Emergency Medicine Cases

Anaphylaxis is the quintessential medical emergency. We own this one. While the vast majority of anaphylaxis is relatively benign, about 1% of these patients die from anaphylactic shock. And usually they die quickly. Observational data show that people who die from anaphylaxis and anaphylactic shock do so within about 5-30mins of onset, and in up to 40% there’s no identifiable trigger. The sad thing is that many of these deaths are because of two simple reasons: 1. The anaphylaxis was misdiagnosed and 2. Treatment of anaphylaxis and anaphylactic shock was inappropriate. So there’s still lots of room for improvement when it comes to anaphylaxis and anaphylactic shock management. With the help of Dr. David Carr of Carr's Cases fame, we’ll discuss how to pick up atypical presentations of anaphylaxis, how to manage the challenging situation of epinephrine-resistant anaphylactic shock, whether or not we should abandon steroids, a rare but ‘must know’ diagnosis related to anaphylaxis, and much more. Plus, we have a special guest apperance by George Kovacs, airway guru, to walk us through an approach to the impending airway obstruction we might face in anaphylaxis.

In this EM Cases episode with Dr. Nazanin Meshkat, multinational ED doc and Dr. Matthew Muller, infectious disease specialist, we discuss the most common tropical disease killers that we see in patients who present with Fever in the Returning Traveler. Every year an increasing number of people travel abroad, and travelers to tropical destinations are often immunologically naïve to the regions they’re going to. It’s very common for travelers to get sick. In fact, about 2/3 of travelers get sick while they’re traveling or soon after their return, and somewhere between 3 and 19% of travelers to developing countries will develop a fever. Imported diseases, like Malaria, Dengue, Ebola, and Zyka can be acquired abroad and brought back to your ED in unsuspecting individuals. This is serious stuff - you might be surprised to learn that Malaria is responsible for more morbidity and mortality worldwide than any other illness. According to a study in CJEM most emergency physicians have minimal or no specific training in tropical diseases and emergency physicians indicated an unacceptably low level of comfort when faced with patients with tropical disease symptoms. In fact, 40% of the cases were incorrectly diagnosed or managed. And Canadian ED docs aren’t the only ones who’s skill isn’t stellar in this department - a similar 2006 study of UK physicians showed a 78% misdiagnosis rate. This misdiagnosis rate isn’t wholly because of lack of knowledge – it almost certainly also has to do with the vague presentations and huge amount of overlap between so many tropical disease. You might be thinking that it’s impossible to learn all the thousands of details of the dozens of different tropical diseases - true. However, in the ED, while we don’t need to know every detail of every tropical disease, and don’t necessarily need to make the exact diagnosis right away, we do need to have a rational, organized approach to diagnosing and managing fever in the returning traveler, so that we can identify some of the more common serious illnesses like Malaria, Dengue and Typhoid fever, and start timely treatment in the ED.

Dr. Salim Rezaie of R.E.B.E.L. EM tells his Best Case Ever of a Low Risk Pulmonary Embolism that begs us to consider a work-up and management plan that we might not otherwise consider. With new guidelines suggesting that subsegmental pulmonary embolism need not be treated with anticoagulants, exceptions to Well's Score and PERC rule to help guide work-ups, the adaptation of outpatient management of pulmonary embolism, and the option of NOACs for treatment, the management of pulmonary embolism in 2016 has evolved considerably. In which situations would you treat subsegmental pulmonary embolism? How comfortable are you sending patients home with pulmonary embolism? How does the patient's values play into these decisions? Listen to Dr. Rezaie provide an insightlful perspective on these important issues and much more...

Dr. Amy Drendel, a leader in pediatric pain management from the Children's Hospital of Wisconsin, shares her expertise on managing procedural sedation in kids. She covers pain relief strategies for emergency scenarios like fractures and scans, emphasizing the use of intranasal fentanyl and nitrous oxide. Dr. Drendel discusses the advantages of IV Ketamine over IM and the importance of family presence during sedation. She also explores advancements like ketofol and highlights safety considerations, ensuring pain-free experiences for young patients.

I caught up with Dr. Anand Swaminathan, otherwise known as EM Swami, at The Teaching Course in NYC where he told his Best Case Ever from Janus General of his heroic and collaborative attempts at saving the life of a gentleman who presented to the ED with a classic story for a ruptured AAA. As William Olser famously said, "There is no disease more conducive to clinical humility than aneurysm of the aorta."

While knowledge acquisition is vital to developing your clinical skills as an EM provider, using that knowledge effectively for decision making in EM requires a whole other set of skills. In this EM Cases episode on Decision Making in EM Part 2 - Cognitive Debiasing, Situational Awareness & Preferred Error, we explore some of the concepts introduced in Episode 11 on Cognitive Decision Making like cognitive debiasing strategies, and some of the concepts introduced in Episode 62 Diagnostic Decision Making Part 1 like risk tolerance, with the goal of helping you gain insight into how we think and when to take action so you can ultimately take better care of your patients. Walter Himmel, Chris Hicks and David Dushenski answer questions such as: How do expert clinicians blend Type 1 and Type 2 thinking to make decisions? How do expert clinicians use their mistakes and reflect on their experience to improve their decision making skills? How can we mitigate the detrimental effects of affective bias, high decision density and decision fatigue that are so abundant in the ED? How can we use mental rehearsal to not only improve our procedural skills but also our team-based resuscitation skills? How can we improve our situational awareness to make our clinical assessments more robust? How can anticipatory guidance improve the care of your non-critical patients as well as the flow of a resuscitation? How can understanding the concept of preferred error help us make critical time-sensitive decisions? and many more important decision making in EM nuggets...

Traditionally we've run at least 2 troponins 6 or 8 hours apart to help rule out MI and recently in algorithms like the HEART score we've combined clinical data with a 2 or 3 hour delta troponin to help rule out MI. The paper we'll be discussing here is a multicentre/multinantional study from the Canadian Medical Association Journal from this year out of Switzerland entitled "Prospective validation of a 1 hour algorithm to rule out and rule in acute myocardial infarction using a high sensitivity cardian troponin T assay" with lead author Tobias Reichlin. It not only looks at whether or not we can rule out MI using a delta troponin at only 1 hour but whether or not we can expedite the ruling in of MI using this protocol.

Pain leads to suffering. Opioid misuse leads to suffering. We strive to avoid both for our patients. On the one hand, treating pain is one of the most important things we do in emergency medicine to help our patients and we need to be aggressive in getting our patients' pain under control in a timely, effective, sustained and safe fashion. This was the emphasis 10-20 years ago after studies showed that we were poor at managing pain and our patients were suffering. On the other hand, opioid dependence, addiction, abuse and misuse are an enormous public health issue. Opioid misuse in Emergency Medicine has become a major problem in North America over the past 10 years at least partly as a reaction to the years that we were being told that we were failing at pain management. As Dr. Reuben Strayer said in his SMACC talk on the topic: “Opioid misuse explodes in our face on nearly every shift, splattering the entire department with pain and suffering, and addiction and malingering and cursing and threats and hospital security, and miosis and apnea and naloxone and cardiac arrest.” So how do we strike a balance between managing pain effectively and providing the seed for perpetuating a drug addiction or feeding a pre-existing drug addiction? How do we best take care of our patients who you suspect might have an opiod misuse problem? To help us sort through this difficult conundrum we have Dr. David Juurlink, a toxicologist and Dr. Reuben Strayer an EM physician, who both a special interest in opioid misuse. Written Summary & blog post prepared by Keerat Grewal, edited by Anton Helman, December 2015 Cite this podcast as: Juurlink, D, Strayer, R, Helman, A. Opioid Misuse in Emergency Medicine. Emergency Medicine Cases. December, 2015. https://emergencymedicinecases.com/opioid-misuse-emergency-medicine/. Accessed [date]. Here are some numbers that may surprise you: In a recent ED study on opioid prescribing patterns in Annals of EM, 17% of patients in the US were prescribed opioids on discharge from EDs. In Ontario, about 10 people die accidentally from prescription opioids every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to prescription opioids, which now kill more people than heroin and cocaine combined. Opioids are the most prescribed class of medication in the US. In 2010, one out of every eight deaths among persons aged 25 to 34 years was opioid-related. Four out of 5 new heroin users report that their initial drug was a prescription opioid. In Ontario, three times the people died from opiate overdose than from HIV in 2011. Fig 1: Opioid sales, admissions, and deaths in the U.S. Who is at risk for Opioid Misuse in Emergency Medicine? All ED patients are at risk for opiod misuse, regardless of their risk factors. Even opioid-naive patients with no risk factors for opioid misuse are at risk for developing opioid misuse problems. Nonetheless, their are particular risk factors, red and yellow flags that should raise your suspicion for pre-existing opioid misuse and help guide management. (see Figure 2 and 3) Patients at particularly high risk for opioid misuse include: Young age (< 40 years old) Psychiatric history Substance abuse history Benzodiazepine use Fig 2: Red & Yellow Flags for Opioid Misuse (courtesy of Dr. R. Strayer) Fig 3: Risk Stratification for Opioid Misuse (courtesy of Dr. R. Strayer) Trajectories of Opioid Use in Emergency Medicine There are various trajectories that patients who are prescribed opioids may follow (see Figure 4). We must consider the risks of prescribing opioids to opioid naive patients, and their risk of opioid misuse. As previously described, even among patients thought to be ‘low risk’ for opioid misuse, some of these patients will develop risky drug behaviours with opioids. Fig 4: Opioid Use Trajectories (courtesy of Dr. R. Strayer) Opioid-Induced Hyperalgesia Opioid-induced hyperalgesia is a phenomenon that develops in patients who are started on opioids for a condition such as back pain, arthritis, or fibromyalgia, and as the dose is increased, rather than their perceived pain decreasing as might be expected, patients develop marked hyperalgesia. The pathophysiology of this phenomenon is not well understood. Opioid Misuse Harm Reduction Strategies in the ED Categories of harm reduction: Prevent opioid misuse and dependency in opioid naïve patients Reduce the number of opioid pills in the community that are available for misuse and abuse Reduce harm and move towards recovery in patients who have evidence of opioid misuse Key harm reduction techniques: Avoid prescribing extended release, long acting preparations of opioids. These types of opioids have been shown to have double the potential for overdose (1). Avoid prescribing opioids to patients who are already taking sedatives, particularly benzodiazepines (2). Avoid prescribing opioids to patients with alcohol dependency, or patients who are regular benzodiazepine or sedative users, especially if they have a known substance abuse history or history of mental illness. Avoid oxycodone (i.e. percocet or percodan). Oxycodone tends to have a side effect of euphoria, therefore, it is more habit forming than oral morphine (3). If prescribing opioids, prescribe a small number of pills to last the patient 2-3 days. Opioid dependence can develop within 5 days, and will usually develop within 14 days (4). If you know the patient is an IV drug user, do not give them oral opioids. There is a risk that these patients will crush the tablets and use them intravenously, which can result in infectious and thrombotic complications (5). Tell patients to discard unused pills immediately, especially if they have adolescents living with them. Many people start their drug addiction in adolescence by experimenting with parent’s opioid prescription pills. Non-medical use of opioids in Ontario is ranked as the 3rd drug of choice for students, and 67% of adolescents report getting these pills from home. Communication Strategies to Use in Patients with Opioid Misuse in Emergency Medicine First, Gather Data: Before seeing the patient, gather as much information as possible regarding the patient, including: previous ED visits, pharmacy refills, ‘double-doctoring’, etc. Set Expectations: Talk to patients about statistics, risks and benefits of opioids. “My job is to manage your pain, at the same time, I manage the potential for some pain medications to harm you” Transfer the Blame: Do not blame the patient for opioid misuse. “Prescription pain medications, even when used as directed, can cause patients to become dependent, and I’m concerned that the pills we prescribed for you in the past, even though you were using them appropriately, you many now be dependent on them.” “We can help you break free of that dependence” Ensure patients know that their medical concerns are taken seriously: “I want to make sure that there is nothing dangerous causing your pain, because that is our main responsibility in the emergency room. I want to relieve your symptoms and make you as comfortable as I can.” “I will not use opioids to control your pain, because I think opioids will make your condition worse, even if it makes you feel better in the short term.” “I think using opioids will be harmful to you, so if you want treatment for your pain I am going to try to treat your pain with other types of medicines” Alternatives to Opioids in Patients who Present to the ED with Acute on Chronic Pain Nerve blocks NSAIDs Ketamine: 0.3mg/kg, 20-30mg for most adults, as an IV drip over 10-20 minutes. Droperidol: available in the U.S. In Canada, other antipsychotics, such as haloperidol, may be helpful. Intravenous lidocaine: 1-3 mg/kg bolus followed by 1-3 mg/kg/h. Gabapentin: for neuropathic pain. For a discussion on the literature on the opioid-sparing effects of Ketamine go to Journal Jam 4 Pain Management Strategies for Specific Conditions Consider alternatives to opioids for common presenting complaints. Some treatment strategies our experts suggest for common complaints are listed below. Mechanical Back Pain: Local anesthetics (i.e. bupivacaine 0.5%, 10cc IM injected directly into the point of maximal pain). Migraines: Opioids are known not to be useful for improving the pain associated with migraine headaches, and are not routinely recommended. Medications options include: metoclopramide, prochlorperazine, NSAIDs, ergot, tryptans and high flow oxygen (8). Low dose propofol for refractory headaches has been reported to be effective in reducing the pain associated migraine headaches in case series (9). Dental Pain: Dental block. Fracture Pain: Combination of acetaminophen and ibuprofen. Sickle Cell Patients: Pain management in Sickle Cell patients is often challenging. Consider low dose IV ketamine for those patients in whom you suspect opiod misuse. For an in-depth discussion on managment of Sicle Cell Anemia in the ED go to Episode 68: Management of Sickle Cell Disease in Emergency Medicine Chronic Abdominal Pain: Haldol, ketamine. NOTE: These strategies do not apply to palliative and end of life care. See Episode 70 for a discussion of opioid use in palliative care and end of life care. Precautions for Prescribing Opioids in Chronic Non-Cancer Pain in the Acute Setting Adapted from Canadian guideline for safe and effective use of opioids for chronic noncancer pain, 2011 (10) In general prescribing opioids for chronic pain in the ED should be avoided when possible. If you do prescribe opioids to these patients, consider the following actions: Contact the patient’s pharmacy: if you are unable to obtain pharmacy records, or if the patient’s history is inconsistent with information from the pharmacy, do not prescribe opioids. Inform the patient that this is a one-time only prescription,

Pediatric seizures are common. So common that about 5% of all children will have a seizure by the time they’re 16 years old. If any of you have been parents of a child who suddenly starts seizing, you’ll know intimately how terrifying it can be. While most of the kids who present to the ED with a seizure will end up being diagnosed with a benign simple febrile seizure, some kids will suffer from complex febrile seizures, requiring some more thought, work-up and management, while others will have afebrile seizures which are a whole other kettle of fish. We need to know how to differentiate these entities, how to work-them up and how to manage them in the ED. At the other end of the spectrum of disease there is status epilepticus – a true emergency with a scary mortality rate - where you need to act fast and know your algorithms like the back of your hand. This topic was chosen based on a nation-wide needs assessment study conducted by TREKK (Translating Emergency Knowledge for Kids), a collaborator with EM Cases. With the help of two of Canada’s Pediatric Emergency Medicine seizure experts hand picked by TREKK, Dr. Lawrence Richer and Dr. Angelo Mikrogianakis, we’ll give you the all the tools you need to approach the child who presents to the ED with seizure with the utmost confidence.

When was the last time you saw ventricular fibrillation in a 4 month old? Dr. Simard tells his Best Case Ever of a Pediatric Cardiac Arrest in which meticulous preparation, sticking to his guns, early activation of the transportation service, and clever use of point of care ultrasound helped save the life of a child. He explains the importance of debriefing your team after an emotionally charged case.