AEM Education and Training 01: Resident Perception of Morbidity and Mortality Conference

Welcome to the first episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to an AEM E&T Article or Article in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find previous AEM Early Access podcasts and suscribe to this series on iTunes here.

A Collaboration between AEM Education and Training and the Brown EM Residency Program

A Collaboration between AEM Education and Training and the Brown EM Residency Program

Discussing open access article (with link to full text):

Emergency Medicine Morbidity and Mortality Conference and Culture of Safety: The Resident Perspective. Kathleen Wittels MD, Emily Aaronson MD et al. AEM Education and Training 2017;1:191–199.

LISTEN NOW: Lead Author Interview with Dr. Kathleen Wittels, M.D.

We discuss the evolution of Morbidity and Mortality Conference from its tradition of "blame and shame" to its current ideal role in emergency medicine training and a culture of safety. Dr. Wittels and her colleagues previously published data on residency program directors' perceptions of M&M at their programs -- but what do residents think? 

KathleenWittels_114.jpg

Kathleen Wittels, MD

Assistant Professor of Emergency Medicine, Harvard Medical School

ARTICLE SUMMARY:

OBJECTIVE: Morbidity and mortality conference (M&M) is an Accreditation Council for Graduate Medical Education (ACGME) requirement for emergency medicine residents. This study aimed to survey the attitudes of EM residents towards M&M conference and to characterize the prevalence of elements of EM M&M conferences that foster a strong "culture of safety".

METHODS: Emergency medicine residents at 33 programs across the United States were surveyed using questions adapted from a previously tested survey of EM program directors and the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety Survey.

RESULTS: The survey response rate was 80.3% (1,002/1,248). A total of 60.3% (601/997) of residents had not submitted a case of theirs to M&M in the past year. A total of 7.6% (73/954) reported that issues raised at M&M always led to change while 88.3% (842/954) reported that they sometimes did and 4.1% (39/954) reported that they never did. A total of 56.2% (536/954) responded that changes made due to M&M were reported back to the residents. Of residents who had cases presented at M&M, 24.2% (130/538) responded that there was regular debriefing, 65.2% (351/538) responded that there was not, and 10.6% (57/578) were unsure. A total of 10.2% (101/988) of respondents agreed that M&M was punitive, 17.4% were neutral (172/988), and 72.4% (715/988) disagreed. A total of 18.0% (178/987) of residents agreed that they felt pressure to order unnecessary tests because of M&M, 22.3% (220/987) were neutral, and 59.6% (589/987) disagreed. A total of 87.4% (862/986) felt that M&M was a valuable educational didactic session, and 78.3% (766/978) believed that M&M contributes to a culture of safety in their institution.

CONCLUSIONS: While most residents believe that M&M is a valuable didactic session and contributes to institutional culture of safety, there are opportunities to improve by communicating changes made in response to M&M, debriefing residents who have had cases presented, and taking steps to make M&M not feel punitive to some residents.

 

FURTHER READING:

To Err is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000.

Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety. Emily L Aronson, MD, Kathleen Wittels, MD, et al. West J Emerg Med. 2015 Nov; 16(6): 810–817.

 

 

 

Serotonin Overload

Presentation and History

A 17-year-old female with a history of depression and eating disorder presents to the pediatric ED after an intentional overdose of citalopram, sertraline and ibuprofen.

Initial work up

On arrival, the patient is noted to have a blood pressure 132/57 mmHg, tachycardic with a heart rate of 128 beats per minute, afebrile with a normal respiratory rate and an oxygen saturation of >95% on room air. On physical examination, the patient was initially alert and oriented to person, place and time. Her lungs were clear to auscultation bilaterally. Cardiac exam was tachycardic and regular without murmur, rub or gallop. The abdomen was soft, non-tender and non-distended with hyperactive bowel sounds. Her neurologic exam was notable for hyperreflexia and 5-6 beats of inducible clonus in the lower extremities as well as a mild resting tremor. EKG demonstrated sinus tachycardia with normal axis and intervals. Bedside glucose was 90. The patient’s acetaminophen and salicylate levels were <10 and <2.5, respectively. The metabolic panel was notable for potassium of 3.3. The LFTs and CBC were within normal limits.

ED course and disposition

15 minutes into her ED stay, the patient had a generalized tonic-clonic seizure lasting approximately 30 seconds. She received lorazepam 2mg intravenous (IV) and was moved to the resuscitation bay. She received repeated doses of benzodiazepines along with aggressive fluid resuscitation and was admitted to the pediatric intensive care unit. 

Serotonin Syndrome

Serotonin syndrome is a life-threatening condition due to increased serotonergic activity in the central nervous system. The syndrome can occur through accidental overdose, deliberate self-poisoning, or even therapeutic medication use. The classic triad of mental status changes, autonomic hyperactivity and neuromuscular abnormalities is not always seen, and the presentation can be subtle.

Classic neuromuscular findings include hyperreflexia and muscular rigidity greater in the lower extremities than in the upper extremities, as well as clonus. Roving eye movements known as “ocular clonus” can also be seen.

Complications of serotonin syndrome include cardiac dysrhythmias, seizures, metabolic acidosis, rhabdomyolysis, and severe hyperthermia resulting in end organ failure and disseminated intravascular coagulation.

Treatment is largely supportive including respiratory support, IV fluids and benzodiazepines.

Adjunctive therapies include GI decontamination with activated charcoal if ingestion is within two hours, and cyproheptadine. Cyproheptadine is a first-generation anti-histamine that also has anti-serotonergic properties, and should be considered if supportive measures fail. Caution must be exercised as this medication is only available in PO formulation and would require NG tube placement in the obtunded patient. Downsides of cyproheptadine include exacerbating hypotension, so it should not be used on patients with profound autonomic instability as can be seen in some cases of serotonin syndrome.

Supportive care also includes treating patients who have a temperature of greater than 41.1C (106F) with immediate intubation and paralysis with a non-depolarizing neuromuscular blocking agent (e.g. rocuronium or vecuronium). Active cooling measures should also be initiated at this point.

Citalopram and escitalopram are worth special mention as these two SSRIs can cause significant widening of the QRS and QTc interval, which can degenerate into torsades de pointes up to 12 hours after ingestion. Thus, patients who have EKG changes or persistent sinus tachycardia should be admitted to a critical care setting and observed on telemetry with serial EKGs for at least this duration.

Case conclusion

The patient’s vitals and physical exam normalized on hospital day one with continued supportive care and she was subsequently transferred to the inpatient psychiatry service.

Faculty Reviewer: Dr. Jason Hack

Sources

Boyer, E. and Michael Shannon. “The serotonin syndrome.” N Engl J Med 2005;352:1112-20.

Boyer, E. “Serotonin syndrome (serotonin toxicity).” UpToDate.

LoVecchio, F. and Erik Mattison. “Atypical and serotonergic antidepressants: Serotonin Syndrome.” Tintinalli’s Emergency Medicine: a comprehensive study guide 8e (2016).

 

AEM Early Access 04: A 0h/1h Chest Pain Protocol

Welcome to the fourth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and links to curated FOAMed supportive educational materials for EM learners.

Find previous podcasts and suscribe to this series on iTunes here.

 

 

 

 

 

LISTEN NOW: Interview with Dr. Arash Mokhtari, lead author, interviewed by Dr. Michael Prucha.

Dr Arash Mokhtari, MD, PhD Department of Internal and Emergency Medicine, Skåne University Hospital, Lund Department of Cardiology, Lund University, Skåne University Hospital, Lund

Dr Arash Mokhtari, MD, PhD

Department of Internal and Emergency Medicine, Skåne University Hospital, Lund
Department of Cardiology, Lund University, Skåne University Hospital, Lund

Open Access Through August 31st. Click here:

A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients. Mokhtari A, et al. 

Article Summary:

Objective: To investigate the effectiveness of a rapid ACS rule-out protocol using 0h and 1h high-sensitivity troponin in conjunction with EKG changes and a modified TIMI risk score in order to safely and quickly discharge patients presenting with chest pain.

Methods: A secondary data analysis was performed on data collected from a prospective observational study on patients presenting to the Emergency Department at the Skåne University Hospital in Lund, Sweden. Evaluation included 0h and 1h troponin, including the absolute change, EKG changes as interpreted by Emergency physicians, as well as a modified TIMI risk score to decide whether patients could be discharged.  Adverse outcomes were defined as major adverse cardiac events (MACE) at 30 days including myocardial infarction, unstable angina, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause.

Results: This study included 1,020 patients who were evaluated on the above parameters, and discharged only if their modified TIMI risk score was less than, or equal to 1, the EKG was non-ischemic, and the 0h troponin was < 5 ng/L or 0 h <12 ng/L with a 1h troponin increase < 3 ng/L.  Using these criteria 432 (42.4%) patients were defined as “very low risk.”  Of those only 2 patients had MACE, both of which were unstable angina.  This produced a negative likelihood ratio of 0.04 for 30-day MACE.

Conclusion: While validation of this study needs to take place in other settings, the results of this study suggest that possibly greater than 40% of patients presenting to the ED could be discharged quickly and safely, after the result of a 1h high-sensitivity troponin or sooner, with a very small risk of missing 30-day MACE. Of course, this study was performed at one unique site in Sweden, but the results provide promising prospects for new accelerated diagnostic protocols.

 

Suggestions for further readinG:

Open access:

The Fast and the Furious: Low Risk Chest Pain and the Rapid Rule Out Protocol, a review, West JEM, February 2017

ERCast: Which Chest Pain Patients Can Be Discharged? February 20, 2016

REBEL EM: Management and Disposition of Low Risk Chest Pain, February 2016

Subscription/Abstracts:

Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis. Ann Intern Med. 2017 May 16;166(10):715-724. 

Present and Future of Cardiac Troponin in Clinical Practice: A Paradigm Shift to High-Sensitivity Assays.Am J Med. 2016 Apr;129(4):354-65. 

High-sensitivity cardiac troponin assays and unstable angina.Eur Heart J Acute Cardiovasc Care. 2016 Jul 7

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes.Hollander J et al, Circulation. 2016 Aug 16;134(7):547-64.

High-sensitivity cardiac troponin assays: answers to frequently asked questions. Arch Cardiovasc Dis. 2015 Feb;108(2):132-49

 

Faculty Editors/Reviewers: Dr. Kristy McAteer and Dr. Gita Pensa

Podcast credits: Used under creative commons license: intro music by freemusicarchive.org , sound effect from freesound.org, exit music by bensound.com