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Emergency Medicine 2009

• Introduction• Review of Course Syllabus• The Emergency Department• Legal Issues In Emergency Medicine• Approach to the ED patient • Shock/Patient Resuscitation

The Emergency Department

Function of the EDProblems faced by most ED’sThe Successful ED

Function of the ED

• Triage-sorting of patients into groups according to priority for

treatment using:Severity of illnessPrognosisAvailability of resources

• Prioritize• Stabilize• Observe• Disposition• Refer

Problems faced by most ED’s

• Patients with lack of adequate medical insurance.• Nursing shortages.• Lack of hospital beds• HIV/AIDS, crack cocaine and other substances.• Street violence.• STD epidemic• The threat of malpractice litigation.• Overwhelmed community social and other non-

medical resources.

The successful ED

• Control over patient intake.• Control of the ED environment.• Control of patient-care events.

-patient flow organization-equipment-policies and procedures

• Ability to control disposition resources.

Legal Issuesin

Emergency Medicine

Legal Issues in Emergency Medicine

• Good Samaritan Acts• COBRA• EMTALA• Disclosure of confidential medical information• Negligence• Abandonment• Consent and refusal of consent• Reporting laws• Resuscitation decisions• Advance directivies

Legal Issues in Emergency MedicineGOOD SAMARITAN ACTS

Division 2.5 of the California Health and Safety Code:

1799.102. No person who in good faith, and not for compensation, renders emergency care at the scene of an emergency shall be liable for any civil damages resulting from any act or omission. The scene of an emergency shall not include emergency departments and other places where medical care is usually offered

Legal Issues in Emergency MedicineFederal Screening and Transfer laws

• Comprehensive Omnibus Reconciliation Act (COBRA)

-Enacted by congress to combat widespread patient dumping.

• Emergency Medical Treatment and ActiveLabor Act (EMTALA):

-This is the section of COBRA that applies to ED’s.

Legal Issues in Emergency MedicineFederal Screening and Transfer Laws

• EMTALA - requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. As a result of the act, patients can be d/c’d only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.

Legal Issues in Emergency MedicineHIPAA

• Health Insurance Portability and Accountability Act (HIPAA)-addresses the use and disclosure of individuals’ health information called “protected health information” by organizations subject to privacy rule—as well as standards for individuals’ privacy rights to understand and control how their health information is used.

Legal Issues in Emergency MedicineDisclosure of confidential information

• Medical Records-Medical providers, nurses and other hospital personnel have access only on a need to know basis.-Police do not have a right to a patient’s medical information without a subpoena.-IRS is authorized access to medical records without subpoena.-Spouses and family members generally do not have a right to other adult family member’s records.-Insurance interests only have a right to access patients’ records with signed releases.

Legal Issues in Emergency MedicineNegligence

• Negligence is defined as the omission to do something that a reasonable practitioner, guided by those ordinary considerations that ordinarily regulate human affairs, would do, or the doing of something that a reasonable and prudent practitioner would not do.

Legal Issues in Emergency MedicineNegligence

• Negligence consists of four components:

• Duty• Breach of duty• Damages • CausationAll four must exist in order to be found

negligent.

Legal Issues in Emergency MedicineConsent

• Express consent entails an awareness of the proposed care and an overt agreement (oral or written) to proceed.

• Implied consent is invoked if an emergency exists and the patient is incompetent (a minor or someone with an altered status)

• Informed consent (written) the patient knows and understands the risks, benefits, and consequences of accepting or refusing treatment.

• Emergency consent bypasses normal consent standards, implied consent is inferred by the patient’s actions, but without specific aggreement.

• Failure to obtain appropriate consent can lead to legal action based on battery(intentional unauthorized touching)

Legal Issues in Emergency MedicineRefusal of consent

• Adult patients my ethically and legally refuse treatment totally or in part.

• Informed refusal should be carefully documented on the chart of a patient who leaves against medical advice (AMA)

• There are five components that should be addressed in the chart.-Capacity-Discussion-Offer of alternative treatment-Family Involvement-Patient’s Signature

Legal Issues in Emergency MedicineMinors and Consent

• The law always implies consent for treatment of a child in the event of an emergency.-Parental consent is not needed—it is implied.

• All states without a general consent statute for minors have provision that specifically permit the physician to treat any minor for venereal disease

• Most states have treatment statutes for minors, which enable them to consent for medical care. Many states also specifically permit treatment of minors for drug or alcohol problems, pregnancy, and psychiatric conditions.

• Mature minor usually 14-18yrs old allow a minor to give informed consent. Generally applies to treatment that do not pose a serious risk.

Legal Issues in Emergency MedicineAdvance Directives/ Resuscitation Decisions

• Do Not Resuscitate (DNR)• Living Wills• Durable Power of Attorney

Legal Issues in Emergency MedicineReporting Laws

• Reportable Events-Communicable Diseases

Gonorrhea, Syphilis, HIV/AIDS, etc...• Violent Acts

-Child and elder abuse-Spousal abuse-Sexual Assault-Stabbings and shootings.

• Deaths

Legal Issues in Emergency MedicineMedical Ethics

• There are five basic principles that should guide ethical decision making in medical practice.-Veracity-Patient autonomy-Beneficence-Nonmaleficence-Justice

Approach to the ED

Patient

Patient Assessment

• Primary assessment• Secondary assessment

Primary Assessment

• Goal of Identifying and treating life-threatening conditions.

• A,B,C,D,E’s

Primary Assessment

• A irway maintenance with C-spine precautions• B reathing/ventilation• C irculation with hemorrhage control• D isability GCS (pg553)

-Neurologic disabilitylevel of consciousnessmental statuspupil size and reaction

• E xposure-completely undressed patient for thorough assessment

Secondary Assessment

• Purpose – to identify as many injuries as possible

– Perform thorough head-to-toe evaluation of patient.

Shock /Patient Resuscitation

Shock

• Shock--circulatory insufficency-creates an imbalance between tissue oxygen supply and demand resulting in an oxygen debt.

Pathophysiology

• Normally, 25% of the oxygen carried by the Hb is consumed by tissues

• Venous blood returning to the R heart is 75% saturated.

• When O2 supply is insufficient to meet demand, 1st compensatory mechanism is to increase cardiac output

• If increase in cardiac output is insufficient, amout of O2 extracted from Hb increases

Pathophysiology

• When compensatory mechanisms fail, anaerobic metabolism results in formation of lactic acidosis

• Most cases of lactic acidosis result from-inadequate O2 delivery (Cardiogenic shock)-Can result from excessively high O2 demand

(status epilepticus)

Pathophysiology

• Shock is usually but not always associated with arterial hypotension: SBP<90mmhg

• MAP= CO X SVR• SBP is not the best indicator of tissue

perfusion• Shock can occur with a normal BP and

hypotension can occur without shock

Pathophysiology

• Onset of shock stimulates the ANS baroceptors in the aortic arch and carotid bodies activates the SNS leading to:-arteriolar vasoconstriction-increased HR and contractility-release of vasoactive hormones (Epi, Ne..)-release of ADH and activiation of RAA

Pathophysiology

• Delivery of oxygen to the brain and heart takes priority!!!!

Pathophysiology

• At the cellular level:-ATP depletion results in ion-pump dysfxn-Influx Na-Efflux of K-Reduction in resting membrane potential-Cellular edema and loss of cellular integrity -Hyperkalemia, hyponatremia, metabolic acidosis, hyperglycemia and lactic acidosis

Etiologies

• Shock can be classified into 4 major types-Hypovolemic-Cardiogenic-Obstructive-Distributive-Combination

Etiologies

• HypovolemicAssociated with decreased preload which could be due to:Hemorrhage:

-Overt in GI bleeding or trauma-Concealed such as aortic aneurysm rupture, retroperitoneal bleeding, long-bone fractures or traumatic cavity bleeds, malignancies, ectopic pregnancy, ruptured ovarian cyst.

Fluid depletion:-GI losses such as diarrhea, vomiting-Insensible losses, e.g., burns-Third space losses, e.g., major surgery, pancreatitis, intestinal obstruction

Decreased preload results in a decreased cardiac output with diversion of blood from the splanchnic circulation to vital organs thus increasing the SVR

History & Physical Exam

• Refer to handout

Diagnostic Tests

CBC, serum chemistries, serum ammonia level, Bhcg, PT, PTT, INR, amylase, LFTs, trial of fluids,

FAST scan, x-ray trauma series, x-ray of affected limb, abdominal x-ray, U/S CT abdomen, CT angiogram,

Treatment of Hypovolemic/Hemorrhagic Shock

• Infusion of 1L crystalloid• Infusion of 1L PRBC• Fluid resuscitation-Isotonic crystalloid with NS or LRNS or LR requires a volume approximately 3x that lost.• Blood transfusion-Cross-matched blood -Type-specific blood-Type-O blood

Etiologies

• CardiogenicResults from heart pump dysfunction (more commonly left-sided) causing a decrease in cardiac output in the setting of increased preload. The compensatory surges in catecholamines lead to increased SVR. However, in some instances (esp Acute Coronary Syndrome), decreased SVR may be observed. Early, aggressive management can lead to improved outcome. Myocardial infarction, viral and alcoholic cardiomyopathies, CHF and cardiac valvular lesions are some of he main contributors massive pulmonary embolism.

History & Physical Exam

• Myocardial infarction-chest pain, radiation to L arm, history of

exertional chest pain; smoking, hypercholesterolemia, FHx; DM; high BP

-signs of heart failure; jugular venous distention, basalilar crackles on lung auscultation; heart murmur

Diagnostic Tests

• Diagnosis should be suspected from the initial HX & Physical exam.

• Ancillary tests are needed to confirm DX.-EKG, CXR, 2-dimensional transthoracic echo, lab

studies (cardiac enzymes, coagulation parameters, serum lactate, and chemistries)

Treatment of Cardiogenic Shock– ABCs– Oxygen– Cardiac monitor– Pulse Ox– Fluids (for Rv infarct) only– Pain control with NTG and morphine sulfate– Aspirin– If hypotensive after adequate fluid resuscitation consider

dobutamine and/or dopamine for inotropic and pressor support

– Reperfusion modalities– Cardiology and/or thoracic surgery should be consulted early

Etiologies

• ObstructiveSecondary to an obstruction to cardiac flow or filing:-Flow restriction; severe pulmonary HTN. Usually accompanies by decreased oxygenation with very minimal physical signs.-Filling restriction; cardiac tamponade or tension pneumothorax.

History & Physical Exam

• Tension pneumothorax-Sudden onset, often pleuritic, chest pain; SOB;

rapid deterioration; recent placement of CVP line; history of emphysema; chest trauma

-Absent unilateral breath sounds on the affected side; trachea deviated to the opposite side; hyper-resonance to percussion on affected side.

Diagnostic Tests

• Diagnostic and therapeutic needle thoracostomy

• CXR before and after decompression

Treatment of Obstructive Shock

• Immediate needle thoracostomy• Maintenance of adequate ventilation• Pain control• Adequate pulmonary toilet (attempts to clear

mucus secretions from the trachea and bronchial tree by deep breathing, incentive spiratomy, postural drainage and percussion.

History & Physical Exam

• Cardiac Tamponade-recent cardiac surgery or angiogram/plasty;

chest trauma; malignancy; pericarditis, increasing SOB on minimal exertion.

-Muffled heart sounds, low BP, jugular venous distention (beck’s triad); pulsus paradoxus

Diagnostic Tests

• ECHO

Treatment of Obstructive Shock

• Fluid replacement• Pericardiocentesis• Thoracotomy

Etiologies

• DistributiveThis is associated with significant vasodilation in the setting of relative hypvolemia and decreased SVR. The classical description of distributive shock includes and elevated cardiac output. However, in a substantial percentage of septic shock patients depression of cardiac function is observed in the earlier phases of shock. Causes of distributive shock include: sepsis, neurogenic shock, adrenal insufficiency, anaphylaxis, thiamine deficiency and AV fistula.

History & Exam

• Septic shock:-recent illness, fever, rigors, chills, symptoms

suggestive of infective focus, recent surgery, immunosuppression

Fever >100.4F(38C) or <96.8F(36C)Tachycardia rate >90; systolic BP less than 90;

MAP<65; warm peripheries (early shock); focus for infective eveident

Diagnostic Tests

• CBC, platelet count, DIC panel (PT, PTT, fibrinogen, D-dimer, and antithrombin concentration) Chem panel (check electrolytes, renal func), LFT’s, ABG, UA

• Cx (CSF, sputum, blood, urine and wounds)• X-ray of suspected foci of infection (chest, abdomen,

etc)• U/S or CT for occult inf (cranium, thorax, abdomen,

pelvis)• Acute meningitis is the most common CNS infection

associated with septic shock

Treatment of Septic Shock

• ABC• Fluid administration• Inotropic support• Cultures and empiric antimicrobial therapy

History & Exam

• Anaphylaxis-Known allergy; new drug or food ingestion;

vaccination; recalls bite or sting; rapid development of symptoms; SOB; facial swelling

-facial edema, tongue swelling, respiratory distress, wheezing, stridor, dyspne,a rash, wheals, erythema, nausea cramps, diarrhea and vomitting.

Diagnosis Tests

• Diagnosis is made clinically.• No tests are diagnostic.

Treatment of anaphylaxis• Intubate if airway is compromised• IV fluids• H1 antagonists• H2 blockers• Corticosteroids• Nebulized B2 agonists• Epinephrine• Discontinue offending antigen• Observe• Consider prescribing Epi-pen @ D/C• Discharge patients with Rx for antihistamines and prednisone• Referral to an allergist

History & Exam

• Neurogenic-Brain or spinal cord injury, epidural or spinal

procedures-Hypotension, bradycardia and hypothermia;

warm dry peripheries with bounding pulses; priapism; flaccid paralysis of limbs

Treatment of Neurogenic Shock

• ABCDE• Fluid resuscitation with crystalloid• Methylprednisne • Vasopressor Support• Stabilize and transfer to a regional spine or

trauma center.

Etiologies

• CombinationWhile the previous classification can guide evaluation, not infrequently a combination of the above processes can co-exist.

Circulatory Stabilization

• Begins with intravenous access• Large bore peripheral lines procedure of

choice

Circulatory Stabilization

• Begin fluid resuscitation with isotonic crystalloid• 500cc to 1L is given with reassessment of the

patient after each amont• Pts with modest hypovolemia usually require

200cc/kg and oftentimes more• Colloid vs crystalloid controversy• Vasopressor agents used when there has been an

inadequate response to adequate volumes of fluid or when there are contraindications

Circulatory Stabilization

• Vasopressors most effective when the vascular space is full and least effective when depleted

• Vasopessors, however, may be needed early in the treatmenht of shock, in order to prevent lethal consequences of prolonged arterial hypotension

• Vasopressors are catecholamine derivatives with variable effects on alpha and beta adrenergic receptors.

Vasopressor agents

• Dopamine-a/b/dopaminergic receptors• Norepinephrine-primarily alpha 1 (reflex bradycardia)• Phenylephrine-alpha ( reflex bradycardia)• Epinephrine-alpha and beta

End points of Resuscitation

• Normalization of BP, pulse and urine output• Restoration of circulatory volume• Hemodynamic parameters are “normalized”• Tissue oxygen delivery is maximized.