UMEM Educational Pearls

Ketorolac: an NSAID that gained popularity since it is not an opioid, has excellent anti-inflammatory/analgesic effects and is given IM or IV. Also has been used in renal colic secondary to smooth muscle relaxation (Prostaglandin mediated) in the ureters. You should know:

• When given IV or IM still causes PUD and has caused GI perforations.
• Renal Insufficiency is larger concern with this NSAID than others.
• Consider misoprostol for GI complications.
• Use for acute pain, limit the number doses given and don't prescribe for more than 3 days. I generally don't prescribe it at all, use another NSAID for outpatient treatment.

Corelli et al. Renal Insufficiency and ketorolac. Ann Pharmacother. 1993; 27(9): 1055-7

• Note that the use of steroids within 8 hours of injury for SCI is not routinely practiced worldwide and was initially based on a controversial study, the National Acute Spinal Cord Injury Study (NASCIS I & II).

• The approved methylprednisolone dose is 30 mg/kg IV bolus over 15 min, followed by 5.4 mg/kg/h over 23 h; begin IV infusion 45 min after conclusion of bolus.
  

Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of
methylprednisolone or naloxone in the treatment of acute spinal-cord injury.
Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med
1990 May 17; 322(20): 1405-11. 

Critical Care Monitoring - End-Tidal CO₂

• End-tidal CO₂ (ETCO₂) monitoring is used to verify ETT placement, monitor procedural sedation, traumatic brain injury, and to estimate prognosis during cardiopulmonary resuscitation
• ETCO₂ concentration typically underestimates P_aCO₂ by 4-5 mmHg in healthy non-intubated patients
• This relationship is less reliable in critically ill patients secondary to shunt, altered alveolar dead space, and inadequate ventilation
• While a low ETCO₂ value is less useful in the critically ill, a high value almost always correlates with an equal or higher P_aCO₂ value
• This can be useful when monitoring conditions such as status asthmaticus, CHF, or increased ICPs in which a high ETCO₂ may signal the need for additional aggressive treatment

Secondary Causes of Hypertension

Although not that common, consider the following (with accompanying history and/or physical examination findings) in patients with hypertension:

• Renovascular hypertension (renal artery stenosis)-abdominal bruits, older patients
• Pheochromocytoma-episodic flushing, htn, headache, new onset htn in younger patient
• Cushing's disease-abdominal striae (not very specific in Baltimore), new onset hyperglycemia, classic electrolyte abnormality: hypokalemic metabolic alkalosis
• Primary Aldosteronism-new onset htn and hypokalemia
• Hyperparathyroidism-htn and hypercalcemia
• Aortic coarctation-younger patients (even young adulthood), unequal upper and lower extremity blood pressures
• Sleep apnea-typically obese patients (but not necessarily), excessive snoring, day time sleepiness (again, not specific)
• Thyroid disease (hypo or hyper)-signs and symptoms of thyroid disease

Although most of the time the patient will end up having essential hypertension, these entities should at the very least be considered.

Journal of Hypertension 2007

The insurance companies are always trying to down code our visits so that they can save money, and unless we diagnosis the patients with the appropriate jargon it can cost us a lot of money.  Here are some coding suggestions as written by Sharon Nicks, President and CEO of Nicks & Associates in EP Monthly .

The moral of this pearl is try to use words like Acute, Severe, Sudden, Serious, Distress, Pain, or Fever so that it is clearer to the insurance companies that the patient warranted a visit to a physician (i.e.: an ED) before their PCP could see them in a week.

What do you do if a patient with an AICD presents to the ED with a shock? 

If the patient receives a single shock and is otherwise asymptomatic and fine, there is probably no need for intervention (or even an ED visit). For the patient in the ED, monitor them and discuss with their cardiologist. Consider checking some labs, but emergent pacer evaluation is not generally necessary (unless there are other concerning issues--abnormal rhythms on monitor, complaints of lightheadedness and preceding chest pain, etc.). You should manage and treat the patient for other symptoms and signs, but not for the shock itself.

If the patient received multiple shocks, however, device interrogation is generally required. Also search for the underlying cause--ischemia, electrolyte abnormalities, etc. Bear in mind that most of the time, multiple shocks are later deemed to be inappropriate (device error).

Post-shock ECG will likely show ST segment changes but they normalize within 15 minutes.

15-20% of the time there will be some TN-I elevation for up to 24 hours due to a shock.

Child Abuse

• An estimated 2,815,600 children are harmed or endangered by their caretakers annually
• Fractures are among the most common injuries seen in these children and are frequently highly specific for a diagnosis of abuse.
• No fracture is pathognomonic of abuse
• Some are suggestive:
  • Spinal fx
  • Digital fx
  • Complex skull fx
  • Spiral Long Bone fx
  • Scapular fx
  • Sternal fx
  • Metaphyseal fx
  • Periosteal separation
• Some are more specific:
  • Posterior Rib fx
  • Acromioclavicular Fx
  • Multiple fxs of different ages
• Infants < 1 year of age with fractures have a high prevalence of abuse.
  
  C Y Skellern, D O Wood, A Murphy, M Crawford (2000). Non-accidental fractures in infants: Risk of further abuse. Journal of Paediatrics and Child Health 36 (6), 590–592.
  
  K. Nimkin, P. Kleinman. IMAGING OF CHILD ABUSE. Radiologic Clinics of North America, Volume 39, Issue 4, Pages 843-864
   

Lithium: Hypothyroidism (5-15% of pts) and goiter (37% of pts), mechanism unclear

Amiodarone (37% Iodine by weight): Hyper or Hypothroidism

Beta-Blockers: by blocking peripheral conversion of T4 to T3 cause hypothyroidism

Corticosteroid: same as beta-blockers but can also cause transient thyrotoxicosis (Jod-Basedow effect)

Iodine, Iodinated contrast, radiactive iodine all can cause hypothyroidism but iodinated contrast material can actually induce thyrotoxicosis and thyroid storm from unknown mechanism.

• IA lytics for stroke emerged to increase the 3-hour window for treatment.

• IA tPA may also be indicated for:

              --  candidates with severe neurological deficits (NIHSS score > 10)

              --  candidates with a recent history of major surgical procedures

              --  candidates with occlusion of major cervical or intracranial vessels

• Early IA lytic trials utilized urokinase and tPA, usually within a 6-hour window, though some reports extended the window to 12 hours for posterior circulation ischemic strokes.

• Studies have shown that THERE IS NO SIGNIFICANT DIFFERENCE IN RECANALIZATION RATE, SYMPTOMATIC HEMORRHAGE, AND NIHSS FOR IV PLUS IA LYSIS VERSUS IA LYSIS ALONE.

Zaidat OO, Saurez JL, Santillan C, et al.  "Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion."  Stroke 2002, 33:  1821-1826.

Bellolio MF, et al.  "Stroke Update 2007:  Better Early Stroke Treatment (BEST)," Emergency Medicine Practice, Augst 2007, Volume 9, Number 8.

Unilateral Pulmonary Edema

• unilateral pulmonary edema is a well recognized and well documented entity
• although there are several causes, the most likely scenarios for EPs are severe mitral valve insufficiency, aortic dissection (with compression of the pulmonary artery), airway obstruction, and heroin use
• even though radiology will read the xray as likely pneumonia, if the story/exam fit with edema then treat as such

Subarachnoid hemorrhage: Unilateral or bilateral headache?

Pretty good evidence exists that most patients with subarachnoid hemorrhage will have a bilateral headache.

In fact, unilateral headache is helpful in the history in ruling out SAH in most cases. Presence of an unruptured aneurysm, however can be present with a unilateral headache.

J NeuroSurg 2006

Women are more likely to present with atypical presentaitons for ACS.

Women are more likely to present without chest pain, but instead with middle or upper back pain, neck pain, jaw pain, dyspnea, vomiting, indigestion, weakness/fatigue, loss of appetite, cough, or palpitations than men.

EMTALA (Part Two)

• Hospitals may not delay screening examinations to inquire about payment.
• Emergency departments should not contact HMOs before completion of the screening examinations and stabilizing treatment.
• Triage does not constitute a MSE.
• For the purposes of EMTALA, a patient has come to the ED when he arrives on hospital property.
• EMTALA does not apply to offsite clinics unless (1) the clinic is licensed as an emergency department, (2) the hospital advertises the clinic as an ED, or (3) during the preceding year, 1/3 of all outpatient visits were for EMCs.
• EMTALA does not apply to inpatients, unless the hospital admitted the patient in bad faith.
• Since Nov. 2003, a specialty represented at the hospital does not always have to be on call.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.

The Premature Infant Delivered in Your Department

An ode to my final NICU Call… just because you don’t work in a Pediatric ED, doesn’t mean you won’t encounter premature infants.

What do you need to remember when a premature infant is born in your ED (or the ambulance / cab / car)?

• Warm them and keep them warm
  • Cold stress, often overlooked, worsens acidosis and decreases surfactant function.
• Neonatal Respiratory Distress Syndrome manifests as cyanosis, tachypnea, grunting, retractions, and/or respiratory failure.
  • CXR has “ground-glass” appearance and air bronchograms
  • It is due primarily to inadequate surfactant.
  • Early administration of surfactant has proven to improve outcomes
  • Contact a neonatologist ASAP and determine if you have easy access to a surfactant product (it really is an amazing therapy).
  • You administer it down the ETT… you’ve likely intubated them by now.
• Fluids
  • Fluid Boluses are done with normal saline (10ml/kg)
  • Maintenance Fluids should be D5W or D10 (no electrolytes at first!)
• Antibiotics
  • One of the most common reasons for premature delivery is neonatal infections… don’t be stingy, start Amp/Gent (consider acyclovir) and send blood cultures at least.
     

Everything you need to know about anti-emetics, mechanism of action, potency and toxicity:

1) 5-HT3 Blockers - Ondansetron, Granistron

- The most potent anti-emetic, only toxicity is really cost

2) Dopamine Blockers - Metoclopramide

- Can titrate to high doses, causes dystonia, akathisia and mild QT prolongation

3) Anticholinergic - Promethazine, meclizine, diphenhydramine

- Cannot titrate, most sedating, urinary retention in elderly, mild QT prolongation

• 325 mg of aspirin should be given within 48 hours of symptom onset in ischemic stroke; while its good form to give it when appropriate while the patient is still in the ED, per recent guidelines, it is not imperative.

• Aspirin should not be given to stroke patients who will receive tPA.

• Prior administration of aspirin is not a contraindication to giving tPA, however.

• If dysphagia and/or aspiration risk is suspected, give 300 mg of aspirin per rectum.

2007 AHA and ASA Guidelines for the Early Management of Adults with Ischemic Stroke and Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults.

ECG gating CTs for aortic dissection/aneurysm rule out

• Increasing evidence supports the use of ECG gating when performing CTs to rule out aortic pathology-dissection and aneurysm.
• The most common artifact on CT is a "psuedo-dissection" flap caused by excessive motion at the aortic root. Administering beta blockers before CT will limit this motion and decrease the chance of this false positive.

AJR 2007

Massive hemoptysis

• Massive hemoptysis is defined by most as the expectoration of > 600 ml in 24 hrs
• Chronic lung inflammatory disease and bronchogenic CA are the most common causes in the US
• TB remains the most common cause worldwide
• The bronchial artery causes approximately 90% of cases
• Get a STAT portable and place the patient in the lateral decubitus position toward the affected side (this is theorectical and has not been proven)
• Options for bleeding control can include endobronchial tamponade methods(pulmonary), bronchial artery embolization (interventional radiology), and emergent surgical resection (surgery)
• Bronchial artery embolization is now the most successful non-surgical treatment of massive hemoptysis

Rheumatic heart disease (RHD) has traditionally been considered the most common underlying condition predisoposing to infective endocarditis. While RHD is still common in developing countries, its prevalence has declined and "mitral valve prolapse is now the most common underlying condition in patients with infective endocarditis."

(from AHA Guideline on Prevention of Infective Endocarditis, Circulation, October 9, 2007)

EMTALA (Part One):

• The three general duties created by EMTALA are to provide (1) an appropriate medical screening examination (MSE), (2) stabilizing care, and (3) appropriate transfer of unstable patients.
• An appropriate MSE is an exam comparable to similarly situated patients (ie: non-discrimatory).
• Patients are stable if it is reasonably likely they will not deteriorate during a transfer.
• The duty to stabilize arises only if the physician diagnoses an emergency medical condition (EMC).
• Once stabilized, the hospital and physician have fulfilled their duties under EMTALA.
• The transfer criteria only apply to unstable patients.
• Receiving hospitals may get fined if they fail to report an inappropriate transfer.
• A hospital with specialized capabilities must accept appropriate transfers if it has the capacity to care for the patient.

Thanks to Larry Weiss, MD, JD

Disclaimer: This information does not constitute legal advice, is general in nature, and because individual circumstances differ it should not be interpreted as legal advice.The speaker provides this information only for Continuing Medical Education purposes.