Em Student Manual

DEPARTMENT OF EMERGENCY

MEDICINE

STUDENT MANUAL

2004

2

Preface To Emergency Medicine Hartmut Gross, M.D. and W. (Ted) Kuhn, M.D.

Beginning in 1997, MCG made the EMED 5001 (and later EMED 5002) course a selective for all senior medical students. Students rotate either through the MCG Emergency Department, Eisenhower Emergency Department, Aiken Regional Hospital Emergency Department in South Carolina , or Tift Medical Center in Tifton, Georgia. Additional rotation sites are added only if there is genuine interest in teaching students and if there is sufficient teaching material to ensure an adequate clinical experience, both in quality and quantity. The EMED 5002 course is arranged by students at other sites who already educate medical students; however, students must fulfill all the other requirements of the EMED 5001 course in addition to any required at the off site location. This manual was written with one purpose in mind: to provide the best possible educational experience for students limited by a one-month’s rotation. There is enough "meat" here for both those who want only a brief experience and for those who want a more in depth experience. The manual is designed to be your reading and study manual for the month. Each of you will work in one of the Emergency Departments for a total of approximately 150 hours for the month, rotating through all the shifts. (Approximately 40 hours per week after EMS time and 911 experiences are added.) The first part of the manual serves as orientation to the logistics of the EMED 5001 and 5002 course. It includes the goals and objectives, orientation, and evaluation methods for the courses. The second part of the manual involves basic issues that face emergency physicians every day of their practice, such as cost containment, consultants, prescription writing and patient expectations. Emergency Medicine, like most specialties, is considerably more complex than just the clinical medicine involved. These issues are addressed to provide the student with some limited concept of what Emergency Medicine is all about. The thrird part of the study guide is the core curriculum. Lastly, we truly hope that you enjoy these materials and your month in Emergency Medicine. Over the years, we have found this specialty to be unusually challenging and stimulating. If we achieve our goal you will not only gain a fundamental understanding of what the ED can provide, its limitations, and how to use it properly; but from time to time you will fondly think back to your experience, or recall special moments in the Emergency Department, no matter what specialty you ultimately pursue.

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Department of Emergency Medicine Student Manual

Table of Contents

Part 1: EMED 5001 Course Logisitics

• EMED 5001 Introduction and Orientation 5 • Goals and Objectives 8 • Grades/Evaluations 11 • Emergency Department Presentation of Patients 17

Part 2: Basic Practice Issues

• Emergency Medicine: A Unique Opportunity for Medical Students 19 • Emergency Medicine and Patient Expectations 20 • Shift Work, Circadian Rhythm and Satisfaction 22 • Triage 25 • Protocols in the Emergency Department 28 • Cost Containment in Emergency Medicine 31 • Clinical Pearls for Cost Containment 33 • Cost Ranges for Tests 35 • Dispensing Medication in the ED 37 • You, the DEA, & the Georgia Composite State Board of Medical Examiners 39 • Conflict Resolution 40 • Malpractice and Emergency Medicine 42 • Clinical Pearls in Emergency Medicine 45

Part 3: Core Curriculum

• COBRA/EMTALA 49 • Evaluation of Abdominal Pain 55 • Airway Management 63 • Evaluation of Chest Pain 69 • Environmental Emergencies 78 • The Febrile Infant 92 • Headache 99 • Neurologic Emergencies 105 • Pelvic Pain and Bleeding 115 • Toxicology 119 • ED Approach to Multiple System Trauma 125 • Dealing with Violence in the ED 129 • Wound Management in the ED 136 • ACLS Algorithms 150

Epilogue 162

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PART ONE

EMED 5001 COURSE LOGISTICS

EMERGENCY MEDICINE

STUDENT MANUAL

Orientation

5

EMED 5001 / 5002 Introduction and Orientation

Hartmut Gross, M.D., FACEP

• Goals / Objectives: See page 9 Introduction to Emergency Medicine • Sites: MCG, EAMC, Aiken, Tifton, other sites • Responsibilities: See patients, do procedures Present all patients

OK to start out with sr. resident but ultimately sign out all patients to attending. Rule: No patient ever leaves the department without being seen by a physician.

READ -- only 40 clinical hours per week • Reading materials

Read them! No need to buy another text The exam will be based upon this text • Lectures-see separate sheet “Additional EMED 5001 Requirements” • EMS Experience – One ride along sessions on an ambulance is a portion of this course to gain

experience in pre-hospital care-an extension to the ED. You will be oriented to this by EMS personnel during the course orientation.

• 911 Center Experience date and time are to be arranged by the student (see separate information sheet) • Grades

60% Clinical (see daily evaluation sheets on page 11 & 12)) 30% Final Exam given on last Friday of the rotation (unless rotation period has been modified). 10% Presentation (see evaluation sheet on page 16 Final Grade (see “page 13)

• Shift Work – Shifts are busy. Rest appropriately.

Arrive on time. When your shift ends, it is time to turn patient care over to the next person. You are not required to stay until all of your patients have left. When you arrive late, the person you are relieving is having to stay over, waiting on you. Sign out all of your patients still physically present in the ED (no matter what their disposition status may be) to someone before you leave. Shifts may be traded; however no shifts back to back, i.e. no one may work more than 12 consecutive hours, there should be a full day between returning from nights back to days. You may work no more than 5 consecutive days without a day off. See chapter on “Shift Work…,” page 18

• Presentation of patients -format: See page 17, “Emergency Department Presentation of Patients”

Also check with individual sites. • Documentation: Focused H&P, assessment, treatment, and plan. Students may independently

complete the medical history, family history, review of systems, medications and allergies sections of the patients’ medical record. History and physical exam may be “scribed” by the student only when the patient is seen simultaneously with a resident or faculty physician. Time your notes and updates. Always finish your notes . Be sure to include timed updates about the patient’s response to interventions.

• All patients receive discharge instructions which include time specific and place specific follow-up

directions.

Orientation

6

• Acuity – for some reason, students tend to gravitate toward low acuity patients. There are many

opportunities to see critically ill patients and each student will need to take the initiative to see types of patients. Push through any perceived barriers to these patients, there are no restrictions to the kinds of patients you may see. When you do see high acuity patients, let someone know, as some patients have very time sensitive conditions (e.g. AMI and TPA, or acute stroke and thrombolysis). You should never be “bumped” from a procedure on “your” patient. Naturally procedures will be supervised.

• Patient Tracking – all students are required to track how many and what kinds of patient illness they

are seeing. This helps students be aware of what type of acuity mix they are seeing as well as how many patients they actually evaluating and treating. It also helps each site assess what the students are doing and where improvements in the course need to be made. Tracking sheets are provided with your course packet. A patient entry should take approximately 15-20 seconds to complete. Tracking sheets should be turned in at the end of the rotation (either on the exam day or turned in to the faculty if there are still shifts to be worked after the exam). Also note the reminder at the bottom of each sheet about daily evaluations.

• Procedure log – all students are to complete a procedure log (see separate sheet). One side of the

procedure log sheet are required procedures to be performed during the rotation. On the reverse side are many other procedures which may be performed during the month and are excellent learning experience, even if only observed. The log should be turned in at the end of the rotation.

• Miscellaneous

Attire - Professional dress expected. No scrubs at Ft Gordon or Aiken ED. Scrubs are permitted in MCG ED. Check with supervising physician at beginning of rotation at other sites. Shirt and slacks are required for EMS “ride-along.” No scrubs or t -shirts permitted. Buzzwords – Certain words or phrases immediately imply certain diagnoses. For example

• Lethargic child = meningitis, therefore must do lumbar puncture and antibiotics • Crushing chest pain = Acute MI, therefore must admit for serial enzymes • Thunderclap headache = subarachnoid hemorrhage, therefore must do CT and LP Be careful not to paint yourself into a corner by indiscriminate use of these terms on the chart.

The ED is a glass house with ears All mistakes made in the ED will be discovered when a patient returns with an unexpected change in condition. Often, a patient changes and the diagnosis finally becomes apparent when the patient returns (scheduled or unscheduled). The ED staff regularly gets “bashed” on the “floor rounds” the next day. This is your chance to see what it is like on the front line and the difficulties inherent with it. Patients and fami lies frequently are standing in the room doorways, listening and observing activities. Voices and conversations carry and are overheard and get misinterpreted. When the staff is heard telling stories and laughing in the halls they are perceived as entertaining themselves on patient’s time. Be aware and sensitive to these perceptions and try not to contribute to them.

Legal climate – the ED is an area which generates many law suites. You spend relatively little time with patients and establish little rapport. You get only one chance to “get the diagnosis right.” Shift change is a particularly vulnerable time for making mistakes. When you pick up a patient from someone else, this should be the first patient you go see and meet and briefly review the complaint, repeat a few portions of the physical exam as appropriate (e.g. heart, lungs, abd.); let the patient know you are assuming care and will be back to discuss any pending lab tests, x-rays, etc. Be sure to read the “Malpractice and Emergency Medicine” chapter, page 38.

• At the end of the overall orientation, the group will be dismissed. Each student should report promptly

to the assigned rotation site emergency department for additional orientation to that facility.

Orientation

7

• Course feedback On the day of the final exam (reminder: last Friday of the rotation) you will be asked to complete an evaluation of the course. This course changes constantly because of the feedback from students. Please take a moment and give constructive criticism.

IMPORTANT

Problems, questions, concerns - Please let someone know immediately. If we don’t know, we can’t help. Don’t wait until the end of the rotation: Clerkship Director: Hartmut Gross, M.D., FACEP Phone: 721-3332 Course Coordinator: Susan Baxley Phone: 721-4412 On-Site Course Director: Phone: On-Site Lead Secretary: Phone: Augusta EMS Contact: Phone: 911 Center: Phone:

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EMED 5001 & 5002 Course Logistics

This month provides an overview of Emergency Medicine – what can and what cannot be done, how patients are appropriately (and inappropriately) referred to the emergency department, how to prioritize problems while managing multiple patients simultaneously. The students will hone their H&P skills, seeing undifferentiated patients under close supervision of an attending physician with or without the assistance of a resident. They will enhance their basic life support skills including cardiopulmonary resuscitation. Students will learn to recognize and treat shock of all causes and all age groups. Intravenous access, airway management, suturing, and other basic procedural skills are available for the students to learn. Students will learn to recognize acute illness and injury and initiate early management. Students are given reading materials to provide additional learning tools to understand what they are practicing in the clinical arena. Students are exposed to prehospital care as well, via ambulance ride-alongs and visiting a 911 center. The scope of the course is covered with the incoming students every four weeks on the first day of the rotation during the orientation given by the course director. Patients are completely undifferentiated. Students are instructed during the orientation, and are reminded during the rotation, to be sure to see high acuity patients in addition to the lower acuity patients (which they tend to gravitate toward). Each student is directly supervised in the ED setting throughout the rotation. The scope of the experience is somewhat variable since there is no control over what or how many patients or problems may present to the ED. Nonetheless, because of the large volume, there is never any lack of teaching cases. Students learn at the bedside under faculty (and sometimes additional resident) supervision. Additionally, there is a Morning Conference 6 days/ week which students at the MCG site attend when they are in the ED at adjacent times. Students (and als o all interns and residents) rotating during the month, and on duty at that time are exempt from clinical responsibilities for this hour each day. Additionally, all students, regardless of rotation site are excused from clinical responsibilities the night before and during each Thursday 5 hour Teaching Conference (held with all EM residents and all rotating interns). Unfortunately, Morning Conference is not realistic for students rotating at Ft. Gordon or Aiken because of the distances involved and the benefit of only one hour teaching; however, their attendance at the 5 hour Weekly Teaching Conference is mandatory. Ft. Gordon does have a short list of conferences for their students (and interns) and also provides an animal lab experience for their students each month. At the moment there is no such substitute available for students at Aiken. However, these students typically see more high acuity patients and perform more procedures because there are no residents rotating there. These types of issues may present problems as additional sites (eg. Albany, Rome, Covington, etc. and 5002 sites) are added to make the course available to all MCG students . The Emergency Department in Tifton is a community hospital which, like Aiken, has no residents with whom students compete for patients. There is direct interaction with attending physicians. Students are evaluated daily (see Grades/Evaluation chapter). These evaluations are carried over to a final grades sheet (see Grades/ Evaluation chapter). These daily and monthly grade forms are distributed at the beginning of each rotation and discussed. Students are responsible for handing the attending they work with most each day a blank grade slip (see Grades/Evaluation chapter). There is direct verbal feedback given at that time, in addition to that given during the shift. The grade slip is then completed to document this interaction and the slip is placed into a locked box. A similar form is completed for the presentation given by the student. These are the basis with which the course director completes the final grade sheet. In addition to the grading, to assure that each student achieves satisfactory clinical proficiency, X-rays and laboratory studies are reviewed with the student. Usually the student is not directly observed performing the initial H&P; however, an attending or resident goes back with the student, to perform their own H&P which the student may “scribe.” This provides one-on-one teaching opportunity and may be used to confirm accuracy and completeness of the student’s patient evaluation and give immediate feedback. This internally written manual is available to the students free of charge and may be downloaded. Purchasing a textbook is not recommended. The final examination is based upon these materials. Every ED has an extensive collection of up-to-date reference books including both EM as well as other specialty texts. A departmental library is also accessible to the students. Additionally, students are to search through current literature in preparation for their presentations.

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Emergency Medicine 4th - Year Medical Student Selective Goals and Objectives for the EMED 5001 and 5002 Courses

The goal of this course is to provide a foundation for future physicians to be able to recognize and initiate first line medical treatment of the acutely ill or injured patient. In general, students will:

1) Build their fund of knowledge through reading. 2) Apply the knowledge they have gained to different situations. 3) Show how they use information in a realistic setting. 4) Demonstrate their abilities and perform tasks in real encounters.

Society generally expects that all physicians possess basic knowledge in emergency care and the skills to manage acute problems. It is anticipated that regardless of what specialty a practitioner chooses, and irrespective of the type of setting or location of that practice, emergencies unrelated to that practitioner’s specialty will arise sooner or later. The physician should have the skills to recognize and initiate treatment of that emergency until help arrives. Also, the public expects physicians to give proper advice about when to be concerned about chest pain or a headache, or problems such as a burn or laceration, epistaxis, a sprained or potentially fractured extremity, diarrhea, or unintentional or deliberate ingestions. Once a patient carries a diagnosis, one can look in a textbook for advice. The greater challenge lies in the undifferentiated patient. Basic skills in recognition and evaluation are critical in the education of physicians. To that end, more specific goals for this course are:

A) Acquisition of basic life support skills, including the diagnosis and treatment of shock, and related basic procedural skills. 1) Recognize the presence of a patient with a serious condition that necessitates urgent attention. 2) Prioritize attention to those patients with more urgent conditions. 3) Take the first steps necessary to save a life, i.e.

a) Open the airway. b) Ventilatory support with bag-mask-valve apparatus. c) Circulation augmentation with intravenous fluid. d) Hemorrhage control using external pressure.

4) Recognize potentially treatable neurological insults. 5) Recognize and initially manage potentially dangerous and treatable poisonings in any age

group.

B) Differentiation and treatment of common acute problems. This could be a long list. Some examples are: 1) Treat superficial burns and recognize when higher level of care is required. 2) Assess injured extremities for possible fracture or dislocation and identify those requiring x-

rays and possibly referral. 3) Stabilize a patient who has had a seizure and determine the need for further evaluation. 4) Etc.

C) Assessment of the undifferentiated patient.

1) Perform a focused (when appropriate) or general history and physical – gather information and assess for emergency.

2) Initiate emergency treatment as needed based on recognized emergency and on limited information as available.

3) Formulate an appropriate differential diagnoses list, distinguishing diagnoses, which are emergencies versus urgencies.

3) Conduct and follow through a work-up for the differential diagnoses. 4) Reassess the patient for response to treatment and redirect care plan as needed. 4) Identify which patients require further consultation or admission with or with out a final

diagnosis, and who may be safely discharged home with proper follow-up.

D) As this is a fourth year medical student rotation, it is expected that the student will advance from the roles of information gatherer and reporter. It is expected that the student will begin learning to interpret the information gathered from the patient’s history and examination, proposing a scheme by which

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the patient should have their problem worked up, an assessment of the problem and developing a plan for further treatment, either inpatient or outpatient, including drug regimens.

E) Students will continue to refine their skills in documentation of the patient’s history and physical examination as well as assessments, interventions, and reassessments, plan of care and final disposition.

F) Many patients in the emergency department require various procedures. Many of these are basic procedure in medicine, which any physician should be able to perform. A goal on this rotation is to become competent in phlebotomy, IV catheterization, and simple suturing. Students will be introduced to advanced airway management such as nasal trumpets, oral airway devices, and bag-mask-valve ventilation. Students improve their skills by being required to perform a minimal number of these basic procedures while still in a protected learning environment. Students are encouraged to perform and participate in more and other available procedures.

G) Pre-hospital care is an integral part of emergency medicine. Regardless of the specialty a physician finally enters, the clinician will have interactions with ambulances, perhaps as first responders at an accident or instead to pick up a patient who has collapsed in their office. Awareness to access to these services as well as of the capabilities is vital. Students will spend time at the 911 Center as well as spend ride-along time on an ambulance.

H) The student will learn to work effectively as a member of a health care team. This includes the physicians in the emergency department, the nursing staff, ancillary support staff, as well as consulting physicians. Effective communication and interaction are valuable skills in any field, but perhaps none more so than in the emergency department. Bibliography: 1. Emergency Medicine in Undergraduate Education, Burdick, et al., Academic Emergency Medicine,

Nov. 1988, 5, p. 1105-1110.

2. Undergraduate Curriculum, DeBehnke, et al., Academic Emergency Medicine, Nov. 1988; 5, p. 1110-1113.

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The intent of a daily evaluation is to provide ongoing feedback so that each student learns immediately where their strengths lie and where they need to improve. Each site handles this process somewhat differently. This form should ideally be given daily to the faculty member with whom you worked with most, either at the beginning or end of each shift. An Emergency Medicine resident whom you have worked a significant portion of the day may also complete the evaluation. Completed forms will be dropped off by the evaluator and will be kept confidential. At MCG, they are slipped into a locked box in the ED. The information from these forms will be compiled to determine the student’s clinical portion of the final grade. (Front Side)

EM Student Daily Evaluation

Student N ame: Date:

Evaluator Name:

Not

A

ccep

tabl

e

Belo

w

Expe

ctat

ions

Mee

ts

Expe

ctat

ions

Exce

eds

Expe

ctat

ions

Not

O

bser

ved

D / F C B A

Patient Care

Medical interviewing

Physical examination

Procedural skills

Patient care skills

Medical Knowledge

Knowledge base

Interest in learning

Correlate knowledge & clinical situation

Practice-Based Learning and Improvement

Teaching others

Use scientific info to manage patients

Initiative

Professionalism

Respect, integrity, honesty, compassion

Response to feedback

Responsibility

Responsive to needs of others

Acknowledgment of errors

Interpersonal and Communication Skill s

Humanistic / therapeutic relationship

Listening& nonverbal skills

Verbal communication skills

Interpersonal skills

Presentations

Written notes

Systems -Based Learning

Utilization of outsid e resources

Systematic approach to reduce error

Improves health care system

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(Back of Form) When assigning a grade for this student’s overall clinical performance, use the following guidelines:

90-100% Exceeds expectations in most areas of clinical competency. At most, 20% of students will perform at this level

Numerical Grade :

80-89.9% Meeting expectations. Clinical competency is appropriate for the student's level of training. Most students will demonstrate competency at this level

%

70-79.9% Compared with peers, this student’s performance is below expectations for his/her level of training, although still at a marginal passing level.

or

<70% This student has significant deficiencies in clinical competency and should not pass the rotation.

Letter Grade :

Please provide written comments about the student’s performance: % Signature (Please sign legibly)

D-F C B (Majority of Students)

A (Top20%)

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MCG Emergency Medicine Clerkship

Medical Student Clinical Performance Evaluation

Student Name: ___________________________ Dates: _____________________

Attending: _______________________________ Site: _____________________

For each area of the evaluation below, please circle or check all the phrases in any category that reflects the student's work. Attributes should be cumulative as ratings increase. Written comments are required.

Not Observ ed

Not Accepta

ble Below Expectations

Meeting Expectations

Exceeding Expectations

Patient Care

Medical Interviewing r r r Incomplete, illogical, superficial histories

r Elicits most pertinent patient information

r Logical, thorough, and efficient histories

Physical Examination r r r Incomplete, inaccurate, cursory, non-directed, unreliable physical examination

r Some omissions but usually complete and accurate r Complete and accurate physical

examinations

Procedural Skills r r r Lacks proficiency in basic procedures r

Proficient in most procedures and attempts to minimize patients’ discomfort

r Proficient at procedures and minimizes patients’ discomfort

Patient Care Skills r r r Lacks initiative in patient care activities

r Actively participates in patient care activities

r Exceptionally conscientious in patient care activities

Medical Knowledge r r r Limited knowledge of basic & clinical sciences r Solid fund of knowledge r Exceptional knowledge of basic

& clinical sciences

r r r Minimal interest in learning r Demonstrates interest in learning r Enthusiastic interest in learning

r r r Poorly correlates knowledge with clinical situations and mechanisms of disease

r Correlates knowledge with clinical situations and mechanisms of disease

r Comprehensive understanding of complex clinical situations and mechanisms of disease

Practice-Based Learning and Improvement

r r r

Shows little interest in facilitating the learning of other students and health care professionals

r Facilitates the learning of other students and health care professionals

r

Unusually proficient in facilitating the learning of other students and health care professionals

r r r Fails to use information from scientific studies to enhance patient care

r Attempts to use scientific studies to manage information for patient care

r Effectively uses scientific studies to manage information for patient care

r r r Lacks insight and personal initiative

r Usually demonstrates personal initiative

r Self-motivated learner

Professionalism r r r Lacks respect, compassion, integrity and honesty r Demonstrates respect,

compassion, integrity & honesty r Always demonstrates respect, compassion, integrity & honesty

r r r Resists or ignores feedback r Readily responds to feedback r Seeks and rapidly responds to feedback

r r r Does not display responsible behavior

r Displays responsible behavior r Teaches/role models responsible behavior

r r r Does not consider the needs of patients, families or colleagues r Considers the needs of patients,

families and colleagues r Consistently considers the needs of patients, families and colleagues above his/her own

r r r Fails to acknowledge errors r Acknowledges errors r Willingly acknowledges errors

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MCG Medical Student Clinical Performance Evaluation Form (Continued)

Not Observ ed

Not Accept

able Below Expectations Meeting

Expectations Exceeding

Expectations Interpersonal and Communication Skills r r r

Does not establish adequate, effective, humanistic and therapeutic relationships with patients and families

r

Establishes effective, humanistic and therapeutic relationships with patients and families

r

Establishes highly effective, humanistic and therapeutic relationships with patients and families

r r r

Demonstrates inadequate listening, written or nonverbal communication skills

r Shows adequate listening, written and nonverbal communication skills

r Demonstrates excellent listening, written & nonverbal communication skills

r r r

Has deficient verbal communication skills with patients and families

r Has adequate verbal communication skills with patients and families

r Demonstrates excellent verbal communication skills with patients and families

r r r Not "interpersonally engaged"

with patients and their families r Relates well to patients and their families r

Always "interpersonally engaged" with patients and their families

r r r

Delivers poorly organized patient presentations. Has difficulty distinguishing pertinent from extraneous information

r

Delivers organized patient presentations, including most pertinent information with little extraneous information

r Delivers well organized presentations, appropriately tailored to the situation

r r r

Writes notes that have some omissions or inappropriate redundancies, showing little application of clinical thinking or reading.

r

Writes organized, accurate notes, of appropriate length, with assessments that are thoughtful and reflect reading

r

Writes exceptionally organized notes, tailored to the situation, with assessments that are consistently thoughtful and reflect reading

Systems -Based Learning r r r

Unable to access/utilize outside resources needed for effective and efficient patient care

r

Attempts to access/utilize outside resources needed for effective and efficient patient care

r Effectively accesses/utilizes outside resources needed for effective & efficient patient care

r r r Resists efforts to improve

systems of care r Attempts to use systematic approaches to reduce errors and improve patient care

r Effectively uses systematic approaches to reduce errors and improve patient care

r r r

Does not use systematic approaches to reduce error and improve health care

r Supports development of activities leading to health care systems' improvement

r Enthusiastically assists in developing health care systems' improvement

( ) Showed Improvement When assigning a grade for this student’s overall clinical performance, use the following guidelines:

90-100% Exceeds expectations in most areas of clinical competency. At most, 20% of students will perform at this level

Numerical Grade :

80-89.9% Meeting expectations. Clinical competency is appropriate for the student's level of training. Most students will demonstrate competency at this level

%

70-79.9% Compared with peers, this student’s performance is below expectations for his/her level of training, although still at a marginal passing level.

or

<70% This student has significant deficiencies in clinical competency and should not pass the rotation.

Letter Grade :

Please provide written comments about the student’s performance: %

(Clinical performance is 60% of final grade)

D-F C B (Majority of Students)

A (Top20%)

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MCG Medical Student Clinical Performance Evaluation Form (Continued) Presentation (10% of final grade) Title: Grade: Numeric: or Letter: Comments: Site Clerkship Director Signature: Examination Score (30% of final grade)

Final Overall Course Grade:

16

Presentation for EMED 5001 Rotation

All students are required to give a 10-15 minute presentation on the topic of their choice with the provision that it be relevant to an ED presentation of a patient (i.e. not chronic, long term care). The topic should be researched with 2-3 up-to-date literature articles. Each site will handle the presentation somewhat differently so be sure to check with the site director early how and when the presentation should be given. The form below has been recommended to each site for use or as a guideline for evaluating a presentation.

EM 5001 STUDENT PRESENTATION EVALUATION FORM Name:

Date:

Topic / Title:

Please circle Letter grade for the following observations: A B C D/F Relevance to EM

A Relevant to EM B Significant part not applicable

C Most of the report not applicable to the EM

Missed the whole intent

Researched literature

A Researched subject with current literature

B Researched & info somewhat relevant

C Information up to date but didn’t go to journals

Copied out of outdated textbook

Knew material

A Knew material. Able to discuss it forward & back

B Good understanding

C Relied heavy on notes Shaky understanding

Read notes Poor knowledge

Handout (Not required)

A Well done B Xeroxed neatly C Marginally relevant and hard to read

Sloppy, irrelevant

Please give an overall grade rating. (+ & - may be added) OVERALL A top 10%

Outstanding B Very good

C Adequate

D/F Inadequate

Please add some constructive criticism about the presentation Use Reverse Side for Comments

(Back of form)

Please discuss with the individual and then place this card in the Evaluation Box at the end of morning conference.

Comments about the individual’s presentation: Grade

Legend A-Outstanding B-Very Good C-Adequate D/F-Inadequate

Signature (Please sign legibly)

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Emergency Department Presentation of Patients Medicine practiced in the Emergency Department is different than that you may have experienced in other settings. The ED is a tactical environment requiring an efficient and direct style which shaves seconds whenever possible. Inefficiency is dangerous. Long, detailed work-ups and presentations, appropriate for other medical practice locations, result in decreased throughput. The result if a more traditional approach is used is that patients with life-threatening emergencies sit in waiting rooms instead of treatment rooms receiving life or limb-saving interventions. Consequently, we request that your presentations fit the following model. 1. Present the chief complaint. 2. Present your best diagnosis or differential diagnosis. 3. Support your diagnosis with pertinent history and physical examination findings. 4. Allow the teaching physician to flush out additional information by asking relevant

questions about the history and physical. Typically, teaching points will be accomplished dur ing this part of the discussion.

5. Finally, make your presentation in the room with the patient whenever appropriate. This allows the teaching physician to confirm your history and finding immediately without subsequent repetition.

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PART TWO

BASIC PRACTICE ISSUES

EMERGENCY MEDICINE

STUDENT MANUAL

19

Emergency Medicine: A Unique Opportunity For Medical Students

Walter Kuhn, M.D., FACEP

In many ways, a rotation in Emergency Medicine is fundamentally well suited for the training of medical students. Because Emergency Physicians normally provide episodic care, in distinction to continuity care as do primary care specialties, we are presented with the greatest number of “undifferentiated patients” seen in any medical field. In other words, our patients present to us without a known diagnosis. This allows the student along with the attending to evaluate “fresh” patients multiple times a day to arrive at their own diagnoses. Not only will this occur during each shift, but in a busy Emergency Department like ours, this will occur from 100-150 times a day. This makes the Emergency Department a veritable learning and skills laboratory of patient’s complaints, diagnoses, and procedures. Emergency Medicine is also a specialty where the student works directly with an attending physician who is board certified in Emergency Medicine 24 hours a day who is always present and available to teach. You receive almost instantaneous evaluation and feedback by a faculty member. Due to the rapid turnover of patients, students do not have a long wait to see if their initial diagnosis or interventions are correct. Even though we, in Emergency Medicine are under time pressure from a clinical perspective, the appropriateness of the diagnosis or intervention is usually immediately apparent within the confines of the shift, as most problems are either solved or resolved before the patient is discharged from the Emergency Department or admitted to the hospital. This immediate and timely feedback is an incredibly powerful tool for medical education. Deans of Medical schools and Curriculum Committees have recognized the significance of teaching each and every student basic emergency care and life saving procedures. Students not only want this training, but the public demands it regardless as to whether the student decides to specialize in a non-clinically oriented field or a very narrow subspecialty. This training is “core” in the generalist curriculum. Each graduate will be presented with a trauma victim or a medically unstable patient in the community sometime during his or her medical career. It is unthinkable that a graduate from this or any medical school would be unable to provide basic life saving techniques and emergency care in the community. These skills are best taught by those most experienced in crisis emergency care: in other words, the Emergency Physician. A month long rotation in a busy Emergency Department is like a “practical” ACLS, ATLS, BLS and PALS course all rolled into one. The motivated student will take advantage of the rotation to practice all of his or her life saving skills on “real” patients under real clinical conditions instead of mannequins and moulaged medical students.

In many ways the Emergency Medicine rotation is a mini 4 years of medical school rolled into one exciting, pulse throbbing month long course. During any 8-12 hour shift, the student will be called upon to use his or her skills in such diverse basic sciences as Anatomy, Physiology, Pharmacology and Physical Diagnosis as well as clinical skills acquired on most if not all the student’s prior clinical rotations. Any 10-15 “undifferentiated patients” you may see during one shift in the Emergency Department may call upon you to use skills as divergent as Pediatrics, OBGYN, Surgery, Medicine, Psychiatry, Ophthalmology, etc. Since you never know what will come through the door, you need to be prepared for everything. Furthermore, Emergency Medicine is best suited to teach students to recognize the difference between sick and well patients, a skill absolutely necessary for every clinician regardless of specialty. Some patients are not as sick as they think and others are not as well as they wish; it is our task to correctly sort them out. This is accomplished many times a day in the Emergency Department. Although this is not a skill easily learned, with practice and experience along with supervision, each student will have acquired a greater level of skill in differentiating sick patients by the end of the rotation. Lastly, the social and emotional issues of medicine are perhaps best taught in the Emergency Department. Dealing with grief, death telling and death counseling, dealing with anger and violence, personal loss and self-destructive behavior are problems faced in the Emergency Department many times a day. Clinical and psychological scenarios that may take months and years to unfold in other specialties can be experienced on a daily basis in a busy Emergency Department. As a student, you are about to embark on a unique, exciting month, unparalleled by any other experience you have ever had. Carpe Diem, “seize the day”, and take the opportunity to take advantage of what’s offered here. You will not only be a better clinician, but a better and wiser individual for having had the experience.

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Emergency Medicine and Patient Expectations


“Healthcare workers at all levels of the medical system often quickly forget that the system exists to serve the individual patient. During years of professional indoctrination, doctors and nurses can easily acquire a cloistered and overly clinical attitude toward the practice of medicine. Medicine, in its purest form, is a service industry; like all service industries, its success or failure is measured by the satisfaction level of the people it serves”1. We proceed by serving 'one patient at a time'. It would be good to borrow a phrase from industry, "we service what we sell!" The practice of medicine may be scientifically correct, yet morally bankrupt! “As a group, patients come to the healthcare system with basically realistic expectations. They expect that the healing professionals will treat patients with dignity and will regard patients' welfare as their principle concern.”1 This expectation that a sense of true kindness and caring will be shown by healthcare workers is held by all strata of society. “The healthcare system in the United States is essentially measured against higher ethical and moral standards than is any other business. Patients, society and the legal system expect that care will be given through the emergency services without regard to ability to pay. It is also their expectation that care will be rendered to the maximum ability of an institution's resources and that transfer to another facility will occur only in the patient's best interest and not for the fiscal strength of the hospital. The belief is so deeply ingrained in the American populace that it has been codified into federal law.”1 In healthcare, patient satisfaction is the only product. “Classic examples of the failed expectations leading to dissatisfaction can be found in multiple Emergency Department situations; return visits to an emergency department are an example as are the patients’ expectations regarding pain relief and waiting times. Patients return with the expectation that people will be more concerned about their problems because they have been seen once and the problem was not solved. In contrast, the Emergency Department personnel often view such patients as annoyances.”1 Similarly, patients often come to the Emergency Department with a painful condition, expecting, rightfully so, that they will obtain relief. Studies indicate that the doctor's perception of the patient's pain is invariably lower than the patient's perception of such pain. Irrational fears about the use of pain medication and myths about the long-term effects of drugs have created an attitude in healthcare workers in which patients with legitimate pain may be denied effective relief from their symptoms. Another area where patient expectation and system performance conflict, is with regard to waiting time. No one likes to wait a long time for services. It is demeaning and gives the impression that his/her time is not important and the patient's pain and suffering are not worthy of the physician’s attention. We often hear hostile phrases like, "I'm glad I don't have a real emergency; I'd be dead by now!" Emergency Physicians will frequently suffer the wrath of patients because of time delays. Studies show that patient perceptions of the time waited are significantly different than actual times waited, with patients overestimating the waiting time from 50-100% and doctors underestimating by the same amount. Nevertheless, patients often do wait inordinate times for care, and that time may be increasing with the continued trend toward overcrowding in U.S. Emergency Departments. As waiting times increase, so do patients' anger and frustrations with the physician and the Emergency Department. Not infrequently, after the patient suffers a long delay, is isolated from friends or relatives, has submitted to painful procedures, has been denied food and drink and suffers criticism at the hand of doctors and nurses, they are given discharge instructions that they can neither read nor understand. This is considered by many to be the ultimate professional arrogance. What then can we as physicians do to both increase patient satisfaction and improve our image? A sign conspicuously placed near a hallway where I once worked declared, "The best way to care for the patient, is to care for the patient". Research has shown that the strongest predictor of patient satisfaction is the patient's perception of the physician's behavior. “It is important for physicians to realize that the patient is not only unable to judge the technical quality of care given, but does not use technical quality of examinations, tests, and medications as the primary measure of satisfaction. Instead, patient's satisfaction is related to nontechnical interventions, such as patient education, stress counseling and negotiation.”2 How do patients judge the competence of the Emergency Physician? Patients are entrusting their entire medical well being to a stranger. They have little data on which to judge that stranger's abilities, and they use whatever data are at hand. Emergency Physicians do not hand out their C.V.'s, testimonials from previous satisfied patients or other professional credentials. So patients are left with other means to decide

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a doctor's competence. The most obvious evidence available to them is the dress of the physician and the cleanliness of the Emergency Department. Several studies on patients' attitudes toward physician dress all state that appropriate dress enhances the professional image of a physician. It has been said that within 15 seconds of the initial interaction, the patient has made a judgment as to whether the physician is competent. “Whether physicians personally agree that patients can judge their professional abilities based on their dress is not the issue; the fact is that patients do assess the Emergency Physician frequently on the basis of dress. Healthcare professionals who dislike "official" dress should regard it as "professional camouflage",2 necessary to their profession. For men, appropriate dress (according to patients) includes a clean white coat, a dress shirt and tie, dress slacks and dress shoes - not running shoes or sneakers. For women, dress should include a clean white coat, blouse and skirt or slacks. They are expected to look clean and well-groomed but not flashy. Another negative image that the Emergency Physician needs to overcome is the common complaint among patients that the physician does not take enough time with them. Time spent with the physician is an important determinant of patient satisfaction. While it is recognized that the emergency interaction by its very nature must be brief, several things can be done to increase the patient's perception that adequate time was taken. “Studies have shown that if the physician sits in the presence of the patient, the perception of time spent with the patient is doubled. The act of sitting down not only signals that time is being taken with the patient, but that the physician's full attention is now focused.”2 Patients coming to Emergency Departments in academic institutions often leave feeling as though they have only seen a "student doctor" and not a "real doctor" when in fact they have seen several doctors, including the attending or several attendings. Why then this misconception? It is true that often the student or intern is the one who spends the most time with the patient, but it is likewise true that oftentimes we do not introduce ourselves and state our position in the Emergency Department. The patient is left to make his/her own mind up exactly who he/she saw and what their position was. It is always appropriate to introduce yourself to your patient and family and to state honestly what your position is. If you are an intern, tell them that you are an intern! It is also good to tell the patient that Dr. (X) is the attending (faculty physician), and that I will be reporting to him/her and that the faculty physician will be directing your care. He/she will see you shortly, or after X-rays or lab, whatever is the case. I remember a specific complaint a patient sent to MCG hospital administration. The patient alleged that he had only been seen by a “student” doctor and therefore was given substandard care and would not pay his bill. In actuality, when the chart was reviewed, he had been seen by a resident, myself as a faculty member, an orthopedic resident and the chief of orthopedics. It is likewise important to remember that a faculty member must see each patient if that patient is to be billed. Under present health care legislation, not to do so would be defrauding the US government under Medicare and Medicaid laws. Lastly, often patients are under the impression they belong to this or that private attending physician. Indeed, the private attending may believe that the patient is "theirs". If this is the case, the private attending should be called to care for "their" patient, regardless of the time or day of the encounter as long as the patient is stable. Nothing you can or will do will satisfy either the patient or the private attending. In this case, the Emergency Physician is being used as a private house physician, which is demeaning to both the Emergency Physician and the patient. “In reality, this is a definitional problem. Physicians do not own patients. Patients are the responsibility of whatever physician they are seeing at the moment for care. An Emergency Physician presented with a patient takes on both responsibility and liability. Not to combine this with the proper authority to manage such patients is to invite disaster.”1 From the time that patients enter the Emergency Department, until they have been properly discharged or admitted into the healthcare system, the Emergency Physicians duties are clear: to provide scientifically based, appropriate timely healthcare in a caring and compassionate manner. 1. Henry, G. Patient Expectations. Emergency Medicine Risk Management: A Comprehensive Review. 1991. American College of Emergency Medicine 2. Little, N. Image of the Emergency Physician. Emergency Medicine Risk Management: A Comprehensive Review. 1991. American College of Emergency Medicine

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Shift Work, Circadian Rhythm and Satisfaction -

Surviving Your Month in Emergency Me dicine


This is probably the first time that most, if not all, of you have attempted to work on rotating shifts. Regardless of how many nights you were up during your surgery and OB-GYN clerkships and how many “all nighters” you pulled to get through your preclinical years- this is different! Shift work is one of the most difficult and stressful parts of emergency medicine. Unlike your other experiences, which mainly involved fatigue, you are now asking your body to adapt to a completely new physiologic environment. If you do not understand how your body adapts to changes in its sleep-wake cycles, you will find that you are chronically tired, irritable and even sick most of this month. Understanding the physiology of circadian rhythms will definitely improve your sense of well being and enjoyment. We know that shifting the sleep-wake cycles is bad for the body. Unfortunately, emergency medicine is a 24 hour a day job. There is never a “safe” time to leave the ED unattended so we can relax and get some much needed sleep. Furthermore, it’s difficult to get physicians to agree to work only night shifts because of problems with family life and professional growth and development. Most medical staff meetings, CME activities and fa mily activities are in the day. I have yet to go to a hospital committee meeting scheduled for 3 am! When 108 emergency physicians were polled in 1985 about the stresses in their practice by the ACEP Behavioral Emergencies Committee, what do you think they listed as their #1 stress? Dealing with sudden death? No! High volume and high acuity patients? No! Malpractice? No! You got it- shift work. The problems of shift work are a modern ailment. When I was a child in the 1950’s and 60’s, no one thought of buying gas in the middle of the night and gas stations were not open. Who would have dreamed then you could do your grocery shopping in the middle of the night and go to Wal-Mart� at 3 am to get your aunt’s birthday present. Emergency “Rooms” closed in the evenings and were staffed by “on call” nurses. If the nurse thought you were sick enough to need attention, he or she would call the doctor for orders to get you through the night and the doctor would see you on rounds in the morning. That was less than 20 years ago! Today, shift work has become common place. Many industries remain open all night and I do most of my shopping from 24 hour a day catalogues when I’m on night shift. We know well the problems of shift workers from industry studies, mostly police and the airline industry. 60-80% of shift workers complain of chronic sleep disturbances. Stomach disorders are 4-5 times more common with an eight fold increase in gastric ulcers. 80% of shift workers complain of fatigue. Depression is mo re likely and physicians who work shifts (emergency medicine and anesthesia) are more likely to be impaired. Shift workers have more accidents, especially over weekends when they try to stay up all day to be with their families. They have more automobile accidents on the way to and from work. Divorce and abuse are higher among those who work night shifts. There is a higher cardiovascular mortality in shift workers (equal to smoking 1 pack per day of cigarettes). Hypertension is more common in shift workers and there is decreased fertility in women and a decreased sperm count in men. Furthermore, length of sleep is a good predictor of survival. People who sleep an average of 4 hours a day have 10 times the mortality of those who sleep 7-8 hours a day. Surveys tell us that people who do all night shift work sleep on the average of 4 1/2 hours a day, whether in industry or medicine. They have a 5-10 year shorter life span than the normal population. Oversleeping does not help. Sleep can not be made up. The “best” sleep is 7-8 hours a day. People who sleep 10-12 hours a day also have increased mortality. It is obvious that sleep is an art that must be mastered if we are to survive shift work . Who then can do shift work? When polled, 20 % of the population of shift workers say they have “no problem” doing shift work. 60% admit that they have a problem and struggle with rotating shifts but are able to do their jobs. About 20% of the population have extreme difficulty with shifts and about half of those are unable to tolerate shift work at all. People who tend to be evening or “night people” (owls or extreme owls) tend to tolerate shifts better than larks or extreme larks. When you are on vacation, if you stay up to 2 or 3 am, you are an extreme owl and will probably adapt relatively easily to shifts. If you are like me, and get up with a cup of coffee at 5:30 to watch the sun rise- you will struggle with shift work as I have for the most part of 25 years. People who do well on rotating shifts tend to be those who handle tension and stress better and have greater social adaptability. They tend to have a high work efficiency and

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a high view of responsibility toward their work. They also have fewer children and little to no child care responsibilities. Let’s look at sleep stages. Stage 1 is a transition period. Normally it takes about 10 minutes for the non-sleep deprived worker to fall asleep. Longer delays are a predictor of a sleep disorder. Shorter delays ( 1-3 minutes) are a predictor of sleep deprivation. Stage 3 (delta sleep) is the most important. This is restorative sleep and is the first to be made up after deprivation. This is the stage when hormones are secreted and many of the body’s homeostatic mechanisms are active. REM sleep is dream sleep and is important for a sense of well being. REM deficiency causes moodiness and loss of mental alertness. Insufficient time spent sleeping can cause REM deficiency as will alcohol and many sleeping aids. Frequent interruptions in sleep will also cause REM deficiency, like a noisy environment (in a call room or motel) or frequent beeper calls. Just because you slept long, does not mean you slept well. Fragmented sleep can be caused by sub-arousal noise, caffeine, benzodiazepams, alcohol and food. Is there any good news here, or do I need to reconsider and go into dermatology? Actually, there are many mechanisms that can help the shift worker. Attention to good sleep and health habits can drastically improve your sense of well being and productivity. First, shorter shifts are better. Even though you may have to work an extra shift to “make up the time”, the 8 hour shift is preferable to the 12 hour shift. This gives you more time to rest and adapt to the changes. No one works 24 hour shifts anymore and surgeons are the only people in the world I know who think they are invincible enough to work 36 hours straight! No one in industry would even consider this. Clockwise rotation is the best method. Start with a morning shift for several days, advance to the evening and then to the night shift. Make sure you have several days off before starting the rotation again. It is easier to delay sleep than to advance it. It takes a worker about 6 days to adjust to a new shift so this is the minimum anyone should be on a particular shift. Actually, for those doing chronic shifts, a rotation schedule spread over 6 weeks to 2 months seems best. With a longer clockwise rotation schedule, industry reports as high as a 90% increase in employee satis faction and a 20% increase in productivity. Sleep difficulties may be down as much as 50%, accidents are down as are the use of alcohol and sleep aids. Some emergency medicine groups are experimenting with longer rotations. I heard of one group that worked 1 year of nights. In exchange for that year, they were guaranteed no more nights for the next 6 years. Industry is going to continuous coverage on the same shift. They are hiring people for a particular shift and offering incentives (money, extra vacation etc.) for those willing to work nights. This is evolving into the circadian “gold standard” of industry and some emergency medicine groups are adopting this as well. For those not able to adopt a longer rotation, the “isolated” night shift may be an alternative. Simply stated, each worker takes 1 night a week. While this is hard while you are working your night, it does not shift your circadian rhythm and after a day or so, you are back into your normal routine (until the next night). There are a few other ways to be kind to your body. You can try “anchor” sleep. This is a period of sleep that one gets every day regardless of rotation. For example, you are working a series of nights and sleep from 8 am till 4 p.m. during your string of nights , on your days off, try to sleep from 8 am till noon. These four hours will be the same regardless of your shift. Sleep will be more physiological and you will be sleeping at least half the time during time normally reserved for sleep. Another alternative is “split sleep”. This is best for a short series of nights like those worked during a one month rotation in the emergency department. Since a short series of nights will not allow for effective shift of the sleep/wake cycle, the goal is to prevent body rhythms from shifting into night. During “split sleep” you will sleep in 2-4 hour cycles adjacent to your normal sleep time. After working a night shift, go to bed immediately and force yourself to get up in 4 hours. Sleeping longer will retard the next night’s sleep. Go about your normal daily activities. If you must work again that night, sleep another 2-4 hours before going into work. This disrupts the rhythm less and you will feel more rested. Another method is to take advantage of a nap. The best napping time (siesta) is during your body’s normal metabolic low, between 2-3 in the afternoon and 2-4 am in the morning. Sleep is of better quality during these hours and is more “restorative”. Short naps can be helpful as well. Pilots on transoceanic flights found that napping during the day or night for 30-40 minutes can cause increased mental alertness. Beware, napping longer (1 hour) can cause “sleep inertia” and actually decreases performance. What else can be done to make shift work easier? First, make sure you have a quiet place to sleep. Noisy environments cause sleep fragmentation. Even though you may not awaken because of “sub-arousal” noise, your sleep may be fragmented by constant shifting sleep stages. Fragmented sleep is not good sleep. Avoid alcohol, sleep aids and fatty foods before sleep all of which tend to fragment sleep. Beware of that

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pizza at 4 am. You can not be responsible for childcare and sleep at the same time. You will do a poor job at both! Ear plugs or “white” noise may be helpful if you do not have a quiet place to sleep. Buy a message machine and turn off the phones and beeper! Second, make sure the room temperature is conducive to sleep. The best temperature is around 75 degrees. Too hot an environment or too cold a room will result in poor sleep and unpleasant dreams. Third, moderate exercise improves sleep. Exercise not only improves sleep and overall general health, but psychological well being as well and should be a lifetime commitment for everyone, regardless as to whether they are shift workers or not! Vigorous exercise has been shown to decrease the time to shift circadian sleep/wake cycles from 8 to 1.5 days in the animal model. Fourth, make sure your bedroom is conducive to sleep and develop and maintain a sleep ritual. Remove the TV and computer from bedroom and do not work in bed. If you do, you are likely to take your work to bed with you or to have the violence on TV upset or effect your sleep. Fifth, very bright light for several hours after awakening decreases the time needed to shift the circadian rhythm. The bright light improves your sense of alertness and refreshment after awakening. Try an outside activity in the bright sun light after awakening. This might even be combined with exercise. You will feel refreshed. Conversely, bright light and exercise before sleep may inhibit sleep. Lastly, work with family and friends to make sure you have quality time with each. If you are happy, you will adapt to shifts better. Your family and friends will never understand the way you feel after working shifts- so don’t expect them to. They expect you to live a normal day lifestyle after working nights. Even though my wife is a physician and I have been working shifts for many years, she still doesn’t understand the way I feel after a string of nights. But our lives are better when I have protected time with my family each evening before I return to the hospital. Understanding some of the stresses of shift work, as well as the coping mechanisms, will make your rotation easier and less stressful not to mention healthier. There is no reason why, with attention to some of the above details, you can not only survive the next month, but actually look forward to it with enthusiasm and anticipation. This will be a different experience for you. Use this month to experiment with some of the above suggestions. No matter if you never do another month of shifts, you will be a better person for it. Some of us have been doing this for more than 20 years and are still happy, healthy, productive and looking forward to our next shift in the emergency department.

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Triage


Traditional wisdom dictates that it is the patient’s duty to define what constitutes an emergency- not ours. This may be changing in the climate of managed care as the gatekeeper on the telephone is being called to make that decision for the patient and the health care system. It is true that if patients are allowed to define what constitutes an emergency, mis takes will be made in both the false-positive (anxiety over presumed illness) and false-negative (denial of real illness) patterns. Emergency Medicine is the science that deals with these difficult realities: not all patients are as sick as they think, and not all patients are as well as they presume. Into this already confusing arena, we add the fact that the medically indigent are increasingly using Emergency Departments for their primary care and the medically underserved see the E.D. as their only resort. We can spend our days as the "social police" for society trying to decide which individuals are deserving of care, but we will shortly tire ourselves and become disillusioned and embittered. We will also antagonize our patients and cause resentment in our staff. It is the responsibility of the Emergency Physician to examine every patient who presents for care to the Emergency Department regardless of the type, duration, or severity of the illness, ability to pay or time of the day of presentation. This makes us unique among the medical profession. We are proud of the fact that we remain as the only specialty that, as a whole, will provide care without discrimination and without ability to pay. Given that, generally speaking, the patient is allowed to define what constitutes an emergency, and given that we will examine each and every patient that presents for care, it is easy to see that the Emergency Department would be sheer chaos if some order were not imposed. That order is called the triage system. Triage is a process where priorities are set and patients are sorted according to critical conditions. Not everyone defines those priorities the same. In the military under battlefield conditions, I am told, those with simple problems that can be rapidly resolved with immediate return to the battlefield are treated first. When I lived and practiced in South Asia, those patients with complicated life-threatening medical problems were sent home or to other hospitals and those with less complicated problems were examined and treated. Triage is thus setting our priorities and matching those priorities with our ability to provide care. Triage is not democratic. Patients are not allowed a vote. It is the medical community that defines the priorities of triage. Emergency Departments in the 1990's have been overcrowded. It is easy to see that if care was democratic, on a first-come-first-serve basis or defined according to ability to pay or social status, patients with relatively minor illnesses would be treated at the expense of those with life or limb-threatening diseases. It would not be hard to imagine our rooms filled with patients with sore throats, sprained ankles, contusions and minor lacerations while heart attacks and G. I. bleeders died in the waiting room. The system of triage used in Emergency Departments is universally based on severity of illness. With almost no exceptions, it has become a nursing function with written protocols directed by the physician staff. Patients are initially interviewed by the nurse, vital signs taken, and a triage category assigned. That triage category determines the order in which patients will be seen. Most E.D.'s use a three tiered triage system (e.g. emergent, urgent, and non-urgent). Using this system, the patients with the most urgent/emergent illnesses are seen first (patients with the lowest number). All patients in that number category must be seen before patients in a higher number category are seen. As you can see, it is possible for a patient to be assigned a #3 triage category (e.g. upper respiratory tract symptoms) and be next to be seen, yet before he can be seen five other patients arrive and are assigned lower numbers (e.g. higher triage priority). All five of those patients normally would be seen before the patient with an upper respiratory tract infection in a #3 triage category. Those who can wait -do wait. Those who can't wait-don't wait. This is why some patients who come first actually may be seen last. Contrary to the above, in the last 5 years, it has become common for Emergency Departments to establish “fast tracks” or “prompt care” attended by physician assistants or nurse practitioners. These serve to decrease the backlog of less ill patients and to decrease overcrowding in our E.D.’s, reserving room and time for the more critically ill patients. However, when run efficiently, it is now possible for patients who are less critically ill to be seen and evaluated before the more critically ill patients.

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Understanding MCG's triage categories CATEGORY 1 LIFE-THREATENING/URGENT (Patients seen immediately by physician) Cardiopulmonary arrest Severe respiratory distress Shock Major trauma Major burns Coma Overdose Anaphylaxis Status epilepticus Uncontrolled hemorrhage Hypothermia, Hyperthermia (105 F/40 C) Chest pain of cardiac/pulmonary origin Multiple fractures Fractures with vascular/neurological deficit Severe asthma Decreased level of consciousness Eye illness/injury with impairment of vision Drug overdose Severe emotional disturbance Disruptive/violent behavior Severe headache Arterial bleeding Urinary retention Renal colic Seizures Vaginal bleeding/ 1st trimester Abdominal pain/ R/O ectopic Nausea, vomiting or diarrhea with dehydration Immunocompromised patients (sickle cell, AIDS, post transplant, chemo) CATEGORY 2 SEMIURGENT (Patients will need to be seen by physician within three hours) Cystitis Pharyngitis Otitis media Mild fever N/V/D without dehydration Lacerations Abscess Hemorrhoids Simple fractures Back pain Foreign body to eye/ \no visual impairment Vaginal bleeding not associated with pregnancy Headache, moderate intensity Sprains/strains

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CATEGORY 3 NONURGENT/NO NEED FOR EMERGENCY MEDICAL CARE (Patients need evaluation, but time is not a critical factor. Physician will examine when all other categories have been seen first.) Attending physician, and only attending, may triage away to appropriate clinic, but only after a medical screening examination. Simple rash Chronic headache Chronic hypertension Chronic arthritis Constipation Rhinitis "Cold" symptoms Vaginal/penile discharge without fever Routine physical exam Superficial scratches/minor bruises/benign mechanism of injury Varicose veins

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Protocols In The Emergency Department


The purpose of written protocols is to have specific criteria set in place to ensure quality care to local and national standards. There are basically two types of protocols used in the Emergency Department: protocols meant to speed patient care and protocols meant to standardize patient care. (Protocols used by EMS personnel are not addressed here.) Although protocols were designed to protect patients, to ensure the highest quality of care, they also set standards that can and often are used in determining if that standard was breached. Subsequently, they are used by both judges and juries as a yardstick to measure your performance in any particular case. It is therefore incumbent upon each physician to familiarize himself/herself with not only the protocols at the institution where you work, but with other protocols in your local region, and most importantly, with national protocols, especially those published by the American College of Emergency Physicians. Each physician may be retrospectively judged in accordance with nationally published protocols wherever he/she practices and whatever the circumstances. In Emergency Medicine, there is a national standard presumed to be equal throughout the U.S. In other words, when there is a nationally recognized protocol, the standard of care is the same whether you are in a small rural hospital or a large university center! Although, only a few protocols will be mentioned here, the Director of Emergency Services in each hospital keeps a complete list of protocols used in that hospital. National protocols in Emergency Medicine are available through ACEP and are kept by most Emergency Physicians. Protocols to speed care (Standing Orders) The MCG Emergency Department has 13 protocols designed to expedite care. A patient who presents to the ED with any of the below listed complaints, may be a candidate for the protocol. The patient is triaged as per policy. If the complaint meets the criteria for the "standing orders", the EM attending or the senior EM resident may sign the orders for the triage nurse. The triage nurse then implements the orders. Thus, when the patient actually is put into a room, appropriate lab and X-ray may already be under way. The MCG "Standing Orders" are: 1 Asthma 2. Chemical burns to the eye 3. Chest pain (or admitted cocaine use within 24 hours) 4. Dialysis patients 5. Fever 6. Altered level of consciousness 7. Care of laceration 8. Abdominal pain in women 9. Renal transplant patients 10. Patients with seizures 11. Minor trauma 12. Sickle cell crisis 13. Patients with dizziness, faintness, or resting tachycardia Protocols meant to standardize care Although there are numerous protocols published that standardize care, listing them all with a discussion is beyond the scope of this manual. Suffice it to be known that there are national protocols (policies). Some examples include the care of patients with chest pain, pediatric fever (in process), sexual assault, child abuse, elder abuse, spouse abuse, AIDS, advanced life support, multiple trauma, pediatric resuscitation, behavioral emergencies, access to care, admission orders, disasters, DNR orders, Emergency Physician qualifications, patient transfers, use of restraints, telephone orders, etc. If you work in an Emergency Department, or if you plan to moonlight (not recommended) and you do not know these protocols - you should! "Patients today are better educated and more aware of how Emergency Departments function; they expect to have their rights honored and their care rendered by prudent and knowledgeable practitioners. When illness strikes, they expect nurses and physicians to follow specific standards and protocols at any given emergency department in which they would seek help." Emergency Medicine Risk Management ACEP, page 350, 1991.

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Tetanus Immunization Protocol Recommendations for tetanus prophylaxis are based on 1) condition of the wound and 2) the patient's immunization history. The table below outlines some of the features of wounds that are prone to develop tetanus. A wound with any one of these features is a tetanus-prone wound. CLINICAL FEATURES TETANUS PRONE CLEAN, MINOR WOUNDS Age of wound 6 hours 6 hours Configuration stellate, avulsion linear, abrasion Mechanism of injury missile, crush, heat sharp surface (knife, glass) Signs of infection present absent Devitalized tissue present absent Contaminants (dirt, saliva) present absent Previously immunized individuals

a. for fully immunized individuals for tetanus prone wounds if more than 5 years has elapsed, give 0.5 ml absorbed toxoid.

b. If excessive prior toxoid injections have been given, the above may be deleted. c. Partially immunized patients who received the last dose more than 10 years ago, give 0.5 ml

of absorbed toxoid for both tetanus prone and nontetanus prone wounds. Passive immunization is not necessary.

Individuals not adequately immunized, i.e. when the patient has only one or no prior injections of toxoid give:

a. Nontetanus prone- 0.5 ml absorbed toxoid and begin the normal immunization schedule for full immunization(three injections) b. Tetanus prone- 0.5 ml absorbed toxoid and 250 units of human, tetanus immune globulin

Rabies Prophylaxis Protocol LOCAL WOUND CARE Scrub wound with Betadine© soap solution Flush with water copiously Provide tetanus prophylaxis as needed Apply dressing POST EXPOSURE IMMUNIZATION For all bite exposures in which rabies can not be excluded and for all non bite exposures (mucous membranes) if the animal is suspected of having rabies:

Hyperrab© Rabies Immune Globulin (human)- give one dose only AND Human Diploid Cell Vaccine- give 1 ml dose on days 0, 3, 7, 14, & 28

Needlesticks, AIDS, AZT and the Health Care Worker All hospitals have a needlestick policy to deal with health care workers exposed to infectious materials. Mostly, this involves the risk of contracting syphilis, Hepatitis B and HIV although there are other, less common illnesses transmitted as well. The policy involving hepatitis B is clear- all health care workers who come in contact with patients should be immunized against hepatitis B. All clinical health care workers are considered at risk and since the vaccine is benign, as far as side effects, it is recommended for everyone. If you are stuck with a sharp and have not had the vaccine- you have proven that you are at risk and should begin the vaccine as soon as possible. If you are stuck with a sharp from a patient with active hepatitis B or at high risk for hepatitis B and have not been vaccinated, you will also be offered hepatitis B immune globulin at the same time you begin your vaccination process. There is almost no reason for a health care worker to refuse to be vaccinated. Unfortunately, the issues surrounding HIV transmission are not as clear. In the event that you have a significant exposure to a patient with known HIV disease or at high risk for disease, an HIV test can be ordered on blood drawn from the patient for other purposes for which the patient consented. An HIV test

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can be done on this blood without the consent of the patient, even against the patient’s will, with the concurrence of two physicians. MCG policy defines exposure as: MASSIVE EXPOSURE* Transfusion of blood Injection of a large volume of blood/body fluids Parenteral exposure to lab specimens with a high HIV titer DEFINITE PARENTERAL EXPOSURE* IM injection with a blood/body fluid contaminated needle Laceration or similar wound which causes bleeding in HCW produced by visibly contaminated

instrument with blood/body fluids Laceration or similar wound inoculated with contaminated blood/body fluid POSSIBLE PARENTERAL EXPOSURE* Subcutaneous injury with blood/body fluid contaminated needle A wound caused by a blood/body fluid contaminated instrument that does not cause visible

bleeding Mucous membrane inoculation with blood/body fluid DOUBTFUL PARENTERAL EXPOSURE Subcutaneous injury with non-bloody, body fluid contaminated needle A superficial wound that does not cause bleeding Mucous membrane inoculation with non-bloody body fluid NON-PARENTERAL EXPOSURE Intact skin visibly contaminated with blood/body fluid *At MCG, you are offered an HIV test as well as AZT and other drug prophylaxis if you have a significant exposure to HIV ( e.g. massive exposure, definite parenteral exposure, possible parenteral exposure). It is wise for every health care worker to ponder the implications of an exposure to HIV infected material, both from a medical and social perspective. Needless to say, all HCW's should be compliant with universal precautions. Also, each one should decide what he/she would do in the event of an exposure so that when AZT is offered, a decision can be made rapidly. Consider the following, circulated by MCG's infection control committee: (paraphrased by WK) 1. AZT is effective in HIV infected persons and those with AIDS by inhibiting the replication of the virus. 2. The effectiveness of AZT prophylaxis is not known after exposure to HIV. One AZT prophylaxis trial failed to show benefit. Limited animal studies demonstrated a possible "modification" in the course of HIV infection (infection still occurred but was slightly delayed) 3. The risk of developing infection with HIV after needlestick exposure to HIV infected material (Definite/possible parenteral exposure) is low, 0.4%. Exposure to other HIV infected body fluids is not known, but is probably lower. 4. Adverse effects of short term AZT prophylaxis most often are nausea, vomiting, and decreased hemoglobin. Instances of severe anemia, peripheral neuropathy and hepatitis have occurred and were reversible. The long-term effects are more serious and are not listed here. 5. Interval between exposure and initiation of AZT prophylaxis, if selected, should be as short as possible, preferably within 2-4 hours with the exceptions of HCW with preexisting illness which would preclude the use of AZT (HIV infection, pregnancy, breast feeding, history of malignancy, treatment with a myelosuppressive or nephrotoxic agent in the preceding 4 weeks, compromised bone marrow, creatinine > 2 times normal or liver dysfunction)

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Cost Containment in Emergency Medicine

Walter Kuhn, M.D., FACEP and Hartmut Gross, M.D., FACEP

Recognize the Problem Although we all say that a problem exists, most of us feel that it is for the "other" guy to cut the cost of his /her care, not for me. Until we all acknowledge that a problem exists and that the solution rests with each and every one of us, there is little personal motivation to make important and difficult changes in established practice patterns. I, myself, have often said, "They pay me to be right, not cheap." In the long run we need to be right and cheap. Cost containment will eventually effect us all. The way we practice medicine in the future depends on what we collectively do today. We must learn what the minimum appropriate work-up is for every illness and discipline ourselves to order only those tests or interventions absolutely necessary. If we are used to ordering a CT scan for every patient in the ED with a headache, eventually, there will be no place for us in the modern health care system! However, it is also true that the tests ordered in the ED are small change when compared to the cost of an inappropriate or unnecessary admission to the hospital. We are seeing increasing use of outpatient therapy and intermediate interventions- like observations units to cut the cost of care. We daily face pressures to discharge patients today who would have been admitted a few years ago. I can easily remember when every patient with pyelonephritis or a kidney stone or undiagnosed abdominal pain was admitted to the hospital for observation. * Many wasteful practice patterns are learned in medical school and during residency training. These patterns are then carried and nurtured during years of clinical practice and lead physicians to order tests that they neither need nor want. Some of the pressures and misconceptions contributing to the wide array and high volume of laboratory and X-ray procedures ordered in the ED are familiar: A. Fear of criticism by other physicians for not ordering a test B. Fear of legal liability C. A need to discover as many things possible wrong with the patient in as short a period of times

as possible D. Pressure from the patient or his family E. Hospital policies mandating certain "routine" admission tests

F. The feeling that we must "do it all" during the current visit because many ED patients may not seek follow-up

Know specific strategies useful in limiting the use of ancillary tests and procedures. 1. Be selective and avoid ordering tests by reflex. The ordering of "baseline" tests is usually inappropriate. Question your motives when you think to order "baseline" tests. 2. Ask the "Golden Question"

The "Golden Question" should be asked before any tests or X-rays are ordered. "How useful will the results of this test be in establishing a diagnosis or influencing a therapeutic decision?" A good example of this is the routine ordering of a CBC, SMA-7 and abdominal X-rays on patients with suspected appendicitis. It is well documented and scientifically proven that appendicitis is a “clinical” diagnosis and that no test or intervention is sufficiently sensitive or specific to make the diagnosis. Clinical impression is still the standard as it was 50 years ago.

3. Don't order a test just to satisfy your own intellectual curiosity. 4. Allow time to be a diagnostic aid. Observe and reassess patients. 5. Reevaluate protocols that call for the automatic ordering of tests. 6. Develop and use a systematic approach when deciding to order newer diagnostic procedures. 7. Avoid ordering a test for purely "medicolegal" reasons.

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Remember- "If it's not medically indicated- it's not legally needed" 8. Involve your patient in your reasons for not ordering inappropriate tests. 9. When you do decide to order certain tests, don't "dribble", that is, don't add the tests to the order sheet a little at a time. This requires the nurses and clerks to take your orders off the chart repeatedly and prolongs the patient stay. Order all you need at the beginning of your evaluation, if possible. Note: in most ED's, patients are charged according to the length of their stay. One final way to think about the ordering of tests is to imagine the Physician’s Orders sheets as a stack of blank checks which the patient has signed. Every time you order a test, you are making a withdrawal from the patient’s bank account. How much do you need to drain the account? * Excerpted with changes by W. Kuhn, M.D. from Cost Containment: Guidelines for Cost Containment in Emergency Medicine, ACEP, 1983.

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Clinical Pearls For

Cost Containment in the Emergency Department*


ABDOMINAL X-RAYS Abdominal X-rays are not indicated for nonspecific signs and symptoms like nausea, vomiting, diarrhea, diffuse abdominal pain and Guiaic positive stools. X-rays almost never assist in the diagnosis with the exception of free air, which is unusual

and normally suspected by the clinical exam. They should be ordered to confirm a suspected significant diagnosis, e.g. small bowel obstruction.

ARTERIAL BLOOD GAS For a patient with uncomplicated asthma-treat first! Consider alternatives that may give you better and more

Information (e.g. bedside pulmonary function testing) BLOOD ALCOHOL A blood alcohol level is not indicated in a mildly intoxicated patient with no other possible cause of his/her "intoxication." It is not necessary to check it on everyone who smells of

alcohol. BLOOD TYPING AND Attempt to estimate the present and future blood loss using ADMINISTRATION objective criteria and order blood 2 units at a time in patients with other than immediate major blood losses. When the need

for blood is gone, be sure to let the blood bank know so the held units of blood don’t expire and get charged to the patient.

CBC AND DIFF Stop reflex ordering. Determine the information actually needed and order only that subcomponent (e.g. hemoglobin or platelets, etc.). A Hemacue©, done quickly and inexpensively in the ED may suffice. CHEMISTRY PROFILE (BMP & CMP) All the information contained in the larger metabolic profiles (fomerly SMA) is rarely needed in the ED care of the patient. Check with your lab to see if doing the individual tests are less expensive. If one result is cheaper than six, and you need only one, order only one (for example a potassium). CHEST X-RAY Routine ordering of chest X-ray without specific indications is to be discouraged, especially in patients less than 40 years of age. The vast majority of pneumonias are clinically apparent, and if you can hear it, why do you need the X-ray? CT SCAN OF HEAD Not every case of head trauma needs a CT scan. Alert patients (Glasglow 14-15) with a history of minor injury or transient loss of consciousness can be managed without CT. Bleeds, if any are missed, are minor and nonoperative, and treated symptomatically. DRUG SCREEN Order a Tox Screen only if the results will alter your Management of the patient ( e.g. acetaminophen). Tox

screens can be inaccurate, misleading, and are expensive. LUMBAR SPINE X-RAY If the physical exam is normal, it is unlikely there will be any

Significant X-ray findings. Save the X-ray for the very young, the old and those with a history of trauma or neurologic deficits.

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CULTURES Cultures of abscesses and vaginal discharge (except for GC)

are of little use. X-RAY FOR RIB DETAIL X-rays do not change the therapy in minor trauma and are not indicated. SKULL X-RAYS Order skull X-rays to evaluate trauma or medical conditions

affecting the skull- not the brain. Often a careful clinical evaluation with observation and follow-up is more helpful than a multiview skull x-ray.

THROAT CULTURE In almost all cases the only type of throat culture that should

be performed is a strep screen. A culture is not indicated if the physician decides to treat presumptively (exception- GC pharyngitis).

URINE C & S The uncomplicated, historically isolated, lower UTI in adult

females can be treated without the extra cost of a culture. Reserve cultures for patients who return with repeat infections, in all men with UTI’s and those with complicated infections (pyelonephritis, infection in pregnancy and with a stone).

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Cost Ranges for Tests

Commonly Ordered In Emergency Departments


LABORATORY TESTS COST RANGE $ CHEMISTRY Alkaline phosphatase 15.50 Amylase 13.13-14.29 Arterial Blood Gases 26.40 AST 6.60-8.80 Bilirubin-total 10.96-15.50 BUN 9.90 Calcium 10.84-30.68 CPK 15.61 CK-MB 15.61 Creatinine 10.78 Electrolytes (Na, K, Cl, CO2) 17.73-24.77 Glucose 10.78-11.00 HCG-Beta subunit 12.10-29.70 Lactic Acid 10.78 HIV 41.80 Toxicology Screen (EMIT) 55.00-77.00 VDRL 20.00 Urinalysis (dipstick and microscopic) 7.15-11.55 HEMATOLOGY CBC and DIFF 14.26 Hemoglobin/hematocrit 11.00-14.30 PTT 25.15 P-Time 9.55-14.19 Peripheral Smear No Charge BACTERIOLOGY Blood Culture 55.04 GC Culture 27.50-38.50 Gram Stain 12.38 Chlamydia Culture 59.00 Strep Screen 13.20 Urine Culture 3.30-15.95 RADIOLOGIC IMAGING C-spine 138.50 PA/Lat Chest 129.20 Portable Chest 128.40 Abdominal Series (4 X-rays) 220.00 LS Spine Series 196.60 Upper Extremity X-ray 85.00 Lower extremity 80.00 Facial Bones 145.00

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CONTRAST X-RAYS IVP 302.00 CT SCANS Head (noncontrast) 562.50 Abdomen (noncontrast) 750.00 NUCLEAR MEDICINE Lung Scan 206.80-275.00 ULTRASOUND Pelvis 137.50 Abdomen 275.00 ELECTROCARDIOGRAPHY EKG 25.00 Updated 6/2000

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Dispensing Medications in the E.D.

And Prescribing Practices


Medications and High Security- Why All the Fuss? The medication dispensing machines were installed for several reasons: a. Rules governing the dispensing of medications from an Emergency Department are very specific and demanding: The Georgia State Board of Pharmacy regulations allow for a physician dispensing of a supply of emergency medication from an emergency room ONLY when a licensed pharmacy is not available. If the physician elects to dispense, he must comply with all labeling, packaging (including child-proof containers) and record keeping requirements that pharmacies must comply with. The dispensers help with the record keeping, packaging and labeling of medications. Medications are also listed with patient numbers. b. In the last years an enormous amount of medicine has been stolen or misplaced from the E.D. This has totaled thousands of dollars each month. Oftentimes it has been from a well intentioned nurse or physician giving medication to patients without regard to proper charges. In any case, the medication dispensers have basically eliminated the loss of medications. Why are there so few medications available in the E.D. that I can give to patients to "get them started"? This is governed by the Georgia State Board of Pharmacy, not by an Emergency Department’s wishes or desires. The following is a statement from the State Board- 480-13-06 (11) Emergency Room Dispensing A physician may, when drugs or controlled substances are not otherwise available from a licensed pharmacy, dispense an emergency amount of medication, but only sufficient quantities until such a time as medication can be obtained from a pharmacy licensed as a retail pharmacy. Nurses may not dis pense medication from the emergency room. Since the Augusta area is covered by a 24 hour pharmacy (Revco© till midnight and Kroger© all night) there should be virtually no circumstance existing in which it should be necessary to dispense drugs from emergency services. (e.g. the stock of medications in the E.D. is for patients while they are present in the facility only). This is likewise the reason that “samples” of medication from drug representatives are not distributed to patients in the E.D. What if the patient is so poor that they can not afford the medication, yet it is urgently needed? We are not in a position to solve all of societies needs, yet we must guarantee the safety of our patients. The MCG pharmacy is authorized to dispense a 48 hour supply of medications without charge in emergency situations. Therefore, when this need arises "after hours," a prescription should be written for the 48 hour emergency supply and taken to the inpatient pharmacy. During normal hospital hours, the patient should be directed to the outpatient pharmacy. A second prescription is written for the remainder of the course of the medication. The patient representative should be notified or social services should be involved to help with the finances for the remainder of the prescription. PRESCRIPTION DRUG SEEKERS* In the past, most narcotic seekers were heroin addicts. The need for prescription narcotics varied inversely with the supply of heroin on the street. However, supply and demand is not the only reason many drug seekers prefer prescription narcotics. First, unlike illicit drugs, the safety and strength of prescription drugs is uniform. Second, unlike illicit substances, prescription drugs may be legally possessed. Third, the drug seeker is dealing with a physician and a pharmacist, rather than an unsavory drug dealer or an undercover police officer (most physicians are easy prey, since we usually are not street smart). Finally, some drug addicts, worried about the transmission of human immunodeficiency virus through the sharing of intravenous needles, are opting instead for oral prescription drugs. Some common disorders feigned by drug seekers seen in the ED* Migraine headache Toothache Tic douloureux Sickle Cell Crisis Back pain Renal colic Colitis Metastatic cancer Acute or chronic pain from orthopedic injury Narcolepsy

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Street Prices of drugs of abuse (1988)* Drug name Street price $ per tablet Diphenoxylate (Lomotil©) 4 - 6 Methylphenidate(Ritalin©) 3 - 5 Propoxyphene (Darvon©) 10 - 15 Tylenol #3© 5 Diazepam 3 - 5 Oxycodone (Percodan©, Percocet©) 10 - 12 Hydromorphone (Dilaudid©) 10 - 15 LSD 6 - 10 Codeine 3 - 5 ‘Crack’ Cocaine 10 - Hit / 20 - Rock / 100 - Gram Forging prescriptions* Prescriptions are forged in one of the following ways:

A. Altering a prescription written by a doctor- the drug seeker uses a pen with the same color ink and alters the number of the medication to be prescribed by changing the Arabic or Roman numerals . You can guard against this by writing both the number and then in longhand, the corresponding number alongside. When in doubt, also omit your DEA (BNDD) number which will force the pharmacist to call you before the prescription is filled.

B. Forging prescriptions from scratch- (common in Augusta) The forger begins with a legitimate prescription blank from a practicing physician (either

stolen or stenciled). (With the advent of computers some drug seekers use desktop publishing to produce prescription pads and can alter the physicians involved at will). They then write for whatever they wish and are often clever in forging the pads and prescriptions. If they have the pads or are producing them on computer, small numbers of pills can be prescribed which often does not alert the pharmacist.

Reducing prescription drug forgery*(ER Reports, Dec 19, 1988) 1. Store all unused prescription pads in a safe place. 2. Minimize the number of pads in use at one time. 3. Number prescription blanks so that missing blanks may easily be detected. 4. Never sign prescription blanks in advance. 5. Write prescriptions in ink 6. Use combination of long-hand plus Arabic and Roman numerals to indicate the amount of the drug

prescribed. 7. Do not use prescription blanks for memos or for instructions to patients.

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You, the Dea, and

The Georgia Composite State Board of Medical Examiners


Georgia has strict laws regarding the prescribing of addictive substances. With a few helpful hints, you can stay out of trouble yet treat your patients appropriately. Consider the following sent to all physicians licensed in Georgia: “The Georgia Board of Medical Examiners is charged by law to protect the citizens of the State from harmful physician management. A significant number of physicians who are asked to appear before the Board are required to do so because of their lack of information about the management and responsibilities in prescribing controlled substances. Frequently, the inadvertent offender is a physician with a warm heart and a desire to relieve pain and misery…” The Board lists steps to assure proper use of addictive substances. Several of those steps are: A. Don't prescribe anything unless your diagnosis is supported by your history and physical. B. Create a plan using nonaddictive drugs first, if possible. C. Document that nonaddictive substances did not work or are not appropriate before giving addictive

drugs. D. Make sure that you are not dealing with a drug-seeking patient.

(A list is kept by many EDs of patients who commonly present to the E.D. with drug seeking behavior) E. Maintain adequate records to support your use/continued use of addictive substances. In most EDs narcotics are under-utilized rather than over-utilized because of fear of drug-seekers and because physicians worry about causing iatrogenic addiction in patients along with the other concerns listed above. There are many patients we see that have legitimate pain and are appropriately managed with narcotics. Always remember that we, as healers, have been charged to "relieve suffering and protect life". Short courses of narcotic analgesics are appropriate and seldom (never) cause addiction when prescribed for an acutely painful condition over a period of several days to 1-2 weeks.

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Conflict Resolution Between Emergency Physicians

And Consultant Physicians


“It is important to recognize that Emergency Physicians have an independent body of knowledge and skills in their own right which forms the basis of their practice, and that they possess an independent, unrestricted license to practice medicine as a physician and surgeon. Emergency Physicians, unlike interns or residents, are not the trainees or apprentices of any other physician on the medical staff. This fact may not be as well recognized by attending or consultant physicians”1 as it is by Emergency Physicians, a discrepancy that can be a source of conflict between Emergency Physicians, consultants and private attendings. This fact does not relieve the Emergency Physician of acting upon his/her own judgment concerning the best interests of the patient while in his care. The Emergency Physician owes an independent duty to the patient to see that the individual understands and agrees to whatever care is administered. When there is substantial disagreement regarding patient care between attending physicians, a potentially dangerous situation arises for physician and patient alike. Six areas of potential misunderstanding exist regarding the relationship between the private attending and the Emergency Physician. These are briefly discussed below. First, it is important to understand that the private attending does not "own" the patient, that is, they cannot dictate the course of the patient’s medical care against their will. Nor can such physicians direct other practitioners to agree to actions that may be against the patient’s will or the Emergency Physician’s best judgment. Attending physicians do have their own duty to patients, and that duty includes both follow-up and consultation. Not to do so would be abandonment, which is against the law. “Clearly, the Emergency Physician and the attending are inextricably intertwined in their respective care of the patient. A smooth working relationship is essential. It is also essential that each party understand his/her own independent duties to the patient.”1 The Emergency Physicians duty to the patient is often one of patient advocacy. We believe that medicine should be practiced the same way at 3 am as 3 pm and that care should not be compromised to fit into another doctor’s social or medical schedule. It is the Emergency Physician’s job to make certain that all necessary and attainable care is rendered to the patient. The Emergency Physician does not have a duty to the attending or consultant physician. We are not his/her advocate. To assume the role of the physician’s advocate would be a direct conflict of interests. You can not be an advocate for two parties with different interests at the same time! “It is not the job of the Emergency Physician to manage the ego, the finances, or the schedule of the attending physician, nor to accommodate that physician's medical practice or sleep patterns!”1 It is true that Emergency Physicians may be the bearers of bad news, requiring a physician to get out of bed in the middle of the night to take care of a patient. But emergency care often involves hard decisions, and the patient’s rights and needs must be the first priority. “The most frequent area of potential conflict is patient admission to the hospital. If the Emergency Physician believes that a patient should be admitted to the hospital, and the attending physician disagrees, this conflict must be resolved.”1 Resolution should never occur on the phone. The attending must come personally to see and examine the patient. This will allow the attending to have the same knowledge base as the Emergency Physician has about the immediate condition of the patient. If the two physicians can still not agree, a third physician, a neutral party, can be asked to arbitrate the dispute. “The timing of follow-up care can be a third area of serious conflict. If the patient's medical condition warrants that a repeat exam occur in the next 24 hours, and it happens to be Saturday night, that means that follow-up should occur on Sunday. To change the opinion on the timing of follow-up based upon usual office practice hours may not be in the best interest of the patient. It's good to remember just whose advocate you are! The Emergency Physician should recommend that the attending conduct a follow-up exam regardless of the day of the week.”1

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A fourth area of conflict can arise over the choice of medication used, or the request of a consultant to be contacted before certain medications or treatments are instituted. If this is the desire, then he/she should come immediately to the E.D. to assume the care of the patient. Often times these requests lead to significant delays in care that may risk a poor outcome, as would be the case in the delay to provide thrombolytic therapy to a patient with an acute M.I. or an antibiotic to a patient with a life threatening infection. “A fifth potential conflict may arise when the "private patient" presents to the E.D. with the expectation of seeing their own private physician. Such arrangements may even have been made. However, this does not relieve the Emergency Physician of his/her duty to examine the patient. While the arrival of the patient and the need for care are certain, the arrival of the consultant physician is not as certain. The Emergency Physician is the primary caregiver”1 of all patients in the E.D. until the private physician/consultant arrives and assumes that care. “The sixth area of potential conflict is the recommendation that the patient needs the consultant physician on the spot. That may mean disrupting the attending physician's office hours, sleep, social commitments etc. which often creates friction between the consultant and the Emergency Physician.”1 In the example of surgical subspecialties this may mean breaking scrub or changing the O.R. schedule to accommodate a patient’s needs. In the heat of battle, always remember that the patient’s immediate need must come first. Going up the ladder In academic institutions especially, often there is disagreement between the interns and residents who are consulting on a specialty and the Emergency Physician. It is wise to remember who is faculty and who is student! The conflict must be resolved and may be best dealt with by " going up the ladder". This essentially means calling the faculty back-up for that specialty and insisting that the faculty member come to the Emergency Department to personally evaluate the patient (his/her responsibility anyway!). If the faculty defers to his resident’s opinion, go up the ladder again. Go to the next immediate superior- usually the Section Chief or the Department Chairman. If still no resolution can be reached (unusual) go up the ladder again, for example to the Chief of the Medical staff at your hospital or the Dean of the Medical School if it is an academic institution. Eventually, someone will listen and it is unlikely that you will have trouble again! However, care must be taken not to be vindictive. You will need mutual cooperation for future encounters in patient care. 1. Little, N. Conflict Resolution: Attending Physician-Emergency Physician. Emergency Medicine Risk Management: A Comprehensive Review American College of Emergency Medicine, 1991.

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Malpractice and Emergency Medicine


Every Emergency Physician fears being sued. Unfortunately, the practice of Emergency Medicine is high risk and malpractice claims stemming from emergency care number about 20% of all claims occurring in hospitals. The Emergency Department is the third riskiest area of the hospital following the operating room and the delivery suite. Malpractice premiums paid by Emergency Physicians have risen dramatically over the last years with a 200 % rise in some States. Lawsuits against Emergency Physicians are not nuisance claims: more than half of legitimate claims involve serious disability or death. Surprisingly, the big payoffs do not go for the missed hard-to-diagnose Zebra conditions. They come from missed bread-and-butter cases such as missed M.I., ectopic pregnancy, appendicitis, meningitis, missed fractures and soft tissue foreign bodies. Half of all patients who file successful lawsuits met standard criteria for hospital admission, yet serious illness was not even considered by the Emergency Physician. As is often said, it is not the one you anticipate that gets you into trouble, but the one you never expect. In other words, if you knew or thought that a patient would have a bad outcome, you would have instituted means to protect both your patient and yourself. Understanding the Law There are two major bodies of legal action; criminal and civil. A criminal action is one in which the state or government sues an individual for a wrongdoing considered against public interest. Examples are murder, rape, theft etc. These are not usually the kind of suits brought against the Emergency Physician unless the physician willfully injured a patient (e.g. assault and battery- restraining a competent patient, forcibly giving an injection, without permission, doing a surgical procedure, sexual battery in the case of a refused pelvic exam). It should be recognized that a physician’s malpractice insurance will not cover criminal liability. The other great body of lawsuits are civil actions which are in essence private disputes of one person against another. Within civil law is one subset of tort law. A tort is simply a wrongdoing. Negligence falls within tort law. Within the tort law governing negligence, is professional negligence or malpractice. In cases of medical malpractice, the plaintiff (patient) has the burden of proof for four elements: 1. The physician owed the patient a duty of care- For the Emergency Physician this includes providing service in the first instance for any patient coming through the door (whether to be seen by the Emergency Physician or another physician or service). That liability may also lie outside his/her Emergency Department door in the case of patients transported under protocol or radio contact by EMS personnel. Patients transferred to the E.D. by consent of the Emergency Physician whether or not transfer occurs by ambulance are his/her liability as are patients who are given telephone advice. 2. The Emergency Physician's care fell below an acceptable standard- This is defined as the failure to provide care that an Emergency Physician of ordinary learning, judgment or skill in emergency medicine would do, or not do, under the same or similar circumstances. This is determined by the jury. If there is a protocol or nationally recognized standard, as in standards published by ACEP, this is the standard by which the physician is judged. Physicians who work (moonlight) in Emergency Departments but who are not trained in Emergency Medicine are held to the same standard of care as those trained/boarded in Emergency Medicine. The standard of care in Emergency Medicine is considered a national standard ,in most cases, rather than a local standard (e.g. assumed to be the same everywhere). 3. The plaintiff had sustained an injury or damages-this does not necessarily just mean a bad outcome. Death is often the result of a patient given CPR; however, the physician may not have delivered substandard care. The damages vary depending on the case. They may include loss of past or future wages, past and future medical expenses, pain and suffering and loss of consortium. Other damages include loss due to embarrassment, humiliation or emotional distress resulting from the injury or disfigurement or loss of business because of inability to work. 4. The injury sustained by the plaintiff directly resulted from the physician's failure to meet an acceptable standard of care. In legal terms, the professional negligence of the defendant was a proximate cause of the injury and damages to the plaintiff.

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OTHER TERMS STATUTE OF LIMITATION- the length of time after medical care has been rendered that a lawsuit can be instituted. Although this varies from state to state, most states have two years as the limit. Some states have a clause that includes a wait of 6 months after the plaintiff discovered the alleged acts of malpractice. This would allow a suit to be instituted many years after the event if it was not discovered by the plaintiff (an example would be the discovery of a foreign body in soft tissue upon operation 10 years later for chronic pain at the site). In the case of minors, often it is stated that a suit can be instituted a period of time (most often 2 years) after d iscovery and after majority (18th or 19th birthday). Thus an injury that occurred at age 2 may be filed 20 years later! Exceptions to the statute of limitations include discovery prevented by fraudulent conduct of the physician, a foreign body wrongfully left in the patient's body, or an injury involving the reproductive system. DOCTRINE OF COMPARATIVE NEGLIGENCE-The plaintiff's negligence, if any, does not bar a recovery by the plaintiff against the defendant doctor. If a physician's care falls below the standard and there is injury, even if the patient contributed to that negligence (not following instructions for example), even though the patient's negligence contributed to the bad outcome, the physician is still liable. Usually, the total amount of damages to which the patient would otherwise be entitled is reduced by the percentage that the patient's negligence contributed to his/her injury. Successful Lawsuits in Emergency Medicine: Most Frequent Cases* 1. Failure to diagnose a fracture or dislocation 2. Failure to diagnose a foreign body in a wound 3. Failure to diagnose complications of lacerations, including tendon or nerve damage 4. Failure to diagnose and treat myocardial infarction 5. Failure to diagnose appendicitis 6. Accident in the Emergency Department 7. Failure to diagnose meningitis 8. Failure to diagnose skull or facial fracture 9. Failure to diagnose ectopic pregnancy 10. Failure to diagnose ruptured spleen, liver or other viscus 11. Failure to diagnose respiratory obstruction * taken from Risk Management in Emergency Medicine ACEP 1985 High-Risk Situations in Emergency Medicine “TEMPORAL FACTORS- approximately 63% of all malpractice incidents occur between the hours of 6 pm and 1 am on weekends and holidays. These are generally the busiest hours in the ED and waiting times tend to be longer and patients are apt to be angry. The hours from midnight to 7 am on weekdays tend to be the second highest risk period.”1 Perhaps the ED is staffed with fewer nurses and doctors during these times or staffed with part-time physicians or moonlighting physicians. Fatigue also undoubtedly plays a role in the early morning hours unless the physician is working permanent night shift. Ancillary tests (X-ray, lab, CT etc.) may not be as available during these times. SHIFT WORK- The risk of malpractice increases with the duration of the physician's shift. The problems with shift work include sleep disorders, decreased vigilance, and poor job performance. PHYSICIAN SHIFT CHANGE- Change of shift is considered by physicians, risk managers and attorneys to be an extremely dangerous time for patients. Normal vigilance is relaxed when a physician thinks a patient has already been evaluated properly by another physician. Change-of-shift lawsuits can be complicated. First, two physicians are involved in the case which may double awards available to the plaintiff. The exact point at which one physician's responsibility ceased and the others began is difficult to determine and may lead to infighting and bickering between the two defendants.”1 Frequently, there is lack of documentation or contradictory documentation. To guard against this problem, the physician who discharges the patient should be the physician of record and carries the responsibility for the evaluation of the patient and for the discharge program. Normally, every patient turned over at shift change should be re-evaluated by the responsible physician within 15 minutes of assuming care.

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RETURN VISITS-The question of return visits to the ED has been carefully studied. The impression of most Emergency Physicians that such patients are abusing or misusing the emergency department is incorrect. The diagnosis on the first visit may be wrong in up to 25% of the cases.”1 Physicians should view the patient with a return visit as a patient that is giving the physician and institution a second chance to solve the problem and should be evaluated as if he/she were a completely new patient. LANGUAGE BARRIERS- Communication is a key element of medical practice. A physician who can not understand his patient or a patient who can not understand his doctor is a high risk situation. Interpreters must always be available. Cases are not dismissed and injury forgiven because of a language barrier. PHYSICIAN ORDERS BY TELEPHONE- An Emergency Physician should never defer to a consultant who has not seen the patient. All too often if a problem arises, the consultant will forget the conversation or say "if I knew he was that ill (or if you would have told me), of course, I would have admitted him". If the consultant disagrees with the Emergency Physicians evaluation, it is the consultant’s responsibility to personally examine the patient and make a disposition regardless of the time of day or night or the inconvenience to the consultant. INFORMED CONSENT-Obtain informed consent when performing procedures that carry some risk to the patient. Physicians should explain risks involved with the treatment, the alternatives and consequences that would ensue should the patient refuse treatment. The general consent form that patients sign when entering the E.D. do not protect against specific injury. Obtain consent for L.P.'s, cardioversion, chest tubes, repair of extensive lacerations, tendon lacerations, removal of foreign bodies, and reduction of fractures. Not only is this good sense- it also is required by the State of Georgia to maintain your license to practice medicine in the State! ADDENDUM: Obtaining consent to treat patients who present for care to the Emergency Department Valid consent to treat is obtained from every patient seeking care in an Emergency Department. This is informed consent and the patient may expect to be informed to the risks versus benefit of seeking or not seeking care. There are several important considerations: THE PATIENT WITH AN EMERGENCY UNABLE TO GIVE CONSENT- The emergency medicine exception to the informed consent doctrine can be summarized by the statement that a physician may treat a patient, in a true emergency, without the patient's consent. This practice assumes that the average, reasonable, competent patient would agree to treatment in an emergency situation if he/she were able to do so. Disagreement ensues over what is an emergency situation (most generally defined as "life or limb threatening"). The responsibility is usually placed upon the physician to make a clinical determination of when an emergency exists. MINOR NOT ACCOMPANIED BY A PARENT OR GUARDIAN- authorization for treatment of a minor is necessary for all children except: 1. Patient is in danger of losing life, limb or body function. Two physicians need to document this in the medical record. 2. Patient is seeking treatment for pregnancy or venereal disease, in which case the minor may consent to treatment of those specific entities- that consent is binding and valid 3. Patient is an emancipated minor (e.g. patient is of minor age but has severed all legal ties with parents or guardian and maintains own separate residence) UNACCOMPANIED UNCONSCIOUS PATIENTS- Patients who arrive in the E.D. unconscious are evaluated and treated upon arrival under the implied consent doctrine. TREATMENT OF INCOMPETENT ADULTS- Incompetent adults are treated without a court order if they are in danger of losing life, limb or body function under the implied consent doctrine. In the case of an incompetent adult patient not under guardianship or conservatorship where the attending physician is of the opinion that emergency treatment is not immediately indicated, treatment should be withheld until a court order is issued authorizing such treatment. 1. Emergency Medicine Reports, Volume 11, No 2, January 15, 1990.

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Clinical Pearls In

Emergency Medicine1


The practice of the art of Emergency Medicine is like that of other specialties. It is learned over time, patient by patient. It has often been said of Emergency Medicine "that you are only as good as the next patient" since we don't have patients that we follow year by year. The expert Emergency Physician is one who has many patient encounters and can quickly recognize the ill patient, especially uncommon presentations of illnesses or unexpected problems. The "sixth sense" used to identify serious illness is an acquired skill, one that comes from years of clinical care. It can never be learned by those reticent or reluctant to see patients! The following list of selected clinical pearls was prepared by Hamilton et al.1 with some additions by WK. Reviewing them is a worthwhile exercise. A. The New Rotation in the Emergency Department 1. Respect is earned. 2. Befriend, through a show of respect, your nursing staff. (I overheard one nurse tell a new resident once that this could be one of the most enjoyable

months of the year or she could assure him that she would make this month pure hell for him; reader take note)

B. Maximizing Patient Satisfaction with Your Care 1. Avoid medical jargon 2. Learn how to tell a patient you don't know what's wrong. 3. Let the patient know that he/she is always welcome to return.

4. Admit an error of judgment or procedure immediately when it occurs. One lie always leads to another, and sooner or later the truth will find you out.

C. Minimize Patient Dissatisfaction 1. One hour feels like three behind the curtain. 2. A companion makes the wait less unbearable.

3. Give the patient an estimate of the time needed to complete the evaluation and try not to underestimate. Significant delays require an honest accounting.

4. If there is a long delay, consider patient comfort in the form of pillows, stretcher, food, etc. Also suggest that those waiting for the patient go for food, etc.

5. Patients don't understand the way we give care and often perceive the process as chaotic. We think that patients understand because it is straightforward in our minds. Explain that first we must do the evaluation in the form of history taking and physical, then we do the appropriate testing (lab and X-rays etc.) and finally we will discuss the results and plan a course of action. If consultants are to be called, explain what needs to be done before calling them. Patients often complain by saying "if they had only called (consultant) two hours ago we would not have had to wait this long!"

D. You are the Patient's Advocate 1. If you must err, err on the side of helping the patient. 2. Respect the patient's need for privacy. (It is not always true that the person waiting with the patient in the exam room is family or a

close relative. The next door neighbor may have brought the patient to the E.D. and undressing the patient in front of him/her may be embarrassing for everyone)

3. Always consider the "costs" of your interventions both from a financial and discomfort perspective.

4. Don't negotiate any medically important interventions with a patient with an altered sensorium or a child.

5. If a patient is a source of potential harm to himself or others, or cannot take care of himself, he must stay for observation or admission.

6. Physical restraint may be necessary and appropriate to protect the patient or emergency department staff.

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7. Do not discharge a now "sobered" patient who has recovered from acute alcoholism without performing a repeat history and physical examination.

8. Anxiety and hysteria are diagnoses of exclusion. E. Clinical Judgment

1. When the clinical impression does not fit the history,physical examination or laboratory evaluation, STOP! Rethink and expand the differential diagnosis.

2. If the patient can't walk, he can't go home. 3. If the ancillary data (laboratory tests) do not fit the clinical picture, reconfirm the accuracy of the

data before making treatment or disposition decisions. 4. If you seriously consider a specific diagnosis when working through a differential diagnosis, then

you should rule it out with the appropriate tests. 5. If you don't know what to do- follow instructions. If you still don't know what to do- do nothing,

then get someone else to help. Observe the patient carefully for the evolution of the disease process instead of gambling on a marginally indicated therapeutic intervention.

6. Always assume that females of childbearing age (menarche to menopause) may be pregnant, and act accordingly.

7. The patient who returns to the E.D. on an unscheduled basis should always be assumed to be a high risk of serious illness.

8. Abnormal vital signs must be repeated and explained! 9. A patient who won't look at you during the exam is usually either depressed or manipulative.

Almost never is such a person shy. 10. Patients usually have one major medical problem for each decade of life after the age of 60. 11. Never completely trust a young child, a geriatric patient, an alcoholic or a drug abuser. That is,

corroborate the history and carefully interpret the physical findings in each of these patients. 12. Listen closely to the suggestions of patients and their families about what is wrong and how they

should be treated. Often the patient knows what is wrong with him/her long before you do. They may even have been told by another physician!

13. "All crocks die of organic disease." 14. If after the initial history, physical and ancillary tests you don't know what's wrong with the

patient, you probably won't figure it out by ordering further tests . You are wasting your time and the patient's money. Get someone else to see the patient.

F. Special Clinical Encounters

1. Since the eye is to see, always record its acuity. 2. Always confirm an Accu-check© with a blood glucose level. 3. Multiple drug allergies often correlate highly with functional or psychogenic complaints. 4. Speak to children in language they can understand. 5. Just because a person is old, don't assume they are hard of hearing. Just because they are old

doesn't mean that they have abdicated decision making to their children. 6. Allow at least one parent to stay in the room with a child during your initial exam. Observing the

child's interaction with the parent is an important part of the evaluation. 7. Children are rarely hypochondriacs. 8. When you hear hoofbeats, think of horses except when in a Zebra watering hole.

G. Avoid Supporting the Legal Profession

1. If you didn't write it down, you didn't do it. 2. Don't think you are going to win just because you are right. 3. Protect yourself by protecting the patient. 4. A printed form never saved anyone. 5. One of the most hazardous moments in emergency medicine is "signing out" patients to a

colleague at the end of a shift. A complete and accurate exchange of information and impressions is necessary.

H. Destroying Your Credibility

1. Subvert the call schedule or be chronically late. 2. Yell at someone. 3. Give an opinion before examining the patient. 4. Treat a number or a disease, not the patient. 5. Miss the lectures without an excuse.

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6. Show disrespect for the nurses, clerks or taps. 7. Be reticent to see patients. 8. Be argumentative with faculty, consultants, other residents, or nurses.

I. Your Mental Health

1. Every physician has moments of self doubt. 2. There is always a disposition ( no one is left in the E.D. from last year!) 3. If you find yourself becoming frustrated or angry with a patient, step away for a while. Anger

and frustration must not be allowed to influence your decision making process. 4. If possible, try to take a brief break(15 minutes) away from the E.D. during each long shift (12

hours). J. Do's

1. Meet every patient turned over to you at the change of shift - preferably within 15 minutes of shift change.

2. Respond to complaints as quickly as possible to avoid irreparable damage. 3. If there is a squeaky wheel, oil it. You will get no rest until you do, regardless of the cause. 4. Always see and interpret every test yourself. (Goes for X-rays, CTs etc.) Don't rely on someone

else to report the results. You are responsible and liable! 5. Have fun during your Emergency Medicine rotation. You will see a lot of patients, do a lot of

procedures, and learn a lot of medicine. At the end of the month- you will be a better physician! Really!

K. Don'ts 1. Never say: "There is nothing wrong with you". 2. Don't expect patients to remember verbal instructions or information. 3. Do not try to weasel out of responsibility when you blew it-admit the error, apologize and get on with life (remember Richard Nixon!). 1. (Partially Excerpted, edited and adapted from Emergency Medicine: An Approach to Clinical Problem Solving, Hamilton et al, Sanders 1991)

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PART THREE

CORE CURRICULUM

EMERGENCY MEDICINE

STUDENT MANUAL

COBRA/EMTALA

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EXPERT REPORTS ON THE NEW EMTALA GUIDELINES

from Emergency Physician LEGAL BULLETIN Volume 9, Number 5, 1999

"EMTALA, known as COBRA to physicians, governs everything we do in the ED," said Robert Bitterman, MD, JD, FACEP during his lecture at the 1998 ACEP Scientific Assembly. "It's hard for emergency physicians to realize that we must also follow a legal, as well as medical, standard of care." Dr. Bitterman is Director of Risk Management and Managed Care in the Department of Emergency Medicine at the Carolinas Medical Center in Charlotte, North Carolina. He's also Clinical Assistant Professor of Emergency Medicine at the University of North Carolina Medical School. He practices academic emergency medicine full time. Under EMTALA, anyone who comes to the ED is entitled to a medical screening exam (MSE) and stabilizing treatment, and that includes managed care patients, illegal aliens and patients managed through phone orders by their physicians. EMTALA even vitiates state consent laws for minors. "If a baby-sitter brings in a two-year-old, you must provide the MSE to determine if the child has a true emergency without waiting to reach the parents," Dr. Bitterman commented. Private patients represent a problematic area. HCFA considers a private patient sent for tests, such as an x-ray or CBC, as simply using the services of an ED. Dr. Bitterman recommended using a different consent form for such patients, one that specifies testing only, particularly for persons brought in by the police for blood alcohol testing. However, it's illegal for a physician to examine a patient, then send him or her to the ED for treatment only. The emergency physician must first perform an MSE on behalf of the hospital, even if the patient is to receive a blood transfusion, rabies vaccine or other treatment. "The ‘migraine headache’ patient sent to the ED for an IM narcotic is one notorious example; not rarely the MSE reveals a subarachnoid hemorrhage or meningitis," said Dr. Bitterman. Private physicians should not be allowed to call in phone orders to the ED unless they intend to come in to examine and manage the patient's care. Dr. Bitterman noted that through ACEP's discussions with HCFA’s Advisory Committee on EMTALA, in which he participated, some interpretations have been modified to benefit emergency physicians. Take the apparently simple matter of "when does a patient come to the emergency department?" HCFA originally interpreted this language very broadly. A person in an ambulance or helicopter owned and operated by a hospital would be regarded as having "come to the ED," even if the vehicle was miles from the ED. HCFA expected the ambulance or helicopter to bring the patient to the hospital's ED for an MSE instead of to the closest appropriate hospital. Following discussions with ACEP, HCFA discarded this requirement as long as the EMS unit operates under reasonable EMS zone protocols. HCFA may, however, review the EMS policies to ensure they are not discriminatory. HCFA's regulations, not yet tested in court, define "comes to the ED" to include all hospital property, such as the cafeteria, waiting room, parking lot and surrounding land. Also included are hospital urgent care centers, clinics, freestanding surgicenters and doctors' offices if owned by the hospital and operated under the same Medicare provider number as the hospital. "HCFA may even extend the definition to hospital-owned facilities that don't share the same Medicare coding number," Dr. Bitterman commented. MEDICAL SCREENING EXAM HCFA states that the MSE must be given by qualified personnel approved and designated, in writing by the hospital's governing board, but does not specify doctors or nurses. According to Dr. Bitterman, most hospitals have failed to make a designation. Also, HCFA can challenge a designation. "In a number of instances, hospitals designated nurses to perform its MSEs, but HCFA held the nurses didn't have adequate medical expertise to conduct screening exams in complicated medical cases and felt the hospitals should have had physicians conduct the MSE in these cases." EMTALA's new guidelines state that triage is not an MSE, contrary to the belief or demands of managed care plans. Furthermore, an MSE must include ancillary services routinely available to the ED, as well as the services of on-call physicians if needed to determine if an emergency medical condition is present. "If you need to rule out appendicitis, you must call in the surgeon on call to examine the patient or even take the patient to the OR as part of the screening process," Dr. Bitterman said. The MSE must be the same for everyone, including managed care patients, Medicaid and private patients, and illegal aliens. EMTALA is not concerned about the adequacy of the MSE to identify an emergency medical condition. Rather, the issue is whether the ED deviated from its standard procedures to evaluate a patient with a similar condition "as perceived to exist" by the examining physician. In fact, the physician could be grossly negligent and subject to malpractice litigation, but not violate EMTALA.

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All this may change, however, because of a case now before the U.S. Supreme Court based on the issue of motive. "The question is did the examining physician fail to provide screening, or screening contrary to policy and procedures, because of the patient's race, sex, economic status or some other illicit motive," said Dr. Bitterman. "Depending on the Court's ruling, in the future, HCFA or plaintiff attorneys may need to prove the hospital or physician acted with an illicit motive as the reason for disparate treatment." MANAGED CARE Dr. Bitterman believes that EMTALA and managed care are at odds with each other because EMTALA exists to remove financial considerations in the emergency care of all persons, while managed care seeks to reinstate economic motivation. He emphasized that HMO authorization is for payment, not for treatment. Yet, hospitals and physicians allow themselves to be manipulated by the managed care companies. "For example, published studies purporting to show 'how bad managed care is' actually showed it was the hospital and emergency physicians who delayed treating patients with emergency conditions while waiting for authorization from HMOs. Preauthorization is undeniably detrimental to patient care." In some emergency departments the patient is told in advance that the HMO has denied payment authorization. This procedure is risky, Dr. Bitterman warned, because the courts have ruled that the burden of proof is on the hospital to show that the patient affirmatively revoked his request for the MSE. According to HCFA, the hospital must "take all reasonable steps to secure the individual's written informed consent to refuse." A Federal appellate court has ruled that in obtaining informed consent a physician must tell the patient that the managed care physician denied payment for an MSE possibly because of an economic incentive, otherwise the patient has not received adequate information to make an informed decision. Furthermore, according to HCFA, telling a patient that medical care may be paid for at another-facility is economic coercion in violation of law. "Neither a registration clerk nor a nurse can obtain informed consent to refuse the screening exam, which is really a leaving 'Against Medical Advice,' because they are not legally allowed to determine a patient's competence," said Dr. Bitterman, “nor can the managed care physician on the phone." HCFAs new interpretive guidelines introduce a major change regarding where an MSE is performed. It can be given anywhere on a hospital’s “campus,” including urgent care centers, pediatric clinics, dental clinics and the offices of on-call physicians. A patient can be triaged in theED and sent to a physician's office on campus if it shares the same Medicare provider number. Triage and patient movement to areas other than the ED must be nondiscriminatory, determined solely on medical criteria, and implemented very carefully. If the ED triages private pregnant patients over 20 weeks gestation with pregnancy related complaints to labor and delivery, then all such pregnant patients must go to labor and delivery, regardless of medical insurance status. Furthermore, a hospital cannot delay a patient's access to an MSE, to stabilizing treatment or to on-call physician specialists because of the method of payment. "Nor can a tertiary hospital delay accepting your patient until authorization is received from an HMO,” said Dr. Bitterman. STABILIZATION The new HCFA guidelines make a distinction between patients who are stable for transfer and those who are stable for discharge, a change that may not be significant because the statutory definition supersedes HCFA's interpretation. A patient is considered "stable for discharge" when, "within reasonable clinical confidence it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions." Furthermore, HCFA also accepts that the determination a patient is "stable for discharge" (or stable for transfer) does not require the final resolution of the patient's emergency medical condition prior to discharge or transfer. HCFA does state that in the event of a disagreement over whether a patient is stable for transfer, the medical judgment of the treating physician takes precedence over that of an off-site physician. This is intended to deal with managed care companies. If the managed care physician or on-call physician disagrees with your judgment, then that physician must come to the ED, personally examine the patient, and take responsibility for the patient's transfer. "Just make sure you tell the patient you don't recommend the transfer and document it," Dr. Bitterman commented, then it's up to the patient to choose whom to believe. PHYSICIAN ON-CALL REQUIREMENT EMTALA is by law the on call policy of every hospital in the nation. Most EMTALA violations involve managed care, but in second place and rising rapidly are violations by on-call physicians. The duty to provide on-call physicians rests with the hospitals, not the medical staff. Physicians have no legal duty

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to take ED call. However, physicians accept such duty voluntarily or because the medical staff bylaws require it. According to Dr. Bitterman, on-call physicians often fail to understand that they are liable under EMTALA because when they are on call they represent the hospital and not their private practice. Therefore, when on call they cannot refuse to come to the hospital or refuse to accept a transfer to the hospital as they can when acting in the capacity of their private practice. Which physicians must take the call? HCFA states that if specialty physicians regularly provide patient services at the hospital, then someone in that specialty should take ED call, even if that specialty previously did not provide on-call services. Under EMTALA, on-call physicians must respond “within a reasonable period of time." Although not in writing, HCFA interprets this as 30 to 45 minutes for an emergency condition in an urban area. However, New Jersey and West Virginia require the on-call physician's presence in the ED within 30 minutes. "A couple of hospitals in New Jersey had problems with recalcitrant on-call physicians," Dr. Bitterman said. "HCFA swooped down and closed the emergency departments, claiming they were a threat to the community. The hospitals should have disciplined the recalcitrant physicians, even to the point of revoking their hospital privileges if necessary." Hospitals must draft EMTALA policies very carefully because "failure to follow your own rules” about the MSE and on-call provisions is a common reason for a violation finding. While on-call, physicians must be available to come to the ED for emergencies promptly, and a busy office schedule or performing scheduled elective surgery are not acceptable excuses for delay. Otherwise, they and the hospital are liable. "Some physicians are responding that because they must be on call and cannot schedule elective surgery, they want the hospital to pay them for their availability," said Dr. Bitterman. "Neurosurgeons in California are getting two thousand dollars a day for standby time." TRANSFERRING PATIENTS Although EMTALA does not apply to the transfer of a stable patient, Dr. Bitterman strongly recommended that the same paperwork and procedures be used as for the unstable patient. Forms should have a place where a check mark indicates the emergency physician did not diagnose an emergency medical condition or considered the patient stable in case the transfer is questioned later. Stable patients can be transferred for economic reasons such as managed care needs. Understand, however, that economic transfers will always be closely scrutinized by government agencies and plaintiff attorneys, so be really sure you're comfortable transferring the patient. Unstable transfers are of two types. They are either medically indicated or patient requested. Medically indicated transfers are intended to obtain a necessary, higher level of care that is unavailable at the transferring institution. The physician must certify in writing that the benefits of transfer outweigh the risks. Patient requested transfers include all other transfers. Although managed care transfers are not recognized by law, a patient may request transfer to a facility where it will be paid for. "Transferring unstable patients when it is not medically indicated and the needed service can be provided at your facility is clearly against medical advise and the standard AMA form should be completed just as with refusal to screen,” said Dr. Bitterman. By law, the reason for the transfer of the unstable patient must be inserted in writing by the patient. ACCEPTING TRANSFERS Who can accept a transfer on behalf of the hospital? The law does not require that a physician be the one to accept transfers on behalf of the hospital. A hospital may designate an administrative transfer team, but Dr. Bitterman believes emergency physicians are the best persons to accept transfers from other EDs. For political reasons many hospitals assign the responsibility to their on-call physicians to accept or reject transfers. This practice is potentially hazardous; the large number of physicians who take call and their general lack of expertise or commitment to EMTALA standards place the hospital at substantial risk of violating EMTALA. Hospitals need to understand they are directly liable for the actions of their on-call physicians. A hospital is not required to accept a transfer if it is at capacity. “But, if you’re not closed to all EMS, you may not be considered at capacity,” Dr. Bitterman stated. "If you normally open your recovery room for an ED patient when the ICU is full, you may need to open it to accept a transfer. Can you refuse to accept an unstable managed care patient until authorization for transfer to your hospital is obtained? Or refuse to accept a managed care plan's patients because you don't have a contract with that company? Absolutely not."

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MANDATORY REPORTING REQUIREMENTS HCFA has "tattletale" provisions that cover inappropriate transfers. If a hospital transfers an unstable patient because its on-call physician did not come in that physician's name and address must be forwarded to the receiving hospital which must then report it to the federal government within 72 hours. Failure to provide this information to HCFA is itself a violation of EMTALA. ENFORCEMENT Dr. Bitterman noted that HCFA has investigated more than a third of hospitals in the United States with an estimated 650 in 1998 alone. HCFA reports violations in about a third of the hospitals investigated and, on review, the Office of Inspector General only fines about a third of the hospitals cited by HCFA for violating EMTALA. HCFA has the power to cancel a hospital's Medicare-provider agreement, which Dr. Bitterman calls the "financial death sentence." As a result, hospitals stop at nothing to come into compliance even if it means firing an emergency physician or curtailing privileges, all without due process. An emergency physician is fired in about a third of the HCFA investigations which find EMTALA violations. The new guidelines do not include any required due process or peer review for physicians. HCFA has the option to seek peer review and the guidelines recommend, but do not require, the regional HCFA office to obtain PRO review in cases where medical issues are in question. Enforcement is not consistent across the nation. A violation in California may not be regarded as such in Wisconsin. The 50 state agencies and ten HCFA regions have their own interpretations of the law, according to Dr. Bitterman, although the new interpretive guidelines should help improve consistent application of the law. HCFA still tends to judge outcomes instead of process. In reviewing HCFAs violation reports, the Office of Inspector General can penalize the physician and hospital or terminate the physician from Medicare. Dr. Bitter man said, "This represents the 'criminalization' of the practice of medicine, like speeding tickets. You violated the law; therefore, you must pay the $50,000 fine no harm need come to the patient, and the fine is not covered by insurance. The OIG is supposed to obtain peer review before assessing a physician a fine, but as a negotiating tactic they may hold off because they don't want to spend the money. They simply send a letter demanding $50,000, or 'we may terminate your Medicare provider agreement."' The OIG is demanding a North Carolina emergency physician pay a fine of $50,000, even though he did not see the patient in question, under the "captain of the ship doctrine." After triage, a nurse and EMS crew independently of the physician's knowledge, transferred a public health patient to another hospital in violation of the hospital's own written protocols. HCFA settled with the hospital for $15,000, but now wants $50,000 from the physician and to terminate him from Medicare for one year. Meanwhile, in malpractice litigation, plaintiffs' attorneys often wait for HCFA and the OIG to complete their investigations, then obtain the data under the Freedom of Information Act, and use it to help sue the hospital and physician for malpractice in state court. In other cases, they threaten to report the hospital to HCFA if it doesn't settle the underlying malpractice suit. If a plaintiff attorney chooses to sue under EMTALA in Federal court, all the state's tort reform procedural provisions are preempted. These include notice requirements, peer review, expert witness rules, restraints of the discovery process, statutes of limitation, sovereign immunity and charitable immunity. Damage caps may or may not be preempted by EMTALA claims depending upon the actual language in the state's tort reform act. Dr. Bitterman closed by noting that emergency physicians who are members of ACEP probably know more about EMTALA issues than some hospital administrators, on-call physicians, and perhaps even hospital attorneys. Thus, the leadership roles and educational burdens fall to emergency physicians to protect a hospital's compliance with EMTALA. COBRA = Consolidated Omnibus Reconciliation Act, essentially anti-dumping laws EMTALA = Emergency Medical Treatment and Active Labor Act

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The “20 Commandments” of COBRA/EMTALA (Version 2.1)*

1. THOU SHALL: Log in every patient who presents, together with diagnosis and disposition;

2. THOU SHALL: Provide a medical screening examination [by physician, preferably], beyond triage, in the hospital to every person presenting to the hospital (including hospital-owned ambulances); 3. THOU SHALT NOT: delay the medical screening examination to secure verification or authorization from third party payor, nor attempt to influence the patient by drawing payor status issues to the patient’s attention prior to screening; 4. THOU SHALL: Provide necessary testing, including on-call services, to exclude the presence of a life-threatening emergency medical condition;

5. THOU SHALL: Provide stabilization, such that the patient is not likely to deteriorate from or during transport or discharge; 6. THOU SHALL: Provide on-call coverage schedule for all medical specialties represented on the medical staff, and maintain the list of the individuals on-call for five years; 7. THOU SHALL: Require on-call specialists respond in timely manner and provide stabilizing care and/or definitive treatment in the hospital;

8. THOU SHALL: Transfer COBRA patients for only services or care not available at your facility; 9. THOU SHALL: Treat OB patients with contractions as unstable patients under the law; 10. THOU SHALL: Obtain and document advance acceptance from the receiving hospital; 11. THOU SHALL: Provide medically appropriate vehicles, personnel, and life support equipment for all COBRA transfers; 12. THOU SHALL: Provide a physician certification with clearly stated risks and benefits of transfer for all COBRA transfe rs; 13. THOU SHALL: Provide medical records, labs, reports and consultation records to accompany the patient on all COBRA transfers; 14. THOU SHALL: Include the name of any on-call physician who refused to respond or failed to make a timely response in the transfer records of any COBRA patient transferred as a result of that refusal or lack of timely response;

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15. THOU SHALL: Obtain written refusal of services by a patient or responsible party that refuses exam, treatment, or transfer that documents the specific risks of refusal associated with the individual case, or document the reasonable efforts by the hospital to obtain written refusal; 16. THOU SHALL: Obtain written consent to transfer from the patient or responsible party, or document the reasonable justification for not obtaining the written consent; 17. THOU SHALL: Document in the medical record sufficient specific date and information to substantiate the appropriate nature of the actions taken in the individual case; 18. THOU SHALL: Obtain discharge vital signs or vital signs at the time of transfer; 19. THOU SHALL: Post COBRA signs in all entries, waiting areas, registration and care areas; 20. THOU SHALL: Report any possible violations of COBRA by another facility within 72 hours of receipt of the patient. *Source unknown

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Evaluation of Abdominal Pain in the Emergency Department


Abdominal pain complaints comprise about 5% of all Emergency Department visits. The etiology

of the pain may be any of a large number of processes. Many of these causes will be benign and self-limited, while others are medical urgencies or even surgical emergencies. As with any complaint in the ED, the worst diagnosis is always entertained first. Therefore, there is one thought, which the ED practitioner must maintain in the foreground of his mind: “Is there a life threatening process?” Etiology A breakdown of the most common diagnoses of abdominal pain presentations is listed below. Note that nearly half of the time, “unknown origin” is the diagnosis made. This is a perfectly acceptable conclusion, after a proper work-up has ruled out any life threatening illness. Common Diagnoses of Non-traumatic Abdominal Pain in the ED

1 Abdominal pain of unknown origin 41.3% 2 Gastroenteritis 6.9% 3 Pelvic Inflammatory Disease 6.7% 4 Urinary Tract Infection 5.2% 5 Ureteral Stone 4.3% 6 Appendicitis 4.3% 7 Acute Cholecystitis 2.5% 8 Intestinal Obstruction 2.5% 9 Constipation 2.3% 10 Duodenal Ulcer 2.0% 11 Dysmenorrhea 1.8% 12 Simple Pregnancy 1.8% 13 Pyelonephritis 1.7% 14 Gastritis 1.4% 15 Other 12.8%

From Brewer, RJ., et al, Am J Surg 131: 219, 1976. Two important factors modify the differential diagnosis in patients who present with abdominal pain: sex and age. Other common diagnoses of abdominal pain in men and women are as follows. Male Female Perforated ulcer Nonspecific Gastritis Diverticulitis Appendicitis Acute Cholecystitis The other factor is age over 70 years. As you can see from the table below, the breakdown of causes varies significantly for this population.

Causes of Abdominal Pain in Patients Over 70 Years Old Acute Cholecystitis 26.0%

Malignant Disease 13.2% Ileus 10.7% Nonspecific Abdominal Pain 9.6% Gastroduodenal Ulcer 8.4% Acute Diverticular Disease of the Colon 7.0% Incarcerated Hernia 4.8% Acute Pancreatitis 4.1% Acute Appendicitis 3.5% Other Causes 12.7%

From Fenya, C, Am J Surg 143: 751, 1982.

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Types of Pain A patient’s description of the pain is vital in assessing the problem. Careful questioning will allow the physician to discern the origin of the pain and formulate a good working differential diagnosis list.

Visceral pain is described as crampy, dull and gaseous. It typically arises from the walls of hollow viscera and capsules of solid organs due to abnormal stretching or distention, ischemia, or inflammation. Localization is often vague and frequently midline. It is generally accompanied by autonomic responses causing nausea, pallor, and diaphoresis.

Somatic pain on the other hand is well localized and sharp in quality. It arises from the parietal peritoneum, mesenteric roots, and anterior abdominal wall due to chemical or bacterial inflammation.

Visceral vs. Parietal pain

Type Location Time Activity (movement)

Vomiting Palpation

Visceral Central Intermittent or constant

Little or no change in pain

Decreases or no change in pain

Little or no change in pain

Parietal Peripheral or generalized

Constant Increases pain Increases or no change in pain

Increases pain

Referred pain is due to fibers from different organs returning to the CNS overlapping with pathways from cutaneous sites which had similar embrylogic origin [e.g. diaphragmatic irritation refers pain to the shoulder via C4 (Kehr’s Sign)]

History

Most diagnoses can be made by history alone. Therefore, it is essential to listen carefully to the patient and ask specific questions. Useful information is listed on the following pages. Clinical Evaluations – The History

1 Time of onset Medications (medication induced gastritis or perforation, e.g. nonsteroidal anti-

inflammatory drugs) Sleep (has the pain been severe enough to impede sleep or did it awaken the patient?) Activity (which may have exposed the patient to trauma, spider bite, or other impacting factor) 2 Mode of onset Abrupt/severe vs gradual a severe pain of abrupt onset (Think catastrophe e.g. vascular, anterior ulcer perforation, or renal obstruction) b less severe initia lly, but increasing c gradual onset with slow progression d intermittent pain 3 Location Migration (e.g. epigastric gradually moving to right lower quadrant or flank pain

moving to groin) 4 Character Severity/magnitude of stimulus Intermittent crampy Severe and colicky 5 Duration New onset of abdominal pain (vs. chronic pain) 6 hours duration

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Elderly delay seeking help (this may allow walling off of an abscess or progression of the process)

6 Progression Sudden increase Sudden change in sensation 7 Medical History Previous surgery MVA Sexual activity Recurrence of same problem Travel COPD Exposure / Occupation CAD Psychiatric Immunosuppression 8 Menstrual history 9 Contributory Symptoms Anorexia Nausea Vomiting (color) Bleeding Diarrhea Constipation Obstipation Belching Flatus Dysuria Sputum SOB Chest Pain (acute myocardial infarction)

Physical Examination The physical exam serves several purposes: 1 To confirm suspicions from the history 2 To localize the area of disease 3 To avoid missing extra-abdominal causes of pain There are numerous components to the examination, all of which are important. These include careful consideration of each of the following items. Vital Signs temperature, BP, pulse, respiratory rate.

Check orthostatic vital signs Abdomen

Observation general appearance: conscious, alert, upright, diaphoretic, pale, distressed, writhing, motionless, smiling.

Inspection distended, ecchymosis, scars, hernias, caput Medusa Auscultation bowel sounds present (listen long enough), pitch, bruits

Palpation Patient must be relaxed. Start gently. Guarding (voluntary and involuntary) Masses Tenderness (watch patients facial expression and use point 1 and 2 comparison method)

Have patient tense abdominal wall and re-palpate –difference? Rebound (vs. startle) peritoneal signs

Rebound without guarding is generally not true rebound Also shake pt., heel strike, have pt cough, have pt jump Some MD’s will kick or jar the stretcher

Special maneuvers / signs Murphy’s sign-respiratory arrest on inspiration during palpation of the

right upper quadrant of the abd. Rovsing’s sign-pain referred to the right lower quadrant on palpation

of opposite side of the abd. Obturator sign-pain with internal rotation of flexed hip Iliopsoas sign-pain with hyperextension of the hip

Turn pt on side and reexamine the abdomen in the lateral decubitus position

Percussion liver size, tympany, localization of tenderness Rectal blood, masses, tenderness Pelvic blood, masses, tenderness, discharge Do Not Forget Heart (including peripheral pulses), Lungs, External Genitalia, and General Exam !

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Formulation of the differential diagnoses

Based on the information obtained from the history and physical examination, a good working list

of possible diagnoses to be ruled out should be formulated. This should be based on a keen knowledge of gross anatomy, embryology, neuroantomy, and physiology. Various lists suggesting causes of pain based on the localization of pain are available and one such list is presented below and it is not exhaustive. It should not be memorized, but rather should be understood. The history and physical will help narrow the possibilities further.

Differential Diagnoses of Acute Abdominal Pain by Location

Right Upper Quadrant Left Upper Quadrant Appendicitis Aortic Dissection Cholangitis Gastritis Cholecystitis Duodenal Ulcer Choledocholithiasis Gastric Ulcer Fitz-Hugh & Curtis Syndrome Herpes Zoster Hepatic Abscess Intestinal Obstruction Hepatitis Ischemic Colitis Hepatomegaly Left Lower Lobe Effusion/Empyema Myocardial Infarction Myocardial Infarction Pancreatitis Pancreatitis Peptic Ulcer Disease Pericarditis Pericarditis Pleurisy (diaphragmatic) Pleurisy (diaphragmatic) Pneumonia (basal) Pneumonia (basal) Pulmonary Embolism Pulmonary Embolism Pyelonephritis Pyelonephritis Renal Colic Renal Colic Splenic Infarction Rupture Subphrenic Abcess Subphrenic abcess Thoracic Aneurysm (dissecting) Thoracic Aneurysm (dissecting)

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Differential Diagnoses of Acute Abdominal Pain by Location (continued)

Right Lower Quadrant Left Lower Quadrant

Appendicitis Diverticulosis Cholecystitis (acute, perforated) Ectopic Pregnacy (ruptured) Diverticulitis Endometriosis Ectopic Pregnacy (ruptured) Epididymitis Endometriosis Fecal Impaction Epididymitis Hip Pain Gastroenteritis Incarcerated/ Inguinal Hernia Hip Pain Intestinal Obstruction Intestinal Obstruction Ischemic Colitis Leaking Aortic Aneurysm Leaking Aortic Aneurysm Mittelschmerz Mittelschmerz Pelvic Inflammatory Disease M∫nchausen Syndrome Peptic Ulcer (perforated) Pelvic Inflammatory Disease Psoas Abscess Perforated Colon Carcinoma Rectus Hematoma Psoas Abscess Regional Enteritis Rectus Hematoma Renal Colic Renal Colic Salpingitis Salpingitis Torsion of Ovarian Cyst or Tumor Torsion of Ovarian Cyst or Tumor Urinary Tract Infection Urinary Tract Infection

Diffuse Pain Abdominal Angina Mesenteric Thrombosis/ Ischemia Aortic Aneurysm (rupture) M∫nchausen Syndrome Appendicitis (early) Pancreatitis Colitis Pelvic Inflammatory Disease (severe) Diabetic Ketoacidosis Peritonitis Gastroenteritis Porphyria Intestinal Obstruction Sickle Cell Crisis Leukemia Tabes Dorsalis Mesenteric Lymphadenitis Uremia

Early Treatment It is easy to become so focused on trying to establish the diagnosis, that one forgets to treat the patient. Frequently, the patient must be treated without a formal diagnosis and sometimes even with minimal history and only a cursory initial physical examination. This may include treatment of shock, intractable vomiting, and bleeding. At some point, as much history as possible must be obtained and a thorough examination be performed. Typical interventions may include the following.

Insert one, preferably 2, large bore intravenous catheters (14 or 16 gauge). No scalp vein needles. Consider a central line: jugular, femoral, or subclavian.

Draw blood for CBC with diff, electrolytes, amylase, lipase, BUN, creatinine. Draw extra tubes for type and cross and other tests which may be needed later.

Begin infusion of isotonic solutions (NS or LR). Record I/O’s, titrate fluid to BP and pulse.

Begin O2 at 5-10 L/min (with significant COPD 2 L/min) Insert nasogastric tube- Generally, do not lavage stomach with NG tube as it can not remove large

particles of food or blood clots. Insert foley

Maintain good urine output Check for blood in urine

Pregnancy test β subunit, either urine or serum Obtain arterial blood gas

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Laboratory Tests

Specific tests to be ordered should be selected to confirm or rule out specific diagnoses on the working differential.

Liver enzymes –SGOT (AST), SGPT (ALT), GGT, Bilirubin (direct and indirect) Amylase [non specific (sources include pancreas, salivary glands, small bowel and

fallopian tubes), rises early and falls early] Lipase (specific for pancreatic injury, rises later and stays elevated longer) CBC H/H WBC and diff. Electrolytes Glucose BUN & Creatinine UA

Most useful if normal since nonspecific: PT/PTT & INR Lactic Acid

Other Tests

EKG

Radiographic Tests CXR or Upright Chest X-ray

1 Pulmonary disease 2 Free air under diaphragm 3 Air filled viscera in chest 4 Mediastinal air

KUB or Plain Film of Abdomen

1 Fluid filled loops 2 Abdominal densities 3 Renal calculi 4 Gallstones 5 Pancreatic or splenic calcifications 6 Air in biliary tree 7 Obscured psoas shadow 8 Displaced stomach bubble 9 Displaced kidney 10 Enlarged splenic shadow 11 Displaced splenic flexure

Upright Abdominal x-ray (If patient can stand, obtain and upright abdomen)

1 Air-fluid levels 2 Air in stomach, intestine, colon 3 Massive dilation of colon

Left Lateral Decubitus (If patient is bedridden, obtain a left lateral decubitus film)

1 Free air 2 Air fluid levels

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Clinical Findings Associated With a Statically Significant Likelihood of an Abnormal Abdominal Radiograph

Clinical Finding Likelihood Ratios*

Likelihood predictive of abnormality (>1) Increased, high pitched bowel sounds 57.5 Distention 9.5 History of abdominal surgery 7.4

Blood in urine 6.3 History of renal-ureteral calculi 5.8 Flank pain, tenderness 5.0 History of abdominal tumor 4.7 History of gallbladder disease 4.2

Severe abdominal pain and tenderness 3.0 Generalized abdominal pain and tenderness 1.8 Abdominal pain for less than 1 day 1.8 † Vomiting 1.8 †

Likelihood predictive of abnormality (<1) History of ulcer disease 0.3 Mild abdominal pain 0.3 Abdominal pain for more than one week 0.5 † Modified from Eisenberg, R, et al.: Ann Surg 197:464, 1983 * Defined as the prevalence of each clinical variable in patients with abnormal abdominal radiographs divided by the number of patients who have abdominal radiographs. P<.001 unless otherwise noted. † p<.005 Don’t leave ill patients alone in x-ray !

Sonography Indications for ultrasound scanning in patients with acute abdominal pain Right upper quadrant pain or possible cholelithiasis Potential abdominal aortic aneurysm Detection of ascitic fluid Potential obstructive uropathy in iodine sensitive patient Potential acute pelvic disorder, such as ectopic pregnancy, tuboovarian abcess, or

ovarian cyst. Treatment Don’t delay therapy while formulating a differential diagnosis or while waiting on laboratory or other tests to be completed. Most patients will ask early on for medication to alleviate pain. Historically, pain medication was universally withheld until a diagnosis was reached and until a surgeon had seen and evaluated the patient and approved of the medication. This archaic system is more and more being replaced with more humane treatment. It is with general approval that some pain medication may be given, titrated to ease the patient. It is nonetheless imperative to have performed an initial examination and to continue to perform serial examinations subsequently. The old fear was always that the medication would mask the problem. In the meantime it has been learned that an exam may be much more productive when the pain has been lessened somewhat and the patient is more cooperative with the exam. Small amounts of narcotics given IV are well suited for this purpose. Beware of large amounts of sedating antiemetics (e.g. 25 mg promethazine, IV. ½ or even ¼ of this dose is recommended), which will render the patient too sleepy to examine. Obtain surgical consultation if necessary. Consult the surgeons as soon as you feel that a consult will certainly be necessary, so they may be involved as soon as possible.

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Causes of Acute Abdominal Pain Requiring an Emergency Operation Acute Appendicitis 36.9%

Intestinal Obstruction 35.2% Perforated Ulcer 8.2% Acute Cholecystitis 6.2% Abscess 4.4% Pancreatitis 2.1% Diverticulitis 1.5% Colon Perforation 1.1% Other Causes 4.4%

Modified from Jordon G.: Adv Surg 14: 259, 1980.

Decision Tree of Evaluation of Abdominal Pain

Conclusion A lesson frequently relearned by everyone is that if one listens carefully, the patient will tell the physician the diagnosis. The history and physical should yield the diagnosis some 90-95% of the time. Additional testing should be used to confirm the presumptive diagnosis. It is rare that “fishing” with laboratory tests will yield a diagnosis when the H&P does not and this practice should be condemned. This cannot be stressed enough. It will keep the physician from “shotgunning” unnecessary laboratory and X-ray tests, wasting time and patient’s money. When in doubt, go back and talk with and re -examine the patient.

AbdominalPain

ShockResuscitation

DiagnosisNotApparent

NoShock

DiagnosisApparent

History/PE

SimpleLabTests

RoutineX-Rays

Admit ToHospital

MinorProblem

SurgeryHome WithTreatment

CompleteIn-Hospital Evaluation

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Emergency Airway Management


Airway skills are perhaps the most important skills that an emergency physician possesses. If the airway is lost in a critically ill patient for any reason, any of the other interventions you might make, or any great diagnoses are superfluous. It is good to remember that in the ABC’s of resuscitation, airway is first and foremost. With the exception of defibrillation in a cardiac arrest situation and possibly a needle decompression in the patient with a tension pneumothorax, airway control always assumes first priority. Since the need to protect the airway most often occurs in a crisis situation in the ED, the emergency physician can not rely on others, like anesthesia, to assist. Even moments of delay can spell disaster for the patient. Since every airway emergency presents in a different fashion, the emergency physician must be proficient in multiple techniques to protect and intubate the airway, and must be prepared with all the necessary equipment to perform these alternative procedures should the initial plan fail. Indications for Intubation There are several indications for intubation. The first occurs when the patient is unable to protect or maintain his/her airway. An example of this might be someone deeply comatose from a head injury or drug overdose who can not protect his airway from aspiration if vomiting should occur. It has been taught that the absence of the gag reflex is a reliable method of assessing whether or not the airway is protected. In fact this might not be the case. Up to 20% of the normal population may not have a gag reflex. A better assessment of airway protection is evaluation of the ability to swallow spontaneously and handle secretions. Even if the patient is “breathing on his own” and ventilation is adequate, this does not assure us that the patient will be protect his airway if vomiting were to occur, and the morbidity and mortality from aspiration is quite high. The second indication is failure of oxygenation or ventilation as might occur in someone with asthma, COPD or pulmonary edema. If the PaO2 can not be maintained with supplemental oxygen or such techniques as BiPAP, the patient will ultimately need ventilation through endotracheal intubation. The third is an anticipated clinical course that makes airway management imperative. This might include such patients as those with oropharyngeal burns from a house fire, facial trauma or facial abscesses. Airway compromise in these conditions is a real possibility and airway management often becomes increasingly difficult as time passes. If there is an anatomical distortion that will make intubation more difficult as time goes on, it is the wise physician who will recognize the problem and provide simple protection before the process progresses. Once it has been established that airway intervention will be necessary, there are several questions the emergency physician must ask: How much time do I have? Is this a critical airway and a crash situation? Do I need to intubate now or do I have a few minutes to prepare? If you are in a crash situation like a full cardiopulmonary arrest, orotracheal intubation must proceed without further delay. If there is time to prepare, then the physician must predict which airway intervention is best and most likely to succeed. He must evaluate whether this will be a difficult airway to intubate and if it is a difficult airway and the first attempt at intubation fails, can the patient be ventilated with a bag-valve-mask. [If I am unable to intubate and I can not ventilate with a bag-valve-mask, am I prepared to manage the situation?] Rapi d Sequence Intubation In most cases, airway management will be amenable to standard practices. “Rapid sequence intubation is the cornerstone of modern emergency airway management. Although other techniques, such as blind nasotracheal intubation and intubation using sedation along with neuromuscular blockade, have been used widely in the past, the superiority of rapid sequence intubation in terms of success rates, complication rates and control of adverse effects, renders it clearly the procedure of choice for the majority of emergency department intubations.” (ACEP-Advanced Airway Management) “Rapid sequence intubation is the virtually simultaneous administration of a potent sedative (induction) agent and a rapidly acting neuromuscular blocking agent to induce unconsciousness and motor paralysis for tracheal intubation.” (ACEP- Advanced Airway Management) Although there are no absolute contraindications for rapid sequence intubation, the presence of a potentially difficult airway requires a careful assessment and a plan with alternatives should the intubation attempt fail.

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Rapid sequence intubation (RSI) consists of a series of discrete steps that are best followed to insure the greatest success. The patient should first be evaluated for the presence of a difficult airway and the ability to ventilate with a bag-valve-mask should intubation not be successful. It is obvious that the intubation should take place in a room that is prepared in advance with all equipment needed for resuscitation should that be necessary. It is the physician’s responsibility to make sure that all equipment is present and in working order before proceeding! Although nurses may assure you that everything is in working order, the physician is ultimately responsible and will be the one to have to handle the problem if some critical equipment is not functioning or a critical drug is not available. 1. Preoxygenation “Bagging” the patient unnecessarily prior to RSI increases the possibility of vomiting and aspiration. Critical to the philosophy of rapid sequence is the “no bagging” principle. Pre-oxygenation is the establishment of an oxygen reservoir within the lungs to permit several minutes of apnea to occur without arterial oxygen desaturation. Pre-oxygenation not only establishes an oxygen reservoir in the lungs, but also creates an oxygen surplus in the blood and body tissue protecting from hypoxia. In the spontaneously breathing patient, administration of 100% oxygen (15 liters of O2 in a non rebreather mask provides 80-90% oxygen) for 5 minutes prior to using paralyzing drugs allows for approximately 5 minutes of apnea before the hemoglobin desaturates below 90% in the adult. (It is of note that this is not the case in a child who has a much lower functional residual capacity and may desaturate after 1 or 2 minutes.) A pulse oximeter should be used throughout the procedure to allow the physician to gauge the oxygen saturation. In situations wherein time is more critical and it is not possible to pre-oxygenate for 5 minutes, a significant pre-oxygenation effect can be obtained by having the patient take 3-5 large capacity breaths on high oxygen. 2. Pretreatment “Pretreatment” is the administration of medications to attenuate the normal physiologic and pathophysiologic reflex responses that are caused by airway manipulation and the physical presence of the endotracheal tube. These are usually medications used to blunt the sympathetic discharge that accompanies laryngoscopy from insertion of the laryngoscope or manipulation of the airway. Situations where pretreatment is desirable include 1) conditions where there is increased intracranial or intraocular pressure, as in a head injured patient; 2) conditions where sympathetic discharge would have deleterious effects on the heart or cardiovascular system as in patients with coronary artery disease, or in children who might have bradycardia and hypotension from airway manipulation; and 3) in patients with airway disease, as in asthma, who might have laryngospasm with airway manipulation. There are also times when it might be advisable to administer a small defasciculating dose of a competitive neuromuscular blocking agent three minutes prior to the administration of succinylcholine. Lidocaine (1.5 mg/kg given 3 minutes prior to intubation) has been shown to suppress the cough reflex and attenuate the increased airway resistance, which results from bronchospasm caused by irritation of the larynx. It also mitigates the effects on a potential increase in intracranial pressure. Thus it should be considered in all patients prior to the administration of a neuromuscular blocking agent who have reactive airway disease or elevated ICP. Fentanyl (3 micro-gms/kg IV 3 minutes before induction) also attenuates the reflex sympathetic response to laryngoscopy. Fentanyl has no effect on ICP and will cause some hypotension and may suppress respiratory effort. However, it is useful in patients who might be adversely effected by an increase in heart rate or blood pressure. This is especially true in patients with ischemic heart disease, pulmonary edema and cardiogenic shock and in patients with vascular catastrophes like a AAA, subarachnoid hemorrhage or thoracic dissection. Defasciculating agents like vecuronium and pancuronium in small, nonparalyzing doses, given 3 minutes before succinylcholine mitigate against potential increases in intracranial pressure and should be considered when increased ICP is of concern. Lastly, almost all children should receive atropine before airway manipulation to mitigate against the bradycardia and hypotension induced from airway manipulation and laryngoscopy. 3. Paralysis and Induction Approximately 5 minutes after pre-oxygenation has begun and 3 minutes after pretreatment drugs are administered, a sedative and a neuromuscular blocking agent should be rapidly administered to induce rapid loss of consciousness and paralysis. This should not be titrated or done tentatively, but should be done as a push to allow for the full effect of the medication. This provides the best chance at rapid intubation without the possibility of partial or incomplete paralysis. Succinylcholine is the drug of choice for almost all emergency department intubations and should be given in a full dose of at least 1.5 mg/kg IV push. Since there are no complications from succinylcholine in larger than normal doses, the medication should be “rounded up” and a slightly higher dose given rather than a low dose, which might not induce full paralysis. A sedative should be given almost simultaneously by IV push. This usually will be midazolam and care must be taken as midazolam may cause some hypotension. Another

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but more expensive drug, Etomidate, is gaining rapid popularity in emergency medicine and eventually may replace Versed. A few seconds after administration of the neuromuscular blocker and sedative, the patient will loose consciousness and respirations will cease. Between 20-30 seconds of apnea is almost universal. Sellick’s maneuver should be applied to the cricoid cartilage to prevent regurgitation of gastric contents and should be maintained throughout the entire sequence until the endotracheal cuff is inflated. It should be noted that Sellick’s maneuver is often improperly performed. Most often those doing the Sellick’s maneuver will press down on the thyroid cartilage instead of the cricoid cartilage. This actually makes intubation more difficult by pushing the cords posterior and out of visualization of the laryngoscopist. It also does not protect the airway as the es ophagus is not occluded. Pressure on the cricoid cartilage occludes the esophagus and tilts the cords upward toward the visual axis of the laryngoscopist. 4. Place the tube Approximately 45 seconds after succinylcholine is administered the patients jaw should be tested for flaccidity and intubation should be undertaken. Intubation attempts before 45 seconds and full relaxation are rarely successful. It is hard to wait the full 45 seconds when the patient is apneic. It is also hard not to want to “bag” the patient when he/she is apneic. However, the full 45 seconds should pass before the tube is introduced. Remember- we pre-oxygenated the patient, so there is plenty of oxygen to last for several minutes (usually 5), which is plenty of time to get the patient intubated with minutes to spare. Intubation can proceed calmly in a non- rushed manner. The success rate should be very high and approach 99% using this algorithm. 5. Post intubation care Tube placement must be confirmed. One of the most disastrous complications from RSI is unrecognized esophageal intubations. Proper placement of the tube can be confirmed if the operator actually saw the tube go through the cords. Otherwise, the best method of confirming tube placement is by end-tidal CO2 monitoring or aspiration techniques. An end tidal CO2 monitor can be easily attached to the ET tube and color changes noted. Purple (“problem”) means you are not in the right place. Yellow (“yes”) means you are in the trachea and CO2 is passing by the monitor. If an intermediate color (tan) is detected, tube placement should be immediately checked. In a small number of cardiac arrest cases, no color change may be detected even though the tube is properly placed in the trachea. This is caused by cessation of carbon dioxide production and delivery to the lungs. If a CO2 monitor is not available, another test, based upon the knowledge that rigid walled structures (trachea) will hold their shape in comparison to structures with no support (esophagus) which collapse, may be used. A 30 cc syringe can be attached to the ET tube and the plunger quickly withdrawn. If there is easy flow of air, you are in the trachea, if there is resistance, you are probably in the esophagus. Chest x-ray can not confirm tube placement in the trachea as the esophagus lies directly behind the trachea- placement in either structure will appear the same on the AP chest film. Absence of breath sounds over the epigastrium, the presence of breath sounds in the lungs and observation of the rising and falling of the chest with ventilation are unreliable signs of endotracheal intubation and should not be relied upon. Pulse oximetry should be used throughout the intubation. Desaturation may suggest esophageal intubation, but desaturation may be delayed several minutes if the patient was properly pre-oxygenated. Desaturation may also occur precipitously when precious little time is available to correct the problem. Therefore, oxygen saturation should not be the only basis used to confirm tube placement. After tube placement is confirmed, attention must be turned to the long term care of the patient on the ventilator. Remember that succinylcholine will last only about 6 minutes and a long acting nondepolorizer such as vecuronium should be administered in full paralyzing doses before the succinylcholine effects subside. Also, since paralysis does not afford sedation or analgesia, a long acting sedative and or analgesia should also be administered to make the patient comfortable. The Difficult Airway Although the vast majority of emergency airways will go smoothly using the above technique of rapid sequence intubation, everyone, regardless of experience, is bound to have problems sometime. It is important to recognize which airways may give you problems before you begin down the road to a possibly failed airway attempt. It is important to choose the most appropriate technique for each particular airway situation before disaster occurs. I suggest that several simple questions be asked in every airway situation: If my intubation attempt does not succeed, will I be able to ventilate the patient with a bag-valve-mask? If I can not ventilate the patient with a BVM, what should be done next and what is my back up plan? Am I prepared to provide a surgical airway?

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Some estimation of the degree of difficulty of an airway is made possible from the following observation and simple maneuvers. Facial hair- facial hair (beards and moustache) in men make it difficult to form a tight seal with a mask. If you need to provide ventilation with a BVM, you will get an air leak which may prevent you from providing adequate ventilation. Simply smearing a water soluble lubricant (like K-Y jelly) on the beard may make bagging easier and more effective. C-s pine mobility- C- spine immobilization makes most airway management more difficult as the neck can not be extended to provide visualization of the cords on laryngoscopy. It also affects performance of the Sellick’s maneuver. Some cervical collars will have holes in the front to access the cricoid cartilage for either a cricothyrotomy or Sellick’s maneuver. In reality, these holes do not provide enough access to make a real difference. In the C-spine immobilized patient, it is often best to remove the collar and have a colleague hold in-line stabilization of the head and neck during intubation which makes intubation easier. It has been said in the past that blind nasotracheal intubation was the airway of choice in the C-spine immobilized patient. However, the complication rate is higher in blind intubation and the movement of the C-spine with blind nasotracheal intubation is as much or more than with in line traction. The success rate for blind nasotracheal intubation is 40-50% compared to nearly 99% with oral intubation combined with RSI. Another example where the C-spine interferes with intubation is in the patient with arthritis of the C-spine or ankylosing spondylitis of the C-spine. Not only will this interfere with extension of the neck but the C-spine can actually be fractured if extended. Mouth opening- an adult with normal TMJ will be able to open the mouth to accommodate 3 or 4 fingers between the incisors. TMJ disease or rheumatoid arthritis may limit mouth opening and thus oropharyngeal and laryngeal visualization. Rheumatoid arthritis can affect the stability of the atlanto-axial joint causing subluxation and instability. Physical characteristics- Patients with small mandibles or receding mandibles have tongues that will obstruct access to the airway during intubation. All children basically fall into this category as they all have tongues proportionately larger than their developing mandibles. A good rule of thumb is that if you can look into the mouth without a tongue blade and visualize the uvula, peritonsillar area and posterior pharynx easily, you should be able to visualize the larynx on intubation. If you struggle with visualization of the posterior aspects of the throat before intubation, you will struggle during the intubation. The length of the neck and the position of the larynx is important. The larynx in the adult should be at the C5-6 level. A larynx that is higher will be difficult to visualize. Typically, there should be 2 fingerbreaths between the top of the thyroid cartilage and the base of the neck in the normal adult. Teeth- All false teeth should be removed prior to intubation. Large upper incisors may obstruct visualization of the larynx because they elongate the AP axis of the mouth. Jagged teeth may lacerate balloons on the ET tubes. [If the patient can eat an apple through a picket fence - you are in for trouble.] Oral dimensions- patients with narrow facial features and high arched palates may have difficult airways. Access will be limited because of reduced space side to side in the mouth. The Failed Airway Although none of us wants to be in a “failed” airway situation, it will happen eventually to all of us. There are basically 2 scenarios, 1) can’t intubate but can ventilate with a BVM or 2) can’t intubate and can’t ventilate. In the first situation, one is at least able to maintain reasonable ventilation and oxygenation. However, the risk of aspiration increases as bagging continues. Even with adequate Sellick’s maneuver, some air will leak into the stomach causing gastric distension and eventually vomiting. The second situation is more desperate and if a decision is not made in seconds, the patient will die. Usually this involves one of two possibilities depending on time. The first is the creation of an immediate surgical airway either by cricothyrotomy, or percutaneous transtracheal jet ventilation. If you do not have the transtracheal jet ventilation already set up before hand, you can not use this as you will NEVER be able to assemble the equipment in time to save the patients life. Neither of these options are viable in the pediatric patient and surgical airways should not be undertaken in children below the age of puberty! The second possibility is to use an airway adjunct. Obviously you need to have access to these adjuncts before the

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crisis arises. Adjuncts include the Combitube©, laryngeal mask airway, fiberoptic laryngoscopically assisted intubation, lighted stylette intubation, retrograde intubation using a cricoid puncture technique and wire, digital intubation and others. The success rates are dependent on availability of the equipment and operator training and experience. The time to plan for a failed airway is now, not in the crisis of the moment when it happens. The patient will pay for your lack of preparation! Special Airway Considerations The Pediatric patient- the principles of airway management in children are the same as in the adult. Confusion and error occur when we try to think about the pediatric airway as “different” than the adult airway. It is just not so! It is true that the dosages of medications are different, we just need to remember the doses in milligrams per kilogram or look them up. The anatomy is slightly different with larynx being somewhat anterior and superior to that of the adult and surgical airways are not recommended in children (The anatomy of the adult larynx is actually more variable than the child’s). With these two exceptions the pediatric airway should be approached in exactly the same way as the adult airway. Medications used for children to facilitate intubation and the need for alternative airway techniques in the case of a failed airway are no different than in the adult. One concern in the pediatric airway is that the functional residual capacity is lower in the child and pre-oxygenation will not “buy” you as much time to intubate. With good pre-oxygenation in the adult, an adult can remain apneic for up to 5 minutes without significant oxygen desaturation. The child may desaturate in 1 minute or less. This is easily overcome by applying Sellick’s maneuver and briefly bagging the patient. During intubation, atropine is almost universally used in children during the pre-treatment phase (3 minutes before intubation) to blunt the bradycardia and hypotension that occurs when the larynx is manipulated. Also, a defasciculating dose of a nondepolorizer is almost never needed in children. The Trauma Patient- The debate over which technique for intubation is safest in the cervical spine injured patient has been raging. Blind nasotracheal intubation was commonly used in the 1980’s but has fallen out of favor because of the high complication rate, high miss rate, stimulation of intracranial pressure and lack of protection of the C-spine. Recently, there is evidence indicating that with properly performed rapid sequence intubation and orotracheal intubation with in-line stabilization, there is little hazard to the patient. Since this affords the best opportunity to intubate with the least risk of a failed airway, RSI with in-line traction stabilization is now being recommended even in the presence of a cervical spine injury. Alternatively, if the patient has a proven C-spine injury and an incomplete neurologic deficit and does not need urgent intubation, then fiberoptic assisted orotracheal or nasotracheal intubation can be performed by those with experience in this technique in a more leisurely fashion. The choice of which neuromuscular blocking agent to use for RSI is also controversial. Most emergency physicians prefer succinylcholine over the longer acting nondepolarizing agents. This is ultimately safer in a failed airway or a “can’t intubate-can’t ventilate” situation as the neuromuscular blockade will last only a few minutes. The principal disadvantage of succinylcholine in trauma is its propensity to cause profound hyperkalemia in some situations. This occurs in burns, crush injuries and denervation processes like stroke or paralysis. However, the hyperkalemic effect does not occur for days to a week after injury and should not be a problem in the acutely injured patient. Succinylcholine will also increase intracranial pressure, which is a concern in many traumatized patients. This can be mitigated by the use of a small dose of a competitive neuromuscular blocking agent in the pretreatment phase- for example 1 mg of Norcuron© 3 minutes before the succinylcholine. Lidocaine should also be used in head injured patients to protect from the rise in BP associated with tracheal stimulation.

In the patient with a distorted airway either from facial fractures or a neck hematoma, the “wait and see” approach will only guarantee a more difficult airway in the future. Most authors now recommend an aggressive approach to the distorted airway with early intubation before the situation becomes more dangerous. Waiting for the nearly obstructed airway to become completely obstructed can be disastrous. The distorted airway always disquiets us, as it should. This is one case where the intubationist should plan ahead and have several options before beginning. Although RSI is not contraindicated, the optimal approach will probably be an awake intubation with the patient protecting his/her own airway as long as possible. A combined approach is sometimes also a good option. A little sedation can be used for a quick

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look for the glottis. If the glottis can be visualized, RSI can proceed. If the glottis can not be visualized, another approach must be entertained or a surgical airway antic ipated. The Patient with Increased Intracranial Pressure- Increased intracranial pressure presents a direct threat to the viability of the brain. Many of the techniques used in airway management may further increase pressure thus compounding the problem. The use of a laryngoscope to visualize the larynx causes a release of catecholamines causing increased BP and pulse- both of which are deleterious to the patient with increased ICP. There may also be a direct increase in ICP not related to tracheal stimulation of unknown etiology. The ICP will also be increased by the use of succinylcholine as a paralyzing agent. Although RSI remains the technique of choice in patients with increased ICP and succinylcholine remains the drug of choice, there are several special considerations. Several pharmacologic agents mitigate against this increased ICP. The administration of fentanyl, a synthetic opioid, can blunt the affect of the catecholamine release as will a beta blocker (not often used). Fentanyl could and should be used in almost all patients with an increased ICP but may cause transient hypotension and premature apnea in some patients at 3 micrograms/kg dose in the pretreatment phase. Lidocaine in a dose of 1.5 mg/kg will blunt the reflex response to intubation and should also be used in the patient with elevated ICP in the pretreatment phase. The increase in ICP related to succinylcholine is temporally related to the muscle fasciculations and can be avoided by use of a competitive neuromuscular blocking agent at 1/10th the paralyzing dose in the pretreatment phase. Since ketamine increases cerebral blood flow, this agent should be avoided in the patient with increased ICP. The Patient with Asthma or COPD- Always remember that if the patient can’t breath secondary to reactive airway disease, you might not be able to breath for them either! These patients can be extremely difficult to ventilate and be hemodynamically unstable. First and foremost there should be aggressive therapy to “break” their asthma or COPD attack. Use of multiple standard agents as well as Heliox®, magnesium, anticholinergic agents, and BiPAP and less standard methods may be attempted before intubation. Asthma is a unique situation in which one MUST intubate the patient on the first try because often the patient can not be successfully bagged because of the high airway pressures. If the patient needs intubation, RSI is the best choice. However, the patient should be left in the sitting position until after the paralyzing medication, succinylcholine, is administered. Although succinylcholine is known to release histamine, this effect does not appear to be clinically significant. All patients with reactive airway disease should receive lidocaine in the pretreatment phase to attenuate the respiratory response to airway manipulation. Ketamine is the induction agent of choice as it has a direct effect on relaxation of bronchial smooth muscles and should be given just prior to succinylcholine. Reference Advanced Emergency Airway Management Walls RM, Luten RC, Murphy ME, Schneider RE. Published by ACEP, 1997

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Evaluation of the Patient with the Complaint of

Chest Pain in the Emergency Department


Patients presenting with chest pain are a common daily occurrence in emergency medicine. Some authors say that as many as 10% of patients have chest pain as their presenting complaint. Some of these patients will have serious, life threatening causes of their pain, such as an acute myocardial infarction (AMI), unstable angina, pulmonary embolus, aortic dissection, pneumothorax or Boorhave’s. Delay in diagnosis and appropriate treatment can lead to increased morbidity and mortality in these patients. However, many patients with chest pain may have less serious disorders, for example, costochondritis, esophageal pain, gastroesophageal reflux, mitral valve prolapse or referred GI pain. It is obvious that correctly sorting out which patient has life threatening illness from those with minor illness is a high priority for the emergency physician. Unfortunately, this is more easily said than done. Errors in the diagnosis of chest pain account for more than 20% of all medical malpractice judgments rendered against emergency physicians. These errors also account for real morbidity and mortality in our patients. These suits are not nuisance suits but usually involve death or significant disability for the patient and enormous impact on the family. Why do we fail to recognize serious illness in the patient with chest pain? First of all, multiple organ systems may be the source of the pain because innervation of the thoracic organs is complex and vague. Pain that is felt in the chest may be caused by organs that are within, around or neurologically connected to the thorax. This may include the heart, the lungs, upper GI tract, esophagus, and also muscle, bone, fascia, skin, abdomen and cervical spine. Frequently, chest pain is also a complaint secondary to anxiety. Secondly, the pain sensation from the organs in the thorax is poorly localized. Multiple organs are innervated through the same neuronal network so that the source of the pain is never precisely perceived. Thirdly, thoracic visceral input may converge on somatic afferent fibers in the spinal gray matter. The cerebral cortex interprets the pain as pain in that somatic location. This is referred pain. Thus, the pain sensation may be at a distance from the actual organ causing the original pain. Lastly, because the pain is vague and poorly localized, it requires interpretation by the patient. How the pain is described is dependent on the patient’s social background, prior experience and communication skills. For example, if I took a pin and touched the cornea of several patients (a neurologically richly innervated area) every one would immediately be able to localize the pain in milliseconds, withdraw, and all would describe that pain almost identically. They would tell me that the pain was sharp, like a pin, and all would describe the area of the cornea touched with accuracy. On the other hand, if I took that same pin and stuck it in the myocardium, some would describe a dull ache, some would have arm pain, some would be short of breath, some would have “indigestion” and several would have no pain at all. Instead of a response in milliseconds, there may be no symptom complaint for several minutes. I would expect several patients to think they are having a life threatening illness and others to be completely unconcerned. This is the problem. Identical pathology in different patients produces varying and confounding responses. Furthermore, patients get very angry at physicians if they miss serious pathology, especially in the chest. An identical pain, interpreted as innocuous when experienced in another part of the body, may seem life threatening when felt in the chest. Patients are trained by the medical profession and the media to take all chest complaints seriously. Look at the magazines in the check out lane at the grocery store the next time you are there. There is bound to be an article addressing the “10 most common symptoms of heart attack” or some related topic. Citizens are bombarded with information that tells them that any pain in the chest may be a heart attack. Remember the TV commercial- “Thank goodness, my doctor said Mylanta” in an elderly male with chest pain and anginal symptoms! Patients and their families are unforgiving when you miss the diagnosis. We know that about 4% of patients who are having heart attacks are sent home from the ED after being examined. 26% of those patients sent home will die from their MI. Is this just bad judgment from emergency physicians? In the majority of those patients sent home from the ED, MI was never seriously entertained as a diagnosis. The patient’s description of the pain never elicited suspicion by the physician that the pain was myocardial. In other words, what the patient complained about never raised the question of myocardial disease in the physician’s mind. Since the diagnosis was never considered, the appropriate diagnostic modalities were not ordered. The physician was completely blindsighted. When the patient suffers injury, they are not only angry, but they sue. These are often young patients, in their high earning capacity years with dependent children. They rightfully reason that they went to the ED, saw a competent physician in a hospital with a good reputation, waited a long time, may have had multiple tests, were

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charged “an arm and a leg” for their care and were assured that they were OK. Now several days later they have a major cardiac complication from the “missed” MI. Their anger is justified. What would you do? All the above is to help you see that the history in the patient with chest pain may be very misleading. It is true that many patients with myocardial ischemic syndromes, for example, will have chest pain. Often they describe it in classical terms, a pressure like band around the chest, causing shortness of breath and radiation to the arms, neck or ja w and exacerbated by exertion. It is unfortunately also true that many patients will have no pain at all and suffer a “silent MI”. Likewise, in the elderly, chest pain is increasingly less specific with age. Patients older than 85 will have no pain in over 60% of myocardial infarctions. As age increases, symptoms like “weakness”, acute confusion, syncope and stroke become more common and chest pain and diaphoresis become less common. Good and competent physicians will, and do, send patients home with MI. Experience and evidence dictates that anyone who cares for a sufficient number of patients, will eventually send home a patient with an MI. The resident, who comes to the ED to evaluate a patient and says, “thank goodness, I have never sent home a patient with an MI,” has just declared that he/she is an inexperienced physician! What can we learn from the history now that we know it may be misleading and unreliable? Among patients who complain of pressure like chest pain, 24% suffered AMI and another 30% met criteria for unstable angina. Of patients who describe “burning” chest pain or “indigestion” in the chest often associated with GI complaints, especially reflux, 23% experienced AMI and 21% had unstable angina. Clearly a description of burning chest pain and pressure-like pain are equally worrisome. The intensity of the pain is not related to the severity of the disease. In other words, you can not speculate that the patient with severe symptoms will have more myocardium at risk that those with milder symptoms. The location of the pain and quality of the pain are likewise not related to the amount of myocardium at risk. However, only 5% who had “sharp” pain proved to have an MI. Reader, beware! In some parts of the country “sharp” means the quality of the pain- a sharp, stabbing or lancinating pain. Very few of these patients may have an MI. In Georgia, “sharp” generally means a “bad” pain- a severe pain. A significant number of these patients have life threatening disease! Since the pain of MI is usually diffuse and poorly localized, a well localized pain that is “sharp” and lasts only seconds is very unlikely to be of life threatening potential. When there is substernal chest pain accompanied by discomfort in the neck, jaw, shoulder or arm, the likelihood of MI increases three or fourfold. However, remember, than any organ in the chest or upper abdomen can refer pain to these locations. The conclusion- although pressure-like discomfort and heaviness is more suggestive of myocardial ischemia, the absence of that description or the presence of a more typical GI or musculoskeletal pain does not exclude the diagnosis of ischemic heart disease. The esophagus may generate pain indistinguishable from that of the myocardium and is the most commonly confused organ system when these patients are admitted. The presence of associated symptoms may also be helpful, especially the presence of dyspnea. In patients with an MI, 14% have dyspnea as their sole complaint and in 50% it is an associated symp tom. Nausea and diaphoresis may also be associated but with a lower predictive value. It is often said that if the patient is sweaty, the doctor should be sweaty. There is some truth in this. “Pleuritic chest pain,” or to use a better term “respirophasic” (pain that increases with respiration), is also nonspecific. Respirophasic pain can be attributed to pain from pleural, pulmonic, pericardial or a musculoskeletal source. Many physicians attempt to use a therapeutic challenge to distinguish myocardial from esophageal pain. These are to be discouraged. Patients with esophageal spasm may experience relief with nitroglycerin and an equal number of patients with myocardial and esophageal disease gain relief with antacids and topical anesthetics. Physicians often use the presence of “risk factors” to aid in their disposition of the patient with chest pain. They reason that if there are multiple risk factors present, coronary artery disease will be more likely as a diagnosis. This is dangerous for several reasons. First, if the patient has a history of coronary artery disease or MI, their risk is 100%. They have the disease- you don’t have to be a rocket scientist and go into more detail. Secondly, many physicians use risk factors inappropriately. Ris k factors compare different cohorts of patients relative to the cohort risk of coronary artery disease. Risk factors are termed “pseudodiagnositc criteria” in emergency medicine. Risk factors are derived from population statistics and epidemiologic data and have little bearing on whether or not the patient in front of you is having an MI. If the patient in front of you has a pulmonary embolus or thoracic aortic dissection, documentation of risk factors are unnecessary and may potentially delay diagnosis or life saving treatment. Risk factors can clearly not exclude any of the life-threatening causes of chest pain. Nevertheless, in most cases, documentation of a family history of CAD (close male relative with CAD before the age of 65), hypertension, diabetes, smoking and elevated cholesterol is reasonable for completeness if you are not

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using them for decision making in individual cases. It is true that uncontrolled hypertension can lead to end organ disease and uncontrolled hypertension increases myocardial oxygen consumption and may be implicated in myocardial ischemic syndromes. Also, patients with diabetes have a high propensity for coronary artery disease. Patients who are diabetic for greater than 5 years should be assumed to have some degree of coronary artery abnormality and patients who have M.I.’s and diabetes have a poorer outcome than the nondiabetic population. Cigarette smoking causes micro-ischemia of the myocardium that may persist for several hours. This is like a stress test of the my ocardium every time you smoke. However, unfortunately, the presence or absence of one or several of these risk factors can not predict whether or not the patient in front of you right now is having a myocardial ischemic syndrome, dyspepsia, dissection of the aorta or an anxiety attack. The physical exam in chest pain syndromes is of limited usefulness. Only a small minority of patients will have a physical finding that either eliminates or enhances the diagnosis. Tachycardia, hypotension and diaphoresis are a sign of “badness” and should alert the physician to be diaphoretic and tachycardia as long as the patient is the same. In fact, no patient should ever be considered for discharge from the ED with abnormal vital signs that are unexplained. However, none of these are either sensitive or specific as diagnostic criteria. The appearance of the patient may be the single most important finding. An apprehensive, anxious, diaphoretic patient with a sense of impending doom often has life-threatening illness. A new murmur may suggest papillary muscle dysfunction, but since emergency physicians do not provide continuity care, they are usually unaware if the murmur is new or not. An S3 or S4 may be observed but is likewise nonspecific and of questionable usefulness. In pulmonary embolism, a normal exam is the rule. Physical examination of the lower extremities for DVT is unreliable and the pulse oximetry and ABG may be normal or only slightly suggestive of the actual diagnosis. There are no confirmatory findings in esophageal reflux disease that reliably differentiate it from ischemic syndromes. Musculoskeletal chest wall pain can be reproduced by palpating the chest wall. Unfortunately, a large proportion of the population has chest wall tenderness on palpation. As many as 50% of normal individuals will complain of chest tenderness on palpation and 15-50% of patients with an acute MI will have chest wall tenderness that partially or completely reproduces the pain they are experiencing from their myocardial ischemic syndrome. Using the presence of chest wall tenderness to diminish the diagnostic likelihood of myocardial ischemia can be disastrous! The single most important diagnostic test for the patient with chest pain is the EKG. Its predictive value is greater than that of the history and the physical exam. The American College of Emergency Physicians has developed a clinical policy that recommends an EKG be obtained on almost all individuals presenting to the emergency department over the age of 35 with any symptom complex that may be suggestive (even remotely) of a myocardial ischemic syndrome. Thus any patient with chest pain, dyspnea, stroke, syncope, confusion etc. will normally get an EKG. If there is recurrence of chest pain while the patient is in the ED or if there is a decline in the patient’s condition the EKG should be repeated. What actually constitutes an EKG that is diagnostic of an AMI is more controversial than you might imagine. Numerous EKG findings have been used as criteria for the diagnosis of AMI. Large thrombolytic trials have used the GISSI criteria which have a specificity of 94%. The criteria are 1) ST segment elevation or depression of 1 mm or greater in any limb lead or 2) ST segment elevation of 2 mm or greater in any precordial lead. Unfortunately, the sensitivity of these criteria even in patients with a strong clinical history is only about 40% in those proven to have an AMI. New ST segment elevation of 2 mm or greater in two contiguous leads is the standard criteria for initiation of thrombolytic therapy. Some will also add the development of a new bundle branch block as thrombolytic criteria along with the ST segment elevation. Of note is that some patients will have ST segment depression with their AMI. ST segment depression is not included as thrombolytic criteria. These patients have an increased morbidity and mortality with thrombolytics for an unexplained reason and thrombolytics should not be given. Also noteworthy is that not all patients having new ST segment elevation are having an AMI. Clearly pericarditis and thoracic aortic dissection can cause elevated ST segments as can a ventricular aneurysm. Anticoagulation is these patients is disastrous. A good rule of thumb is that if you think you have thrombolytic criteria - think twice, act once. Consider everything before acting- but then act. Don’t be paralyzed by fear or uncertainty- but do take the above into consideration. Unfortunately, a significant number of patients having an MI will have either ST segment depression or a normal EKG. Although, it is true that most patients who have an MI will show some EKG abnormality sometime during the course of their illness, unfortunately, those abnormalities may not be present when they are in the ED. Across the board, up to 20% of patients who have an MI may have a perfectly normal EKG. Normal EKGs are repeated in up to 50% of patients who present very early, within the first minutes to hours, to the ED with their ischemia/infarction. The EKG, although it is the best criteria we have, is far

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from perfect for several reasons. First, unstable ischemia syndromes have rapidly changing demand and supply characteristics. A single EKG rarely tells the whole story. A patient with unstable angina may have a normal EKG one minute and a very different tracing the next minute. Secondly, the standard EKG is limited because of its lack of perfect detection in areas of the myocardium it samples. Small areas of ischemia or infarction may not be detected. Conventional leads do not sample the right ventricle or the posterior or lateral walls of the ventricles. Additionally, AMI’s in the area of the circumflex artery are likely to have a nondiagnostic EKG. A third reason why the EKG is limited is that some baseline abnormalities of the EKG make interpretation difficult to impossible. Baseline findings like early repolarization, left ventricular hypertrophy, bundle branch block, arrhythmias and prior Q waves may mask zones of infarction. Lastly, there may be disagreement in interpretation between readers. One man’s ST segment elevation consistent with ischemia/infarction may be another man’s nonspecific ST-T segment abnormality. However, in a study of patients sent home from the ED with M.I’s who had EKG’s in the ED, 23% were found to have EKG diagnostic criteria consistent with AMI on review. Clearly, emergency physicians must make sure that their EKG reading skills are honed to perfection before making important decisions about patient care based on their EKG interpretative skills. The chest x-ray is commonly ordered in patients with chest pain but is only of limited value. In myocardial ischemic syndromes the chest x-ray is normally noncontributory in making the diagnosis. In patients with pulmonary embolus the chest x-ray is usually normal or demonstrates minimal nondiagnostic findings. A V/Q scan or pulmonary arteriogram will be necessary to make the diagnosis. Even in patients with chest wall trauma, rib fractures are commonly missed the first few days after injury and may be demonstrated only as they show calcification secondary to healing. Pneumonias can be demonstrated on CXR but are usually anticipated by the history and the finding of rales or rhonchi on the physical exam and is rarely a surprise for the mature physician. Aortic dissection may be suspected by a wide mediastinum but this finding alone is nondiagnostic and must be followed by an trans-esophageal echo or an aortogram. The take home lesson is that the CXR, while considered standard practice for the patient with chest pain, is rarely diagnostic or of help in defining unexpected conditions. Up to this point, we have seen that the history and physical exam may be helpful at times and misleading other times. We have seen that the chest x-ray is unlikely to be helpful and the EKG, while very helpful if it shows the characteristic changes of infarction or ischemia, may also be normal in the presence of an infarction or unstable angina. The “gold standard” for the diagnosis of infarction is the characteristic rise and fall of the cardiac enzymes. The best marker we have is the creatinine kinase (CK) and its MB fraction (CK-MB). This enzyme is released from necrotic heart muscle and enters the circulation through the lymph system. The CK and CK-MB may be detectable in the serum as early as 4 hours post infarction and will peak 12 to 20 hours post infarction. The CK-MB is considered positive for myocardial muscle necrosis if the fraction is greater than 2-3 % of the total CK. The CK, while it is the best marker we have, is of little use in the emergency department for several reasons. Generally, we see patients early before the CK rise and since we are a time limited specialty and generally do not follow patients or admit them, we can not benefit diagnostically from the longitudinal rise in the CK-MB. It is not uncommon in the ED in the patient with an MI to have a normal CK and CK-MB only to show the rise after admission. Another limitation is that since CK is released only from necrotic cells, it is not helpful in the diagnosis of unstable angina when muscle necrosis has not yet occurred. In other words, it will not help us predict which patients with coronary artery disease, but without infarction, will have complications hours or days from their visit to the ED. Also improving our tests to increase the sensitivity of detection of CK and CK-MB in serum are limited in that, no matter the sensitivity of the test, there is time required for the muscle cell to die and for that biochemical to enter the general circulation before we can detect it. Tests that detect the enzyme earlier will be helpful, but the problem of detection very early in MI and detection of the patient with unstable angina remain. Other biochemical markers for myocardial muscle necrosis include LDH and isoenzymes which rise 8-12 hours after MI and peak 72-144 hours after MI share the same limitations as the CK. Troponin T and I are proteins specific for myocardial cells and are reported to be helpful in the early detection of the MI patient, however, clinical experience is still too limited to comment on its ultimate place in our diagnostic armamentarium. What should now be apparent is that the diagnosis of the cause of chest pain in the emergency department is fraught with difficulty and uncertainty.

Chest Pain

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The history can be misleading, the physical exam nonspecific and all ancillary testing normal and the patient can still harbor an acute life threatening illness from which he/she will suffer significant morbidity or mortality is the succeeding hours or days. The prudent physician knows when to trust data and when to suspect data. It will be the wise physician who is cautious in the approach to the patient with chest pain. A physician who says that he/she has never sent home a patient with unstable angina or an MI or pulmonary embolus is most likely a physician who is relatively inexperienced and has not had a great deal of patient contact. The very nature of the patient who presents to the emergency department with chest pain makes eventual error almost inevitable.

Chest Pain Bibliography

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Annotated Bibliography of Recent References on

Evaluation and Treatment of the Patient with Chest Pain

(Not in any order)

1. GISSI, Lancet 1986;1:397-402. (STK reduced mortality in acute MI) 2. Norwegian Multicenter Study Group, N Engl J Med 1980;304:801-807 (Timolol improves long tern survival and decreases reinfarction rates) 3. BHAT JAMA 1981;246:2073-2080

(Propranalol shows a 26% reduction in mortality after MI) 4. Goteburg Trial, Lancet 1981;2:823-827 (Metoprolol reduces death after MI) 4. APSI Trial, Am J Cardiol 1990;66:251-260

(Acebutolol reduces mortality by 58% 1 year after MI) 5. Science 1983;220:1181-1183

(rt-PA can selectively lyse coronary thrombi improving myocardial perfusion) 6. MIAMI Trial, Eur Heart J 1985;6:199-226

(Metoprolol reduced mortality by 13% as well as enzyme and ECG evolution) 7. VA Cooperative Trial JAMA 1973;225:724-9

( Anticoagulants reduced systemic thrombi after MI but not mortality) 8. Circulation 1986;74;III-1-10

(Embolization prophylaxis recommendation for patients for large anterior M.I.'s) 9. Western Washington Randomized Trials N Engl J Med 1983;309:1147-82

(Use of intracoronary STK in Acute MI) 11. ISAM (IV SK in Acute MI) N Engl J Med 1986;314:1465-71 12. TIMI (Thrombolysis in MI) N Engl J Med 1985;312:932

(Compared STK and TPA- TPA had much higher incidence of reperfusion but there was no difference in hospital mortality)

13. TAMI (Thrombolysis and Angioplasty in MI) N Engl J Med 1987;317:581-588

(Patients given TPA have a 75% patent coronary artery- no change in LV function at 7 days between those with and without TPA)

14. European Cooperative Study Brit Med J 1988;297:1374-9 (TPA reduces mortality and reinfarction compared to placebo) 14. ISIS-2 (Second International Study of Infarct Survival) Lancet 1988;2:349-60

(STK verses ASA, neither or both- STK and ASA used alone or both reduced mortality at 5 weeks compared to placebo)

15. ASSET (Anglo-Scandinavian Study of Early Thrombolysis) Lancet 1988;2:525-530

(TPA reduces mo rtality early and reduces 1 month mortality over placebo) 17. AIMS (APSAC Intervention Mortality Study) Lancet 1988;ii:545-549 (Overall reduction in mortality 47% but reinfarction was common) 18. PAIMS (Plasminogen Activator Italian Multicenter Study) J Am Coll Cardiol 1989;13:19-26

(Compaired TPA and STK- reperfusion better with TPA but reocclusion higher so that the net result was the same with both drugs.)


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19. TIMI 2 (Thrombolysis in MI) JAMA 1988;260-2849-56

(Immediate coronary arteriography or angioplasty provides no advantage) 20. TIMI 2-b N Engl J Med 1989;320:618-627 (Angioplasty can be safely deferred until patients

have recurrent ischemia. Patients given IV metoprolol verses oral drug- patients given Beta blockers had lower incidence of ischemia and reinfarction- patients treated within first 2 hours and low risk patient benefited the most)

20. White New Zealand Study N Engl J Med 1989;320:817-821

(STK verses TPA using LV function as end point-( EF the same, reinfarction the same, patency the same but mortality lower with TPA at 30 days and 9 months)

21. GISSI-2 Lancet 1990;336:65-71

(All patients got standard therapy for MI plus STK with or without heparin or TPA with or without heparin- No advantage for subQ heparin)

23. SCATI (Subcutaneous calcium-heparin in acute MI) Lancet 1989;182-186 (Mortality was lower

in heparin and STK group compared to controls. Also less thrombus in heparin group by echo) 24. HART (Heparin Aspirin Reperfusion Group) J Am Coll Cardiol 1990;15 (suppl A):64A

(Patients either received heparin + TPA or ASA+TPA,-heparin and TPA lead to better patency at day 1)

25. 2nd ACCP Conference on Antithrombotic Therapy Chest 1989;95:73S-97S

(No recommendation on which agent to use, recommends use of various adjunct agents, e.g ASA, Beta Blockers, NTG etc.)

26. ISIS-1 Lancet 1986;2:57 (Atenolol decreased mortality at 7 days by 15%) 27. Chest 1988;93:25-28S (NTG reduces death rate in acute MI) 28. Circulation 1988;78:906-919

(NTG reduces infarct size by 27%, infarct expansion reduced by 87%, thrombus formation by 77%, cardiogenic shock by 67% and inhospital mortality by 50%)

29. Lancet 1986;1:234-5 (Magnesium reduces overall mortality by greater than 50% and reduces

arrhythmias by more than 50%) 30. N Engl J Med 1986;315:417-23 (Calcium Channel Antagonists and Non Q Wave MI) 31. Diltiazem Reinfarction Trial N Engl J Med 1986;315:423-9

(Effects of Diltiazem on non Q wave MI- No difference on mortality but a decrease incidence of reinfarction- those with diltizem had a high incidence of adverse effects)

32. HINT Research Group Br Heart J 1986;56:400-413

(Trial of Ca Channel antagonists - verapamil and nifedipine- with unstable angina more likely to have an MI or recurrent ischemia with Ca Channel antagonists than with metoprolol)

33. Danish Verpramil Trial; Norwegian Nifedipine Multicenter Trial; TRENT Study- (all say the

same- verapamil or nifedipine either have no effect or an increased mortality on acute Q wave MI) 33. Br Med J 1989;299:1187-1192

(Ca Channel Blockers do not reduce risk of infarction of death in acute MI) 35. Arch Intern Med 1989;149:1669-1677 (Ca Channel antagonists are contraindicated in patients

who have acute MI or in patients with LV dysfunction)


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36. Multicenter Diltiazem Postinfarction Research Group N Engl J Med 1988; 319:385-392 (No decreased mortality or cardiac events in patients on long term diltiazem after MI- increased mortality in patients early on and in patients with pulmonary congestion)

37. JAMA 1988; 260:1910-1916 (Lidocaine can reduce the odds of ventricular fibrillation by 1/3.

There is no beneficial effect on mortality- but mortality is increased by 1/3 in the lidocaine group) 38. Am J Cardiol 63:772 1989 Comparison of clinical presentation of AMI in patients older than 65.

Multicenter Chest Pain Study (Older you are, the less typical your presentation is for MI) 39. Am J Cardiol 1987;60:219-214 (Study of characteristics of patients with MI who are sent home.

Miss patients who are having pain at rest. 50% of patients with MI sent home could have been diagnosed if physician had better EKG reading skills)

40. N Engl J Med Vol 327 No 3 Pg 175 Use of ASA in Ischemic Heart disease

(a review of the literature) 41. N Engl J Med 1988 :319:1105-11 (Montreal Heart institute study of heparin in unstable angina)

Aspirin, heparin or both to treat acute unstable angina (both aspirin and heparin are associated with a reduced incidence of AMI in unstable angina. Trend favors heparin)

41. N Engl J Med July 16 1992 Vol 327 No 3-

Reactivation of unstable angina after discontinuation of heparin 43. LIMIT-2 Lancet 1994;343:816-19

(Magnesium given before thrombolytics decreases mortality and decreases LV dysfunction) 44. Clinical characteristics and outcome of AMI in pts with initially normal or nonspecific EKG. Am

J Cardiol 1989;64:1087-92. (Pts had lower CPK and mortality was lower) 45. Clinical characteristics and natural history of Pts with AMI sent home from the ED. Am J Cardiol

1987;60:219-224. (Pts with missed AMI younger, had less typical symptoms, less likely to have prior ASCVD and had normal EKG. Mortality higher than controls. 50% could have been diagnosed if physician had better EKG reading skills)

46. Missed AMI in the ED... Ann Emerg Med 1993;22:579-582

(25% of pts with missed MI could have been diagnosed if EP had better EKG reading skills.) 47. Unstable angina, Mayo clin proc 65:384-406, 1990

(good review article on current state of knowledge on unstable angina) 48. Reperfusion in AMI, Mayo clin Proc 65:549-564, 1990

(good review article on current state of knowledge on reperfusion injury after thrombolytics) 49. Magnesium in AMI Annals of Emerg Med 1993;22:754-756 (This is an annotated bibliography of articles on Mag in AMI) 50. Acute MI: Initial manifestations, managment and prognosis Mayo Clin Proc 65:531-48, 1990 (Review article) 51. The Golden Hours of the MI: Nonthrombolytic therapy Annals of Emerg Med 1991:20:540-48.

(This is a review article covering lidocaine, nitrates, Ca Channel blockers, B Blockers, Aspirin) 52. ACC/AHA Guidelines for the Early Management of patients with AMI

Circ 1990;82(2):664-707. (Exhaustive review of the literature on all aspects of the care of patients with AMI- a must read for all emergency physicians)

53. Silent myocardial ischemia Mayo Clin Proc 65:374-383, 1990

(Review of current understanding of silent ischemia)


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54. Hostility Predicts Restensois after PTCA Mayo Clin Proc 1996; 71(8):729-734 Patients who had higher hostility index had > # restenosis of coronary artery after PTCA than those with lesser hostility index.

55. Effect on Outcome of the Presence or Absence of Chest Pain at the initiation of TPA in AMI Am

J Cardiol 73:729-736, 1994 ( Pts with EKG evidence of AMI but without chest pain still benefit from early initiation of TPA)

56. Influence of pseudodiagnostic information on the evaluation of ischemic heart disease Green and

Yates Ann Emerg Med 25:451-457, 1995 (Physicians in ED rely heavily on epidemiologic factors to make disposition on patients with chest pain although epidemiologic criteria on populations bear no relationship to individual patients risk factors)

57. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department:

Executive summary of a National Heart Attack Program Working Group Report, Selker HP, Zalenski RJ, Antman EM, et al Annals of Emergency Medicine, Vol 29, Number 1, Jan 1997, pages 1-88 (Literature review with recommendations on the current state of understanding of diagnostic modalities for acute coronary event. Review includes, standard EKG, Prehospital EKG, continuous EKG, nonstandard EKG and body mapping, EKG stress test, ACI predictive instrument, ACI-TIPI, Goldman chest pain protocol, computer based decision aids, Creatinine kinase, other biochemical tests, echocardiogram, thallium scanning, sestamibi and technecium 99m scanning- conclusions are that standard EKG is useful as is the ACI predictive instrument. Less important is the prehospital EKG, ACI-TIPI, Goldman Chest Pain Protocol)

Environmental Emergencies

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Only the creativity and the multitude of activities, which people engage in limits the diversity of injuries and insults to the human body. This section is only a hint at some of the more commonly seen environmental injuries that present themselves in the Emergency Department. Included at the end of this section are a few tidbits, which may entice the reader to further explore some of the special entities. Cold Injuries Localized Exposure to cold may result in a wide variety of injuries, each with its own unique problems to address. Long term (and especially repeated) prolonged exposure to wet, near freezing temperatures causes localized ischemic injuries. Presumably, localized tissue damage as well as localized vasoconstriction play important roles in the evolution of this nonfreezing injury. Classic examples of this are immersion foot or trenchfoot. Another nonfreezing injury occurs with dry cold exposure, particularly in mountain climbers or individuals living in areas the windy, cold conditions. This is chilblain or pernio, which causes local pallor from vasoconstriction and with rewarming causes pain and erythema. Chronic repetition produces permanent injury with pain in these areas. With more prolonged exposure, a local freezing injury will set in. This is called frostbite. Frostbite is assessed like burns: in 1st, 2nd, 3rd, and 4th degree injuries. 1st degree partial skin freezing PE: Erythema, edema, hyperemia. No blisters or necrosis.

Occasionally may desquamate in 5-10 days. Sx: transient stinging and burning 2nd degree full thickness skin freezing PE: Erythema, substantial edema, vesicles with clear fluid.

Blisters desquamate and form black eschars. Sx: Numbness 3rd degree full thickness skin and subcutaneous freezing PE: Violacious / hemorrhagic blisters. Skin necrosis. Blue-gray

discoloration Sx: Initially no sensation. Tissue feels like “block of wood.” Later

may feel pain, burning, throbbing, aching. 4th degree Full thickness skin, subcutaneous tissue, muscle, tendon, and bone

freezing PE: Little edema. Initially mottled, deep red, or cyanotic. Eventually

dry, black, mummified. Sx: As above. May have joint discomfort. Amputation of frozen extremities should be delayed, as the wound should be allowed to demarcate itself. There may be more or less tissue, which may survive. It was noted that prolonged exposure to cold will cause these kinds of freeze injuries; however, brief exposure to cold in the presence of wind may cause rapid tissue freezing due to “wind chill”. For example, skin exposed to +5 Fahrenheit in a 10-mph wind will cause freezing within 1 minute (equivalent to -25 F). At -30 F in a 16-mph wind, freezing may occur in 30 seconds (equivalent to -80 F)! Another example to demonstrate this is to throw a cup of water into the air during extreme cold periods in one of the northern states. The water will be frozen before it falls to the earth and shatter when it hits the ground! In spite of these impressive illustrations, it is possible to get frostbite in Georgia. If an extremity is frozen, it should not be rewarmed until there is no chance of it refreezing. This is an important point to remember in the field as the thaw/refreeze cycle will cause more tissue damage. Also, the part should not be rubbed to try to promote warming. This well-intentioned effort actually causes tissue damage, and merely triggers pain fibers to give a burning sensation perceived as warming. So don’t do it! Instead simply warming with a blanket or a warm (no higher than 41 C) water emmersion of the part may be used. Have the patient stay away from an open fire. Decreased sensation may result in getting too close and result in a burn injury on top of the cold injury.


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Systemic Hypothermia is defined as a core temperature less than 35 C.

Many conditions may predispose an individual to hypothermia. See Table 1. Hypothermia is typically divided into three stages based on the actual core temperature of the victim: mild--32-35 C (89.6-95 F), moderate--28-32 C (82.4-89.6 F), and severe--<28 C (<82.4 F). Usually, special thermometers are required to check the temperature of cold victims as most hospital thermometers only read as low as 34 C. These temp eratures are not cast in stone and some authors will site slightly different numbers. Their use is in correlating clinical signs and to help in the management of these patients. Table 2 demonstrates the continuum of responses to hypothermia. Three additional interesting facts about hypothermic patients are worth mentioning. 1) Paradoxical undressing may occur as confusion sets in. It was once thought that people found naked in the snow had been assaulted or robbed, but these individuals actually undres sed themselves in their hypothermic confusion and inadvertently worsen there predicament. 2) Loss of reflexes occurs in a gradual fashion. Interestingly the patellar tendon reflex is the last to be lost as cooling takes place and the first to be regained as the victim is rewarmed. 3) Bronchorrhea may be prominent in the hypothermic patient. It was once thought to be pulmonary edema, which it closely mimics, but is actually fluid leaking though the damaged cold alveolar membranes. The treatment for hypothermia is of course rewarming. This should begin by preventing further heat loss. Rewarming may be achieved by passive rewarming, basically by having the patients rewarm themselves by shivering while wrapped in a blanket. More active external rewarming may be accomplished by applying heating blankets, heat lamps, warm fluids to drink, humidified and even warmed air or oxygen to breathe, and warmed IV fluids (yes, a microwave oven may be used to warm fluids, NOT BLOOD, but fluids must be well mixed before administration because of uneven heating in the bag). As seen in Table 1, shivering ceases below a certain level, and confusion or even unresponsiveness may prohibit several of the methods listed to rewarm the victim. More invasive measures such as warm fluid gastric lavage, rectal lavage, peritoneal lavage, or thoracic cavity lavage may be required. Extracorporeal techniques including hemodialysis and cardiopulmonary bypass are also options.

Table 1. Factors Predisposing to Hypothermia

Decreased heat production Impaired thermoregulation Endocrine failure Peripheral failure Hypopituitarism Neuropathies

Hypoadrenalism Acute spinal cord transection Hypothyroidism Diabetes Insufficient fuel Central failure Hypoglycemia CNS trauma Malnutrition CVA Neuromuscular insufficiency Toxicologic (EtOH) Age extremes Pharmacologic Inactivity/imobilization Neoplasm Increased heat loss Multiple sclerosis Environmental Miscellaneous associated states Immersion Recurrent hypothermia Nonimmersion Episodic hypothermia Induced vasodilation Sepsis

Pharmacologic Pancreatitis Toxic (EtOH) Carcinomatosis Erythodermas Cardiopulmonary disease Burns Vascular insufficiency Exfoliative dermatitis Sarcoidosis Iatrogenic Shaken baby syndrome Emergent deliveries Psychologic Cold infusions Heat stroke treatment Trauma management (exposure)

Modified from Danzl DF, Accidental Hypothermia. In: Rosen et al, eds. Emergency Medicine: Concepts and Clinical Practice. 3rd ed. St. Louis, MO: CV Mosby; 1992: 918.


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Table 2. Physiologic Characteristics of the Three Stages of Hypothermia Core temperature Stage C F Characteristics Mild 37.6 99.6 Normal rectal temperature 37 98.6 Normal oral temperature 36 96.8 Increase in metabolic rate 35 95 Urine temperature34.8 C; maximum shivering thermogenesis 34 93.2 Amnesia and dysarthria develop; normal blood pressure;

maximum respiratory stimulation 33 91.4 Ataxia and apathy develop Moderate 32 89.6 Stupor; 25% decrease in oxygen consumption 31 87.8 Extinguished shivering thermogenesis 30 86 Atrial fibrillation and other dysrhythmias; poikilothermia;

pulse and cardiac output two-thirds normal; insulin ineffective 29 85.2 Progressive decrease in level of consciousness, pulse, and

respiration; pupils dilated 28 82.4 Ventricular fibrillation susceptibility; 50% decrease in oxygen

consumption and pulse Severe 27 80.6 Losing reflexes and voluntary motion 26 78.8 Major acid -base disturbances; no reflexes or response to pain 25 77 Cerebral blood flow one-third normal; cardiac output 45%

normal; pulmonary edema may develop 24 75.2 Significant hypotension 23 73.4 No corneal or occulocephalic reflexes 22 71.6 Maximum risk of ventricular fibrillation; 75% decrease in

oxygen consumption 20 68 Lowest resumption of cardiac electromechanical activity;

pulse 20% of normal 19 66.2 Flat EEG 18 64.4 Asystole develops 16 60.8 Lowest accidental hypothermia survival in an adult 15 59.2 Lowest accidental hypothermia survival in an infant 10 50 92% decrease in oxygen consumption 9 48.2 Lowest therapeutic hypothermia survival

Emergency Medicine Reports Vol. 13, No. 1, p. 3, 1992. Another phenomenon known to occur with aggressive external rewarming is core temperature after-drop. As warming of the superficial layers of the skin occurs, vasodilation of the constricted vascular beds (which occurred earlier to slow core temperature loss) now is reversed quickly. Cold blood from the periphery now is allowed to be mobilized into the warmer core circulation. The result is dangerous cooling of the core temperature. A similar mechanism is in effect when mildly cold patients drink alcohol. The peripheral vasodilation induced by the alcohol brings more warm blood from the core to the skin giving a pleasant warm sensation. Unfortunately, it allows the body’s heat to be lost faster.

At low temperature, the heart is more irritable and likely to convert to ventricular fibrillation. An example, which demonstrates this principle daily, is the cardiac activity during cooling in preparation for coronary artery bypass grafting. In the outdoor victim, this rhythm may not convert despite aggressive ACLS techniques until the patient’s core temperature has risen. This has given rise to the expression, “You’re not dead until you are warm and dead.” There are rare reports of neurologically intact survivors after prolonged and profound hypothermia, usually in cold water immersion, in which there is rapid temperature loss rather than prolonged slow deterioration. An EKG obtained on a profoundly hypothermic patient may demonstrate an Osborne or “J-wave” (See Figure 1). This unusual change in the EKG is pathognemonic for hypothermia. It may occur in any lead or multiple leads without any particular pattern of distribution.


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Emergency Medicine Reports Vol. 13, No. 1, p. 4, 1992.

In summary, the best method of treatment for hypothermia is avoidance, particularly iatrogenically induced. For individuals who must subject themselves to cold temperatures, proper dress, avoidance of alcohol and other substances which alter mental or metabolic function, and staying dry are of utmost importance. Recognition of hypothermia is essential. This includes making sure that temperature readings are accurate. Most often, no more than supportive measures are required.


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Heat Injuries A wide variety of illness and injury is attributable to problems related to heat exposure or hyperthermia. Maladies may range from minor to life threatening. The body makes use of the various methods of heat transfer, but once these are overwhelmed its temperature will rise.

Methods of Heat Transfer

Conduction 2% of heat may be lost via this route Convection wind speed dependent Radiation up to 65% heat may be lost via this route in a cool

environment. Evaporation 0.58 kcal/ml sweat due to evaporative loss

Acclimatization to an environment has a profound effect on the body’s ability to dissipate heat. There are reports of sweat production of 4 liters per hour! Skin blood flow may increase to 8 liters per minute. (Incidentally, this is the reason for warnings around hottubs. The individual may take on more heat than they can dissipate, marked vasodilation may make them hypotensive, and significant skin blood flow demands a hyperdynamic cardiac state which may overwhelm a diseased heart.) Heat may be picked up exogenously, or there may be conditions which do not allow for adequate dissipation of normally produced body heat, or a condition producing abnormal amounts of heat may prevail. The latter includes conditions such as malignant hyperthermia and neuroleptic malignant syndrome. These two unique illnesses will not discussed further in this monograph. Minor Heat Illnesses Heat edema is a self limited condition presenting as mild swelling, usually confined to the lower extremities. Shoes may be tight. It occurs in unacclimatized individuals during the first few days of exposure to a hot environment. Treatment consists of reassurance, elevation of the legs, and support hose. CHF is obviously in the differential diagnoses. Heat cramps usually occur in young physically fit, but unacclimatized patients. They occur after vigorous exercise, effecting the most used muscle groups. There is usually a history of copious sweat production and hypotonic fluid consumption. The mechanism is unknown, but most likely due to electrolyte shifts. Treatment consists of rest, removing the victim from the hot environment, and oral rehydration. Unacclimatized individuals produce sweat with large amounts of electrolytes. Once adapted, the sweat produced is nearly pure water. Heat syncope is a true syncopal event precipitated by prolonged exposure to hot environments, particularly with standing still in “parade” posture. It is accelerated in dehydrated patients, but is self limited. Treatment consists of continued supine positioning, leg elevation and oral or IV hydration. Prickly heat seen in infants and occasionally in intertrigenous areas is often referred to as heat rash or simply “heat” is nothing more than milia rubra. Treatment includes washing with soap and water and keeping the area dry. Severe Heat Illnesses Heat exhaustion is the first step in the progression into severe heat injury. Moderate water and salt depletion and a light rise in temperature are underlying problems. Symptoms include vague malaise, fatigue, and headache. Mental status is normal and core temperature is less than 40 C (104 F). Vital signs will demonstrate tachycardia and orthostatic hypotension. Examples of prime candidates for this type of illness are road construction workers and roofers. Treatment consists of rest, a cool environment (even just getting under a tree), and IV and oral hydration. Fans and moist sheets placed over the patient or spraying water on patient with fans blowing will rapidly cool the patient’s temperature. These methods are preferable to ice packs being applied which are not only uncomfortable, but also induce vasoconstriction which actually slows heat loss and often induces shivering which may actually increase the patient’s


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temperature. Most of these patients will be healthy otherwise and may be discharged after treatment; however, elderly patients and patients with electrolyte abnormalities should be admitted. Heat stroke is a medical emergency. It is an extension of a continuum form heat exhaustion. It is hall-marked by altered mental status, most notably coma seizures, and delirium. It is often divided into classic and exertional (See Table 3.). The typical example of classic heat stroke is that of an elderly person found unresponsive in bed in a house with no air-conditioning and perhaps a ceiling fan running during a heat wave. On the other hand, a football player practicing under poor supervision in the humid heat of the South may finally collapse in exertional heat stroke. The same techniques listed under heat exhaustion may be used to cool the victim. Also, cold lavage of the stomach and rectum may be performed. In addition to being cooled rapidly, the end organ damage (CNS, renal, hematopoetic, or muscular) must be aggressive treated. An extensive differential diagnosis list must be considered while treating the heat stroke patient (See Table 4.).

The best method for determining whether or not conditions are suitable for vigorous outdoor activities is based on a wet-bulb globe temperature, which takes into account temperature, humidity, and radiation. Acclimatization and maintaining adequate hydration are the most important additional factors in avoiding heat injury.

Table 3. Comparison of Classic and Exertional Heat Stroke

Classic Exertional Age group Elderly Men (15-45)

Health Status Chronically Ill Healthy Activity Sedentary Strenuous Exercise Drug use Anticholinergics Usually none Diuretics,

Antipsychotics, Antihypertensives Antidepressants Sweating Usually absent Often Present Lactic Acidosis Usually Absent Common, may be marked Poor prognosis if present Acid / Base Changes Respiratory Metabolic Acidosis

Alkalosis Respiratory Alkalosis Rhabdomyalysis Uncommon Common Hyperuricemia Modest Severe Acute Renal Failure <5% of Patients 25-30% of Patients Hypocalcemia Uncommon Common DIC Mild Marked CPK/Aldolase Mildly Elevated Markedly Elevated Hypoglycemia Uncommon Common

Major Organ System CNS Renal, Muscle, Hematologic Mechanism Poor dissipation of Excessive Endogenous Heat

Environmental Heat Production Epidemics Yes (Heat Waves) Yes (Group Athletics) Predisposing Weather Heat Wave Variable


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Table 4. Differential Diagnoses of Heat Stroke

Alcohol Withdrawal Syndrome Meningitis Neuroleptic malignant syndrome Brain Abscess Malignant hyperthermia Malaria (cerebral falciprum) Anticholinergic Toxicity Typhoid Fever Salicylate toxicity Status Epilepticus PCP, Cocaine, or Amphetamine Toxicity Cerebral Hemmorhage Tetanus Diabetic Ketoacidosis Sepsis Thyroid Storm Encephalitis


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Burns Minor burns are commo n occurrences and are familiar to everyone. There are many different kinds of burns; however, only a few common ones and their evaluation and management will be described in this section. Thermal Burns These are by far the most common (if one excludes radiation burns due to sunburn). These are classically broken down into first, second, and third (sometimes also fourth) degree burns based on the depth of the injury. First-degree burns are minor and are confined to the epidermis. They are characterized by erythema and pain. If blistering is present, the injury has extended into the dermis and it is a second-degree burn. If dermal elements are also destroyed, the wound is a third-degree wound. It is painless as the nerves are dead. It typically appears waxy or charred. Some authors describe fourth-degree burns as those which involve muscle and/or bone. Injuries are commonly caused by steam, hot water, or grease, but possibilities are endless. The significance of these wounds begins with the violation of skin integrity. First and second degree wounds are responsible for large amounts of fluid leakage from the body as well as fluid leakage into the third space. A commonly used method for determining the amount of body surface area burned is called the “rule of 9’s.” It is helpful in assessing a patients injury as well as calculating IV fluid resuscitation requirements.

Rule of Nines to Calculate Injured Body Surface Area

Body surface Area % Total Upper extremity 9 each 18 Lower extremity 18 each 36 Trunk (front) 18 18 Trunk (back) 18 18 Head 9 9 Perineum 1 1 100 % The patient’s palm is roughly equivalent to 1% body surface area and may be helpful for estimating irregular areas. Children have a slightly different distribution of surface area because of their relatively larger head. The ratios are changed to reflect this and may be easily looked up when the need arises. Only 2nd and 3rd (and 4th) degree area burns are of significance in calculating fluid loss. A commonly used formula is called the “Parkland Formula.”

4 ml/kg x % burn area = IV crystalloid to be given in the first 24 hours. ½ of the calculated fluids are given in the first 8 hours. The rest is given over the remaining 16 hours.

For example if a 100 kg man sustains 2nd and 3rd degree burns over 40% of his body, the formula indicates he will need 4 x 100 x 40 = 16 liters of IV NS or LR in the first 24 hours! His fluid rate will be 1 liter/hour for 8 hours and then 500 cc/hour for 16 more hours. This is on top of maintenance IV fluids. Fluid administration is also guided by urine output. If UOP drops below 50cc/hour (which is quite likely),the patient will require additional fluid boluses! That is a lot of fluid. Patients get in trouble when their caretaker is too timid to give these massive amounts of fluid or when there is delay in getting therapy started (Remember that half of the calculated fluids are give in the first 8 hours from the time of injury, not from the time the patient arrives in the ED or the burn unit). If therapy is delayed the time must be made up and the fluid rate increased. Tetanus status must be assessed for any significant burn. Patients with large burns must be protected from hypothermia due to massive evaporative heat losses. Prophylactic antibiotics are contraindicated. Patients with circumferencial burns may require an escharotomy to relieve the tourniquet effect which may be impeding vascular flow to an extremity or prevent the patient from breathing if around the chest. Finally, patients must also be assessed early for any other concomitant injuries. Inhalation Burns and Injuries Some patients will present following entrapment in a house fire or with steam injuries to the face (often from car radiators). The hot air or steam will scald the airway and lead to airway edema which may become life threatening. Clues to this problem which may be evolving while assessing the patient are the presence of singed facial hair, burns in the mouth, carbonatious sputum, hoarseness or stridor. These are all important because rapid assessment of the airway must be made. It may still be possible to intubate the


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patient now, but it may be impossible in 5 minutes due to interval progression of edema formation. Patients in fires must also be assessed for carbon monoxide and other lethal gas poisoning. Electrical Burns This last category of burns to be discussed poses interesting problems because there tends to be little skin damage, while there may be large amounts of underlying or remote injury. Electrical current tends to follow the path of least resistance. This happens to be along nerves and vessels and muscle tissue, not skin. Rhabdomyalysis is a major complication and may lead to renal failure. Another curious injury is to the lips when children chew on electric cords. The classic wound is in the corner of the mouth with relatively little bleeding. These are at high risk for delayed significant bleeding and therefore should be watched closely. Lightning Numerous people are struck by lightning every year. Lightning is still a poorly understood phenomenon. Injuries from lightning may be from a direct strike or from spray. Lightning typically does not travel through a victim but over and around him producing typical feathery lesions on the skin. Sweat on the skin nearly explodes off during the sudden intense, localized heat from the lightning bolt, sometimes blowing clothes and shoes and socks off of the victim. Eardrums are frequently perforated by the shock wave. Death from a lightning strike is an interesting physiologic process. There may be a momentary cardiac stun; however, the heart automatically resumes its normal beat. There is generally no direct cardiac injury. Lightning also produces a major CNS stun, which induces unconsciousness and disables the respiratory drive centers. As the patient remains apneic, he becomes hypoxic and then has a secondary cardiac arrest due to the prolonged hypoxia. Therefore, a lightning victim must immediately be assessed for airway and ventilation status (In spite of folklore, lightning victims do not hold a charge, and they do not shock anyone who comes in contact with them).


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Food Poisoning and Infectious Diarrhea

Acute gastrointestinal symptoms, particularly vomiting and diarrhea, bring many patients to the ED. Many will have a benign self-limited viral illness and can be treated at home. Patients at the extremes of age, however, may require admission to the hospital. A history of possible exposure to some etiologic agent should be explored. In addition to a thorough examination, laboratory testing is occasionally required in the more ill patients. Stool specimens may help in establishing a more definitive diagnosis. Several types of gastroenteritis may be attributable to a particular organism. Infectious diarrhea and food poisoning are generally classified by the types of etiologies. These are intoxication, invasive, E. coli, and parasitic.

Intoxication is the mechanism by which, what we classically think of when we imaging food poisoning, occurs. Most acute forms are from ingestion of food with a bacteria which produces an exotoxin which causes the symptoms. Bacterial invasion is not a factor in this group. This results in laboratory studies being fairly normal. No fecal leukocytes are present and no antibiotics are required. The following are typical representatives of this class. Staph. aureaus 4-16 hours “incubation” Vomiting most prominent Clostridium perfringens 12-24 hours “incubation” Diarrhea prominent Clostridium botulinum rare Mild diarrhea, ocular and respiratory paralysis Invasive gastroenteritis is a true infection of the intestinal tract. As the organism grows in the gut, it invades the mucosal lining. These patients are often febrile and have fecal leukocytes. Occasionally, Staph. aureus will be the causative agent, particularly if the patient was receiving broad spectrum antibiotics. A similar mechanism is true for Clostrim difficile. Similarly, Salmonella may cause symp toms 1-3 days after ingestion. Antibiotics are contraindicated as routine treatment as they prolong the carrier state; treatment with antibiotics is reserved for those with severe toxicity. Campylobacter jejuni may also cause diarrhea, similar to Salmonella. Shigella tends to produce a diarrhea with bloodier stool. Typhoid tends to cause more systemic effects. Trimethoprim-sulfamethoxizole typically suffices against most of these organisms if antibiotics are chosen. E.coli is often listed separately. It both grows in the intestinal tract and may invade the mucosa and produces a toxin, which can cause debilitating diarrhea. Vibrio cholera acts similarly, although with less direct mucosal invasion. The latter is important to consider in travelers, as it is not endemic in the U.S. E. coli on the other hand is common and is the cause for “travelers’ diarrhea.” Again, bismuth preparations (Pepto-Bismol™) are very helpful; in treating the illness and killing the bacteria. Parasitic infections such as Giardia and Entamoeba are typical examples of this class. Their diagnosis will be from the stool smear looking for ova and parasites. A fecal smear to look for leukocytes, ova, parasites, and blood is one of the most helpful test in the ED in assessing a patient diarrhea. Allergic Reactions Few entities cause as much concern and fear as the manifestations of an acute allergic reaction or anaphylaxis. Symptoms may range from mild to life threatening. Prompt recognition and treatment may indeed save a patient’s life. The most common causes of fatal allergic reactions are from parenteral penicillin and hymenoptera (wasp and bee) envenomations. Most severe allergic reactions which develop in seconds to minutes are IgE mediated and may or may not have an IgG component. These include extrinic asmtha attacks, allergic rhinitis, urticaria, angioedema, and anaphylaxis. These are generally classified as Type I hypersensitivity reactions.


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Common Causes of Allergic Reactions

Drugs Penicillins and related antibiotics Aspirin Trimethoprim-sulfamethoxazole Vancomycin Nonsteroidal antiinflammatory agents Foods and Additives

Shellfish Soybeans Nuts Wheat Milk Eggs Monosodium glutamate Nitrates and nitrites Tartrazine dyes Other Hymenoptera stings Inset parts and molds Radiographic contrast material An anaphylactic response may occur with in seconds or be delayed up to an hour after the exposure. Cardiovascular (tachycardia, hypotension, shock), respiratory (layngospasm, bronchospasm), integumentary (erythema, pruritis, urticaria, wheals), and GI systems (nausea, camps, vomiting, diarrhea) will typically be the first involved. No laboratory studies will confirm the diagnosis. It is reached clinically. Treatment begins with airway management. Oxygen and 0.3-0.5 mg of 1:10,000 epinephrine (IV or SQ) are administered if indicated. Occasionally, oral or pharyngeal edema has progressed too far for orotracheal intubation. Cricothroidotomy or transtracheal jet ventilation may be required in this instance. If the patient is being infused with the offending agent, stop it immediately. The patient should be closely monitored. IV fluids should be administered as blood pressure dictates. Antihistamines should be administered. 50mg of diphenhydramine may be given and repeated every 6 hours. H2 blocker therapy is also recommended. 300 mg of cimetidine may be administered every 6 hours. Inhaled B agonist agents such as albuterol should be given to relieve bronchoconstriction. Additionally, aminophylline (4-6 mg/kg IV) may be beneficial to alleviate bronchoconstriction. Methylprednisolone (125 mg IV) may help prevent late recurrence of symptoms after first line medications have been metabolized. Allergic reaction mediators appear to account for an occasionally seen biphasic reaction. It occurs in about 20% of patients with allergic reactions and peaks at 4-12 hours and lasts up to 48 hours. Any patient whose symptoms are not relieved or recur should be considered for admission. Any patient with significant symptoms should be admitted for 24 hours. One other condition known as angioneurotic edema bears mentioning. It presents as swelling of the tongue, lips and/or face. It is classically associated with use of angiotensin converting enzyme (ACE) inhibitors. It may occur years after the patient has been using the medication uneventfully, and despite continued use of the same medication, it may never recur. Management of this curious phenomenon is primarily supportive. H1 and H2 blockers are frequently used and occasionally epinephrine and steroids are used, although this condition may be completely refractory to medical management. The swelling may be very impressive and patients may appear as though they could lose their airway at any moment. Fortunately, the edema rarely progresses to that point and slowly resolves again. Care should be taken to ensure that a patient’s medical record is prominently labeled regarding allergies and that new allergies are promptly recorded. The patient should be instructed as well to ensure that repeat exposures might be avoided. Insect envenomations, however, are less preventable. Patients with more than localized reactions should be referred to an allergist for desensitization and should be prescribed, and instructed in the use of, an epinephrine autoinjector for emergency use.


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Envenomations Snakes There are many different kinds of snakes found around the world of which only a small percentage are venomous. To many people, unfortunately, all snakes are considered dangerous, and they panic at the mere sight of a snake. Some individuals have merely been scratched by a stick in the brush, but in their panic imagine they saw a snake and rush to the emergency room. Additionally, there is much lore about snakes and there are also antiquated medical practices still being endorsed by word of mouth by lay people. The physician, who keeps a level head and has some basic knowledge about snakes, will be able to confidently manage a snake bit victim. Fortunately, the victim or a friend will often bring the offending snake along to the Emergency Department. BEWARE ! Often the snake is still alive. Ask before you open the sack or bucket and if need be, take it outside. In the United States, there are several venomous snakes, which can be identified using a few simple tricks. Most fall into a category called pit vipers. As their name suggests, they have a “pit” which is a heat-seeking organ on either side of the head between the tip of the head and the eye. Their head has a prominent triangular or “arrowhead” shape. Also the pupil in their eyes is unmistakably elliptical. If the snake is dead you may open the mouth and visualize the modified teeth known as fangs. Often the head is too mutilated or even missing. In this case the tail may be examined for single vs. double rows of caudal plates. I recommend looking this up in a textbook with diagrams while you have the snake in front of you. It isn’t difficult, but the diagram will show you exactly where to look. Rattles at the tip of the tail are, of course, a give away, but young rattle snakes, which may not have a rattle yet, actually have more concentrated venom. There is one other venomous snake in the U.S., which goes against all of the rules listed. This is the Coral Snake, which has no pits, a slender head, round pupils and no prominent fangs. It is easily recognized by its bright yellow, red, and black alternating rings along the entire length of its body. It does have a close look-a-like which is the non-venomous Scarlet King Snake. Their similarity has prompted the correct jingle: “Red next to black, venom lack; red next to yellow, kills a fellow.” I recommend that if you can’t remember the different identification tips “positively for sure”, look them up before you touch any living snake or before you start treating or reassuring your patient. Do not extrapolate the rules and exception to all snakes of the world. Not all snakebites by venomous snakes inject venom. In fact, up to 25% are “dry bites.” This makes sense considering that humans are not snakes’ natural prey. They only bite humans in defense when they feel threatened and would not want to waste their small quantities of precious venom. Additionally, if an envenomation has occurred, the reaction may vary from a localized minor reaction to edema of the extremity, to a full blown systemic or lethal reaction. Thus, bites with no or minimal local reaction and no other symptoms may be observed conservatively; if there is no change, the patient may be safely discharge. Antivenin is indicated only in the presence of severe or rapidly expanding reactions. Shock, localized tissue necrosis, DIC, and ARDS are typically encountered complications of severe envenomations.

Excision of the wound has long been abandoned. Making crucial incisions across each puncture wound to suck out poison is typically discouraged because of numerous reports of overzealous laypersons who have caused major nerve, vessel, etc, damage from their incisions. In proper hands it may have some use. Incidentally, if you should ever be in a field situation where you might actually have to use you mouth to suck out poison from a wound (eg. yourself, or someone you aren’t worried you might contract some illness from), you may rest assured that you will not be poisoned (unless you have lacerations in your mouth) as much of the venom is a combination of digestive enzymes. Normally, these enzymes would help the snake digest food faster and help avoid spoilage of the food in its digestive tract. Lizards There are only two venomous lizards in the world, both of which live in the southwest U.S. These are the Gila Monster and the Mexican Beaded Lizard. They do not have fangs but tend to bite and hold on to their victim tenaciously, while grinding their jaws to “work in” venom along multiple tooth bites. Treatment is supportive and there is no antivenin. Spiders While all spiders are venomous, most do not have mouth parts strong or long enough to penetrate human skin. Several Families of spiders, however, can successfully bite humans and typically only cause a minor local reaction. Only two spiders endemic to the U.S. may cause significant envenomation. These are the Black Widow spider and the Brown Recluse Spider. Other venomous spiders are occasionally introduced from other countries, either accidentally, or to be sold as pets. A spider very recently introduced to North America is the Yellow Sac Spider (Cheircanthium mildei) whose bite will cause local pain and swelling, followed by local wound necrosis. These spiders’ progress in and impact on the U.S. bears watching. Remember to check patients’ tetanus status.


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Black Widow Spider (Latrodectus mactans) Widow spiders’ bites cause sharp pin-prick pain with minimal local erythema or swelling. Later, a target lesion develops, blanched centrally with peripheral erythema. 15- 60 minutes later, a dull ache in extremity gradually spreads, then muscle rigidity develops, along with a board-like abdomen, stiff shoulders, or back pain. Associated symptoms include dizziness, anxiousness, restlessness, sweating, ptosis, periorbital swelling, nausea & vomiting, skin rash with pruritis, salivation, weakness, EKG changes, seizures, elevated blood pressure, and increased CSF pressure. Symptoms gradually resolve over 2-3 days.

Treatment Widow Spiders If positive ID & no symptoms after 2-4 hours, then DC home. If have symptoms -admit. Hypertension with diastolic greater than 130, treat with nitroprusside. Labs: CBC, SMA-6, PT, PTT, UA and EKG. Treat cramps with calcium gluconate, 10 cc's of 10% solution over 20 minutes. Repeat Q 2-4 hours, EKG, calcium levels (children, 50 mg/kg/dose up to 250 mg/kg/24 hr).

Cramps also relieved by methocarbamol (Robaxin©) 10 cc (2000 mg) over 5 minutes. Repeat 5-10 cc IV drip over next 4 hours. Then 500 mg PO q 6 H. (Children 15 mg/kg q 6 H).

Diazepam to ease cramps. Antivenin (Latrodectus mactans) - horse serum Use in patients not relieved by above measures. 1 vial (6000 U) reconstitutes in 2.5 cc may be given IM or preferably IV in 10-50 cc IVF over 15 min. 1 vial usually sufficient. Dantrolene sodium also reported used to relieve muscle spasm PO & IV. Brown Recluse Spider (Loxosceles reclusa) Brown spiders - little or no local pain initially, pain develops over the next several hours. Next local vasoconstriction; lesion pale, followed by bleb and peripheral erythema (bull's eye). Necrosis over next several hours to days, spreads deeply and radially. Systemic symptoms include nausea & vomiting, fever, chills, petichiae, malaise, hemolysis, thrombocytopenia, shock, renal failure, hemorrhage, pulmonary edema. Death is rare, occurring most often in children.

Treatment Brown spiders Do not excise wound. Labs: CBC, PT, PTT, UA, If no signs or symptoms after 6 hours, DC If skin lesion in first 12 hours give steroid (eg methylprednisolone 100 mg IM/ IV and 5 day oral regimen. Dapsone 50-200 mg qd helpful Colchicine 1.2 mg. Then 0.6 mg q2h for 2d, then q4h for 2d Both Dapsone and Colchicine function as PML inhibitors. Consider hyperbaric oxygen Antivenom exists in Brazil, not available in US. Local wound care for ulcer up to 10-15 cm diameter. Insects Insects constitute one of the most diverse and most abundant creatures on the planet. Most pose no threat to humans, but many may cause annoyances or problems, and certainly more cause irrational fear. Insects may pinch, bite or sting humans. Some insects have prominent mandibles, which may have the strength to break human skin as the insect is trying to get away. No venom is injected by the bite. Some may bite to hold on while they sting, however. Fire ants do this, stinging some 10 to 15 times. Other insects may bite (actually puncture) humans to obtain a blood meal. Flies (diptera, eg. mosquitoes, horse flies, biting midges, black flies), some true bugs (hemiptera, eg. bed bugs and assassin bugs and kissing bugs), and chiggers (larval mites which are not actually insects) are the most notorious for biting. Some of these bites are painful while others are not. Some inject anticoagulants which cause a local reaction. Others inject digestive juices into the tissue to suck out a digested meal. None inject venoms, but only locally irritating substances. Some unfortunately are vectors for other illnesses such as malaria, equine encephalitis, and Chagas disease. Others sting and inject venom though a modified ovipositor. These are


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the wasps, hornets, and ants. In large quantities (eg. multiple stings), the venom can induce sickness in humans. This may occur when disturbing a nest or attracting African Killer Bees. Worse for humans is the local and occasionally the generalized or even anaphylactic reaction which may be lethal. It is treated the same as any other anaphylactic reaction. Fire ants, which are common in the southern U.S., cause a vesicular eruption which turns into a sterile pustule. It often gets infected secondarily as the patient scratches the lesions. Local care is all that is required, unless a local cellulitis sets in. Stings to eye may result in cataract formation, depigmentation of iris, and optic nerve atrophy. Stings to throat (swallowing bee in soft drink) emergency due to potential of airway obstruction from local swelling.

Treatment:

ABC's IVF crystalloid Epinephrine Adults: 1:1000 0.3-0.5ml sq or IM or 1:10,000 3-5ml via ETT Q 10 min prn or 1mg in 250 D5W at 1MCG/min-titrate Children:1:1000 0.01ml/kg sq or IM up to .35ml or 1:10,000 0.1ml/kg via ETT Q 10 min if HR<180 Diphenhydramine Adult: 50mg (or 1-2mg/kg/dose) IV or IM, then 25-50mg q 4-6h for 24-72 hours Children:2mg/kg IV then 0.5mg/kg/day IV,IM, or PO q6h Aminophilline IV 5.6mg/kg over 20min, then 0.9mg/kg/hr drip Nebulized beta adrenergic agonist (metaproterenol, isoethrane) Steroids methylprednisolone 100mg IV Refractory anaphyllaxis Atropine Adult: 0.5-1.0mg IV Children: 0.01-0,02mg/kg IV q 5min up to .04mg/kg Naloxone Adult 0.4 mg-2mg IV Children:0.01-0.1mg/kg IV Serum sickness antihistamines for urticaria course of prednisone 40mg/d for 5-10d. Prophylaxis recommended for anyone showing signs of allergy Whole body extract Venom specific extract for various groups: honeybee, yellow jacket, yellow hornet, white-

faced hornet, and wasp. IgG antibodies are monitered-when levels are up (>4mcg/ml) sensitivity is decreased. Mechanism believed involves binding of IgG to antigen making less antigen available for IgE to bind.

Emergency insect sting kit: includes tourniquet, epi 1:1000, antihistamine. Some arthropods cause no more than major annoyance. Examples include lice, ticks and scabies which cause infestations. Some caterpillars possess stinging hairs which will produce a localized painful and urticarial reaction. Others are carriers for significant human illnesses, e.g. fleas, ticks and mosquitoes for Lymes, Rocky Mountain Spotted Fever, Plague, Malaria, etc. Obviously, there are too many animals for anyone to be an expert on all of them; however, people will continue to expose themselves to them and will present with injuries from these animals. It is reassuring to the patient when their physician has at least a basic knowledge of these types of injuries and can calmly initiate treatment.

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Febrile Infant

Jim Wilde M.D., FAAP and Larry Brannam M.D., FACEP

Introduction Fever is the single most common chief complaint of children presenting to the Emergency Department, accounting for approximately 25% of pediatric visits. Children under two years of age present unique challenges to the clinician due to the difficulty in obtaining a specific history and defining physical findings. The extent of the work-up and the appropriate management will be guided by many factors such as clinical assessment, physical findings, age of the patient, and height of the fever. This chapter will focus on the differentiation of the moderately ill from the seriously ill child. The discussion will be limited to general aspects of the initial Emergency Department evaluation and management of the child with fever. The student is encouraged to review the referenced article for more detailed information on the management of fever without a source in children, particularly focusing on the entity of occult bacteremia.

Temperature Management Fever in infants and toddlers is a rectal temperature of 38 C/100.4 F or higher. It is important to remember that oral temperatures are generally 0.6 C/1 F lower than rectal temperatures and axillary temperatures are 0.6 C/1 F lower than oral temperatures. Oral temp eratures may be useful in a cooperative, older child but can be affected by such factors as respiratory rate and oral intake. The tympanic membrane can be used for temperature measurement but most experts consider “ear thermometers” to be relatively insensitive in detecting fever, particularly in very young children. The rectum remains the most reliable site for temperature measurement in infants and toddlers, and is the preferred site for children less than two years of age who present to the MCG emergency department. The relationship between the height of fever and occurrence of bacteremia has been the topic of much discussion. In general, as the temperature rises above 39 C, the risk of bacteremia and serious bacterial infection increases. Hyperpyrexia is defined as temperature greater than 41 C/105.8 F. Hyperpyrexia may be a sign pointing to serious underlying disease such as meningitis. However, temperature elevations greater than 42 C/107.6 F are most often non-infectious in origin. Cases of extreme temperature elevation of this magnitude can be caused by head injury, ingestion of psychotropic agents, heat stroke, or malignant hyperthermia. Children often feel uncomfortable during periods of temperature elevation and so it is appropriate to institute measures to directly lower the temperature to achieve symptomatic relief. Also, temperature reduction is important in the initial evaluation of the febrile infant to reliably assess the child’s level of irritability. Children who initially appear ill or irritable may markedly improve with lowering of the temperature. The antipyretics acetaminophen and ibuprofen are commonly used for temperature reduction. The dosage of acetaminophen is 10-15 mg/kg given at 4 hour intervals with a maximum dose of 600 mg. Increasing the dosage beyond this level does not result in better or more sustained effect. Rectal suppositories may be used in the child unwilling or unable to take oral medications. The dosage of ibuprofen is 10 mg/kg given every 6 hours with a ma ximum daily dosage of 40 mg/kg. Other measures that may facilitate heat loss in a child might include unwrapping a bundled infant or rehydrating a dehydrated child. Tepid baths should never be used without antipyretic medications to bring fevers down, since they can actually increase the temperature if used as the sole method of fever control. Clinical Findings Studies have shown that viral infections such as URI, gastroenteritis, or viral pharyngitis are the cause of fever in 95-96% of febrile children. It is the physician’s primary role to identify the 4-5% who have a bacterial infection since these children will need antibiotics for treatment. Most viral infections require only symptomatic care, such as administration of antipyretics. A good medical history is the most critical part of the evaluation of a febrile child, and can usually identify children likely to have a viral source. It is important to determine whether symptoms related to the respiratory system or gastrointestinal tract are present, since they are the sites for most viral infections in children. Changes in behavior such as irritability or lethargy may be the only presenting symptoms in cases of urinary tract infections, CNS infections, or sepsis. It is also important to note whether the child has recently attended day care, has had contact with other people with similar symptoms, or has recently received vaccination such as DPT or MMR, since all help to identify a non-bacterial source.

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Parents will usually report non-specific changes in behavior such as decreased activity, poor appetite, or the familiar “not acting right.” Parents often use the word “lethargic” to describe their child’s behavior when in fact true lethargy is not present. Febrile children generally are less active or subdued, but still react to environmental stimuli such as ear exam or blood draw. The febrile child who has a markedly diminished response to stimuli such as these is truly lethargic, and is likely to be seriously ill. Similarly, poor appetite is exp ected during a febrile illness, but a child who has stopped all oral intake is likely to be seriously ill. The physical examination should focus initially on careful observation of the child’s general behavior. A happy, smiling, playful infant that interacts well with his parents is unlikely to have a serious infection such as meningitis or sepsis. However, an irritable, lethargic, or ill appearing child that has a weak cry and is uninterested in his environment demands a rapid assessment. A search for physical findings suggestive of a serious bacterial infection should be performed while the child is distracted with play objects. Observe his general physical appearance and check for abnormalities such as rashes, limited movement of a limb, areas of point tenderness or pain, or signs of increased work of breathing such as retractions or nasal flaring. Nuchal rigidity, Kernig or Brudzinski signs may not be apparent in children under the age of 18 months. The finding of petechiae on physical examination should alert the physician to the possibility of a serious underlying bacterial infection. Poor perfusion can also be a clue to a more serious illness. Pus behind a tympanic membrane suggests acute otitis media, which has a bacterial component in two thirds or more of cases. The combination of history and physical exam alone generally will suffice to diagnose most viral infections. Most children whose fever started acutely around the same time as respiratory or gastrointestinal symptoms will have a viral infection. Similarly, blanching rashes or pharyngeal findings such as ulcers or tonsillar exudates usually indicate a viral source. Group A streptococcus (GAS) pharyngitis, or “strep throat,” is rare under the age of two years, and even in older age groups GAS causes only about 15% of cases of pharyngitis. While a test for GAS is indicated for children over two years with pharyngitis, blood tests are not usually required for most other clinically apparent viral illnesses. Infants Up To 3 Months Diagnosis The age of the infant directly influences the extent of the work-up. Infants under 3 months of age are felt to have a higher risk for serious life-threatening infections, partly because they do not localize infections as well as older children and can deteriorate rapidly. Careful clinical assessment, along with judicious use of laboratory tests, is the key to appropriate management in this age group. History and physical examination may provide clues to the diagnosis. A history of lethargy, irritability, poor eating, or continuous crying suggests a serious infection. A history of recent exposure to other children with viral illnesses would suggest a similar diagnosis in the infant, particularly if the infant’s symptoms mirror those of the other children. The physical examination may reveal a focus of infection such as an inflamed eardrum. Cough, tachypnea, retractions, or nasal flaring with an increased respiratory rate would suggest a lower respiratory infection. However, there may be no specific findings despite the presence of a systemic infection. Increased irritability, lethargy and inconsolable crying is frequently seen in infants with meningitis. Urinary tract infections may not produce symptoms other than fever. The absence of any specific diagnosis based on history and physical examination suggests the need for laboratory testing to detect occult infection. Tests to be considered include a complete blood count with differential, sedimentation rate, blood culture, lumbar puncture, chest x-ray, urinalysis and culture, and a stool culture if there is a history diarrhea. Management The appropriate management of the febrile infant under 3 months of age is an area of intense controversy. Most experts currently recommend a full sepsis work-up and hospital admission for febrile children under 1 month of age. Children above 1 month of age who have normal physical examination, history and laboratory results may be monitored as outpatients with or without parenteral antibiotics if follow-up can be assured. All febrile infants with abnormal laboratory results should be hospitalized. The decision not to hospitalize a febrile infant should be made by a clinician experienced in the evaluation of young children, and after assuring that follow-up will occur in the following 12 - 24 hours.

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Infants 3 - 24 Months Diagnosis The general guidelines used in the evaluation of the infant less than 3 months of age also apply for older children. Clinical judgment is more reliable in the assessment of older infants and remains the most important indicator of toxicity. The examining physician should observe the child’s interactions with his environment. “State variation” refers to a child’s abilty to alter his activity state between quiet and agitated depending on the stimulus. A child who cries and fights the exam but then calms in the mother’s arms has good state variation. A child who remains agitated despite comforting from the parent, or who remains quiet or passive even with noxious stimuli such as the ear exam or blood draws, has poor state variation. Poor state variation suggests a more serious illness. “Toxic” generally implies that the child has symptoms consistent with the sepsis syndrome, such as poor perfusion, lethargy, extreme tachycardia, or tachypnea. Occult bacteremia is defined as clinically inapparent bacteremia, and has a peak incidence in febrile children 10-14 months of age. Bacteremia is differentiated from sepsis in that bacteremia does not include the symptoms of the sepsis syndrome, other than fever. These children do not appear toxic, and do not have an obvious bacterial source for the fever. Occult bacteremia by definition cannot be diagnosed by physical exam alone; this is a diagnosis that requires laboratory tests. The specific work-up and management of children with suspected occult bacteremia is beyond the scope of this discussion. Although opinions vary on the most appropriate work-up and management of these children, a few generalizations can be made. A temperature over 39 C has been associated with a higher risk of bacteremia, as has a white blood cell count of 15,000/mm3 or greater. It is important to remember that bacteremia can also occur at lower temperatures and with lower WBC counts. Children under 24 months whose temperature is 39 C or greater, whose WBC is 15, 000 or greater, and who do not have a clinically apparent viral or bacterial source for the fever have an approximately 3-5% risk of occult bacteremia. Streptococcus pneumoniae is by far the most common organism responsible for occult bacteremia in children. Up to 65% of cases of occult bacteremia resolve spontaneously, without any specific therapy. Management Children in whom a specific bacterial focus of infection has been identified should receive antibiotic therapy directed at the most likely organisms. Some of these children may require hospitalization, depending on the focus of infection and the severity of the symptoms. Those with symptoms consistent with a viral illness should be instructed on appropriate symptomatic care. Controversy surrounds the question of treating children with suspected occult bacteremia. Published fever guidelines suggest a single dose of ceftriaxone and close follow-up for these children. Non-toxic children who have no identified source for their fever and whose WBC is less than 15,000 receive symptomatic care only, along with appropriate follow-up. If ceftriaxone is used, blood and urine cultures should be sent first to identify those who truly have a clinically inapparent bacterial infection. Regardless of which treatment option is chosen, careful follow-up with repeat examination in 12 - 24 hours must be assured before the patient is discharged. All patients with positive blood cultures should have repeat evaluation with repeat blood culture. If the patient is receiving appropriate antibiotics and is clinically well they should be instructed to complete the course of therapy. If the patient is afebrile and clinically well but has never received antibiotic treatment, antibiotic therapy is not necessarily indicated unless the child develops a specific focus of infection. Any patient with a positive blood culture who remains febrile or does poorly on antibiotic therapy should receive a complete sepsis work-up including a CBC, blood culture, lumbar puncture, chest x-ray, urine culture, and be hospitalized for parenteral antibiotic therapy.

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FEBRILE INFANT A 6 month old male infant is brought to the Emergency department at 3pm by the child’s parents. They state he has been running a slight fever all day, but had no other symptoms. The mother states that she tried to feed the infant during the day, but was unsuccessful as the child was not acting himself and would not take a bottle. She states that the child is usually a happy child and is awake, alert, and playful at this time of the day. She denies any history of vomiting, diarrhea, cough, ear pulling, or other associated symptoms. The child has had some crying off and on which is unusual for the child. Examination reveals a child who is not interested in his surroundings and does not respond to the examiner’s voice or the examination. The child is somewhat pale and cold to the touch. Vital signs are: Temperature 39 C/102.2 F, Respirations are 50, Pulse is 180/minute, Blood Pressure 80 palpable, HEENT examination reveals clear tympanic membranes and clear posterior pharynx. Anterior fontanalle appears full, but not tense. His eyes appear somewhat sunken, but there is no crying or tearing noted. Lungs are clear and cardiac exam reveals tachycardia. The abdomen is soft without distension. Neurologic exam reveals a child who is somewhat lethargic and not interested in his surroundings. When placed on the stretcher for examination, the child does not interact with the examiner, nor does he cry in response to the examiner’s touch or movements. Spontaneous motor activity is noted in all extremities.

1. Do you feel the infant in the above description is minimally ill or severely ill? What aspects of the history and physical exam lead you to believe this conclusion?

2. What diagnostic studies would be indicated to define the source of fever in this

infant?

3. What initial treatments should be started in this child and how rapidly should these interventions be undertaken?

4. With a WBC count of 6,500, with 40% bands, a normal UA, a normal chest x-ray and cloudy spinal fluid, what would be the most likely diagnosis in this child?

5. How would the laboratory tests described above affect your disposition of this child?

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FEBRILE INFANT A 16 month old female is brought to the Emergency Department at 10 pm by her parents with a 2-day history of fever to 104 F. The mother states that the child has had diarrhea today, but has had no other symptoms. The mother denies any history of vomiting, ear pulling, coughing, difficulty breathing or abdominal pain. Upon entering the examination room, you notice a well appearing female child, running about the room playing with toys on the floor. The child immediately runs up to you and waves at you trying to say, “Hi.” The child appears to be very happy, playful and in no acute distress. The vital signs are stable with a recorded temperature of 39 C/102.2 F. There is no apparent focus of infection on physical exam. The parents state that they were going to take the child to the pediatrician tomorrow, but wanted to make sure the child was “ok” until then. The parents appeared concerned and reliable.

1. What other historical factors would be important in the evaluation of this child ? What specific physical findings would you look for?

2. What laboratory test if any would be ordered on this child and explain the rational for there use?

3. Assuming a WBC count of 4500, with a normal differential and a normal urinalysis, what would be your disposition of this patient ? Explain why?

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Febrile Infant 1. When is a child considered to have a fever? 2. Define hyperpyrexia and differentiate this condition from fever. 3. Discuss the various methods of temperature measurement and the accuracy of each. 4. List some aspects of the history and physical examination which may provide clues to the

diagnosis of the cause of fever. Which of these findings would suggest a serious source of infection?

5. Identify aspects of the clinical assessment which reliably differentiates seriously ill from non-toxic

infants. 6. What is the correct dose of acetaminophen and ibuprophen for fever control in the febrile infant? 7. Identify what other appropriate measures to use for fever control in addition to antipyretic therapy. 8. Identify specific laboratory tests and radiographic examinations which should be undertaken in a

full septic work-up. 9. Discuss some of the differences in the management of infants under the age of 3 months versus

infants 3 - 24 months. 10. Outline possible discharge plans for an infant 7 months old with a fever greater than

39 C and a WBC count greater than 15,000. Include a discussion of follow-up planning. Bibliography Baraff LJ et al. Practice Guideline for the Management of Infants and Children 0-36 Months of Age with Fever Without Source. Pediatrics, Vol. 92, No. 1. July 1993. Pages 1-12. Barkin et al. Pediatric Emergency Medicine. 1994, Mosby Year Book, Inc. Fleisher et al. Textbook of Pediatric Emergency Medicine , 4th ed., 1999, Williams and Wilkens.

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Appendix I : Rapid Physical Assessment of the Irritable/Lethargic Febrile Pediatric Patient System Key Finding Comments Airway grunting ominous sign, occurs with meningitis, sepsis and pneumo nia stridor consider epiglottitis and tracheitis wheezing and decreased breath sounds must R/O pneumonia rales often not heard in infants with pneumonia Breathing tachypnea rate elevated by fever and anxiety (repeat/repeat) pulse ox normal indicates that there is no respiratory decompensation but it does not R/O pneumonia Circulation decreased peripheral caution: early septic shock may present as perfusion “warm” shock with warm extremities and strong pulses and normal capillary refill abnormal BP look for a low diastolic or a low elevated pulse pressure as early warning signs of septic shock long before mean BP is abnormal petechiae look closely for this early warning sign of septic shock Neck meningismus not reliable in infants, often difficult to evaluate in the irritable toddler Fontanelle firmness an ominous sign, however, a bulging but soft

fontanelle, though not to be ignored, is often secondary to fever alone and is probably not in itself a reason to perform a LP

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HEADACHE

Michael J. Caudell, M.D., FACEP and Shawn E. Gunder, MPAS, PA-C

Up to 40% of people have a significant headache at some time in their lives. One in five Americans has a headache at least once weekly. As many as 10% of people see a healthcare provider for episodic headache, and non-traumatic headache accounts for 1-2% of all emergency department visits. There are approximately 300 pathological etiologies for headache, making the definitive diagnosis of headache etiology quite challenging. HEADACHE ETIOLOGY Headaches present in four general patterns. First is a simple minor headache for which the patient requires no treatment, does not seek medical attention, and recognizes on his or her own that this is a benign, self-limiting process. This patient does not present for emergency care because his or her perception of the problem is that whatever the cause, he or she can manage well enough on their own. This points to the fundamental difference from this patient and those presenting for care in the emergency department; the perception is that this headache is either too severe or caused by a problem too serious for them to manage at home. The remaining headaches then are considered to be of a somewhat greater severity and can be divided into three groups based on pattern of the headache. Some patients will present with a first occurrence of an acute headache and have no history of severe headache (therefore no prior work-up). Other patients will present with complaints of a chronic recurrent headache (such as migraine, tension) and will have had a thorough work-up conducted previously. There is no change in the headache pattern and this patient will have presented for pain control. The remaining patients will have headache as part of a systemic syndrome. 1. Serious Etiologies

• Subarachnoid Hemorrhage (SAH) • Infection • Arteritis • Increased Intracranial Pressure • Glaucoma

2. Uncomfortable, Benign

• Vascular/Migraine • Tension • Cluster • Other

3. Other Secondary Headaches

• Dental • Sinus • Toxin (caffeine, cocaine)

EMERGENCY DEPARTMENT EVALUATION An extensive work-up is both costly and time consuming. These general guidelines are helpful to decide who is likely to require an extensive work-up. Clinical presentations that suggest secondary headaches and should prompt further work-up:

• Sudden onset headache • Headache occurring for the first time in a patient > 50 years old

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• A change in the character of a chronic or recurrent headache syndrome • Any headache described as the “worst headache of my life”, especially if associated with

nucchal rigidity and/or focal neurologic signs • Headaches associated with fever, photophobia, and/or neck stiffness • Headaches that worsen under observation • Headaches associated with an abnormal neurologic exam (including focal neurologic

findings, changes in mental status, or changes in personality) • Headaches of increasing severity over days to weeks

GOLDEN RULES When evaluating patients with headache in the emergency department it may be helpful to consider two basic rules:

1. Every patient has a serious life threatening etiology for his headache until proven otherwise 2. If the patient ever passes out, do not send him home.

Critical History Physical examination is often non-diagnostic in the search for the cause of a headache. This makes a thorough history essential. Certain historical points are critical to making an accurate diagnosis. Timing of onset of symptoms can be quite helpful. Sudden, severe headache sometimes described as a “thunderclap” headache perhaps following vigorous exercise or intercourse suggests the possibility of subarachnoid hemorrhage. Symptoms may demonstrate a regular pattern or duration, perhaps in conjunction with prodromal symptoms. Symptoms may be correlated with ingestion of certain foods, medications, or with menstrual cycling. Presence of a prodrome itself begins to suggest migranous or vascular etiologies for the headache. Location of the headache will not clinch the diagnosis but may be helpful. Two-thirds of migraine headaches are unilateral. A headache that recurs in the same place every time may suggest a mass lesion. In contrast, tension headaches may be bilateral or circumferential. The quality of the pain may vary from the throbbing pain associated with vascular headache (thought to be vasodilatation of extracranial arteries) to the transient pain of trigeminal neuralgia. Cluster headaches are usually associated with a deep piercing unilateral pain. Associated symptoms such as photophobia or fever are also helpful. If the patient notes fever only at home this must not be discounted. Family history and other acute or chronic illness should be elicited as well. Other Key History Points Certain questions must always be asked to prevent overlooking serious etiologies of headache. Every patient must be asked it there was a loss of consciousness. Any history of trauma, regardless of how trivial it may seem to the patient, must be noted. Not all patients recall what medications they take so it is worth while to ask specifically if they take warfarin or other “blood thinning” medications. Attempting to narrow the differential diagnosis, it is beneficial to try and summarize the history and place it within a broad category. For example, a patient with a continuous headache that is progressive over weeks to months should be considered for evaluation for the presence of mass or tumor. A patient with a headache different from usual recurrent headaches, or new onset in persons over age 40-50 with a new onset headache, are somewhat more likely to have a serious organic cause for the etiology. Presence of certain accompanying symptoms can also be helpful. Nausea and vomiting are seen most commonly with migraine headache and after head trauma. Fever is usually only seen in the presence of infection but can be seen with subarachnoid hemorrhage. Facial weakness or neurological symptoms (such as numbness, paresthesia, and blurred or double vision) support the diagnosis of mass or tumor but can be seen in the migraine patient. One other area to consider is precipitating factors. Emotional stress and depression may lead to tension headaches. Migraine headaches may be precipitated by menses, exposure to carbon monoxide, or even by caffeine withdrawal.

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Physical Examination The majority of headache patients will have normal vital signs. This makes it very necessary to explain abnormal vital signs in a patient presenting with headache. Hypertension may be associated with subarachnoid hemorrhage. Tachycardia is nonspecific and may be associated with severe pain. Tachypnea can also be associated with severe pain, but consideration should be given to carbon monoxide exposure or hypoxia. The presence of even a low-grade fever should promp t consideration of infectious processes to include meningitis, encephalitis, or abscess. The bulk of the examination of patients presenting with headache is comprised by a through neurologic examination, and examination of the head and neck in general. There are several fundoscopic findings that must be sought out. Papilledema suggests intracranial pressure as does lack of retinal venous pulsation in an erect patient. This is especially important if the patient had venous pulsation on earlier examination. Acute hemorrhagic exudates are consistent with hypertensive encephalopathy. Palpation of the head enables the examiner to recognize occult trauma, detect muscle spasm, or elicit tenderness of the temporal arteries. Tenderness when palpating and percussing the sinuses, dental tenderness to percussion, or tenderness in the trigeminal nerve distribution may be enlightening regarding etiology. Regardless of findings from this examination the patient has a heightened sense of thoroughness and caring on the part of the practitioner, creating genuine therapeutic benefit. During examination of the neck, attention is given to signs of trauma or nucchal rigidity. To elicit nucchal rigidity it is helpful to have the patient lay supine and be as relaxed as possible. The examiner then raises the head gently from the bed. Nucchal rigidity is defined as an involuntary resistance to flexion when the examiner flexes the neck. This is often a subtle finding, and not simply pain with flexion. With marked meningismu s (particularly in the child or infant) the neck musculature will spasm firmly to protect against the pain associated with flexion. It may be possible to literally lift the patient off the bed with an attempt at flexion. Even subtle involuntary resistance to flexion should be noted and not ignored. Additionally, involuntary hip flexion as the neck is flexed (Brudzinski sign) or pain in the neck and resistance as the knee is extended (Kernig sign) may be useful in eliciting nucchal rigidity. Patients will often present with a complaint of a “stiff” neck. This complaint may be triaged verbatim by paramedics and/or support staff. The lay public is cautioned through the media that headache, fever, and stiff neck are warning signs of possible meningitis. Reports of community outbreaks may prompt individuals to present to the ED with specific concerns about meningitis. Many of these patients may have fairly mild symptoms due to some other process, but have a high level of anxiety. Most patients would define stiff neck as one that would not move because of pain. In medical terminology we would more exactly refer to stiffness as a joint which should be mobile and cannot be moved. However, it would seem preferable to have these patients evaluated in the emergency department and be screened and relieve their concerns, rather than not disseminating this information to the public. Certain signs should be considered when evaluating the peripheral nervous system. Pronator drift is a good indicator of subtle abnormalities. To elicit drift have the patient stand with arms extended to the front, palms up, eyes closed for a period of 10 seconds. Note any drift or pronation of the extremities. When considering a posterior fossa mass the patient should be specifically examined regarding gait (heel walking, toe walking, tandem walking, and walking on outer edges of the feet) and cerebellar function (finger to nose, heel to shin).

HEADACHE SYNDROMES Subarachnoid Hemorrhage Although this is not the most common headache syndrome, subarachnoid hemorrhage has such severe consequences it is a concern that must be addressed in every headache presentation to the emergency department. This is a frequently misdiagnosed headache etiology. The mortality rate from subarachnoid hemorrhage approaches 50-60%, yet when warning signs are identified and the patient receives prompt treatment good outcomes are possible. Untreated, 50% of those who survive the first 24 hours of a subarachnoid hemorrhage will die within two weeks. Interestingly, approximately 5% of the population have a pre-existing berry aneurysm, increasing risk of subarachnoid hemorrhage. Warning symptoms of subarachnoid hemorrhage result from a variety of causes. Aneurysmal expansion may result in cranial nerve palsy (especially oculomotor, CN III), localized head pain, or visual

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field defects. A sentinel bleed may result in generalized headache with or without nausea and vomiting, but generally without photophobia or meningismus. Frequently presenting symptoms include sudden severe headache (“thunderclap”) which is focal at onset and then spreads, seizures, diminished level of consciousness, focal neurologic deficits, dizziness, vertigo, and vomiting. Common signs include clouding of consciousness, fundoscopic changes, nucchal rigidity, delirium, and other neurologic and cardiac effects. Because of the low specificity of presenting symptoms, subarachnoid hemorrhage is often misdiagnosed as a systemic infection, migraine, “flu”, sinusitis, tension headache, cervical disc herniation, or hypertensive encephalopathy. When evaluating these patients up to 15% will have normal non-contrasted CT scans. Contrast actually reduces the sensitivity of identifying subarachnoid hemorrhage. For this reason when subarachnoid hemorrhage is being considered in earnest, a lumbar puncture must be obtained after the scan to rule out the presence of xanthrochromia. Some patients with an expanding aneurysm may have both negative scans and lumbar punctures requiring cerebral angiography to make the definitive diagnosis. Patients requiring such an evaluation would be those with a remote history of a possible aneurysm or a strong family history of intracranial aneurysm. Treatment of subarachnoid hemorrhage consists of analgesia, nimodipine to reduce spasm, and measures directed to reduce intracranial pressure. The use of intubation and subsequent hyperventilation to induce hypocapnia can be helpful to lower intracranial pressure. In some populations agents such as mannitol or furosemide are used as diuretics to reduce intracranial pressure but are used much less commonly than in the past. Hypertension should be controlled but mean arterial pressure generally does not need to be reduced below approximately 120-140 mm Hg. Reducing mean arterial pressure to normal or below normal levels in the face of increased intracranial pressure may result in cerebral hypoperfusion and have serious consequences. Definitive management in the OR may be undertaken based on the results of the CT scan or may require cerebral angiography to better define the source of bleeding prior to surgery. Meningitis Headache associated with meningitis usually involves the entire head. It is usually associated with fever and a stiff neck (nucchal rigidity). Diagnosis and treatment of meningitis are discussed elsewhere. Temporal Arteritis Headache associated with temporal arteritis is usually severe, throbbing in nature and located over the frontotemporal region. There may be jaw claudication or strong association with polymyalgia rheumatica. The involved temporal artery may be nonpulsatile or tender, or have a diminished pulse. The most serious complication of temporal arteritis is non-reversible loss of vision. Treatment should begin immediately when there is strong suspicion of temporal arteritis in order to prevent blindness. Begin oral steroid therapy with 40-60 mg of prednisone daily and urgently refer for temporal artery biopsy. Space Occupying Lesions Mass lesions causing increased intracranial pressure include intracranial hemorrhages (epidural and subdural hematoma), tumors, and abscesses. The brain parenchyma is not pain sensitive, so in order to have symptoms (headache) pressure must involve pain sensitive structures such as meninges or vasculature. Suspicion of tumor should increase if there is pain upon awakening, pain worsens with a valsalva maneuver, or the headache is new and associated with nausea and vomiting. Focal neurologic deficits may or may not be present. CT scan with contrast makes the diagnosis. Brain abscess will present similarly to other space occupying lesions but may have accompanying fever and infection such as frontal sinusitis. Pseudotumor Cerebri (benign intracranial hypertension) should also be considered in the differential diagnosis. This is a non-specific headache accompanied by visual complaints and papilledema on examination. CT scan reveals slit -like ventricles without mass effect. Diagnosis (elevated opening pressure) and treatment (relief of pressure) are made by lumbar puncture.

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Glaucoma Acute glaucoma may present as a headache accompanied by nausea, vomiting, and orbital pain described as a headache. Patients with iritis or optic neuritis may describe eye or supraciliary pain as a headache. Careful history should aid in confirming these types of diagnoses. Thorough eye examination to include measuring intraocular pressures makes the diagnosis. Other Major Causes of Headache Other presentations to consider in the differential diagnosis of headache include temporal mandibular joint pain, hyperopic eye strain, sinusitis, trigeminal neuralgia, post concussive headache, muscular lesions, and dental lesions. Although painful, these etiologies carry far less potential for bad outcome. History and thorough physical examination are key to diagnosis. Migraine Headache and Variants Vascular headaches have been traditionally divided into classic migraine (with aura) and common migraine (without aura). Migraine headaches may have a variable aura but tend to have a predictable unilateral pattern. The aura represents transient neurologic changes and it is postulated that these may be due to ischemia during vasoconstriction. The mechanism for migraine remains unclear and controversial. One theory suggests that stress results in vasospasm of cerebral arteries. Another more recent theory is that serotonin has been implicated as the cause for vasoconstriction of the innervated vascular system. Either of these mechanisms can lead to the aura that is experienced. There is subsequent serotonin absorption followed by reaction with histamine, tyramine, bradykinin, free fatty acids and prostaglandins that result in a sterile perivascular inflammation. Serotonin metabolism results in a rapid decrease in blood serotonin which in turn leads to rebound vasodilatation of arteries and capillaries. This distention and inflammation results in pain. Classic migraine usually presents with prodromal symptoms that are fairly constant to the patient. Among the most common complaints are scintillating scotoma, homonymous hemianopsia, or photophobia. Patients may also complain of hand or face tingling, extremity weakness, or mild aphasia, all of which suggest a more concerning headache etiology. Many patients experience nausea and vomiting with peak headache intensity. Duration of the headache is typically 6 -12 hours. Common migraine may not have any of the well-defined neurologic symptoms of classic migraine. There may be only a vague prodrome such as irritability. A positive family history and two additional findings from nausea and vomiting, photophobia, unilateral pain, throbbing, or increased incidence associated with menses strongly suggest the diagnosis of common migraine. Other causes of vascular headache not thought to be migraine include hypoxia, carbon monoxide exposure, acute anemia, diastolic blood pressure greater than 130 mm Hg, tyramine ingestion, nitroglycerine ingestion, and certain metabolic causes. Some toxic exposures will cause this type of headache as well, such as the headache associated with alcohol hangover (caused by acetaldehyde, an ethanol metabolite and potent vasoconstrictor). Treatment consists of abortive or preventive therapy. Abortive therapy can be accomplished with many different medications to include dihydroergotamines or other serotonin receptor agonists, anti-emetics, anti-inflammatory medications, and fluid hydration. Opioid analgesics should be avoided and may even cause exacerbation of headache. Preventive therapy may be accomplished with many types of medications to include beta-blockers, calcium-channel blockers, tricyclic antidepressants, and non-steroidal anti-inflammatory medications. Preventive therapy should not be started in the emergency department without first obtaining neurological consultation. Tension Headache It was previously thought that tension headache resulted from extracranial muscle tension. This relationship has been questioned and current thought is that there is some connection between tension-type headaches and migraine headache via pathophysiology and they simply represent different ends of a spectrum.

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To differentiate tension from migraine tension is defined as bilateral, non-pulsating headache not worsened by exertion or accompanied by nausea and vomiting. However, when severe, tension headache may be accompanied by nausea and vomiting. Treatment is effected with mild analgesics or non-steroidal anti-inflammatory medications. When severe, treatment may consist of modalities similar to abortive treatment of migraine headache. Cluster Headache Cluster headache is generally rare, frequently occurring in men. The onset is usually after 20 years of age and there is usually no significant family history of headache. Trigeminal nerve dysfunction is thought to be the cause of cluster headaches and the fact they respond to serotonin agonists suggests a commonality with migraine headache. The pain is characterized by sudden, severe unilateral orbital, supraorbital, or temporal pain lasting from a few minutes to three hours. The pain in unrelenting and the patient appears uncomfortable, unable to remain at rest. The pain may be accompanied by one of the following signs on the ipsilateral side: injected conjunctiva, tearing, rhinorrhea, miosis, or ptosis. Because of the transient nature of the pain any attempt at relief must come from a fast acting modality. 100% oxygen has been shown to be effective relief in up to 70% of these patients. Serotonin agonists (which act rapidly) have also had success in relieving this pain. Oral agents are poorer alternatives since they take longer to sustain the desired effect. Non-steroidal anti-inflammatory medications may be of some use in reducing the frequency or severity of attacks. Bibliography Schull M: Headache and facial pain. In Tintinalli JE, Kelen GD, Stapczynski JS: Emergency Medicine, A Comprehensive Study Guide, 5 th Edition, Chapter 219, pp. 1422-29, 2000. Mengert, et al (ed.). Emergency Medical Therapy, 4 th Edition; Saunders, pp. 109-127, 1996. Solomon S, Lipton RB: Criteria for the Diagnosis of Migraine in Clinical Practice. Headache 1991; 31(6): 384-7.

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NEUROLOGIC EMERGENCIES

Michael J. Caudell, M.D., FACEP

The approach to the patient who presents to the Emergency Department (ED) is altogether different than the approach to the patient who is presenting to the clinic or inpatient setting. A clinic patient is usually considered healthy unless pathology is proven, whereas an ED patient should be considered to have a life -threatening etiology for his or her complaint until proven otherwise. In the ED, history is often scarce or vague, no medical records are immediately available for review, and the patient is usually not known to the practitioner. Emergency physicians often are required to treat patients prior to arriving at specific diagnoses. We must first treat the patient, “rule-out” life-threatening causes for the patient’s symptoms, and then sort through the facts to arrive at a diagnosis. This is all the more true in the patient who presents with a neurologic complaint. Subject to varying degrees of symptomatology, the patient is often unable to provide an accurate HPI, and the practitioner must rely on observations of family members, friends, or EMTs for data. The following is intended to provide a brief introduction and initial approach to the patient that presents to the ED with selected neurologic problems, i.e., patients with an altered level of consciousness, seizures, or stroke syndrome.

APPROACH TO THE PATIENT WITH ALTERED MENTAL STATUS First and foremost, the standard approach to all patients presenting to the ED should be applied to the patient with altered mental status (AMS). Specifically, this refers to the “ABCs” – Airway management, assessment of Breathing and Circulation, and immobilization of the Cervical spine. Once the “ABCs” have been assessed and the patient has been stabilized, you can then step back and attempt to determine the etiology of the patient’s problem.

Definitions We often hear patients being described as being lethargic or delirious, and an appropriate understanding of these terms is essential. Consciousness is defined as an awareness of oneself, one’s acts, and one’s surroundings. Patients who appear asleep may actually just be sleeping. These patients are arousable to a normal level of awareness. This is to be compared with the patient who is lethargic, a state in which the patient may have global depressed awareness of self and environment, and may even appear wakeful. The stuporous patient is the patient that appears asleep, is arousable with noxious stimuli but not to a full state of awareness. Coma describes the state of unresponsiveness from which one cannot be aroused. Confusional states present in a wide variety of ways. Delirium is an acute confusional state associated with psychomotor excitement, marked by impaired perception and memory, and often accompanied by hallucinations. Examples include alcohol withdrawal, toxic ingestions, metabolic abnormalities, and CNS infection. Dementia is characterized by chronic or gradual deterioration of mental function. Dementia is usually seen in elderly patients, and is exemplified by the patient with Alzheimer’s disease.

Pathophysiology The main causes of AMS can be classified into diffuse or global causes, or causes that involve suppression of the reticular activating formation (RAF). It is important to remember that focal lesions in the cerebral cortices usually cause focal deficits rather than AMS. If a focal lesion does result in AMS, it should be a lesion that involves bilateral cerebral cortices. The diffuse or global causes of AMS are most commonly secondary to toxins such as alcohol or drugs, hypoxia, or hypoglycemia. The reticular activation system consists of a group of fibers that traverse the brainstem en route to the thalamus. The RAF is responsible for maintaining the state of awakeness. The function of the RAF can be suppressed by supratentorial or infratentorial direct pressure. A mass lesion in the supratentorial area results in the displacement of tissue that can compress the brainstem and RAF. An increase in pressure in the posterior fossa may displace the contents of the fossa (the cerebellum, the fourth ventricle, and the Aqueduct of Sylvius) upward through the tentorial notch or downward through the foramen magnum, thus compressing the RAF. Pontine hemorrhage or infarction may directly involve the RAF.


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General Approach to the Patient with AMS

As in all patients presenting to the ED, first assess and secure the airway, check breathing and circulation, and immobilize the cervical spine. If intubation is required, it should be followed by hyperventilation to a pCO2 of 25-30 mmHg. Lowering of the pCO2 is the most effective and rapid means of reducing intracranial pressure. An intravenous line should be inserted and blood withdrawn for laboratory analysis. The patient should be placed on a cardiac monitor, and pulse oximetry measurement should be obtained. It is standard practice to then administer thiamine 100mg, glucose 25-50g, and naloxone 2-4mg IV. Thiamine is given to facilitate carbohydrate metabolism and prevent Wernicke-Korsakoff syndrome in nutritionally deficient patients. If rapid serum glucose testing can be done immediately, the administration of glucose can be guided by test results. Naloxone is an opiate and synthetic narcotic antagonist. Once the patient had been stabilized, the history of the patient’s illness may be obtained. The patient may not be in a condition to give a reliable history, therefore, all available resources should be utilized. EMTs are a valuable source of information in the initial phase of management. Further history should be obtained (by phone if necessary) from family, friends, and/or witnesses of immediately preceding events. The patient’s medical record should be obtained for review. A detailed physical exam may provide clues to the etiology of the patient’s symptoms. Examination of the skin may reveal needle tracks (IV drug overdose), cyanosis (hypoxia), or cellulitis (infection/sepsis). Breath odors, such as that of ethanol or acetone (diabetic ketoacidosis) may be helpful. (The prudent physician, however, must never assume that AMS is due to alcohol simply because the patient smells of alcohol). Cardiac examination may reveal an arrhythmia. Examination of the abdomen may show ascites or organomegaly (hepatic encephalopathy) or a pulsatile mass (abdominal aortic aneurysm). Evaluation of respiratory patterns may provide clues. Cheyne-Stokes respirations (a gradual increase in depth of respirations followed by a period of apnea) result when the cerebral cortex is no longer functioning. Hyperventilation may be due to a variety of causes, such as attempts to correct hypoxia or compensate for a metabolic acidosis. The neurologic status of the patient should be initially assessed using the Glasgow Coma Scale. This will rapidly categorize the severity of injury as well as allow standardized objective assessment of the patient’s neurologic status (Table 1). Cranial nerve function should then be assessed. The eye function is the best measure of cranial nerve integrity. The size, shape, and reactivity of the pupils should be evaluated and funduscopic exam should be performed. Ocular movement can be evaluated by cold-caloric testing, and the corneal reflex should be assessed. Facial assymetry should also be noted, if present. Testing of cranial nerves VIII-XII is seldom helpful in those patients with coma (with the exception of the gag reflex). Physical findings of ataxic respirations, contralateral hemiparesis, and ipsilateral pupillary dilation are indicative of impending herniation of the temporal lobe (uncus) into the infratentorial space. If these findings are present, immediate neurosurgical consultation is indicated before proceeding with further work-up. Table 1. Glasgow Coma Scale

Eye Opening Spontaneously 4 To verbal command 3 To pain 2 No response 1 Best Verbal Response Oriented & converses 5 Disoriented and converses 4

Inappropriate words 3 Incomprehensible sounds 2 No response 1

Best Motor Response To verbal command: Obeys 6 To painful stimulus: Localizes pain 5 Flexion-withdrawal 4 Abnormal flexion 3 Abnormal extension 2 No response 1

Total 3-15


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Routine ancillary studies should include: CBC, electrolytes, BUN, creatinine, glucose, ABG, and toxic drug screening. Further laboratory evaluation should be guided by the history and physical findings (i.e., liver function tests, serum ammonia level, serum acetone).

CT scan is indicated in the patient with AMS and any of the following: 1) evidence of or

suspected trauma, 2) suspected intracranial hemorrhage, 3) presence of an unexplained focal neurologic deficit, 4) papilledema, 5) suspected intracranial abscess, or 6) other causes of AMS have been ruled out or etiology remains unexplained. Cervical spine x-rays should also be obtained. A lumbar puncture (LP) is indicated if meningitis is suspected. LP should be done immediately if no focal neurologic findings or evidence of increased intracranial pressure are found on physical exam. LP is also indicated if the CT scan is negative and either intracranial abscess or subarachnoid hemorrhage is suspected. Evidence of trauma and/or increased intracranial pressure are contraindications to LP. Etiology of AMS The differential diagnosis for causes of AMS and coma is extensive. Table 2 represents a limited but useful mnemonic aid for causes of coma, with the following additional points:

1) The most frequent cause of AMS in the ED is hypoglycemia. This is seen not only in diabetics, but also in patients with liver disease, pancreatic tumors, and chronic alcoholism.

2) Space-occupying lesion include not only neoplasms, but also intracranial hemorrhages (i.e., epidural or subdural hematoma) as well as focal infections and abscesses.

3) Patients with seizure disorder may present in a postictal state with AMS. 4) Psychogenic coma is a diagnosis of exclusion. 5) Endocrine/exocrine disorders include thyroid storm, as well as myxedema coma.

Table 2. Causes of AMS A – alcohol, arrhythmia T – trauma, temperature disorders E – endocrine/exocrine, I – infection

electrolytes, encephalopathy P – psychiatric, porphyria, poisons I – insulin S – space-occupying lesions, stroke, O – oxygen, opiates subarachnoid hemorrhage, U – uremia shock, seizures

Treatment As with most entities in medicine, treatment of AMS is directed toward the underlying disorder. Specific management of the myriad of causes of AMS is beyond the scope of this discussion. The most critical portion of ED management is the initial stabilization of the patient. However, it is important to note the following “pearls”:

1) Immediate neurosurgical consultation is indicated if signs of uncal herniation are present. In addition to intubation and hyperventilation, mannitol 1-2 g/kg IV is indicated.

2) If infection is suspected, administration of antibiotics should not be delayed by the work-up. 3) Do not be misled by the odor of alcohol. 4) Immobilization of the cervical spine is imperative. All patients with AMS must be considered

to have a cervical spine injury until proven otherwise. 5) Toxic drug screens only test for common drugs of abuse. Specific drug assays may be

indicated. 6) Romazicon© (a benzodiazepine antagonist) should be considered if isolated benzodiazepine

overdose is determined to be the etiology of AMS. However, Romazicon® is to be avoided in any patient with a history of seizure disorder or cyclic antidepressant overdose, as seizures and/or death can be precipitated by its administration.


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APPROACH TO THE PATIENT WITH SEIZURES As with the patient presenting with altered mental status, the first step in management of the patient with seizures is assessment and stabilization of the “ABCs”. This includes immobilization of the cervical spine and compression of any obvious hemorrhage, as previously mentioned. After the “ABCs” have been assessed and the patient has been stabilized, you may then begin assessment and treatment of the patient’s seizure activity. Definitions and Classification A seizure is a paroxysmal event due to excessive neuronal discharge that leads to focal or generalized manifestations. Status epilepticus is defined as a seizure lasting >30 minutes, or intermittent seizure activity, also lasting >30 minutes, during which the patient does not regain consciousness. Seizures can be divided into two classes: generalized, which are always associated with loss of consciousness, and focal, which may or may not be associated with impaired consciousness. Although this text is not intended to describe in detail the pathophysiology of each type of seizure, further classification of seizures is noted in Table 3. Generalized seizures are bilaterally symmetrical and without focal onset, and begin with an abrupt loss of consciousness. Auras may occur, but are not always a component of seizures. Partial seizures begin focally, but may progress to generalized seizures. Simple partial seizures may include motor, sensory, autonomic, or psychic signs and symptoms. With simple partial seizures, consciousness is not impaired, whereas, complex partial seizures are accompanied by impaired consciousness.

Table 3. Seizure Classification Generalized Partial

a. Absence a. Simple partial seizure i. Typical (petit mal) b. Complex partial seizure ii. Atypical c. Partial seizure with secondary generalization

b. Tonic and/or Clonic (grand mal) c. Myoclonic/atonic

HISTORY Seizure activity is not always due to a primary seizure disorder. Seizures may be occurring secondary to an infectious process (such as meningitis), a toxin, or a metabolic disorder. A cardiac arrhythmia may result in syncope, which may be mistaken for a seizure. Several sleep disorders, as well as movement disorders, may present as seizure activity. Psychiatric disorders including hyperventilation syndromes, fugue states, and pseudoseizures can be mistaken for a primary seizure disorder. Therefore, the precise history of events surrounding the seizure activity must be carefully elicited from witnesses. If the patient had a seizure, he or she will have no true recall of the event. The patient may be able to tell you the immediately preceding activities, but will not be able to recall the actual event. Beware of the patient who ”heard everyone talking” but couldn’t move or respond. Information that should be obtained from witnesses includes a description of the patient’s activity at the onset of symptoms, the progression of the patient’s activity during the episode, the duration of the activity, and the patient’s activity and mental state immediately following the event. A seizure typically has an abrupt onset and termination, and most only last 1-2 minutes. The pattern of activity may assist in the classification of seizures, or may altogether rule out a seizure as the etiology of the event. Movements during seizures are generally purposeless and inappropriate. With the exception of most petit mal or simple partial seizures, most seizure activity is followed by a period of confusion and lethargy, termed a “postictal state.” The patient may have an established diagnosis of seizure disorder, but may have concomitant problems that lowered the seizure threshold and precipitated the current seizure activity. Therefore, it must be determined from witnesses if the patient has had other recent health problems, recent trauma, or if the patient has been compliant with the prescribed anticonvulsant regimen. A careful review of systems must be obtained to determine if the patient has had recent complaints indicative of concurrent infection, or if there has been other drug use. The patient’s usual pattern of seizure activity, as well as the frequency of


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occurrence, must be ascertained to determine if the current event deviates from the patient’s “baseline” disorder. If the patient has no history of seizure disorder, it is imperative that a very detailed review of systems be obtained. PHYSICAL EXAM A thorough physical exam should be performed and directed toward discovery of any systemic illness that may have precipitated the event or any injury that may have been sustained during the event. An elevated temperature should prompt a search for a source of infection. Laceration of the tongue often occurs during a seizure. Once it has been determined that no injury has occurred involving the cervical spine, examine the neck for nuchal rigidity (i.e., evidence of meningitis). Examine the lungs for rales, as pneumonia may have precipitated the seizure activity, or may have occurred as a complication of the seizure (i.e., aspiration). The extremities should be examined for evidence of trauma (seizures are the most common cause for posterior dislocation of the shoulder). The neurological exam may be difficult to perform, as the patient may remain lethargic in a postictal state. Serial neurologic exams should be performed as the patient progresses through the postictal course. ANCILLARY STUDIES Specific ancillary studies that should be obtained depend on the clinical situation. For example, in a patient with a known seizure disorder who has just had a seizure that is typical for them, consider only a finger stick glucose determination and relevant serum anticonvulsant levels. However, in a patient with new-onset seizures, consider obtaining a CBC, electrolytes, BUN, creatinine, calcium and magnesium levels, liver function tests, urinalysis, toxic screen, alcohol level, and a pregnancy test. Patients with any of the following should undergo neuroradiographic imaging (CT scan or MRI): a patient with a new-onset seizure, persistent global or focal deficits, recent history or evidence of head trauma, and/or a sudden change in the patient’s usual seizure pattern. Further studies, such as an EEG, may be obtained in consultation with a neurologist. TREATMENT The treatment of seizures is based on protecting the patient from self-harm, as well as from complications that may arise from seizure activity. The mortality of status epilepticus has been reported as approximately 10%. Complications may include trauma, hypoxia, and circulatory collapse. Treatment and assessment should begin concurrently, with assessment and stabilization of the “ABCs” including cervical spine immobilization. One of the most important things is to protect the patient from aspiration. Do not place anything in the patient’s mouth – a nasal airway may be used when necessary. Place the patient in the Trendelenburg position, with suction available at the bedside. Soft restraints may be necessary to prevent a fall or other injury.

After initial assessment and stabilization has been performed, place the patient on a monitor, including pulse oximetry. Obtain IV access (withdraw blood for labs), and place the patient on oxygen. Obtain a finger stick glucose or administer 1 amp of dextrose. At this point, perform a thorough physical exam. If infection is suspected, administer antibiotics. If seizure activity persists, institute pharmacologic therapy (Table 4.). DISPOSITION Not all patients presenting with seizures must be admitted to the hospital. Those that require admission are those with status epilepticus and most patients with new-onset seizures. A patient with a known seizure disorder should be admitted if 3 or more seizures have occurred in a 24 hour period, or if the patient is significantly subtherapeutic on anticonvulsants and cannot be loaded in the ED (e.g., carbamazepine, valproic acid). Patients with a history of seizure disorder who have had their typical seizures may be safely discharged home, provided their anticonvulsant levels are therapeutic, their mental status has returned to normal, they have no other condition mandating admission, and specific follow-up has been arranged. A neurologic consultant may choose not to admit a patient with a new-onset seizure. This is acceptable only if all of the following conditions are met: the physical exam is normal, CT scan is unremarkable, no other condition mandating admission is present, the home situation is adequate (including the availability of


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close patient observation by family or friends), the patient is reliable, and specific follow-up has been arranged.

Table 4. Pharmacologic Control of Active Seizures

Lorazepam 0.1 mg/kg IV (<2 mg/min; total dose 4-8mg) or Diazepam 0.15-0.25 mg/kg IV ( <5mg/min; usual adult dose is 5 mg; maximum total adult dose is 20 mg) then Phenytoin 15-20 mg/kg IV load (no faster than 50 mg/min)

If seizure activity persists: ET intubation (if not already performed) Phenobarbitol 20 mg/kg IV at 100 mg/min Consider lidocaine 100 mg IV bolus

If seizure activity persists: Consider barbiturate coma, general anesthesia, or diazepam drip. If this is done, continuous EEG monitoring is mandatory.


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APPROACH TO THE PATIENT WITH A STROKE SYNDROME As in every patient who presents to the ED, first assess and secure the “ABCs”. Once this has been accomplished, you may proceed with further evaluation. In the patient presenting with a stroke syndrome, the goals of the ED physician are stabilization and support, exclusion of nonvascular causes of the patient’s symptoms, definition of the type and vascular territory of the TIA or stroke, expedition of appropriate consultation, minimization of secondary damage, and assistance with the prevention of subsequent similar events. Definitions A stroke, as defined by the World Health Organization (WHO), is the rapid development of clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting longer than 24 hours or leading to death, with no apparent cause other than that of vascular origin. A Transient Ischemic Attack (TIA) is defined as an acute episode of focal loss of cerebral function (including focal visual field loss) lasting < 24 hours, and is attributed to a temporarily inadequate blood supply. Therefore, a patient presenting to the ED with a new-onset (<24 hour) neurologic deficit cannot be classified into either category, and must be presumed to be experiencing an acute stoke. Pathophysiology Stoke is the leading cause of disability and the 3rd leading cause of death in the United States. Stroke causes brain damage via one of two mechanisms: 1) from ischemia due to vessel occlusion (primary atherosclerosis or an embolic event) which deprives neurons of oxygen and nutrients, or 2) from hemorrhage due to vessel rupture, which causes brain injury by direct cell trauma, mass effect, elevated intracranial pressure, and/or the release of detrimental biochemical substances. Approximately 80-85% of all strokes are ischemic in etiology, with the remaining 15-20% attributable to hemorrhage. History

Risk factors for stroke are much the same as those for coronary artery disease, as atherosclerotic

disease globally effects the vasculature. In fact, cardiac disease is a risk factor for stroke. This includes arrhythmias, such as atrial fibrillation, due to the potential for intracardiac thrombus formation. Other risk factors include: age (elderly), hypertension, diabetes, smoking, hypercholesterolemia, obesity, and oral contraceptives. A detailed account of the patient’s symptoms should be obtained. This may, of necessity, be obtained from family or witnesses, since the patient may often be dysarthric or aphasic. The time of onset, the rapidity of onset, and the activity at onset should be determined. Gradual onset with waxing and waning neurologic symptoms suggests a thrombotic stroke, whereas sudden onset of symptoms suggests and embolic or hemorrhagic event. A history of recent TIAs or similar symptoms should be obtained. A TIA with a resultant deficit that is in the same distribution as the acute presenting deficit suggests thrombotic disease, whereas, TIAs with deficits in varying distributions (as compared with the current deficit) suggests an embolic event. A history of headache or trauma should be obtained, if present. Headache occurs in the majority of patients with an intracranial hemorrhage, but occurs in only 10-20% of those with ischemic stroke. In addition to the usual past medical, social, and family history, current medications and a complete review of systems should be obtained. Physical Exam A general physical exam should be preformed prior to initiating a detailed neurologic exam. Certain findings may need to be immediately addressed, while others may suggest the mechanism of the stroke. Vital signs may reveal fever, which may suggest underlying infection that is “unmasking” the cerebral event. It is not uncommon for a patient with a stroke to have concurrent hypertension. The thickened smaller perforating vessels may require a higher pressure to remain patent.

Examination of the head and neck should include funduscopic exam, which may reveal papilledema (suggestive of mass effect) or preretinal hemorrhage (suggestive of subarachnoid hemorrhage). Pupil size, equality, and reactivity should be assessed. The temporal artery should be palpated for tenderness suggestive of arteritis. Nuchal rigidity may indicate meningitis or subarachnoid hemorrhage.


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Cardiac examination may reveal an arrhythmia such as atrial fibrillation, which may suggest a cardioembolic event. Other stigmata of cardioembolism should be sought out, such as Osler’s nodes, Janeway lesions, and splinter hemorrhages. The goal of the neurologic evaluation is to localize the site of the lesion, while excluding other neurologic diseases. Mental status should be assessed, including level of consciousness, orientation, memory, speech, and understanding. Cranial nerves II-XII should be assessed, including visual field assessment. Muscle tone, strength, and fine motor control should be included in the motor exam. Pronator drift suggests cortical dysfunction. Deep tendon reflexes are initially hypoactive on the affected side; later they become hyperactive. Plantar responses (Babinski’s) should be performed. The sensory exam should include assessment of pain, temperature, light touch, and vibration sense. Cerebellar function testing should be performed, including balance, heel-to-shin, finger-to-nose, and, if the patient is safely ambulatory, gait. Stroke Syndromes The following are examples of classical patterns of stroke, categorized into ischemic and hemorrhagic syndromes. Ischemic stroke syndromes

• Dominant hemispheric infarction : In all right-handed patients, and in up to 80% of left handed patients, the left hemisphere is the dominant hemisphere. Ischemia in this hemisphere results in contralateral weakness and numbness, contralateral visual field deficits, a gaze preference, dysarthria, and aphasia.

• Nondominant hemispheric infarction: Findings may be similar to those seen as a result of infarction in the dominant hemisphere; however, patients may be dysarthric, but typically are not aphasic. Patients often will neglect the contralateral extremities.

• Middle cerebral artery infarcts: Infarcts in the distribution of the middle cerebral artery results in a contralateral sensory deficit as well as motor weakness, with the face and the affected arm weaker than the leg. These patients may have aphasia if the dominant hemisphere is involved.

• Anterior cerebral artery infarct: An infarct in the distribution of the anterior cerebral artery results in deficits similar to those found in middle cerebral artery infarcts, except, in this case, leg weakness is greater than arm weakness.

• Vertebrobasilar artery syndrome : The posterior circulation supplies the brainstem, cerebellum, and visual cortex. Dizziness, vertigo, diplopia, dysphagia, cranial nerve palsies, and bilateral limb weakness may be associated with infarcts involving the posterior circulation. The finding of crossed neurologic deficits is the hallmark of a vertebrobasilar artery infarct (ipsilateral cranial nerve weakness with contralateral motor weakness).

• Basilar artery occlusion : Occlusion of the basilar artery results in severe quadriplegia, coma, or locked-in syndrome.

• Lacunar infarct: These infarcts result in pure motor or pure sensory deficits, and result from infarction from small penetrating arteries, and are primarily located in the pons and basal ganglia. Lacunar infarcts are commonly associated with chronic hypertension.

• Arterial dissection: Most often associated with severe trauma, arterial dissection can also result from minor events, such as a quick turn of the head. Dissection may occur in both the carotid and vertebral circulation. Patients may complain of sever headache or neck pain hours to days prior to onset of neurologic deficits.

Hemorrhagic stroke syndromes

• Intracerebral hemorrhage : This entity may be clinically indistinguishable from cerebral infarction. However, the presentation differs in that most patients are lethargic and may have hypertension. Headache, nausea, and vomiting often precede the onset of neurologic deficit.

• Cerebellar hemorrhage: Patients with cerebellar hemorrhage experience the sudden onset of dizziness, vomiting, marked truncal ataxia, and inability to ambulate.

• Subarachnoid hemorrhage (SAH): These patients experience the sudden onset of a severe headache (“thunder-clap headache”) that is often occipital or nuchal in location. The headache is often accompanied by vomiting. Patients with SAH may have associated neurologic deficits secondary to the compression of brain tissue or cranial nerves by an enlarging aneurysm.


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Ancillary Studies Every patient presenting with a stroke syndrome should receive the following ancillary studies: CBC, electrolytes, glucose (hypoglycemia can often mimic acute stroke), BUN, creatinine, PT, PTT, pregnancy (in females of child-bearing age), chest XR (to assess cardiac size, and rule out congestive heart failure as well as infiltrates), and EKG (4% of patients with stroke will have a life -threatening arrhythmia and 3% will have concurrent myocardial infarction). They should also have a noncontrasted head CT. The primary goal of performing a head CT in these patients is to rule out hemorrhage and mass effect. Areas of acute ischemia are usually not seen on CT scan until 12-48 hours after onset of symptoms. CT scan has been reported to be 90-95% sensitive for visualizing SAH; if SAH is suspected and CT is negative, a lumbar puncture (LP) is mandatory to exclude the diagnosis. (SAH is discussed in further detail in the next section). Magnetic Resonance Imaging (MRI) is the preferred method of imaging in the evaluation of a brainstem stroke, subacute hematoma (age 10-20 days), demyelinating diseases, and arteriovenous malformations. Additional studies should be considered on a case-by-case basis. Obtaining an erythrocyte sedimentation rate (ESR) is mandatory on any patient 50 years old or more with a headache or transient vision loss, to rule-out temporal arteritis. LP is indicated if meningitis is suspected. Carotid artery doppler (duplex), echocardiogram, angiography, and magnetic resonance angiography (MRA) are all useful adjuncts to therapy and evaluation, and should be obtained in consultation with a neurologist. Differential Diagnosis The differential diagnosis of stroke includes the following:

• Hypotension (from cardiogenic, hypovolemic, or septic shock, or from an arrhythmia) • Complications of migraine variants • Labyrinthine disorders, including acoustic neuroma and vertigo • Postictal (Todd’s) paralysis • Infections, including meningitis, brain abscess, encephalitis, and neurosyphilis • Toxins • Metabolic disorders • Subdural or epidural hematomas • Demyelinating diseases, such as Multiple Sclerosis and optic neuritis

Treatment The approach to the patient with a stroke syndrome should begin as with any patient who presents to the ED: assessment and stabilization of “ABCs”. Because of the significant risk of arrhythmia, the patient should be placed on a cardiac monitor. IV access should be established (blood should be withdrawn for laboratory analysis), and pulse oximetry should be obtained. Consider a finger stick glucose (for reasons mentioned above). Do not attempt to lower the blood pressure in the hypertensive TIA or stroke patient, unless the systolic blood pressure is >220 mmHg, the diastolic blood pressure is >120 mmHg, or the mean arterial pressure is >140 mmHg on three repeated measurements made at 15 minute intervals, or if the patient is in danger of myocardial, aortic, or renal damage associated with elevated blood pressure. If blood pressure reading meet the aforementioned criteria, urgent consultation with a neurologist (or a neurosurgeon in the event of intracerebral hemorrhage) is mandatory prior to initiating therapy. History and physical should be performed; ancillary tests should be obtained. Appropriate neurologic consultation should then be obtained. A new treatment that is currently at the forefront is the use of thrombolytic agents in those patients with ischemic stroke. This is an instance in which the time of onset of symptoms is critical. If this therapy is to be instituted, it must be initiated within 3 hours of onset of symptoms, intracranial hemorrhage must be ruled out, and therapy should only be instituted in consultation with a neurologist. Disposition

All decisions regarding the disposition of a patient with a stroke syndrome should be made in consultation with a neurologist. If a patient with a stroke is to be discharged home, the patient must be


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reliable, otherwise well without other conditions mandating admission, with a small completed stroke >48 hours old, and close follow-up has been arranged.

A patient with an isolated TIA may be safely discharged and referred for an outpatient work-up if he or she is reliable, otherwise well, and does not live alone; if symptoms have completely resolved and the patient now has a normal neurologic exam; carotid duplex has been performed and reveals <70% occlusion; evidence of a cardioembolic source has been ruled out, and there is no indication for anticoagulation with heparin; if antiplatelet therapy (aspirin or ticlodipine) has been initiated; and if close follow-up has been arranged.

All patients with new onset strokes should be admitted to the hospital. Patients with TIAs that do not meet the aforementioned criteria should be admitted. BIBLIOGRAPHY Binder LS. Stroke; Emergency Medicine: An Approach to Clinical Problem-Solving ; Hamilton, et al (ed.) Saunders, 1991; p 877-893. Henry GL. Coma and Altered States of Consciousness; Emergency Medicine: A Comprehensive Study Guide, Fourth Edition; Tintinalli JE, et al (ed.); McGraw-Hill, 1996; p 225-233. Kothari RU, Barsan W. Management of stroke; Emergency Medicine: A Comprehensive Study Guide, Fourth Edition; Tintinalli JE, et al (ed.); McGraw-Hill, 1996; p 1014-1021. Mengert, et al (ed.). Emergency Medical Therapy, Fourth Edition; Saunders, 1996; p 734--778. Nelson MS. Seizures; Emergency Medicine: An Approach to Clinical Problem-Solving ; Hamilton, et al (ed.) Saunders, 1991; p 862-876. Pelligrino TR. Seizures and Status Epilepticus in Adults; Emergency Medicine: A Comprehensive Study Guide, Fourth Edition; Tintinalli JE, et al (ed.); McGraw-Hill, 1996; p 1026-1033. Seip R, Martin M. Approach to Coma and Transient Loss of Consciousness; The Clinical Practice of Emergency Medicine, Second Edition; Harwood-Nuss, et al (ed.); Lippincott-Raven, 1996; p 26-30. Starkman S. Altered Mental Status; Emergency Medicine: An Approach to Problem-Solving; Hamilton, et al (ed.); Saunders, 1991; p 807-829. Starkman S, Barron D. Stroke: Emergency evaluation and management; Emergency Medicine Reports, 15:75-82, 1994. Stedman’s Medical Dictionary, 24th Edition. Williams and Wilkins, 1982.

Pelvic Pain & Vaginal Bleeding

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Pelvic Pain and Vaginal Bleeding

Brian Hughes, M.D. FACEP

Vaginal Bleeding The main approach to non pregnant patients with vaginal bleeding in the Emergency Department centers on determining the stability of the patient. Vital signs and the patient’s description of bleeding are used to estimate the magnitude of hemorrhage. You must ask yourself: If I send this patient home, what is the likelihood that she will bleed significantly? Is close follow-up sufficient? Does hormone therapy need to be implemented in the ED? If bleeding has not led to hemodynamic compromise (and is not likely to), and pregnancy has been ruled out, the majority of patients can be safely discharged with close follow-up. Any patient with abnormal uterine bleeding needs their endometrium evaluated by an OB/Gyn before hormo nal therapy is implemented. Endometrial biopsy can be significantly altered by premature hormone therapy in the ED. Occasionally an OB/Gyn consultant will recommend implementing hormonal therapy in the ED. A young person may be placed an Ovral© 4 times daily for five days to stabilize the endometrium. Older patients require an ultrasound and biopsy. Patients who are hemodynamically unstable because of vaginal bleeding require a hemoglobin, a type and screen, IV resuscitation, and admission. Patients who have suffered trauma such as a vaginal laceration must be evaluated by an OB/Gyn in the ED. In all cases pregnancy must be excluded. Pelvic Pain Chronic pelvic pain is rarely investigated primarily in the ED. Once pregnancy is ruled out, acute conditions such as infection, ovarian torsion, urinary tract infection, renal colic, or a ruptured ovarian cyst must be considered. Your history and physical exam will assist in determining which of these conditions among others are most likely to be present. Urinalysis, CBC, ultrasound, and CT scan are the most useful tests to consider. As in all cases of patient management in the ED, the first rule of business is to take care of the patient. Patients with moderate pain and no peritoneal signs may be sent home on analgesics with appropriate follow-up. Patients with intractable pain or those with a surgical abdomen should be admitted for further evaluation. Etopic Pregnancy (EP) Any physician engaged in patient care in Emergency Medicine must consider this diagnosis in any female presenting to the ED with pain or bleeding. Ectopic pregnancy represents approximately 2 percent of pregnancies. Patients who have undergone tubal ligation have a risk of 3 in 1000 of having an ectopic pregnancy. Its importance cannot be overstated. The classic triad of abdominal pain with vaginal bleeding or spotting in a female with amenorrhea may not be present. Menstrual histories cannot always be relied upon. Abdominal or pelvic pain may be transient. Bleeding or spotting does not have to be present. Neither do risk factors such as the presence of an IUD or prior history of pelvic inflammatory disease (PID).

Pregnancy testing is mandatory. Once a positive urine HCG is established, a quantitative βHCG is drawn along with a CBC and a type and screen, particularly if there is bleeding. Diagnosis is confirmed by ultrasound or laparoscopy. The goal of ultrasound is to determine whether or not an intrauterine pregnancy (IUP) exists. If an IUP is seen, there is still a 1 in 3000 risk of having a co-existing ectopic pregnancy (heterotopic pregnancy). This condition is most commonly seen in in-vitro fertilization (IVF) patients. In this group, an ectopic pregnancy should still be considered, even in the presence of an IUP. For other patients, the presence of an IUP on ultrasound is a fairly reliable finding to rule out an ectopic pregnancy. If nothing is seen on ultrasound, an ectopic pregnancy is not ruled out. The patient still may have an ectopic pregnancy, but one of insufficient size to cause findings such as embryonic cardiac activity outside the uterus. When a pelvic mass or free fluid are seen in conjunction with an empty uterus, EP is considered highly likely. If ultrasound fails to confirm a definite IUP, or findings suggestive of an EP, it is deemed indeterminate. The OB/Gyn may choose to admit the patient, or follow the patient with serial quantitative HCGs as an outpatient. The patients clinical stability, βHCG level, and examination help guide the emergency department disposition. Confirmed ectopic pregnancies may be managed either surgically or medically with methotrexete.


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Pelvic Inflammatory Disease Neisseria gonorrhea and Chlamydia trachomatis are isolated in most cases of PID. However, Gardnerella, Streptococcus, and Hemophilus are also implicated. Lower abdominal pain is the most frequent chief complaint in PID. Diagnostic criteria must also include cervical motion tenderness, adnexal tenderness, tenderness on lower abdominal examination and at least one of the following: •Temperature > 100 F (38.3 C) •Abnormal cervical or vaginal discharge •Elevated sedimentation rate or C-reactive protein •WBC count > 10,000 •Positive gram stain for gram negative diplococci Because of the implications of fertility, assigning a patient a diagnosis of PID should not be taken lightly. For example, a reproductive age female has a 30% incidence of infertility with her first episode of PID. The incidence increases to 50% with her second episode. Therefore, if a patient with PID has vomiting, a pelvic mass, high fever or uncertain diagnosis admission should be sought. IV antibiotics and serial examinations are efficacious in these cases. Adolescents or patients who have never been pregnant should be admitted. Outpatient antibiotic management of PID includes the following: Ceftriaxone 250 mg IM or Cefoxitin 2 g IM plus Probenecid 1 g p.o.

plus Doxycycline 100 mg p.o. bid x 14 days Or Ofloxacin 400 mg p.o. bid x 14 days plus Metrondiazole 500 mg p.o. bid x 14 days Note that these regimens are different from the recommended treatment for uncomplicated cervicitis, which includes single doses of ciprofloxacin and a 10 day course of doxycycline or a single large dose of azythromycin. Vulvovaginitis The most common causes of acute vulvovaginitis include infections with Trichomonas, Candida albicans, Gardenerella, and Herpes. Trichomonas Trichomonas in the female patient presents as an itchy foul smelling discharge that is sometimes associated with dysuria and abdominal pain. It is diagnosed by visualizing a foamy green or gray discharge and an erythematous “strawberry” cervix or vagina. On wet prep, there are flagellated, motile, tear drop shaped organisms and PMNs. Male patients are asymptomatic 90 percent of the time. Sexual partners must be treated to prevent reinfection. Treatment in the nonpregnant patient is metronidazole 2 grams p.o. in a single dose or 500mg BID for 7 days. In the pregnant patient or the metronidazole allergic patient. It is clotrimazole cream or suppositories Q HS for 7 days. Monilial vaginitis Yeast is normal vaginal flora in 50% of healthy women. Colonization or overgrowth of the organism can be caused by diabetes, pregnancy, postmenopausal state, menstruation, immunosuppressive drugs, or antibiotics. The clinical presentation is classically of extreme pruritis, vaginal discharge, and sometimes dysuria or dyspareunia. Physical diagnosis is made by observation a thick white discharge, vulvovaginal erythema and edema, and satellite lesions on perineum. Pseudohyphae and spores may seen on KOH wet prep; however, 20% of cases have no pseudohyphae on KOH prep. Treatment includes terconazole vaginal


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cream or fluconazol 150 mg p.o. single dose. Patients who are on oral hypoglycemics cannot take fluconazol. Bacterial Vaginosis Symptomatic bacterial vaginosis is the result of alterations in the vaginal microflora that promote the synergistic activity of aerobic Gardnerella vaginalis and vaginal anaerobes. The CDC states that for the disease to be diagnosed, three or four of the following criteria should be present: homogenous discharge, pH of discharge greater than 4.5, positive amine odor test, or presence of clue cells. The diagnosis of Gardnerella vaginitis is often made from the wet mount saline preparation which shows clue cells or clusters of bacilli clinging to the surface of desquamated epithelial cells. Addition of 10% KOH to vaginal secretions will result in the release of the fishy odor. Treatment of bacterial vaginosis is achieved with metronidazole 500 mg BID for 7 days. Clindamycin 300mg p.o. BID for 7 days is the other option. Metronidazole vaginal gel q d x 5 days or clindamycin vag cream with application q HS x 7 days are two more options. Herpes Genital Herpes is a sexually transmitted disease caused by a DNA containing virus specific to human beings. Eighty to 90% of genital herpes is felt to be caused by HSV2. It has an incubation period from 1 to 45 days with a mean of 5.8 days post exposure. Usually the initial infection of genital herpes is the most severe and lasts longer than subsequent infections. Local manifestations of the disease include painful, fluid filled vesicles or papules that progress to well circumscribed, occasional coalescent, shallow based ulcers. Systemic manifestations include generalized lymphadenopathy, severe urethritis, pharyngitis, rash other than at the primary site, hepatitis, aseptic meningitis, myalgias, fever, headaches, and autonomic dysfunction. Recurrences are less severe and of shorter duration. Treatment of active infection is acyclovir 200 mg p.o. 5 times daily for 7-10 days or until clinical resolution or Valtrex bid 500mg for 5 days. Recurrent episodes are treated with 200 mg orally 5 times/day for 5 days. Suppression is 400 mg orally BID. STDs in Children Abused children present to the ER with a variety of somatic complaints including dysuria, discharge, and abdominal pain. Diagnosis of gonorrhea, chlamydia, trichomonas, genital herpes, and condylomata indicate sexual contact. Presence of the above infections should prompt full investigation for probable sexual abuse. Prepubertal gonorrhea presents as a vaginitis in a child rather than the endocervicitis of an adult. In culture proven gonorrhea, all household contacts should have cultures taken from the vagina, urethra, and pharynx. Problems in Pregnancy Pregnant patients present to the ER with a multitude of medical problems. They provide a particular challenge and many factors must be considered. The ER physician often has to prescribe drugs in the pregnant patient or advise her to stop or continue a drug that she is already on, in light of her newly diagnosed pregnancy. The evaluation of an effect of a drug on a fetus is a complex issue. The Food and Drug Administration lists five categories of labeling for drug use in pregnancy. A: - remote fetal harm, studies performed in women. B: - no obvious fetal harm, studies performed in animals. C: - either studies show adverse effects on animal fetuses or no studies have been performed. D: - positive evidence of fetal risk, but benefits may outweigh risks. X: - studies in animals or humans have demonstrated definite fetal abnormalities.


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Antibiotics that are safe in pregnancy include penicillin, cephalosporins, nitrofurantoin, macrolides, and clindamycin can be used on any tissue. There are two category D antibiotics. Tetracyclines distort tooth and bone growth. Quinolones cause abnormal cartilage formation. Avoid sulfamethoxisole/trimethoprim in pregnancy. Antiemetics that are safe in pregnancy included meclizine, dramamine, diphenhydramine, and trimethobenzamide (Tigan), promethazine (Phenergan), and prochlorperazine (Compazine). Treatment of asthma in pregnancy is relatively easy. β-agonists such as terbutaline and albuterol are safe. Steroids are also acceptable if the benefits in the mother outweigh the risks to the fetus. Analgesics that are safe in pregnancy include narcotics, acetaminophen, propoxyphene, codeine, meperidine, and morphine. Do not give nonsteroidal intiinflammatory drugs. It is safe to extrapolate that if a drug is safe in pregnancy, it is safe in breastfeeding and vise versa.

Toxicology

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General Approach to the Poisoned Patient

James Sinex, MD., FACEP

Definition of Terms Poisoning can be defined as exposure to a chemical or other agent that adversely affects functioning of an organism. The circumstances of exposure can be occupational, environmental, recreational, medicinal, or intentional. The route of exposure can be by ingestion, injection, inhalation, insufflation, or cutaneous exposure. Incidence and Characteristics There are between 3 and 4 million poisonings annually in US. Variability in reporting makes exact incidence somewhat unclear. More than half are pediatric 50% of adult overdoses will be multidrug Roughly 10,000 poisoning deaths occur each year Evaluation: ABCs Always the first step in evaluation of any potentially ill patient Airway – check for presence of gag reflex, pooling of secretions Breathing – evaluate respiratory efforts, pattern, ventilatory sufficiency Circulation – examine pulses, perfusion These should always take precedence over everything else, both initially and throughout the patient’s course. Initial Management After ABCs, there are two other groupings of three actions which should be followed or considered IV - acquire reliable access Oxygen - check pulse oximetry, administer supplemental oxygen Monitor - cardiac, BP, pulse ox This second grouping regards interventions in those patients with altered mentation Narcan Glucose – either administer or check fingerstick glucose level Thiamine – not only in alcoholics, but also in cancer patients and the chronically ill Consider the need for immediate skin decontamination. This is particularly important in cutaneous exposures, most commonly seen in organophosphate toxicity. If suspected: Undress patient completely Flush the skin with water, scrubbing patient down with soft brush Don protective clothing, for the entire health care team Properly d ispose of clothing and all potentially contaminated material Evaluation: History The history in poisoning, particularly intentional ingestions, is notoriously unreliable, and yet of critical importance. Talk with EMS personnel, family, friends, etc. Try to determine what was taken (or to what patient was exposed), how much, and when. Ask specifically about other meds (including over-the-counter) and substances of abuse taken coincidentally – especially salicylates and acetaminophen, as well as alcohol Examine pill bottles, if brought with patient - date prescribed, pill count Use medical record, regular MD, or pharmacy records to look for other possible drugs Send someone back to the scene if necessary Try to establish intent – was this suicidal, homicidal, accidental? Get a feeling for onset and progression of symptoms Establish PMH: Other medical problems Alcohol or drug abuse Psychiatric history, past ingestions Pregnant?

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Evaluation: Physical Exam Do a complete exam on a fully exposed patient Look for any vital sign abnormalities. These can be valuable clues (see Toxidromes below), as well as indicators of severity Check pockets and clothing (carefully – look out for needles) Skin for cyanosis, flushing, dryness or diaphoresis, tracks, bullae, signs of injury Eyes for pupil size/reactivity, nystagmus Oropharynx for hypersalivation or dryness Chest for wheezing Cardiovascular for rate, rhythm, regularity Abdomen for bowel sounds, bladder distention, muscle rigidity Extremities for tremor/fasciculation, pulses Complete neuro exam Evaluation: Reassessment Frequent reassessment for complications or progression of toxicity is essential. Frequently seen developments include: Airway compromise Ventilatory insufficiency Bronchospasm Pulmonary edema Dysrhythmia Hypotension / Hypertension Altered mental status Seizure Toxidromes This is a term referring to toxicologic syndromes, or complexes of signs and symptoms. It is inserted here because looking for these signs or symptoms during the course of your assessment can guide you identifying the toxic agent and intervention. The major four toxidromes are: Anticholinergic Sympathomimetic Opiate/Sedative -hypnotic/Ethanol Cholinergic See the included Table 1 for further elaboration Evaluation: Ancillary Testing There is no set template regarding what testing to do on every toxicologic presentation Not everyone needs a urine drug screen (though they usually get one) The screen is not comprehensive Results are often delayed Possible false negatives - i.e., low urine concentration of recently taken agent Possible false positives - i.e., incidental positives Multiple studies show that results of screens do not change clinical management or patient outcome Salicylate and acetaminophen levels in all is debatable Availability of specific levels of other toxins is rather limited Look for metabolic complications as indicated by specific toxins (anion or osmolar gaps, etc) ABGs and EKGs are often helpful Pregnancy testing in all women capable of childbearing is advisable Management: GI Decontamination • Syrup of Ipecac – to induce emesis

Essentially never indicated in ED Many parents have ipecac in the home, and you may see it used before presentation in pediatric patients Home use contraindications:

Ingestion with potential to alter mental status (so not vomiting with compromised airway) Toxin with more pulmonary than GI toxicity (as with hydrocarbons, to avoid aspiration of already-ingested agent)

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Caustic ingestion (similar to above, as well as to avoid esophageal and oropharyngeal re-exposure) Prior or current vomiting

• Activated Charcoal (AC) Almost always indicated Adsorbs toxins in the gut Establishes a drug concentration gradient favoring movement back into GI tract (“GI dialysis”) for some toxins, as well as adsorbing from bile Administer 1 gm/kg PO Contraindications: alkalis/acids, metals, hydrocarbons. (Charcoal can obscure subsequent attempts at endoscopy in alkali/acid ingestion, and is not very effective with metal and hydrocarbon exposure. That said, keep in mind that many toxic presentations are multidrug, history is unreliable, and the AC may help with another agent taken) Complications: aspiration, bowel impaction.

• Cathartics Sorbitol: Adult - 1gm/kg 70% solution, Child - 0.5gm/kg 35% solution, not used if <5 years old Generally given with first dose AC, and comes pre-mixed with some commercial preparations of AC Can also use magnesium citrate Contraindications: intestinal obst/ileus, diarrhea, caustics, abdominal trauma

• Multi-dose activated charcoal (MDAC) – or repeated doses of AC Administer 0.5 gm/kg q4-6 hours, without cathartics Only if gut working, and good bowel sounds Indications: theophylline (best evidence), salicylates, barbiturates, heterocyclics, sustained release formulations, bezoar formers, or very large ingestions.

• Orogastric lavage Demonstrated drug removal 35-56% However, the clinical efficacy is debatable, and use of lavage variable Indications:

Life -threatening ingestion Within 1 hour of ingestion

Contraindications: Caustic agent or low-viscosity hydrocarbon Nontoxic ingestion Airway not protected (to avoid aspiration)

Complications: Tracheal insertion Aspiration Perforation Knot formation of tube in stomach.

Intubate first if any question about airway. Position patient left lateral decubitus – delays gastric emptying, and helps if emesis does occur. Use a 36-40 French orogastric tube (commonly called an Ewald tube). Confirm placement by insufflation of air with auscultation. Use a room-temperature water lavage (250cc or so at a time) until the return is clear. Administer AC down tube (many do this both before and after the lavage)

• Whole bowel irrigation. Controlled studies of efficacy are still lacking. Indications:

Lithium, Iron, Heavy metals Sustained-release formulations Agents that form bezoars Body stuffers / packers (respectively, pts who swallow packets of drugs to avoid police seizure, and pts who are “mules”, swallowing many packets of drugs for smuggling purposes).

Contraindications: Intestinal obstruction/ileus Preceding diarrhea Administer polyethylene glycol (Golytely) at 0.5 - 2 liters per hour PO or NG until rectal effluent is clear.

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Management: Enhanced Elimination Acidification – essentially not efficacious and not used. Alkalinization

of blood - Heterocyclics (antidepressants) - improves/prevents cardiac effects primarily

of urine - Salicylates Phenobarbital Chlorpropamide Enhances elimination by ion trapping

Hemodialysis Indicated, in short, in a life -threatening ingestion that is amenable to dialysis (a toxin with a small volume of distribution, small molecular weight, and which is not highly protein bound). Ethylene glycol Methanol Salicylates Lithium Theophylline

Charcoal hemoperfusion Molecular weight and protein binding are not as relevant here. Less widely available. Theophylline Barbiturates

Management: Antidotes Relatively few available See Table 2 for a list of some of these Management: Disposition Depends on ingestion, intent, and patient status

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TTAABBLLEE 11 TTooxxiicc SSyynnddrroommeess SSeeeenn iinn tthhee EEDD

Anticholinergic syndromes Common signs Delirium with mumbling speech, tachycardia, dry, flushed skin, dilated

pupils, myoclonus, slightly elevated temperature, urinary retention, and decreased bowel sounds; seizures and dysrhythmias may occur in severe cases.

Common causes Antihistamines, antiparkinson medication, atropine, scopolamine, amantadine, antipsychotic agents, antidepressant agents, antispasmodic agents, mydriatic agents, skeletal-muscle relaxants, and many plants (notably jimson weed and Amanita muscaria).

Sympathomimetic syndromes Common signs Delusions, paranoia, tachycardia (or bradycardia if the drug is a pure (á-

adrenergic agonist). hypertension. hyperpyrexia, diaphoresis, piloerection, mydriasis. and hyperreflexia. Seizures, hypotension, and dysrhythmias may occur in severe cases.

Common causes Cocaine, amphetamine, methamphetamine (and its derivatives 3.4-methylenedioxyamphetamine, 3,4- methylene-dioxymethamphetamine, 3,4-methylenedioxyethamphetamine, and 2,5-dimethoxy -4- bromoamphetamine), and over-the-counter decongestants (phenylpropanolamine, ephedrine, and pseudoephedrine). In caffeine and theophylline overdoses, similar findings. except for the organic psychiatric signs, result from catecholamine release.

Opiate, sedative, or ethanol intoxication Common signs Coma, respiratory depression, miosis , hypotension, bradycardia,

hypothermia, pulmonary edema, decreased bowel sounds, hyporeflexia, and needle marks. Seizures may occur after overdoses of some narcotics. notably propoxyphene.

Common causes Narcotics, barbiturates, benzodiazepines, ethchlorvynol, glutethimide, methypryIon, methaqualone, meprobamate, ethanol, clonidine, and guanabenz.

Cholinergic syndromes Common signs Confusion, CNS depression, weakness, salivation, lacrimation, urinary and

fecal incontinence, gastrointestinal cramping, emesis, diaphoresis, muscle fasciculations, pulmonary edema, miosis, bradycardia or tachycardia, and seizures.

Common causes Organophosphate and carbamate insecticides, physostigmine, edrophonium, and some mushrooms.

From Kulig K: Initial management of ingestions of toxic substances. N Engl J Med 326: 1677. 1992: with permission.

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TABLE 2 Antidotes Used in the ED

Antidote Toxin used for Dose and comments Naloxone Opiates

2 mg: less to avoid narcotic withdrawal, more if inadequate response; same dose in children

Nalmefene Opiates 2 mg; much longer half-Iife than naloxone Bicarbonate Tricyclics 44-88 mEq in adults; 1-2 mEq/kg in children; best used IV push and not by

slow infusion FlumazeniI Benzodiazepines

0.2 mg, then 0.3 mg, then 0.5 mg, up to 5 mg; not to be used if patient has signs of TCA toxicity; not approved for use in children but probably safe

Calcium Calcium channel blockers 1 gm calcium chloride IV in adults, 20-30 mg/kg/dose in children, over a few minutes with continuous monitoring .

Glucagon

Beta-blockers and calcium channel blockers

5-10 mg in adults, then infusion of same dose per hour

Physostigmine Anticholinergics 1-2 mg IV adults, 0.5 mg in children over 2 min for anticholinergic delerium, seizures, or dysrrhythmias

Ethanol Methanol and ethylene glycol

Loading dose 10 ml/kg of 10%; maintenance dose 0.15 ml/kg/hr of 10%; double rate during dialysis

Atropine Organophosphates and carbamates

Test dose 1-2 mg IV in adults, 0.03 mg/kg in children: titrate to drying of pulmonary secretions

Protopam

Organophosphates and carbamates

Loading dose 1-2 gm IV in adults: 25-50 mg/kg in children: adult maintenance 500 mg/hr or 1-2 gm q 4-6 hr

Pyridoxine Isoniazid, Hydrazine, and monomethylhydrazine

5 gm in adults, 1 gm in children, if ingested dose unknown: antidote may cause neuropathy

Pyridoxine Ethylene glycol 100 mg IV daily Thiamine Ethylene glycol, chronic

eth~mol

100 mg IV

Digoxin-specific FAB fragments

Digitalis glycosides 10-20 vials if patient in ventricular fibrillation: otherwise dose is based on serum digoxin concentration or amount ingested

N -acetylcysteine Acetaminophen 140 mg/kg, then 70 mg/kg q 4 hr: IV form still investigational Sodium nitrite Cyanide. H2S 10 ml of 3% (300 mg; 1 ampule) in adults: 0.33 ml/kg in children, slowly

IV Sodium thiosulfate Cyanide

50 ml of 25% (12.5 mg; 1 ampule) in adults: 1.65 ml/kg in children, IV

Deferoxamine Iron 15 mg/kg/hr IV; higher doses reported to be safe EDTA Lead 75 mg/kg/day by continuous infusion: watch for nephrotoxicity, best done

in hospital DMSA Lead Reported useful for arsenic and lead as well: one 100 mg capsule per 10 kg

body weight tid for 1 wk then bid, with chelation breaks BAL Arsenic, mercury, and lead 3-5 mg/kg IM only D- Penicillamine Arsenic, lead, and mercury 20-40 mg/kg/day; 500 mg tid in adults: may cross-react \\-ith penicillin in

a1lergic patients Methylene blue Methemoglobin-forming

agents

1-2 mg/kg IV, one 10 m110% solution (100 mg) is initia1 adult dose

Folate or leucovorin Methanol 50 mg IV q 4 hr in adults while patient has serious toxicity Cyproheptadine Serotonin syndrome 4 mg PO as needed; no parenteral form available; antidote may cause

anticholinergic findings Crotalidae antivenin Rattlesnake bite

5. vials minimum dose, by infusion in normal saline, at increasing rate dependent on patient tolerance; may cause anaphylaxis

Latrodectus antivenin Black widow spider bite 1 vial, by slow IV infusion. usually curative; may cause anaphylaxis

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ED Approach to Multiple System Trauma

David Ledrick, M.D., FACEP

Trauma systems and epidemiology Deaths due to trauma take a tri-modal distribution of peak incidence from the time of injury. The first peak occurs in the first seconds to minutes after the injury. These types of injuries include massive head trauma, disruption of the great vessels, or uncontrolled hemorrhage. The second peak occurs in the first few hours after the patient’s arrival to the hospital. These injuries are again significant but not enough that they were immediately lethal. They include problems such as aortic ruptures with hematoma formation, pneumothorax, liver and spleen lacerations, or slower uncontrolled hemorrhage. The third peak occurs days to weeks after the injury when treatment in the hospital leads to post-surgical complications, sepsis, or pulmonary emboli. The value of a systems approach to trauma becomes clear. By passing laws regarding speed limits, helmet use, firearms limitations, and drunken driving we can reduce the trauma deaths in the first peak. By having designated centers with experts in the treatment of the complications (including rehabilitation and social services) of major trauma we can reduce the deaths in the third peak. In the ED we obviously have the greatest effect on the second peak by recognizing and treating possibly occult but life -threatening injuries. The rest of this chapter will be devoted to this issue. Primary Survey The treatment of the trauma patient in the ED is directed to identifying immediately life -threatening injuries. These injuries may not be readily apparent. The primary survey is a way of prioritizing the initial assessment. Once an accurate primary survey is complete, a more methodical and comprehensive secondary survey can be done. The primary survey should take approximately 30 – 60 seconds and should only be interrupted to deal with the problems it identifies. If a trauma patient becomes unstable during any part of the assessment, one should go back and quickly reassess the primary survey (That hematoma on the neck that looked benign initially may be expanding and causing airway compromise). It is as easy as ABC: A – Airway maintenance with C-spine control B – B reathing/ventilation C – Circulation with hemorrhage control D - neurologic Disability E – Exposure (the patient should be entirely undressed) While the primary survey is occurring, other members of the team should be “throwing the safety net under the patient.” This means that trauma patients, like all other critically ill patients, should have some level of intervention being performed even before the data is collected. Placing the patient on the monitor, obtaining IV access, and getting high flow oxygen started can easily occur without interrupting the primary survey. The team leader should ensure that all members of the team are working simultaneously without interfering with each other during the resuscitation. Airway maintenance with C-spine control Rapid assessment for airway patency includes inspecting for foreign bodies or maxillofacial fractures that may result in airway obstruction. The chin lift or jaw thrust maneuver, or the insertion of an oral or nasal airway, is a first response to a patient making an inadequate respiratory effort. With enough personnel available, one person should be designated to hold in-line stabilization of the cervical spine. Patients who are vomiting should be rolled with maintenance of C-spine immobilization and suctioned. Patients who are talking and able to give even a confused history are unlikely to have an immediate airway problem and you can move on to breathing. Breathing/ventilation The patient’s neck and thorax should be inspected, auscultated, and palpated to detect abnormalities such as a deviated trachea, crepitus, flail chest, sucking chest wound, fractured sternum, and absence of breath sounds on either side of the chest. Possible interventions here include application of an occlusive dressing

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to a sucking chest wound, withdrawal of the endotracheal tube from the right mainstem bronchus, reintubation of the trachea if no breath sounds are heard, and insertion of a large chest tube to relieve a hemopneumothorax. Circulation with hemorrhage control Hemorrhagic shock, a common cause of postinjury death, should be assumed to be present in any hypotensive trauma patient until proven otherwise. Direct pressure should be used to control obvious external bleeding, and a rapid assessment of hemodynamic status is essential during the primary survey. This includes evaluation of level of consciousness, skin color, and presence and magnitude of peripheral pulses. Attention should be paid to the specifics of heart rate and blood pulse pressure (systolic minus diastolic blood pressure), particularly in young, previously healthy patients. Not all hemorrhage results in hemorrhagic shock, and an unsuspecting clinician may fail to appreciate ongoing hemorrhage with blood loss of up to 30 percent of the circulating blood volume. While Class I hemorrhage (loss of up to 15 percent of circulating blood volume ) is associated with minimal symptoms and is clearly no shock, Class III hemorrhage associated with gross hypotension is readily appreciated as a state of hypoperfusion. Yet, consider a young, healthy trauma victim who has lost 25 percent of his circulating blood volume (Class II hemorrhage) and had a preinjury blood pressure of 130/70 mmHg and a pulse rate of 60. If this patient experiences a 50 percent increase in his pulse rate (to a rate of 90) and a greater than 50 percent decrement of his pulse pressure (from 130/70 mmHg pulse pressure of 60 to 116/90 mmHg pulse pressure of 26), the unsuspecting clinician may assume that the patient is “hemodynamically stable.” A false sense of security may lead to delays in aggressively pursuing the source of bleeding via ultrasound, peritoneal lavage, operative exploration. From this example it should be clear that the practice of omitting diastolic blood pressure (and reporting “116/palpable,” thus omitting the pulse pressure) is potentially hazardous. The alert , suspicious clinician identifies hemorrhage before it reaches the class III category of obvious shock. Two large intravenous lines should be established and blood obtained for laboratory studies. While there are varying preferences, there are significant advantages to a percutaneous large line in the groin for unstable patients in whom upper extremity peripheral veins are not available. Subclavian lines are potentially dangerous in the hypovolemic patient, saphenous vein cutdown at the ankle may not be appropriate for the patient with an injured lower extremity, and complications encountered from the femoral venous line may be minimized if the line is removed early, on completion of resuscitation in the early postoperative period. Unstable patients without an obvious indication for surgery should be assessed for their response to 2 L of rapid infusion of crystalloids. If there is not marked improvement, type O blood should be transfused (O-negative for females of childbearing age). Auscultation for breath sounds and heart sounds and inspection of neck veins are included in the assessment of circulation because two major causes of hypotension may be present in trauma patients with minimal blood loss: cardiac tamponade (hypotension, agitation, distended neck veins, muffled heart sounds) and tension pneumothorax (hypotension, distended neck veins, absent breath sounds). Neurologic disability An abbreviated neurologic evaluation should be performed. This includes an assessment of the level of consciousness, pupil size and reactivity, and motor function. The Glasgow Coma Scale(GCS) should be used to quantify the patient’s level of consciousness. Despite the common presence of alcohol and drugs in trauma patients, it should be assumed that alterations in level of consciousness are due to head injury. A GCS between 13 and 15 is considered mild, between 9 and 12, moderate. Patients with a GCS of 8 or less have a severe head injury and should be intubated regardless of their airway and breathing status. Further investigation of the head injury with a CT should occur as soon as possible after the patient’s other injuries have been stabilized. Peripheral neurologic disability must also be rapidly assessed and spinal immobilization maintained until instability has been ruled out. A complete cervical spine series must include AP, lateral, and odontoid views. Obtaining only a lateral film can result in missed fractures in as many as 15% of C-spine injuries. An intoxicated patient cannot be cleared with radiographs as ligamentous instability can still be present despite normal x-rays. A recent study with over 34,000 patients enrolled has suggested criteria which can safely be used to clear the cervical spine without x-rays. Patients who are not intoxicated, with no

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alterations in mental status, have no peripheral neurologic deficits, no distracting injuries, and no cervical spine tenderness can be cleared from immobilization without radiographs. Of course, x-rays of the neck, chest, and pelvis, which are considered standard on all major multi-system trauma patients should wait for the secondary survey. Exposure No primary survey is complete without thoroughly disrobing the patient and examining the total body surface area carefully for bruises, lacerations, impaled foreign bodies, and open fractures. If hemodynamically stable and with a stable airway, the patient should be log-rolled with one attendant assigned to maintain cervical stabilization. Check the back and thoracic and lumbar spine for tenderness. Check the gluteal cleft and perineum for injury. When the exam is completed, the patient should be covered with warm blankets to prevent hypothermia. Secondary Survey An AMPLE history should be obtained from the patient once a primary survey is completed. It is certainly possible to obtain the history during the primary survey; however, the initial priority should be on securing the airway, breathing, and circulation of the patient. The AMPLE history consists of: A- allergies. It is important to know the medication (and other) allergies of a patient as the patient may soon be receiving antibiotics, tetanus, and anesthetics. M – medications. Knowing the patient’s medications will not only give you an idea of expected drug-drug interactions but it gives you an idea of the physicologic status of the patient. For instance, the patient on beta-blockers may not have an appropriate tachycardia. P – past medical history. Again, it is important to know the patient’s underlying diseases. A patient with chest pain may be having an MI or the patient may have had a significant syncopal event leading to the accident. L – last meal. A patient my have gastric distension or be at risk for aspiration if taken to the operating room. E- events. This is the history of the mechanism of the trauma. It will tell you what to look for in terms of injury pattern and will heighten your awareness to certain types of injuries. Don’t forget that the medics who were at the scene are a valuable source of information in estimating the speeds involved and the extent of the injuries and blood loss. The secondary survey is a more thorough assessment of the trauma patient which includes a detailed exam of the head and neck, exploration of wounds, and a more careful neurologic exam. A rectal and bimanual pelvic exam should be performed. This is done simultaneously with the performance of indicated x-rays. As already stated, x-rays of the chest, cervical spine, and pelvis are standard on the multi-system trauma patient. If the patient, however, is acting appropriately, gives a good history, and can be adequately assessed, not all of these films are indicated. The chest x-ray is the single most valuable film in the unstable trauma patient. A significantly injured trauma patient should also receive “tubes and lines in every orifice.” An NG tube may help prevent aspiration and the stomach must be decompressed prior to a diagnostic peritoneal lavage (DPL). A foley catheter will help monitor urine output. A foley also must be placed prior to a DPL. Remember, the rectal exam should be performed prior to the placement of the foley to prevent pushing the foley through a disrupted urethra. Other invasive monitoring may be required such as arterial lines, CVP monitoring, or a Swan-Ganz catheter. Further diagnostic testing A whole book could be written about the use of the following tests and procedures and a discussion of their limitations is beyond the scope of this chapter. The following table is simply a starting point.

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Test Indications Limitations Contraindications CT of the abdomen Suspected intra-

abdominal or retroperitoneal injuries due to blunt force trauma

Poor with diaphragmatic injuries Limited with penetrating injuries to the bowel Possible reactions to dye load

Do not perform if patient has not been reasonably stabilized

CT of the head Suspected intracranial hemorrhage or edema due to blunt force trauma

Few limitations other than time in the scanner for an unstable patient

Do not perform if patient has not been reasonably stabilized

Diagnostic Peritoneal lavage (DPL)

Intra-abdominal or diaphramatic injuries due to blunt or penetrating trauma

Sensitive but not specific for injuries Not for use if retroperitoneal injury is suspected

Do not perform without and NGT and Foley in place

Abdominal Ultrasound Suspected intra-abdominal or retroperitoneal injuries due to blunt force trauma

Operator dependent Cannot diagnose bowel injuries

Few contraindications. This is a fast, noninvasive bedside test

Summary The care of the trauma patient should be a coordinated effort. This effort certainly must come from the treating team in the hospital with pre-determined tasks for each member of the team. The effort must also come from the system in which the triage mechanism and pre-hospital protocols mesh with the treating trauma service. Using a systematic approach to the critically injured patient is mandatory. A high index of suspicion should exist for occult life-threatening injuries and a reassessment made on a nearly continuous basis.

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Dealing with Violence in the Emergency Department


There is no doubt that we live in a violent society. Violence in our streets, in our schools and in our homes is a national emergency and a national shame1. Violence in our emergency departments is becoming increasingly common and lethal. Emergency physicians and nurses are alarmed and incidences of serious harm or death receive widespread media coverage2,3. ED personnel are demanding more and more security measures to protect themselves and their patients. Some staff members are taking safety measures into their own hands and some even carry weapons with them to work. The Scope of the Problem Incidences of hostage situations, gunshot wounds and assaults on emergency personnel are common4,5,6 . In a study in the Annals of Emergency Medicine in 1988, Lavoie reported the results of a survey of 127 teaching hospitals with a volume of 40,000 or more patients visits per year7. 32% reported 1 or more verbal threats per day. 18% reported that weapons were displayed at or near staff at least once per month. 57% of ED staff said they had been threatened by a weapon in the last 5 years. 43% said there was a physical attack on a staff member at least once per month and 81% of the ED’s had staff injured in the last 5 years. 7% of the ED’s surveyed said they had violence that resulted in death in the last 5 years. From the patient perspective, 25% of the ED’s surveyed restrained at least 1 patient per day, 13% of patients that had to be restrained had injuries resulting from the restraint and there were multiple lawsuits against hospitals by patients injured through restraint. Clearly, both staff and patients are at risk8. Weapons in the ED Data have also been collected on weapons in ED’s. Ordog reported that 26% of major trauma patients presenting to the ED carried weapons9. Interestingly, female trauma patients were more likely to be carrying lethal weapons (36%) than their male counterparts. 46% of the ED’s surveyed by Lavoie confiscated 1 or more weapons per month7. Metal detectors at one hospital identified and led to the confiscation of over 300 weapons in one month. These were not pocketknives but included shotguns, 357 magnum handguns, M-1, AK-47 and a 9mm UZI9. Goetz, at the University of Oregon emergency department where they see a volume of about 39,000 patients per year found that weapons carrying was about equal in medical and psychiatric patients 10. In his study, they searched 1.3% of all patients. 16% of those with weapons were medical patients and 17% were psychiatric patients. Disarming the Patient Patients who are armed should not be evaluated until disarmed11. Generally, patients should be disarmed by security before entering the emergency department. If you suspect a weapon, you may simply ask the patient if they are armed. If they tell you they are armed, or if you discover the weapon during your exam, ask the patient to check the weapon at the front desk with security. Assure them that you will be glad to evaluate them when disarmed and they may retrieve their weapon upon discharge from the ED. It is unwise to take the weapon yourself. If offered, have them lay the weapon on the stretcher and call for security to hold the weapon for the patient. Since weapons, legal or illegal, are personal property, they should be returned at the end of your exam unless you are committing the patient for potentially violent behavior. Why do we have all this violence in our emergency departments? Many of our ED’s, especially our major trauma centers, are in intercity, urban settings where violence is endemic. I once worked in an ED that was 1-2 blocks from the illicit drug area of the city. It was not uncommon for fights to break out there, and because of the proximity, the violence would spill into the ED. The injured combatants would find themselves side by side with their enemies, police, and medical personnel minutes after leaving the streets. ED personnel are sometimes involved as innocent bystanders in drug related vendettas. Emergency departments are also high stress areas for patients, a place where unexpected sudden illness and death are common. Recently, we had one of our patient representatives injured when she was trying to assist a grieving family. The family’s grief had gotten out of control and she became a victim when she was body slammed by a large, muscular male relative of the deceased. It is also true that hostility is increased by long waiting times and delays in care, much of which is not under emergency department control7. A normally pleasant and well-adjusted patient can become irritated after a 3 or 4-hour wait, and a not so well adjusted patient may become dangerous after the same wait.

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ED’s also offer ready availability of drugs and hostages and have open access 24 hours per day. A patient experiencing the discomfort of drug withdrawal may to go the ED when the street supply is exhausted. Being told that no drugs will be given by the doctor or nurse may illicit a violent outbreak in an already agitated, paranoid and perhaps hallucinating patient. Our nation’s ED’s are also increasingly called upon to be the safety net for psychiatric patients since “deinstitutionalization” some years ago. Few citizens realize that this “deinstitutionalization” was dependent on the 24 hour open access to the care provided by our nations ED’s. A great deal of the care once provided by psychiatric facilities is now provided in our ED’s and we are often called upon for “medical clearance” for psychiatrically ill patients. Most of the above, can not be changed or modified. With all this evidence, still many of our ED’s are unprepared to deal with the violent patient. Many ED’s do not have protocols for dealing with violence even though it is a JCAHO requirement12. In Lavoie’s study, many of the ED’s had no specific training for nursing staff on the management of the aggressive patient7. It is clear that we need to protect ourselves, we need to protect our patients and the community expects us to be able to protect them. Profiles of potentially violent patients Some patients demonstrate habitual violent behavior and others are violent depending on the circumstances. The habitually violent patient is often a male in his teens to 30’s who has access to weapons and may be involved in alcohol or substance abuse. This is a person who has absent “roots” and problems with authority13. He may have multiple arrests, often for assault, and if he has been in the military, he may have a dishonorable discharge. This is a “fighter” who rarely backs down from a fight and has had many battles since childhood. It is well to remember that 5% of homicidal threats culminate in murder. This means that most patients are still ambivalent about homicidal threats and can still be treated. Patients delirious from medical problems can often strike out without warning. Depressed patients who are suicidal sometimes feel as though they have nothing to loose and might as well take you or their loved ones along with them- the ultimate in power and control. After all, if they are so miserable, why let you live a happy life or why let their spouse live to remarry when they are gone? Psychiatrically ill patients do not account for any more violence than the “normal” population. However, paranoid patients are especially worrisome, particularly when the paranoid person shifts from generalized paranoia (“they are after me”) to a specific person or group ( “John is after me”, or the FBI etc.). Recognizing the warning signs Often our own gut reaction is sufficient to warn us of impending violence14. If you begin to feel uncomfortable around a patient- listen to you own feelings. If a nurse or colleague says that they feel uncomfortable, this should be enough to alert us to take further precautions. Most of the time, but not all of the time, there is a period of mounting tension before physical violence occurs. This may involve a tense, threatening posture or loud, profane speech with increased motor activity or restlessnes s15. Recognizing the clues and taking precautions may prevent a violence outburst. Unfortunately, at times, especially in medical conditions that cause delirium or confusion, violence may be sudden and unpredictable and even the most sensitive interviewe r may not be able to predict the violence16. Safety Tips The emergency department can be a cauldron for violence with long waiting times, high acuity illness and both patients and staff can be easily provoked by disagreements and overheard informal remarks. ED staff should be careful not to aggravate patients with discourteous remarks and unnecessary roughness. If you find yourself with a potentially violent patient, minimize eye contact and give the patient plenty of “body space”. Some advocate a “body space” or buffer zone about 4 times larger than normal. Patients are especially attuned to incursions into their “body space” from the rear. A patient who moves back from the examiner is trying to tell you something17. At times you can ask the patient where they want you to stand so that they are comfortable. If you are frightened, it’s OK to say so. Tell them that they frighten you. When you become aware of a threat- deal with it immediately. Alert other staff or security at your first “gut” feelings and enforce limits. Don’t bargain or compromise your safety, the patients’ safety or the safety of other staff. The emergency physician frequently finds that he or she must interview and examine a potentially dangerous patient to determine the degree of danger the patient represents or to medically clear the patient who will be committed for violent behavior. This is best done with the help of security personnel. Notwithstanding, there are multiple ways to make this encounter safer. When interviewing or examining a potentially violent patient, make sure the room is free from all objects that can be used as weapons or are

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light enough to be thrown. This might include trays, hot drinks, scalpels, all sharps and instruments and electrical cords etc. Remove all potential weapons from yourself as well. Consider stethoscopes, scissors, necklaces, pocketknife, belts and clothing such as neckties as possible weapons (I was once held down for several minutes by a large hand on the knot of my favorite tie). It is preferable to have two doors, one for your escape and one for the patient’s escape if things escalate. If there is only one door, negotiate with the patient so you are both equidistant from the door. If you are blocking the exit, the patient will have no choice but to go through you to get outside, thus you are exposing yourself to an unnecessary risk. Maintain a safe distance- usually at least one arm’s length and position yourself to one side since it is easier to dodge a blow from the side than one coming straight on. If you are choked, tuck in your chin to protect your carotids11,18. If bitten, do not pull away as this causes tearing. Push towards the patient and hold their nose closed. Eventually they will open their mouth. If a weapon is displayed, try not to display fright but comply with demands. Avoid argument, despair, crying or whining. Never run or fight unless assured of success and try to establish an emotional human relationship. A hostage taker will seldom murder a hostage if a relationship has been established. Safety Tips for Dealing with Unanticipated Violent Patients Call security when you first become aware of a threat Trust your “gut” reaction if you feel uncomfortable Minimize eye contact and provide increased “body s pace” Make sure both you and the patient are near a door for “escape” Maintain a safe distance (at least 1 arms length) and stay to one side Never run or fight unless assured of success

Tips for Interviewing or Examining a Potentially Violent Patient Security personnel in or just outside the exam room with an open door Have security search and remove weapons from the patient ahead of time Use a room with two doors if possible, one for you, one for the patient Remove all potential weapons from the room ahead of time Remove all potential weapons from yourself ahead of time (tie, scissors etc) Maintain a “body space” or buffer zone 4 times larger than normal Never approach from the rear

Organic versus psychiatric causes of violent behavior As physicians, we will need to make an estimation of whether this behavior is organic or psychiatric. We need to know if the patient can be safely discharged home, or whether they need to be admitted to care for their medical condition or will need psychiatric admission or commitment for their or others’ safety. It is a common error to assume that all violent behavior is psychiatric19. Be especially aware of the patient with abnormal vital signs and remember that no patient should be discharged from the ED without an explanation or understanding of each abnormal vital sign. Clues that the violence may be organic include rapid onset of psychotic, agitated or violent behavior in a patient without a prior history of psychiatric disease. Also be careful of diagnosing patients with psychiatric illness after the age of 40 without a prior history of psychiatric illness. Violence from organic illness can be more severe than that from psychiatric illness and can be sudden without warning signs. Other clues to organicity include confusion or slow mentation, intellectual or cognitive deficits, slurred speech, visual hallucinations and disorientation. Psychiatrically ill patients also present with violent behavior. Paranoid schizophrenia accounts for the largest amount of ED violence by psychiatrically ill patients. Personality disorders are the second largest group. Health care workers often underestimate the potential for violence in bipolar affective disorders. A manic patient may give the staff a false sense of security but may turn quickly on them when demands are made. Clues to the psychiatric diagnosis of agitation include a previous psychiatric history, auditory hallucinations and a logical thought content even if it is bizarre. Usually the patient is alert and oriented with normal vital signs. The patient is rarely over the age of 45 and avoids drugs of abuse. Verbal de-escalation

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If violence appears eminent or actually erupts, there are three methods that may be helpful: verbal de-escalation, physical restraint and chemical, or pharmacologic restraint. Some authors advocate verbal management of the violent patient and believe this is as effective as pharmacologic restraint. They encourage empathizing with the patient’s concerns, even if it involves another staff member. Try to let them know that you are their advocate and on their side. Offer food and drink, which may gain cooperation of agitated patients. Verbal techniques are not effective in florid psychosis, delirium, severe intoxication and agitation and manic episodes. You may even ask the patient if he/she would like to be restrained- sometimes they agree and this helps them feel like they are a part of the decision and helps them gain control of their lives16. If you need to apply physical restraints for safety, don’t offer or bargain20. If they disagree and you have to apply them anyway, this will increase the patient’s distrust of the health care worker. Physical restraints and patient rights Most emergency departments apply physical restraints daily. In Lavoie’s study, 32% of EDs surveyed applied physical restraint daily7. Once the decision is made, do not discuss further and do not negotiate. For legal and ethical purposes, you must clearly state why you are restraining the patient even if you don’t think he/she will hear or understand- a kind of physician’s Miranda rights21. You are, after all, removing the patient’s civil liberty. All orders for physical restraint must also be in writing stating the time restraints were applied and the reasons22. You are now in complete control of the patient’s welfare. Once restraints are applied, any injury or harm to the patient is de facto evidence that you were negligent. The American Psychiatric Association lists several criteria for physical restraints23. These include 1) to prevent harm to the patient or others when less severe means are ineffective or inappropriate, 2) to prevent serious disruption of the treatment program or significant damage to the physical environment, 3) to decrease stimulation the patient receives and 4) at the request of the patient. Remember, never use restraint as a punitive measure or for convenience or for mild obnoxiousness. Patients can be injured or killed in the process of restraint. Ideally, five people, including security officers, are needed to apply restraints properly with the least amount of force; one for each extremity and one for the head. If the patient is a woman, at least one woman should be in attendance. Use 4 point, padded restraints either supine or on the side to prevent aspiration. A Philadelphia collar can be applied to control head banging, spitting and biting. If additional straps are necessary, place them over the pelvis or knees, not the chest as this may interfere with respiratory effort. If a patient is restrained, a health care worker must attend the patient at all times and there should be a q 15 minute check for peripheral perfusion, mobility, posture and mental status. American Psychiatric Association Criteria for Application of Physical Restraints To prevent harm to patient or others when less severe means ineffective To prevent serious disruption of treatment program or significant damage to the physical environment To decrease stimulation the patient receives At the request of the patient

Application of Physical Restraints Security to assist with ideally 4-5 people- one for each extremity, one for head If the patient is a woman, at least one woman to help restrain 4 point padded restraints supine or on the side to prevent aspiration Philadelphia collar, if needed, to prevent head banging or spitting Additional straps, if needed, over pelvis or knees Q 15 minutes checks of perfusion, mobility, posture and mental status

Pharmacologic restraint Pharmacologic (chemical) restraint is considered by many to be more humane than physical restraint. Medications such as opiates, barbiturates, neuroleptics, benzodiazepams and in extreme conditions neuromuscular blockade have been used.23-26 Medications may be given orally, intramuscularly, or intravenously and given in combination depending on the situation and adjusted as needed. No one medication is right for every situation. An oral benzodiazepam may be appropriate for mild to moderate agitation or a patient suffering from cocaine or alcohol withdrawal. Intravenous benzodiazepam or a parental neuroleptic is appropriate in agitation where there is immediate threat to safety. However, more

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extreme measures might be necessary for a multiply injured trauma patient who is combative and whose injuries necessitate the OR. In such a situation, the best solution may be total paralysis using neuromuscular blockade and intubation in the ED in preparation for operative intervention.24-26 This addresses the safety issue for both staff and patient and prepares the patient for anesthesia. The most common drugs used for chemical restraint or rapid tranquilization are the benzodiazepams and the neuroleptics. Diazepam (Valium) or lorazepam (Ativan) are benzodiazepams that are recommended for use in incremental dosing depending on the situation. Diazepam in dosages of 2 to 10 mg or lorazepam in a dosage of 2 to 4 mg may be used initially and titrated up as needed. The main side effects of the benzodiazepams are sedation and respiratory depression. Haloperidol (Haldol) and droperidol (Inapsine) are neuroleptics and may be given alone or in combination with the benzodiazepams. Both haloperidol and droperidol work well in patients with acute psychosis resulting from multiple causes and relieve agitation regardless of etiology.27 Either drug may be considered as a first-line drug with the exception of patients with drug withdrawal or sympathomimetic -induced symptoms, such as cocaine intoxication, where the benzodiazepams are preferred. Haloperidol and droperidol can be given intramuscularly or intravenously. Haloperidol additionally is effective given orally. Response occurs within minutes and patients remain awake and alert. Both drugs are relatively safe with minimal adverse respiratory or hemodynamic effects (e.g., transient hypotension with droperidol) and no lowering of the seizure threshold. Extrapyramidal side effects occur in less than 10% of patients and are more common with haloperidol. Such effects are not dose related and usually occur outside the ED at least 12 hours following administration. Conclusion It is clear that emergency physicians and nurses are exposed to a variety of patients with violent potential. Physicians and nurses are injured every day in emergency departments across the nation and, unfortunately, that will probably continue to be the case. While it is every worker’s right to have a safe workplace, it is also true that we can not deny patients the right to access the health care we provide29. However, we can control that access to make our ED’s safer. Modern ED’s that are properly planned and control patient access through protected entrances, metal detectors, perimeter doors that allow staff to exit but remained locked and secure from the outside, protective plexiglass and 24 hour on site security will help decrease the risk of injury significantly30. Still, the major burden lies with the individual staff members. Training programs aimed at rapid identification and appropriate treatment or restraint of the violent patient must be a priority for each of us who work daily in the emergency departments of our nation.

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Bibliography 1. Pardes H. An Overview of Violence. Resident & Staff Physician 1982:60-70. 2. Allison J. Violence in America: a shameful epidemic. ACEP News 1992:4-5. 3. Smith M, McCabe J . Violence in the ED is a concern across the nation. ACEP News 1993;

May:8-9. 4. Foust D, Rhee KJ. The Incidence of Battery in an Urban Emergency Department. Annals of

Emergency Medicine 1993; 22:583-585. 5. Anderson AA, Ghali AY, Bansil RK. Weapon Carrying Among Patients in a Psychiatric

Emergency Room. Hospital and Community Psychiatry 1989; 40:845-847. 6. Armed patients belie stereotypes. ED Management. Vol. March, 1991:39-40. 7. Lavoie FW, Carter G, Danzl DF, Berg RL. Emergency Department violence in the United States

teaching hospitals. Annals of Emergency Medicine 1988; 17:1227-1233. 8. Pane GA Winiarski A, Salness KA. Aggression directed toward emergency department staff at a

university teaching hospital. Annals of Emergency Medicine 1991; 20:283-286. 9. Ordog GJ, Wasserberger J, Ordog C, Ackroyd G, Atluri, S. Weapon carriage among major trauma

victims in the Emergency Department. Academic Emergency Medicine 1995; 2:109-114. 10. Goetz RR, Bloom JD, Chenell SL, Moorhead JC. Weapons possession by patients in a University

Emergency Department. Annals of Emergency Medicine 1991; 20:8-10. 11. Rice MM, Moore GP. Management of the violent patient: therapeutic and legal considerations.

Emergency Medicine Clinics of North America 1991; 9(1):13-30. 12. Lehmann LS, Padilla M, Clark S, Loucks S. Training Personnel in the Prevention and

Management of Violent Behavior. Hospital and Community Psychiatry 1983; 34:40-43. 13. Rockwell D. Can you spot potential violence in a patient? Hospital Physician 1972; 10:52-56. 14. Reid W. Clinical evaluation of the violent patient. Psychiatric Clinics of North America 1988;

22:527-537. 15. Dubin W. Evaluating and Managing the violent patient. Annals of Emergency Medicine 1981;

10(9):481-484. 16. Young G. The Agitated Patient in the Emergency Department. Emergency Medicine Clinics of

North America 1987; 5:765-781. 17. Perry S. Effective Management of the Violent Patient. ER Reports 1983; 4:31-36. 18. Tardiff K. Management of the Violent Patient in an Emergency Situation. Psychiatric Clinics of

North America 1988; 11:539-549. 19. Tintinalli JE, Peacock FW, Wright MA. Emergency Medical Evaluation of Psychiatric Patients.

Annals of Emergency Medicine 1994; 23(4):859-862. 20. Tupin J. The Violent Patient: A Strategy for Management and Diagnosis. Hospital and

Community Psychiatry 1983; 34:37-40. 21. ACEP. Use of Patient Restraints, 1991.

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22. Lyndon DR, Miller CS. Violent and Suicidal Patients: Special Handling Required. Emergency Medicine Reports- Legal Briefings 1991; 2:9-15.

23. Lavoie F. Consent, involuntary treatment and the use of force in an urban emergency department.

Annals of Emergency Medicine 1992; 21(1):25-31. 24. Dubin WR, Feld JA. Rapid tranquilization of the violent patient. American Journal of Emergency

Medicine 1989; 7(3):313-320. 25. Kuchinski J, Tinkoff G, Rhodes M, Becher JW. Emergency Intubation for paralysis of the

uncooperative trauma patient. Journal of Emergency Medicine 1991; 9:9-12. 26. Rotondo MF, McGonigal M, Schwab CW, Kauder DR, Hanson CW. Urgent Paralysis and

Intubation of Trauma Patients: Is It Safe? The Journal of Trauma 1993; 34:242-246. 27. Redan JA, Livingston DH, Tortella BJ, Rush BF. The Value of Intubating and Paralyzing Patients

with Suspected Head Injury in the Emergency Department. The Journal of Trauma 1991; 31:371-375.

28. Clinton JE, Sterner S, Stelmachers Z, Ruiz E. Haloperidol for sedation of disruptive emergency

patients. Annals of Emergency Medicine 1987; 16(3):319-322. 29. Ordog G. Violence and general security in the emergency department. Academic Emergency

Medicine 1995; 2:151-154. 30. ACEP. Emergency Department Violence: Prevention and Management. Dallas, TX, 1988.

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Wound Management in the Emergency Departme nt


Objectives After reading this chapter, the reader will be able to: 1. Understand the general process of wound healing. 2. Understand the different types of wounds and give examples of each. 3. List factors which affect wound healing and increase the risk of infection or other complication. 4. Be familiar with the different classes of anesthetics and maximum doses of commonly used agents.

Also be able to list instances in which epinephrine is contraindicated. 5. Know the basic instruments, the suture materials and when which kinds are used, where, and for how

long. 6. Understand the basic techniques of suturing including suture placement, spacing, buried knot

techniques, and management of “dog-ears.” 7. Understand issues related to special types of wounds including bites, puncture wounds, and foreign

bodies. Understand the use of prophylactic antibiotics. 8. Know who should receive tetanus immunization and who should receive tetanus immunoglobulin. Introduction Literally millions of traumatic wounds are treated each year in emergency departments in the U.S. Wound management is an area of still ongoing research, much of which supports traditionally performed techniques, but some of which also is still trying to resolve controversial topics. The basic principles of wound care are simple, as long as one keeps in mind what the intent of the care being rendered is. First of all, one must remember that the wound heals itself. If the patient is not mortally wounded, then the wound will heal all by itself. The physician who believes that he made the wound heal is deluding himself and does not understand wound healing. So, what is the big deal and what are the doctors good for if the wound is going to heal no matter what? In essence, the objective is to restore tissue integrity, and function, while avoiding infection and morbidity, and minimizing scarring. To achieve this outcome, a thorough understanding of wounds is necessary. Wound Healing Critical to the management of wounds is a good understanding of how tissue heals. While the process is a continuum of overlapping steps, it is generally divided into several convenient phases.

Injury - While not technically part of the healing process, this is the moment that initiates the healing process.

Infla mmatory - Vascular - transient vasoconstriction lasting 5-10 minutes.

Cellular - leukocytes “stick to damaged vessel walls and migrate into surrounding tissue and begin phagocytosis of wound debris.

Fibroblastic - fibroblasts migrate into the wound at 48 to 72 hours. Also, local undifferentiated mesenchymal cells are transformed into fibroblasts. Presence of too much fibrin in the wound will hinder their influx. Neovascular / endothelial budding and capillary formation follows the influx of fibroblasts. This phase may last 2-4 weeks depending on the amount of necrosis, infection, and hematoma.

Contraction - starts in 3-4 days. It is due to the presence and action of myofibroblasts which reside in the granulation tissue.

Collagen Synthesis - deposition begins by day 4 and increases until week 2 to 3. Not surprisingly, the wound has its greatest bulk at 2-3 weeks. It is

this component which gives the healing wound its gradually increasing tensile strength.

Remodelling Phase - crosslinking and re modeling of the collagen fibers continues

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for the rest of the patient’s life. It will occur quickly early on and later slow down. Patients should generally be instructed that the wound appearance 6 months to 1 year from the time of the injury will be fairly representative of the final outcome.

Table 1. % Wound Tensile Strength vs. Time

As can be seen in Table 1, a wound only has approximately 10-15 % of its original tensile strength at the time of usual suture removal (typically 7-14 days. See also Table 7.) You may recall that at 21 days post-op, surgeons typically remove abdominal “retention sutures.” While the greatest bulk of collagen in the wound is present at this time, there is still only 30 % of the original tissue strength. A number of factors may impair the normal rate of wound healing. They are typically grouped and classified as shown in Table 2.: Table 2. Factors Altering Wound Healing Technical Factors Inadequate wound preparation Excessive suture tension Reactive suture materials Local anesthetics Anatomic Factors Static skin tension Oily skin Dynamic skin tension Body region Pigmented skin Associated Conditions and Diseases Advanced age Severe alcoholism

Acute uremia Diabetes Ehlors-Danlos syndrome Hypoxia Severe anemia Peripheral vascular disease Malnutrition Drugs Corticosteroids NSAID’s Penicillamine Colchicine Anticoagulants Anti-neoplastic agents

0102030405060708090

100

0 3 10 15 19 22 27 40 60 100

200

1 yea

r

Days Post Injury

% W

ou

nd

Ten

sile

Str

eng

th

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Types of Wounds Lacerations may be classified by the type of mechanis m through which they are produced. Shear injuries are violations of tissue by a sharp object which causes very localized tissue damage but no injury to surrounding cells. Examples include a surgical incision, a laceration from a piece of glass, or a stab wound. Tension lacerations are produced by blunt mechanisms, generally with a tangential force component. The result is tissue tearing with ragged edges and contusion of adjacent tissues. Examples are lacerations from colliding with asphalt at high speeds, wounds from oblique blows with a baseball bat, and some types of industrial accidents. Crush or compression lacerations occur when skin is injured between an object and underlying bone. These lacerations may have a stellate appearance and are associated with a considerable amount of local tissue trauma. Resultantly, infection rates are higher and poor cosmetic outcomes are common. Examples of this type of wound include bottle and club blows to the scalp or extremities, and children with eyebrow lacerations due to falling against the coffee table. Finally, combinations of any of these mechanisms are possible. Abrasions and burns are two other kinds of wounds. Their classification is based upon the depth of tissue destruction. First degree involves damage only to the epidermis. It is characterized by the presence of erythema and pain of otherwise intact skin. If there is any dermal involvement , as evidenced by blistering or bleeding or exposed dermis, the wound becomes classified as a second degree wound. Sensation is still intact and the tissue will heal by re-epithelializing from the deeper dermal elements (hair follicles and sweat glands). Small blisters should be left alone as long as they are completely intact as they are natural sterile dressings. Very large blisters which will probably rupture shortly anyway may be opened and treated with silver sulfadiazine (Silvadene™) cream (not on face) or combination polymyxin, bacitracin, neomycin (Neosporin™) ointment. If sensation is lost and the wound has a leathery or waxy appearance and the deeper dermal elements are destroyed, the wound is classified as third degree. These will need to heal by formation of granulation tissue and in-growth of epithelial tissue, or if larger than a few centimeters, may require skin grafting. Fourth degree wounds involve underlying muscle, bone, or tendon. Anesthetics Nearly all wounds will be associated with some degree of pain (exceptions are 3rd and 4th degree burns and patients with diabetic neuropathy). Pain control must be addressed at some point during a patient’s visit. Frequently, some type of analgesia will be required even to adequately assess a wound. This may be in the form of systemic medication (PO, IM, or IV), regional anesthesia (nerve block), or local administration of some agent (topical or injected). The power of “verbal anesthesia” should not be underestimated and cannot be stressed enough as it may make a significant difference in the management of a patient (e.g. local anesthesia versus conscious sedation in a child). Agents Anesthetic agents are typically divided into 2 groups based on their molecular structure: amides and esters. The primary reason for the importance of this classification is the rare case of allergy to an agent. Patients allergic to an agent are likely to be allergic to other drugs in the same class. Therefore, an agent in the other class should be selected. It is felt that true allergy to amides (lidocaine and bupivacaine) is rare and is most often actually due to the preservative methylparaben in the the multidose vials; the preservative is an ester). Cardiac lidocaine does not contain the preservative and may be given initially as an intradermal test dose to check for true allergy. Another, unrelated medication which has been used by some is diphenhydramine (Benadryl™). It is suggested that a 0.5 –1.0% concentration can be used without risk of allergy. However, the drug is not approved for this use and the 2000 PDR still specifically lists its use as a local anesthetic as a contraindication because of the risk of local tissue necrosis.

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Table 3. Commonly Used Local Anesthetic Agents Medication e.g. Trade Name Duration Dose Esters

procaine Novocaine 1 hour 10-15 mg/kg 500-600 mg max.

tetracaine Pontocaine 30-60 min. Topical, eyes, 30 mg max cocaine 1 hour Topical, 150-200 mg max Amides lidocaine Xylocaine 1-2 hours 4.5 mg/kg mepivacaine Carbocaine 1-3 hours 5-7 mg/kg, 400 mg max bupivacaine Marcaine, Sensorcaine 6-8 hours 3 mg/kg, 175 mg max Other diphenhydramine Benadryl 30-45 min.? See above contraindication A useful quick trick to remember if an agent is an amide or an ester is to count the number of “i’s” in the generic (not the brand) name. If there is only one, the agent is an ester; if there are 2 “i’s”, the drug is an amide. The pneumonic is right most of the time but as always, if you are unsure, look it up! Epinephrine is frequently used in conjunction with a local anesthetic. Its use may be for a number of reasons, but they are all related to its vasoconstrictive properties. First, it will control oozing of blood in the wound, allowing for better inspection of the wound and less hematoma formation. This is particularly useful on very vascular areas such as the scalp. Secondly, with the localized vasoconstriction, the local anesthetic is not washed out of the area as quickly, hence longer anesthesia time. Finally, because there is slower absorption into the systemic circulation, higher doses of anesthetic may be used in the patient. For example: instead of 3-5 mg/kg of plain lidocaine, 5-7 mg/kg of lidocaine with epinephrine may be used. Instead of 1-2 hours of effect, 2-3 hours of anesthesia may be achieved. There are several times when use of epinephrine is relatively, or even absolutely, contraindicated. Use of epinephrine should be avoided in any tissue which appears to have already significantly compromised blood flow. Additionally, it must not be used in any structure with a single or terminal blood supply: fingers, toes, tip of the nose, ear block, or penis. There are several reports of thumb necrosis secondary to accidental discharge of an Epi-Pen™ into the thumb. It injects automatically when pushed against a surface, normally the thigh, and is used in case of an anaphylactic reaction. Nearly all patients complain of pain from the anesthetic agent as it is being injected. This is due to at least two factors. The first is the rate of injection. Rapid tissue distention causes pain and may be avoided by injecting slowly. Taking a bit more time here may add 1-2 minutes to the procedure, but may decrease time spent having to calm and reassure an otherwise frightened patient afterward, significantly. The second factor is due to the pH of the anesthetic agent. Lidocaine is stored in an acidic solution in which it is stabile. Buffering lidocaine with bicarbonate evens out the pH difference and makes the solution better tolerated. Unfortunately it cannot be stored for long periods of time as it breaks down. Buffered lidocaine is mixed 9cc of lidocaine with 1 cc sodium bicarbonate for a volume of 10 cc (Incidentally, bupivacaine cannot be buffered the same way). Finally, anyone administering medications of any kind should be aware of common potential side effects of these medications. Side effects encountered from local anesthetic agents are typically dose related and include the following in gradually increasing doses:

CNS: restlessness, circumoral paresthesias, tinnitus, tremors, shivering, drowsiness, lassitude, amnesia, and seizures

Cardiovascular: bradycardia, decreased blood pressure, and heart block Local Anesthesia Prior to injecting any agent, an assessment of the injured area must be performed. This includes assessment of distal motor, sensory and vascular function and integrity. Any dysfunction should be recognized and documented before proceeding with injection of anesthetic agents. Sensory exam of the

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hand is particularly important to perform carefully, including checking two-point discrimination. This can easily and quickly be checked with a bent paper clip. Finally an inspection of the wound should be performed, as well as the patient can easily tolerate, to assess the severity the wound and see how the wound should best be managed and determine exactly what type of anesthesia is required. Injection of local anesthetic agents should be performed with a 25, 27, or even a 30 gauge needle if available to minimize discomfort. Anecdotally, I have also found that children do better not seeing the syringe or needle before starting. So rather than loading and squirting a syringe like in the movies at the beside, I draw up the medication in another room and keep the syringe in my shirt pocket until the last possible moment and even then out of view. The injection should be made through the exposed wound edge; usually no pain is experienced as the needle is inserted and there is no increase in risk of infection. Going through the adjacent intact skin, however, causes extra pain and damages intact skin and should be condemned. Again, anecdotally, I warn my patients that the injection of the agent (and not the needle) will sting for about 5 seconds. I have children count slowly to five before I start and each time I slowly inject. Anxious patients seem to calm down better with this activity to keep them occupied, as well as with the assurance that I am not deceiving them and that there is an endpoint to their pain. Even though nothing works every time, I highly recommend trying the technique. Typically, the anesthetic agent is deposited into the dermis around the edges of the wound so that the wound may be sutured painlessly. In areas where this will cause too much tissue distortion, particularly areas where cosmetic outcome is important, or the area is too great to infiltrate locally, a regional block or nerve block may be required. Most commonly performed blocks in the ED are fingers, hands, feet, mouth, and face. Digital Block The most commonly performed nerve block performed in the ED is the digital or ring block. It consists of depositing anesthetic agent around each of the four nerves in a finger or toe. Even though the palmar nerves supply most of the enervation to the digit, crossover from the dorsal nerve branches requires that they be block too. The technique begins with raising a wheal, dorsally over either side of the bone, somewhere distal to the metacarpal (metatarsal) phalangeal joint and proximal to the distal end of the web space. The needle is then directed perpendicular to the skin toward the dorsal nerve branch. Approximately 0.5 cc of agent (NO EPINEPHRINE) is injected here. The needle is advanced further to the level of the volar nerve and another 0.5 cc of anesthetic is deposited. The needle is then withdrawn. The needle is then reintroduced through the same wheal, this time tangentially as advanced to the opposite side and another wheal is placed here (this decreases the discomfort of sticking the needle through an unanesthetized site on the other side). The needle is then withdrawn; agent may also be injected across the top of the digit as the needle is being withdrawn. The needle is then reinserted through the new wheal and the procedure repeated. Wait approximately 5 minutes and test distal sensation before proceeding with the laceration repair. Occasionally the digit will require injection of additional medication (See Diagram 1). Diagram 1. Digital Nerve Block Technique

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Topical Anesthesia Another method of analgesia involves application of a topical agent. It most often used in children and may induce sufficient anesthesia by itself or ameliorate the pain of subsequent injection of additional medication. This topical agent is often referred to as LAC, or LEC [lidocaine 4%, adrenaline (epinephrine) 0.5-1%, and cocaine 4-11.8%], or TAC (tetracaine 0.5%, adrenaline 0.5-1%, and cocaine 4-11.8%). Typically 10cc of medication are used. A small amount of cotton is soaked with a portion of the agent and is gently stuffed into the wound so the cotton has very good contact with the wound edges (do not simply lay the cotton on the wound-it won’t work) and leave in place for 10 minutes. Then reapply for 10 more minutes. The result should be a wound with no oozing and an area of blanching around the edge and good anesthesia for about 20-30 minutes. Best results are achieved on relatively thin skin. There are rare reports of seizures and death secondary to topical anesthetic use felt to be related to use on, or close to, mucosal surfaces with more rapid systemic absorption. Skin and Wound Preparation As noted before, a wound must be thoroughly assessed. A preliminary inspection will give you an idea of what kinds of injuries you may expect to find. When bleeding is present, it is best controlled by direct pressure. This means using one or two fingers if possible, as opposed to dumping a box of 4x4 gauze over the area and applying an ACE elastic bandage around the limb. The latter usually doesn’t work because the pressure is too spread out to compress the damaged vessels adequately. This is a common mistake. Focal pressure for ten minutes will generally control most bleeding. Clamps should never be blindly placed into the wound. Remember that nerves run alongside vascular structures. They are very likely to be injured with clamps. Tourniquets provide another option but must be used with discretion and only for very short periods of time. They are rarely needed for life threatening hemorrhage, but they are frequently used to achieve a bloodless field. You can’t see what is going on under a constant re-accumulating pool of blood, therefore, proximal control of blood inflow to the wound is an invaluable tool. Blood pressure cuffs make good tourniquets so that this bloodless field can be achieved and the wound may be adequately assessed. The extremity should be lifted to passively drain some of the venous blood as well as create a small arterial pressure gradient. Additionally, an elastic bandage may be wrapped around the extremity to mechanically force blood out of the extremity. The blood pressure cuff is then inflated above the level of the patient’s systolic blood pressure ( 20-30 mm Hg above is frequently adequate. Some authors advocate inflating to 300 mm Hg), the bandage removed, and the extremity lowered. The cuff will be painful, so work should proceed quickly and efficiently. The cuff should not be left inflated for longer than 15 minutes, not because of tissue necrosis, but because of pain from the cuff. The procedure may be repeated if necessary. All wounds (excepted those created in the operating room) are contaminated with debris and bacteria to some degree. To decrease the risk of infection, all wounds should be cleaned. This may be achieved in several manners, but before proceeding, the wound should be adequately anesthetized. Hair removal is generally the first consideration. Unless hair strands are continuously in the way and/or at risk for being sutured into the wound, they may be left in place. Sometimes, removal of a tiny strip of hair may be necessary. Often, hair may be wet and teased down on either side of the wound to get it out of the way. Scissors are probably the best method for removing hair (it has been shown that shaving shin on the day prior to surgery actually causes additional skin nicks and increases the incidence of wound infection. Whether or not this extrapolates to the ED setting in unknown.) Never shave eyebrows! They are reported to have a tendency to grow back erratically resulting in poor cosmetic outcome. The next step is some method to dilute the bacterial load as well as clean out debris. This is best accomplished with irrigation of the wound. This may easily be accomplished using normal saline, a 30 cc syringe, and an 18 gauge catheter. The syringe is loaded and squirted at full force each time from about 3 mm distance. This provides maximal irrigation and “pressure washing” (at about 25 psi.) without causing tissue damage. This is repeated so that a wound is irrigated with roughly 50 - 100 cc for every cm in wound length (a good surgical adage to remember: “dilution is the solution to pollution”). It is a good idea to wear a face shield (or at least eye protection) and a water resistant gown as there will be a significant amount of back spray and you will otherwise get wet and possibly be exposed to HIV and

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hepatitis B. There are some neat devices to assist in the irrigation process: Zerowets are small dome shaped devices attached directly to the end of the syringe and have a built-in nozzle so that the back spray is contained. Another device is a self-reloading syringe, which connects to an IV solution bag. After you draw-up, spray with full force, and irrigate with 1000 cc of saline, you will find your hand to be quite tired and/or sore. Remember that these are niceties, not necessities, and they do add to the patient’s bill. It is a good idea to try to catch the irrigation fluid rather then letting the patient lie in it or have it run all over the floor. Aside from being messy, you will have created a dangerous work area for your self (your nurses will like you better too). A kick bucket under the main drip area and some towels on the floor will work nicely. After you have irrigated a wound thoroughly, especially a particularly dirty wound with skin flaps, close inspection may reveal more dirt ground into the tissue. This may require patiently sitting there and picking out each piece. Selection of a wound cleanser must be considered next. The following table lists commonly used agents, their pros and undesirable side effects. Table 4. Commonly Used Wound Cleaning Agents Product/ Agent Benefits Side effects/ Precautions Water Inexpensive,

Universal solvent Hypotonic, will cause cell swelling and lysis

Saline Iso-osmotic to tissue, no tissue toxicity

No germicidal activity

Hydrogen Peroxide Good germicidal activity Good mechanical debridement of wound via effervescent activity

Very tissue toxic

Povidine-Iodine Betadine™ solution

Betadine™ scrub

Excellent germicidal activity May be used around eyes and in mouth safely

Solution (green label) is very tissue toxic in stock solution (10%). When diluted to 0.001% (essentially clear with faint hint of brown color, it is still germicidal but not tissue toxic. Scrub (yellow label) is an external skin detergent and should never be used in a wound

Phisohex™ Good germicidal effects Once used commonly, then relegated to hand cleaner.

Associated with kernicterus in infants. Product is rarely seen anymore

Chlorhexidine Hibiclens™

Excellent germicidal activity Tissue toxic. Keep out of eyes, ears and mouth

Alcohol One of the best bactericidal and viricidal agents

One of the most tissue toxic agents

Sure Clens™ Nonionic polymer which is essentially painless in wound. No tissue toxicity. Has detergent qualities which help to float debris out of the wound.

No germicidal activity

As can be seen in the table, each product has its own unique qualities and applications. A thorough familiarity with each agent is highly recommended. Instruments and Materials Before beginning with the wound repair, is important to have all the necessary supplies assembled at the bedside.

• This begins with barriers: Face shield, water-repellant gown, sterile gloves, and sterile drapes. • A syringe and additional anesthetic agent is often useful as well • A good bright overhead light source, positioned so that your head will not immediately be in

the way.

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• A stool to sit on or the stretcher raised to a comfortable height when you stand. This point should not be underestimated. One’s back quickly gets tired hunched over even for short periods of time.

• Gauze sponges • Instruments are typically already pre-packed into a tray. They include towel (not skin)

clamps, skin hooks, smooth and toothed pickups, straight and curved hemostats, a scalpel, a needle driver (holder), suture scissors, and medicine cups (shot glasses) for anesthetic and antiseptic solutions, and a small basin for saline. They also have a supply of gauze sponges and several sterile towels. Fine suture or “plastics” trays will typically have more and finer instruments, but are over-kill for most minor laceration repairs.

Here are a few additional tips on each of the major instruments:

Towels - Are useful to keep hair down and out of the way. I can not recommend covering a patients eyes and nose routinely when closing facial lacerations. It makes patients very claustrophobic as well as uncomfortable. Drapes often make you forget about your patient under them while you are focused on the wound. While it is OK and encouraged to stabilize your hand against the patient, don’t lean on the drapes (and hence your patient).

Towel clips - These may be useful in securing the towels which have positioned around the wound. Do not clamp them into the skin as you may have seen done in the OR on patients under general anesthesia (Incidentally, some patients complain of more pain from the towel clamp site than the main wound).

Pick-ups (forceps) - These come in smooth and toothed. The smooth should be used only very gently as they will crush tissue. They are generally used for vascular and bowel handling. For skin, the toothed forceps should be used. Hemostat - Very useful for grasping and clamping well visualized bleeding vessels until they can be ligated. They are often used for loading and unloading a scalpel handle with a blade or removing a needle from a syringe. They are of course self retaining.

Needle driver - Shaped much like a hemostat, this instrument has a sturdier, wider jaw with or with out teeth. The smooth jaw is usually on small drivers for holding small needles without allowing the needle to spin. Larger drivers for larger needles have finely serrated ridges. Additionally, a needle driver’s jaws come together flat, while a hemostat comes together at the point first and then gradually closes in the center with increased pressure on the handle. This is why suture slips out of the hemostat and not the needle holder when instrument tying.

Skin hooks - They are sharp and dangerous. Often you will need an assistant to hold these while you use other instruments to explore or repair the wound.

Scalpel - Occasionally wound edges are jagged or already showing signs of necrosis and must be trimmed. The scalpel will make a straight cut with minimal adjacent trauma.

Suture Scissors - These are for cutting suture. Cutting tissue with these will cause adjacent crush injury.

• Suture material is the final component (see next section)

Suture Materials By now the decision has been made that active intervention will be required, but there are still many choices to make. This begins with deciding whether or not to use Dermabond™ (glue), Steri-stips™ (butterflies), thread (suture), or staples. Dermabond™ is a rapidly drying glue which may be applied topically (NOT into the wound) to hold he skin edges together. It can be used for small lacerations which are relatively superficial and where the skin edges have no tension pulling them apart. Application typically requires two people: one to hold the edges

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together, the other to apply the glue. Caution must be used not to glue the assistant to the wound. The glue dries in 15-30 seconds, depending on how thick it is applied. Steri strips™ are simply tapes applied to hold the skin edges together. Like the skin glue they have no use for deep wound closure alone. They will not work if there is much tension across the suture line. They may not work in some children who may play with them and pull them off prematurely. They are painless to apply, however, which makes them very appealing. Additional adhesion may be obtained by applying tincture of benzoin to the skin edges (it will cause pain if inadvertently introduced into the wound). Staples are available in pre-sealed staple guns which apply the staple. They are quick to apply, sometimes requiring little or no local anesthetic (since the anesthetic agent hurts too, you can give the patient the option). For good placement, the skin edges need to be held symmetrically with the edges everted somewhat. This implies that you should have an assistant. The cosmetic result is not as good as with sutures, hence their use is limited to the scalp, back and extremities. Sutures come in many varieties. The suture material may be swaged onto the needle (stuffed and crushed into the hollow end of the needle), or be threaded into an eyed needle. The former is typically used. Needles are also classified by the type of point they have. When the tip is viewed in cross section, it may appear round indicating a tapered needle (it basically has a cone shape). It may appear triangular or diamond shaped in cross section indicating it is a cutting needle (the tip is basically a 3 or 4 sided pyramid shape). The edges actually will cut slightly into the tissue making it easier for the needle to pass. The taper needle simple pushes tissue aside and gradually distracts it until the hole is large enough for the needle to pass through. The packaging will indicate with a small symbol which type of needle it contains. Diagram 2. Needle Tip Classification

Taper needles have little role in the ED. They are principally used for bowel and vascular repairs. Cutters, however, are great for fascia, and skin. If you are having trouble pushing a needle through tissue or bending a needle you might check and make sure you didn’t accidentally pick up a tapered needle. There are also other types of specialty honed points available for special uses beyond the scope of this discussion. Next, there are straight and curved needles. Straight needles are most often found in kits for placing vascular accesses such as central venous line kits. These are long enough that they may be used without a needle driver. They come with cutting tips. Curved needles are available indifferent varieties based on how large an arc they make. They may be ¼ circle, 3/8 circle, ½ circle, or 5/8 circle. The thickness of each needle will be determined by the size thread to be used. Suture material comes in different sizes, with the ones used most commonly in the ED ranging from 0 to 6-0 (Sizes actually range from #5 to 10-0). Table 5. Typical uses for Different Size Suture Materials #2-#5 bone and tendon repair String size #0-#1 heavy fascia repair and securing vascular access lines #00 to4-0 standard for area under moderate to minimal tension 3-0 and 4-0 most commonly used 5-0 to 7-0 hands, face, abdominal vascular anastomoses Hair size 8-0 to 10-0 microvascular and eye repairs Microscopic

Taperpoint

Cuttingpoints

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Finally the type of suture material must be decided upon. Here again there are several considerations. The first is to decide on an absorbable or non-absorbable suture. Absorbable suture will be used on mucous membranes and subcutaneous tissue while non-absorbable suture is used on skin and sometimes fascia. Next one must decide on the specific type of material to use. In Table 6., you will see an extensive list of available suture materials (purely as a reference and not to be memorized). Choice will depend upon how long support from the suture material is desired, how reactive it is, whether or not it is braided, or if infection is present. Table 6. Types of Suture and Examples Absorbable

1. Catgut (nowadays made fro m cow or sheep tendon) a. Plain- very reactive and dissolves in about 1 week b. Chromic- chromic acid treatment renders it less reactive.

It lasts about 2-3 weeks 2. Polyglycolic acid- Dexon (lasts about 4 weeks)

Maxon (lasts about 6 months) 3. Polyglactic acid- Vycril (lasts about 4 weeks) 4. Poly dioxanone- PDS

Non-absorbable 1. Silk-fairly reactive, frequently gets “spit” out of wound.

Now most commonly used to secure lines and tubes. 2. Cotton 3. Polyester- Dacron, Dermalene, Merselene, Teflon(Tevdek), Silicone (tri-cron), and

Polybutilate (Ethibond) 4. Nylon- Dermalon, Surgilon, and Ethilon 5. Polyprophylene- Prolene and Surgilene 6. Stainless Steel (yes, it comes on a needle and is sewn. It is not used much, but

occasionally you may see it on a patient’s x-ray.) 7. Staples 8. Skin tape

Some of the sutures are braided and some are not. Braided suture tends to handle easier and is stronger, but it has a larger surface area and has a higher infection rate than monofilament suture. Basic Suture Techniques Wound closure may be undertaken by primary, secondary, or tertiary intent. Primary closure is a repair immediately after the injury. Secondary intent refers to allowing the wound to scar and heal in by itself. Tertiary closure is a delayed closure undertaken on dirty wounds in which the chance of infection is unacceptably high. Therefore, the wound is packed open with frequent dressing changes to clean the wound and allow for a rich vascular bed to grow in over the next 4 or 5 days, after which the patient is brought back and the wound is closed then. The infection rate with tertiary closure is essentially 0% as opposed to approximately 5% with primary closure. Rather than reviewing the step by step methods for placing a stitch and how to tie a knot, which you can review in any basic suturing manual, some pointers to make your work easier and outcome better are listed below. • Evert wound edges. Inverted edges will leave an eventual dimple, which will cast a large shadow in

tangential light. This is a very undesirable cosmetic result. To achieve evertion, the “bite” with the needle should be deeper than wide. See Diagram 3. below. Note that that path of the suture is slightly pear shaped. Shallow “bites” will invert the edges.

• Sutures should enter the skin at a right angle to the skin. • Follow the curve of the needle (twist your wrist). • Grasp the edge of the wound your are presently passing the suture through with forceps to stabilize the

tissue. • Make sure the suture is the same depth on both sides

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Diagram 3. Suture Placement to Optimize Wound Edge Evertion

• Don’t be greedy. Take each side at a time instead of trying to pass the suture through both sides in one

bite. • Sutures should be place close enough and tight enough to simply approximate the wound edges. Use

only as many sutures as needed to achieve this result. • The pattern formed by successive sutures should roughly be a square; i.e. if the sutures are 3 mm back

from the edge on each side, then the sutures should be placed approximately 6 mm apart from each other.

• Be gentle with the tissue. • Don’t stand in front of your light. • Don’t be afraid to remove one or several sutures if the wound is not coming together like you want.

And if your patient asks why you removed a stitch, “Because I didn’t like the way it looked,” is a perfectly good response. Your patient wants the wound to look good too.

• Remove “airknots.” They obviously aren’t holding anything and only promote more scarring. • Use “surgeon’s” knots instead of “granny’s.” Lay each hitch down flat. • Deep sutures or buried sutures should be absorbable with the knot placed at the bottom of the wound

instead of at the top. Otherwise the knot and the reaction around it may be palpable through the skin. This is done by starting the stitch placement on one side at the bottom of the wound and coming up through the skin on that side. Next, the needle is passed into the skin on the other side and comes out of the bottom of the wound on that side; then a knot is tied.

“Dogears” are another problem which bears mentioning. They occur when the edge of one side of a wound is longer than the other side. As the wound is closed, a pucker emerges on one side. This is easily corrected by extending the laceration at a 45 B angle toward the side of the tissue buckle (See Diagram 6.). Then the newly created flap of tissue (A) is lain flat on top of the other skin and the excess flap is trimmed away. Then the laceration is closed as usual. The final result is a hockey stick shaped wound.

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Diagram 4. Management of “Dogear”

Dressings and Splints and Care After the wound is repaired, the area should be thoroughly cleaned of blood and skin prep agents. A topical anti bacterial ointment may be applied. Next a non-adherent dressing may be applied (e.g. Adaptic™ or Xeroform™) or simply a light gauze dressing. If some wound compression is required to inhibit additional hematoma formation, a bulky dressing may be used. Sometimes there is concern that the sutures may be ripped out by flexion of an extremity. Splints may be required to limit activity until the wound is in a more advanced stage of healing. The epithelial layer of skin is usual closed within 48 hours. Some surgeons will say the wound is water repellant in 6-8 hours already. Patients should be instructed to keep the wound clean and free of eschar at home. This may be achieved with ½ strength peroxide or soap and water. Soaking of the wound for any prolonged period is to be discouraged strongly, while running water over the wound briefly during a shower is fine. Wound checks in 48 hours are generally recommended. Additionally the patient should be instructed of signs of infection to look for: calor, rubor, tumor, and dolor (heat, redness, swelling, and pain). Remember that patients will need the issue of pain control addressed. Minor wounds will require little more than acetaminophen or ibuprofen. Burns are likely to require narcotics. Suture Removal Suture removal is dictated by several factors. The first is the usual rate of wound healing (see Table 1.). Next is the amount of tension across the wound. If the wound is on a extensor surface across a joint line then flexion of the extremity may place a large amount of tension across the suture line and cause in to rupture if the sutures are removed too early. General guidelines are listed below (see Table 7). Sutures left in too long will leave scars in and of themselves. Epithelial “tubes” form around the suture from epithelial cells, which have migrated along the material. They can become permanent. Suture removal does not always require a “suture removal set” which typically contains a sterile pick-up and scissors and a piece of gauze. The set adds considerable expense and the same result can usually be achieved with a pointed scalpel (11 blade).

45 degrees

Cut here

A

A

1

2

3

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Table 7. Guidelines for Suture Removal

Site Days Until Removal

Scalp 6-7 Face 4-5 Trunk 7-10 Arm 7-10 Leg 8-10 Joint 8-14 Hand 7-12 Foot 7-12

Tetanus Prophyllaxis The following table concisely lists factors which delineate what constitutes a tetanus prone wound, what the time lines are for the duration of effectiveness of a tetanus booster injection, and who should receive a booster, immunoglobulin, or nothing at all. Table 8. Anti Tetanus Prophylaxis, Wound Classification, Immunization Wound Classification Immunization Schedule Clinical Features

Tetanus Prone Non-Tetanus Prone

History of Tetanus Immunizations

Tetanus Prone Wound

Non-Tetanus Prone Wound

Age of Wound > 4 hours #4 hours Td1,2 TIG Td TIG Configuration Stellate,

avulsion Linear Unknown or <3

doses Yes Yes Yes No

Depth >1 cm #1 cm 3 or more doses No3 No No4 No Mechanism of Injury

Missile, crush, burn, frostbite

Sharp surfaces (glass, knife)

Devitalized Tissue

Present Absent

Contaminants (dirt, saliva, etc.)

Present Absent

1

2

3

4

Td-Tetanus and diphtheria toxoids adsorbed (Adult). TIG-Tetanus ImmuneGlogilin Yes if wound >24 hours old. For children <7 yo, DPT (DT if pertussius vaccine contrindicated). For persons > 7 yo, Td preferred to tetanus toxoid alone. Yes if > 5 years since last booster. Yes if > 10 years since last booster.

Bites, Puncture Wounds, and Foreign Bodies Animal bites are unfortunately frequently seen in the ED. They are by definition contaminated wounds. Cat, dog, and human bites are the most common causes and each has some unique characteristics. Cat bites tend to be puncture wounds. Puncture wounds are nearly impossible to irrigate to the bottom of the wound. As a result, if closed primarily they have a high rate of infection. The most common organisms are the Gram + skin pathogens, Staph and Strep. But special organism carried by cats and occasionally dogs is Pasturella multocida. This bacteria is very sensitive to penicillin. Dog bites on the other hand tend to be lacerations rather than puncture wounds. These can more readily be thoroughly cleaned and repaired primarily. The other bite is a human bite. Its classic presentation is that of an individual with a laceration over a metacarpal-phalangeal joint, sustained in a fight in which the skin was broken on a tooth. These wounds are at risk for joint penetration and contamination with Eikenella corrodens. This too is susceptible to penicillin but with joint involvement will require operative debridement if infection develops. One final consideration related to animal bites is consideration of the possibility of transmission of rabies. This is particularly important in bites involving skunks, raccoons, bats, foxes, cattle, and dogs. Rodents, rabbits, hares, chipmunks, rats, and mice are not carriers.

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Puncture wounds to the foot present another common problem seen in the ED. The classic story is that of stepping on a nail which penetrated the shoe or boot and skin. As a puncture wound, it can not be thoroughly cleaned. It is generally recommend to excise a small plug of tissue and irrigate the wound. Osteomyelitis is a concern and Pseudomonas is an offending organism which is sensitive to ciprofloxacin. Effectiveness of this therapy is controversial. Foreign bodies may present interesting and unusual dilemmas. They may include wood splinters, glass, metal (needles, bullets, BB’s), pencil leads, etc. Some foreign bodies may be left in place as long as there is little risk associated with their particular location. Metal can of course be seen on x-ray. Most glass can be seen. Wood is very difficult to visualize on x-ray but must be removed. Fishhooks can present a challenge because of their barb, however, there are multiple techniques described for removing them. It easy to spend a large amount of time trying to find a small foreign body in a small wound and it is frequently unsuccessful. Fluoroscopy may be helpful. Prophylactic Antibiotics This is an extremely controversial topic. It is known that patients who have therapeutic tissue levels of an antibiotic at the time of injury (surgery) have a decreased incidence of wound infection. Obviously this is not an option for patients presenting to the ED with a wound. Some experiments have suggested that there may be some protective effect if the antibiotics are started within 3 hours from onset of the wound. Few physician will argue with use of prophylactic antibiotics in an infection prone wound – crush, dirty, bites, deep and complex wounds or in an immunocompromised host. It is generally agreed that tissue has usually regained its immune state within 4 days, hence prophylactic antibiotics may be discontinued by day four. Conclusion Keep in mind that no matter how good you may perceive the final result, if you didn’t remind or teach the patient that THERE WILL BE A SCAR, no matter who does the repair or how, you may have an unhappy patient. Many patients have the misconception that placing stitches prevents scar formation. It behooves you to dispel this myth early. Adhering to all of the concepts described in this chapter will optimize your chance of a favorable outcome. When the functional and cosmetic out come is excellent, both you and the patient will be very satisfied. And that, after all, is what medicine is all about.

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ACLS Algorithms

From American Heart Association Advanced Cardiac Life Support Manual 2001.

Comprehensive Emergency Cardiovascular Care Algorithm

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Using Automatic External Defibrillator

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Treatment Algorithm for Emergency Cardiovascular Care Pending Arrival of Emergency Medical Personnel

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Electrical Cardioversion Algorithm

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Ventricular Fibrillation and Pulseless Ventricular Tachycardia Algorithm

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Asystole Algorithm

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Ischemic Chest Pain Algorithm

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Bradycardia Algorithm

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Unstable Tachycardia Electrical Cardioversion

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Tachycardia Algorithm

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Stroke Algorithm

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Epilogue

The material contained in the manual thus far has been written purely with the scope of this course in mind. The course is unique as a required 4th year student rotation. You have learned much about medicine during your 3-4 years in medical school and during this month in the emergency department, have had a chance to apply some of most everything you have learned from previous clerkships. Unfortunately, there is little time to learn about much else or to prepare for the future. In a very short time you will be graduating from medical school and pursuing different walks and specialties of medicine. Our very best wishes go with you as you strive toward your next endeavors. In parting, we wish to leave you with the following gift. It was the graduation speech given by the residency director, Dr. Walter “Ted” Kuhn in 1997. While it is addressed to the graduating class of residents, it contains information which you can never think about too soon. It may also be the only time during your medical career that you will be presented with the information. It has since been published: An Open Letter to Young Physicians, Emergency Medicine, Oct. 1998, p.100.

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Letter To Graduating Residents From The Heart Of The Residency Director-

Everything I Wanted To Tell You But Didn’t Have Time

W. (Ted) Kuhn, M.D.

Program Director

MCG Emergency Medicine Residency

1997

Shortly, you will be leaving the residency to begin a new life. It is a right of passage and a culmination of many years of hard work. You are to be commended on your diligence and perseverance. This will finally be the end of your formal training which began 24 or more years ago. Education in medicine is a lifelong commitment and you will now need to rely on the study habits you have developed over these years to see you into the future of your careers. For me, a clinician and teacher, it is both a happy time, a sad time, and a time to reflect. I am delighted to see you succeed and move into the forefront of Emergency Medicine. It is for that purpose we are both here. However, I will be sad to see you go. I have watched many classes of residents leave over the years, and although intentions are good, I do not hear from or see many former residents again. It is also a time for me to reflect on the direction of my own life and the quality of the training I have passed on to you. I have no doubt that each of you will do well in the practice of Emergency Medicine. However, I fear that there are still many things that we could have discussed, but never took the opportunity. A great number of these issues do not deal with medicine, but with philosophical and life style issues. Because these are not "core curriculum", I fear they have been overlooked. Some of this is hard won wisdom distilled through years of trial and error. Some has come to me easily through the wise council of those who have gone before me. In any case, I think there is something here for everyone. Medical Issues 1. Whenever you enter a new practice situation, you are welcomed by the ED staff, but there is a time of "testing" by the medical staff. For whatever reason, you will need to prove you are capable, determined and friendly in the face of adversity. This will come in the form of challenges both personally and medically. Perhaps disagreement over admission of a patient, or the work-up of a patient with a certain problem. How you are welcomed, depends on how you react to these challenges. I expect that most, if not all of you, will eventually be accepted by the medical staff because it is in their interest to make you a friend. It is a sort of right of initiation. I don't understand it, but expect it. Don't make enemies in your first several weeks. Be firm but gentle. After all, these are people with whom you will need to work for years to come. 2. It is quite likely that you will make a serious or embarrassing error in the first 2-4 weeks of your new practice. I have seen this happen over and over again and it has happened to me more than once. I expect that we make errors because we are not comfortable with a new system and medical environment. It is always humiliating to make errors, but even more so when we are new and trying to make a good impression. Watch out for this, and when it happens, take it in stride, remember what I told you and go on to the next patient. Until you are very comfortable with your new environment, reflect carefully on every controversial decision you make. When in doubt, always put the patient's best interest above your own and that of the other doctors. Play it by the book. 3. Private practice is much harder and more demanding than residency. Although I know that you all are working hard and spending a lot of hours working, private practice assumes more of your time and energy. There are the inevitable committee meetings, ED meetings, EMS meetings, disaster drills, ACLS, BLS and ATLS that they never told you about when you interviewed. I was actually made assistant medical examiner of the county when I started practice- a position always given to the newest member of the group. No one ever told me! I know that you are looking forward to easier days and easier work schedules. It doesn't happen. Long hours of single coverage can be very stressful and very lonely.

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4. If possible, write your contract for less than a 40-hour week. (See # 3 above.) I recommend a 32-36 hour workweek. You can always get more time by asking for it and the group sees you as a hero helping them out. Backing off and asking for less hours is difficult and gives people the impression something is wrong and you can't handle the stress etc. It's better to be a hero and volunteer for more hours than feel like a traitor and back off-hours that you have contracted for. 5. There are very few opportunities in your life to take prolonged quality time off. This is one of them. These opportunities only come once in many years and this may be the first opportunity you have ever had. Take advantage of it! Don't start work immediately. Fulfill one of your dreams. Everybody has a dream of what they want to do if they had the time - travel, visit a friend, learn a skill, see the world, climb a mountain, learn a language, etc. You have time before you start your practice. I have never met a person who complained that he/she took too much time off for a vacation, but I have meet many people who wished they had time to take off. I have taken two blocks of time off. I took 6 months between the time I quite my job as faculty at Penn State before I went to Bangladesh and I took 3 and a half months off before I came to MCG. I have never been sorry! 6. Recognize the importance of your family. In the long run, you will have more satisfaction with the role you play in your family than as an Emergency Physician. Although I love to practice Emergency Medicine, and I hope I have passed some of that along to each of you, it would be meaningless without my wife and children. I still have many years ahead of me to practice the art of medicine, but time not spent with Sharon or the kids can never be made up. Time passes by and opportunities lost never come again. 7. Emergency Physicians (and hospital administrators) tend to be a mobile group. I have heard that a large percentage of Emergency Physicians change jobs every five to six years. This is mostly because of "dissatisfaction" and "disillusionment" with Emergency Medicine. My observation is that the problem is not with the practice of Emergency Medicine, but with crisis and unhappiness with one's life. When you are unhappy in your heart, changing jobs may be a short-term reprieve, but your problems will follow you. If you are unhappy with your new practice position, make sure the problem is the practice before you move. Many people blame external circumstances as justification for anger, frustration and unhappiness that is within. If you are at peace with yourself, your family and your God, you can endure even the worst of circumstances with equanimity. If you are unhappy in your heart, you can find wrong in the best. 8. One of the worst situations you can find yourself in, is to be unhappy and feel trapped. You may feel trapped in a practice situation for many reasons: financial indiscretions that do not allow you to move or to take a lower paying job, family considerations- children or spouse that do not want to leave or even the guilt of feeling you are leaving the group when the chips are down. Life is too short to be unhappy. Always leave the door open for escape(reflect on #7 first). If you are unhappy, chances are that your boss is unhappy and your spouse and children are unhappy if they have your best interest in mind. Change can sometimes be good medicine(remember # 5). 9. Your formal education is over. You will find it difficult to develop new skills since you have no teacher and no opportunity to practice new skills in a supervised environment. Everywhere I have been, I have found a physician who is a gifted clinician. Search for such a person and quickly make friends with him or her. Watch everything he/she does. Ask them why they do it that way- there will be a good reason. Make them your informal mentor and emulate that person until you have learned all that you can. Be sure to encourage and thank them as you grow in your skills. It will make you a better, stronger more compassionate physician. Financial Some of the biggest mistakes you may ever make, may be financial mistakes. I do not claim any special expertise in financial matters, but I have sought out people who are wise in these matters and followed their advise. It was a wise move. Permit me to advise you of some of the principals that I believe are the foundation to financial good health. 10. You are moving from a low-income environment to a high-income environment. You each will become the top 10% in income earners of all Americans and the top 1% in income of all people on earth. Your lifetime income will be considerable if you continue to practice Emergency Medicine (Health Care Reform aside). First and foremost, you have not made the money yet- don't spend what you have not yet earned! Often, residents put off purchasing items they want while they are in residency (wise). After years

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of putting things off, they suddenly see the possibility of a large income. They no longer see the need to budget their incomes and begin to buy all the things they have wanted for years. Consequently, many physicians amass a considerable debt in the first several months to year of practice- debt that will take years to pay off. I suggest that you defer your desires until you actually have the money to pay for them, then purchase those items in cash- not credit. Your spouse may also have big ideas as to what he/she wants. Old debt along with new cars, new houses, down payments, new furnishings, new computers, vacations, conferences, moving expenses and private school for children can set you back for years to come and trap you in a situation where you are unhappy. 11. Keep an amount of money in "liquid" assets for an unexpected time of need. This should be money you can tap in several days and should never be used except in emergency. It may be for a new car if there is an accident. You may need a new roof on your house or you may need traveling expenses to visit a sick relative or to pay for private care for an elderly parent or you may want to give it to a friend or relative who is experiencing an acute financial need. Each family may decide on a different amount. However, I recommend at least $5,000. Sharon and I have kept $10,000 in liquid treasury certificates which can be sold in 48 hours. This gives us a liquid investment that is secure and earns above what we could get through a money market account at the bank. This money should always be replaced rapidly if ever used and should not be in risky investments. You will not get top interest- but it will always be there for you in time of need. 12. Understand the difference between need, want and desire. You may need a car to get you back and forth from work. This might cost you $8-10,000 for a reasonably reliable car. You may want a new car- that can cost you $18-24,000. You may desire a sports car- that can cost you $35-65,000. There is nothing wrong with buying what you want or desire if you have the money as long as you realize that it is not a need and you have no other outstanding debts. 13. Understand the principal of compound interest. This is perhaps the most important financial principal for any one to understand. Also remember, you never make money (regardless of what the real estate person tells you) by paying interest even considering the amount you supposedly "save" on taxes. You make more money paying taxes on interest you earn than you save by deducting from your taxes the money you pay for interest. This has several applications. a. A small amount of money put aside each month for many months builds into a large amount of money relatively painlessly. An example of this is saving for retirement or for your children's education. For instance, all of you should be able to put aside at least $500 a month your first year of practice and at least that much or more each year thereafter. At age 30, assuming 7% interest, by the time you are age 60, you will have $616,000 set aside for retirement. This will give you a monthly income of about $4,800 a month for the next 20 years. If you wait until you are 40 to begin your retirement savings and put in the same amount, you will only have $262,000 at age 60. Likewise, if you wait until you are 50 to begin saving the $500 a month, you will have only $87,000 at age 60. This is especially attractive if you can put money into a tax-deferred account (IRA or a 401 K or 403 B). You save on taxes and build up retirement at the same time. To take full advantage of compounding, you need to keep the money invested as long as possible. It is best to be disciplined and begin with whatever you can afford at an early age to allow it to compound. If you are not disciplined with a little now, you may not be disciplined with a lot later. b. The law of compounding is also readily seen with mortgages. If you borrow $100,000 for a mortgage at 7.5%, that money will cost you another $152,000 in interest over 30 years; or $ 67,000 over 15 years or; $20,000 over 5 years. If the initial house cost $125,000 and you paid $25,000 as a down payment and borrowed $100,000 as above, you will pay $277,000 for that $125,000 house if you choose the 30 year option. Like wise, you will pay $192,000 for the house on the 15-year option, or $145,000 if you pay the mortgage in 5 years. Compounding can work for you in the case of retirement savings, or against you in the case of loans and mortgages. c. The best investment you can make with the best return is to pay off your mortgage. Mortgage rates are always higher than what you can safely make in investments. If this was not true, professional lending institutions would not lend you the money at that rate for such a long period of time. They understand the power of compound interest. 14. Doctors make poor investors. They are too busy with medicine to understand completely what they are doing financially and make frequent and costly mistakes (Ask any honest broker). There are several important principals here! Interest or dividends received is proportional to the risk taken. The riskier the

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investment, the more the interest or possible income. They pay you more because the risk is higher. Doctors, because they are high income earners, do not need to make risky investments. For example, say you are saving for retirement. Your income is $140,000 and you are putting aside $6,000 ($500 a month) or more a year for the next 30 years using the example above in #13 a. If you make safe investments, that money will grow (compound)to all you need for retirement in the time allowed. You will not get top interest on your money, but you will not loose it either. On the other hand, say you earn $20,000 a year and have a family of 4. You need all your money to feed and cloth your family. You can only afford $50 a month ($600 a year) to put aside for retirement. To provide for your retirement, you will need "growth" investments. You can not settle for an investment at 6 or 7% but need to take a risk at a higher percentage so you will have enough to retire on. It is the poor man who is forced to take the risk. There is no reason I know, except ignorance or greed, for the wealthy to take high risk. You can plan for the future comfortably without risking (and potentially loosing) it all! Personal 15. In the story of “Alice in Wonderland”, Alice becomes lost in the woods. Suddenly she looks up and sees the Cheshire Cat. “Please, Mr. Cat, can you tell me the way to go?” The cat replies, “It depends on where you want to go.” “I do not know where to go.” The Cheshire Cat then replies (something I think we should all memorize) “If you are on the road to nowhere, any road will take you there.” We all need to know where we are going. I would suspect that most, if not all of us, avoid answering this question- yet we all know that it is one of the most important questions we will deal with in out lives. I suggest that you sit down now and try to answer this so you know when you arrive and when you are still lost in the woods. Personally, I have drawn up a “mission statement” for myself that is the guiding principle of my life. I have also drawn up “objectives” for myself- just like any company. My objectives are titled, doctor, residency director, father, son, husband, steward (body, mind, spirit, materials) and so on. I have listed “objectives” for each of the above. I know what direction I am going and when I stray from those objectives. This is a good exercise for each of you and I encourage you to complete this BEFORE you take a new job. 16. Be careful not to over commit yourself in whatever you do. You will need to learn to say NO to your employer and community. Each of us needs time to reflect and recover from our jobs and the general stress of just living in the 20th century. If you do not have AT LEAST 1-2 hours for yourself each day- you are over committed. Activity overload takes the pleasure out of anticipation and the delight out of reminiscence. 17. Vacations are for relaxation and recuperation. We even over commit ourselves and work ceaselessly when we are trying to relax. I took a trip in Sinai three years ago with several friends. Our guide, Awad, told us of a Bedouin proverb. He said that if you make a days journey into the desert, you must wait at least three days for your spirit to catch up. If that is the case, most of our “spirits” are so far behind that they may never catch up. Remember to spend time relaxing and don’t run where we were meant to walk. I hope that some of these suggestions will be helpful for you. They were done with your best interest in mind because I care for each one of you. I wish you the best. Years of happiness. Productive lives. Peace and security in your homes.

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