Transcript Update in Emergency Medicine

Objectives
 Lots
of topics requested
– Acute cardiopulmonary disease
– Anaphylaxis
– Cardiac arrest – ALS and BLS
– Septic shock
– Paediatrics
– Head injury
– TIA and Stroke
Acute respiratory distress
24 year old with history of asthma arrives
in some distress with a respiratory rate
of 32 and SaO2 of 94%. Speaking in
phrases.
– Moderate to severe exacerbation
– Initial treatment
 Salbutamol
5mg x 3 q20min
 Ipratropium 500mcg x 1
 Oral or IV steroids
 Reassess
Asthma continued
 No
improvement after 2 nebs with
increasing resp distress, intercostal
recession, speaking in words
 Urgent situation
 Continuous nebulised salbutamol
 Intravenous salbutamol
 IV Magesium
 CPAP/ BiPAP
 Intubation preparation
 IV adrenaline in small doses eg 0.1mg
diluted (1ml of 1:10,000)
Take home messages

Severe asthmatic
– Continuous oxygen driven nebulisers
– Get to hospital
– Small doses of IV adrenaline can buy
time
– Intubation last resort
 82
year old man presents by
ambulance with sudden shortness of
breath, chest tightness. Chest
sounds wheezy and rattly. Coughing
frothy pink sputum.
 Obs: pulse 96, BP 200/130, RR 32,
sats 96% on NRB
 Diagnosis?
 Treatment?
 Hypertensive
and LVF – need to
reduce afterload, increase preload
 Fluid overload not usual problem
 ECG to rule out STEMI,
 Monitoring, O2, IV access
 Nitrates +/- morphine
 BiPAP
– Reduces work of breathing
– Forces fluid out of alveolar space
 LVF
plus hypotension
– Too much nitrate?
– Tachyarrhythmia?
– Cardiogenic shock
 Fluid
gently if inferior AMI
 Inotropic
 Cath lab urgently if AMI
Pneumothorax
 Types:
– Primary
spontaneous
– Secondary –
underlying lung
disease
– Traumatic +/- rib
fractures
Primary Pneumothorax
18yo presents with
sudden onset of
left pleuritic chest
pain.
 Some SOB when
walking
 No past med hx

Primary pneumothorax

Risk factors:
– Smoking
–
–
–
–

 12%
lifetime risk in men vs 0.1% non-smokers
Pleural blebs and bullae
Tall, thin males
Asthma history
50% recurrence rate in 4 years
Evaluation of size:
– British Thoracic Society Guideline 2003
– Expiratory CXR not required
– Small vs Large ptx – 2cm rim of air = 50% ptx
Primary pneumothorax cont

Options for treatment:
– Leave vs aspiration vs chest tube
Leave < 2cm rim of air on CXR and not
breathless
 Attempt aspiration > 2cm rim of air and/or
breathless- 70-80% success
 Unsuccessful aspiration

– Try again
– Small bore intercostal catheter, remove at 24
hours if fully reexpanded
– High flow oxygen

Surgical pleurodesis at 5 days if persistent
leak
Aspiration
 Re Xray 4 hours after
procedure
 Home if reexpanded
• Warn if increasing
pain,
breathlessness to
seek help
immediately
 Re X ray next day
then at 1-2 weeks
 Same if conservatively
treated

Follow up
Reabsorbs over weeks
 No flying till fully resolved (airline rules
6 weeks)
 No diving ever
 Resumption of sporting activity ? 2-4
weeks

Secondary pneumothorax
 Age
> 50, underlying pulmonary
disease
 High rate of failure of conservative
treatment
– Only small apical asymptomatic, < 1cm ptx
 Usually
need hospitalisation with a
small bore chest drain until reexpanded
 BTS guideline:
– < 50yo, < 2cm rim of air, not breathless –
try aspiration and admit 24 hours
– > 50yo or > 2cm air or breathless - ICC
– Early surgical referral (3 days)
Traumatic ptx
 Ptx
on CXR usually requires ICC and
admission
 Especially if requiring GA
 Traumatic ptx on CT scan less
important
Take home messages

Asymptomatic ptx < 2cm can be
treated conservatively
– in under 50,
– no underlying lung disease

Many primary pneumothoraces can
be aspirated – 70-80% success
 60
year old with no known history of
allergy eating an asian meal at a
local restaurant.
 Within 2 minutes develops
generalised erythema and itch,
vomits, dizzy and collapses.
 Develops increasing of face and
tongue and a hoarse voice, difficulty
breathing
Anaphylaxis
 Classified:
– mild: skin and subcutaneous tissues
only
 non-sedating
antihistamines (cetirizine,
loratidine) for symptoms
– moderate: features suggesting
respiratory, cardiovascular, or
gastrointestinal involvement
– severe: hypoxia, hypotension or
neurological compromise
Treatment of mod/severe
anaphylaxis

Emergency management of anaphylaxis:
– Adrenaline
– Adrenaline
– Adrenaline
0.5ml
of 1:1000 amp IM in the lateral
thigh (0.1 ml/kg to maximum 0.5ml)
ie half a 1ml amp for an adult
May be repeated every 3-5 minutes
depending on response
Beware of using IV adrenaline
Adjunctive treatment
 Lie
patient flat
 Oxygen
 IV access/ NS 20mg/kg
 Salbutamol neb for bronchospasm
 Neb adrenaline for upper airway
obstruction
 Atropine for bradycardia
 Glucagon for beta blocked patients
 Steroids,
antihistamines - H1 and H2
blockers (eg ranitidine)
 Keep
for 4 hours minimum post
Adrenaline – should be observed in
ED
 Follow up with allergy specialist if
severe – RNSH OPD
 If severe provide EpiPen (0.3mg)
and instructions
Cardiology
 Acute
coronary syndromes
– ETAMI
– High sensitivity troponins
ETAMI - Emergency Treatment of AMI
 Ambulance
paramedics do an ECG on
patients with chest pain
 Across Northern Sydney transmitted
to RNSH ED 24 hours
 ECG Read by EM specialist/registrar call back to ambulance via mobile
– STEMI: transport to RNSH/ Cath lab
alerted
– others: to local hospital
ETAMI
 Pioneered
at RNSH from 2004
 Front door to needle time of 18
minutes
 Sydney wide system from August to
cath labs at major hospitals
High sensitivity troponins





6-7% patients present to ED with chest pain –
about 3,500 pa. Half have ACS.
Over 10,000 troponins a year
Until end 2009 using 3rd gen trop test:
– NR < 0.03 mg/L, 0.03 – 0.2 equivocal
Now 4th generation troponin assay
– < 14ng/ml negative, 13-100ng/mL equivocal
What does this mean?
– Many more false positives
– How do you interpret a low positive test?
High sensitivity troponins cont.



Patients need to be clinically risk stratified
– Good ACS story plus N trop = admission for Ix
– Poor ACS story plus low N trop may be able to
go home
Change in serial troponin important
– We are using 30% change in 6 hours
– 3 hour trop for high risk patients
Be aware of other diagnoses causing rise in
troponin
Non ACS causes of raised troponin
 Pulmonary
embolism
 Acute cardiac failure
 Myocarditis
 Aortic dissection
 Acute decompensated AV disease
 Renal insufficiency
BLS and ALS changes
 BLS
– New literature
 emphasising
minimal interruptions to ECM
 questioning role of early breathing interventions
– compression only CPR?
– ARC: "ANY ATTEMPT AT
RESUSCITATION IS BETTER THAN NO
ATTEMPT" and if a rescuer is unwilling
to do rescue breaths then chest
compressions are better than
nothing.”
– Revised ARC guidelines due Dec 2010
– www.resus.org.au/
BLS
– Rate of compression to breath 30:2
– 2 initial rescue breaths
– ECM 100/min (5 cycles in 2 minutes)
– Frequent rotation of rescuers – every 2
minutes
– Don’t interrupt CPR to check for signs of
life
– Use AED as soon as available
ALS for VF /pulseless VT
 Early
defibrillation for VF
 Look for alternative reversible causes
 Witnessed arrest
– Precordial thump
– Stacked shocks x 3 - 200J biphasic defib
– AEDs will only deliver a single shock
– Commence CPR ASAP
ALS for VF/pulseless VT
 Further
DC shocks for VF/VT:
– Given every 2 minutes
 Adrenaline
(1mg) IV
– 10mls of 1:10000
– Given every 3 minutes
 Securing
airway – no more than 20
seconds break in CPR
ALS - other drugs
 Antiarrhythmics
– Amiodarone drug of choice for
prolonged VF/pulseless VT
– 300mg (5mg/kg)
 Atropine,
Calcium, Bicarbonate,
Magnesium
– No evidence of benefit except in specific
circumstances
Patient in non-shockable rhythm
 Asystole/Pulseless
Electrical Activity
– CPR / Rescue breathing 30:2
– Adrenaline every 3 minutes
– Search for a reversible cause:
4
H’s and 4T’s:
 Hypoxia
 Hypovolaemia
 Hypo/hyperkalaemia
 Hypo/hyperthermia
cardiac
Tamponade
Tension ptx
Toxins / drugs
Thrombosis – pulm or
Paediatric resus
 Rare!
 Shocks:
first 2J/kg then subsequent
4J/kg
 Importance of CPR/rescue breathing
 Ratio for advanced providers 15:2
 Using IO access
Take home messages

Don’t interrupt chest compressions
– 100/min
– change regularly

Place of rescue breathing being
questioned but still in guidelines
– Ratio 30:2


DC shocks 2 minutely for VT/VF
Adrenaline 1mg IV q3min
 70
year old man presents with a
week of left loin pain, difficulty
passing urine, poor oral intake. Now
confused and febrile.
 At triage vital signs:
– P 120, BP 90/60,
– RR 28/min, sats 98% room air,
– T39.2
EGDT in septic shock
 Early
2000’s US study (Rivers)
– aggressive early resuscitation,
– Early ICU care,
– maintenance of blood pressure with
inotropes,
– Hb/haematocrit optimisation,
– Careful monitoring of oxygenation via CVC
– improved mortality 50% to 35%
Clinical Excellence Commission
Sepsis Review

Recent NSW study showed septic shock
markedly over represented in major reported
incidents
– Across all types of hosp.
– Non-recognition of sepsis
– Delays in starting treatment
 ABx
 Treatment
of poor organ perfusion
– Poor monitoring of vital signs
– Over 65 yo and after hours over represented
– Oliguria, hypotension, tachycardia +/- fever =
septic shock until proven otherwise
ARISE trial


attempting to study role of EGDT in
Australian population - RNSH lead hospital
Patients who present with:
– sepsis (T >38 or < 34 with evidence of an infection)
– BP < 90 systolic not responding to 1000mls IV fluid
or
– Lactate > 4


All get early antibiotics
Randomised into trial for EGDT vs normal
treatment
ADULT Sepsis / SIRS Guideline*
0 Hrs
Does the Patient meet the
SEPSIS CRITERIA?
SEPSIS CRITERIA
Known or Suspected Infection
PLUS:
≥ 2 SIRS criteria
 Temp ≤ 36.0 or ≥38.0°C
 Heart Rate > 90
 Resp Rate >20 or PaCO2 <32
mmHg
 WCC >12 or <4
+
Triage to Resuscitation
Room or acute area
Category 2
YES
Initiate Initial management
 Insert IV line
 Bloods / ABG & lactate
 Blood Cultures / Urine
MC&S / Swabs & CXR
 Consider LP
 IV fluids
 IV Antibiotics
 Reassess in 1 Hr
For Surgical causes contact the
Surgical Team
NO
ORGAN DYSFUNCTION
 Pale / Clammy skin
 Tachycardia / Tachypnoea
 Systolic < 90 or > 40mmHg
drop from baseline in
hypertensive pt
 Acute change in mental status
 Oliguria (<0.5 ml/kg/hr)
 Lactic Acidosis – Lactate  4
(For Elderly/ Frail patients, more
frequent reassessment may be
required)
Exit
Guideline
Refer to
admitting
team
NO
SEPTIC SHOCK CRITERIA
 Acute Circulatory failure
and
 Persistent hypotension despite
fluid resuscitation & not
explained by other causes
EVIDENCE OF ORGAN
DYSFUNCTION or
SEPTIC SHOCK
O
YES
Inform Registrar in charge







Transfer to Resus room
Insert second IV line
Second set of Blood Cultures
Coags/DIC screen
Bolus 500mls Crystalloid over 10
mins / Reassess & repeat up to
2litres Crystalloid as required +
Broad Spectrum IV Antibiotics
Insertion of IDC & hourly U/O
monitoring
Early Treatment goals (2hrs)
 Capillary Refill < 2secs
 U/O > 0.5 ml/kg/hr
 MAP >65
Contact ED Consultant for:


ICU referral and Admission
Ongoing Fluid Resuscitation
500mls Crystalloid over 10 mins /
Reassess & Repeat
Consideration of
 CVP Line Placement
 Arterial line
 Vasopressors
2 Hrs
NO
Is the Patient
achieving the Early
Treatment goals
within 2 hrs?
YES
Continue to monitor and reassess
patient. Aim to maintain vital signs.
Admit to appropriate Inpatient team /
ICU as necessary
*This is a general guideline only – it is always important to consider the individual requirements of
the patient and to give consideration to other clinical causes
Adapted from Manly Hospital Sepsis guideline, Drs Phipps, Rochford, Franks & LKirkwood
 70
yo patient with urosepsis:
– Recognition at triage – resus bed
– Aggressive fluid resuscitation to restore
BP > 90 systolic – may need 2-4 litres
– After 1000mls NS if BP< 90 or lactate >
4 entered into ARISE trial
– Early antibiotics essential – broad
spectrum ABx should be given within
one hour
– Early inotropic support eg noradrenaline
– Look for a source – urine, abdominal,
chest, cannulas, cellulitis, others
Take home messages
 Think
about sepsis as a diagnosis –
subtle early signs
 Urosepsis, hypotension dangerous
combination
 Early antibiotics and resuscitation
Paediatrics - dehydration
 DOH
CPG: Management of Children
with Gastroenteritis
http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf
 Major
themes:
– Rehydration:
 Less
use of IV fluids
 More emphasis on oral rehydration
– If child requires IV:
 Use
of NS + 2.5% glucose rather than hypotonic
solutions
Oral rehydration
 Oral
rehydration solutions
– Hydralyte, Gastrolyte (no sports drinks,
fruit juice, soft drinks)
 Parent
should offer 0.5mls/kg every
5 minutes eg with a syringe
– Charted by parent including vomits, U/O
 Parental
attention, persistence
encouraged by staff
 Rapid rehydration via NGT an option
– ORS via Kangaroo pump @ 10mls/kg/hr
x 4hrs
Medications in gastroenteritis
 Antiemetics:
– Ondansetron: some evidence of benefit
– No evidence for prochlorperazine or
metoclopramide
 Antidiarrhoeals
– No evidence
 Antibiotics:
– Rarely required
/ antimotility agents
IV therapy
 Who
for?
– Mild (3%) - Reduced UO, Thirst, Dry
mucous membranes, mild tachycardia
– Oral only required
– Moderate (5%) - Dry mucous membranes,
tachycardia, abnormal respiratory pattern,
lethargy, reduced skin turgor, sunken eyes
– try oral first if fails go to IV
IV therapy
– Severe (10%)
– all of above, poor perfusion: mottled, cool
limbs/Slow capillary refill/Altered
consciousness
 Shock:
thready peripheral pulses with marked
tachycardia and other signs of poor perfusion
– IV or IO therapy, 20mls/kg bolus NS
Which IV solution?
 NS
plus 2.5% or 5% glucose
 Reduced risk of hyponatraemia
 All get an EUC, BGL
 Low BGL < 3.5 or formal BSL < 2.6
– extra glucose bolus IV
 Rehydration:
rapid over 4 hours or
standard over 24 hours
Who gets admitted?
Go home
 Most Mild Dehyd
– Must have passed
urine, able to take
some fluid
– occasional social
admission
– GP review in 24-48
hours

Moderate who pass
TOF go home
Admitted
 Mild < 6mths
 Moderate who fail
TOF
 any severe get
admitted for IV
therapy
 Any question about
diagnosis
 RNS doesn’t do
acute paed abdo
surgery < 14yo eg
appendicitis,
torsion testis
Red flags

Gastroenteritis = V + D + fever
– Beware vomiting in the absence of diarrhoea

Differential diagnosis large:
– Appendicitis
– Intussusception < 2yo








Beware:
Abdominal distension
Bile-stained vomiting
Fever >39ºC
Blood in vomitus or stool
Severe abdominal pain
Headache
n
n
n
n
n
n
n
Reintroduction of diet
 BF
should continue with ORS
supplement if needed
 Resume N diet as soon as vomiting
stops
 Fact sheet on CHW website
 Some evidence probiotics helpful
 2yo,
presents in the late evening, 2
days of upper respiratory symptoms,
barking cough
 Tonight increasing, cough, agitation,
stridor
 Immunised
 On exam sitting forward, alert but
not interacting much, insp. stridor at
rest, intercostal recession, accessory
muscle use
 Not toxic looking
 Hopefully hear the cough!
 Moderate/severe
croup
 Straight into resus area
 Monitor pulse and saturations P140, RR 36, sats 99%
 Nebulised adrenaline - 5mg of
1:1000
– Rapid action, lasts 2 hours
 Dexamethasone
mg/kg
– IM (or po) 0.3
Paeds - croup
 New
DOH clinical practice guideline
in Aug 2010:
http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_053.pdf
 Mostly
6-36 months
 Mostly viral - RSV, parainfluenza
 Spasmodic croup – atopic group,
sudden onset, improve quicker,
recurrent
Worry if:
 Rising
pulse, RR
 Less interactive, more
agitated/anxious, sleepy
 More respiratory distress
 Cyanosis/pallor or low O2 sats a
late sign
Disposition

•
If settle after neb Adrenaline
– 4 hours obs and home
– Expect illness last 4-5 days
– GP review
– Mostly only need one dose steroids - Use of
steroids has dramatically decreased admission
and intubation rates
Admit
– If further neb Ad needed
– Age < 6 mths
– Any uncertainty about dx
 Differential
diagnosis:
– Less than 3 months think ? Structural
/congenital problem
– Foreign body
– Epiglottitis
– Bacterial tracheitis
Croup – take home messages

Nebulised adrenaline 0.5mls/kg to
5mls of 1:1000 (5mg) for mod or
severe. At least 4 hours obs needed.
 Steroids
– one (or two) doses only
has reduced admission/complication
rates
A 4 month old child presents snuffly for
the last couple of days, occasional
coughing, low grade fevers. Breast
feeding poorly, decreased wet nappies.
Today mum has noticed breathing
rapidly, seems to be working hard.
On exam: pulse 160, RR 40, nasal
flaring, intercostal recession, sats 92%
room air
Chest auscultation: fine crackles on
inspiration, occasional exp wheeze.
Most likely diagnosis?
Management?
Paeds - bronchiolitis
 DOH
CPG available
 Mostly children less than 12 months
 RSV causes > 90%
 Clinical diagnosis
– No CXR unless another dx eg bacterial
pneumonia suspected
Differential dx in this case?
 Acute
asthma – less than 12 months,
not recurrent episodes
 Pneumonia – not toxic, URTI sx
 Bronchial foreign body – infective
history, not sudden onset in well
child
 Pertussis – cough not prominent, no
contacts
 Cardiac failure – usually earlier, well
child till now, normal growth
Management of bronchiolitis
 Self
limiting viral illness – red flags:
– Less than 3 months, preterm/small –
risk of apnoeas
– Underlying heart or lung disease
– Feeding poorly/dehydrated
– Apnoeas
– Resp distress – tiring, marked chest wall
retractions, grunting, low O2 sats
 Treatment
mainstays:
– Oxygen, adequate hydration
– No role for bronchodilators, steroids or
antibiotics
How sick is this child?
A 4 month old child presents snuffly for
the last couple of days, occasional
coughing, low grade fevers. Breast
feeding poorly, decreased wet nappies.
Today mum has noticed breathing
rapidly, seems to be working hard.
On exam: pulse 160, RR 40, nasal
flaring, intercostal recession, sats 92%
room air
Chest auscultation: fine crackles on
inspiration, occasional exp wheeze.
How sick is this child?
A 4 month old child presents snuffly for
the last couple of days, occasional
coughing, low grade fevers. Breast
feeding poorly, decreased wet nappies.
Today mum has noticed breathing
rapidly, seems to be working hard.
On exam: pulse 160, RR 40, nasal
flaring, intercostal recession, sats 92%
room air
Chest auscultation: fine crackles on
inspiration, occasional exp wheeze.
Moderate bronchiolitis
 Admit
for:
– O2 to keep sats > 95%
– Look at child feed: IV fluids vs oral
rehydration
– Close observation for apnoeas
– NPA for RSV
– no CXR
 Home
when normal feeding, little or
no resp distress, not hypoxaemic
Head Injury – Case 1
18yo who presents after a having a
few drinks, falling with a short LOC
less than a minute. Now alert and
orientated but complaining of
dizziness and a headache, vomited
once. Haematoma over forehead.
 Does he need to come to hospital?
 Does he need a CT scan?
 Follow up needed?
 Time off sport?
Head Injury – Case 2
 72
year old on warfarin for chronic
AF. INR 2.3 last week. Simple fall at
home with a scalp lac needs
suturing. Possible short loss of
consciousness, amnesic for event.
 Does
he need to come to hospital?
 Does he need a CT scan?
 Follow up needed?
Mild head injury
Low Risk Factors
 LOC < 5 minutes
 Amnesia < 30 min
 GCS 15 at 2 hours
 No focal neuro deficit
 No evidence for skull fracture
 No seizure post event
 Nausea or single vomit
 Mild headache
 Age < 65
 No coagulopathy
 Isolated HI
 No drug or alcohol ingestion
High Risk Factors
 LOC > 5 minutes
 Amnesia > 30 min
 GCS < 15
 Focal neuro deficit
 Possible skull fracture
 Post event seizure
 2 or more vomits
 Severe headache
 Age > 65
 Coagulopathy
 Multiple injury/ dangerous
mechanism
 Drugs or alcohol
 Representation
Indication for CT scanning
and prolonged observation
Mild head injury
4 hours observation
and home if:
- normal cognition
and alertness
- N CT or no
indication for a CT
- should be a
responsible person
at home
- given HI advice
sheet
- be able to return
Keep in hospital if:
- clinical symptoms
not improving at 4
hours
- abnormal CT scan
- use judgement
- elderly
- coagulopathy
- intoxicated
- social issues
 Case
1 - 18yo – 4 hours obs and
home if well to parents with HI
advice card
 Case 2 - CT scan head, check INR,
observe. May need overnight stay.
CT radiation effective dose


Chart giving effective dose in
mSv/CXRs/cigarettes/hours of plane travel
Eg CT head
= 2.3 mSv
= 115 CXR
= 1 yr of background
radiation
= 920 cigs
= 329 hours of plane travel
CT radiation effective dose
Lumbar spine XR = 65 CXR
 CT chest = 400 CXR
 CT abdo/pelvis = 500 CXR

Increase in cancer risk under 40yo
 Head CT on a 1yo may give lifetime
cancer risk of 1:1000
 1 mSV = 500CXR = smoking 400 cigs =
1:17,000 ca risk

 74
year old presents with a episode
of left arm weakness lasting 30
minutes which has now resolved.
 P 72 regular, BP 145/95
 Not diabetic, no cardiac history
 You diagnose a TIA. What is his risk
of having an early acute stroke?
ABCD2 Score for TIA

Age ≥ 60?
Yes +1
BP ≥ 140/90 mmHg at initial evaluation?
Yes +1

Clinical Features of the TIA:

– Unilateral Weakness
– Speech Disturbance without Weakness


+2
+1
Duration of Symptoms? 10-59 minutes
≥ 60 minutes
Diabetes in Patient's History?
+1
+2
Yes +1
High risk TIAs
 Score
of 3 or above:
– Start aspirin (as with all TIA)
– Early specialist investigation in next 24
hours ie hospitalisation
– TIA clinic
 Why?
– New onset TIA - 10% risk of stroke in
next 90 days however half will have
their stroke in the first week
Acute stroke management at
RNSH
IV TPA is offered for acute
thrombotic/embolic stroke able to be
investigated and treated within 3 hours
 IA thrombolysis is offered up to 6 hours
 Time is from the time last seen normal
 ED arranges CT, rings stroke team,
neurologist makes decision and
administers
 Stroke unit/HDU bed after procedure

That’s All Folks!