5.9.19 Conference Summary

Critical Palliative Care: Dr. Carrie Harvey

Case 1: 31 yo M found in PEA arrest- Death Notification

  • Prepare: Think about your words, quiet room/area, know patient’s name

  • Family: Introduce yourself with proper tone, deliver a warning shot

    • “I’m afraid that I have bad news”

  • Notification: Use the “D” word

    • Either say it outright or give one sentence of context

  • Silence

  • Aftermath: Be available, provide information if desired, offer to see the patient

Case 2: 80 yo with dementia who comes to ED in shock, respiratory failure, in extremis (imminent death)

  • Prepare: Think about what words you want to say, quiet room, sit down to talk to the family

  • Family: Warning shot, introduce the room

  • Communication: Do not make families make a life or death choice if there is not one to make

    • ie: don’t make them to decide to stop treatments if there are not any beneficial treatments left

    • Talk about giving comfort, dying a natural death

  • Silence

  • Aftermath: Give more information if desired, leave family in the hands of SW or RN, offer to have them see patients

Case 3: 88 yo with confusion and respiratory failure. Stated DNI + DNR arrest but might need noninvasive

  • Prepare

  • Family: Ask where they prefer to talk, warning shot

    • Warning shot different this time- “I am hoping for the best but it is my job to prepare for the worst”

  • Ask: See what the goals are for the patient and her family, what they want at the end of life, learn values

  • Make a recommendation

    • Make sure they know that decision could end in a natural and peaceful death

  • Aftermath: provide more information if desired

3 one-liners to keep handy

  • That is a good thing to hope for.

  • I can’t imagine what this is like.

  • Our treatments won’t interfere with a miracle

Facts about opioids:

  • Morphine: first line for pain/dyspnea

  • Tolerant vs naive: assume tolerance if the patient has been on an opioid for >1 week, has a fentanyl patch, or takes an ER drug

  • All opiods can be converted to morphine equivalents, use a calculator and do the mouth

  • IV morphine 3x as strong as PO- remember when converted to oral morphine equivalents

  • Breakthrough dose is 10% of the daily dose

  • Peak effect is 5-15 minutes for morphine- can redose every 20 minutes

  • AKI: consider alternative agent, consider having dose, consider doubling frequency

Hospice Patient in the ED

  • What is hospice: philosophy (maximizing quality of life), insurance benefit (when you enroll in hospice, the hospice benefit takes over and pays for all care)

  • Who is eligible?

    • Terminal illness with life expectancy <6 months

  • What does it provide?

    • MD oversight, nursing, social work, counseling, medications, medical equipment, home health aid, therapy, bereavement support, short term admission for uncontrolled symptoms, short term respite care

  • What is not covered?

    • 24/7 nursing care in the home, room and board

  • What could happen in an emergency?

    • Might come to the ED for symptom control, treatment for something unrelated to their terminal condition

    • End of Life is scary

      • Half will die within 3w of enrollment, a third within 1 week. Inability to cope common for late referrals

  • What should we do?

    • Do not assume that presentation to the ED is a want for aggressive care

    • Do your best to root out why they are there with a focused goals of care discussion

    • Notify the hospice agency

    • Disposition: Return home, admit for dying or uncontrolled symptoms, or follow their wishes and admit for care

  • Hospice pearls

    • No hospice benefit will cover 24/7 home care or room and board

    • Don’t have to be DNR

    • Do not equate an ED visit with do everything

    • What are you hoping for today?

    • Notify hospice agency

The Crashing Valvulopathy: Dr. Carrie Harvey

Case: 70sF with difficulty breathing. 1 week of progressive SOB, fatigue, malaise. Recent discharge from heart failure service. Also had a recent referral to the TAVR clinic.

  • Labs with elevated BNP, leukocytosis, elevated troponin

  • CXR with worsening R side fluid

  • Echo with severe aortic stenosis but normal EF on previous admission

  • Clinical worsening with hypotension, fever, tachycardia, cold extremities, worsening mental status

    • Bedside echo now with severely reduced EF

    • Within 5 minutes: got hypoxic, bradycardic, unresponsive -> atropine, epinephrine, BVM, transcutaneous pacing -> arrest -> death (all within 15 minutes)

Positive airway pressure with cardiogenic shock:

  • PPV hurts the R ventricle- impedes venous return and reduces preload, increase RV afterload

  • PPV helps the L ventricle- Helps decrease the negative inspiratory pressure required to ventilate

    • Increasingly negative inspiratory pressure required to ventilate -> increase preload to increased workload of the left ventricle -> increase myocardial oxygen consumption -> worsening LV failure

Mitral Stenosis

  • pressure buildup in L atrium causing fluid overload

  • Generally a chronic pressure, almost always from chronic rheumatic disease.

    • Exacerbated with increased heart rate or volume load (the longer the filling time, the more blood that can be pushed past the stenosis)

      • Can cause new heart failure in pregnancy, heart failure in new onset afib

  • Most come in stable- treat with rate control, PPV, diuresis

    • If unstable, need surgeon: balloon valvotomy then MVR

Mitral Regurgitation

  • Increased L atrial volume/pressure and fluid backs up into lungs

  • Acute MR

    • Endocarditis (valvular abscess/rupture), papillary muscle rupture after MI (3-5 days)

    • Look cold/wet/shocky but have a normal LVEF on POCUS

      • If looking at the valve on POCUS, be concerned if the LA looks normal and the regurg jet is eccentric (concern for a valve leaflet being taken out)

    • Need transfer ASAP to surgical center from ED

    • Stable: afterload reduction with nitroprusside

    • Unstable: intubate, IABP, emergent MVR

Aortic Regurgitation

  • Acute: aortic dissection (dissection + new murmur), endocarditis

    • Problem: you decrease your aortic dissection heart rates immediately but a decrease in heart rate is contraindicated for new AR patients

  • Stable: after load reduction with nitroprusside

  • Unstable: intubate, dobutamine/nitroprusside, emergent AVR (NO beta blockers or balloon pump)

Aortic Stenosis:

  • Chronic problem

  • Symptoms: syncope (classically exertional), angina, heart failure

  • Echo: LVOT diameter 0.5 cm below valve in systole, continuous wave doppler

    • Severe: peak aortic jet velocity 4 m/s,

  • Treatment:

    • HDS + mild symptoms = diuresis, ACE-i, avoid exertion, surgical referral

    • HDS + acute asymptomatic = admit, urgent surgery, don’t touch them

    • Unstable patient: evidence of low flow and cardiogenic shock

      • Arterial line

      • Start phenylephrine if hypotensive

      • Start nitroprusside if normotensive

      • Intubate with etomidate or fent/midazolam

      • Sedate and paralyze

      • Euvolemia as best as you can

      • Rate control, consider cardioversion

      • AVOID central line in right IJ- will need a PA cath

Pharmacology Series: Opiate Analgesia in the ED: Dr. Brian Lauer, PharmD

  • Opiate

    • Structurally similar to opium

    • Natural plant alkaloid

      • Morphine and opium

    • Receptors present both in the CNS and PNS

      • Mu, Kappa and Delta receptors

      • Mu receptor is primarily targeted for analgesia

      • Adverse events are mainly caused from Mu and Kappa receptors resulted in respiratory depression, sedation, and decreased GI motility

    • Opiate receptor activation

      • Desensitization: minutes to hours

      • Tolerance: days to weeks

        • Decrease in opioid effectiveness with repeat doses

        • Resolves after several weeks after agonist removal

      • Dependence

    • Classification

      • Phenanthrenes: morphine, codeine, hyrodcodone, oxycodone, hydromorphone,

      • Phenylpiperidine: miperidine, fentanyl

      • Diphenylhepatines; methadone

      • Phenylpropyl amines: tramadol

      • Further classification by action (i.e. agonist, partial agonist, agonist/antagonist, antagonist)

    • Commonly utilized parenteral opioids in the ED

      • Morphine

        • Onset: 5-10 min

        • Peak: 20 min

        • Duration: 3-5 hours

        • Elimination/Metabolism: Renal/hepatic (use caution in CKD patients as morphine will stay in system longer and can result in adverse effects more easily)

      • Hydromorphone

        • Onset: 5 min

        • Peak: 10-20 min

        • Duration: 3-4 hours

      • Fentanyl

        • Onset: 1 min

        • Peak: 10-30 min

        • Duration: 10 min-1 hour

        • Avoid concurrent use with benzos as serotonin syndrome can result

      • Hydrocodone

        • Onset: 15-30 minutes

        • Peak: 1 hour

        • Duration: 4 hours

      • Oxycodone

        • Onset: 10-15 minutes

        • Peak: 30 min-1 hour

        • Duration: 3-6 hours

    • Adverse events

      • Mood alteration

      • Respiratory depression

      • Opioid-induced hyeralgesia

      • Nausea and vomiting

      • Peripheral vasodilation (caused histamine release from mast cells, particularly with morphine and codeine)

      • Gi tract alterations, resulting in inhibition of peristalsis

    • Allergies

      • Adverse event: predictable based on medication properties

      • Pseudo-allergy: reactions occurring on first dose (thought to be caused by mast cell degranulation)

        • More common with morphine and codeine

      • True Allergy: requires prior exposure

        • If the patient has a true allergy, must switch to a different structural class (i.e. morphine allergy -> switch to fentanyl)

    • AVOID use of tramadol, morphine, and codeine co-administration with MAOIs

    • Metabolism and Disposition

      • Primarily hepatic

      • Variation in metabolic rates exist between individuals causing “slow metabolizers” and “fast metabolizers”

      • Morphine/codeine/tramadol are metabolized by 1 CYP system, hydromorphone by another, and fentanyl by a third system

        • If patient has less analgesic response to one class (i.e. morphine) due to “fast metabolism”, consider switching to another class that utilizes another CYP system (i.e. hydromorphone)

    • “Ceiling Effect”

      • No additional analgesic benefit at escalating doses

      • Increased side effects at increased doses

        • Except respiratory depression

Point of Care Ultrasound in Community Emergency Departments: Dr. Courtney M. Smalley

Ultrasound Director, Cleveland Clinic Foundation

  • POCUS in the Community is important

    • Increased patient satisfaction

    • Improved disposition

    • Improved safety with procedures

    • Enhanced decision making ability

    • Low cost and no radiation

  • Pillars of an effective POCUS program in the community

    • Leadership

    • Equipment

    • Training

    • Competency

    • Credentialing

    • Archiving

  • How is POCUS different in the community?

    • Limited scope of practice

    • Motivations for privileges/credentialing

    • Providers less likely to learn new machines/modalities

    • Simplification of workflows in VITAL

    • QA requirements need to be decided for your group

  • Barriers with community physicians

    • Getting appropriate windows and labeling

    • Phantom scanning (i.e. scanning without documentation)

Biliary Diseases: Dr. Kevin Choong

Biliary Colic:

  • No fever, pain should resolve over hours, discharge after PO challenge

  • Send home with low fat diet, refer to surgery clinic

Cholecystitis: Chronic vs Acute

  • Thickened walls, large stone impacted at the neck, pericholecystic fluid

    • Sonographic Murphy’s sign

    • CT scan with cholecystitis -> still need the ultrasound

  • Sometimes clinical- immobile stone at the neck, could this be early cholecystitis?

    • Usually can’t tolerate PO even after 4-5 hours


  • Obstruction in the common bile duct

  • If LFTs are dilated and ultrasound does not show a stone, GI now wants an MRCP instead of an ERCP

    • alkaline phosphatase elevates first, followed by bilirubin

  • At risk for cholangitis = start on antibiotics in ED


  • Choledocholithiasis + signs of infection

    • Triad: fever, jaundice, RUQ pain

    • Pentad: fever, jaundice, RUQ pain, sepsis, AMS

    • Likely need an ERCP before a cholecystitis

Gallstone Pancreatitis

  • Need an ERCP, likely get a cholecystitis

  • Do not need antibiotics