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Update in Emergency Medicine. Robert Day Director of Emergency Medicine Royal North Shore Hospital. Objectives. Lots of topics requested Acute cardiopulmonary disease Anaphylaxis Cardiac arrest – ALS and BLS Septic shock Paediatrics Head injury TIA and Stroke.
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Update in Emergency Medicine Robert Day Director of Emergency Medicine Royal North Shore Hospital
Objectives • Lots of topics requested • Acute cardiopulmonary disease • Anaphylaxis • Cardiac arrest – ALS and BLS • Septic shock • Paediatrics • Head injury • TIA and Stroke
Acute respiratory distress 24 year old with history of asthma arrives in some distress with a respiratory rate of 32 and SaO2 of 94%. Speaking in phrases. • Moderate to severe exacerbation • Initial treatment • Salbutamol 5mg x 3 q20min • Ipratropium 500mcg x 1 • Oral or IV steroids • Reassess
Asthma continued No improvement after 2 nebs with increasing resp distress, intercostal recession, speaking in words Urgent situation Continuous nebulised salbutamol Intravenous salbutamol IV Magesium CPAP/ BiPAP Intubation preparation IV adrenaline in small doses eg 0.1mg diluted (1ml of 1:10,000)
Take home messages • Severe asthmatic • Continuous oxygen driven nebulisers • Get to hospital • Small doses of IV adrenaline can buy time • Intubation last resort
82 year old man presents by ambulance with sudden shortness of breath, chest tightness. Chest sounds wheezy and rattly. Coughing frothy pink sputum. Obs: pulse 96, BP 200/130, RR 32, sats 96% on NRB Diagnosis? Treatment?
Hypertensive and LVF – need to reduce afterload, increase preload • Fluid overload not usual problem • ECG to rule out STEMI, • Monitoring, O2, IV access • Nitrates +/- morphine • BiPAP • Reduces work of breathing • Forces fluid out of alveolar space
LVF plus hypotension • Too much nitrate? • Tachyarrhythmia? • Cardiogenic shock • Fluid gently if inferior AMI • Inotropic • Cath lab urgently if AMI
Pneumothorax • Types: • Primary spontaneous • Secondary – underlying lung disease • Traumatic +/- rib fractures
Primary Pneumothorax 18yo presents with sudden onset of left pleuritic chest pain. Some SOB when walking No past med hx
Primary pneumothorax • Risk factors: • Smoking • 12% lifetime risk in men vs 0.1% non-smokers • Pleural blebs and bullae • Tall, thin males • Asthma history • 50% recurrence rate in 4 years • Evaluation of size: • British Thoracic Society Guideline 2003 • Expiratory CXR not required • Small vs Large ptx – 2cm rim of air = 50% ptx
Primary pneumothorax cont • Options for treatment: • Leave vs aspiration vs chest tube • Leave < 2cm rim of air on CXR and not breathless • Attempt aspiration > 2cm rim of air and/or breathless- 70-80% success • Unsuccessful aspiration • Try again • Small bore intercostal catheter, remove at 24 hours if fully reexpanded • High flow oxygen • Surgical pleurodesis at 5 days if persistent leak
Aspiration • Re Xray 4 hours after procedure • Home if reexpanded • Warn if increasing pain, breathlessness to seek help immediately • Re X ray next day then at 1-2 weeks • Same if conservatively treated
Follow up Reabsorbs over weeks No flying till fully resolved (airline rules 6 weeks) No diving ever Resumption of sporting activity ? 2-4 weeks
Secondary pneumothorax • Age > 50, underlying pulmonary disease • High rate of failure of conservative treatment • Only small apical asymptomatic, < 1cm ptx • Usually need hospitalisation with a small bore chest drain until reexpanded • BTS guideline: • < 50yo, < 2cm rim of air, not breathless – try aspiration and admit 24 hours • > 50yo or > 2cm air or breathless - ICC • Early surgical referral (3 days)
Traumatic ptx Ptx on CXR usually requires ICC and admission Especially if requiring GA Traumatic ptx on CT scan less important
Take home messages • Asymptomatic ptx < 2cm can be treated conservatively • in under 50, • no underlying lung disease • Many primary pneumothoraces can be aspirated – 70-80% success
60 year old with no known history of allergy eating an asian meal at a local restaurant. Within 2 minutes develops generalised erythema and itch, vomits, dizzy and collapses. Develops increasing of face and tongue and a hoarse voice, difficulty breathing
Anaphylaxis • Classified: • mild: skin and subcutaneous tissues only • non-sedating antihistamines (cetirizine, loratidine) for symptoms • moderate: features suggesting respiratory, cardiovascular, or gastrointestinal involvement • severe: hypoxia, hypotension or neurological compromise
Treatment of mod/severe anaphylaxis • Emergency management of anaphylaxis: • Adrenaline • Adrenaline • Adrenaline • 0.5ml of 1:1000 amp IM in the lateral thigh (0.1 ml/kg to maximum 0.5ml) • ie half a 1ml amp for an adult • May be repeated every 3-5 minutes depending on response • Beware of using IV adrenaline
Adjunctive treatment Lie patient flat Oxygen IV access/ NS 20mg/kg Salbutamol neb for bronchospasm Neb adrenaline for upper airway obstruction Atropine for bradycardia Glucagon for beta blocked patients Steroids, antihistamines - H1 and H2 blockers (eg ranitidine)
Keep for 4 hours minimum post Adrenaline – should be observed in ED Follow up with allergy specialist if severe – RNSH OPD If severe provide EpiPen (0.3mg) and instructions
Cardiology • Acute coronary syndromes • ETAMI • High sensitivity troponins
ETAMI - Emergency Treatment of AMI • Ambulance paramedics do an ECG on patients with chest pain • Across Northern Sydney transmitted to RNSH ED 24 hours • ECG Read by EM specialist/registrar -call back to ambulance via mobile • STEMI: transport to RNSH/ Cath lab alerted • others: to local hospital
ETAMI Pioneered at RNSH from 2004 Front door to needle time of 18 minutes Sydney wide system from August to cath labs at major hospitals
High sensitivity troponins • 6-7% patients present to ED with chest pain – about 3,500 pa. Half have ACS. • Over 10,000 troponins a year • Until end 2009 using 3rd gen trop test: • NR < 0.03 mg/L, 0.03 – 0.2 equivocal • Now 4th generation troponin assay • < 14ng/ml negative, 13-100ng/mL equivocal • What does this mean? • Many more false positives • How do you interpret a low positive test?
High sensitivity troponins cont. • Patients need to be clinically risk stratified • Good ACS story plus N trop = admission for Ix • Poor ACS story plus low N trop may be able to go home • Change in serial troponin important • We are using 30% change in 6 hours • 3 hour trop for high risk patients • Be aware of other diagnoses causing rise in troponin
Non ACS causes of raised troponin • Pulmonary embolism • Acute cardiac failure • Myocarditis • Aortic dissection • Acute decompensated AV disease • Renal insufficiency
BLS and ALS changes • BLS • New literature • emphasising minimal interruptions to ECM • questioning role of early breathing interventions – compression only CPR? • ARC: "ANY ATTEMPT AT RESUSCITATION IS BETTER THAN NO ATTEMPT" and if a rescuer is unwilling to do rescue breaths then chest compressions are better than nothing.” • Revised ARC guidelines due Dec 2010 • www.resus.org.au/
BLS • Rate of compression to breath 30:2 • 2 initial rescue breaths • ECM 100/min (5 cycles in 2 minutes) • Frequent rotation of rescuers – every 2 minutes • Don’t interrupt CPR to check for signs of life • Use AED as soon as available
ALS for VF /pulseless VT • Early defibrillation for VF • Look for alternative reversible causes • Witnessed arrest • Precordial thump • Stacked shocks x 3 - 200J biphasic defib • AEDs will only deliver a single shock • Commence CPR ASAP
ALS for VF/pulseless VT • Further DC shocks for VF/VT: • Given every 2 minutes • Adrenaline – 10mls of 1:10000 (1mg) IV • Given every 3 minutes • Securing airway – no more than 20 seconds break in CPR
ALS - other drugs • Antiarrhythmics • Amiodarone drug of choice for prolonged VF/pulseless VT • 300mg (5mg/kg) • Atropine, Calcium, Bicarbonate, Magnesium • No evidence of benefit except in specific circumstances
Patient in non-shockable rhythm • Asystole/Pulseless Electrical Activity • CPR / Rescue breathing 30:2 • Adrenaline every 3 minutes • Search for a reversible cause: • 4 H’s and 4T’s: • Hypoxia Tamponade • Hypovolaemia Tension ptx • Hypo/hyperkalaemia Toxins / drugs • Hypo/hyperthermia Thrombosis – pulm or cardiac
Paediatric resus Rare! Shocks: first 2J/kg then subsequent 4J/kg Importance of CPR/rescue breathing Ratio for advanced providers 15:2 Using IO access
Take home messages • Don’t interrupt chest compressions • 100/min • change regularly • Place of rescue breathing being questioned but still in guidelines • Ratio 30:2 • DC shocks 2 minutely for VT/VF • Adrenaline 1mg IV q3min
70 year old man presents with a week of left loin pain, difficulty passing urine, poor oral intake. Now confused and febrile. • At triage vital signs: • P 120, BP 90/60, • RR 28/min, sats 98% room air, • T39.2
EGDT in septic shock • Early 2000’s US study (Rivers) • aggressive early resuscitation, • Early ICU care, • maintenance of blood pressure with inotropes, • Hb/haematocrit optimisation, • Careful monitoring of oxygenation via CVC • improved mortality 50% to 35%
Clinical Excellence Commission Sepsis Review • Recent NSW study showed septic shock markedly over represented in major reported incidents • Across all types of hosp. • Non-recognition of sepsis • Delays in starting treatment • ABx • Treatment of poor organ perfusion • Poor monitoring of vital signs • Over 65 yo and after hours over represented • Oliguria, hypotension, tachycardia +/- fever = septic shock until proven otherwise
ARISE trial • attempting to study role of EGDT in Australian population - RNSH lead hospital • Patients who present with: • sepsis (T >38 or < 34 with evidence of an infection) • BP < 90 systolic not responding to 1000mls IV fluid or • Lactate > 4 • All get early antibiotics • Randomised into trial for EGDT vs normal treatment
70 yo patient with urosepsis: • Recognition at triage – resus bed • Aggressive fluid resuscitation to restore BP > 90 systolic – may need 2-4 litres • After 1000mls NS if BP< 90 or lactate > 4 entered into ARISE trial • Early antibiotics essential – broad spectrum ABx should be given within one hour • Early inotropic support eg noradrenaline • Look for a source – urine, abdominal, chest, cannulas, cellulitis, others
Take home messages • Think about sepsis as a diagnosis – subtle early signs • Urosepsis, hypotension dangerous combination • Early antibiotics and resuscitation
Paediatrics - dehydration • DOH CPG: Management of Children with Gastroenteritis http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf • Major themes: • Rehydration: • Less use of IV fluids • More emphasis on oral rehydration • If child requires IV: • Use of NS + 2.5% glucose rather than hypotonic solutions
Oral rehydration • Oral rehydration solutions • Hydralyte, Gastrolyte (no sports drinks, fruit juice, soft drinks) • Parent should offer 0.5mls/kg every 5 minutes eg with a syringe • Charted by parent including vomits, U/O • Parental attention, persistence encouraged by staff • Rapid rehydration via NGT an option • ORS via Kangaroo pump @ 10mls/kg/hr x 4hrs
Medications in gastroenteritis • Antiemetics: • Ondansetron: some evidence of benefit • No evidence for prochlorperazine or metoclopramide • Antidiarrhoeals / antimotility agents • No evidence • Antibiotics: • Rarely required
IV therapy • Who for? • Mild (3%) - Reduced UO, Thirst, Dry mucous membranes, mild tachycardia • Oral only required • Moderate (5%) - Dry mucous membranes, tachycardia, abnormal respiratory pattern, lethargy, reduced skin turgor, sunken eyes – try oral first if fails go to IV
IV therapy • Severe (10%) • all of above, poor perfusion: mottled, cool limbs/Slow capillary refill/Altered consciousness • Shock: thready peripheral pulses with marked tachycardia and other signs of poor perfusion – IV or IO therapy, 20mls/kg bolus NS