1. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Emergency Topics Back to Basics 2008 Dr. Brian Weitzman Department of Emergency Medicine Ottawa Hospital

2. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Review of 14 Common Emergency Medicine Topics Acute Abdominal Pain Acute Dyspnea Hypotension/Shock Syncope Coma Cardiac Arrest

3. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Emergency Medicine Topics continued Urticaria/Anaphylaxis Malignant Hypertension Animal Bites Burns Near-drowning Hypothermia Poisoning

4. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Abdominal Pain MCC Objectives 1.Common causes of pain –intra and extra abdominal, metabolic –Localized vs diffuse –Peritoneal signs vs no peritoneal signs 2.Neurologic basis of pain 3.Perform focused detailed hx 4.Focused examination: vitals, abd, rectal, pelvic GU 5.Interpret clinical and lab data 6.Management plan for pts with abd pain 7.Which patients need immediate attention and treatment 8.Manage common causes of abdominal pain 9.Unusual causes of pain in elderly and immunocompromised

5. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

6. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Neurologic Basis of Abdominal Pain Visceral Somatic Referred

7. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Visceral vs Somatic Abdominal Pain Where are these fibers located? What stimulates them? Where is pain perceived with stimulation? What are associated symptoms or signs?

8. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Visceral Abdominal Pain Stretch receptors in walls and and capsules of hollow and solid organs Stimulated by distention, inflammation, or ischemia Unmylinated fibers return to both sides of the spinal cord at multiple levels Brain cannot localize source

9. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

10. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Somatic Abdominal Pain Receptors located in 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

11. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Referred Pain What is it? What are some examples?

12. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Referred Pain Pain perceived in an area that is distant from the disease process Due to overlapping nerve innervations Ex. Shoulder pain with diaphragm stimulation

13. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Examples of Referred Pain Shoulder pain with diaphragm stimulation –C 3,4,5 stimulation Back pain with biliary colic, pancreatitis, or PID

14. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Differential Diagnosis Suprapubic Epigastric DIFFUSE

15. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Differential Diagnosis Suprapubic Epigastric DIFFUSE

16. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 MCC-Causes of Abd Pain Diffuse With peritoneal signs –Perforated viscus –AAA rupture –Small bowel infarction/obstruction –Bacterial peritonitis No peritoneal signs –Gastroenteritis –Irritable bowel syndrome –Constipation –Metabolic disease

17. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Causes of Abd Pain - Localized    RUQ LUQ RLQ LLQ Epigastric

18. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Differential Diagnosis Which has peritoneal signs?  Biliary Colic/Cholecystitis  Hepatitis / Hepatic Abscess  Pneumonia / Pleurisy  Appendicitis  Appendicitis   Splenic Infarction  Splenic Rupture  Splenic Aneurysm  Pneumonia RUQ LUQ RLQ LLQ Inflammatory bowel disease Diverticulitis Ectopic Ruptured Ovarian Cyst Salpingitis/PID Renal Stones/UTI Testicular torsion Psoas abscess Incarcerated Hernia Gastritis,GERD/PUD Pancreatitis MI

19. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Differential Diagnosis Which has peritoneal signs?  Biliary Colic/Cholecystitis  Hepatitis / Hepatic Abscess  Pneumonia / Pleurisy  Appendicitis  Appendicitis   Splenic Infarction  Splenic Rupture  Splenic Aneurysm  Pneumonia RUQ LUQ RLQ LLQ Inflammatory bowel disease Diverticulitis Ectopic Ruptured Ovarian Cyst Salpingitis/PID Renal Stones Testicular torsion Psoas abscess Incarcerated Hernia Gastritis,GERD/PUD Pancreatitis MI

20. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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.

21. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

22. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

23. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 High Yield Questions

24. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 High Yield Questions 1. How old are you? Advanced age means increased risk. 2. Which came first—pain or vomiting? Pain first is worse (i.e., more likely to be caused by surgical disease). 3. How long have you had the pain? Pain for < 48 hrs is worse. 4. Have you ever had abdominal surgery? Consider obstruction in patients who report previous abdominal surgery. 5. Is the pain constant or intermittent? Constant pain is worse. 6. Have you ever had this before? A report of no prior episodes is worse. 7. Are you pregnant? Test for pregnancy - consider ectopic.

25. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 High Yield Questions cont’d 8. Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease? All are suggestive of more serious disease. 9. Do you have human immunodeficiency virus (HIV)? Consider occult infection or drug-related pancreatitis. 10. How much alcohol do you drink per day? Consider pancreatitis, hepatitis, or cirrhosis. 11. Are you taking antibiotics or steroids? These may mask infection. 12. Did the pain start centrally and migrate to the right lower quadrant? High specificity for appendicitis.

26. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 High Yield Questions, cont’d 13. Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation? Consider mesenteric ischemia and abdominal aneurysm. Reference from: Colucciello SA, Lukens TW, Morgan DL: Emerg Med Pract 1:2, 1999. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc.

27. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Physical Examination

28. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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! Remember: very young and very old patients may present atypically - don’t get mislead by this!

29. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

30. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Risk Factors for Acute Disease Extremes of age Abnormal vital signs Severe pain of rapid onset Signs of dehydration Skin pallor and sweating

31. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Initial Stabilization

32. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

33. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Pain: ER Management Is it OK to give a patient pain medications before you determine their diagnosis?

34. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Abdominal Pain: ER Management Anti-inflammatories (NSAIDs): –po/pr/iv; very effective, esp. for MSK pain –ensure no allergy, renal disease, CHF, concurrent NSAIDs, active bleeding; recent hx of PUD is relative contraindication –Ex. Ketorlac (Toradol) 30 mg IV Narcotics –sc/im/iv; wide range of doses, strengths –care re: sedation, confusion, addiction, etc. –very effective, esp. for visceral or undifferentiated pain –Ex. Morphine 2.5-10 mg, hydromorphone 1-2 mg

35. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Nausea/Vomiting: ER Tx

36. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Nausea/Vomiting: ER Tx Gravol: po/pr/im/iv –beware of anticholinergic side effects –sedating, may cause confusion Maxeran/Stemetil: iv –beware of possible EPS –less sedating; may help with pain control Domperidone: po/iv –especially useful with diabetic gastroparesis Ondansetron: iv –very useful in patients with refractory vomiting –expensive!

37. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Investigations

38. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Investigations Most patients with acute abdominal pain require: - CBC, differential; may need type and cross-match - electrolytes, BUN, creatinine - liver enzymes, liver function tests - amylase/lipase - beta-hCG - urinalysis; stool for OB They may also need: ECG, cardiac enzymes, ABG, lactate

39. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Investigations Imaging ultrasound CT scan plain Xrays

40. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What are specific problems related to the emergency room diagnosis and treatment of abdominal pain in the geriatric population?

41. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Abdo Pain: Geriatrics Elderly patients present some unique challenges in diagnosis and treatment in the emergency room: -presentations often atypical -Fever and WBC elevation may not be present -Guarding and rebound often not present with peritonitis - more likely to have life-threatening disease - often quite vague historians - multiple other medical issues confound the current problem - pain often causes confusion in elderly patients -

42. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Influence of Aging on Abdominal Pain Small bowel obstructionPrior Surgery PUD, PancreatitisMedications Colonic volvulusImmobility Large bowel obstruction, intussuception Carcinoma Cholecystitis, pancreatitisCholelithiasis AAA, mesenteric ischemia, ischemic colitis Atherosclerotic Disease Resultant DiseaseIncreased Risk in the Elderly

43. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Geriatric Abdo Emergencies Vascular catastrophies –AAA - leak or rupture –Aortic dissection –Mesenteric ischemia Malignant disease –chronic wasting, anemia - less able to tolerate acute insult –bowel obstruction, intussusception, infarction Appendicitis - often atypical presentation; presents after perforation, as sepsis/peritonitis Diverticulitis - may perforate, create fistulas, lead to abscess formation

44. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 HIV and Abdominal Pain

45. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 HIV and Abdominal Pain Gastroenteritis: Salmonella, Shigella, Camphlobacter, Giardia, CMV, Cryptosporidium, Mycobacterium avium Cholecystitis with or without stones Biliary obstruction from neoplasm Esophagitis

46. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What is the cause of this 45 y.o. man’s LLQ pain?

47. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What is the cause of this man’s pain?

48. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Why is this woman vomiting?

49. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What is the cause of this man’s abdominal pain?

50. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Summary: Approach to Abdominal Pain in the ER 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)

51. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Summary: Common Causes of Abdominal Pain MCC Categorization Diffuse –peritoneal signs Perforated viscus, AAA rupture, bowel ischemia Peritonitis –No peritoneal signs Gastroenteritis, irritable bowel, constipation Metabolic disease

52. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Summary: Common Causes of Abdominal Pain MCC Categorization Localized Upper –Peritoneal signs: cholecystitis/cholangitis Pancreatitis, appendicitis –No Peritoneal signs: Epigastric: PUD/gastritis, GERD RUQ: biliary colic, hepatitis, abcess LUQ: splenic infarct/abcess

53. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Common Causes of Abdominal Pain MCC Categorization Localized Lower –Peritoneal Signs Bowel: appendicitis, mesenteric lymphadenitis –Diverticulitis, incarcerated hernia Genital: PID, ectopic, ovarian torsion/ruptured cyst –No peritoneal signs UTI, renal colic, inflammatory bowel disease, Psoas abcess

54. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 ?

55. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 *Common Causes of Abdo Pain - biliary colic/cholecystitis - appendicitis - renal colic - UTI - testicular torsion - irritable bowel syndrome - inflamm. bowel disease - bowel obstruction - diverticulitis - peptic ulcer disease - perforated viscus - ectopic pregnancy - STDs - vascular catastrophe - extra-abdominal conditions

56. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Acute Dyspnea 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 lung imaging –Select and interpret heart and lung investigation (ECG< ABG) Diagnose and manage acute dyspnea

57. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What drives us to breath? Chemoreceptors in medulla, carotid and aortic bodies respond to increased CO2 or H+ ion or decreased 02. Stretch receptors from lungs Baroreceptors

58. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Definitions Dyspnea: – sensation of shortness of breath Hyperpnea: –increase in rate or depth of breathing –Ex. Metabolic acidosis, ASA

59. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Definitions Tachypnea: –rapid, shallowing breathing Hyperventilation: –breathing in excess of metabolic needs of body lowering C02 –Need to rule out organic disease

60. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 55 year old woman comes in shouting and screaming that she can’t breath. She is very agitated, sitting forward, using her accessory muscles. What is her problem?

61. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Most Common Causes of Acute Dyspnea COPD Asthma CHF PE Pneumonia Pneumothorax

62. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Acute Dyspnea-Cardiac Causes 1.Acute coronary syndrome 2.Myocardial dysfunction 1.Ischemic/hypertensive cardiomyopathy 2.Valvular dysfunction 3.Pulmonary edema 4.Dysrhythmia 3.Pericardial disease-tamponade

63. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Acute Dyspnea-Respiratory Causes Upper airway: –FB, epiglottis, angioedema, t rauma Bronchi: –asthma, bronchitis/iolitis, tumor Alveoli: –Pneumonia, emphysema, contusion, toxic inhalation, ARDS

64. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Acute Dyspnea-Respiratory Causes Insterstitium and Vasculature: – PE, fibrosis Thoracic Cage/lung interface: –Pneumo/hemothorax, effusion Respiratory Muscles and Thorax –Rib #, flail, MS, Guillain Barre, Myasthenia

65. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Acute Dyspnea Misc. Causes CNS stimulation: –head trauma, ASA, sepsis, mass lesion Decreased O2 carrying: anemia, CO, methem Metabolic acidosis –MUDPILES Hyperthyroidism, Pregnancy, Psychogenic

66. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 55 year old woman comes in shouting and screaming that she can’t breath. She is sitting forward, gasping for air, appears cyanotic, using accessory muscles What will you do?

67. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Rapid Assessment ABC’s : 5 vitals: P, RR, BP, T, 02 sat. O2, IV, Monitor, ECG

68. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

69. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Rapid Assessment Airway: –Is the patient protecting it? –Is the patient able to oxygenate and ventilate adequately? –Is there stridor

70. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Oxygen Nasal prongs max. 4-5l/min Venturi: up to 50% 02 reservoir: 90-95%

71. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 5 Reasons to Intubate Protection Creation Oxygenation Ventilation Pulmonary toilet

72. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Breathing Look, listen, feel, or IPPA Wheezes, rales, rubs, decreased air entry Is it adequate? O2 sat?

73. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Circulation Pulse, BP, Heart sounds ? Muffled JVP Edema

74. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Rapid Assessment Does this person need immediate treatment? Ventolin Nitroglycerin ASA Furosemide BiPap Needle decompression

75. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

76. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 History-What are the key questions? Medications, home 02 Allergies What has helped in the past Past medical history: –Cardiac, pulmonary, recent surgery

77. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Labs/Investigations ABG CBC, Lytes, Cardiac enzymes D dimer ECG Pulmonary Function Tests

78. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Imaging CXR VQ Helical CT Pulmonary angiogram

79. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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 Theophylline: poor bronchodilator Antibiotics BiPap

80. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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 aminophylline 5 mg/kg over 30 min, –then infusion 0.5 mg/kg/hr

81. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Status Asthmaticus Intubation sedate with ketamine 1.5 mg/kg paralyze with succinylcholine, or vec permissive hypercarbia (hypoventilate) inhalation anesthetics (halothane) lung massage bilateral chest tubes if patient arrests

82. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 75 y.o. man with dyspnea

83. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Principles of Management Pneumonia Oxygen to maintain 02 sat at 92-94% Antibiotics: –Macrolides –Fluroquinolones –2 nd or 3 rd generation cephalosporin Beta agonists and BiPap as required

84. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 79 yo woman with dyspnea

85. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Principles of Management Pulmonary Edema Oxygen BiPap Nitroglycerin sc, IV Furosemide 40-160 mg IV Morphine 2-4 mg IV ECG-rule out ACS

86. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 25 year old with dyspnea

87. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Principles of Management Pneumothorax Tension: 14 gauge needle 2 nd ICS, MCL 30 Fr chest tube Pigtail catheter Small spontaneous pneumothorax: @20% –May observe, discharge, repeat CXR 24 hrs

88. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Hyperventilation Syndrome Must rule out organic causes –PE, myocardial ischemia ABG: respiratory alkalosis and normal 02 Avoid rebreathing from paper bags Treatment: reassurance, mild anxiolytic ex. Lorazepam 1 mg

89. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 55 year old woman comes in shouting and screaming that she can’t breath. She is very agitated, sitting forward, using her accessory muscles. What is her problem?

90. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 55 year old woman comes in shouting and screaming that she can’t breath. She is very agitated, sitting forward, using her accessory muscles.

91. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Pericarditis or Acute Inferior MI

92. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Acute Inferior MI

93. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Pregnancy and Dyspnea Increased 02 consumption Increased minute ventilation Decreased resistance Decreased FRC Increased risk: PE, Pulmonary edema

94. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

95. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 ?

96. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Syncope

97. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Syncope http://www.blogtelevis ion.net/p/Videos- Watch-a- Video___1,2,,59315.ht ml

98. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Syncope-MCC Objectives Definition Physiology Distinguish from Seizure Causes: serious or not, cardiac or not Initial Management Plan Hx, Px, Investigations

99. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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 liklihood he had a cardiac cause of syncope? What is your workup and management of this patient?

100. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What is syncope? Sudden, transient loss of consciousness Rapid and complete recovery May have minor myoclonic jerks or muscle twitching No postictal state

101. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

102. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What are the common causes of syncope? (MCC) Cardiovascular (80%) –Cardiac arrhythmia (20%) –Decreased cardiac output –Reflex/underfill (60%) Cerebrovascular (15%) Other –metabolic –psychiatric

103. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

104. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Cardiovascular Causes of Syncope Reflex/Underfill (60% of syncope) –Vasovagal (common faint) –orthostatic/postural ex. Blood loss –Situational (micturition, cough, defecation)

105. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Cerebrovascular Causes (15%) –TIA –vertibral basilar insufficiency –high ICP Metabolic : hypoxia, low BS, drugs, alcohol Psychiatric: hyperventilation, panic

106. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

107. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Physiology Cerebral perfusion pressure= MAP-ICP MAP = CO x PVR (peripheral vascular resistance) CO= SV x HR (stroke volume) SV a function of preload, contractility, afterload

108. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

109. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

110. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Review of Systems volume status (eating, diarrhea, exercise) recent blood loss chest pain, palpitations, SOB, any focal neurologic symptoms pregancy

111. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

112. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

113. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Lab Investigations CBC Type and xmatch –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

114. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Vasovagal Faint Common (20% all syncope) Increased parasympathetic tone Bradycardia, hypotension

115. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Vasovagal Faint-Predisposing Factors Fatigue Hunger Alcohol Heat Strong smells Noxious stimuli Medical conditions anemia, edehydration Valsalva (trumpet player)

116. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

117. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Cardiac Syncope 20% all syncope Serious prognosis Exertional syncope –Outflow obstruction AS, IHSS Ischemia/MI Conduction disorders dysrhythmias

118. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Orthostatic Decrease in systolic BP by 20-30 or increase in pulse by 20-30 on standing Supine Meds -antihypertensives Blood loss, dehydration

119. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

120. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 San Francisco Syncope Rule 98% sensitive and 59% specific for predicting serious outcome Patient requires admission with any of: CCHF history HHematocrit < 30 EECG abnormal SSOB SSystolic < 90

121. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

122. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 An 80 y.o. man complains of recurrent syncope What is his diagnosis and treatment?

123. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 65 y.o. man on diuretics has recurrent syncope

124. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Torsades de Pointes

125. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Treatment of Torsades Correct electrolytes Magnesium 2 gm over 20 min Isoproterenol 2-20 mcg/min Overdrive pacing

126. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Cardiac Pacing When is it required? 3 rd degree (complete HB) 2 nd degree type ll Sick sinus syndrome Symptomatic bi or trifasicular blocks –Ex. RBBB + LAH + 1 st degree HB Symptomatic bradycardia

127. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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.

128. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 ?

129. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Coma

130. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 MCC Objectives 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)

131. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What is Coma? Deepest level of a decreased level of consciousness Unresponsive, no useful speech Def’n: pt who is unarousable and unaware

132. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 An 80 y.o. man is comatose 2 weeks after falling down stairs? Why is this patient comatose?

133. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Isodense Subdural Hematoma Enhanced CT Head

134. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A diabetic patient present in a coma and is found to have a BS of 1.5 Why are they in a coma?

135. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Coma Can be induced by structural damage or chemically depressed 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

136. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 45 y.o. ‘street’ person is brought in to the ED in a coma. What are the reversible 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)

137. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Causes of Coma Structural –Bleed, CVA, CNS infection, Metabolic (medical) –A,E,I, O, U, TIPS

138. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What is your initial approach with this comatose patient? A-airway protection (and c spine) B-breathing O2 sat 5 vitals (pulse, BP, temp) Glucoscan Thiamine (if giving glucose) Naloxone IV, ECG monitor, foley, labs Hx, Px Determine level of consciousness

139. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Level of Consciousness AVPU –Awake, verbal, pain, unresponsive Glasgow Coma Scale

140. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 GCS Best Eye Response. (4) 1.No eye opening. 2.Eye opening to pain. 3.Eye opening to verbal command. 4.Eyes open spontaneously. Best Verbal Response. (5 ) 1.No verbal response 2.Incomprehensible sounds. 3.Inappropriate words. 4.Confused 5.Orientated Best Motor Response. (6) 8 or less = coma 1.No motor response. 2.Extension to pain. 3.Flexion to pain. 4.Withdrawal from pain. 5.Localising pain. 6.Obeys Commands

141. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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,

142. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

143. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Physical Exam Structural lesions: –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

144. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

145. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

146. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Respirations Cheyne stokes –Fast alternating with slow breathing Brain lesions, acidosis Apneustic –Pauses in inspiration Pons lesions, CNS infection, hypoxia

147. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Physical Exam HEENT: –Battle’s sign, hemotympanum. –Breath odour Ex. Acetone = DKA

148. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Pupils Metabolic: –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

149. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Pupils Fixed dilated pupils ominous Dead, central herniation, hypoxic injury Small pinpoint pupils –Lesion in pons (ischemic or bleed –Opiate OD

150. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Physical Exam Pupils

151. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Physical Exam Corneal Reflex –Sensory CN 5, and Blink is CN 7

152. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Extraocular Movements Helps determine brainstem function in coma Doll’s eyes –Eyes move in opposite direction to head movement –indicates functioning brainstem

153. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

154. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

155. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

156. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Physical Exam cont. Disc Nuchal rigidity Resp/CVS/Abd/Extrem Neuro: level of consciousness, CN, Motor, Sensory, DTR

157. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

158. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Motor Exam Decerebrate posture –Extends elbow with internal rotation –Lesions or metabolic effect in midbrain Flaccidity –Ominous sign –Toxin/OD

159. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Labs ? CBC, Lytes, Bun Cr, BS LFT, Ca, Mg, ABG Alcohol, Osmolality Tox screen CO level

160. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Diagnostic Tests/Imaging CXR CT Head LP ECG EEG

161. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Brain Death Irreverisble failure of clinical function of the whole brain Coma, apnea, loss of brain stem reflexes Difficult to assess in 1 st few hours Ensure no hypothermia, barbituates Better to use concept of cardiopulmonary death, some brainstem reflexes may persist Spinal cord reflexes may persist

162. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

163. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

164. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 30 y.o. man, hit on the head, awake alert with a unilateral fixed dilated pupil? Is he having uncal herniation?

165. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

166. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Uncal Herniation

167. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Summary COMA ABC, Vitals, O2, CO2, BS, Naloxone Metabolic vs Structural Key to Exam –Respiration –Pupils –EOM –Motor response

168. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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.

169. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Do you: 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

170. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Restraining People 1)Is the patient competent to decide for themself? 2)Is the patient suffering from a mental illness that allows us to restrain them. Ie Formable 1)Unable to care for self 2)At harm to self or others 3)In the past has shown evidence of the above when suffering from this mental illess

171. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Competence / Capable Understands medical issue Understands treatment proposed Understands consequences of accepting or refusing treatment

172. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Valid Consent Relate to treatment Informed Voluntary Can’t misrepresent or be fraudulent

173. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

174. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Substitute Decision Making Highest of

175. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 ?

176. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Hypotension Shock – MCC Objectives Causes History Examine Diagnose Labs Management strategy Physiology of cell hypoxia

177. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 What Is Shock Tissue hypoperfusion or tissue hypoxia

178. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Shock Catecholamine surge Vasoconstriction, increased CO Renin-angiotensin, vasopressin –Salt and water retention

179. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

180. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Shock What are the causes? Cardiac Obstructive Hypovolemic Distributive

181. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Obstructive Shock –PE, tamponade, tension pneumothorax Cardiac –Pump failure: MI, ruptured cordae or septum Contutsion, aortic value dysfunction –Dysrhythmia

182. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Hypvolemic –Blood Loss Trauma, AAA, aneurysm, GI bleed, ectopic –Dehydration Gastro, DKA, Burns Distributive –Sepsis –most common –adrenal, neurogenic, anaphylactic –Toxins (cyanide), CO, acidosis

183. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

184. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

185. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Labs BS CBC, lytes, liver/renal function Lipase, fibrinogen, fibrin split products, Cardiac enzymes, ABG, ECG, urine, Tox screen Stool OB

186. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Treatment Know specific treatment of each type of shock MI Tension Sepsis GI bleed

187. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 ?

188. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008

189. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008

190. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Cardiac Arrest – MCC Objectives Causes –Cardiac and noncardiac Hx Recognize impending and actual cardiac arrest Investigations Management plan Communicate –DNR –Death Ethics –Providing care where no consent is available

191. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Cardiac Arrest - Causes Cardiac –Coronary artery –Conduction Metabolic: hypo Ca, Mg, K, anorexia Brady or tachydysrhythmia –Myocardium Hereditary: cardiomyopathy Acquired: LVH, Valve disease, myocarditis

192. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Cardiac Arrest - Causes Non Cardiac –Tamponade –PE –Tension –Trauma

193. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Sudden Cardiac Arrest electrical accident 80% due to VF or VT most due to ischemia or reperfusion

194. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Mechanism of Fibrillation ischemia: slows conduction adjacent myocardium in various phases of excitation and recovery multiple depolarizing reentrant wave fronts

195. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Survival from Sudden Cardiac Arrest function of time –ICU, Emerg, Cardiac rehab90% survival decreases by 10% /min if defibrillation > 10 min : 5-10% survival

196. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Chain of Survival early access early CPR early defibrillation early advanced care airway and drug therapy

197. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008

198. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008

199. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008

200. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Public Access Defibrillation trained nonmedical individuals acting independantly with AED city-wide programs across Canada ex. police, security, first aid volunteers, airlines, recreation centers, pools, arenas

201. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A patient, who has been complaining of chest pain, collapses while you are talking to them

202. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Is this A)Normal sinus rhythm B)Ventricular tachycardia C)Ventricular fibrillation D) Can I call a friend? You grab the paddles and have a quick-look

203. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 After verifying no pulse, which is the most appropriate treatment? A) begin CPR B) give 1 mg epinephrine C) give 300 mg amiodarone D) defibrillate at 200j E)give 100 mg lidocaine F)pee in your pants

204. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Route of Drug Administration IV IO ETT

205. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Drugs and VF Sympathomimetic: –Epinephrine 1 mg –Vasopression 40 units

206. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Drugs and VF Antidysrhythmics: –Amiodarone 300 mg IV Repeat once 150 mg –Lidocaine 1.5 mg/kg –Magnesium 2-4 gm

207. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

208. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Therapeutic Hypothermia for Cardiac Arrest ILCOR June 8, 2003 Circulation 2 studies NEJM 2002; 346: 549-563 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

209. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008

210. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 You are asked to see a 69 y.o. man complaining of palpitations Is this A)Normal sinus rhythm B)Ventricular tachycardia C)Supraventricular tachycardia D)I don’t know but it looks bad

211. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 BP 110/60, no SOB, no chest pain A) Give procainamide 30 mg/min to 17 mg/kg B) give amiodarone 150 mg IV C) sedate and cardiovert D) defibrillate E) lidocaine 100 mg IV

212. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Wide-Complex Tachycardia Your colleague says there is a 15% chance this could be SVT with a BBB or accessory pathway They recommend 2.5 mg of verapamil or 20 mg of diltiazem A) agreeB) disagree

213. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 How Certain Can We Be That Wide-Complex Tach is VT ?

214. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Epidemiology 80-85% of wide complex tachycardias are VT

215. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 How is the past history helpful? Previous MI or structural disease –increases probability of VT Long history of recurrent tachydysrhythmia dating back to youth –suggests SVT with abberancy

216. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Clues on Physical Exam About 25% of VT will have AV dissociation on ECG Variable JVP (cannon a waves), variable S1 definitive evidence of VT

217. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Which medications are useful for terminating monomorphic VT Lidocaine: 6 studies (8-30% effective) Procainamide: 1 study: 60% effective Amiodarone: small studies -30%

218. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

219. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Procainamide in V. Tach 20-30 mg/min up to 17mg/kg stop bolus when: –v. tach terminates –hypotension –QRS widens –max dose given

220. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

221. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Ventricular Tachycardia Do not give multiple antidysrhythmics if one has failed (pro-arrhythmic effects) pick one antidysrhythmic, if it fails, go to electrical cardioversion.

222. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 An 80 y.o. patient was found unresponsive in their room by the RN What is your management This is his rhythm on the monitor!!

223. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Asystole Uniformly bad outcome if arrest unwitnessed Consider CPR, causes (hypoxia, K, acidosis, OD, hypothermia’

224. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Asystole Epinephrine 1 mg IV – q5min Atropine 1 mg IV max. 3 mg Pacing no longer recommended

225. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 65 y.o. man collapses in the waiting room of a busy emergency department He has the following rhythm

226. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 PEA Consider causes: –six H’s : – hypovolemia, hypoxia, H ion, hyper/hypo K, hypoglycemia –six T’s: –trauma, tamponade, tension pneumo, thrombosis-coronary or pulmonary, tablets OD

227. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 PEA Treatment: Find and treat cause Epinephrine 1 mg IV Atropine 1 mg IV (if bradycardic)

228. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 49 y.o. woman develops palpitations while you are talking with her

229. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 SVT How often do you have to electrically cardiovert an unstable patient in SVT?

230. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008

231. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Your patient develops this rhythm Pulse 40 BP 60/40 Is this A)Normal sinus rhythm B)Wenkeback -2 nd degree Heart Block, type 1 C) Complete Heart Block

232. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Would 1 mg of epinephrine be appropriate if her BP was 60/40 A)Agree B)Disagree

233. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Bradycardia When to Treat ? Symptomatic: chest pain, SOB, hypotension Therapy: –atropine –transcutaneous pacemaker –dopamine 5-20 microgm/kg/min –epinephrine 2-10 microgm/min

234. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 A 72 year old man complains of persistant retrosternal chest heaviness What is your management ?

235. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Is this patient a candidate for a thrombolytic? A) Agree B) Disagree

236. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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?

237. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 CPR and ACLS Purpose: treatment of sudden unexpected death.

238. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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 Joint Statement on Resuscitative Interventions CMAJ Dec 1, 1995

239. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 When to Discontinue CPR Judgement that patient is unresuscitatable Variables: –down time, rhythm, age, premorbid conditions –advance directives

240. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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.

241. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

242. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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 ?

243. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

244. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 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

245. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Summary CPR Push hard, push fast, don’t interrupt Effective rapid defibrillation Electricity is better, more effective Intubation is not an emergency Don’t overventilate

246. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Summary Cardiac arrest: Is there a shockable rhythm. Don’t delay defibrillation consider drugs Tachydysrhythmia: unstable-cardiovert stable-can use medications

247. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 Summary Bradydysrhythmia –Does it need immediate treatment –Can it deteriorate –Does it need long term pacing

248. Copyright: Dr. Brian Weitzman, Department of Emergency Medicine University of Ottawa April 2008 ?