4.4.19 Conference Summary

EM/IM Conference: “From PERC to PESI: Evaluation and Disposition of Low Risk PE in the Emergency Department”

Dr. Samia Farooqi, Emergency Medicine Attending

  • Question 1: How do we assess for PE in the ED?

    • Symptoms

      • Dyspnea

      • Pleuritic chest pain

      • Hemoptysis

      • Known DVT

    • Signs

      • Tachycardia (HR>100)

      • Hypoxia (Pulse Ox <90%)

      • Low grade fever (T >38)

        • High grade fever (T>39) has negative predictive value

      • ECG findings suggesting PE

        • TWI in V1-V4

        • S1Q3T3

        • Right axis deviation

    • Risk factors that raise your underlying clinical suspicion?

      • Age >50

      • Surgery within last 4 weeks that required ET intubation

        • Highest risk surgeries: cranial, joint, abdominal, spine

      • Trauma (major trauma that required hospitalization)

      • Joint immobility (i.e. recent sprain or fracture requiring splinting)

      • Pregnancy (70% of pregnancy-related PE cases occur in the post-partum period)

      • Exogenous estrogen use (highest risk in first few months of initiation)

    • Determining pretest probability?

      • Well’s score vs Clinical Gestalt

        • Clinical gestalt has same sensitivity as Well’s score at predicting likelihood of PE

  • Question 2: What is the PERC rule?

    • First published in 2004

    • Group of clinical criteria that obviate need for further testing for PE

      • I.e. Used to prevent unnecessary diagnostic testing in the ED in patients with low likelihood of pulmonary embolism

    • Derivation population of 3000 patients in 10 EDs using retrospective data to perform logistical regression

    • Rule out criteria

      • Age >50

      • HR>100 (at any time during ED visit)

      • Pulse Ox<95% (at any time during ED visit)

      • Unilateral leg swelling

      • Hemoptysis

      • Recent surgery or trauma

      • Prior PE or DVT

      • Hormone use

    • If the above criteria are all not present, risk of PE <2%, so further diagnostic work-up is not necessary

    • Validated in multiple studies after publication

    • False negative PERC Patient Characteristics?

      • Developers of PERC rule looked at retrospective data to find general features of PERC negative patients who were ultimately diagnosed with PE

      • PERC negative-PE positive patients have more benign hospital course, less likely to develop RV strain or respiratory distress, and had lower all-cause mortality at 30 days

        • Ultimately, researchers felt that PERC rule should not be used in isolation in pregnant or post-partum patients

  • Question 3: Once a diagnosis of PE has been made, how do we determine appropriate disposition for low-risk patients?

    • Classifying PE patients as “Low Risk”

      • Pulmonary embolism severity index (PESI)

        • Increasing 30 day mortality with increasing PESI score

        • Characteristics include age, gender, hx of cancer/heart failure/chronic lung disease, pulse >110 BPM, SBP <100 mmHg, RR >30/min

      • Hestia criteria is similar system (primarily used in Europe) to determine low risk population

      • Importance of considering evidence of RV dysfunction?

        • In low risk patients, presence of RV dysfunction is independently associated with early mortality and higher rate of adverse outcomes

    • Choice of anticoagulant?

      • In general, avoid NOACs in malignancy, thrombophilia/thrombocytopenia, renal and hepatic disease

      • Novel Oral anticoagulant (NOAC) options

        • Rivaroxaban (Xarelto)

        • Apixiban (Eliquis)

        • Edoaban (Savaysa)

        • Dabigatran (Pradaxa)

      • Patients should have reliable follow up if placed on NOAC when discharged from ED

  • Discharge from ED in Practice: Why don’t we do this more?

    • Cost

    • Poor follow-up

    • Underutilization of Validated Risk-Assessment scores

    • Clinical gray areas or subsegmental and incidental PEs

EM/IM Conference: "Pulmonary Embolism: Using PERT for Assisting Management”

Dr. Teresa L. Carmen, Director of Vascular Medicine

  • Background Statistics

    • Estimated 1-2 PEs/1000 patients in US

    • 60-100k Americans die of VTE

    • 10-30% of people with PE will die within one month of diagnosis

  • Incidence of PE is going up, but overall fatality is going down. Why?

    • Improved diagnostic testing

    • Increased recognition

    • Improvements in heparin management?

    • Increasing recognition and use of adjunctive therapies?

  • Pulmonary embolism response team (PERT)

    • Similar to STEMI or BAT team

    • Allows for systematic assessment and evaluation of PE patients and mitigates variability

    • Utilizes a multidisciplinary approach to evaluation and management of high and intermediate risk PE patients

    • Allows for consistent approach to patient care

    • Optimize resource utilization

    • Creates a pathway to consistent follow-up

    • Variability in PE management between EM, IM, ICU, ortho, FM, peds can cause harm and sub-optimal care

    • Consistent PE management

      • Assess for acute needs within first few hours (ABCs, circulation and hemodynamics, initiation of AC) and provides long term needs, etiology confirmation, and appropriate follow up with risks for post-thrombotic syndromes

University Hospitals System PERT Algorithm

University Hospitals System PERT Algorithm

  • Initial management and Diagnosis of VTE/PE

    • Ideally, begin therapy while awaiting definitive testing, unless there is an overt contraindication

  • CT Pulmonary Angiography for diagnosis

    • Currently considered the mainstay for diagnosis

    • Fast, reproducible, reliable

    • Contrast timing is important, but contrast exposure is significant

    • Can help provide some assessment for RV strain

    • Now considered to be as good as formal angiography

  • “Radiographically Massive'“

    • Not a helpful term as it does not take into account RV strain or cardiac biomarkers (troponin, BNP, etc.)

  • Mortality and PE

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  • Echocardiography Risk stratification

    • 30-day survival

      • 83.7% with RV hypokinesis

      • 90.6% without RV hypokinesis

  • Biomarker Risk Stratification

    • Should obtain troponin, BNP, and lactate once diagnosis of PE is made

    • If all markers are normal, very low risk of poor outcomes

    • If any marker is positive, 4-15% of poor outcome

  • Anticoagulation choice?

    • UFH

      • Short t1/2

      • Easily reversed

      • Not renal dependent

      • Best if thrombolysis or intervention is a consideration

    • LMWH

      • Once or twice daily dosing

      • Cleared by the kidneys – renal dosing may be required

    • Low risk PE with appropriate renal function, drug coverage and follow up can be started on DOAC

  • Thrombolysis in PE?

thrombolysis.png
  • Advanced Therapies for PE

    • Systemic tPA – in patients without contraindications to thrombolysis

      • Full dose IV tPA – 100 mg/2 hours

      • Half-dose IV tPA – 50 mg/2 hours

    • Catheter directed thrombolysis (CDT) – less thrombolytic exposure

      • CDT – multi-side hole catheter and slow drip infusion 1-2 mg/hour

      • EKOS – US assisted CDT

    • PMT - thrombus removal strategies – saddle and proximal thrombus (not helpful for distal emboli)

      • Inari Flowtriever

      • Suction thrombectomy

    • Pulmonary embolectomy

    • ECMO support (sometimes V-V, but more often V-A)

      • Often a salvage technique and considered last line

  • Conclusions:

    • PE is too common and too high risk to ignore

    • Heparin is first-line therapy

    • Patient risk stratification impacts outcomes

    • Management strategies are expanding and should be used in a responsible and cost-effective manor

    • PERT brings the stakeholders to the table to create order, pathways and consistency for management

“Power Half Hour”: Important Clinical Images in Emergency Medicine

Dr. Elena Castleberry, PGY-3

Case 1

  • 63 yo Male fell out of wheelchair while transferring from bed

  • Complaining of 10/10 back pain

  • PMH: HFrEF, DM, HTN, OSA, CKD

  • PSH: tonsillectomy

  • Social hx: poor living environment

  • Exam: AOx3, 5/5 strength in UEs, 0/5 strength in LEs, insensate in lower extremities, poor rectal tone

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  • Hospital course: admitted to NSU, intubated for hypercapnic respiratory failure, medically optimized, attempted OR fixation but unsuccessful due to poor tidal volume upon start of case

    • Made comfort care and expired 3 days later

  • Vertebral injuries

    • Compression fractures

      • Common in osteoporosis and often chronic in nature

    • Burst fractures

    • Flexion-distraction

    • Fracture-dislocation

Case 2

  • 57 yo AA female presented with sudden onset severe sudden back and chest pain

  • PMH: HTN

  • Meds: none

  • Soc hx: tobacco use

  • PE: distressed, diaphoretic, equal radial pulses

Type A Aortic Dissection

Type A Aortic Dissection

  • Hospital course: started on esmolol and nitroprusside in ED and taken to OR with CT surgery

    • Had good outcome and DC’d to SNF

  • Aortic dissection

    • High mortality risk ~30%

    • Highest odds ratios for diagnosis

      • Immediate onset of pain

      • Severe pain

      • Tearing in sensation

      • Chest pain + neurologic symptoms

Case 3

  • 13 yo healthy Amish male presented with abdominal pain

    • Hit in abdomen while playing baseball (collided at home plate)

    • Went home but later developed chest pain and nausea

Grade III/IV Splenic Laceration

Grade III/IV Splenic Laceration

  • Splenic rupture

    • Children have thick splenic capsule so bleeding is contained and surgery is less needed

    • Adults have thinner capsule and often require surgical management

Case 4: 60 yo AA female presented unresponsive in a ditch in her car on the side of the road, tachycardic and hypotensive

  • EKG on arrival…

Torsades de Pointes

Torsades de Pointes

  • Patient given 2 g IV calcium chloride and 2 g IV magnesium with return of sinus rhythm

  • CT head ordered after stabilization….

CT head w/o contrast showing sub-arachnoid hemorrhage

CT head w/o contrast showing sub-arachnoid hemorrhage

  • SAH and ECG changes

    • ECG findings present in 27-100% of SAH patients

    • Most pronounced in first 72 hours after onset

    • Mechanism (somewhat unclear)

      • Hypothalamic stimulation and autonomic dysregulation?

      • Catecholamine surge?

    • ECG morphology changes

      • 19% with High R waves

      • 15% with ST depression

      • 32% with T wave abnormalities

      • 47% with large U waves

      • 23% with prolonged QTc (can lead to Torsades de Pointes, similar to this patient’s case)

Clinicopathologic Conference

Dr. Ross McDermott, PGY-2 vs Dr. Sorapat Vijitakula, Emergency Medicine Attending

Case: 39 yo F presented via EMS with multiple medical complaints

  • Chest pain, SOB, abdominal pain, fever, nausea and vomiting x 3-4

  • Gradual onset abd pain started day before with no clear inciting event

  • PMH: schizoaffective disorder, Hepatitis C, ETOH abuse

  • PSH: C-section

  • Sochx: current daily smoker, smokes crack daily, heavy ETOH use

  • Meds: none

  • VS: BP 91/47, otherwise normal; no fever (T 35.9)

  • BMI: 18

  • PE: intoxicated, disheveled, abdomen diffusely tender to palpation, voluntary guarding with deep palpation; otherwise normal exam

  • Labs and urine ordered, IV toradol and 1 L IVF given

  • One hour later…

    • Patient became less cooperative and aggressive with nursing staff over IV placement

    • EKG showed normal sinus rhythm with no ischemia

    • BP now 80s/40s, pulse still in the 60s

    • Venous full panel: pH 7.36, PCo2 43, HCO3 24.3, lactate 2.1, glucose 183, iCal 1.19

  • AND A SINGLE DIAGNOSTIC WAS ORDERED…

Rebuttal by Dr. Vijitakula

  • Approach: DO NOT ANCHOR

  • Differential for CP/SOB

    • STEMI, Tamponade, pericarditis, PE, Tension PTX, PNA

  • Differential for nausea

    • Obstruction, functional, inflammation, meningitis, pseudotumor, uremia, meds, ETOH, illicit drugs

  • Differential for abdominal pain

    • AAA, aortoenteric fistula, aortic dissection, SBP, appendicitis, obstruction, ruptured ectopic, mesenteric ischemia, portal venous thrombosis, pancreatitis, acute liver failure

  • VS: BP 91/4 with MAP 62

  • Differential for Shock

    • Hemorrhage, dehydration, MI, Arrhythmias, cardiogenic, drug toxicity (BB, CCB), neurogenic

  • PE: disheveled and diffusely tender abdomen with guarding

  • So…

    • Liver disease history + abdominal pain + cocaine abuse

  • Top 3 differential diagnosis

    • Mesenteric ischemia, acute portal venous thrombosis, SBP

  • Diagnostic test of choice ordered

CT ANGIOGRAPHY OF THE ABDOMEN (to evaluate for mesenteric ischemia)

Follow-up by Dr. McDermott

  • Diagnostic test ordered: Ultrasound (FAST exam)

    • Showing positive fluid in the hepato-renal space!

  • IV access x2, 1 u O- pRBCs given, foley catheter placed and urine obtained (+ urine pregnancy test)

  • OB called for ruptured ectopic pregnancy

  • CBC showed H/H 10.7/31; CMP unremarkable, Lactate 3.4, Alcohol 54, beta-HCG 1150

  • BP stabilized after 2 u pRBCs, HR remained stable

  • Went to OR with OB for ectopic pregnancy removal

    • L ectopic pregnancy with 1750 cc of blood in abdomen

  • Ectopic pregnancy

    • Implantation of conceptus outside uterine cavity

    • Leading cause of maternal death in 1st trimester

    • Risk factors: PID, IUD, tubal surgery, assisted conception, previous ectopic

    • Many ectopic pregnancies have no risk factors

    • Tubal implantation accounts for 82.2% of location

    • Heterotopic pregnancy is extremely rare (<1:3000 pregnancies), but much more common in in-vitro fertilization (IVF)

    • Presentation: variable but generally with abdominal pain and 70% will report missed pregnancy

    • Vital signs DO NOT correlate with amount of hemoperitoneum

      • Free blood in abdomen can stimulate vagus nerve and despite hemorrhagic shock, patients will often have relative bradycardia in relation to hypotension

    • <50% rise in beta-HCG in 1 day can be concerning for ectopic pregnancy

    • Yolk sac is 1st definitive sign of IUP on ultrasound

    • IUP essentially rules out an ectopic pregnancy in general population

    • General rule of thumb: if no IUP on trans-abdominal ultrasound, obtain transvaginal ultrasound, regardless of HCG level

    • Treatment

      • Medical treatment with methotrexate IV/IM usually 1mg/kg in the ED has a high success rate (~70-80%) for stable (non-ruptured) tubal pregnancy

        • beta-HCG >5000 and gestational sac >5 cm have lower success rate with methotrexate so consider consultation with OB for surgical removal

      • Surgical treatment for all suspected or confirmed ruptured ectopics and give blood for hemorrhagic shock

    • US for hypotension: SHOC-ED (Annals of Emergency Medicine, 2018)

      • 5 views: Cardiac (4 views), lung (bases), IV, abdominal aorta, FAST

      • Inclusion: sustained SBP <100 mmHg or shock index <1 and >19 yo

      • Exclusion: pregnancy, requiring ACLS/CPR, trauma in last 24 hours, acute MI on ECG, clear cause of hypotension or shock

Supertrack Series: General Approach to Ear Pain

Dr. Zeinab Shafie-Khorassani, PGY-1

  • Otitis media

    • Infection of middle ear with bulging of TM

    • 1st line treatment: amoxicillin 45 mg/kg PO divided in 2 doses for 7-10 days

    • Severe symptoms, symptoms for >48 hours, T>39 should be treated with amoxicillin/clavulonic acid

    • Conjunctivis-Otitis syndrome should also be treated with amoxicillin/clavulonic acid

  • Acute mastoiditis

    • Inflammation/Infection of mastoid air cells

    • Management: IV antibiotics (typically Unasyn) and ENT consultation for possible surgical debridement

  • Perichondritis

    • Infection of cartilaginous portion of outer ear

  • Otitis Externa

    • Inflammation of external auditory canal or auricle

    • Management: topical ciprofloxacin +- hydrocortisone

  • Contraindications to ear canal irrigation: TM perforation and organic matter within ear canal

  • TM perforations do not require emergent ENT consultation or antibiotics but can be managed conservatively as outpatient

    • 90% heal within 2-3 months without any specific treatment

  • Labrynthitis

    • Infection/inflammation of middle ear labyrinth

    • Typical viral causes in children: measles and mumps

    • Sudden onset, persistent vertigo and possible hearing loss and tinnitus

    • Treatment: steroids, hydration

  • Cholesteatoma

    • Congenital or acquired

    • Can cause chronic or recurrent middle ear infection

    • Treatment: surgical resection

  • Otitis externa

    • Infection of outer ear

    • More common and severe in diabetic and immunocompromised patients

    • Malignant OE should be admitted and treated with IV Cipro

      • Complications: osteomyelitis of skull base/TMJ, CN palsies, and CNS infections (meningitis

  • Ramsey Hunt Syndrome: VZV reactivation involving the ear

  • Auricular hematoma

    • Often direct trauma from shearing of perichondrium from underlying cartilage

    • Management: drainage with pressure bandage to prevent re-accumulation of hematoma + oral antibiotics (with coverage for pseudomonas) and very close follow up with ENT within 48 hours

    • Complications: “Cauliflower ear” and necrosis

  • Middle ear foreign bodies

    • Insects can be killed with mineral oil, ethanol or lidocaine prior to removal

    • ENT consult for removal if button battery (necrosis can occur within 2 hours of presence so emergent removal is key)

    • Give topical ciprofloxacin for prophylaxis if EAC or TM excoriated during FB removal

Consultant of the Month: Traumatic Ocular Emergencies

Dr. Marwan Abdulaal, Ophthalmology resident

eye.jpg
  • Always obtain visual acuity (may use topical anesthesia to assist if necessary)

  • Inferior and medial orbital bone fractures are most common as these are the thinnest walled areas and can result in entrapped inferior rectus muscle

  • Ruptured globe can result in:

    • 360 degree subconjunctival hemorrhage

    • Hyphema

    • Corneal staining

    • Irregularly shaped pupil

    • Exposed retinal tissue

    • Dilated, minimally reactive pupil (due to damage to optic nerve)

  • Blunt ocular trauma is more dangerous than sharp, penetrating because it can disrupt the mechanics of the orbit and cause permanent changes in the globe shape

  • Important past ocular history to know:

    • Amblyopia

    • Serious ocular trauma/inflammation

    • Hx of eye surgeries

    • Refractive error

  • Danger signs/symptoms

    • Sudden loss or decrease in vision

    • Loss of field of vision

    • FB sensation

    • Halos around lights

    • Hyphema or hypopyon

  • Chemical ocular injuries should be irrigated copiously until pH 7.0-7.3

    • If sclera appears entirely white after chemical injury without any vessels, eye is permanently damaged and permanent blindness is likely

  • Facial lacerations involving the medial aspect of the lower eyelid should be evaluated for lacrimal duct damage and required emergent ENT/ophtho evaluation

  • Rust rings are typically not dangerous and with proper lubrication, will be healed within 1 week without issues (unless easy to remove rust rings, don’t worry about aggressive removal techniques)

Environmental Lecture Series: Cold/Hot Emergencies

Dr. Jordan Hitchens, PGY-1

  • Cold Emergencies

    • Non freezing Cold Injuries

      • Trench Foot

      • Chilblains (Pernio)

    • Do not rewarm if possibility of tissue refreezing (especially important in pre-hospital setting)

    • Frostbite

      • Warm slowly and steadily

      • tPA can be used if necrosis present in frostbite after rewarming

      • Frostbite is a risk factor for tetanus so be sure to give tDAP to all frost bite/nip patients

  • Hot Emergencies (aka exertional heat illnesses)

    • Heat cramps -> Heat exhaustion -> Heat injury (heat exhaustion + T>104 + normal neuro exam) -> heat stroke

      • Oral hydration

      • Remove sweaty clothing

      • Move patient to shaded area

      • Active cooling measures with IV hydration and rapid cooling with circulating fans and cool mist

    • If heat injury or heat stroke is suspected, always be sure to obtain a core temperature (preferably rectal)

    • Prevention is key

Community Emergency Medicine: Approach to Shoulder Dislocation

Dr. Matthew Harcha, PGY-2

  • Shoulder joint

    • 4 rotator cuff muscles (commonly injured or torn during dislocations)

      • Supraspinatus, infraspinatus, teres minor, subscapularis

  • Anterior dislocation

    • ~95% of injuries

    • Presentation

      • Slight abduction

      • Squared off appearance

    • Can be diagnosed based on X-ray or Ultrasound

    • Reduction should be performed quickly as delays will result in more difficult reduction attempts

    • Delayed presentations are more difficult to reduce as there is a higher risk of vascular injury

    • Intra-articular injection can be performed for better pain control

    • Reduction techniques

      • Hennipen technique

        • External rotation plus abduction to 90 degrees

      • Stimson technique

        • Affected shoulder is draped over side of bed and 5 pounds of weight is added until successful reduction

      • Scapular Manipulation

        • 2 hands around scapula and stablize

      • Traction-Counter Traction

        • Use assistant to pull inferiorly and externally

      • Snowbird Technique

      • Milch Technique

      • Hippocratic Technique

      • Kocher Technique

      • Spaso Technique

      • Cunningham Technique

        • Massage the deltoid and biceps while applying downward traction on elbow

      • Fares Method

      • Boss-Holzach-Matter Technique (Davos Technique)

      • Pneumatic Stretcher Technique

  • Posterior Shoulder Dislocation

    • Commonly missed on X-ray

      • AP view will be read as normal in 50% of time

      • Lateral view increased diagnostic accuracy

      • Rim Sign: Anterior glenoid rim and articular surface is increased >6 mm

      • Ice Cream cone or Bulb Sign: internal rotation of greater tuberosity give the humerus appearance of ice cream or light bulb

    • Orthopedics consult should be obtained in all posterior and inferior dislocations and pediatric cases

    • Reduction Technique

      • Traction-Countertraction

        • Similar to anterior approach but shoulder be rotated externally

  • Inferior Shoulder Dislocation

    • <0.5% of all dislocations

    • Commonly associated with fractures and complete rotator cuff tears and nerve injuries

    • Reduction Technique

      • Traction-Countertraction

      • Two step technique

        • Convert initial inferior dislocation to anterior, then perform reduction with external rotation

  • Arrange orthopedic follow within 48 hours for all dislocations

  • Immobilization time varies but typically 1-2 weeks if ages 20-40 or 1 week if age >60

  • Avoid external rotation or abduction after reduction

  • Complications

    • Hillsachs Lesion (typically present before reduction) in up to 50% of cases

      • Impaction of posterolateral portion

    • Bankhart Lesion

      • Injury to inferior glenoid labrum

    • Vascular injury

      • Axillary artery, particularly concerning if dislocation has been present for >1 week and delayed presentation

    • Neurologic injury

      • Typically resolves within weeks-months and does not require specific surgery or treatment