On the Horizon: Propofol for Migraines

Propofol for the treatment of migraines in the ED might be on the horizon.

This will possibly be a new practice in emergency medicine, although it has been known for some time. Propofol, when given at procedural sedation doses, seems to miraculously terminate migraines refractory to usual treatment. Patients awake with minimal to no headache and may be discharged from the ED much quicker than traditional treatment with possibly less side effects. The proposed mechanism of action is described in below papers, but in short, propofol seems to "reboot" the brain and terminate the migraine.

What is the evidence?

It all started with a paper by Krusz et al in Headache 2000 in the late 1990s at a headache clinic using propofol for procedural sedation during epidural blocks.

Who:

77 patients with headache severity ≥7/10 on VAS failing outpatient oral regimens

Intervention:

Non-blinded 20-30 mg of IVP propofol every 3-5 minutes until symptom resolution not to exceed 1 hour

Results:

Average reduction in headache severity = 95.4% at 30 minutes
82% had total abolition of migraines and associated symptoms
18% had a VAS-pain decrease of 50-90%
3 of 77 patients had return of headache the following day
Average dose of propofol 110 mg (~1-1.5 mg/kg for average size adult)
No adverse events

Then in 2012, Soleimanpour et al published in BMC Neurology, a prospective randomized double-blind trial conducted in Iran.

Who:

90 adult ED patients presenting with a migraine

Intervention:

Propofol 10 mg IVP every 5-10 minutes (maximum of 80 mg) versus dexamethasone 0.15 mg/kg (max 16 mg) IVP

Results:

Propofol performed statistically better as measured by VAS pain reduction at 5, 10, 20, 30, and 45 minute marks
Propofol group adverse events: 2 patients desat to 89% resolving with O2 administration

Don't forget that kids get migraines too! A 2012 retrospective case-control review by Sheridan et al in Pediatric Emergency Care from a pediatric ED studied kids with migraines who received propofol compared to standard treatment.

Who:

7 pediatric patients with migraines receiving sub-anesthetic doses of propofol were compared to those with usual abortive therapy (NSAIDs + prochloroperazine + diphenhydramine)

Intervention:

Average of 1.71 mg/kg of propofol total given as 10-50 mg IVP doses

Results:

Propofol was significantly better at decreasing VAS pain (80% vs 60%)
No difference in length-of-stay after medications
No difference in re-visits after 24 hours
No adverse events

There is more data on the horizon. Study NCT01604785 will be recruiting 160 kids to evaluate propofol versus standard treatment for pediatric migraines.

If you do decide to use propofol for migraines, here are some recommendations:

Consider for patients failing usual rescue treatments
Follow your ED's protocol for procedural sedation
Administer propofol as 10-20 mg IVP every 3-4 minutes up to 1 mg/kg
Aim to have a lightly sedated patient - the goal is not for the EtCO2 to disappear
Consider one-dose of dexamethasone 10 mg IV/PO prior to discharge to prevent recurrence (Colman et al in BMJ & Huang et al in Eur J Neuro)

We at UCSF are also doing a multi-center retrospective study of propofol in the ED. If you've given or seen propofol in your ED for migraines, we'd love to have you participate.

Conclusion
There might be some benefit to the milky goodness of propofol for intractable migraines in the ED, but adequate trials are currently lacking.

Let me know your feedback!

Zlatan Coralic, PharmD
(@ZEDPharm)
Assistant Clinical Professor, UCSF
Emergency Department Clinical Pharmacist

Image 1

References

Krusz JC, Scott V, Belanger J. Intravenous propofol: Unique effectiveness in treating intractable migraine. Headache. 2000Mar;40(3):224-30. PMID 10759925
Soleimanpour H, Ghafouri RR, Taheraghdam A,Aghamohammadi D, Negargar S, Golzari SE, et al. Effectiveness of intravenous dexamethasone versus propofol for pain relief in the migraine headache: Aprospective double blind randomized clinical trial. BMC Neurol. 2012 Sep29;12:114,2377-12-114. PMID 23020264
Sheridan DC, Spiro DM, Nguyen T, Koch TK,Meckler GD. Low-dose propofol for the abortive treatment of pediatric migraine in the emergency department. Pediatr Emerg Care. 2012 Dec;28(12):1293-6. PMID 23187986
Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, et al. Parenteral dexamethasone for acute severe migraine headache: Meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008 Jun 14;336(7657):1359-61. PMID 18541610
Huang Y, Cai X, Song X, Tang H, Huang Y, Xie S, et al. Steroids for preventing recurrence of acute severe migraine headaches: A meta-analysis. Eur J Neurol. 2013 Apr 11. PMID 23577697

05.24.13

by Academic Life in EM

Maximizing Conferences through Twitter

Conferences are necessary. It’s how we network, exchange research ideas, and share advances in emergency medicine. The reality is that we cannot attend every conference out there because of time, money, and schedule conflicts. But thanks to Twitter, it is no longer necessary to be physically present to reap benefits of a conference.

This post lists information on how to get involved and stay involved with the Twitter conversation and learn from our great conferences without breaking your bank or schedule.

Tweets

In general there are 5 different types of tweets that are sent out from conferences:

Session related – discussions about sessions/workshops
Social – arranging unofficial meetings/meeting new people
Logistics – change in room locations/events, information about an individual’s presentation
Advertising – Tweets from companies present at the meetings

Efficiently filtering through the various tweets will expose you to new material, gain exposure to expert opinion on evidenced based medicine, while also be sure to not miss out on a poster session due to a venue change.

# Hashtags

Knowing which hashtag to follow is the next step. Generally conference hashtags are intuitive and therefore searchable. For example, this past SAEM meeting's hashtag was #SAEM13. Simply using your twitter account to follow the hashtag will keep you in the loop of the conversation. Websites such as Symplur and its Healthcare Hashtag Project can help you create hashtags for conferences and keep track of healthcare related conferences that are easy to find and follow.

Contributing and filtering conference tweets
It can be overwhelming deciding whose tweets to follow while at conferences. Admittedly, it can be distracting if you are in the middle of an interesting session but can’t put down your twitter feed that is buzzing about another session next door. Some people will tweet 1-2 pearls per workshop, while others are giving a second by second playbook to the action, akin to a CNN newsfeed. It is up to you to decide which type of tweeting is your style.

Introducing ALiEM Conference Twitter account (@ALiEMconf)

The writers at this blog have decided to create a joint twitter account that can represent the ALiEM blog at conferences. Our goal is to share pearls, evidence based medicine, and exciting events in the world of emergency medicine.

Virtually follow us at conferences and join in on the conversation!

Note: David Marcus, EM IM resident from Long Island Jewish Hospital in NYC has also approached the problem of getting conferences onto the social media band wagon. Through his blog www.emimdoc.wordpress.com, he has assembled an up to date list of upcoming EM/IM/Critical Care conferences with affiliated hashtags.

Please share your comments!

Nikita Joshi, MD
(@NJoshi8)
Medical Education Fellow
Stanford University, Division of Emergency Medicine

References:

Neill A et al. The Impact of Social Media on a Major International Emergency Medicine Conference. Emerg Med J 2013; 0: 1 – 4. PMID:23423992.

Images 1 Image 2

05.23.13

by Academic Life in EM

PV Card: Contraindications to Thrombolytics in Stroke

This PV card is an updated version of the PV card on Thrombolytic Contraindications for CVA from September 10, 2010, based on the Stroke 2013 AHA/ASA new guidelines that were just published. Some changes include:

There is new mention of new anticoagulants in the market with additional absolute exclusion criteria.
A blood glucose < 50 mg/dL has been upgraded from a relative exclusion to an absolute exclusion criteria. There is no more mention of glucose > 400 mg/dL as an exclusion criteria.
Seizure at onset of presentation has moved from an absolute to a relative risk.
Post-AMI pericarditis is no longer a relative exclusion criteria.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Jauch EC, et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947. PubMed PMID: 23370205. Free article PDF

05.22.13

by Academic Life in EM

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

The Case
A 56 y/o man presents to the ED via ambulance. He was sent from clinic for 'new onset afib.' His pulse ranges between 130 and 175 bpm, while his blood pressure is holding steady at 106/58 mm Hg. He has a past medical history significant for hypertension and hypercholesterolemia. His only medications are hydrochlorothiazide and atorvastatin. The decision is made to administer an IV medication to 'rate control' the patient with a goal heart rate < 100 bpm.

The Clinical Question
Calcium channel blockers, such as diltiazem and verapamil, can both cause hypotension. In the case above, the patient has borderline hypotension.

What is the evidence behind giving IV calcium as a pre-treatment to prevent hypotension from calcium channel blockers?

The Data

The following table only includes studies where patients received calcium before the calcium channel blocker:

Citation	Study Design	N	Drug	Calcium Form/Dose	Results
Weiss AT, et al. Int J Cardiol 1983; 4:275-84.	Prospective	13	Verapamil	Calcium gluconate 1 gm	SBP ↑ 5 mm Hg
Roguin N, et al. Clin Cardiol 1984; 7:613-6.	Case series	2	Verapamil	Calcium gluconate (pediatric pts)	No hypotentsion
Haft JI, et al. Arch Intern Med 1986; 146:1085-9.	Sequential study of 2 treatment protocols	50	Verapamil	CaCl 1 gm	SBP ↑ 2 mm Hg
Salerno DM, et al. Ann Intern Med 1987; 107:623-8.	Sequential study of 2 treatment protocols	5	Verapamil	Calcium gluconate 1gm	SBP ↓ 12 mm Hg
Stringer KA, et al. Drug Intell ClinPharm 1988; 22:575-6.	Case Report	1	Verapamil	CaCl 1gm	No hypotension
Barnett JC, et al. Chest 1990; 97:1106-9.	Prospective report of protocol	19	Verapamil	Calcium gluconate 1gm or CaCl 1gm	SBP ↑ 4 mm Hg
Kuhn M, et al. Am Heart J 1992; 124:231-2.	Retrospective chart review	18	Verapamil	Calcium gluconate 3gm or CaCl 1gm	No hypotension
Miyagawa K, et al. J Cardiovasc Pharmacol 1993; 22:273-9.	Sequential study of 2 treatment protocols	7	Verapamil	Calcium gluconate 3.75 mg/kg	SBP: no change

Kolkebeck T, et al. J Emerg Med 2004; 26(4):395-400.	Prospective, randomized, double-blind, placebo-controlled	34	Diltiazem	CaCl 0.333 gm	SBP ↓ 8 mm Hg (placebo had SBP ↓14 mm Hg)

SBP: systolic blood pressure

CaCl: calcium chloride

Clinical Impact

The data supports administering calcium before verapamil to prevent hypotension, without negatively impacting the desired rate control effect.

There has been only one study trying this approach with diltiazem (Kolkebeck 2004). Although there was NOT a statistically significant difference, the group that received calcium did have less of a blood pressure decrease than the group receiving placebo (SBP difference -8 vs -14 mm Hg).

LimitationsThe biggest weakness of this study, to me, is that the authors used the manufacturer-recommended dose for diltiazem of 0.25 mg/kg first (max 20 mg), then 0.35 mg/kg (max 25 mg). This dose is rather large and often causes hypotension. The authors note limitations including the small sample size, the convenience sample design, and that a low dose of calcium was used (333 mg of 10% calcium chloride, 90 mg elemental calcium).

Why not use smaller doses of diltiazem starting at 5 or 10 mg and repeat as needed? We have had good success using this approach with diltiazem combined with pre-treatment calcium gluconate 1-2 gm. Others have utilized diltiazem infusions without a bolus to avoid the hypotensive effects. This approach allows for slow titration and the option to stop (or slow) the infusion if hypotension occurs.

Still others might argue to just give metoprolol. Actually, calcium channel blockers have performed admirably versus beta-blockers in this scenario and are recommended as first line (more to come in a future post).

Conclusions

Although most of the data is with verapamil, administering calcium before diltiazem may prevent some of the hypotension.
There currently isn't much published data for diltiazem. The one study, which was a negative one, had some limitations.
The appropriate calcium dose is unknown, but 90 mg of elemental calcium (calcium gluconate 1 gm or calcium chloride 0.333 gm) is often used. We use 1 or 2 gm of calcium gluconate.

- Bryan Hayes, PharmD
( @PharmERToxGuy)

Reference
Moser LR, et al. The use of calcium salts in the prevention and management of verapamil-induced hypotension. Ann Pharmacother 2000;34:622-9. [PMID 10852091]

05.21.13

by Academic Life in EM

How Social Media is Making an Impact in Medicine

Whether you realize it or not, the use of social media (i.e. Facebook, twitter, and blogs) has found its way into the world of medical students, residents, physicians, and medical educators all around the world. The use of these resources has several advantages versus in-person/print educational tools:

Overcomes physical or temporal barriers
Provides searchable content
Encourages interactivity

What are the most common social media tools used, opportunities, and challenges in medical education?

What they did:

Systematic literature review of 14 studies

Questions asked:

Do social media tools affected outcomes of satisfaction, knowledge, attitudes, and skills for physicians and physicians-in-training?
What challenges and opportunities specific to social media have educators encountered in implementing these interventions?

Results:

Most common social media tools used:

Blogs 71%
Wikis 21%
Twitter 14%
Facebook 14%

Most common social media aims:

Enhance clinical skills or knowledge 50%
Promote empathy, reflection, or professionalism 36%
Increase interest in a field 14%

Most commonly cited opportunities:

Active learning 71%
More feedback 57%
Enhanced collaboration 36%
Professional development 36%
Career advancement/networking 21%
Supportive learning communities 14%

Most commonly cited challenges:

Technical issues 43%
Variable learner participation 43%
Privacy/security concerns 29%

Limitations:

Only one randomized controlled trial reviewed
No comparison group in evaluation of satisfaction
Studies included were too heterogeneous to perform sensitivity, subgroup or meta-analyses

Conclusion:

Social media use in medical education is an emerging field of scholarship that merits further investigation.

How can social media impact a conference?

What they did:

Documented the use of social media at The International Conference on Emergency Medicine (ICEM) 2012
Determine the presence and activity of speakers on social media platforms
Use of Twitter by attendees and non-attendees

Primary Objective:

Report the presence and use of social media

Results:

212 speakers:

41.5% use Linkedin
15.6% use Twitter
9.4% use a website/blog
<1% use Google Plus

4,500 tweets during conference:

>400 people produced tweets, but only 34% were physically present at the conference
74.4% of the tweets were related to the clinical and research material presented at the conference

Limitations:

Difficult to determine the significance and impact of Twitter on changing clinician practice patterns

Conclusion:

A large number of original tweets regarding clinical material at the conference were produced, with a very large portion coming from non-attendees.

Can Tweets Predict Citations?

What they did:

Looked at all tweets containing links to articles in the Journal of Medical Internet Research (JMIR)
4,208 tweets cited 286 articles

Goals and questions:

To measure social impact of and public attention to scholarly articles by analyzing buzz in social media
To explore the dynamics, content, and timing of tweets relative to the publication of a scholarly article
Question: Are social media metrics sensitive and specific enough to predict highly cited articles?

Results:

Most tweets were sent on the day (43.9%) or the day after (15.9%) an article was published in a 60 day period.
9/12 (75%) of highly tweeted articles were highly cited
Top-cited articles can be predicted from top tweeted articles with 93% specificity and 75% sensitivity

Limitations:

Internal validation of one journal and no external validation

Conclusions:

Tweets can predict highly cited articles within the first three days of article publication

Summary
These three publications demonstrate that social media is here to stay in Medicine and medical education. Twitter especially has grown in popularity. Overall social media has an incredible potential to enhance and engage active learning among physicians and physicians-in-training. The next step now is to focus future research on outcomes (i.e. change in practice patterns) to help validate this technology.

References:

Cheston CC et al. Social Media Use in Medical Education: A Systematic Review. Acad Med 2013 June; 88 (6). PMID: 23619071
Eysenbach, Gunther. Can Tweets Predicts Citations? Metrics of Social Impact Based on Twitter and Correlation with Traditional Metrics of Scientific Impact. J Med Internet Res 2011; 13 (4): e123. PMID:22173204
Neill A et al. The Impact of Social Media on a Major International Emergency Medicine Conference. Emerg Med J 2013; 0: 1 – 4. PMID: 23423992

05.20.13

by Academic Life in EM

Review: Emergency Medicine: Avoiding The Pitfalls and Improving The Outcomes

A pitfall is defined as "an unapparent source of trouble or dagner; a hidden hazard" by thefreedictionary.com.

In the book Emergency Medicine Avoiding the Pitafalls and Improving the Outcomes edited by Dr. Amal Mattu along with Dr. Deepi Goyal, you can find many pitfalls that should be considered when managing patients in the emergency department. The book, relatively affordable ($57) when it comes to print hard-bound textbooks, consists of 13 quick-read chapters of common chief complaints in emergency medicine. Some of the authors in this book include: Drs. Peter DeBlieux, Jairo Quintanilla, Robert Rogers, Michael Winters, and others.

The chapters are arranged by chief complaints, and each chapter is subdivided into pitfalls. The chapters include the evaluation and management of chest syndromes, dyspnea, abdominal pain, back pain, headache, neck pain, trauma, infectious disease, wound care, pregnant patient, pediatric patient, heme/onc, and intoxicated/violent patient. The content skips the basic evaluation and management of these chief complaints and focuses on key facts and pitfalls. At the end of each chapter you will find "Pearls for Improving Patient Outcomes", which is a list summarizing the salient, advanced-level pitfalls.

The book does not feel as if I am reading a textbook, but rather as if I was having a conversation with someone telling me how, with evidenced practice, they avoid these hidden hazards. The book is pretty thin which lends itself to be stored in the department for learning purposes. It is geared toward practicing clinicians and physicians-in-training as well. Although it is supposed to be used by physicians-in-training, it serves a different purpose than the traditional textbook which focuses on teaching the basics and classic presentations of clinical syndromes. The book has definitely broaden my knowledge of medical practice. I have thus become more vigilant of when things might go wrong in practice and not be so locked into the clinical patterns learned in medical school.

Should pitfalls be part of our early training? After all, it is part of the practice of medicine.

Images: 1, 2

jvrbntz profile

Javier Benítez (@jvrbntz)

Disclaimer: No conflict of interest

05.19.13

by Academic Life in EM

Patwari Academy video: Discharge instructions

Read more about the writing ED discharge instructions. It's a crucial part of your care of patients. Learn about the pearls and pitfalls in writing instructions. It's your continued communication with your patients.

ReferenceSamuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012 Aug;60(2):152-9. PMID: 22221840.

05.17.13

by Academic Life in EM

SAEM/CORD slides: Social Media for Emergency Educators

As requested by an audience member at today's talk at SAEM, Drs. Rob Cooney, Mike Bond, and I are sharing our slides and handout with you here.

Handout in Google Docs

05.17.13

by Academic Life in EM

Sim Case Series: Pediatric WPW

ALiEM Sim Case Series:

Pediatric WPW

Case Writer: Nikita Joshi, MD

Keywords
Pediatrics, Syncope, Wolff Parkinson White (WPW), PALS

Educational Objectives
Medical

Discuss a broad differential diagnosis for pediatric syncope
Identify critical findings in pediatric EKG
Manage WPW tachycardia

Communication

Obtain a focused history in a pt with WPW focusing upon family history
Communicate as an interdisciplinary team

Case Synopsis

10 yo boy BIBEMS s/p syncope. Pt was playing on the football field, running down field when he suddenly collapsed. Bystanders quickly went to the boy and within 1 minute the pt had regained consciousness without any intervention. When EMS arrived on the scene, the boy was sitting with his mother telling everyone he wanted to go back and play.

Upon arrival in the ED, pt is well appearing, however had a heart rate of 180 bpm and BP of 115/80. EKG shows a wide complex tachycardia rhythm. If team gives AV nodal blocking agents, the pt will devolve into a VF rhythm, and the pt will become nonresponsive. If team administers procainamide, pt will go into a rate controlled rhythm that reveals WPW and should then be placed on a procainamide drip. If team performs cardioversion, the pt will go into a rate controlled rhythm that reveals WPW. If the team does nothing, the pt will eventually go into a ventricular fibrillation cardiac arrest.

Download PDF of this flowchart

PDF this case-specific ABEM Milestone breakdown of PC1

PDF of more detailed scenario description

Critical Actions

Analyze and interpret pediatric EKG for life threatening causes of syncope
Initiate PALS for tachydysrhythmia
Avoid AV nodal blocking agents in undifferentiated wide complex tachycardias
Cardiovert pt early to avoid further decompensation
Obtain family history of WPW with ablation

Learners

Residents (EM, pediatrics)
Nurses
EMS providers
Students (medical, nursing, EMS)

Location: ED resuscitation bay

Patient: 10 yo boy

Equipment

Advanced airway equipment
Airway adjuncts
Broselow tape
Cardiac monitor
Cardioverter / defibrillator
IV fluid
Pediatric cardiac arrest cart
Syringes

Moulage

Sports clothing for manikin

Confederates

EMS provider – Gives history of well appearing pt on the football field. They did not obtain vitals because pt was so well appearing upon their arrival.
Mother – Unconcerned of syncopal episode, not good historian, thinks her son does not require medical care
Nurse – Completes and executes all orders provided
PICU attending (voice) – Discusses case with team over phone
Pediatric cardiology attending (voice) – Discusses case with team over phone

Supporting Files / Media

CXR – normal
EKG 1 – wide complex tachycardia, irregularly irregular
EKG 2 – VF
Echocardiography – normal, no effusion, good ejection fraction

Translation
AV	atrioventricular
BIBEMS	brought in by EMS
BP	blood pressure
CXR HR	chest x-ray heart rate
IV	intravenous
LOC	loss of consciousness
neg	negative
RR	respiratory rate
pt	patient
s/p	status post
T	temperature
WPW	Wolff Parkinson White
US	ultrasound
VF	ventricular fibrillation
yo	year old

References

Boren SD. Commotio cordis. N Engl J Med. 2010. 362(23):2229-30. PMID: 20568311
Fischer JWJ. Cho CS. Pediatric Syncope: Cases from the Emergency Department. Emergency Medicine Clinics of North America. 2010. 28;3. PMID 20709241
Life in the Fast Lane Blog Post: http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/
Mottram AR. Svenson JE. Rhythm Disturbances. Emergency Medicine Clinics of North America. 2011. 29;4. PMID 22040704

Image 1

05.16.13

by Academic Life in EM

PV card: Early repolarization vs STEMI on EKG

Image courtesy of Dr. Steve Smith at HQMedEd-ecg.blogspot.com

You are handed this EKG for a 50 yo man with moderate chest pain for 2 hours now and no associated symptoms typical for ACS, PE, aortic dissection, or any other red flags of chest pain. He has no prior EKG's on file.

Is this early repolarization or ST elevation MI?
Should I activate the cardiac catheterization lab?

Here are some great literature-based pearls compiled by Dr. Jason West (@JWestEM), an EM resident from Jacobi/Montefiore.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Below is the calculator widget, which Dr. Steve Smith created for his blog and kindly let me use here as well. To use the widget, enter the following pieces of data from the EKG:

ID = [you can leave this blank]
STE60V3 = STE elevation height at 60 msec (1.5 small boxes) after the J-point in lead V3 (mm)
QTc = The computer-read QTc interval
RA V4 = R wave amplitude in lead V4 (mm)

The formula to differentiate early repolarization vs STEMI, per Dr. Smith's publication, equals:

(1.196 x STE60V3) + (0.059 x QTc) - (0.326 x RA V4)

A result of > 23.4 is predictive of an LAD occlusion causing a STEMI, rather than early repolarization.

P.S. The above EKG image shows early repolarization.

References

Brady WJ, et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med. 2001 Oct;8(10):961-7. PMID: 11581081.
Brady WJ, et al. Reciprocal ST segment depression: impact on the electrocardiographic diagnosis of ST segment elevation acute myocardial infarction. Am J Emerg Med. 2002 Jan;20(1):35-8. PMID: 11781911.
Chung SL, et al. Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED. Am J Emerg Med. 2013 Mar 8. PMID: 23478112.
Smith SW. Upwardly concave ST segment morphology is common in acute left anterior descending coronary occlusion. J Emerg Med. 2006 Jul;31(1):69-77. PubMed PMID: 16798159.
Smith SW, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012 Jul;60(1):45-56.e2. PMID: 22520989.
Larson DM, et al. "False-positive" cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007 Dec 19;298(23):2754-60. PMID: 18165668.
Nfor T, et al. Identifying false-positive ST-elevation myocardial infarction in emergency department patients. J Emerg Med. 2012 Oct;43(4):561-7. PMID: 22284976

05.14.13

by Academic Life in EM

Three predictors for success in cardiac arrest resuscitations

The goal of resuscitation in cardiac arrest is to respond in a timely, effective manner that leads to good patient outcomes. Resuscitation is not taking an ACLS and BLS course and going through the motions of a code. There have been several studies looking at the quality of intubation and CPR, and their association with good patient outcomes.

1. Is first pass success of orotracheal intubation important?

What they did:

Is there an association of first pass intubation success with incidence of adverse events (AEs)?
Retrospective analysis
1,828 orotracheal intubations
Single academic ED

Primary Outcomes:

AEs: aspiration, oxygen desaturation, dental trauma, laryngospasm, pneumothorax, esophageal intubation, hypotension, dysrhythmia, and cardiac arrest

Results:

Most common AE was oxygen desaturation
First attempt success = 14.2% AEs
Two attempts = 47.2% AEs
Three attempts = 63.6% AEs
Four or more attempts = 70.6% AEs

Limitations:

Single center study
Retrospective analysis
Data was self-reported which could cause recall bias and under reporting of AEs

Conclusion: As the number of attempts increases, the incidence of AEs increases substantially

2. Does the rate of CPR matter?

What they did:

Prospective observational study
3 hospitals
97 cardiac arrests
Measured chest compression rates

Primary Outcome:

Return of spontaneous circulation (ROSC)

Results:

CPR rate <80 in 36.9% of cases
CPR rate <70 in 21.7% of cases
CPR rate of patients with ROSC 90 +/- 17
CPR rate of non-survivors 79 +/- 18

Limitation:

Data collected from an observer (human error)

Conclusion: Suboptimal chest compression rates correlate with poor ROSC.

3. Does End-Tidal Carbon Dioxide predict successful resuscitation and survival from cardiac arrest?

What they did:

Prospective, observational study
737 cases of out-of-hospital cardiac arrest
Recorded the partial pressure of end-tidal carbon dioxide (PetCO2) measured during CPR

Primary Outcome:

PetCO2 predicting restoration of spontaneous circulation (ROSC)

Results:

Average PetCO2 = 6.9 +/- 2.2 mmHg in patients without ROSC
Average PetCO2 = 32.8 +/- 9.1 mmHg in patients with ROSC
PetCO2 <14.3mmHg discriminated between ROSC and No ROSC after 20 minutes of ACLS with sensitivity, specificity, NPV, and PPV of 100%

Conclusions: PetCO2 > 14.3 mmHg after 20 minutes of ACLS predicts ROSC with accuracy

Summary
First pass intubation success, high-quality chest compressions at rate of 100 bpm, and PetCO2 >14.3 mmHg during CPR are important predictors for success in the resuscitation of patients in cardiac arrest.

References:

Abella BS et al. Chest Compression Rates During Cardiopulmonary Resuscitation are Suboptimal: A Prospective Study During In-Hospital Cardiac Arrest. Circulation 2005; 111: 428–34. PMID: 15687130
Abella BS. The Importance of Cardiopulmonary Resuscitation Quality. Curr Opin Crit Care 2013 Apr. PMID:23587758
Sakles JC et al. The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med 2013 Jan; 20: 71–8. PMID: 23574475
Weil MH et al. Partial Pressure of End-Tidal Carbon Dioxide Predicts Successful Cardiopulmonary Resuscitation in the Field. Crit Care 2008; 12 (6): 90. PMC:2646332

05.13.13

by Academic Life in EM

Improving Consultation Communication Skills

This is a great article by Chad Kessler, et al. where the authors delve into the world of communication skills. Talking to colleagues is an essential skill especially as we advocate for our patients. We should not only know what's going on with our patients, but also how to communicate our thoughts effectively and succinctly with our colleagues. In this article published in April 2013 in Academic Medicine, the authors state that although "communication skills may not develop naturally, [they] can be taught and fostered through evidence-based educational models."

Working on improving communication skills is especially in the emergency department because of its high volume of consults. Without adequate training, miscommunications both on the telephone and in person can lead to significant delays and errors in patient care.

The article reviews the 5Cs of consultation (Contact, Communication, Core question, Collaboration, Closing the loop) which were previously published by Kessler et al. Added in this article is the PIQUED approach, an educationally focused communication-method developed by Chan, et al which stand for:

P: Preparation before the encounter
I: Identification of involved parties
Q: Questions (Clinical question; Answering questions)
U: Urgency of the request
E: Educational modification

The authors then proposed a mixed model, combining elements from both validated models (5C's, PIQUE), which hopefully can be externally validated in ED's as well as other settings:

1. Preparation

Perform initial work up and resuscitation
Review investigations

2. Contact and Communication

Contact and communicate with colleague about patient

3. Core questions

Address questions or concerns

4. Collaboration

Be open to recommendations and collaboration

5. Urgency

Modify behavior and information on the basis of urgency

6. Closing the loop

Review agreed-on plan and thank consultant for time and help

7. Educational modifications

Make adjustments for colleagues (especially junior ones)

8. Debrief and discuss

Elicit or provide feedback regarding case

The practice of medicine keeps getting more complex. The volume of information keeps getting greater, forcing a more team-based approach to patient care. Medical educators are always on the look out for ways to improve medical education with the end goal of taking care of patients safely and efficiently.

I agree with the authors that this tool should be further explored and integrated into the curriculum. Communication is an essential part of our practice and should also be an essential part of our training.

A great listen:
Dr. Kessler discusses communicating with consultants on EMRAP:EE podcast (Feb 2010). It is very informative, educational, and full of practical advice.

Reference:

Kessler CS, et al. I'm Clear, You're Clear, We're All Clear: Improving Consultation Communication Skills in Undergraduate Medical Education. Acad Med. 2013 Apr 24 PMID:
[23619069]
Kessler CS, et al. A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: the 5 Cs of consultation. Acad Emerg Med. 2012 Aug;19(8):968-74. PMID: [22905961]
Chan T, et al. Understanding communication between emergency and consulting physicians: a qualitative study that describes and defines the essential elements of the emergency department consultation-referral process for the junior learner. CJEM. 2013 Jan 1;15(1):42-51. PMID: [23283122]

Images by Paul Shanks, Joan M. Mas, David Cosand

Javier Benítez (@jvrbntz)

05.12.13

by Academic Life in EM

Patwari Academy videos: Salter Harris fractures

Dr. Rahul Patwari discusses Salter-Harris fractures in pediatric patients with a helpful mnemonic to help you remember the categories. He also poses several questions in the first video, which are answered in the second video.

05.10.13

by Academic Life in EM

Deception and Simulation

Have you ever created a simulation case with hidden objectives that the learners were not aware of? Would you ever purposefully try to trick or deceive learners in a simulation case?

Simulation can be used to reinforce clinical and procedural knowledge. It can teach important teamwork skills. It can also be used to learn about ourselves in morally and ethically challenging situations.

But maybe if the learners knew that they were about to be morally and ethically challenged, they would always elect the high road. Perhaps to truly challenge the learners, these types of cases might have to involve deception in order to really see what will unfold when challenged. (Great example of human behavior was demonstrated during the Stanford Prison Experiment.)

With the cloak of deception, educators can actually challenge the learner’s psychology, leadership skills, and crisis management skills.

Examples of purposeful deception are:

Nurse confederate administers the wrong medication that leads to significant adverse outcome, and then lies about it.
Confederate leader who gives wrong and harmful directions to the team, and expects it to be done.
Confederate team member has adverse outcome during procedure and attempts to cover it up (e.g. guidewire left in the body)

These are simulation cases where the learners are not pre-debriefed about the real objectives of the case and are not aware confederates are purposefully deceiving them. The real objectives would be handling of unforeseen, ethical dilemmas that evolve.

Unfortunately our good side does not always come out when we are challenged. Remember Lord of the Flies? Imagine what happens to the learners in the post-debriefing when asked by the facilitator about knowingly allowing the confederate leader to execute the wrong decision. We all want to imagine ourselves always doing the right thing, no matter the situation, for the patient’s best interest. Leaders are courageous and always battle for the right; they are not weak.

This type of debriefing session would have to be handled with extreme caution in order to maintain a safe learning environment, stay productive, and develop effective learning take away points. Deterioration into guilt by perceived inadequate leadership skills should be prevented.

Ultimately I feel that this type of situation is appropriate for a simulation session and a necessary topic. Medicine is full of examples of bad outcomes from mortally questionable behavior such as billing fraud and falsifying of charts to cover up errors. Educators must teach their learners how to handle these real-life situations so that in the real world, the learners always land on top and can be the shining leaders that they can be.

Please share your thoughts and experiences.

Nikita

Twitter: @njoshi8

References:

Corvetto M, Taekman J. To die or not to die? A review of simulated death. Simul Healthc2013;8:8-12. PMID: 22960702
Gaba DM. Simulation that are challenging to the psyche of participants: how much should we worry and about what? Simul Healthc 2013;8:4-7. PMID: 23380693
Truog RD, Meyer EC. Deception and death in medical simulation. Simul Healthc 2013;8:1-3. PMID: 23380692

Image 1 Image 2

05.09.13

by Academic Life in EM

PV card: Ectopic pregnancy

Ectopic pregnancy is the leading cause of maternal death in the first trimester of pregnancy. A recent JAMA systematic review, from The Rational Clinical Examination series, looked to risk-stratify women in early pregnancy presenting with abdominal pain or vaginal bleeding for ectopic pregnancy. The authors, Crochet et al, set out to identify the accuracy and precision of elements in the history, physical examination, beta hCG, and ultrasound in ectopic pregnancy.

The systematic review consisted of 14 studies (n=12,101). The search consisted only of English language studies from 1965 to 2012 in which ectopic pregnancy was the final diagnosis with 100 or more patients per article. The summary prevalence of ectopic pregnancy was 15% (95% CI, 10-22%) in women presenting with abdominal pain or vaginal bleeding.

History and Physical:

Patients symptoms had limited clinical value. Most symptoms had an unhelpful positive LR of less than 1.5.
The absence of cervical motion tenderness, peritoneal signs, adnexal mass, or adnexal tenderness did not significantly decrease likelihood of ectopic pregnancy.
In descending order, the most significant physical exam findings were:

Cervical motion tenderness (Positive LR = 4.9)
Peritoneal findings (Positive LR = 4.2-4.5)
Adnexal mass (Positive LR = 2.4)

Ultrasound showing normal IUP as shown by the double decidual rings and presence of a yolk sac in a gestational sac

Ultrasound:

Findings of an intrauterine pregnancy (IUP) such as gestational sac or fetal pole ruled out ectopic pregnancy, except in rare cases of heterotropic prengnacy.
Bedside ultrasound is the single most useful diagnostic test. Positive LR = 111.

hCG:

The "discriminatory zone" continues to be debated - no consensus on the number.
A one-time hCG level does not rule out ectopic pregnancy.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Javier Benítez, MD (@jvrbntz)

Reference
Crochet JR, et al. Does This Woman Have an Ectopic Pregnancy? The Rational Clinical Examination Systematic Review. JAMA.2013;309(16):1722-1729. PMID [23613077]

Image Source

05.08.13

by Academic Life in EM

Pediatric Appendicitis: CT or Ultrasound?

Appendicitis is the most common pediatric surgical emergency accounting for 5% of urgent pediatric outpatient visits for abdominal pain. Computed tomography (CT) and ultrasonography (US) are two imaging modalities used in the diagnostic evaluation of acute appendicitis. Both have decreased the incidence of negative appendectomy results. It is well known that CT has greater diagnostic accuracy than US for diagnosing acute appendicitis, but there is concern over long-term cancer risk, with routine use of CT in children.

Is CT or US more accurate in the diagnosis of acute appendicitis?

Doria AS et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology 2006 Oct; 241(1): 83–94. PMID: 16928974

What they did:

Meta-analysis
26 studies involving children
9,356 total patients

Primary outcome:

Pooled sensitivity and specificity of CT and US in diagnosis of acute appendicitis in children

Results:

Pooled sensitivity and specificity for US in diagnosis of appendicitis in children: 88% and 94%
Pooled sensitivity and specificity for CT in diagnosis of appendicitis in children: 94% and 95%

Conclusion: CT has a higher sensitivity than US for diagnosis of acute appendicitis in children.

Does duration of abdominal pain increase accuracy of ultrasound?

Bachur RG et al. The Effect of Abdominal Pain Duration on the Acuracy of Diagnostic Imaging for Pediatric Appendicitis. Ann Emerg Med 2012; 60: 582–90. PMID:22841176

What they did:

Prospective multicenter observational study
2,349 children with suspected appendicitis at 9 pediatric EDs
Age 3 – 18 years
Placed into categories based on duration of time of symptoms: <12 h, 13 – 24 h, 25 – 36 h, 37 – 48 h, and 49 – 72 h

Primary Outcome:

The presence or absence of acute appendicitis

Results:

1,884 underwent CT only
586 underwent US only
282 underwent CT and US
Most frequent abdominal pain duration at presentation: 12 – 23 hrs category

Limitations:

1,082 pts did not undero surgery, but followed up with telephone calls (Only had 88.6% follow up)

Conclusions:

Duration of abdominal pain DID NOT affect sensitivity or specificity of CT to diagnose appendicitis
Duration of abdominal pain DID increase sensitivity and NPV for US with longer duration of abdominal pain, but no affect on specificity or PPV
US sensitivity and NPV is as good as CT after 48 hrs of pain symptoms.
Do not rely on US to rule-out appendicitis early in the course of illness.

Read more about this paper at PEMLit.org!

Summary
The advantages of US include low cost, lack of radiation, and dynamic information with graded compression. The advantages of CT include: no operator dependency, delineation of extent of disease (i.e. perforated appendicitis), easier visualization, unchanged quality of imaging over time, and multiplanar reconstruction of images. Based on the above study, if symptoms have been present for >48 hours, US is just as good as CT for ruling out the diagnosis of acute appendicitis.

The decision to obtain an US vs CT for children with suspected appendicitis remains a challenge. On a case by case basis, one should consider the following 4 major goals in care:

Minimize rates of missed appendicitis
Minimize risk from radiation exposure
Avoid misdiagnosis leading to negative appendectomy
Properly identify appendicitis before perforation

Question
How do YOU approach a pediatric patient in whom you have a moderate pretest probability for appendicitis?

References

Bachur RG et al. The Effect of Abdominal Pain Duration on the Acuracy of Diagnostic Imaging for Pediatric Appendicitis. Ann Emerg Med 2012; 60: 582 – 90. PMID:22841176
Doria AS et al. US or CT for Diagnosis of Appendiitis in Children and Adults? A Meta-Analysis. Radiology 2006 Oct; 241 (1): 83 – 94. PMID: 16928974

05.06.13

by Academic Life in EM

App Review: EMRA Basics of Emergency Medicine

The app EMRA Basics of Emergency Medicine covers the 20 most common EM complaints in a concise manner. I first heard about it from Dr. Rob Orman's (@emergencypdx) podcast (ERCast) where he endorsed it when it was only in book format. The book is great, thin, and it fits in a white coat pocket.

The app similarly is user-friendly and very appropriate for junior residents and medical students.

For instance, let's look at the chief complaint of syncope (below). The app gives you what signs and symptoms should concern you the most. It also has a tab where you can view the differential diagnosis.

I liked the fact they give you suggestions on what to document and very important clues on pearls and pitfalls. Other great features are integration and external links to TheNNT and MDCalc. It is interesting how this app integrates both evidence based medicine and information management.

There is also a phone tab that lets you input the numbers you use for different services. The book can be found here at emra.org, and the app can be found at the iTunes store. I would definitely recommend it. It makes a great learning tool with integration of some evidence based medicine resources.

Let me know what you think of this app if you try it or have tried it.

Javier Benítez

Javier Benítez (@jvrbntz)

Disclaimer: No conflict of interest.

05.05.13

by Academic Life in EM

Patwari Academy video: Early goal directed therapy

Do you know the protocol for early goal directed therapy (EGDT)? It's all about IV fluids. Get the scoop here in this video.

You can test also your knowledge on the free, online Septris game created at Stanford. Note, you'll need to run this on your desktop's Firefox (with pop-ups allowed) or on the iPad.

05.03.13

by Academic Life in EM

Death and Simulation

Should the manikin ever die in a simulation scenario?

Effective simulations require suspension of disbelief and willingness by learners to play along with the game created by the facilitators. Without this buy-in, learners could argue against discrepancies, simply on the basis that the scenario is not real. Learners give their trust that the educators will also play the same game, and that the rules will not change.

Where does death factor into the rules of the game?

There are 3 types of simulation deaths according to Leighton (2009):

Expected death
Unexpected death
Death resulting from action/inaction

What happens when the educator feels the learners have managed the case wrong? Or when the team has not made any management decision? Should the patient crash and die if that was the trajectory of their illness, or even if it was not in the trajectory? And what does this do to the learner psyche to see such severe consequence of their actions or inactions?

Essentially, can learning happen through fear, stress, and remorse?

Or the opposite - can learning happen when there are no negative consequences and there is always a fairy tale ending?

We can all agree death happens in medicine. We must prepare our learners on how to manage it, both clinically and emotionally. The answer cannot be to completely avoid the serious topic entirely. But the opposite is also true. Death must be recognized as a serious event, and especially for early learners, it can leave a lasting mark. We all have had nightmares of patients we have tried to save, but didn't or couldn't.

Corvetto and Taekman 2013 wrote a review on this topic in the February issue of Simulation Healthcare and provided some recommendations:

1. Do not use death punitively.
Imagine the situation where the learners are messing around and not taking your hard work seriously. Or perhaps they didn’t do the preparatory work that was assigned to them prior to arrival.You are irritated and frustrated. The first rule is take a deep breath... don’t take it out on the manikin.

2. Give early learners a break.
If the scenario is about death, or if it is anticipated the patient will be critically ill, give a pre-briefing session in which the medical topic may be discussed (e.g. ACLS protocol). Discuss the possibility of death. Is this cheating? Absolutely not, because at the end of the day, the goal is to create competent doctors and confident leaders -- not to pass an arbitrary test.

3. Acknowledge the emotional toll.
Often we are expected to be emotional robots. After we declare a code on the traumatic arrest patient, we turn right around and discharge the asthmatic who only needed a few nebs and steroids. These emotions are kept zipped up tight inside. Simulation is a great time to have a discussion without distractors. We can acknowledge and talk through the emotional and psychological ups and downs of having a critically ill patient who could not be resuscitated.

4. Give it some thought.
Spend time thinking about the ethical and psychological components of the game that are you asking your learners to participate within. Luckily, we do not live in a society like that depicted in the Hunger Games.

5. Back to basics.
Always come home to your learning goals. Every scenario grows from them. This will drive the case, the pre and post debriefing, and the take away points for the learners.

Please share your thoughts and experiences.

Nikita

Twitter: njoshi8

References

Corvetto M, Taekman J. To die or not to die? A review of simulated death. Simul Healthc2013;8:8-12. PMID: 22960702
Gaba DM. Simulation that are challenging to the psyche of participants: how much should we worry and about what? Simul Healthc 2013;8:4-7. PMID: 23380693
Leighton K. Death of a simulator. Clinical Simulation in Nursing. 2009;5:e59-e62. Abstract
Truog RD, Meyer EC. Deception and death in medical simulation. Simul Healthc 2013;8:1-3. PMID: 23380692

Image 1 Image 2

05.01.13

by Academic Life in EM

Transient Synovitis vs Septic Arthritis of the Hip

Limping is a common reason for parents to bring their children to emergency departments. Fischer et al state that 77% of acute, atraumatic limp is dealt with in the ED, and 20% do not even complain of pain. Our job as physicians is to complete appropriate assessments to not miss any serious pathology. Specifically, differentiating between transient synovitis (TS) and septic arthritis (SA) of the hip can be difficult and frustrating for everyone.

TS is an inflammation of the joint space, classically following a URI, with a benign clinical course.
SA is an infectious arthritis associated with poor outcomes with diagnostic delays, including osteonecrosis, growth arrest, and sepsis. Both can both present as an atraumatic, acutely irritable hip with progressive signs of fever, limp, refusal to bear weight, limited range of motion, and abnormal labs. This overlap makes them difficult to differentiate. Although the diagnostic gold standard is to perform an invasive arthrocentesis (positive synovial culture), can we diagnose using clinical criteria alone, such as Kocher's criteria?

What are Kocher's clinical criteria for septic arthritis?

Fever > 38.5C
Non-weight bearing on affected side
ESR > 40 mm/hr
WBC >12k

Can we use clinical criteria alone to distinguish transient synovitis from septic arthritis?

Conclusions about using Kocher's Criteria

Kocher’s clinical criteria is, at best, only OK at helping to differentiate TS from SA.

It is, however, the most studied criteria that we have. Despite that, there is still inadequate external validation studies (Caird et al study: 0 predictors still has 16.9% chance of SA). The criteria are helpful depending on pretest assumptions. So when applied to a HIGH risk group with HIGH prevalence of SA, the predictive value of the algorithm is high (Kocher and Caird et al). And when applied to a LOW risk group with a LOW prevalence of SA, the predictive value of the algorithm is low (Luhmann et al).

What does the American College of Radiology (ACR) recommend as the initial imaging modality? (ACR Appropriateness Criteria)

If traumatic mechanism: XR should be primary imaging modality
If no trauma and no signs of infection: XR should be primary imaging modality, and if negative consider US Hip
If no trauma, possible signs of infection: US should be primary imaging modality, and if negative consider XR; If both are negative and still concerned for SA, MRI is the next imaging modality of choice

What is the Role of US in Differentiating TS from SA?

Zamzam MM. The Role of Ultrasound in Differentiating SA from TS of the Hip in Children. J Pediatr Orthop B 2006; 15: 418–22. PMID: 17001248

What they did:

154 Children (91 boys and 63 girls)
Mean age 4.3 years
Hip pain suspected to be TS vs SA based on clinical and lab findings sent for US

Primary Outcome:

Accuracy of US of hip to diagnose SA of hip and differentiate from TS

Results:

Use of clinical parameters, lab, and XR: Sens 74%, spec 74%, PPV 76%
Hip US alone: Sens 86.4%, spec 89.7%, PPV 87.9%
8/69 (11.6%) of hip US's that were negative for SA were ultimately confirmed to have SA

Conclusions:

Clinical parameters and XR are only suggestive in diagnosing hip SA. Hip US performs only slightly better diagnostically. Both, however, are UNRELIABLE in definitively differentiating SA from TS.
Hip US can confirm and exclude hip effusion, but can have false negatives, especially early in disease process (<24hours)

Given that the Kocher clinical criteria and imaging (XR and US) modalities are only moderately helpful, at best, you should use a combination of your history and physical findings, imaging results, and gestalt to help guide your management decisions. Many clinicians err conservatively and perform an arthrocentesis in uncertain cases despite it being a relatively invasive procedure.

What diagnostic approach do you use?

References

Fischer SU et al. The Limping Child: Epidemiology, Assessment and Outcome. J Bone Joint Surg 1999; 81: 1029–34. PMID: 10615981
Kocher et al. Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Eveidence-Based Clinical Prediction Algorithm. J Bone Joint Surg 1999 Dec; 81 (12): 1662–70. PMID:10608376
Luhmann SJ et al. Differentiation Between Septic Arthrtis and Transient Synovitis of the Hip in Children With Clinical Prediction Algorighms. J Bone Joint Surg 2004 May; 86 (5): 956–62. PMID: 15118038
Sultan J et al. Septic Arthritis or Transient Synovitis of the Hip in Children: The Value of Clinical Prediction Algorithms. J Bone Joint Surg 2010 Apr; 92 (9): 1289–93. PMID: 20798450
Taekema HC et al. Distinguishing Between Transient Synovitis and Septic Arthritis in the Limping Child: How Useful are Clinical Prediction Tools? Arch Dis Child 2009 Feb; 94 (2): 167–8. PMID: 19158141
Zamzam MM. The Role of Ultrasound in Differentiating SA from TS of the Hip in Children. J Pediatr Orthop B 2006; 15: 418–22. PMID: 17001248

04.30.13

by Academic Life in EM

Trick of the Trade: Urine Collection in Neonates

The Case: A 8-day-old, uncircumcised male is brought to the ED with fever, irritability, and decreased urination.

The Problem: Getting a clean catch urine in a timely, non-invasive manner

Trick of the Trade:

Provide oral intake to the neonate
25 minutes after feeding, clean genitals with soap and water; dry with sterile gauze
Give non-pharmacologic analgesia (Pacifier or 2% sucrose syrup)
One person holds neonate under the axilla with feet dangling
Another person starts bladder stimulation with gentle tapping of the suprapubic area (100 taps/min) and stimulation of lumbar paravertebral zone (light circular massage)
Perform steps 4 and 5 for 30 secs at a time, as many times as needed
Catch midstream urine sample in a sterile collection container

Study Publication:
Herreros Fernandez ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child 2013 Jan; 98(1): 27-9. PMID:23172785

Study methodology:

Prospective feasibility and safety study
Single center in Madrid
80 neonates (31 girls and 49 boys)
Mean ages: 6.66 day old boys and 6.23 day old girls

Results:

86% success rate in obtaining urine in <5 min
Mean time for sample collection: 57 sec
Mean time spent collecting samples in males: 60.48 sec
Mean time spent collecting samples in females: 52.04 sec

Limitation: Lack of control group

Conclusion: A new method to obtain midstream urine in newborns is safe, quick, and effective.

Collection of urine from neonates is a time-consuming and unpredictable task that requires time and attention. Although a small study, this new technique does not cause discomfort or waste time as is typically the case with catheterized urines and bag collection methods, respectively.

References:

Davies P et al. Randomised trial of a vibrating bladder stimulator – The time to pee study. Arch Dis Child 2008; 93: 423–4. PMID: 18192318
Herreros Fernandez ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child 2013 Jan; 98(1): 27-9. PMID:23172785

04.29.13

by Academic Life in EM

Tweet Pearls of the Week 4/19 to 4/26

04.26.13

by Academic Life in EM

Coping with Simulation Case Derailment

Author: Corey Heitz, MD

Peer Reviewer and Editor: Nikita Joshi, MD

“The best laid plans of mice and men...”

The simulation scenario starts and things are going well. The learners are on their game. Instability - recognized, managed. Initial orders - done. And then it all falls apart. We’ve all been there.

The learners zigged when they should have zagged (Sepsis?? The pt’s having an AMI!)
They missed the KEY item that would have given the diagnosis, now they’re stuck in nowhere Land.
They’re about to perform a painful procedure on someone who doesn’t need it!!

The sim case has officially derailed.

Whatever the situation, you as the facilitator need to prepare how to fix sim-case-derailment in advance. If you are like many of us, and believe in realism, then you need to know what you’re going to do to keep the scenario going, or, when you need to break realism and “fix it.”

The following are potential issues and options for how to work through or around issues that arise during simulations. Options can be separated into “adapting” the case (keeping your changes within the scenario) and “restoring” the case (fixing it, often from without).

The underlying concept to any scenario rescue or modification is to remember:
What are your objectives?

Problem	In-scenario fixes (adapt)	Out-of-scenario fix (restore)
Learner Error (misdiagnosis, missed exam finding, wrong med/dose)	• let it play out • confederate redirection • patient redirection/cues	• few good options if trying to maintain realism – if egregious enough, pause, debrief, resume/restart
Technology Failure	• let it play out - new case on the fly? • confederate correction - “breath sounds are decreased on the right, doc” • confederate redirection - “let me get a manual blood pressure on him, I don’t trust that reading”	• restart case - “sorry, let’s run it back” • pause case, fix problem, resume • “voice of God” - tell them what they’re supposed to be seeing
Dangerous actions (uncapped needle, scalpel, etc)	• confederate correction • patient cueing • address during debrief	• pause case, resume once corrected
Mismatched competency (case too easy or too hard for the learners)	• have senior physician step in “Hey I heard you were having trouble...” • modify case on they fly (make him better/worse)	• end case, restart with a more straightforward one

When applying any of the above corrections, or others not listed here, remember to consider your original objectives. Would letting the scenario progress naturally, albeit differently than planned keep the learner from meeting their objectives? Interrupting the case for correction or redirection may ruin the flow and result in artificiality.

Other considerations for any correction:

Correcting within the case must follow scenario logic -- i.e. patients don’t magically improve!
“In-scenario” fixes are psychological and not physical. Any form of communication may be used. Consider confederate consultant questions such as, “Are you SURE it’s atrial fibrillation?”
Another “in scenario” fix to restore (not adapt) the case could be as simple as having the nurse confederate correct the vital signs (“sorry, we haven't updated the monitor to the new patient”)
For “out of scenario” fixes, think about at what point you should restart the case or simply resume the case.

Videos Highlighting Correction Techniques
Below are two videos showing options for case management when unexpected events occur.

Wrong Type of Shock

Wrong Patient

Acknowledgements: adapted from “Keeping it Real When Faking it” presented at CORD AA 2010, Mike Smith MD, Thomas Noeller MD Corey Heitz, and Raymond Ten Eyck MD.

Further reading:

Dieckmann P, Lippert A, Glavin R, Rall M. When Things Do Not Go as Expected: Scenario Life Savers. Simul Healthc. 2010;5:219.

Images 1, 2

04.25.13

by Academic Life in EM

The SCRAP Rule: Indications for chest CT in blunt trauma

At my institution, trauma patients frequently receive the “Pan Scan,” to rule out acute injury. Recently, Payrastre et al published the SCRAP Rule article in CJEM 2012 looking to derive and internally validate a clinical decision rule that would identify blunt trauma patients at very low risk for major thoracic injury with 100% sensitivity, thereby eliminating need for a chest CT. Currently, the decision on whether to perform a chest CT is made mostly by clinical judgment.

Reducing the number of unnecessary CT scans would be in the best interest of patients and physicians for several reasons:

Radiation exposure from a CT scan can cause long-term damage (i.e. malignancy).
Hospitals without 24-hour CT capabilities are forced to transfer trauma patients after hours.
Time spent in the CT scanner can potentially delay transfer to operating room for definitive care.
False positive CT scans can lead to other invasive tests and procedures.
Contrast induced nephropathy and anaphylactoid reactions
Significant financial costs associated with scans

What is the SCRAP Rule?

If all five variables below are normal, you do not need chest CT. If any one variable is positive, you need a chest CT.

Oxygen Saturation (<95% on RA or <98% on any supplemental 02)
Chest Radiograph (Abnl = any acute change that could be due to trauma)
Respiratory Rate (RR > 25)
Chest Auscultation
Thoracic Palpation

Study Methodology:

Retrospective medical record review
Single trauma center in southern Ontario
614 patients (434 in derivation and 180 in internal validation)

Inclusion Criteria:

Injury Severity Score (ISS) > 12
Underwent chest CT at admission
Major thoracic injury documented in trauma database

Exclusion Criteria:

Penetrating injuries
Signs of paralysis
GCS < 9
Intubated patients
Age < 16 years
ISS < 13

Primary Outcome:

SCRAP rule's ability to detect the presence of a major thoracic injury noted on a CT scan, at discharge, or at clinic follow up

Results:

Derivation Set

274/434 (63.1%) patients had a major thoracic injury
When all 5 variables were normal (SCRAP neg): Sens 100%, Spec 46.9%, Neg LR of 0, PPV 76.3%, & NPV 100%
This would lead to 17% absolute reduction in CT scans and a 47% reduction in negative CT scans
NO missed major thoracic injuries

Internal Validation Set

104/180 (57.8%) had a major thoracic injury
When all 5 variables were normal (SCRAP neg): Sens 100%, Spec 44.7%, Neg LR 0, PPV 71.9%, & NPV 100%
This would lead to a 19% absolute reduction in CT scans and a 45% reduction in negative CT scans
NO missed major thoracic injuries

Limitations:

Retrospective chart review
Only derivation and internal validation study (Still needs large multi-center, prospective, external validation)
28 patients with rib, clavicle, or spinous process fractures were documented as having no thoracic tenderness
CXR interpreted by staff radiologists (not all institutions have staff radiologists)

Conclusions:

In major blunt trauma patient with a GCS >8, the SCRAP Rule has a 100% sensitivity for major thoracic injury.

Currently, there are no accepted guidelines that aid physicians in determining which patients are at low risk for major thoracic injury in blunt trauma. Published results reveal that approximately half of the thoracic CT scans performed in blunt trauma are negative for major thoracic injury.

“Selective Scanning” as opposed to “Pan Scanning” in blunt trauma patients, is an interesting clinical concept, but the SCRAP Rule still needs a prospective, multicenter external validation before implementation into the clinical setting.

References:

Payrastre J et al. The SCRAP Rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma. CJEM 2012; 14(6): 344-53. PMID: 23131481

04.23.13

by Academic Life in EM

Trick of the Trade: Making the NG and NP procedures less painful

When doing nasogastric (NG) tubes and fiberoptic nasopharyngoscopy (NP) procedures, there many approaches in how patients can be locally anesthetized. Getting things pushed up your nose is so profoundly irritating that most patients only give you 1 or 2 changes to get it right.

One option is to use nebulized lidocaine, although it takes a while to prepare and anecdotally tends to numb mainly the hypopharynx, placing the patient at risk for aspiration later on. Another option is to use viscous lidocaine to coat the NG or NP tubing, but this is fairly messy and only mildly helpful. Commercial intranasal atomizers, which disperse lidocaine over the nasal mucosal surfaces well, are generally effective, but may not be available in some emergency departments.

Trick of the Trade:

Make your own intranasal lidocaine-oxymetazoline spray

Put 5-10 mL of 1-2% lidocaine into a new oxymetazoline spray bottle with a 25g needle. The oxymetazoline provides great vasoconstriction and thus mucosal edema reduction. It also provides great hemostasis in case you cause a little intranasal trauma.

Insufflate the oxymetazoline spray bottle 2-3 times into the patient's nose to atomize the anesthetic plus vasoconstrictive medication mixture. The solution is perfectly atomized and anesthetizes the painful areas. Anecdotally, most people have excellent anesthesia in just a few minutes.

Thanks to Dr. Matt Wong (@MatthewLWong), an EM resident at BIDMC/HAEMR in Boston for sharing this trick. He asserts that, "Since using this method my rates of painless and successful NG tube insertions has gone way up. FYI, I also still use a water-based lubricant on the NG tube to facilitate the insertion process."

04.22.13

by Academic Life in EM

Learning "Information Management" instead of "Evidence Based Medicine"?

Keeping up with the literature these days is quite a daunting task. Medical information has increased exponentially over the past few decades and continues to do so. We spend a great deal of time and energy memorizing information which soon may become obsolete (see this excerpt from the book The Half-Life of Facts by Arbesman). Expecting physicians to keep a busy practice AND keep up with all the most current literature is impractical. By the time textbooks are published, the information is already a few years old and this puts us at risk of not practicing the most up to date and best evidence practice. We also know that with the increasing volume of information there has been new development on statistics on how to evaluate this vast amount of data. Most physicians are not properly equipped with the necessary statistical skills or time to analyze this vast amount of information.

So how DOES a practicing physician keep up with the most current, evidence-based medicine (EBM)?

The classic way
We are taught in medical school the classic 5-step approach to the medical literature:

Develop a PICO format question
Find research that answers that specific question
Evaluate the research for validity, impact, and applicability
Apply the information to clinical decision making
Periodically evaluate one’s effectiveness at performing the previous four steps

In a 2005 Academic Medicine article, Drs. Slawson and Shaughnessy propose that physicians should learn how to manage information instead of becoming experts in EBM. The authors point out that having physicians read the literature using the traditional EBM approach is time consuming, not patient oriented, and often too impractical to be applied at the point of care. Furthermore, it is unrealistic to expect that all physicians expertly conduct critical appraisals of all the literature.

In contrast, information management "focuses on using currently available information tools to remain up to date with new valid information that is relevant to the care of patients and is accessible while taking care of patients."

The argument
Information management is based on the key formula to finding useful information regarding patient care:

Variables

1. Relevance = direct applicability of information to patient care and focuses on 3 qualifications:

Does the information focus on outcomes patients care about?
Is the intervention or practice feasible, and is the problem addressed common in one’s clinical practice?
Would the information, if true, require a change in one’s clinical practice?

Patient-Oriented Evidence that Matters (POEM), a term which characterizes research which meets this criteria, was developed by the authors.

2. Validity = technical rigor that is the focus of EBM

3. Work = the time, money, or effort required to obtain an answer to a clinical question.

So the ideal resource is one that has direct relevance and high validity in answering your patient care-related question, which takes the least amount of effort to obtain.

A proposed new approach
The authors propose tools and skills that can help us with information management.

Information tools are divided into:
1. "Foraging tools" to allow clinicians to "keep up" with literature

Tools that alert clinicians to new, relevant, and valid information.
Includes levels of evidence and specific recommendations.
Examples: Journal watches, daily POEM alerts, daily emailed clinical pearls

2. "Hunting tools" to find the answer

Point-of-care tools that present information, pre-filtered for relevance, pre-appraised for validity using explicit criteria, marked with levels of evidence, and placed in clinical context.
Allow clinicians to find "just in time" answer, when needed.
Includes explicit method for searching the literature to find relevant and valid information.
Examples: DynaMed, UpToDate

What skills should be taught in Information Management?

Select tools for "keeping up" (foraging tools).
Select the appropriate hunting tool(s).
Practice patient-centered (not just evidence-centered) decision making.

This includes consideration of the patient as a person along with seeing the patient in the standard biomedical model of a person with a disease. The clinical decision is based on by balancing the evidence with the desires of the patient.

The current use of technology plays a major role in today's practice of up to date medicine. Pre-filtered, EBM appraised, valid information is at our fingertips and ready for use. Because not all tools are created equal, we need to ensure that the tools we use are valid and relevant to our practice.

A nice summative quote from the article about why Information Management will be a key skill for today's and tomorrow's physicians:

To keep pressing the standard of EBM approach is like asking everyone who wishes to make a cake to buy the wheat to grind their own flour, refine their own sugar, and extract their own flavorings before ever starting the cake. Cakes aren’t made this way.

Questions for you:

What do you think about the author's proposal that all physicians become experts in information management rather than EBM?
Which foraging and hunting tools do you use? Do they significantly help your practice?

References

Slawson DC, et al. Teaching evidence-based medicine: should we be teaching information management instead?Acad Med. 2005 Jul;80(7):685-9. PMID 15980087
Hurwitz SR, et al. Should We Be Teaching Information Management Instead of Evidence-based Medicine? Clin Orthop Relat Res. 2010 October; 468(10): 2633–2639. PMC3049623
University of Georgia. (Uploaded May 28, 2010) Teaching Evidence Based Medicine: Should We Be Teaching Information Management Instead? Presenter: David Slawson, MD Retrieved April 19, 2013.
Free online course on evidence based medicine by Dr. Mark H. Ebell MD from the University of Georgia

Images: 1, 2

04.21.13

by Academic Life in EM

Patwari Academy video: Altered mental status

Get an organized approach on the broad chief complaint of "Altered Mental Status". Learn about the AEIOU TIPS mnemonic.

04.19.13

by Academic Life in EM

Disability Insurance – Yes or No?

I am set to graduate residency this June 2013 and among all the other things on my to-do list such as credentialing paperwork for my future employer is to explore disability insurance. Because I know very little about insurance, I decided to do some research.

What is disability insurance?
Why should I get it?
Do I need it as a physician?
Do I need it as an emergency physician?

According to Wikipedia, “Disability Insurance (DI) is a form of insurance that insures the beneficiary’s earned income against the risk that a disability creates a barrier for a worker to complete the core functions of their work.” It’s basically a form of insurance that will give you money if you become injured and are unable to work.

In researching if other EM physicians had disability insurance, I polled my physician friends via Twitter and Facebook. These are a few of the comments that I received:

“You are much more likely to become disabled then die. Has to be EM specific”
“Absolutely need it. Get it in residency, you can increase amount later. More important than life insurance.”
“Yes! Better rates and discounts available to residents.”
“Make sure you can purchase more later when your salary increases without another physical.”

But the pesky question still remains – WHY should I get disability insurance?

It comes down to the eternal question of risk. It is the same question that is asked about any form of insurance. What is the risk that I will become disabled and require disability insurance? In the 2012 NY Times article, according to the Social Security Administration, a 20 year old person in 2011 had a 30% chance of being disabled at least for 6 months before retirement. But then they cite another NY Times article from 2010 which claims that the statistics involving disability vary WILDLY depending on whom you ask.

So what is real and what is not real? Should I get disability insurance in case I might not be able to perform my job? My job, which entails intubating people, placing central lines and transvenous pacers, and being mobile enough to examine hallway patients in the tiniest of spaces due to ED overcrowding? It’s a physical job, and don’t forget that most of this must be done urgently (and many times emergently).

There are many other considerations for disability insurance when debating whether to get it.

How long can you afford to not get paid if you cannot work due to injury?
How much disability does your current job provide?
How much do you have in savings?

Other important considerations that I have read regarding disability insurance when considering policy and coverage.

As a woman, disability insurance is more expensive than it is for men, but the rates are not so disproportional if you get it during residency.
Partial coverage is very important to consider. For example if you injury your ankle, you are still able to work, but maybe not as many hours as before. Many policies will provide for partial coverage.
Own occupation policy. A very important caveat to have in your policy is this contingency which states that disability prevents you from doing your OWN job. Therefore, as an emergency physician, I will not be expected to go back to work in the hospital as a radiologist, even though both are physician occupations. My OWN job trained me specifically for the ED.

What do you think? Any opinion and thought is welcome!

Nikita (@njoshi8)

References for further reading:

What Every Physician Should Know About Disability Insurance – AMA White Papers (PDF)
EP Money: Disability Insurance Fact vs. Fiction – Emergency Physician Monthly
The Odds of a Disability Are Themselves Odd – New York Times 2010
Weighing the Odds of Disability, for Insurance Purposes – New York Times 2012

Image 1 Image 2

04.18.13

by Academic Life in EM

Management of Syncope a.k.a "Done Fell Out"

"Done Fell Out", or DFO, is a common saying in the South to describe syncope. Although the saying is funny the diagnosis is not. Syncope accounts for about 3–5% of ED visits and 1–6% of hospital admissions. In patients >65, syncope is the 6^th most common cause of hospitalization.

The most common causes of syncope are: Unknown (34-36%), Vasovagal (18-21%), and Cardiac (9.5-18%). Soteriades et al noted that if patients have a history of CV disease, the incidence of cardiac etiology also increases.

Causes of Syncope & The Presence or Absence of CV Disease
CV Disease	CV Disease Absent		CV Disease Present
Sex	Male	Female	Male	Female
Cardiac Etiology	6.5%	3.8%	26.7%	16.8%

Why Does CV Disease Matter?

Bottom Line: Cardiac etiologies of syncope (red line above) have the highest associated mortality!

Do Risk Stratification Tools Work?

There is no “gold standard” evaluation for syncope, but there are several different scores and more coming out every month. Here is a list of several:

These rules are difficult to evaluate in part because of different weights on different variables contributing to the scoring system. A major problem with most of these scoring systems is that older patients are underrepresented. This is an issue because as our patient population gets older so does the incidence of syncope and the incidence of cardiac etiologies.

Bottom Line: Educated clinician judgment based on EBM guidelines (European Society for Cardiology and ACEP) seems to be the best strategy for management. Syncope prediction rules can certainly aid this process, but they do not yet fit for use alone for risk stratification in any population.

What is the ACEP Level-B Recommendation for Admission?

Older age and associated comorbidities (No set definition)
Abnormal EKG findings (acute ischemia, dysrhythmias, or significant conduction abnormalities)
Hematocrit <30
History or presence of CHF, CAD, or structural heart disease

Does Everyone with Syncope Need a Head CT?

ACEP's Level C recommendation states Cranial CT scanning need NOT be routinely performed unless guided by specific findings in the history or physical exam. So what are those findings?

Bottom Line: Clinicians might consider obtaining a Head CT as part of the syncope evaluation for the following findings:

Trauma above the clavicle
Persistent neurologic deficit or complaint
Age >65
Sudden onset headache
Patients on warfarin (coumadin)

Do Syncope Management Units (SMUs) Increase Diagnostic Yield & Decrease Hospital Admissions?

Because a definitive diagnosis cannot be established immediately, hospital admission is frequently recommended as the "default" approach to ensure patient's safety and guarantee an expedited evaluation. The problem with this is the hospital care is expensive, and no studies to date have shown that clinical outcomes are improved by the in-patient practice approach. The concept of the SMU is like a chest pain observation unit. Place syncope patients under observation in the ED, and use a multidisciplinary team of physicians to perform the consultation, echo, telemetry, and other diagnostic tests from the ED.

Below are the findings from the Syncope Evaluation in the Emergency Department Study (SEEDS) study:

Bottom Line: This is an interesting concept and shows decreased hospital admission. This particular study, however, was poorly powered, unblinded, and had no cost-benefit analysis. A multicenter, multidisciplinary study would need to be performed to externally, validate and standardize the risk stratification scheme and concept of a SMU before implementation.

It is our job as emergency physicians to NOT identify a precise cause of syncope. Instead, we should aim to risk-stratify our patients: Who needs to be hospitalized (high risk) versus who can be safely discharge home (low risk) with outpatient follow up? The keys are:

Use clinician judgment aided partly by risk stratification scores.
Remember ACEP's recommendations on syncope admissions.

References:

Al-Nsoor NM. Brain Computed Tomography in Patients with Syncope. Neurosciences 2010 Apr; 15 (2): 105 – 9. PMID: 20672498
Del Rosso A et al. Clinical Predictors of Cardiac Syncope at Initial Evaluation in Patients Referred Urgently to A General Hosptial: The EGSYS Score. Heart 2008 Dec; 94 (12): 1620 – 6. PMID:18519550
Giglio P et al. Syncope and head CT Scans in the Emergency Department. Emerg radiol 2005 Dec; 12 (1-2): 44 – 6. PMID: 16292675
Goyal N et al. The Utility of Head Computed Tomography in the emergency Department Evaluation of Syncope. Intern Emerg Med 2006; 1 (2): 148 – 50. PMID: 17111790
Grossman SA et al. Reducing Admissions Utilizing the Boston Syncope Criteria. J Emerg Med 2012 Mar; 42 (3): 345 – 52. PMID: 21421292
Grossman SA et al. The Yield of Head Ct in Syncope: A Pilot Study. Intern Emerg Med 2007 Mar; 2 (1): 46 – 9. PMID: 17551685
Huff JS et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Syncope. Ann Emerg Med 2007 Apr; 49 (4): 431 – 44. PMID: 17371707
Numeroso F et al. Syncope in the Emergency Department of a Large Northern Italian Hospital Incidence, Efficacy of a Short-Stay Observation Ward and Validation of the OESIL Risk Score. Emerg Med J 2010 Sep; 27 (9): 653 – 8. PMID: 20515909
Pires LA et al. Diagnostic Paterns and Temproal Trends in the Evaluation of Adult Patients Hospitalized With Syncope. Arch Intern Med 2001 Aug; 161 (15): 1889 – 95. PMID: 11493131
Reed MJ et al. The ROSE (Risk Stratification of Syncope in the Emergency Department) Study. J Am Coll Cardiol 2010 Feb; 55 (8): 713 – 21. PMID: 20170806
Snead GR et al. Can the San Francisco Syncope Rule Predict Short-Term Serious Outcomes in Patients Presenting with Syncope? Ann Emerg Med 2013 Jan. PMID: 23332611
Soteriades ES et al. Incidence and Prognosis of Syncope. NEJM 2002; 347: 878 – 85. PMID: 12239256.
Sun BC et al. Predictors of 30-day Serious Events in Older Patients with Syncope. Ann Emerg Med 2009 Dec; 54 (6): 769 – 778. PMID: 19766355

04.17.13

by Academic Life in EM

Sim Case Series: Perimortem C-Section

ALiEM Sim Case Series:

Perimortem C-Section

Case Writer: Clare Desmond, MD
Peer Reviewer and Editor: Nikita Joshi, MD

Keywords: Cardiac arrest, Perimortem C-section

Educational Objectives

Medical	Communication
Recognize and manage cardiac arrest in pregnant patient	Communicate emergent need of perimortem CS to team leader
Identify need for perimortem CS	Consult NICU and OB stat
Perform perimortem CS

Case Synopsis

28 year old female, 37 weeks pregnant, BIBEMS after high speed MVC. Pt was a restrained driver in a head-on collision with a tree. Estimated speed at impact was 75 mph. The car was completely damaged with spider webbing of the windshield. Pt was responsive to pain but was not oriented in the field. EMS noted a protuberant abdomen. Upon arrival in the ED, her initial GCS was 5 (abnormal flexion to pain with decorticate response), it is noted that the pt becomes pulseless within 5 minutes of arrival to the ED and has an asystolic cardiac arrest.

PDF of more detailed scenario description

PDF of case-specific ABEM Milestones PC9

Critical Actions

Initiate ATLS on high speed MVC pt
Initiate ACLS on asystolic cardiac arrest
Identify pregnant pt with uterine fundus greater than 20 cm above pubic symphysis
Initiate and complete perimortem CS within 5 minutes loss of pulses

Learners

ED residents
OB residents
Pediatric residents
Medical students
ED nurses
Nursing students

Location: ED resuscitation bay

Patient: 28 yo female, 37 wks pregnant

Equipment

Advanced airway equipment
Airway adjuncts
Bedside ultrasound
Cardiac arrest code cart
Cervical c-spine collar
IV fluid
Monitor
Neonatal warmer
Retractors
pRBCs
Scalpel – 10 blade
Spinal immobilization back board
Stretcher with sheets

Moulage

Ecchymotic patches on chest
Fetus manikin
Gravid abdomen with uterus moulage capable of being cut
Manikin for with trauma and pregnancy capabilities

Confederates

EMS provider— helpful, gives initial history and discuss initial vitals on scene, gives details of completely destroyed car and tree at the scene of the accident
Husband- frantic, informs team that pt is pregnant
Nurse – helpful, performs orders given by team, gives helpful hints suggesting decision to perform CS
NICU (voice) – calls when consulted, discusses case
OB (voice) – calls when consulted, not in house, discusses case

Supporting Files / Media

Asystole rhythm strip
Bedside ultrasound trans-abdominal images of large fetus with fetal heart movement
Labs: Shock panel, Urine HCG, Type and Screen / Cross

Translation
Abd	abdominal / abdomen
BIBEMS	brought in by EMS
BP	blood pressure
CS	cesarean section
HR	heart rate
IV	intravenous
MVC	motor vehicle collision
Neg	negative
RR	respiratory rate
PEA	pulseless electrical activity
pRBCs	packed red blood cells
TA	transabdominal
T	temperature
US	ultrasound

References:

Mercado, J. et al Critical Obstetric and Gynecologic Procedures in the Emergency Department. Emerg Med Clin N Am. Elsevier. 31 (2013). 207-236.
Newfield E. Third-Trimester Pregnancy Complications. Prim Case Clin Office Pract. Elsevier 39 (2012). 95-113.

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PV Card: Contraindications to Thrombolytics in Stroke

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

How Social Media is Making an Impact in Medicine

Review: Emergency Medicine: Avoiding The Pitfalls and Improving The Outcomes

Patwari Academy video: Discharge instructions

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Sim Case Series: Pediatric WPW

Translation

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Three predictors for success in cardiac arrest resuscitations

Improving Consultation Communication Skills

Patwari Academy videos: Salter Harris fractures

Deception and Simulation

PV card: Ectopic pregnancy

Pediatric Appendicitis: CT or Ultrasound?

App Review: EMRA Basics of Emergency Medicine

Patwari Academy video: Early goal directed therapy

Death and Simulation

Transient Synovitis vs Septic Arthritis of the Hip

Trick of the Trade: Urine Collection in Neonates

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Coping with Simulation Case Derailment

Problem

In-scenario fixes (adapt)

Out-of-scenario fix (restore)

The SCRAP Rule: Indications for chest CT in blunt trauma

Trick of the Trade: Making the NG and NP procedures less painful

Learning "Information Management" instead of "Evidence Based Medicine"?

Patwari Academy video: Altered mental status

Disability Insurance – Yes or No?

Management of Syncope a.k.a "Done Fell Out"

Sim Case Series: Perimortem C-Section

Medical

Communication

Translation