LLSA 2018 Take Home Points

Management of Spontaneous ICH The bottom line for us: lower the BP and reverse coagulopathy

If on Vit K anticoagulant:

Give vitamin K AND Prothrombin complex concentrate FFP may be insufficient and requires large volumes Target unclear but shoot for INR <1.3-1.5

ICH with SBP 150-220:

Lower SBP to a target of 140—safe and improves functional outcomes

If there are seizurestreat with AED; prophylactic AED is not recommended. If there is a question of seizure, then EEG. Intraventricular hemorrhage: Put in a drain if there is hydrocephalus and monitor ICP if AMS, GCS <8. Surgical evacuation is recommended for: cerebellar hemorrhage with deterioration, brainstem compression and/or hydrocephalus. Supratentorial hematoma evacuation in deteriorating patients may be life-saving.

HEART Score and Chest Pain BACKGROUND: Low risk chest pain is extremely common and more than half of patients with acute chest pain undergo full cardiac evaluation but acute coronary syndrome (ACS) is diagnosed in fewer than 10%. The HEART pathway is a decision aid to identify emergency department patients with acute chest pain for early discharge. No randomized control trials have compared the HEART Pathway with usual care. Previous studies of the HEART Pathway among patients identified for chest pain demonstrated 100% sensitivity and NPV for MACE at 30 days METHODS: In this study from Wake Forest School of Medicine, 282 patients presenting with possible ACS without ST elevations were randomized to the HEART Pathway or the usual care group which was to follow American College of Cardiology/AHA guidelines. The HEART Pathway consisted of assessment of five elements relating to history, EKG, age, risk factors and troponin levels (measured at baseline and 3 hours). Each element was sscore on a scale of 0-2 and a summed score of 0-3 inclusive was considered low cardiac risk. THe pathway suggested discharge without any further testing for low-risk patients with instructions to follow up with primary care provider RESULTS: The primary outcome was the rate of objective cardiac testing within 30 days of presentation, defined as the proportion of patients receiving any stress testing modality within 30 days. Secondary outcomes included early discharge rate, index LOS, cardiac related recurrent ED visits and non-index hospitalization at 30 days. Patients randomized to the HEART pathway had 30-day objective cardiac

testing at a rate of 56.7% (80/141) compared with 68.8% (97/141) in the usual care group: absolute reduction of 12.1% (p=.048)

Early discharge occurred in 39.7% (56/141) of patients in HEART pathway group compared with 18.4% (26/141) with absolute increase of 21.3% (p<.001)

HEART pathway patients had median LOS of 9.9 hours compared with 21.9 hours, a median reduction in LOS of 12 hours (p=.013)

No patients identified for early discharge had missed MACE in either group during the 30-day follow up period

CONCLUSION: These findings suggest that application of the HEART pathway significantly reduces cardiac testing and hospitalization among patients with acute chest pain, without an increase in adverse events

Pregnancy Complicated by Venous Thrombosis

DVT 5 times greater in pregnancy More common in the LLE and in the proximal iliofemoral veins Compression duplex US if suspected DVT VQ scan preferred initial test for PE (high NPV) CTPA vs VQ: similar NPV; 20-100x higher maternal radiation dose to

breast tissue with CTPA; fetal radiation exposure is negligible and similar; very small risk of childhood malignancy

LMW heparins preferred over unfractionated heparin for tx NO Coumadin or NOACs—they (may) cross the placenta Treatment for a minimum of 3 months and until 6 weeks post partum

Imaging Foreign Bodies: Ingested, Aspirated and Inserted

This is a button battery in a 2 y/o male with drooling and poor appetite but otherwise

appears well. What do you do?

Which foreign body is most concerning for complications? ☐Blunt object 2.0 cm imaged in the stomach ☐Ingested plastic bread clip not visible with imaging ☐Peanut inserted into the nasal cavity by a toddler ☐Swallowed decidual tooth imaged in the duodenum

Fever in the Well-appearing Child

This article lays out recommendations for the work-up of children aged 2 months to 2 years old who have fever (defined as temp ≥ 100.4°F) and are well-appearing and are immunocompetent. Clinical predictors for UTI (Level C): female < 12 m/o, uncircumcised males, non-black, fever > 24 hrs, T>39°C, no respiratory pathogens, no obvious source of infection. How should we diagnose UTI?

Level B: (+)LE, nitrites, leukocyte count on u/a, +gram stain Level C: get a urine Cx if starting abx or if suspect UTI but (–) u/a

Are there clinical predictors for pts at risk for PNA in whom CXR should be obtained?

Level B: CXR if cough, hypoxia, rales, T >39°C, fever > 48hrs, tachycardia and tachypnea out of proportion to fever

Level C: if wheezing, high likelihood of bronchitis NO CXR For well appearing, full-term infants 29-90 days old with fever, are there predictors that identify pts at risk for meningitis for which LP should be done?

No Level A or level B recommendations Level C

o You should consider LP o Defer LP if viral illness is suspected o IF LP is deferred, withhold abx unless another bacterial source

is identified o Admission, close f/u with PCP or return ED visit for recheck is

needed

Elder Abuse 5 Major types: physical, psychological/verbal, sexual, neglect, financial

exploitation Overall estimate 10% in community dwelling > 60 y/o RF: female>male, lower income, lack of social support, younger age-living

with spouse/children who are most common perpetrators Screening not recommended by US Preventive Services TF Interview patient and care-givers separately The most important tasks for the physician are to recognize and

identify elder abuse, become familiar with resources for intervention and refer to coordinate care with resources.

If concerned report to Adult Protective Services-mandatory except for NY

Pelvic Inflammatory Disease Diagnosis:

Test all for GC and CT with NAAT; also send HIV test Wet mount: check for increased WBC’s—WBC + clue cells suggest

PID ESR and CRP can increase specificity of PID dx

Treatment (from the CDC guidelines):

Cover for GC and CT (regardless of results) AND anaerobes (fund in Cx and BV often found in pts with PID)

Outpatient: single IM dose of Ceftriaxone, cefoxitin plus probenicid or another 3rd generation ceph PLUS oral doxycycline +/- flagyl x 2 weeks

ADMIT IF: pregnant, severe illness, can’t tolerate PO, tubal abscess, can’t r/o competing dx.

If TOA: Clindamycin and an aminoglycoside (gentamicin) If there is an IUD, leave it in place

Complications of CVP by Site Head to head comparison of complications from IJ, subclavian and femoral CVP insertion with respect to: PTX, DVT, and blood stream infection. Findings:

PTX: subclavian > jugular > femoral DVT: femoral > jugular > subclavian BSI: jugular > femoral > subclavian

Task Switching and Multitasking Multitasking: simultaneous performance of 2 distinct tasks. Task switching: changing between two separate tasks, sometimes rapidly Interruptions can lead to medical errors and risk potential harm to patients. Recommendations for reducing the effect /risks from task switching include: decrease external interruptions, teach methods to improve TS, education staff on the dangers of interruptions, use appropriate technology to increase rates of task completion, design standardized work flow to decrease interruptions.

Suicidal ED Patients

Summary quote: “Emergency physicians pride themselves in risk-stratifying

patients for myriad physical conditions without consulting specialists for every

patient potentially at risk. Similarly, we suggest emergency physicians take

ownership (and pride) in identifying which suicidal patients do not require an

emergency mental health consultation. "

Getting collateral info is important and you do not need a patient’s permission to ask family/friends questions to help determine risk. Asking a patient questions about suicide does not encourage suicide.

“Medical clearance” is NOT the best term for what we do; “focused medical assessment” is preferred. The goals are identifying ingestions, trauma, or other medical conditions that may be affecting a patient’s mental state or that need emergency treatment. “Routine” labs are largely useless, but mental health providers often want them.

Some low-risk patients who do not need emergency mental health consultation during their ED stay. Example: someone vague suicidal thoughts but no plan or intent, no h/o mental illness, no substance abuse history, and not acting irritable/agitated/aggressive

Discharged patients still benefit from “safety planning” which is distinct from the disproven concept of “contracting for safety.” This includes individualized action plans that can include recognizing warning signs of an impending mental health crisis, ways to cope with suicidal thoughts, sources of support to call. Other facets are involving supportive friends and family, making a follow-up appointment, and discussing how to keep lethal means away, i.e., getting guns out of the home.

Since suicide is often impulsive, keeping lethal means away from a person does help. Guns are especially lethal, with a >90% fatality rate when used for suicide. More info on lethal means counseling: https://www.hsph.harvard.edu/means-matter/recommendations/clinicians/

One resource for discharged patients is the National Suicide

Prevention Hotline (1-800-273- TALK [8255]). Though not mentioned in the article, I would also add the Trans Lifeline (8 7 7 - 5 6 5 - 8 8 6 0 ) and the Trevor Lifeline for LGBTQ youth (866-488-7386) as discharge resources for the appropriate patients.

In settings without readily available mental health professionals, ED

physicians may need to do a more comprehensive risk assessment. One discussed in the article is called SAFE-T (below).

Shared Decision-making

This article discusses shared decision-making (SDM)-a collaborative process in which the patients and health care team work together to decide the best treatment plan for the patients taking into account multiple factors, including patient values and preferences as well as scientific-based medical evidence. One study, cited in this paper, demonstrated that patients randomized to SDM facilitated by use of the chest pain choice decision aid had increased knowledge and engagement in decision-making, a lower rate of observation unit admission for stress testing, and a lower rate of cardiac stress testing within 30-days of the index ED visit. The paper also discussed an SDM Model proposed by Charles et al that is a framework for SDM in the context of potentially life-threatening disease with key treatment decisions that occur only once early on in the course of the disease and have major trade-offs for the patient.