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Update in Emergency Medicine

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  1. Update in Emergency Medicine Robert Day Director of Emergency Medicine Royal North Shore Hospital

  2. Objectives • Lots of topics requested • Acute cardiopulmonary disease • Anaphylaxis • Cardiac arrest – ALS and BLS • Septic shock • Paediatrics • Head injury • TIA and Stroke

  3. Acute respiratory distress 24 year old with history of asthma arrives in some distress with a respiratory rate of 32 and SaO2 of 94%. Speaking in phrases. • Moderate to severe exacerbation • Initial treatment • Salbutamol 5mg x 3 q20min • Ipratropium 500mcg x 1 • Oral or IV steroids • Reassess

  4. Asthma continued No improvement after 2 nebs with increasing resp distress, intercostal recession, speaking in words Urgent situation Continuous nebulised salbutamol Intravenous salbutamol IV Magesium CPAP/ BiPAP Intubation preparation IV adrenaline in small doses eg 0.1mg diluted (1ml of 1:10,000)

  5. Take home messages • Severe asthmatic • Continuous oxygen driven nebulisers • Get to hospital • Small doses of IV adrenaline can buy time • Intubation last resort

  6. 82 year old man presents by ambulance with sudden shortness of breath, chest tightness. Chest sounds wheezy and rattly. Coughing frothy pink sputum. Obs: pulse 96, BP 200/130, RR 32, sats 96% on NRB Diagnosis? Treatment?

  7. Hypertensive and LVF – need to reduce afterload, increase preload • Fluid overload not usual problem • ECG to rule out STEMI, • Monitoring, O2, IV access • Nitrates +/- morphine • BiPAP • Reduces work of breathing • Forces fluid out of alveolar space

  8. LVF plus hypotension • Too much nitrate? • Tachyarrhythmia? • Cardiogenic shock • Fluid gently if inferior AMI • Inotropic • Cath lab urgently if AMI

  9. Pneumothorax • Types: • Primary spontaneous • Secondary – underlying lung disease • Traumatic +/- rib fractures

  10. Primary Pneumothorax 18yo presents with sudden onset of left pleuritic chest pain. Some SOB when walking No past med hx

  11. Primary pneumothorax • Risk factors: • Smoking • 12% lifetime risk in men vs 0.1% non-smokers • Pleural blebs and bullae • Tall, thin males • Asthma history • 50% recurrence rate in 4 years • Evaluation of size: • British Thoracic Society Guideline 2003 • Expiratory CXR not required • Small vs Large ptx – 2cm rim of air = 50% ptx

  12. Primary pneumothorax cont • Options for treatment: • Leave vs aspiration vs chest tube • Leave < 2cm rim of air on CXR and not breathless • Attempt aspiration > 2cm rim of air and/or breathless- 70-80% success • Unsuccessful aspiration • Try again • Small bore intercostal catheter, remove at 24 hours if fully reexpanded • High flow oxygen • Surgical pleurodesis at 5 days if persistent leak

  13. Aspiration • Re Xray 4 hours after procedure • Home if reexpanded • Warn if increasing pain, breathlessness to seek help immediately • Re X ray next day then at 1-2 weeks • Same if conservatively treated

  14. Follow up Reabsorbs over weeks No flying till fully resolved (airline rules 6 weeks) No diving ever Resumption of sporting activity ? 2-4 weeks

  15. Secondary pneumothorax • Age > 50, underlying pulmonary disease • High rate of failure of conservative treatment • Only small apical asymptomatic, < 1cm ptx • Usually need hospitalisation with a small bore chest drain until reexpanded • BTS guideline: • < 50yo, < 2cm rim of air, not breathless – try aspiration and admit 24 hours • > 50yo or > 2cm air or breathless - ICC • Early surgical referral (3 days)

  16. Traumatic ptx Ptx on CXR usually requires ICC and admission Especially if requiring GA Traumatic ptx on CT scan less important

  17. Take home messages • Asymptomatic ptx < 2cm can be treated conservatively • in under 50, • no underlying lung disease • Many primary pneumothoraces can be aspirated – 70-80% success

  18. 60 year old with no known history of allergy eating an asian meal at a local restaurant. Within 2 minutes develops generalised erythema and itch, vomits, dizzy and collapses. Develops increasing of face and tongue and a hoarse voice, difficulty breathing

  19. Anaphylaxis • Classified: • mild: skin and subcutaneous tissues only • non-sedating antihistamines (cetirizine, loratidine) for symptoms • moderate: features suggesting respiratory, cardiovascular, or gastrointestinal involvement • severe: hypoxia, hypotension or neurological compromise

  20. Treatment of mod/severe anaphylaxis • Emergency management of anaphylaxis: • Adrenaline • Adrenaline • Adrenaline • 0.5ml of 1:1000 amp IM in the lateral thigh (0.1 ml/kg to maximum 0.5ml) • ie half a 1ml amp for an adult • May be repeated every 3-5 minutes depending on response • Beware of using IV adrenaline

  21. Adjunctive treatment Lie patient flat Oxygen IV access/ NS 20mg/kg Salbutamol neb for bronchospasm Neb adrenaline for upper airway obstruction Atropine for bradycardia Glucagon for beta blocked patients Steroids, antihistamines - H1 and H2 blockers (eg ranitidine)

  22. Keep for 4 hours minimum post Adrenaline – should be observed in ED Follow up with allergy specialist if severe – RNSH OPD If severe provide EpiPen (0.3mg) and instructions

  23. Cardiology • Acute coronary syndromes • ETAMI • High sensitivity troponins

  24. ETAMI - Emergency Treatment of AMI • Ambulance paramedics do an ECG on patients with chest pain • Across Northern Sydney transmitted to RNSH ED 24 hours • ECG Read by EM specialist/registrar -call back to ambulance via mobile • STEMI: transport to RNSH/ Cath lab alerted • others: to local hospital

  25. ETAMI Pioneered at RNSH from 2004 Front door to needle time of 18 minutes Sydney wide system from August to cath labs at major hospitals

  26. High sensitivity troponins • 6-7% patients present to ED with chest pain – about 3,500 pa. Half have ACS. • Over 10,000 troponins a year • Until end 2009 using 3rd gen trop test: • NR < 0.03 mg/L, 0.03 – 0.2 equivocal • Now 4th generation troponin assay • < 14ng/ml negative, 13-100ng/mL equivocal • What does this mean? • Many more false positives • How do you interpret a low positive test?

  27. High sensitivity troponins cont. • Patients need to be clinically risk stratified • Good ACS story plus N trop = admission for Ix • Poor ACS story plus low N trop may be able to go home • Change in serial troponin important • We are using 30% change in 6 hours • 3 hour trop for high risk patients • Be aware of other diagnoses causing rise in troponin

  28. Non ACS causes of raised troponin • Pulmonary embolism • Acute cardiac failure • Myocarditis • Aortic dissection • Acute decompensated AV disease • Renal insufficiency

  29. BLS and ALS changes • BLS • New literature • emphasising minimal interruptions to ECM • questioning role of early breathing interventions – compression only CPR? • ARC: "ANY ATTEMPT AT RESUSCITATION IS BETTER THAN NO ATTEMPT" and if a rescuer is unwilling to do rescue breaths then chest compressions are better than nothing.” • Revised ARC guidelines due Dec 2010 • www.resus.org.au/

  30. BLS • Rate of compression to breath 30:2 • 2 initial rescue breaths • ECM 100/min (5 cycles in 2 minutes) • Frequent rotation of rescuers – every 2 minutes • Don’t interrupt CPR to check for signs of life • Use AED as soon as available

  31. ALS for VF /pulseless VT • Early defibrillation for VF • Look for alternative reversible causes • Witnessed arrest • Precordial thump • Stacked shocks x 3 - 200J biphasic defib • AEDs will only deliver a single shock • Commence CPR ASAP

  32. ALS for VF/pulseless VT • Further DC shocks for VF/VT: • Given every 2 minutes • Adrenaline – 10mls of 1:10000 (1mg) IV • Given every 3 minutes • Securing airway – no more than 20 seconds break in CPR

  33. ALS - other drugs • Antiarrhythmics • Amiodarone drug of choice for prolonged VF/pulseless VT • 300mg (5mg/kg) • Atropine, Calcium, Bicarbonate, Magnesium • No evidence of benefit except in specific circumstances

  34. Patient in non-shockable rhythm • Asystole/Pulseless Electrical Activity • CPR / Rescue breathing 30:2 • Adrenaline every 3 minutes • Search for a reversible cause: • 4 H’s and 4T’s: • Hypoxia Tamponade • Hypovolaemia Tension ptx • Hypo/hyperkalaemia Toxins / drugs • Hypo/hyperthermia Thrombosis – pulm or cardiac

  35. Paediatric resus Rare! Shocks: first 2J/kg then subsequent 4J/kg Importance of CPR/rescue breathing Ratio for advanced providers 15:2 Using IO access

  36. Take home messages • Don’t interrupt chest compressions • 100/min • change regularly • Place of rescue breathing being questioned but still in guidelines • Ratio 30:2 • DC shocks 2 minutely for VT/VF • Adrenaline 1mg IV q3min

  37. 70 year old man presents with a week of left loin pain, difficulty passing urine, poor oral intake. Now confused and febrile. • At triage vital signs: • P 120, BP 90/60, • RR 28/min, sats 98% room air, • T39.2

  38. EGDT in septic shock • Early 2000’s US study (Rivers) • aggressive early resuscitation, • Early ICU care, • maintenance of blood pressure with inotropes, • Hb/haematocrit optimisation, • Careful monitoring of oxygenation via CVC • improved mortality 50% to 35%

  39. Clinical Excellence Commission Sepsis Review • Recent NSW study showed septic shock markedly over represented in major reported incidents • Across all types of hosp. • Non-recognition of sepsis • Delays in starting treatment • ABx • Treatment of poor organ perfusion • Poor monitoring of vital signs • Over 65 yo and after hours over represented • Oliguria, hypotension, tachycardia +/- fever = septic shock until proven otherwise

  40. ARISE trial • attempting to study role of EGDT in Australian population - RNSH lead hospital • Patients who present with: • sepsis (T >38 or < 34 with evidence of an infection) • BP < 90 systolic not responding to 1000mls IV fluid or • Lactate > 4 • All get early antibiotics • Randomised into trial for EGDT vs normal treatment

  41. 70 yo patient with urosepsis: • Recognition at triage – resus bed • Aggressive fluid resuscitation to restore BP > 90 systolic – may need 2-4 litres • After 1000mls NS if BP< 90 or lactate > 4 entered into ARISE trial • Early antibiotics essential – broad spectrum ABx should be given within one hour • Early inotropic support eg noradrenaline • Look for a source – urine, abdominal, chest, cannulas, cellulitis, others

  42. Take home messages • Think about sepsis as a diagnosis – subtle early signs • Urosepsis, hypotension dangerous combination • Early antibiotics and resuscitation

  43. Paediatrics - dehydration • DOH CPG: Management of Children with Gastroenteritis http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf • Major themes: • Rehydration: • Less use of IV fluids • More emphasis on oral rehydration • If child requires IV: • Use of NS + 2.5% glucose rather than hypotonic solutions

  44. Oral rehydration • Oral rehydration solutions • Hydralyte, Gastrolyte (no sports drinks, fruit juice, soft drinks) • Parent should offer 0.5mls/kg every 5 minutes eg with a syringe • Charted by parent including vomits, U/O • Parental attention, persistence encouraged by staff • Rapid rehydration via NGT an option • ORS via Kangaroo pump @ 10mls/kg/hr x 4hrs

  45. Medications in gastroenteritis • Antiemetics: • Ondansetron: some evidence of benefit • No evidence for prochlorperazine or metoclopramide • Antidiarrhoeals / antimotility agents • No evidence • Antibiotics: • Rarely required

  46. IV therapy • Who for? • Mild (3%) - Reduced UO, Thirst, Dry mucous membranes, mild tachycardia • Oral only required • Moderate (5%) - Dry mucous membranes, tachycardia, abnormal respiratory pattern, lethargy, reduced skin turgor, sunken eyes – try oral first if fails go to IV

  47. IV therapy • Severe (10%) • all of above, poor perfusion: mottled, cool limbs/Slow capillary refill/Altered consciousness • Shock: thready peripheral pulses with marked tachycardia and other signs of poor perfusion – IV or IO therapy, 20mls/kg bolus NS