Low Risk Chest Pain in the ED

I had a conversation with a few of the residents about the management of low risk chest pain in the Emergency Department. The issues which always seem to come up are:

• If the first troponin is normal, can I send them home?
• I don't think this is cardiac, let's just get one troponin and then send 'em home.
• Okay fine, let's just do two sets and then send 'em home.

The patients which are obviously cardiac and obviously not cardiac are easy, but what about those ones in which there's some question?

Interactive Medical Cases

With the advent and ongoing evolution of online medical education several excellent interactive case management simulations have been developed.  Below are two of those outstanding simulation resources:

1. NEJM Interactive Medical Cases
2. DIEM (Digital Instruction in Emergency Medicine) courtesy of CDEM

Enjoy!

VIPER: Video Instruction of Procedures in ER

The following link is to an excellent blog for Emergency Medicine named 'Academic Life in Emergency Medicine'.  Dr Michelle Lin is the author of the blog and an Associate Professor in the Department of Emergency Medicine at UCSF. Enjoy...

Click Here to visit VIPER

SBP: Understanding Malpractice 2

Just a little education on medicine and the law

There are two kinds of legal action within the law. Criminal action is when the government sues an individual for going against public interest - such as murder, rape, robbery. Physicians usually are not subject to these sorts of cases, unless they wilfully hurt their patients. Malpractice insurance won't cover you against criminal action.

Civil action is when one individual sues another. When wrongdoing (such as negligence under which malpractice falls) is involved, this is called tort. In order to be prosecuted for medical malpractice, the plaintiff needs to prove four things:

1. The physician owed the patient a duty of care. This happens whenever anyone comes into an Emergency Department. We are obliged to see this patient.
2. The physician falls below the standard of care. This means the physician didn't do what an average physician would do in the same circumstances. This is what the jury decides. If there's a recognizeable standard of care, this is what the doctor will be held up against. If there isn't, then they may call in expert witnesses.
3. The patient sustained harm. This can be morbidity or mortality suffered by the patient, but also loss of wages, pain and suffering, etc.
4. The harm is a result of not meeting standard of care, that is the negligence of the physician caused the injury. Not all bad outcomes are the result of the physician.

What do you think the cost of defensive medicine is? How can it be reduced? Given these four aspects necessary to win a verdict against a physician, pick a diagnosis and list everything that must be met in that particular case in order for damages to be awarded to the plaintiff.

SBP: Understanding malpractice

Lawsuits are one of the most dreaded possibilities facing doctors. Within Emergency Medicine, missed fractures, retained foreign bodies, MI's, and ectopic pregnancy are our most common causes of lawsuits. Whether we like to admit it or not, it does affect our practice.

Given your experience in the Emergency Department so far, how would you suggest we protect ourselves from these foils?

ACLS 2010 - Bradycardias

This video goes over the algorithm for bradycardias. I love the fact that they really simplified everything quite a bit. I'm not as sleepy in this video... no, I actually am.

ACLS 2010 - Cardiac Arrest

Here are the 2010 ACLS Guidelines for Cardiac Arrest. This catch-all category encompasses anything without a pulse, but what had previously been separated out into the separate rhythms of ventricular fibrillation, pulseless ventricular tachycardia, asystole and pulseless electrical activity. I love the fact that they simplified this into one algorithm - and they stress:

• early, deep and uninterrupted chest compressions, and
• early defibrillation (when indicated - VF/VT)

The first video covers the algorithm and drugs

The second video goes into more details about these drugs

The third video looks at PEA and asystole

Case of the Week: 'My Inhaler... Not Working'

Chief Complaint: "My inhalers.... not working"

HPI:
52 year old man presenting via CFD wtih acute onset of shortness of breath.  Per CFD patient was sitting on the edge of his couch holding his inhaler with moderate respiratory distress.  En route he was given 2 treatments of nebulized bronchodilators without much improvement in symptoms.  The patient is refusing to lay on cart sitting on edge of cart, anxious appearing with only one word answers to questions.

From a brief review of electronic medical record you see:

Past Medical History: HTN, asthma (moderate persistent)
Medications: Combivent MDI, Singulair, Lisinopril, HCTZ
Allergies: NKDA
Social History: 20 pack year smoking history - continues to smoke 1/2 pack per day
Vital Signs:

T 99.2F        HR 100       BP 154/92           RR 40          SaO2 88% on 2L via NC
Gen: middle aged man in moderate respiratory distress
HEENT: clear op otherwise unremarkable
Neck: habitus limits jvd assessment, no visible jvd
Pulm: exp wheezing diffusely, no rales, intercostal retractions and tracheal tug noted
CV: tachycardic, reg rhythm, no murmurs, normal s1/s2, no rubs
Abd: soft, nd, nt, +bs
Extrem: 2+ distal pulses throughout
Neuro: alert, oriented, no focal motor/sensory deficits
Skin: warm, no rashes noted

ED Course:
As you ordered patient started on continuous neb, given IV methylpred, mag sulfate while IV, O2 via NRB started and placed on monitor.  Respiratory is en route with noninvasive ventilation and your tech is setting up intubation equipment and RSI medications in case necessary...

Labs are not yet back however you have access to the following EKG and CXR...

 

Despite continuous neb, iv corticosteroids and mg sulfate patient continues to have moderate respiratory distress...  repeat vitals are obtained:
T 99.5F      HR 130    BP  102/64    RR 44   SaO2 90% on NRB

• What is the diagnosis?  What treatment needs to be initiated for this?

General questions pertaining to asthma management in the ED...

•  What criteria can be used to determine suitability for admission to the hospital for patients with   asthma exacerbations?
• What criteria can be used to determine readiness for discharge from the ED or hospital?
  

   

  ---------------------- (scroll down for answers)-------------------------

   

   

   

   

Diagnosis:  Tension Pneumothorax

Treatment: Needle decompression and chest tube placement

 What criteria can be used to determine suitability for admission to the hospital for patients with   asthma exacerbations?

After treatment in the emergency department for 1 to 3 hours, patients who have an incomplete or poor response, defined as an FEV₁ or PEF of less than 70% of the personal best or predicted value, should be evaluated for admission to the hospital. Patients who have an FEV₁ of less than 40%, continuing moderate-to-severe symptoms, drowsiness, confusion, or a partial pressure of arterial carbon dioxide of 42 mm Hg or greater should be admitted.

What criteria can be used to determine readiness for discharge from the ED or hospital?

According to the authors, patients may be discharged if the FEV₁ or PEF after treatment is 70% or more of the personal best or predicted value and the lung function and improvement of symptoms are sustained for at least 60 minutes. After discharge, patients should continue to use inhaled short-acting β₂-adrenergic agonists as needed and should be prescribed oral corticosteroids for 3 to 10 days.

Reference:

Lazarus, S. Emergency Treatment of Asthma. N Engl J Med 2010; 363:755-764

ACLS 2010 - Intro & Airway

Here's an introduction to ACLS 2010, an important skill you should pick up not only for your ER rotation, but for all your rotations! Let me know if you have any questions. I'll be putting up more vids as I make 'em.

Again, leave me feedback in the comments.

The first part of ACLS is A and B... yes, the order has changed to CAB for adults suffering from likely cardiac causes, but I'm old fashioned, so let's cover A & B first...

So let's talk about capnography and intubations, etc. The use of capnography is a big change in the new 2010 guidelines. Looks like we got some new equipment to buy.

Treatment of Status Epilepticus

Here's a quick video on the treatment of Status Epilepticus, one of the few neurologic emergencies we see in the Emergency Department. This is a method I'm experimenting with (you can see more videos at my EM Blog. Feel free to ask questions and comment on the format (I could use the feedback).

Introduction to EPIC 05 - Discharging Patients

And this last morsel is on how to discharge patients. One point I'd like to stress is to remember that this is information patients take home and likely the only thing they'll remember. What you tell them often gets quickly forgotten. So document your instructions clearly in a language they can understand.

Introduction to EPIC 04 - Admitting Patients

This video covers how to admit a patient to the floor. Remember these few points:

• You can't enter a diagnosis (and shouldn't - it messes things up later)
• Ask the attending with whom you're working to enter the Dx
• Tell the clerks the patient is "ready to move" or your patient will never get a bed

Introduction to EPIC 03 - Order Entry & Procedures

Here the inimitable Dr. Casey describes the process of placing orders, the use of order sets and the documentation of procedures using procedure templates. Enjoy. Maybe with a glass of Chardonnay.

Introduction to EPIC 02 - Documentation

Here's a very quick introduction to documentation.

Introduction to EPIC 01 - Main Tracking Board

Hello all,

This is the first of five very short videos introducing you to EPIC ASAP (the ER module of EPIC). Please feel free to watch as many times as you need to and ask any questions. Here are the delicious videos:

1. Main Tracking Board
2. Documenting
3. Order Entry & Procedures
4. Admitting Patients
5. Discharging Patients

Case of the Week - 7/16/11

 Grampa's Really Sleepy...



   A 74 year old man with a history of moderate dementia who is routinely cared for by his daughter is brought by the granddaughter, who indicates that “Grandpa is too sleepy.”  She drove him to the Emergency Department initially against his wishes. He is now less responsive to her, and “feels cold.”

    The daughter is the usual full time caregiver, but the granddaughter was filling in so that she could go to a seminar.  Grandpa is somnolent and not a reliable historian. The granddaughter brought his medication list. The daughter is now on the way to the ED, having been called by granddaughter. 

    The nurse calls you to area one to assess the patient.  On entering to room you see an elderly somnolent man laying on the cart  in no distress.  As you walk toward the patient the nurse informs you of the vitals from triage:

Review of Systems:  unable to obtain due to dementia / altered mental status

PMH:

Alzheimer's Dementia

CKD - stage 3

HTN

PSH:

no prior surgeries

Allergies: NKDA

Medications:

Aricept 10mg daily

HCTZ 50mg daily

Diltiazem 240mg SR daily

Social History:

no etoh, tobacco

lives with daughter and granddaughter

Family History: noncontributory

Physical Exam:

T 35.9C       BP 90/50     HR 35     RR 24       SaO2 94%

General: elderly man laying on cart, no distress, sonorous respiration, arousable only to painful stimuli

Neuro: solmnolent, arousable to painful stimuli, localizes to pain

HEENT: OP patent, no cervical lad, PERLA, atraumatic

CV: bradycardia, reg rhythm, no murmurs noted

Pulm: clear to auscultation bilaterally, no w/r/r

Abd: soft, nt, nd, +bs, no rebound/guarding

Extrem: cool to touch, cap refill 2-3 seconds,  1+ symmetric bilateral LE edema

Skin: mottled, cool, no rashes noted

 

 

 

CT head - negative for acute changes

EKG - 

Final Diagnosis:  CALCIUM CHANNEL BLOCKER OVERDOSE
Manifestations:

• Hypotension
• Bradycardia
• Heart block
• CNS depression

Work-Up

• EKG essential to check for conduction blocks
• tox screen
• electrolytes (for acidosis) and glucose (for hyper/hypo-glycemia)

Key Management Principles:

• Primary survey (ABC's)
• IVF resuscitation - vasopressors if no response (I did not give you changes in vitals based on therapy in this case)
• Calcium (Ca chloride 3 times more calcium available than Ca-Gluconate but more irritating to peripheral veins)
• Glucagon
• Insulin-Glucose (believed to work via cAMP mechanism like glucagon - maintain euglycemia while on insulin drip)
• Consider co-ingestion (tox screen, consider dig level as Ca could be deleterious)
• Detoxification 
• charcoal
  
• whole bowel irrigation is particularly useful for sustained-release preparations 
• calcium channel blocker acts as smooth muscle relaxant adversely affecting bowel motility

• Remember you can always use poison control as a resource in these cases (800-222-1222) 

 Disposition: ----> MICU

Great Work!  As always, contact me with any questions...






Suggested reference for further reading:

1. http://emedicine.medscape.com/article/813485-overview
2. Hasin T, Leibowitz D, Antopolsky M, Chajek-Shaul T. The use of low-dose insulin in cardiogenic shock due to combined overdose of verapamil, enalapril and metoprolol. Cardiology. 2006;106(4):233-6.