Dr. Brian Weitzman Department of Emergency Medicine Ottawa Hospital Back to Basics 2012 Dr. Brian Weitzman Department of Emergency Medicine Ottawa Hospital Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Review of 14 Common Emergency Medicine Topics Today Acute Abdominal Pain Acute Dyspnea Hypotension/Shock Syncope Coma Cardiac Arrest Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Emergency Medicine Topics March 28 and April 5 Malignant Hypertension Animal Bites Burns Near-drowning Hypothermia Poisoning Urticaria/Anaphylaxis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Abdominal Pain MCC Objectives Common causes of pain Localized vs diffuse Upper vs Lower Abdominal History Physical exam: appropriate-vitals, abd, rectal, pelvic GU Investigate: order appropriate tests Interpret clinical and lab data Management plan: Who needs immediate attention and treatment/surgery Non-emergency management Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Case 1: Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ. What disease process is this typical for? What causes the change in the pain pattern? What other diseases must you consider? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Neurologic Basis of Abdominal Pain Visceral Somatic Referred Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Visceral Abdominal Pain Stretch receptors in walls of organs Stimulated by distention, inflammation return to spinal cord: bilateral, multiple levels Brain cannot localize source Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Visceral Abdominal Pain Pain felt as crampy, dull, achy, poorly localized Associated with autonomic responses of palor, sweating, nausea, vomiting Patients often writhing around Movement doesn’t alter pain Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Somatic Abdominal Pain parietal peritoneum Returns to ipsilateral dorsal root ganglion at 1 dermatomal level Sharp, localized pain Causes tenderness, rebound, and guarding Patients lie still, movement increases pain Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Referred Pain What is it? What are some examples? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Referred Pain Pain perceived in an area that is distant from the disease process Due to overlapping nerve innervations Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Examples of Referred Pain Shoulder pain with diaphragm stimulation C 3,4,5 stimulation Back pain with biliary colic, pancreatitis, or PID Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Differential Diagnosis Diffuse vs Localized Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Diffuse Abdominal Pain Peritonitis AAA Ischemic Bowel Gastroenteritis Irritable Bowel Syndrome Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Causes of Abd Pain - Localized Upper Abdominal Lower Abdominal Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Localized Abdominal Pain Gastritis,GERD/PUD Pancreatitis MI Biliary Colic/Cholecystitis Hepatitis / Hepatic Abscess Pneumonia / Pleurisy Splenic Infarction Splenic Rupture Pneumonia Inflammatory bowel disease Diverticulitis Ectopic Ovarian(torsion or cystA) Salpingitis/PID Renal Stones/UTI Testicular torsion Incarcerated Hernia Bowel obstruction Appendicitis Mesenteric lymphadenitis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Case 1: Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Case 1: Questions 1. What further history do you need from the patient? 2. What would you do in your physical exam? 3. What are you looking for on physical examination? 4. What initial stabilization is required? 5. What is your differential diagnosis? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

History Onset / Duration Nature / Character / Severity Radiation Exacerbating / Relieving Factors Location Associated Symptoms Nausea / Vomiting Diarrhea / Constipation / Flatus Fever Jaundice / other skin changes GU (dysuria, freq, urgency, hematuria…) Gyne (menses, contraception, STDs,,,) PMHx Prior Surgery Medical Problems Medications Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

High Yield Questions Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

High Yield Questions 1. Age Advanced age means increased risk. Which came first—pain or vomiting? Pain first is worse (i.e., more likely to be caused by surgical disease). 3. When did it start? Pain for < 48 hrs is worse. 4. Previous abdominal surgery? Consider obstruction. 5. Is the pain constant or intermittent? Constant pain is worse. 6. Previous hx of pain? 7. Pregnant? consider ectopic. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

High Yield Questions cont’d History of serious illness is suggestive of more serious disease. HIV? Consider occult infection or drug-related pancreatitis. Alcohol? Consider pancreatitis, hepatitis, or cirrhosis. 11. Antibiotics or steroids? These may mask infection. 12. Did the pain start centrally and migrate to the right lower quadrant? High specificity for appendicitis. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

High Yield Questions, cont’d 13. History of vascular or heart disease, hypertension, or atrial fibrillation? Consider mesenteric ischemia and abdominal aneurysm. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Examination Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Examination Vitals General appearance: writhing/motionless, diaphoresis, skin, mental status Always do brief cardiac and respiratory exam Abdominal exam: inspect, auscultate, percuss, palpate Pelvic, genital and rectal exam in ALL patients with severe abdominal pain Assess pulses! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Abdo Exam: Specifics Always palpate from areas of least pain to areas with maximal pain ?Organomegaly, ?ascites Guarding: voluntary vs. involuntary Bowel sounds: increased/decreased/absent Rectal exam: occult/frank blood, ?stool, ?pain, ?masses Pelvic exam: discharge, pain, masses Peritonitis: suggested by: rigidity with severe tenderness, pain with percussion/deep breath/shaking bed, rebound Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Risk Factors for Acute Disease Extremes of age Abnormal vital signs Severe pain of rapid onset Signs of dehydration Skin pallor and sweating Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Initial Stabilization Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Initial Stabilization All patients with acute abdominal pain: Assess vital signs Oxygen Cardiac Monitoring/12 lead ECG Large bore IV (may need 2) 250-500 cc bolus of NS in elderly with low BP 500-1000 cc bolus in younger patients with low BP Consider NG and Foley catheter Brief initial examination : history and physical Consider analgesics ??Do they need immediate surgical consultation? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Pain: ER Management Is it OK to give a patient pain medications before you determine their diagnosis? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Abdominal Pain: ER Management Anti-inflammatories (NSAIDs): very effective, esp. for MSK or renal colic pain Ex. Ketorlac (Toradol) 30 mg IV Narcotics sc/im/iv very effective, esp. for visceral or undifferentiated pain Ex. Morphine 2.5-10 mg, hydromorphone 1-2 mg Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Nausea/Vomiting: ER Tx Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Nausea/Vomiting: ER Tx Ondansetron (Zofran) : iv 4-8 mg very useful in patients with refractory vomiting Gravol: po/pr/im/iv 25-50 mg beware of anticholinergic side effects sedating, may cause confusion Maxeran/prochlorperazine (Stemetil): 10 mg iv beware of possible EPS less sedating; may help with pain control Domperidone: po/iv especially useful with diabetic gastroparesis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Investigations Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Investigations Most patients with acute abdominal pain require: - CBC, differential; may need type and cross-match - electrolytes, BUN, creatinine, lactate - liver enzymes, liver function tests - lipase - beta-hCG - urinalysis; stool for OB They may also need: ECG, cardiac enzymes, ABG, Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Investigations Imaging ultrasound CT scan plain Xrays Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is the cause of this 45 y.o. man’s LLQ pain? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is the cause of this 45 y.o. man’s LLQ pain? Renal stone Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is the cause of this man’s pain? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is the cause of this man’s pain? Double lumen sign of free air in abdomen Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Why is this woman vomiting? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Central location, plica circularis (valvulae coniventes) Small bowel obstruction central, stack coins, Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Why is this woman vomiting? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Large bowel, haustra, air LLQ Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Sigmoid Volvulus 34yr female: cerebral palsy, no BM’s, abdo distension massive bowel dilation single loop “bent rubber tube” 34yr female: cerebral palsy, no BM’s, abdo distension Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is the cause of this man’s abdominal pain? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is the cause of this man’s abdominal pain? Free air Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Summary: Approach to Abdominal Pain in the ER ABC assessment Stabilize the patient, and refer early if unstable Careful, detailed history Focused physical examination Early, thorough work-up: Appropriate laboratory investigation Diagnostic imaging where indicated Continuous reassessment Consider patient circumstances (age, pmhx, reliability, home situation) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Summary: Common Causes of Abdominal Pain MCC Categorization Is it diffuse or localized? Do they need immediate resuscitation, referral or surgery? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Acute Dyspnea (minutes to hours) MCC Objectives Differentiate dyspnea from hyperpnea, tachypnea and hyperventilation Differentiate cardiac and pulmonary causes Focused efficient hx Interpret clinical and lab data Select and interpret heart and lung investigation (ECG, ABG, lung imaging) Diagnose and manage acute dyspnea Determine who needs to stay Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What drives us to breath? Chemoreceptors in medulla, carotid and aortic bodies: High CO2 High H+ ion Low 02. Stretch and baroreceptors in lungs Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Definitions Dyspnea: Hyperpnea: sensation of shortness of breath increase in rate or depth of breathing Ex. Metabolic acidosis, ASA Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Definitions Tachypnea: Hyperventilation: rapid, shallowing breathing breathing in excess of metabolic needs of body lowering C02 Need to rule out organic disease Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 55 year old woman comes into the ED in obvious respiratory distress A 55 year old woman comes into the ED in obvious respiratory distress. She is very agitated, sitting forward, using her accessory muscles. What is her problem? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Most Common Causes of Acute Dyspnea Cardiac: MI CHF/ARDS Pericardial Tamponade Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Acute Dyspnea-Respiratory Causes Upper airway: Aspiration, anaphylaxis, FB, Lower airway COPD Pneumonia CHF/ARDS PE Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Acute Dyspnea-Respiratory Causes Ventilatory Pump Pneumothorax Asthma Misc: Metabolic: acidosis, ASA toxicity Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Our 55 year old woman is still in respiratory distress. What will you do? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Rapid Assessment ABC’s : 5 vitals: P, RR, BP, T, 02 sat. O2, IV, Monitor, ECG Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Rapid Assessment-General Ability to speak Mental status, agitation, confusion Positioning Cyanosis: Central: Hgb desats by 5 g. Not evident in anemia Peripheral: mottled extremities Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Rapid Assessment Airway: Is the patient protecting it? Is the patient able to oxygenate and ventilate adequately? Is there stridor Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Oxygen Nasal prongs max. 4-5l/min Venturi: up to 50% Increase FIO2 by 4%/L Venturi: up to 50% 02 reservoir: 90-95% Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

5 Reasons to Intubate Protection Creation Oxygenation Ventilation Pulmonary toilet Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Breathing Look, listen, feel, or IPPA Wheezes, rales, rubs, decreased air entry Is it adequate? O2 sat? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Circulation Pulse, BP, Heart sounds ? Muffled JVP Edema Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Rapid Assessment Does this person need immediate treatment? Ventolin Nitroglycerin ASA Furosemide BiPap Needle decompression Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

History-What are the key questions? Previous hx of similar event How long SOB Onset gradual or sudden What makes it better or worse Associated symptoms: Chest pain, cough, fever, sputum, PND, orthopnea, SOBOE Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

History-What are the key questions? Medications, home 02 Allergies What has helped in the past Past medical history: Cardiac, pulmonary, recent surgery Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Labs/Investigations ABG CBC, Lytes, Cardiac enzymes D dimer ECG Pulmonary Function Tests Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Imaging CXR VQ Helical CT Pulmonary angiogram Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

COPD 72yr female: chronic SOB, worse x few days hyperlucent lung fields increased retrosternal air low set diaphragm increased AP diameter flat diaphragm vertical heart 72yr female: chronic SOB, worse x few days Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Principles of Management COPD Oxygen Titrate with 02 sat: Monitor pC02, avoid loss of hypoxic drive Beta agonists and anticholinergics Ventolin 1 cc in 2 cc atrovent or MDI Steroids ex. Solumedrol 125 mg IV BiPap Antibiotics Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Status Asthmaticus 100 % oxygen continuous ventolin in atrovent solumedrol 125 mg IV magnesium S04 2 gm over 2 min isoproterenol 0.1-6.0 microg/kg/min epinephrine 0.2 mg IV over 5 min then 1-20 microg/min Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

RML pneumonia 46yr male: chills, pleuritic C/P, ant R creps diaphragm preserved R heart border obscured lat confirms ant location 46yr male: chills, pleuritic C/P, ant R creps Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

LLL pneumonia 58yr female: weakness, cough, SOB lat confirms post location diaphragm obscured 58yr female: weakness, cough, SOB Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75 y.o. man with dyspnea Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75 y.o. man with dyspnea RLL pneumonia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Principles of Management Pneumonia Oxygen to maintain 02 sat at 92-94% Antibiotics: Macrolides Fluroquinolones 2nd or 3rd generation cephalosporin Beta agonists and BiPap as required Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Pulmonary edema 69yr male: past MI, SOB, orthopnea, PND increased cephalic blood flow increased periph blood flow alveolar infiltrates Kerley B lines prominent hilar vessels cardiomegaly 69yr male: past MI, SOB, orthopnea, PND Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 79 yo woman with dyspnea Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 79 yo woman with dyspnea CHF Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Principles of Management Pulmonary Edema Oxygen BiPap Nitroglycerin SL, IV Furosemide 40-160 mg IV Morphine 2-4 mg IV ECG-rule out ACS Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 25 year old with dyspnea Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Spontaneous Pneumothorax no mediastinal shift outline of R lobes tall thin stature 21yr male: acute SOB + pleuritic C/P Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Pneumothorax Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Principles of Management Pneumothorax Tension: 14 gauge needle 2nd ICS, MCL 30 Fr chest tube Pigtail catheter Small spontaneous pneumothorax: @20% May observe, discharge, repeat CXR 24 hrs Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Ruptured Aorta 34yr male: MVC hit tree, unrestrained, c/o chest pain widened superior mediastinum loss of aortic knuckle 34yr male: MVC hit tree, unrestrained, c/o chest pain Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75 y.o. with a history of CHF comes in drowsy, gasping for air. : pH 7.15 pC02 70 HCO3 30 P02 60 Acute or Chronic Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75 y.o. with a history of CHF comes in drowsy, gasping for air. : pH 7.15 pC02 70 HCO3 30 P02 60 Acute Respiratory Acidosis HCO3 has not had time to increase very much Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75. y.o. with COPD and dyspnea x 2 days pH 7.28 pC02 80 HC03 40 p02` 65 Acute or Chronic Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75. y.o. with COPD and dyspnea x 2 days pH 7.28 pC02 80 HC03 40 p02` 65 Chronic Respiratory Acidosis HC03 very high therefor pH not that low Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 25 y.o. diabetic, vomiting x 2 days, looks dyspneic pH 7.10 HC03 10 pC02 18 P02 95 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 25 y.o. diabetic, vomiting x 2 days, looks dyspneic pH 7.10 HC03 10 pC02 18 P02 95 Acute metabolic acidosis, and partially compensating respiratory alkalosis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

An anxious woman Our 55 y.o. woman, recent mulitple stressors, comes in to the ED, hyperventilating. Feels short of breath and thinks she is having an anxiety attack. What else will you do? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Our 55 year old woman in distress… Pericarditis or Acute Inferior MI Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Acute Inferior MI Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Admission Criteria for Dyspnea Abnormal vitals including 02 sat Abnormal level of consciousness Significant illness ex. Pneumonia Patient fatigue No improvement despite treatment Home situation Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Syncope Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Syncope http://www.blogtelevision.net/p/Videos-Watch-a-Video___1,2,,59315.html Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Syncope-MCC Objectives Definition Physiology Distinguish from Seizure Causes: serious or not, cardiac or not Initial Management Plan Hx, Px, Investigations Who needs referral, pacing, fitness to drive Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Syncope A 73 y.o. man collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430. He awakes fully, and is brought to the Emergency Department by his wife. Is this a syncopal episode? What are the causes of syncope? What is the likelihood he had a cardiac cause of syncope? What is your workup and management of this patient? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is syncope? Sudden, transient loss of consciousness Rapid and complete recovery May have minor myoclonic jerks or muscle twitching No postictal state Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

How is a generalized seizure different than a syncopal episode? Aura (parasthesia, noises, light, vertigo) Tonic-clonic movements and loss of consciousness Post ictal confusion for minutes-hours Tongue biting Incontinence bowel or bladder Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What are the common causes of syncope? (MCC) Cardiovascular (80%) Cardiac arrhythmia (20%) Decreased cardiac output –MI, Ao. Stenosis Reflex/underfill (60%) (vasovagal, orthostatic) Cerebrovascular (15%) Other metabolic psychiatric Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiovascular Causes of Syncope Cardiac arrhythmia (20%) Tachy or bradycardia Carotid sinus syndrome Decreased cardiac output Inflow obstruction (to venous return) ex. PE Squeeze: Myocardial ischemia (decreased contractility) Outflow obstruction (Aortic stenosis, hypertrophic cardiomyopathy Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiovascular Causes of Syncope Reflex/Underfill (60% of syncope) Vasovagal (common faint) orthostatic/postural ex. Blood loss Situational (micturition, cough, defecation) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cerebrovascular Causes (15%) TIA vertibral basilar insufficiency high ICP Metabolic : hypoxia, low BS, drugs, alcohol Psychiatric: hyperventilation, panic Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physiology What happens in the brain to make us lose consciousness? injury or dysfunction of bilateral cerebral hemispheres or reticular activating system due to toxins, loss of nutrients (oxygen or glucose), or decrease cerebral blood flow Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is your initial approach with your patient with syncope? Check ABC,s, 5 vitals -postural monitor, IV, ECG, blood tests Bolus fluids if hypotensive 250-1000cc NS glucosan give thiamine if giving glucose consider naloxone if patient not fully awake history and physical Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

History what happened (witnesses important) what were you doing (ex. urination, standing up quickly etc.) prodrome (hot, sweaty, vomiting) any tonic-clonic activity postural or neck turning recovery – long or short any confusion Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Review of Systems volume status (eating, diarrhea, exercise) recent blood loss chest pain, palpitations, SOB, any focal neurologic symptoms pregnancy Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

PMH previous history of syncope ex. occasional episodes over the years vs several episodes recently (more sinister) cardiac disease or medications bleeding disorders or PUD diabetes medications ex. antihypertensives often cause orthostatic syncope Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Exam ABC Orthostatic Vitals HEENT: trauma, papilledema, Resp/CVS: S3, AS murmur, Abd: aorta, pulses, peritoneal, blood PR Pelvic: bleeding, tenderness Neurologic: focal findings Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Lab Investigations CBC Type and xmatch Lytes, BS, BUN, Cr D dimer If suspect acute blood loss AAA, ectopic, GI bleed Lytes, BS, BUN, Cr D dimer Pregnancy Test ECG CT Head if suspect cerebrovascular cause Holter EEG Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Vasovagal Faint Common (20% all syncope) Increased parasympathetic tone Bradycardia, hypotension Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Vasovagal Faint -Predisposing Factors Fatigue Hunger Alcohol Heat Strong smells Noxious stimuli Medical conditions anemia, dehydration Valsalva (trumpet player) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Vasovagal Faint Symptoms and signs Warm, sweaty Weak Nausea Confused Unprotected fall Eye rolling, myoclonic jerks, Resolves in 1-2 min Rarely tongue biting or incontinence Not confused afterward Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Syncope 20% all syncope Serious prognosis Exertional syncope Outflow obstruction AS, IHSS Ischemia/MI Conduction disorders dysrhythmias Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Orthostatic Decrease in systolic BP by 20-30 or increase in pulse by 20-30 on standing Supine Meds -antihypertensives Blood loss, dehydration Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Syncope-When to Admit Uncertain diagnosis Elderly (more likely cardiac) Suspected cardiac etiology Abrupt onset with no prodrome (typical for dysrhythmia) Unstable vitals Blood loss Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

San Francisco Syncope Rule 98% sensitive and 59% specific for predicting serious outcome Patient requires admission with any of: C CHF history H Hematocrit < 30 E ECG abnormal S SOB S Systolic < 90 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Our 73 y.o. man who collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430. In the ED, he had another brief syncopal episode, following by sinus tachycardia What is his problem? What would you do? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Sick sinus syndrome: need pacer Our 73 y.o. man who collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430. Sick sinus syndrome: need pacer Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

An 80 y.o. man complains of recurrent syncope What is his diagnosis and treatment? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

An 80 y.o. man complains of recurrent syncope What is his diagnosis and treatment? Third degree Heart Block Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 65 y.o. man on diuretics has recurrent syncope Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Torsades de Pointes Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Treatment of Torsades Correct electrolytes Magnesium 2 gm over 20 min Isoproterenol 2-20 mcg/min Overdrive pacing Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Pacing When is it required? 3rd degree (complete HB) 2nd degree type ll Sick sinus syndrome Symptomatic bi or trifasicular blocks Ex. RBBB + LAH + 1st degree HB Symptomatic bradycardia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Fitness to Drive Single episode of syncope that is easily explained ie. Simple faint dosen’t need reporting Recurrent episodes or suspected cardiac cause is more serious, needs to be reported and the patient shouldn’t drive til a cause is determined and treated. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

? Break Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Coma Coma Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

MCC Objectives Definition and Causes of coma Clinical Assessment Know how to examine a patient in a coma Differentiate coma due to abnormal brainstem vs cortical injury Investigation: appropriate lab and imaging Management plan Who needs immediate treatment Who needs specialized treatment Management of Incompetent Patients Assess for suspected brain death (prior to referring for definitive diagnosis) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is Coma? MCC Defintion: state of pathologic unconsciousness (unarousable) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

An 80 y. o. man is comatose 2 weeks after falling down stairs An 80 y.o. man is comatose 2 weeks after falling down stairs? Why is this patient comatose? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Isodense Subdural Hematoma Enhanced CT Head Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A diabetic patient present in a coma and is found to have a BS of 1.5 Why are they in a coma? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Coma Can be induced by structural damage or chemical depression 1) reticular activating system in brainstem, midbrain, or diencephalon (thalamic area) Ex. Pressure from a mass Toxins 2) Bilateral cerebral cortices Ex. Toxins, hypoxia, hypoglycemia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 45 y. o. ‘street’ person is brought into the ED in a coma A 45 y.o. ‘street’ person is brought into the ED in a coma. What are the causes? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Causes of Coma Structural Metabolic (medical) Bleed, CVA, CNS infection, Metabolic (medical) A,E,I, O, U, TIPS Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 45 y. o. ‘street’ person is brought in to the ED in a coma A 45 y.o. ‘street’ person is brought in to the ED in a coma. What are the causes? AEIOU TIPS A - alcohol, anoxia E – epilepsy, electrolytes (Na, Ca, Mg), encephalopathy (hepatic) I - insulin (diabetes) O - overdose U - uremia, underdose (B12, thiamine)   T- trauma, toxins, temperature, thyroid I - infection P - psychiatric S - stroke (cardiovascular) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What is your initial approach with this comatose patient? A-airway protection (and c spine) B-breathing O2 sat C-5 vitals (pulse, BP, temp) D-dextrose Glucoscan Thiamine (if giving glucose) Naloxone IV, ECG monitor, foley, labs Hx, Px Determine level of consciousness Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Level of Consciousness AVPU Awake, verbal, pain , unresponsive Glasgow Coma Scale Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

GCS Best Eye Response. (4) Best Motor Response. (6) 8 or less = coma No eye opening. Eye opening to pain. Eye opening to verbal command. Eyes open spontaneously. Best Motor Response. (6) 8 or less = coma No motor response. Extension to pain. Flexion to pain. Withdrawal from pain. Localising pain. Obeys Commands Best Verbal Response. (5) No verbal response Incomprehensible sounds. Inappropriate words. Confused Orientated Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

History What happened? Symptoms: depression, Headache Gradual or sudden LOC Sudden = intracranial hemorrhage Gradual more likely metabolic, could be subdural PMH: diabetes, thyroid, hypertension, substance abuse, alcohol Meds, Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Exam Goal: Try and determine if a structural lesion is present, or a metabolic cause. How do structural lesions present differently than metabolic causes of coma? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Exam Structural lesions: Metabolic causes: Often have focal findings, abnormal pupils, evidence of increased ICP Metabolic causes: No focal findings, pupils equal mid or small, no evidence of increased ICP Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Signs and Symptoms of Increased ICP Headache, N, V, Decreased LOC Abnormal posturing Abnormal respiratory pattern Abnormal cranial nerve findings Cushing Triad: late sign of high ICP) high BP, bradycardia, and low RR = high ICP Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Exam Vitals BP > 120 diastolic may cause encephalopathy Hypotension uncommon with intracranial pathology Temperature Infection, CNS or otherwise Neuroleptic malignant syndrome Altered mental status, muscle rigidity, and fever Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Respirations Cheyne stokes Apneustic Fast alternating with slow breathing Brain lesions, acidosis Apneustic Pauses in inspiration Pons lesions, CNS infection, hypoxia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Exam HEENT: Battle’s sign, hemotympanum. Breath odour Ex. Acetone = DKA Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Pupils Metabolic: Structural: 10% normal people have 1-2 mm difference pupils usually react Structural: may be unilateral dilatation Why? Uncal herniation presses on CN 111, Lose Parasympathetic tone Unapposed sympathetic stimulation 10% normal people have 1-2 mm difference Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Pupils Fixed dilated pupils ominous Small pinpoint pupils Dead, central herniation, hypoxic injury Small pinpoint pupils Lesion in pons (ischemic or bleed Opiate OD Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Exam Corneal Reflex Sensory CN 5, and Blink is CN 7 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Extraocular Movements Helps determine brainstem function in coma Doll’s eyes Eyes move in opposite direction to head movement indicates functioning brainstem Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Oculocephalic Reflex Ensure C spine cleared Awake person: eyes look forward, some nystagmus Comatose patient with brainstem function: Eyes deviate completely in opposite direction to head movement Comatose Patient with no brainstem function Eyes follow head movement Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Oculovestibular Reflex Cold Calorics Check eardrum 50 cc iced saline Awake person: COWS Nytagmus away from cold Driving a car, cerebral cortex keeps you on the road Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Oculovestibular Reflex Cold Calorics Comatose patient, intact brainstem Eyes deviate to cold side Hey who’s putting ice in my ear Comatose patient, nonfunctioning brainstem No reaction Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Physical Exam cont. Disc Nuchal rigidity Resp/CVS/Abd/Extrem Neuro: level of consciousness, CN, Motor, Sensory, DTR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Motor Exam Is there asymmetry in response to pain Evidence for seizures? Withdrawing: nearly awake pt Decorticate: Abnormal flexion response. Flexes elbow, wrist, and adducts shoulder Cerebral cortex injury Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Motor Exam Decerebrate posture Flaccidity Extends elbow with internal rotation Lesions or metabolic effect in midbrain Flaccidity Ominous sign Toxin/OD Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Labs ? CBC, Lytes, Bun Cr, BS LFT, Ca, Mg, ABG Alcohol, Osmolality Tox screen CO level Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Diagnostic Tests/Imaging CXR CT Head LP ECG EEG Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Brain Death Irreverisble failure of clinical function of the whole brain Coma, apnea, loss of brain stem reflexes Difficult to assess in 1st few hours Ensure no hypothermia, barbituates Better to use concept of cardiopulmonary death, some brainstem reflexes may persist Spinal cord reflexes may persist Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Testing for Brain Death Brainstem reflexes Doll’s eyes, Oculocephalic reflex Cold water calorics Gag, cough, corneal Apnea testing: off ventilator, allow pC02 to rise to 60 mmHg while supplying O2 Takes 8-10 minutes Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 25 y. o. woman presents in a coma. Pupils pinpoint. RR 8 A 25 y.o. woman presents in a coma. Pupils pinpoint. RR 8. No focal findings? What will you do? ABC’s, vitals BS Naloxone 0.4-2 mg IV What if she is chronically taking narcotics? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 30 y.o. man, hit on the head, comatose with a unilateral fixed dilated pupil? What would you do? Intubate, pC02 to 30 mmHg Mannitol .5 gm/kg CT Head Stat Neurosurgery consult Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Uncal Herniation Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Summary COMA ABC, Vitals, O2, CO2, BS, Naloxone Metabolic vs Structural Key to Exam Respiration Pupils EOM Motor response Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

He says he knows his rights and he wants to leave. A 25 y.o. man is seen in the ED, and is drunk. He is swearing and screaming, jumping out of bed and staggers when he walks holding onto a chair to keep him upright. He has no evidence of trauma and no focal findings. He says he knows his rights and he wants to leave. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A) be thankful that he wants to go and get security to escort him out Your options: A) be thankful that he wants to go and get security to escort him out B) Face the wrath of the nurses and other patients and forcibly restrain him Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Restraining People Is the patient competent to decide for them self? Is the patient suffering from a mental illness that allows us to restrain them. ie Form 1 Unable to care for self At harm to self or others In the past has shown evidence of the above when suffering from this mental illness Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Competence / Capable Understands medical issue Understands treatment proposed Understands consequences of accepting or refusing treatment Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Valid Consent Relate to treatment Informed Voluntary Can’t misrepresent or be fraudulent Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Informed consent Information that a reasonable person would need to make a decision about the proposed treatement Risks, benefits, side-effects, Alternative course of action Consequences of not accepting treatment Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Substitute Decision Making Highest of Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Hypotension Shock – MCC Objectives Causes History Examine Diagnose Labs Management strategy Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What Is Shock Tissue hypoperfusion or tissue hypoxia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Shock Catecholamine surge Vasoconstriction, increased CO Renin-angiotensin, vasopressin Salt and water retention Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Shock If persists Lactic acid, decreased CO and vasodilation Cell membrane ion dysfunction, intracellular edema Leakage of intracellular contents Intracellular acidosis Cell and organ death Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Shock What are the causes? Obstructive Obstructive Cardiac Hypovolemic Distributive Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Obstructive Shock Cardiac PE, tamponade, tension pneumothorax Pump failure: MI, ruptured cordae or septum Contutsion, aortic value dysfunction Dysrhythmia Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Hypovolemic Distributive Blood Loss Dehydration Sepsis –most common Trauma, AAA, aneurysm, GI bleed, ectopic Dehydration Gastro, DKA, Burns Distributive Sepsis –most common adrenal, neurogenic, anaphylactic Toxins (cyanide), CO, acidosis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Initial Management ABC’s Vitals MAP = DBP + 1/3 PP (SBP-DBP) MAP <70 = shock (inadequate perfusion) IV How much? Fill the patient up Two, 16 ga, 500-1000cc bolus Cardiac shock: bolus 250 cc at a time Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Hx and Px Ask questions and examine carefully to rule in or out all of the major causes of shock ABC approach Head to Toe Survey Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Labs BS CBC, lytes, liver/renal function Lipase, fibrinogen, fibrin split products, Cardiac enzymes, ABG, ECG, urine, Tox screen Stool OB Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75 y.o. comes in confused x 2 days, lethargic BP 80/50 P. 130 T 38 RR 25 02 85% What is his diagnosis? What would you do? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Septic Shock Fluids: normal saline 1-2 litres Oxygen Treat the infection: Antibiotics: broad spectrum 3rd generation cephalosporins Pip-tazo BP support: inotropes: dopamine Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 39 y.o. man arrives in the ED having been stung by a bee 30 minutes ago. He has hives, facial and tongue swelling and is dyspneic. What will you do? BP 70/50 P. 140 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Anaphylaxis 100 % oxygen bolus 1-2 litres normal saline epinephrine 0.3 mg IM q5min or 5-15 microgm/min IV with shock benadryl 50 mg IV ranitidine 50 mg IV solumedrol 125 mg IV Glucagon 1mg IV if on beta blockers Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Arrest – MCC Objectives Causes Cardiac and noncardiac Investigations Management plan-CPR and ACLS protocols Communicate DNR Death Organ donation Autopsy request Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Arrest - Causes Coronary artery Conduction Metabolic: hypo Ca, Mg, K, anorexia Brady or tachydysrhythmia Myocardium Hereditary: cardiomyopathy Acquired: LVH, Valve disease, myocarditis Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Arrest - Causes Non Cardiac Tamponade PE Tension Trauma Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 72 y.o. man clutches his chest and collapses in the ED Why did he collapse? What are you going to do ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Sudden Cardiac Arrest electrical accident due to ischemia or reperfusion 80% ventricular fibrillation or ventricular tachycardia 20 % asystole pulseless electrical activity Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Mechanism of Fibrillation ischemia: slows conduction adjacent myocardium in various phases of excitation and recovery multiple depolarizing reentrant wave fronts Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Ventricular Fibrillation (V. fib.) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Ventricular Tachycardia (V. tach) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Arrest What are the key actions that are required to improve survival from cardiac arrest? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Chain of Survival Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

C-A-B rather than A-B-C... Major Changes of BLS Change in CPR sequence to : C-A-B rather than A-B-C... Begin with chest compressions !!! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Major Changes of BLS Trained Layperson or Health Care Provider 30 compressions, 2 breaths Untrained layperson Compression only CPR acceptable ‘Hands Only’ CPR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Major Changes of BLS Elimination of : “Look, Listen & Feel” for breathing... …except for hypoxic arrest Pulse check for Health Care Providers < 10 sec. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Why the change to CAB? Beginning with airway significantly delays compressions Most cardiac arrest victims have oxygenated blood Survival related to adequate chest compressions Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

High Quality CPR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

High Quality C.P.R. Compression : Ventilation ratio (30 : 2) Until advanced airway Minimize interruptions in CPR Push Hard & Fast : 2 inches / 100/ min. Full chest recoil-lift hands off chest Change compressors q2min Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Airway Management BVM (Bag-Valve-Mask) Avoid hyperventilation! 8 – 10 breaths / min. interposed with CPR Secure Airway & Confirm Placement No need to pause compressions! Advanced airway: LMA, ETT ETCO2 monitoring ! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Exhaled CO2 Detectors 100% sensitivity and 100% specificity in identifying correct endotracheal tube placement. MAJOR NEW CLASS 1 RECMENDATION. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012 214

Airway & Adjuncts Role of cricoid pressure during cardiac arrest has not been studied. Routine use of cricoid pressure in cardiac arrest is not recommended. May actually impede times Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012 215

Supraglottic Airways LMA King LT Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What are the only things that should interrupt CPR? Rhythm and pulse check Ventilation (if advanced airway not present) Advanced airway and intubation Defibrillation Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A patient you are talking to suddenly becomes unresponsive Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

The crash cart arrives, you grab the paddles and have a quick-look Is this Normal sinus rhythm Ventricular tachycardia Ventricular fibrillation Can I call a friend? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Do 2 minutes of CPR then defibrillate Defibrillate immediately Would you: Do 2 minutes of CPR then defibrillate Defibrillate immediately What if the patient had an unwitnessed arrest? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

New CPR Guidelines Even with unwitnessed arrest…. Once V fib is recognized…shock ASAP Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Shock Protocol Shorten interval between compressions and shocking improves shock success. After shock delivery, resume CPR immediately Don’t delay chest compressions for rhythm or pulse check Talk about Whites prospective study if not already done by now Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012 222

How many times do you defibrillate? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

No Change in Recommendations 1 shock then resume CPR Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

If you can’t get an IV, what other route can you give drugs? Intraosseus Endotrachael: (not a good route) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Intraosseous Access Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Your patient is still in this rhythm ! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Arrest Medications No Significant Change in New Guidelines Vasopressors Epinephrine 1 mg q3-5 min Vasopressin 40 units May replace 1st or 2nd dose of epinephrine Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Cardiac Arrest Medications No Significant Change in New Guidelines Antiarrythmics Don’t revert v fib. Work by preventing V.Fib, Amiodarone – Procainamide Lidocaine Magnesium Sulfate Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Amiodarone First line antidysrhymthmic 300 mg IV bolus May give 2nd dose: 150 mg Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Lidocaine 1.5 mg/kg Repeat x 1 prn. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

The paramedics brings in a 56 y. o The paramedics brings in a 56 y.o. man who arrested at home, was successfully defibrillated but remains comatose and intubated. BP. 100/70, P. 75 NSR What other treatment options are available to you to increase survival? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Therapeutic Hypothermia for Cardiac Arrest Cool to 32-34°C x 24 hrs Criteria: adult patient prehospital cardiac (v.fib) arrest . Spontaneous circulation BP > 90 Patient remains comatose and intubated Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 69 y.o. patient you are assessing for chest pain suddenly complains of palpitations Is this Normal sinus rhythm Ventricular tachycardia Supraventricular tachycardia I don’t know but it looks bad Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 69 y.o. patient you are assessing for chest pain suddenly complains of palpitations Is this Normal sinus rhythm Ventricular tachycardia Supraventricular tachycardia I don’t know but it looks bad Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

What do you do next? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Determine if patient stable or unstable! What do you do next? Determine if patient stable or unstable! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

BP 110/60, no SOB, no chest pain A) Give lidocaine 100 mg B) give amiodarone 150 mg IV C) sedate and cardiovert D) Adenosine 6 mg IV Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Adenosine recommended as a safe and potentially effective therapy in wide-complex tachycardia stable undifferentiated regular monomorphic wide-complex tachycardia. Level 11b: Observational retrospective studies Critical Care Medicine – Marill, KA Sept 2009   Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Which medications are useful for terminating monomorphic VT Lidocaine: 6 studies (8-30% effective) Procainamide: few studies 30% effective Amiodarone: small case reports only 30% Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Amiodarone in V. Tach 150 mg over 10 min may repeat up to 5-7mg/kg infusion: 1 mg/min for 1st 6 hours then 0.5 mg/min Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Lidocaine in V. Tach 1.5 mg/kg bolus 2nd and 3rd dose: 0.75 mg/kg q 5 min Total maximum: 3 mg/kg Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Ventricular Tachycardia Do not give multiple antidysrhythmics if one has failed (pro-arrhythmic effects) pick one antidysrhythmic, if it fails, go to electrical cardioversion. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Ventricular Tachycardia-Summary If stable: can try drugs but cardioversion best choice If unstable: cardiovert (synchronized) If pulseless: defibrillate Drugs rarely effective Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

An 80 y.o. patient admitted for pneumonia is found unresponsive by the medical student What is your management This is his rhythm on the monitor!! Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Hyperkalemia Drug overdoses Asystole Witnessed Arrest ? Yes No CPR - Intubate - IV access Confirmation in 2 leads  Possible causes Hypoxia Acidosis Hyperkalemia Drug overdoses Hypokalemia Hypothermia  Epinephrine 1 mg IV q 3 - 5 min (consider 1 dose Vasopressin 40 IU IV may replace 1st or 2nd dose epinephrine) Consider termination of efforts Atropine no longer recommended ACLS futile? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 65 y.o. man admitted to the CCU with chest pain is found unresponsive by the medical student. He has no pulse. He has the following rhythm Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

PEA Treatment: Find and treat cause (Is there a shockable rhythm?) Epinephrine 1 mg IV (no longer atropine) Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

PEA Consider causes: 5 H’s : hypovolemia, hypoxia, H ion, hyper/hypo K, 5 T’s: tamponade, tension pneumo, thrombosis-coronary or pulmonary, tablets OD Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 49 y.o. patient arrives in the ED complaining of palpitations for 1 hour. What is this? A) Atrial fibrillation B) Atrial flutter C) Ventricular tachycardia D) A-V nodal re-entrant tachycardia E) Sinus tachycardia What will you do? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 75 year old woman complains of dizziness. A) NSR B) Second degree HB type 1 C) Second degree HB type 2 D) Third degree HB What are the treatment options if: 1) her BP is 120/80 and she looks well 2) her pulse was 45, BP 70/30 and she looks ill Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Second degree HB type ll Dysfunctional His Purkinje system can lead to complete heart block If stable, send to monitored bed, and arrange permanent transvenous pacer If unstable: external pacing, or dopamine or epinephrine infusion. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

B) Second degree HB type 1 C) Second degree HB type 2 A 70 yo woman complains of dizziness x 3 days What is this rhythm? A) NSR B) Second degree HB type 1 C) Second degree HB type 2 D) Third degree HB Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

B) Second degree HB type 1 C) Second degree HB type 2 A 70 yo woman complains of dizziness x 3 days What is this rhythm? A) NSR B) Second degree HB type 1 C) Second degree HB type 2 D) Third degree HB Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Would 1 mg of epinephrine be appropriate if her BP was 60/40 Agree Disagree Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Bradycardia When to Treat ? Symptomatic: chest pain, SOB, hypotension Therapy: atropine 0.5-1 mg (max total 3 mg) transcutaneous pacemaker OR dopamine 5-20 microgm/kg/min OR epinephrine 2-10 microgm/min Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

A 72 year old man complains of persistant retrosternal chest heaviness What is your management ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Is this patient a candidate for PCI or a thrombolytic? A) Agree B) Disagree Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Myocardial Infarction What can you do? MONA ASA 160 mg chew oxygen nitrates sublingual or IV morphine 2-3 mg prn Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Myocardial Infarction What can you do? Antiplatelets: clopidogrel 600 mg Heparin Thrombolytics < 30 mins Primary PTCA <90 mins Percutaneous transluminal coronary angioplasty Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

An 80 year old man is being treated in hospital for pneumonia An 80 year old man is being treated in hospital for pneumonia. He is found VSA at 0300. His rhythm shows asystole. How long are you required to perform CPR for? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

CPR and ACLS Purpose: treatment of sudden unexpected death. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

When Not To Initiate CPR CPR is inappropriate and ineffective for medical problems where death is neither sudden or unexpected don’t offer CPR as an option to patients or families if it is not medically indicated communicate openly Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

When to Discontinue CPR Judgement that patient is unresuscitatable Variables: down time, rhythm, age, premorbid conditions advance directives Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

You have just finished a 45 minute unsuccessful resuscitation attempt on a 42 y.o. man. His wife is anxiously waiting. How do you tell her that her husband has died? How do you make it less stressful on the survivors when a sudden unexpected death has occurred. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Sudden Unexpected Death Develop multidisciplinary approach Develop intervention strategy Contacting Survivors Avoid disclosure on the phone meet family at a specific site CMAJ 1993 149(10) 1445-1451 Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Sudden Unexpected Death Arrival of Survivors met by RN, or Social Worker updated regularly Should the family be brought to the bedside if the resuscitation attempt is ongoing ? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Sudden Unexpected Death Notificiation of Death obtain all information prior to meeting quiet room, have RN also there sit next or across from closest relative explain in lay terms sequence of events use the words dead or died express condolences answer questions now or later Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

Sudden Unexpected Death Grief Response private time Viewing Deceased encourage family clean patient and remove equipment if possible Conclusion return valuables, address concerns give family permission to leave Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012

? Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa March 20 2012