Heather T. Streich, MDUniversity of Virginia

Department of Emergency Medicine

Brown DJ, Brugger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J Med. 2012;367(20):1930-8.

¡ Swiss clinical staging system: useful if actual temperature measurement is not available§ HT I: conscious, shivering§ HT II: impaired consciousness, not shivering§ HT III: unconscious, not shivering, vital signs present§ HT IV: no vital signs

¡ If HT II-IV, assess for cardiovascular stability§ If stable, minimally invasive warming (warm IVF,

heating packs, warm drinks)§ If unstable, transport for ECMO/bypass

¡ CPR cessation§ Serum potassium >12 mmol/L§ Asystole persists at >32°C§ Burial in snow >35 minutes with snow in airway

and asystolic arrest▪ If buried >35 minutes with clear airway, continue

resuscitation

¡ ECMO/bypass initiation§ Cardiovascular instability despite medical

management and non-invasive rewarming§ All HT IV patients

Fein JA, Zempsky WT, Cravero JP; Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine; American Academy of Pediatrics. Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems. Pediatrics.2012;130(5):e1391-405.

¡ Pain assessment§ 0-10 scale in older children§ FACES scale in younger children§ Neonatal scale in infants§ FLACC (Face, Legs, Activity, Cry, Consolability) in

cognitively impaired individuals

¡ Simple methods to lessen pain in minor procedures§ Using topical anesthetics before

injections/venipuncture§ Buffering and warming lidocaine prior to injection

¡ Age-appropriate analgesia§ Sucrose on a pacifier for infants under six months of age§ Inhaled medications▪ Nitrous oxide: excellent analgesia, no-needle; contraindicated

with pneumothorax, bowel obstruction, intracranial injury, or cardiovascular instability

§ Oral medications

¡ Consider benzodiazepines for anxiolysis

¡ Sedation protocols including end-tidal carbon dioxide monitoring and a dedicated person to monitor the patient’s airway and vital signs

Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department KetamineDissociative Sedation: 2011 Update. Ann Emerg Med. 2011;57(5):449-61.

¡ Absolute contraindications§ Less than three months old§ History of schizophrenia

¡ Relative contraindications§ History of coronary artery disease, thyroid disease, or porphyria§ History of tracheomalacia, laryngomalacia, tracheal stenosis§ History of intracranial mass, structural abnormality, or

hydrocephalus▪ Head trauma no longer listed as a contraindication

§ Acute globe injury or glaucoma§ Current upper respiratory tract infection§ Anticipated major oropharyngeal manipulation

¡ Adverse events (no relation to dose)§ IM dosing: increased vomiting and longer

recovery time§ IV dosing: respiratory depression with rapid IV

push§ Emesis: peaks in adolescents; consider

prophylactic antiemetics in this population§ Reemergence phenomenon: more common in

adults; should administer benzodiazepine pretreatment in this population

Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. PrehospitalEpinephrine Use and Survival Among Patients with Out-of-Hospital Cardiac Arrest. JAMA. 2012;307(11):1161-8.

Callaway CW. Questioning the Use of Epinephrine to Treat Cardiac Arrest. JAMA. 2012;307(11):1198-1200.

¡ Prospective, observational study in Japan of 417,188 patients

¡ Outcomes measured: § return of spontaneous circulation, § survival at one month, § survival with good or moderate cerebral

performance (CPC 1 or 2), and § survival with no, mild, or moderate

neurological disability (OPC 1 or 2)

¡ Controlling for many variables, prehospitalepinephrine was assocated with:§ Increased rate of return of spontaneous

circulation§ Decreased one month survival§ Decreased rate of good neurological outcome

(CPC 1-2 or OPC 1-2)

Hoen B, Duval X. Clinical Practice. Infective Endocarditis. N Engl J Med.2013;368(15):1425-33.

¡ 50% occurs without known risk factor

¡ 80% staphylococci/streptococci

¡ Duke Criteria for diagnosis (2 major, 1 major/3 minor, or 5 minor)§ Major criteria: positive blood culture, positive

TTE/TEE§ Minor criteria: fever, risk factors, vascular

phenomena, immunologic phenomena, positive blood culture

§ >80% sensitivity and specificity

¡ Antibiotic duration is debatable, but most agree intravenous administration is necessary

¡ Early surgery seems to give better outcomes§ Indications: uncontrolled infection, heart failure, and

prevention of embolic events

¡ No indication for aspirin or other antiplatelet therapy to prevent emboli

¡ Prophylaxis now only recommended for invasive dental work in those with a history of endocarditis, prosthetic valves, or unrepaired cyanotic congenital heart disease

Hoffmann U, Truong QA, Schoenfeld DA, et al.; ROMICAT-II Investigators. Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain. N EnglJ Med. 2012;367(4):299-308.

¡ Randomized controlled multicenter trial of 1000 patients§ CCTA versus “standard care” after initial

electrocardiogram was without ischemic changes and first troponin was negative

§ Followed up at 28 days after emergency department presentation

¡ CCTA was associated with:§ Decreased overall length of stay§ Decreased time to diagnosis (acute coronary syndrome or

other diagnosis)§ Increased diagnostic testing§ Increased radiation§ Increased number of patients discharged directly from the

emergency department

¡ Similar cost between CCTA and standard of care groups

¡ No missed acute coronary syndrome events in either group (death, MI, UA, urgent PCI)

Holden RJ. Lean Thinking in Emergency Departments: A Critical Review. Ann Emerg Med. 2011;57(3):265-78.

Key Principles Tools and Methods•Eliminate unnecessary waste•Achieve smooth, continuous flow of work with minimal delays (heijunka)•Just-In-Time delivery of products and materials•Worker involvement and empowerment•Immediate machine detection of defects in production (jidoka)•Solve problems at their source•Continuous improvement

•Value stream mapping (diagramming and describing current and desired future process steps)•Short-cycle continuous improvement sessions (kaizen)•Work standardization based on “best way” to do the work•Work done by multiskilled teams•Organizing and standardizing workplaces (5S)•Layout improvement to minimize travel time•Root cause analyses (5 Why)•Assembly lines•A3 report (standard organization tool for problem solving)•Mistake proofing (poka-yoke)•Information systems for knowing when products are ready to be pulled to the next step or when a problem exists

¡ Literature review of emergency department implementation of “Lean” thinking

¡ Typical first step: value stream mapping to identify areas for improvement

¡ Kaizen- most implemented tool

¡ Very important to have front-end participation, management buy-in, and site-specific plans for success

¡ Most locations reported positive patient impact (decreased length of stay, increased satisfaction) but made no mention of impact on employees

Link MS. Clinical Practice. Evaluation and Initial Treatment of Supraventricular Tachycardia. N EnglJ Med. 2012:367(15):1438-48.

Pollack CV Jr. New oral anticoagulants in the ED setting: a review. Am J EmergMed. 2012;30(9):2046-54.

¡ 2012 review article

¡ Three novel anticoagulants§ Dabigatran (Pradaxa): direct thrombin inhibitor▪ Non-inferior and with decreased bleeding versus warfarin in

DVT/PE treatment and prevention and stroke prevention in atrialfibrillation

§ Rivaraoxaban (Xarelto): factor Xa inhibitor▪ Non-inferior and with decreased bleeding versus warfarin in

DVT/PE treatment , stroke prevention in atrial fibrillation, and with decreased recurrent MI/death versus aspirin or plavix alone in ACS

§ Apixaban (Eliquis): factor Xa inhibitor▪ Superior to aspirin and clopidogrel for stroke prevention in atrial

fibrillation, similar DVT recurrence and bleeding events as warfarin in DVT treatment

¡ Reversal§ No clear answer; FFP and vitamin K ineffective

based on mechanism§ Consider PCC, recombinant factor VII§ Recombinant factor Xa being researched for

rivaroxaban/apixaban

¡ When prescribing from the emergency department, remember to renally adjust dose if the patient has renal insufficiency

Quinn J, McDermott D. Electrocardiogram Findings in Emergency Department Patients with Syncope. Acad Emerg Med. 2011;18(7):714-8.

¡ Prospective data analysis of 684 patients with syncope

¡ Assessed using San Francisco Syncope Rule electrocardiogram criteria (non-sinus rhythm or any new changes on EKG)

¡ 218 patients with positive EKG findings

¡ 42 patients with “bad outcomes” (death, MI, arrhythmia, newly discovered structural issue)

¡ San Fracisco Syncope Rule EKG Criteria§ 86% sensitive§ 70% specific§ 99% negative predictive value§ EKG changes most predictive of negative

outcome:▪ Any left bundle branch block (OR 3.2)▪ Any non-sinus rhythm (OR 2.8)▪ Q waves, right bundle branch blocks, ST segment

changes, and sinus rhythm were NOT associated with serious outcomes

Sommerkamp SK, Gibson A. Cardiovascular Disasters in Pregnancy. Emerg Med Clin North Am.2012;30(4):949-59.

¡ DVT/PE§ Diagnosis:▪ D-dimer is less specific as pregnancy progresses, but remains

reliably sensitive▪ Lower extremity ultrasound is less sensitive due to increased

pelvic DVTs in pregnancy▪ CTPA has more breast radiation for mother, V/Q scan has more

radiation to fetus; equal negative predictive value§ Treatment: warfarin is category X; use fondaparinux§ Code/Pericode: thrombolysis acceptable on a case-by-case basis

¡ Aortic Dissection§ More common than DVT/PE§ Diagnosis: transesophageal echocardiogram; CTA if not available§ Treatment: no change

¡ Cardiovascular Disease§ Adverse events in pregnancy increased for mitral/aortic stenosis

and EF <40-45%§ BNP increases naturally in pregnancy, but should remain below

100; remains reliably sensitive§ Heart failure treatment: angiotensin converting enzyme inhibitors

are contraindicated in pregnancy§ MI treatment: PCI as in non-pregnant patients; avoid

thrombolysis; statins/ACE-inhibitors/ARBs contraindicated in pregnancy

¡ Dysrhythmias§ No change to treatment with adenosine, cardioversion, or

management of atrial fibrillation§ Amiodarone is teratogenic; use alternative antiarrhythmic

¡ Cardiac Arrest§ Offload the IVC by displacing uterus to

improve hemodynamics§ No change to defibrillation or code drugs§ Airway management may be more difficult

(friable tissue, increased aspiration risk)§ Therapeutic hypothermia is indicated if ROSC

is achieved§ Perimortem cesarean section should be

initiated within four minutes of maternal arrest

Varon J, Marik PE, Einav S. Therapeutic hypothermia: a state-of-the-art emergency medicine perspective. Am J Emerg Med. 2012;30(5):800-10.

¡ 2012 review article

¡ 12-24 hours at 32-34°C begun as soon as possible after return of spontaneous circulation

¡ Rewarming over 24 hours to 36.5°C

¡ Other indications besides post-arrest:§ Traumatic brain injury/increased intracranial pressure§ Acute respiratory distress syndrome§ Neonatal hypoxic/ischemic encephalopathy§ ? Liver failure with encephalopathy

¡ Side effects§ Decreased heart rate§ Increased systemic vascular resistance§ Increased QTc§ Decreased ventilator requirements§ Increased renal perfusion leading to diuresis§ Intracellular shift of potassium (hypokalemia)§ Hyperglycemia§ Hypomagnesemia/hypophosphatemia

Thank you for your attention!