undifferentiated ED patients. Modified from Dorian, P et al. A novel, simple scale for assessing the Give 25 mg PO metoprolol prior to discharge from the ED.
symptom severity of atrial fibrillation at the bedside: The CCS-SAF Metoprolol is contraindicated if allergy and may impact asth- Scale. Can J Cardiol. 2006 Apr;22(5): 383-386. ma or COPD. Don't use it if the patient is actively wheezing.
In the ADP, patients with a score of 0-3 are eligible for dis- Diltiazem is contraindicated if allergy or a low baseline ejection fraction. The literature indicates that number is probably 35%. If the patient is stable, do you initiate anticoagulation in the
If you do not have a baseline ejection fraction, you should be ED and what do you use? They prescribe anticoagulation in the
cautious if there is a history of pre-existing heart failure.
ED. They do not usually administer it prior to discharge as the You should stick to one medication until maxed out rather
thrombotic risks are long term. Patients with a CHA2DS2-VASc than jumping to another therapy. Beta-blockers with calcium
score of 2 should be given anticoagulation. You can determine channel blockers may be safe in a limited cohort of patients. bleeding risk using the HASBLED score.
The Canadian Cardiovascular Society SAF Scale
Asymptomatic with respect to atrial fibrillation Symptoms attributable to AF have minimal effect on patients general quality of life
Minimal and/or infrequent symptoms (palpitation, dyspnea, dizziness, presyncope or syncope, chest pain, weakness or fatigue Single episode of AF without syncope or heart failure Symptoms attributable to AF have minor effect of patient's general quality of life
Mild awareness of symptoms in patients with persistent/permanent atrial fibrillation or Rare episodes (less than a few per year) in patients with paroxysmal or intermittent AF Symptoms attributable to AF have a moderate effect on patient's general quality of life
Moderate awareness of symptoms on most days in patients with persistent/permanent AF or More common episodes (> every few months) or more severe symptoms in patients with paroxysmal/intermitted AF Symptoms attributable to AF have a severe effect on patient's general quality of life
Very unpleasant symptoms in patients with persistent/paroxysmal AF and/or Frequent and highly symptomatic episodes in patients with paroxysmal or intermittent AF and/or Syncope thought to be due to AF and/or Congestive heart failure secondary to AF EMRAP Written Summary www.emrap.org PRIMARY DIAGNOSIS OF ATRIAL FIBRILLATION
Primary Diagnosis of
Duration less than 48 hours
Rate Control
First choice is metoprolol. Use unless actively wheezing.
If paroxysmal atrial fibrillation Give IV metoprolol 5mg q5 min x3 as needed to achieve target heart rate. An addi- recurring in ED, do not cardiovert.
tional 1-2 doses may be administered as needed.
Start PO metoprolol tartrate 25mg po BID. Give the first dose prior to discharge from the ED.
Second choice is diltiazem. This is contraindicated if ejection fraction is less than 35% Is the Patient Stable?
CCS symptom class 0-3 HR < 110 bpm Start anticoagulation if indicated
Admit. Consult cardiology service.
Initiate if CHA DS -VASc score ≥ 2 Consider if CHA DS -VASc score ≥ 1 First choice for nonvalvular atrial fibrillation is apixaban (alternatives are rivarox- aban or dabigatran) Second choice is warfarin.
Dose is 2.5 mg qd if elderly, frail, malnourished, high bleeding risk, serious liver disease, serious comorbidity or significant drug interaction Otherwise dose is 5 mg qd Check INR in 5-7 days in clinic.
Discharge Home. Follow-up in clinic.
February 2016: Volume 16, Issue 2 www.emrap.org LIN Session:
Michelle Lin MD and Robert Rodriguez MD
Abnormal renal and liver failure Take Home Points
The use of CT scans in blunt trauma has increased dramat-
ically but the incidence of injuries remains the same.
A chest CT scan is 5-7 mSv and has a risk of cancer of
1/300 for young women.
Modified from Pisters, R et al. A novel user-friendly score (HAS-BLED)
Patients do not need a CT scan in the absence of abnormal
to assess 1-year risk of major bleeding in patients with atrial fibril- CXR, distracting injury, chest wall tenderness, sternum
lation: the Euro Heart Survey. Chest. 2010 Nov;138(5):1093-100. tenderness, thoracic spine tenderness, scapula tender-
ness or rapid deceleration mechanism.
There is a lot of thought that goes into the decision to start oral
anti-coagulation. Our job is to start the conversation. It is fine
Rodriguez, RM et al. Derivation and validation of two decision in- if the patient wants to follow-up with their primary care doctor struments for selective chest CT in blunt trauma: a multicenter pro- or cardiologist, but most patients with a higher score will end up spective observational study (NEXUS Chest CT). PLoS Med. 2015 on anticoagulation and there is no reason to delay. Berg prefers the newer oral anticoagulants. They have fewer
The use of CT scans to evaluate blunt trauma has increased
medication interactions. Although the existing data is skewed dramatically over the last decade even though the incidence of
by industry bias, it does suggest a lower incidence of danger- injuries has remained the same. A chest CT scan is about 5-7
ous hemorrhagic events. None of the trials were powered or mSv. This is about 300-400 chest x-rays. This radiation increases configured to make a definitive conclusion. We have apixaban, the risk of cancer. Trauma patients are usually young and more dabigatran, edoxaban and rivaroxaban available. susceptible to adverse outcome from radiation. The risk of can-cer for a young woman receiving a chest CT is about 1/300. The drugs that end in –aban are oral Xa inhibitors like enox-
aparin in a pill.
The yield of chest CTs are low, especially in the identification
of injuries that would change management. There is a lot of
Dabigatran is different and is a direct thrombin inhibitor.
concern about missed injuries and malpractice. What do you do for patients that are unstable? Truly unstable
Patients were enrolled from eight US, urban level 1 trauma
atrial fibrillation can be difficult to manage. Berg typically gives centers. They included patients with blunt trauma who received
more medication and sometimes multiple agents for rate con- either chest x-ray or CT. They derived two decision rules; Chest trol. If the rhythm is dangerous and life-threatening, cardiovert CT-Major and Chest CT-All. them. Berg avoids diltiazem drips. Diltiazem is not short-acting and boluses are simpler and easier for nurses. It is easy to assess Why did they develop two different decision rules? There is a
for response after boluses. Berg sometimes uses esmolol. wide spectrum of viewpoints and risk tolerance regarding the need to diagnose minor injuries in trauma. Everyone agrees that we need to identify aortic injuries, pneumothorax or diaphrag-matic injury. Our surgical colleagues are often risk averse and want to diagnose all minor injuries. Chest CT-All has a high sensitivity for both major and minor
injuries. It is 99% sensitive for major injuries and 95% sensitive
for minor injuries. What are examples of minor injuries? For example, 1-2 rib
fractures or a minor pulmonary contusion that doesn't cause hypoxia or require ventilation, small pneumothoraces, etc. Chest CT-Major has a sensitivity of 90% for minor injuries.
Both decision instruments had 99% sensitivity for major injuries.
EMRAP Written Summary www.emrap.org The decision rules missed one patient who was an elderly man The negative likelihood ratio for any injury is 0.18. The like-
with a pneumothorax that required a chest tube and subarachnoid lihood ratio for major injury is 0.04. What does this mean? If you have low suspicion or pre-
Chest CT-Major has a higher specificity of 37%. It will allow you to
test probability for major thoracic injury and the CT-Major forgo imaging in a greater number of patients than with Chest CT-All. instrument is negative, it is highly unlikely that the patient has a major injury. Chest CT-All Chest CT-Major
If your pretest probability was moderate and the CT major instrument is negative, it is unlikely the patient has an in- 2. Distracting injury 2. Distracting injury 3. Chest wall tenderness 3. Chest wall tenderness If you have a high pretest probability for major injury, you 4. Sternum tenderness 4. Sternum tenderness should still obtain a CT chest even if the decision rule is neg- 5. Thoracic spine tenderness 5. Thoracic spine tenderness 6. Scapula tenderness 6. Scapula tenderness For a more in depth discussion of likelihood ratios, you can 7. Rapid deceleration mechanism revisit the EM:RAP segment by David Newman in March 2012.
May forego CT if all criteria absent.
One or more criteria present cannot exclude thoracic injury
What if the patient has a motor vehicle crash and is intubat-
but presence of criteria does not indicate need for CT.
ed for head injury? These decision instruments are intended
Abnormal chest x-ray includes any thoracic injury, including for use in the hemodynamically stable, non-intubated pa- clavicle fracture or widened mediastinum. tient. This is the vast majority of patients. Distracting injuries are any condition thought by the clinician The presence of one or more criteria does not mandate a CT
to produce significant pain to distract the patient from a sec- of the chest.
ond injury. Examples include but are not limited to long bone fractures, visceral injuries requiring surgical consult, large lacerations or degloving injuries, crush injuries, large burns , spine fractures, spinal cord injuries or any other injury produc-ing acute functional impairment.
Rapid deceleration mechanism is defined as a motorized vehi- cle accident greater than 40 mph or a fall greater than 20 feet. These are meant to be used in conjunction with the NEXUS
C-spine criteria.
Aortic or great vessel injury Pneumothorax: no evacuation but observed >24h Ruptured diaphragm Hemothorax: no drainage but observed >24h Pneumothorax: received evacuation procedure Sternal fracture: no surgical intervention Hemothorax: received drainage procedure Multiple rib fracture: no surgery or nerve block Sternal fracture: received surgical intervention Thoracic spine fracture: no surgical intervention Multiple rib fracture: received surgery or epidural block Scapular fracture: no surgical intervention Pulmonary contusion: received ventilation for respiratory Pulmonary contusion/laceration: no ventilation failure within 24 hours but observed >24h Thoracic spine fracture: received surgical intervention Mediastinal or pericardial hematoma: no surgery Scapular fracture: received surgical intervention Mediastinal or pericardial hematoma: no surgery Mediastinal or pericardial hematoma: received drainage Esophageal injury: no surgical intervention Esophageal injury: received surgical intervention Tracheal or bronchial injury: no surgical intervention Tracheal or bronchial injury: received surgical intervention February 2016: Volume 16, Issue 2 www.emrap.org obvious other reasons for QT prolongation including some who Paper Chase 1:
had documented QT prolongation from medications. 0.6% of Is Droperidol Safe?
the analyzed sample had QT prolongation that could not be at- Sanjay Arora MD and Michael Menchine MD
tributed to another cause. This is not very much. No patients had torsades, dysrhythmia or cardiac arrest. The QT prolonga- Take Home Points
tion in the 6 patients was minimal.
IV and IM droperidol are safe and effective for the manage-
The median time to sedation was 20 minutes and 70% of pa-
ment of acute agitation with minimal risk of prolonged QT.
tients were effectively sedated after the first dose.
In this study, the median time to sedation was 20 minutes
The most common adverse event was oversedation which
and 70% of patients were effectively sedated after the
happened in 7%. This was more common in patients who re-
first dose.
ceived droperidol with a benzodiazepine. There were 34 staff No patients had torsades, dysrhythmia or cardiac arrest.
injuries; some kicked, some punched and a needle stick.
The study was limited as it was not a randomized controlled
Calver, L et al. The safety and effectiveness of droperidol for trial. The adverse events can't be directly compared across oth-
sedation of acute behavioral disturbance in the emergen- er agents such as haloperidol, benzodiazepines or ketamine. cy department. Ann Emerg Med. 2015 Sep;66(3):230-238. However, the risk of prolonged QT in this large cohort was very small. The QT prolongation when present was mild and there IV and IM droperidol are safe and effective for the manage-
were no dysrhythmias. ment of acute agitation. The risk of prolonged QT was minimal.
This is fair evidence that droperidol has a good safety profile
Acutely agitated patients are common in the ED. An ideal drug
and is highly effective at sedating agitated patients, even as a
for management would be rapid onset and offset with a good safety profile. Benzodiazepine and neuroleptics either alone or in combination are the mainstay but there are some problems with these such as dystonic reaction, hypotension and respira- Paper Chase 2:
tory depression.
Ketamine for Pain
Droperidol is a first generation anti-psychotic of the butyro-
Sanjay Arora MD and Michael Menchine MD
phenone class. It was used for decades to manage agitation and
nausea. In 2001, the FDA issued a black box warning stating Take Home Points
that it caused QT prolongation and torsades de pointes. They recommended using alternatives when available and advised IV ketamine is just as effective as IV morphine in treating
cardiac monitoring. This was very controversial. Critics have as- acute moderate to severe pain.
serted that droperidol is safe and the incidence of QT prolonga- Ketamine is associated with increased minor adverse
tion and torsades is probably no more than any other anti-psy- events such as dizziness and disorientation.
chotic. The black box warning caused the use of droperidol to drop dramatically. Motov, S et al. Intravenous subdissociative-dose ketamine versus The authors of this study looked for QT prolongation with the
morphine for analgesia in the emergency department: a random- administration of high dose parenteral droperidol. The second-
ized controlled trial. Ann Emerg Med. 2015 Sep;66(3):222-229. ary objective was to look at the risk of other adverse events and success of sedation.
IV ketamine is just as effective as IV morphine in treating acute
The study was performed at 6 large hospitals in Australia. By
moderate to severe pain but with increased minor adverse
protocol, they gave 10mg of IV or IM droperidol as a bolus. The events such as dizziness and disorientation.
dose was repeated in 15 minutes if the patient was still agitat- Relieving pain is an important part of our jobs. Although we
ed. After 20mg, the management was deferred to the treating often use opiates for moderate to severe pain, some have sug- physician. Patients were monitored closely with ECG obtained gested ketamine as an effective opiate sparing agent. In low or as soon as feasible. There was no control group.
subdissociative doses, ketamine works as an NMDA receptor There were 1009 patients with an ECG performed within 2 antagonist to decrease the wind-up phenomenon that occurs hours of droperidol administration. 13 patients had QT prolon- when more pain receptors are recruited and decrease pain gation. Most of the time it was mild. 7 of these 13 patients had memory. It has been used in a variety of settings including rural and prehospital settings. It has also been used in a variety of EMRAP Written Summary www.emrap.org patient populations such as cancer, post-operative and patients with sickle cell disease. Most of the available data is retrospec- Paper Chase 3:
tive. The few prospective randomized controlled trials compare No Need To Irrigate Abscesses
ketamine and morphine to morphine alone. Sanjay Arora MD and Michael Menchine MD
In this paper, ketamine alone was compared to morphine alone
Take Home Point
with a primary outcome of comparative reduction in pain at
thirty minutes. This was a prospective, double-blinded, random-
Irrigation of cutaneous abscesses does not improve treat-
ized controlled trial. They looked at the safety and efficacy of the medications. They enrolled a convenience sample over a one year period. Patients were aged 18 to 55 with acute abdominal, Chinnock, B et al. Irrigation of cutaneous abscesses does not im- flank or musculoskeletal pain rated at least 5 out of 10 on the vi- prove treatment success. Ann Emerg Med. 2015 Sep 10. sual analog scale. Patients who were hemodynamically unstable Irrigation of abscesses after I and D did not improve outcomes.
or had contraindication to ketamine or morphine were excluded.
Irrigation is described in most emergency medicine and surgi- Patients were randomized to 0.3 mg/kg of ketamine or 0.1 mg/
cal textbooks as part of the standard approach to incision and kg of morphine. The pain scores, vital signs and adverse effects
drainage. However, it is not validated in studies. were recorded at 15, 30, 60, 90 and 120 minutes. They looked at the need for rescue medications at 30 and 60 minutes.
This was a non-blinded, randomized controlled trial of irriga-
tion versus no irrigation for the treatment of abscesses. The
90 patients were randomized with 45 in each group. The
group without irrigation had a standard incision and drainage groups were similar at baseline.
while the other group received irrigation. However, the physi- Both medications worked equally well in reduction in pain
cians were free to irrigate however they wanted. Physicians in scores at 30 minutes (8.5 to 4 in both groups). At 15 minutes,
both groups were allowed to give antibiotics and determine an- more patients in the ketamine group reported complete resolu- tibiotic selection. tion of the pain (49% compared to 13%). However, this evened The primary outcome was need for further intervention such as re- out by 30 minutes. peat incision and drainage or change of antibiotics within 30 days. Patients in the ketamine group did need more rescue fen-
They had relatively broad inclusion criteria. Patient with comor- tanyl at two hours.
bidities such as diabetes were included. 209 patients were en- There were no serious or life-threatening side effects in either
rolled and randomized over 4 years. 187 patients had complete group. Ketamine had more associated minor adverse effects
follow-up data.
such as dizziness or disorientation.
There was no difference in need for repeat procedures across
This is a small but well-conducted controlled trial reminding us
the treatment groups. 15% of patients in the irrigation had re-
that ketamine is available for pain control in the ED. It is not just
peat incision and drainage or antibiotic change compared to for musculoskeletal pain. It is nice in trauma and burn patients 13% in the control group. Procedural pain was the same in the although they were excluded in this study. Does your hospital treatment groups. consider this to be procedural sedation? It depends on the hos- The study was limited by a lack of blinding. The assessors were
pital. Check before you use it. Don't use more than 0.5mg/kg IV. blinded. The physicians had a lot of discretion in management of For more on dosing of ketamine, check out Ruben Strayer's
these patients. Irrigation may have been minimal. post on this topic:
This was a small study from a single site with some significant
limitations. However, the key finding that 1 in 8 cutaneous ab-
scesses will require further treatment is probably correct. Irriga-tion does not appear to change this.
February 2016: Volume 16, Issue 2 www.emrap.org The best method is unclear. We should think twice about plac- Paper Chase 4:
ing foley catheter and consider removing them when no longer Who Should Get a Foley
Sanjay Arora MD and Michael Menchine MD
Take Home Points
Paper Chase 5:
Implementation of a protocol to decrease urinary cathe-
Workload and Work Quality
ter placement in the ED improved practitioner knowledge
Sanjay Arora MD and Michael Menchine MD
and slightly decreased the rate of catheter insertion.
Don't place catheters in patients for staff convenience.
Take Home Points
ED providers are interrupted on average, 5.5 times per
Mulcare, MR et al. A novel clinical protocol for placement and man- hour and spend over 30% of their time multitasking.
agement of indwelling urinary catheters in older adults in the emer-gency department. Acad Emerg Med. 2015 Sep 22(9):1056-66. There was a significant negative association between
the ED providers' self-assessed mental workload and pa-
tients' perceived quality of care.
Implementation of a protocol to decrease urinary catheter
placement in the ED improved practitioner knowledge and
Interruptions and multitasking were positively associated
slightly decreased the rate of catheter insertion.
with patient satisfaction and the quality of handoffs.
Decreasing catheter use in the emergency department is a pos- Weigl, M et al. Work conditions, mental workload and patient care itive thing for patients. Foleys are often placed reflexively in quality: a multisource study in the emergency department. BMJ elderly patients for convenience. This is not a benign event. It Qual Saf. 2015 Sep 8. causes pain, discomfort and places the patient at risk for cathe-ter associated infections. Research suggests that this comprises This study looked at the prevalence of work flow interruptions
1 in 10 health-care associated infections. This is bad for patients and multitasking and impact on patient perceived quality of
and Medicare reimbursement.
care and handoffs in the hospital. We have a lot of interruptions
and frequently multitask. When workload was higher, perceived The authors went to a lot of effort to develop and implement
quality of care was lower. Interruptions had a positive associa- a clinical protocol designed to reduce inappropriate catheter
tion with quality of handoffs.
placement and encourage early reassessment and removal
when possible. They did a very thorough literature review. They
Workflow interruptions, multitasking, high work demands are
developed focus groups with physicians and nurses and brought as central to emergency medicine as the ABCs. Some studies
together local experts. They developed a protocol utilizing have estimated the number of interruptions to be 1 to 30 times green, yellow and red schema for the placement of catheters per hour. There are some studies that show when an ED pro- for a variety of diagnosis (ventilated and spinal cord injury are vider is interrupted, they fail to return to original activity about green, mild CHF exacerbation is yellow, convenience for care 20% of the time. Multitasking represents a lot of our work ac- is red). The protocol was distributed to the doctors and nurses tivity. These issues have been demonstrated to cause mental with a presentation, pocket card and posters. stress for emergency care providers. The ED is a mentally task- ing place to work. Can we handle it? Does it affect the quality of Providers were given surveys immediately before and after im-
care and patient safety? plementation of the protocol as well as 6 months after assess-
ing knowledge. They had an 86% response rate.
This paper reports on a complex study of a single, community
ED in Germany. They had two questions. What is the preva-
They showed that knowledge about who should and shouldn't
lence of interruption and multitasking? Are these events associ- get a catheter did increase. However, most providers still were
ated with lower patient perceived quality of care or care transi- willing to place a catheter despite the protocol. They looked at the rate of catheter placement in elderly ED patients in the 6 month pre- and post- period. They saw a drop from 19% to They had direct observation of ED MDs and nurses. They ob-
15%. We don't know if the drop was appropriate or inappropri- served and clicked every time they were interrupted. They then ate. We don't know if it changed practice for physicians, nurses asked the ED providers to complete an index of mental work- or mid-level providers.
load. This involved 5 items to gauge how stressed the provider felt. They asked the patients seen by the provider to complete It is a positive thing that you can change your groups practice.
a patient satisfaction questionnaire immediately at the end of EMRAP Written Summary www.emrap.org

their ED care. If the patient was admitted, they asked the receiv- There is an easy mnemonic for that: LIMPSS.
ing doctor to fill out a survey regarding the quality of the handoff. L is for Legg-Calve-Perthes Disease.
Overall, they had twenty observation periods during which
565 patients received care.
This is a progressive idiopathic avascular necrosis of the fem- Providers were interrupted on average, 5.5 times per hour.
They spent over 30% of their time multitasking. It is typically seen in kids between 3 and 12. Males more than females (4:1). Caucasians more than African Americans.
There was a significant negative association between the ED
providers' self-assessed mental workload and patients' per-
The classic presentation is unilateral pain with difficulty in- ceived quality of care. However, the interruptions and multi-
ternally rotating and abducting the hip. However, up to 1 in 6 tasking were positively associated with patient satisfaction and kids will have bilateral presentation.
the quality of handoffs to other providers. This is what we do. The diagnosis is made on x-ray of the hips. Remember to get
We are good at multitasking and have good coping skills but
the "frog leg lateral" to get the best views. X-rays may be
when we get stressed, our patients feel it. If you feel stressed,
unremarkable early in disease. Findings may range from cres- try to give yourself a break and decompress.
cent sign (subcortical lucency) early on to complete bony de-struction. The patient may need an MRI which is considered the gold standard in imaging.
Why do we care? A significant portion will develop arthritis
later in life.
Annals of Emergency Medicine:
Once diagnosed in the ED, these kids typically can go home Why The Limp?
with instructions for limited activity, non-steroidal anti-in- Paul Jhun MD and Ryan Raam MD
flammatory drugs for pain and orthopedic surgery follow-up within the week.
Take Home Points
I is for infection or inflammation.
Limp in children can be evaluated with the mnemonic
The lower extremity is the most common site for pediatric
LIMPSS; Legg-Calve-Perthes disease, Infection/inflam-
cellulitis. Keep it on your differential. Undress the kid and get
mation, Malignancies, Pain from trauma, Slipped capital
a good exam.
femoral epiphysis or a Source somewhere else.
Osteomyelitis is a common presentation in a limping child.
Obtain an ultrasound of the hip when ruling out septic ar-
This affects boys more than girls. The most common bones thritis; a joint effusion of 2mm is concerning.
are the femur, tibia and fibula (these 3 sites make up more Some studies show ESR> 40 and CRP> 2 to be sensitive
than 50% of osteomyelitis in kids). Staph aureus is the most common organism. Some studies have shown serum erythrocyte sedimenta-
tion rate and C-reactive protein to be sensitive in evaluat-
ing for osteomyelitis.
An 11-month-old female presented to the pediatric emergency department with a one day history of refusal to bear weight on Don't be tricked by normal x-rays. The classic "rat bite"
the right lower extremity after a two week progression of pain finding of bony cortex destruction doesn't appear until 2-3 and limping. There was no history of trauma or fever. Her vital signs were within normal limits. The right ankle was noted to How can you differentiate between transient synovitis and
be edematous, warm to the touch, diffusely tender to palpation septic arthritis of the hip? Patients with transient synovitis
and she had diminished creases when compared to the left. Her can go home with NSAIDs and expectant management and exam was otherwise unremarkable. Serum laboratory studies patients with septic arthritis need surgical washout in the op- were all within normal limits with the exception of an elevated erating room. Both can present with fever, pain with passive white blood cell count of 16,400 cells/mm3. Plain films of the movement of the hip and refusal to bear weight. ankle revealed a lucency in the posterior aspect of the talus and soft tissue swelling of the ankle joint. MRI was subsequently The best decision rule is Kocher's criteria. This decision
completed and revealed a 7mm abscess in the lateral subcuta- rule has 4 criteria; refusal to bear weight, fever >38.6, WBC neous soft tissues. Diagnosis? Talar osteomyelitis.
count > 12,000 cells/mm3 and ESR >40mm/h. The study February 2016: Volume 16, Issue 2 www.emrap.org found that the more criteria present, the greater likelihood years old and caused by normal toddler activities like tripping, of septic arthritis. If the patient had 0 out of 4 criteria, the falling from low heights, etc.
likelihood of septic arthritis was 0.2%. In patients with four predictors was 99.6%. Toddler's fractures are difficult to identify on x-rays. The AP
view is your best bet and you may just see a subtle oblique Kocher, MS et al. Differentiating between septic arthritis and lucency through the distal tibia that ends medially. There may transient synovitis of the hip in children: an evidence-based not be a break in the cortex.
clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70. Always consider child abuse or non-accidental trauma. Up
to 20% of fractures are the result of non-accidental trauma Another study found that CRP>2.0 mg/dL and refusal to
and 80% occur in children less than 18 months old. Be aware bear weight might be the best clinical predictor.
of the developmental stage of the patient, the clinical history, Caird, MS et al. Factors distinguishing septic arthritis the mechanism and the type of fracture. Don't mistake a spi- from transient synovitis of the hip in children: A prospec- ral fracture of the midshaft of the tibia for a Toddler's fracture tive study. J Bone Joint Surg Am. 2006 Jun;88(6):1251-7. (which occurs in the distal half to third of the tibia). When in doubt, get child protective services involved.
Don't forget to get an ultrasound of the hip. A hip effu-
S is for SCFE (slipped capital femoral epiphysis).
sion greater than 2mm in diameter is septic arthritis until In this disease, the epiphysis is falling off the metaphysis at
proven otherwise. Get your orthopedic surgeon on board.
the physis ("the ice cream is falling off the cone"). SCFE tends
M is for malignancies.
to affect overweight tweens, boys more than girls and African Americans and Hispanics more than Caucasians. There are a lot of bone tumors. You don't need to know all of
them but you should know about Ewing's sarcoma and osteo- In 25% of cases, patients will complain of knee or thigh pain
sarcoma. These make up 90% of all bone cancers in kids.
and not hip pain.
Classically, kids complain of constitutional symptoms like
This is second most missed pediatric orthopedic emergency
fever and weight loss with a subacute, insidious leg pain that
might be worse at night. Local trauma to the area might be
SCFE can present bilaterally 10% of the time. X-rays are used the inciting event that draws attention to the lesion. to diagnose this condition. Get the frog-leg view. Klein's line They are usually found in the long bones of the lower ex-
on the AP view misses this diagnosis 60% of the time. tremity such as the proximal tibia and distal femur. Ewing's
SCFE leads to avascular necrosis of the hip. The child should
sarcoma likes to hide in the pelvis. be placed in non-weight bearing status with immediate or- On x-ray you may see characteristic "onion-skinning" and
thopedic consultation for admission and inpatient surgical "sunburst" appearance of the pelvis. This is a reactive perios-
teal change that occurs because of the rapidly growing tumor S stands for somewhere else.
at the margins of the bone. If you do a complete work-up of the lower extremity and
Patients may have fever, swelling, redness, an elevated
don't find anything, consider sources above the legs such as
WBC and ESR with periosteal changes on x-ray similar to
psoas abscess, appendicitis, discitis, urinary tract infection, osteomyelitis. Beware.
ectopic pregnancy, torsion and pelvic inflammatory disease. Acute lymphoblastic leukemia is the most common pediat-
Most the diseases may cause referred pain through irritation ric cancer and children may present with long bone pain and
of the iliopsoas or obturator internus muscles or obturator limping. If you have a kid with constitutional symptoms, some
abnormalities on the CBC and insidious pain in the legs, keep Back to the case. The patient with a talar osteomyelitis was
ALL on your differential.
managed operatively with incision and drainage of the abscess P is for pain from trauma.
as well as irrigation and debridement of the talus. She received antibiotics and recovered well.
The most obvious cause of pain we encounter is from frac-
tures. These are the most commonly missed pediatric ortho-
pedic emergency diagnoses. Toddler's fracture is a nondisplaced oblique fracture of the
distal tibia. It is usually found in toddlers between 1 and 4
EMRAP Written Summary www.emrap.org Does the C-collar restrict movement? We have no evidence
Do We Still Need the
that C-collars restrict movements that could be harmful. Rob Orman MD and Chris Colwell MD
A drunk patient found down gets placed in a cervical collar until Take Home Points
sober. There are repeated battles; the patient sits up with the collar askew. Once they take off the collar, it rarely goes back on. There is no evidence that C-collars restrict harmful move-
Sedate these patients so they are not thrashing about. We
C-collar use may result in harm to patients and pain.
don't have to intubate and paralyze all these patients.
Most literature on the cervical collar discusses the non-utility
of the cervical collar. How did every trauma patient end up in a
A drunk patient arrives in a collar. You don't know what hap- C-collar? There has never been any evidence that suggests that
pened to them. Do you leave the collar on? the C-collar benefits our patients in any way.
Practice varies. Colwell will remove the collar when they are We use C-collars because trauma patients may have an un-
sedated or cooperative. Sometimes the agitation is due to the stable C-spine injury. If we move the injury, the patient could
collar. Sedation to keep the collar on can lead to respiratory be paralyzed. We make every effort to not extend the neck, in- compromise. Some of these patients will just fall asleep when cluding during intubation. However, it is not motion that causes the collar comes off.
harm but energy. This terror of causing any mobility is unfound-ed and goes against reason. What is the harm of placing patients in a collar? Taking patients
An 80 year old with fall and large hematoma with 8cm occip- out of a position of comfort and placing them into a rigid cer- ital scalp lac. They deny neck pain. You know they have a C1 vical collar that extends their neck does not make them safer. There is evidence that C-collars reduce venous return and in-crease intracranial pressure. These patients are very risk for high cervical spine injuries.
These are the most concerning injuries and the reason we im- An article by Gaither on failed airways found that C-spine im- mobilize. However, we may be causing more harm.
mobilization was a primary reason that we struggle with airways in the field. Gaither, JB et al. Prevalence of difficult airway pre- Rigid cervical collars can stretch the spinal cord in unstable
dictors in cases of failed prehospital endotracheal intubation. J high cervical fractures and reduce the blood flow to the spi-
Emerg Med. 2014 Sep;47(3):294-300. nal cord.
This something that was never based on evidence, causes
harm and pain and we have allowed it to become our standard
and culture.
A patient in a motor vehicle accident walks into triage with neck pain and tingling in the arms. A study by Hauswald on emergency immobilization on neuro- logic outcome of patients with spinal injuries comparing the US The patient has proved to you that movement will not para-
to Malaysia where spinal immobilization is not performed found lyze them. Putting them in a less comfortable position won't
patients that were immobilized did worse with similar injuries.
Hauswald, M et al. Out-of-hospital spinal immobilization: its ef- We can't do this in isolation. We need to have this conversation
fect on neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9. with the entire team including orthopedics, trauma and neuro- Culture is difficult to change.
For more, check out
Forcing immobilization on a combative and resistant patient could increase the energy and potential for damage. Sedate the patient so they don't move around so much. What about penetrating trauma? The literature shows the mor-
tality doubles with immobilization. Immobilization is not indicat-ed in penetrating trauma. February 2016: Volume 16, Issue 2 www.emrap.org The clotting bandages do not work alone and must be ac-
Doc In The Bay:
companied with direct pressure. We are bad at continuing di-
Stop Bleeding Without a Hospital
rect pressure to control bleeding. It may take several minutes Howie Mel MD and Roy Alson MD
of direct pressure. If the patient is anticoagulated, it may take much longer. Take Home Points
Apply pressure with one finger to the site of bleeding. Hold
Properly applied tourniquets are life-saving in exsangui-
firm pressure. Don't let go for a while. Don't peek.
nating hemorrhage and have a low rate of complications.
Sanitary napkins are another option. They are designed to soak
Direct pressure should be applied with one finger for a
up a large amount of blood. long time.
Start with direct pressure unless it is a life-threatening bleed.
Israeli bandages with clotting agents or sanitary napkins
may be used to control bleeding.
A true arterial bleed is an emergency lasting a few minutes un-
less you can get control. If the artery is completely transected,
Out of Hospital Cardiac Arrest
it may retract and the bleeding won't be apparent until the pa- Darren Braude MD and Brent Myers MD
tient receives crystalloid fluids. Much of the arterial bleeding in extremity wounds is due to small surface arterioles and arteries. Take Home Points
These may have pumping blood but rarely exsanguinate. We If the patient with cardiac arrest has been in asystole for
rarely deal with exsanguinating bleeding in the civilian sector 20 minutes, the chance of neurologically intact survival is
aside from the tactical environments. less than 1%.
There are a lot of misconceptions regarding tourniquets. There
Approximately 5% of patients with PEA arrest with in-
is a perception that using a tourniquet will result in the loss of creasing end-tidal CO2 or end-tidal CO2>20 will have
the limb. This dates to the Civil War when patients experienced ROSC and good neurologic outcome after prolonged re-
cannonball and artillery injuries. Patients would be placed in a suscitation for 40-60 minutes.
tourniquet and receive amputation. The tourniquet was a marker of an injury requiring amputation rather than a cause. In more re- Patients with refractory ventricular fibrillation may ben-
cent conflicts, prolonged evacuation times led to limb ischemia. efit from alternate pad placement and double sequential
Our orthopedic colleagues perform surgeries with a tourni-
quet in place for several hours with no damage. Abdominal
aortic aneurysm repair also does not result in limb loss. EMS arrives on scene to a witnessed cardiac arrest with rescu- In reality, the literature shows that properly applied tourni-
er CPR in progress. The patient is 60 years old. EMS places an quets in exsanguinating hemorrhage are life-saving. The tour-
airway. CPR is continued. The patient has received two doses niquet registry showed three cases of permanent damage. All of epinephrine and the resuscitation has been in progress for had the tourniquet in place for more than eight hours and the 25 minutes. The patient is 15 minutes away from the hospital. complications were numb fingertips. EMS calls to request termination of the resuscitation. We need to stop this dogma that the patient will lose their limb
if you place a tourniquet. They will not. Use the tourniquet. If you
What is the role of the rhythm, end-tidal CO , age and length
have a brisk arterial bleed that you can't control with direct pres- of resuscitation? How do we make the best evidence based de-
sure, place a tourniquet and note the exact time of placement. How long can the tourniquet remain in place? 1-2 hours seems
Scenario 1. The patient is in asystole.
like a relatively safe recommendation. Hopefully, you will be If the patient is in asystole for the duration of the resuscita-
able to get the patient to definitive care before this. tion, can you stop?
Are there other options? The Israeli bandage. This is an elastic
If the patient has been in asystole for twenty minutes, the bandage with a gauze pouch impregnated with a clotting agent. chances of neurologically intact survival are less than 1%. This It can be wrapped around like a tourniquet with direct pressure. is medically futile. It can also be balled up and placed into a body cavity with injury. EMRAP Written Summary www.emrap.org An initial rhythm of asystole without an obvious sign of death Scenario 3. The patient is in ventricular fibrillation.
and unwitnessed arrest deserves some effort at resuscitation but they do not need prolonged resuscitation.
These codes need to be managed aggressively. We need to
minimize interruption in compressions and deliver a shock as What if the end-tidal CO is high? It doesn't matter. If the
soon as possible. end-tidal CO is high with persistent asystole, you must be perfusing with compressions but you are not getting return of Pad placement. These are placed on the anterior chest and
apex to allow chest compressions to continue while the pads rhythm. With good chest compressions, minimal interruptions are placed. The original pads are left in place for 3-4 defibril- and controlled ventilations, we can create end-tidal CO values lations. If the patient remains in fibrillation after the ACLS al- that reflect high quality CPR but are unrelated to survivability. gorithm is completed, Myers then places a second set of pads The trend of the end-tidal CO is far more important than
in the opposite pad placement configuration which is usually any single value.
anteriorly and posteriorly. They have found anecdotally that changing the pad placement makes a difference and the pa- Scenario 2. The patient is in PEA. There is no ultrasound on scene.
tient is more likely to convert. PEA is a survivable rhythm.
If the patient remains in ventricular fibrillation, Myers will
Rate is important. A rate above 40-60 beats per minute is
charge both defibrillators and perform a double sequential
external defibrillation with the maximum Joules. This is only
performed in the setting of ventricular fibrillation that is re- The trend in the end-tidal CO is important. A trend upward
fractory to the ACLS algorithm. Attempt to deliver the shocks above 20 or a current value above 20 should have consider- simultaneously although a small delay might result between ation of prolonged resuscitation. shocks. Make sure the team is on the same page; "3, 2, 1, Prolonged resuscitations of 40-60 minutes have decreased
survival but patients who survive have a good chance of
neurologically intact survival.
Is this safe for the patient? There is some data but this is
primarily in refractory perfusing rhythms such as atrial fibril- If the patient has point-of-care ultrasound (POCUS) that lation. Some feel that leaving the patient in ventricular fibril- shows no cardiac activity, the resuscitation may be terminat- lation does more myocardial damage than the theoretical ed earlier. Most EMS will not have this capability. damage due to double sequential defibrillation.
History obtained on scene can be used to make the decision What are the chances of triggering an R on T phenomenon
to stop resuscitation. with double sequential defibrillation? At this point, the pa-
tient is pretty much dead. You are unlikely to make things Age decreases your odds of survival by 0.03 per year of life
but is not a sole reason to end resuscitation.
If the initial end-tidal CO was 30 but dropped to 5 or was
Will this damage the machines or void the warranty? The de-
fibrillators are designed to prevent electricity from going back at 5 throughout the resuscitation despite good CPR, do you
up into the machine. Myers uses the Lifepak defibrillator. It is continue the resuscitation for 40-60 minutes? Most would
unclear if this is true for all devices. not continue a resuscitation of a PEA arrest with an end-tidal CO of 5 after 20-25 minutes of resuscitation. Resuscitation is a prehospital science. We need to make sure
that all of our EMS responders have the best knowledge avail- What percentage of PEA patients with prolonged resuscita-
able to conduct resuscitations where they find them. tion survive? Most neurologically intact survivors with PEA
arrest are attained by 40 minutes of resuscitation. The rate of neurologically intact survival with resuscitation between 40-45 minutes is 8%, 6% between 45-50 minutes and 5% at 50 minutes. At an hour of resuscitation, the rate of neurolog-ically intact survival is 2% and this is consistent with medical futility. The rate of neurologically intact survival is 20% at 25 minutes of resuscitation.

Does prolonged resuscitation increase the likelihood of per-
sistent vegetative state? The chance of survival decreases
but the proportion with persistent vegetative state remains consistent until 40-60 minutes of resuscitation.
February 2016: Volume 16, Issue 2 www.emrap.org The Canadian Cardiovascular Society SAF Scale
A 44 year old patient with no comorbidities presented with
a massive PE without hypotension. The heart rate was 110
Rob Orman MD and Anand Swaminathan MD
and bedside ultrasound showed an estimated right ventricu-lar systolic pressure of nearly 70mmHg. The pulmonary and The EMRAP Mail Bag.
critical care physicians did not do anything. The emergency From Ash Mukherjee. Can we change the terminology of ‘he-
physician had a long discussion with the patient and his wife. modynamically stable' when talking about submassive PE?
Within 15 minutes of receiving thrombolysis, the tricuspid re- Someone with a heart rate of 110 to 130 would never be called gurgitation had disappeared.
hemodynamically stable in any other circumstance. It should be From Chris. What are your thoughts regarding prescribing over
called massive PE without hypotension.
the counter medications? Some patients have a difficult time
Even this statement is suboptimal. A person with a normal
just paying for food. It depends on the situation.
BP of 150 should be considered hypotensive with a blood Does the slope of the hemoglobin dissociation curve really fall
pressure of 95. Too many clinicians take the conservative off at 85% rather than 90%? Some of this has to do with the
route because the systolic is above 90. You have to get an percentage error of the oxygen saturation monitor. Previously, echocardiogram to grasp the actual situation.
we were worried at an oxygen saturation of 90% because the It is up to emergency physicians to make this call. The mo-
monitor had accuracy of +/- 5%. Newer generations are proba- ment you ask others to assist in the decision, thrombolysis bly more accurate with an error rate of 1-2%. An oxygen satura- goes out the window. tion of 88% is more likely to be accurate. Temperature, pH and 2,3-DPG also affect the hemoglobin
EMRAP Written Summary www.emrap.org

Source: http://zna-jena.de/zna_media/EM_RAP/EMRAP_2016_02_Feb_Vol_16_02-p-830.pdf

Microsoft word - whole thesis

The Effects of Salvia hispanica L. (Salba) on Postprandial Glycemia and Subjective Appetite A thesis submitted in conformity with the requirements for the degree of Master's of Science Nutritional Sciences University of Toronto © Copyright by Amy Sanda Lee 2009 The Effects of Salvia hispanica L. (Salba) on Postprandial Glycemia and Subjective Appetite


A Practical Approach to the or Moisture-associated Skin Damage, due to Perspiration: Expert Consensus on Best Practice Consensus panel R. Gary Sibbald MD Professor, Medicine and Public Health University of TorontoToronto, ON Judith Kelley RN, BSN, CWONHenry Ford Hospital – Main CampusDetroit, MI

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