UMEM Educational Pearls

The Alcoholic Patient in the ED

Well, we have all been there....EMS rolls in with "another drunk guy" found down in the street. The nurses tell you, "he is here all the time...he is just drunk." You should be scared any time you hear this phrase uttered. Always be a little nervous about this group of patients and you won't fall victim to many of the pitfalls that some of us have experienced.

Pearls and Pitfalls in Caring for the Intoxicated Patient in the ED:

• Get a glucose early. Many of these patients are hypoglycemic when they arrive.
• Assume the worst and NEVER tell yourself or others,"He's just drunk." That statement is the kiss of death. Always assume there is occult trauma present. Did they fall and sustain a head bleed, splenic injury, hip fracture?
• Reevaluate during your shift. There is nothing worse than placing an intoxicated patient in a room and ignoring them, only to find out that hours (or shifts) later that they won't wake up.
• Consider a head CT. Although you can't scan them all, have a low threshold to image them. They fall all the time, and you will be surprised at how many subdural hematomas you pick up when you scan this group of patients. If you don't image, perform reassessments frequently during your shift.

T-wave inversions are commonly found in many conditions other than ACS. Many pulmonary conditions, elevated intracranial pressure, LVH, bundle branch block, and young age are associated with T-wave inversions.

T-wave inversions are especially notable in patients with pulmonary embolism, and one study identified a key difference in T-wave inversion patterns in PE vs. ACS: T-wave inversions in leads III and V1 simultaneously were far more likely to be assocaite with PE, whereas the presence of T-wave inversions in I and aVL were almost always ACS.

A key takeaway point is to maintain a broad differential even in the presence of T-wave inversions...it's not necessarily just ACS!

[ref: Kosuge M, et al. Electrocardiographic differentiation between acute PE and ACS on the basis of negatie T waves. Am J Cardiol 2007;99:817-821.]

Manibular Dislocations:

• Mandibular dislocations can be extremely difficult to reduce at times.
• The classic method of reducing a mandible dislocation is for the provider to wrap his thumbs in guaze (to prevent them from being bitten), and while placing his thumbs bilateraly as far posterior on the mandible as possible, he applies downward, and then posterior pressure to reduce the dislocation.
• Significant muscle spasms can result from the dislocation, requiring procedural sedation, but even with sedation it can be very difficult if not impossible to reduce the mandible.
• Dr. Cheng's article, referenced below, describes a new technique, where the provider use both of his thumbs to press down on a single side of the mandible posterior until the side reduces.
  • For a bilateral dislocation, the technique would be to reduce one side and then the other.

Some authors also recommend using rolled guaze to hold the patient's mouth shut so that they do not inadvertantly dislocate their jaw a second time if they happen to yawn while awakening from their sedation.

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Patients who present to the ED with an elevated INR due to vitamin K antagonists many times do not need to be reversed.  Simply holding a dose is all that is usually necessary for patients with an INR < 9.  Fortunately, guidelines published in CHEST are available to help guide management.
 

• INR: >Therapeutic to 5.0 with no bleeding - Lower warfarin dose, or omit a dose and resume warfarin at a lower dose when INR is in therapeutic range
• INR: >5.0 to 9.0 with no bleeding - Omit the next 1 to 2 doses of warfarin, monitor INR more frequently, and resume treatment at a lower dose when INR is in therapeutic range, or omit a dose and administer 1 to 2.5 mg oral vitamin K.* [*This option is preferred in patients at increased risk for bleeding (eg, history of bleeding, stroke, renal insufficiency, anemia, hypertension.]
• INR: >9.0 with no bleeding - Hold warfarin and administer 5 to 10 mg oral vitamin K. Monitor INR more frequently and administer more vitamin K as needed.
• Any INR with serious or life-threatening bleeding - Hold warfarin and administer 10 mg vitamin K by slow IV infusion; supplement with prothrombin complex concentrate, fresh frozen plasma, or recombinant human factor VIIa, depending on clinical urgency. Monitor and repeat as needed.
   

Reference:

Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.

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• Patients who have recently undergone aneurysmal coiling commonly present to the ED with complaints of new or worsened focal neurologic deficits that may be suggestive of stroke.

• Aneurysms can be stabilized by clipping or coiling them.  Coiling is performed in a minimally invasive manner, wherein platinum (a material that can be visualized radiographically and is flexible) coils are deployed into the bulb of the aneurysm, via femoral artery cannulation.

• The relative risk of mortality or morbidity at one year post-coiling was found to be 22.6% less than that associated with clipping.  The latter is an older, more invasive technique requiring craniotomy and direct manipulation of the brain.

• Hemorrhage is a less likely complication related to aneurysm coiling, thus your indication for a non-contrast Head CT in these patients would most appropriately be "rule out infarct" rather than "rule out bleed." 

• Brain infarct is the more common complication of this treatment, and results from the accidental embolization of plaque during the coiling procedure.

• Here are a couple of great links with illustrated overviews of the process of coiling, including a real time You Tube clip:
  
  http://www.brainaneurysm.com/aneurysm-treatment.html
  
  http://www.youtube.com/watch?v=Mvy8g_oDbbk

 

Transient Hypotension and Mortality in Sepsis

• Not surprisingly, septic ED patients with persistent hypotension despite fluid resuscitation have increased mortality.
• What about the more common scenario of septic ED patients who have a transient drop in their BP?
• Recent evidence suggests that ED patients with sepsis who have non-sustained decrease in their BP (SBP < 100 mm Hg) have a 3-fold increased risk of in-hospital mortality compared with those who maintain arterial pressure.
• Take Home Point: Any drop in BP in a septic patient, even if it responds to fluids, portends a higher mortality.  Be vigilant and aggressively resuscitate these patients.

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Some Pearls on ED Teaching:

• Don't teach so much. Limiting the number of points taught will lead to increased retention. Quality, not quantity.
• Make sure your learners are "with you." If the learner isn't attentive, forget it. Move and and return to teaching when the learner is ready. You are wasting your time if they are paying attention.
• Be creative in adapting your teaching style when it is busy. You don't have to be at a dry erase board drawing metabolic pathways (sorry Fermin) to be teaching. Simply discussing your thought process outloud is a great way of teaching "on the fly."
• Be flexible and remember: the focus should be on the learner (what they get out of it) and not the teacher. Many forget that when they teach in the ED.

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• Rates are highest for children <5yrs and between 15-24 yrs old.
• Most of pathology is related to duration of asphyxia from time of submersion until adequate respiration is restored.
• The brain and heart are most vulnerable to anoxic and ischemic injury.
• Prognosis for near-drowning depends primarily on the degree of brain anoxia.
• Prolonged submersion (>25 min); apnea or coma at presentation to ED; and initial arterial pH <7.0 are all poor prognostic indicators.
• 96% of victims who require <10min of CPR survive with no or only mild neurologic impariment.

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Whereas only 6% of young patients with PE present with syncope, 15-20% of elderly patients with PE present with syncope. The simple takeaway point is that whenever an elderly patient presents with syncope, always strongly consider the possibility of PE, even though they may lack classic pleuritic chest pain.
Count that respiratory rate for an inexpensive clue!

 

 

Shoulder Dislocations -- Treatment

• Shoulder dislocations once reduced have typically been treated by placing the arm in a sling and swathe which holds the shoulder in adduction and internal rotation. 
• However, several studies have now shown that placing the arm in a splint with the shoulder adducted and in 10 degrees external rotation helps to prevent recurrent shoulder dislocation. 
• Patients should remain in the brace/split for 3 weeks.
• External rotation is not recommended if there is an associated fracture.
• Some commerical splints are now available to hold the shoulder in external rotation, however, you can make a small strut with plaster or fiberglass to achieve the same result.

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Oseltamivir (Tamiflu)

• Has low protein binding and does not inhibit CYP450 (resulting in a low incidence of drug interactions)
• Requires dosage adjustment with creatinine clearance of < 30 ml/min
• Does not require dosage adjustment in patients with liver failure or the elderly
• Most common adverse effects are nausea and vomiting
• Serious effects include anaphylaxis and skin reactions. Neuropsychiatric effects reported include hallucinations, delerium and abnormal behavior
• It may be administered to infants and children due to the high potential morbidity associated with influenza

 

For complete indications and dosing: www.cdc.gov/h1n1flu/recommendations.htm

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• Syncope is defined as a transient loss of consciousness and accounts for an estimated 1% to 3% of emergency department (ED) visits.
   
• While syncope typically is of benign origin, it occasionally signals significant mortality and morbidity, which can make determining the disposition of syncope patients a challenge.
   
• The San Francisco Syncope Rule (96% sensitivity, 62% specificity) is a clinical tool used to determine which syncope patients are at low risk for a short-term (7-day) serious outcome (i.e. MI, arrhythmia, PE,  stroke, SAH, significant hemorrhage, any condition causing or likely to cause a return ED visit or hospitalization).
  Specifically, absence of all of the following 5 findings (acronym CHESS) were associated with no serious outcome within 7 days of the syncopal episode according to this rule:
  • Congestive heart failure
  • Hematocrit less than 30
  • EKG Abnormalities
  • Systolic BP less than 90
  • Shortness of breath
     
• While this decision rule, in addition to one's clinical skill, may be used as a guide in caring for and dispositioning syncopal patients, know that its ability to be extrapolated to a general population of ED patients has yet to be validated.

 

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Heparin for Maintaining Arteral Catheter Patency ?

• Arterial catheter placement is common in many critically ill ED patients.
• Typically, a heparin solution is used in arterial catheters based on the belief that it helps to maintain catheter patency.
• In one of the most recent studies (referenced below), the use of a heparinized solution did not improve the functionality, or increase the duration of patency, of arterial catheters when compared to a saline solution.
• As the incidence of heparin-induced thrombocytopenia (HIT) continues to increase, it is worth noting that the routine use of heparin to maintain arterial catheter patency is not well supported by the literature.

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With few exceptions, always assume that elderly patients presenting to the ED with an acute illness are very dehydrated. Here are a few reasons why the elderly patient, even on a normal day, may be mildly dehydrated:
1. The elderly have been shown to have decreased total body water.
2. The elderly have a decreased thirst response.
3. The elderly have a decreased renal vasopressin response.

Given these issues, when an elderly patient develops a systemic illness (especially pulmonary process), they lose even more fluid via insensible losses. By the time they arrive in the ED, unless they are presenting because of overt pulmonary edema, they almost always will benefit from generous IV fluid administration.

Amal

Nursemaid Elbow:

It is typically taught that the way to reduce a nursemaid's elbow is to hold the elbow at 90 degrees, then firmly supinate and flex the elbow. Place your thumb over the radial head and apply pressure as you supinate.(Taken from Sean Fox's Pearl on 7/20/2007)

However, there is a growing body of evidence that is showing that hyperpronating the forearm actually has a higher success rate on first attempt, is easier to perform, and is associated with less pain then supinating the forearm.  The overall reducation rates where similar for both methods.

The hyperpronation method consists of hyperpronating the forearm and then flexing the elbow.  Since the child tends to already hold their arm in partial pronation, the hyperpronation technique tends to need less force and has been associated with less pain.

 

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• The majority of those afflicted with bell palsy experience neurapraxia or a local nerve conduction block, which usually predicts a prompt and full recovery.  80% to 90% of Bell Palsy patients experience recovery without any noticeable disfigurement within 6 weeks to 3 months.

• Some Bell Palsy patients experience axonotmesis, disruption of the axons, which increases their risk of an incomplete recovery.

• One is at higher risk of developing sequelae in the following scenarios: 

          --  Age greater than 60 years

          --  Diabetes

          --  Decreased taste or salivary flow on the affected side

          --  Complete paralysis

• Common post-Bell Palsy sequelae that you may see clinically include:

          --  Synkinesis - abnormal contracture of facial muscles with smiling or

               closing eyes; may cause slight chin movement with blinking, eye closure

               with smiling, contracture around mouth with blinking.

          --  Crocodile tears - lacrimation while eating.

          --  Hemifacial muscle spasms - tonic contractures of affected side of face, 

               rare, often seen during times of fatigue, stress, or while sleeping.

 

NICE-SUGAR and Glucose Control in the Critically Ill

• Hypergycemia is associated with increased morbidity and mortality in hetergeneous populations of critically ill patients.
• Over the past few years there has been great interest in aggressively controlling glucose through the use of continuous insulin infusions.
• Results of recent trials and meta-analyses, however, question the benefit of tight glucose control and highlight the marked increase in severe hypoglycemia rates.
• Recently, the results of the NICE-SUGAR study were published, the largest trial to date (6000 patients)evaluating intensive vs. conventional glucose control in the critically ill.
• Investigators found an INCREASED mortality among adults randomized to intensive glucose control
• Given the lack of benefit, potential harm, risks of severe hypoglycemia, and resource utilization, intensive glucose control should not be a therapy routinely implemented in the ED.

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Transvenous pacing

We had a very interesting case the other day in the ED. A 60 yo male presented after a syncopal episode. After arriving in the ED he was awake (with a pulse of 50) but then became asystolic, without warning. He then woke up and 10 minutes later became asystolic again. He then woke up again. So, we decided to put in a transvenous pacer.

Some considerations when putting in a transvenous pacer:

• You need to use a small cordis (e.g. 6 French)
• Right IJ is the preferred approach so that when the balloon is inflated you will have easy entry into the right heart
• You will need transvenous pacing wires, obviously.
• Once you open the wire kit, you will find 2 adaptors that fit over the two ports of the pacemaker wire. Snap them on, then these connect to the ventricular leads of the pacer box-ignore the atrial side. Here is the key: the POSITIVE lead connects to the PROXIMAL port on the pacemaker (PROXIMAL=POSITIVE) and the distal lead connects to the distal port.
• Turn the pacer on then set rate to 80 or so. And start the mAmp at 20.
• Advance the wire through the Cordis and after the wire has cleared the Cordis, blow up the balloon with a syringe and lock it.
• The key is in determining capture: While the patient is on the monitor, and as the wire is being slowly advanced, look for pacer spikes and the development of wide complexes. This indicates electrical capture. Be sure to check for mechanical capture by checking the patient's pulse.
• After capture, the mAmps can be turned down to the capture point.
• DON'T forget that transcutaneous pacing is clearly the first option as this is easy to initiate.

 

Post-cardiac arrest care of patients is a hot topic in the resuscitation literature and is gaining increasing attention. We've discussed induced hypothermia; another important intervention is to apply the concepts of goal-directed therapy for these patients. The goal is to optimize MAP (> 65 mm Hg) and provide IVF and pressors when needed. Look for more literature on this in the coming year. Also, for more on this topic, be sure to listen to the June EM Cast, in which Dr. Evie Marcolini will be discussing post-cardiac arrest care of patients.

Elbow Dislocation

• The elbow is the second most commonly dislocated joint after the shoulder in adults. 
• It is the most commonly dislocated joint in children.
• 90% of all elbow dislocation are posterior.  A considerable amount of force is required to dislocate the elbow so be highly suspicous for associated fractures of the radial head, or coronoid process of the ulna. 
• The combination of a radial head fracture, coronoid process fracture and elbow dislocation is known as the terrible elbow.
• Anterior elbow dislocations can be associated with injuries to the brachial artery, median and ulnar nerves. 

Quick clinical clues that the elbow is dislocated:

• Posterior dislocation typically will have a prominent olecranon process, the arm is flexed at the elbow, and the forearm will appear shortened.
• Anterior dislocation typically present with the arm in extension and the forearm will appear elongated.