Escaping from Emergency department pitfalls

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Escaping from Emergency department pitfalls

  1. 1. Montinee Sangtian, MD Emergency Physician BUMRUNGRAD INTERNATIONAL HOSPITAL
  2. 2. INTRODUCTION  high-risk specialty  not purely due to a lack of knowledge but rather to simply “letting one’s guard down.”  Did not use the evidence-based in clinical decision.
  3. 3. COMMON PRESENTING SYMPTOMS IN ED  Abdominal Pain  Chest Pain  Dyspnea, Shortness of Breath
  4. 4. CHEST PAIN  5% of all ED visits  Ranging from benigh to life-threatening.  ACS is 20% of all deaths in US.  Fear of being sued : increased hospital cost and admit non-cardiac caused in IPD or CCU
  5. 5. IMMEDIATE LIFE THREATENING CAUSED OF CHEST PAIN
  6. 6. FINAL DIAGNOSIS OF CHEST PAIN FROM ED i*trACS registry data, Jun1, 1999- Aug1, 2001
  7. 7. BUT, MORE OVER…  Missed Cardiac Ischemia 2-4%, with mortality rate 10-25%  It means : every 100 chest pain patients - 4/100 : Missed Cardiac Ischemia - 1/100 : dead from missed diagnosis.
  8. 8. Characteristics associated with inadvertent discharge of a patient with missed cardiac ischemia • Younger patient • Atypical symptoms • Women • Nonwhite • Physician inexperiences • Lower-volume EDs • Failure to detect ischemia on initial ECG • Failure to obtain an ECG (Ann. Emerg Med 1989;18(10):1029-34)
  9. 9. CLINICAL QUESTIONS  How to rule out or rule in life-threatening chest pain?  Characteristics of pain, History, Risk factors, Physical exam, ECG, Lab, CXR  Outcome.
  10. 10. CHARACTERISTICS OF CHEST PAIN  NRMI2 – 1/3 of MI – no chest pain  20% of MI – with presenting symptoms other than chest pain Risk Factors % Without chest pain Prior Heart Failure 51 Prior Stroke 47 Age > 75 yr 45 DM 38 Non-White 34 Woman 39
  11. 11. ATYPICAL CHEST PAIN  7% of ACS : chest wall tenderness  6% of costochondritis dx : enz - proven MI ( Arch. Intern Med 1994; 154(21):2466-9) To define low-risk group : use combination of 3 1. sharping or stabbing pain 2. no history of angina 3. pain reproduced by palpation Without these combination – 5% were MI. ( Arch. Intern Med 1985; 145(1):65-9)
  12. 12. HISTORY  Burning, Indigestion complaints – as strong as chest pressure (QJM 2003;96(12);893-9)  Precipatating factors : physical activities 35%, eating 8.2%, emotional stress 6.8% (Int. J. Cardiol.; 117(2):260-9)  Relieving factor : GI cocktail, antacids, NTG – not reliable. (Ann. Emerg Med 1996;26(6):687-90)
  13. 13. Features that increased the probability of an acute MI Jama 1998;280:1256 • CLINICAL FEATURES Likelihood ratio (95% CI) • Pain in chest or left arm 2.7 • Chest pain radiation : Rt shoulder 2.9(1.4-6.0) • Chest pain radiation : Lt arm 2.3(1.7-3.1) • Chest pain radiation : Both Lt and Rt arm 7.1(3.6-14.2) • Nausea or vomiting 1.9(1.7-2.3) • Diaphoreis 2.0(1.9-2.2) • 3rd Heart sound on ausculation 3.2(1.6-6.5) • Hypotension (SBP < 80 mmHg) 3.1(1.8-5.2) Features that decreased the probability of an acute MI • Pulmonary crackles 2.1(1.4-3.1) • Pleuritic Chest Pain 0.2(0.2-0.3) • Sharp or Stabbing Chest Pain 0.3(0.2-0.5) • Positioning Chest Pain 0.3(0.2-0.4) • Chest Pain reproduced by palpation 0.2
  14. 14. Classic or traditional Non-traditional Risk Factors Risk Factors • Advanced age • HIV • Male • SLE • Hypertension • ESRD • DM • Cocaine • Hypercholesterolemia • Type A Personality • Premature CAD in • Genetic and Acquired 1st degree relatives thrombophilias • Cigarette smoking
  15. 15. 4 RISK FACTOR : DM, HT, HYPERCHOL, FAMILY HX OF CAD Group No Risk Factors ≥ 4 Risk Factors LR – LR + Age < 40 yr 0.17 7.39 (95% CI 0.04-0.66) (95% CI 3.09-17.67) 40 – 65 yr 0.53 2.13 (95% CI 0.40-0.71) (95% CI 1.66-2.73) 65 yr 0.96 1.09 (95% CI 0.74-1.09) (95% CI 0.64-1.62) i*trACS registry data analysis
  16. 16. RISK STRATIFICATION : TIMI, GRACE, ETC.  Don’t be confuse !  TIMI, GRACE, ESSENCE – for predicting outcome, adverse events.  Not for rule out Acute Coronary Syndrome.  Can not use for discharge decision making.  Even TIMI score = 0, rate of adverse events in 30 days = 1.7% (95% CI 1-4%)
  17. 17. ECG AND CARDIAC BIOMARKERS  Single initial normal EKG and Cardiac Enz can not be used for rule out ACS.  7.8% of MI : normal initial ECG  35.3% of MI : non-specific finding on initial ECG  Be careful in LBBB and Ventricular Pacing Rhythm (VPR) ECG.
  18. 18. LBBB • Widened QRS complex > 0.12s • Monophasic notch R-wave in the lateral leads Lead I, V5 • Absent of Q-wave in Lateral leads. • There is discordant between the major vector of QRS complex and the major vector of ST-segment/ T-wave complex that follows
  19. 19. ACUTE MI IN THE PRESENCE OF LBBB •There is concordant ST-segment elevation in lead I, aVL, V5, V6 •Concordant ST-segment depression in leads V1-V3
  20. 20. Scarbossa’s criteria for STEMI in the presence of LBBB ST-segment elevation ≥ 1 mm concordant Score 5 with QRS complex ST-segment elevation ≥ 1 mm Score 3 in lead V1, V2 or V3 ST-segment elevation ≥ 5 mm discordant to Score 2 QRS complex Score ≥ 3 : likely to experience STEMI Score < 3 : indetermined
  21. 21. VPR •Small amplitude spikes before the widened QRS cpx •Predominate negative QRS cpx (9/12), less opportunity for Concordant ST-segment elevation
  22. 22. ACUTE MI IN THE PRESENCE OF VPR Concordant ST-segment elevation in leads II, III, aVF and Reciprocal ST-segment depression in leads I and aVL
  23. 23.  Only 1 useful to detect STEMI in VPR :  ST-segment elevation ≥ 5 mm discordant to QRS complex.  The ECG in VPR is more likely to rule in the diagnosis of acute MI than to rule it out.
  24. 24. PRIOR NEGATIVE CARDIAC WORKUP : Stress test (Am J Cardiol 1997; 80(8): 1086-7) • 3 yr Event rate for prior negative stress test is 5-15%. • A Stress test can be considered to rule out coronary disease during that visit only. Cardiac Cath. (Arch Intern Med 2006; 166(13): 1391-5) • 1 yr Event rates for prior negative C.Cath • 3.3% : mild CAD (< 50% stenosis) • 1.2% : serious event rate. • Normal angiogram equals to no short-term risk of ACS
  25. 25. OTHERS CAUSES OF ACUTE LIFE-THREATENING CHEST PAIN  Aortic Dissection  Pulmonary embolism  Pericarditis with cardiac tamponade  Tension pneumothorax  Esophageal ruptured.
  26. 26. AORTIC DISSECTION OF THORACIC AORTA  Chest pain (sensitivity 67%), Back Pain (32%), Abd. Pain (23%), ANY PAIN (90%)  Other symptoms : syncope (4-13%), stroke (6%), other neuro deficit (17%)  In AD patients : 62% Widening mediastinum , 50% Abn. Aortic contour, 12% normal CXR
  27. 27. PERICARDITIS  Failure to differentiate Pericarditis from other chest syndrome  Classic symptoms : progressive, central, pleuritic shest pain that worse in supine  PE : friction rub, heard best in sitting up and leaning forward.  ECG : diffuse ST elevation , PR depression ( except lead aVR)  35-50% of Patients : elevated Troponin level  Always look for Signs of Pericardial tamponade!
  28. 28. a. Acute Pericarditis : Concave ST segment Elevation b. Acute MI : Convex ST segment Elevation
  29. 29. Ratio of the ST segment and T wave amplitudes, Lead V6 a. ratio ≥ 0.25 : Pericarditis b. ratio < 0.25 : BER (Benign Early Repolarized)
  30. 30. BOERHAAVE’S SYNDROME  Classic Triad: forceful emesis, chest pain, subcutaneous emphysema.  CXR abnormalities usual on the Left : 90% tear in the left posterolateral wall of lower 1/3 esophagus  pneumomediastinum, hydropneumothorax  20% of case : no vomiting  Other caused : swallowing sandwich, violent cough, weight lifing, seizures, blunt abdomen.  Diagnosis : CXR, CT, Esophagogram
  31. 31. SUMMARY : PITFALLS IN CHEST PAIN  Over-reliance on the classic presence of chest pain for the diagnosis of acute myocardial infarction (MI)  Exclusion of cardiac ischemia based on reproducible chest wall tenderness  Assumption that acute MI cannot be diagnosed with a 12-lead ECG in the presence of pre- existing left bundle branch block or ventricular paced rhythm
  32. 32.  STEMI can be diagnosed on an ECG with LBBB … the ECG is more useful in ruling in the diagnosis than in excluding it.  Use of a “GI cocktail” to distinguish between cardiac versus non-cardiac chest pain  Assumption that a normal ECG rules out cardiac ischemia  Single determinations of cardiac markers at the time of presentation appear to be inadequate to exclude the diagnosis of acute MI and provide no information about the possibility of cardiac ischemia
  33. 33.  Over-reliance on a “classic” presentation.  Use of the chest X-ray to exclude AD  The use of ECG findings to rule in or rule out PE
  34. 34.  Failure to differentiate pericarditis from other chest syndromes  Assumption that the standard chest X-ray completely rules out pneumothorax  Excluding the diagnosis of Boerhaave’s syndrome due to an absence of antecedent retching or vomiting  Failure to evaluate a patient with chest tenderness for herpes zoster
  35. 35.  Frequent chief complaint in ED  Common associated with hospital admission  Subjective symptom  Crucial for EPs to consider related underlying disease.  Delayed diagnosis and treatment can lead to increase morbidity and mortality.
  36. 36.  Pericardial Effusion and Cardiac Tamponade  Pneumothorax  Pulmonary Embolism  Asthma, COPD  Anemia, etc.
  37. 37.  Ausculation in Hemothorax, Pneumothorax : sensitivity 50-82%, PPV 97-98%  Normal ausculatory exam : up to 800 cc of hemothorax, 28% of pneumothorax  Pneumonia : sensitivity 47-69%, specificity 58-75%
  38. 38.  Pulse oximetry : useful for detect hypoxia,  Not for hypercarbia, hypoventilation  Anxiety and depressive are common in elderly and more likely with non-specific symptoms.
  39. 39.  < 50% of Pt with cardiac tamponade have the classic finding.  Doppler Echocardiography : sensitivity 96%
  40. 40.  Classic symptoms: pleuritic chest pain and SOB  20% asymptomatic or minor symptoms  23% missed pneumothorax in standard CXR in ICU patients. 26% missed in severe injured patients  CXR Upright 80% sensitivity, Supine 50% Sens.  Others options : expiratory CXR, lateral decubitus film, US, Chest CT  Bedside US : up to 98% sensitivities  CXR and US cannot diff. Bullous and Pneumothorax
  41. 41.  Not including pulmonary embolism in the differential diagnosis of the patient with dyspnea  Use objective criteria to assess pretest probrobility.  Over-reliance on the D-dimer, ABG, CXR, or EKG to exclude PE  CXR, EKG should not be used alone to exclude PE.  A D-dimer test should not be used to exclude PE in patients with moderate or high clinic pre-test probability.
  42. 42.  Only 20% present with classic triad of chest pain, dyspnea, hemoptysis  In PE patients only 44% has pleuric chest pain  80-92% of PE patients presented with dyspnea.  67% of Pt : rapid onset of dyspnea over sec to min.  Classic S1Q3T3 ECG only 12-50% of PE.  Precordial T-wave inversion was the most common finding in ECG of PE (68%)  Sinus tachycardia : 8-69% of PE
  43. 43.  Low risk Wells score + Negative D-Dimer : NPV 96-100% (Ann Intern Med 2001;135(2):98-107)  PERC : can exclude PE in low pretest prob. (Am J Emerg Med 2008;26(2):181-5)  D-Dimer  normal D-Dimer level (ELISA): 95% likelihood of not having PE  Poor PPV, Good NPV  (Mayo Clin Proc 2003;78(11):1385-91)
  44. 44.  CXR : poor diagnostic tool for PE (Chest 1991;100(3):598-03)  ECG : neither sensitive nor specific for PE (Emerg Med Clinic North Am 2006;24(1):133-43)  CXR, EKG should not be used alone to exclude PE
  45. 45.  Bedside US : sensitivity 51-93%, specificity 82-90% ( Int J Cardiol 1998;65(1):101-9)  V/Q Scan :  normal, low, intermediate, high probability of PE  High Probability : PPV 85-90%  Normal and High Prob : powerful prognostic tool.
  46. 46. CONTRAST-ENHANCED HELICAL, SPIRAL, OR ELECTRON-BEAM CT  Pulmonary Computed Tomography Angiography (PTCA) : Senstivity 53-70%  PTCA + Scoring System: 83-96% (N Engl J Med 2006;354(22):2317-27)
  47. 47.  Gold standard : Pulmonary angiography  Disadvantage : Invasive
  48. 48.  Identifying asthmatics at risk  Assessing asthma severity  Clinical presentation : slow or fast onset  Some Pt. have low perception of dyspnea
  49. 49.  Overly or underly aggressive oxygen administration in patients with COPD  Do not withhold oxygen from a hypoxic COPD patient; however, be cautious with its use and follow PCO2 levels.  Initial Goal : SaO2 > 90%, PaO2 60-70 mmHg  Cutoff at Sao2 92%, detect hypoxia : sensitivity 100%, specificity 86%  Not considering non-invasive positive pressure ventilation; that is, CPAP/BiPAP as an alternative to intubation in selected patients  Data support for using NPPV is strongest for COPD.  Decreased Intubation Rate (RR 0.42, 95%CI 0.31-0.59)  Decreased Mortality (RR 0.41, 95%CI 0.26-0.64)
  50. 50.  5-10% of all ED visits.  18-25% admitted for investigation  10% : operation  Challenge for emergency physician (EP):  About 1/3 have an atypical presentation.  If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly.  Problematic : Women (child-bearing age), HIV, Elderly.
  51. 51.  A 65 yr Male, DM,HT with epigastric pain, nausea, no fever  A 43 yr Female, Lower abdominal pain, vaginal bleeding  A 25 yr Male: fever with RLQ pain  A 78 yr Male, ESRD on HD : abdominal pain
  52. 52.  Who is the patient of acute abdomen?  What are the probable diagnoses you have in mind?  Why do you consider such diagnosis?  How do you prove it?  When will you consult surgeon for operation?
  53. 53.  Common, lifetime risk 7%  Only 20% of elderly pt have classic findings.  MANTRELS (Alvarado) Score : less suited for elderly, women  Missed Appendicitis in score < 5 : age 60-80 yr  High score in women has a lower PPV  Score > 7 in women : 1/3 were normal appendix
  54. 54.  No lab test specific for appendicitis.  Scoring system : MANTRELS, Ohmann score : none of these are accurate enough to predict appendicitis.
  55. 55.  CT : sensitivity 94%, specificity 94%  CT : appendix > 6 mm, wall thickening, RLQ inflammatory changes, appendicoliths.  Contrast CT vs NonContrast CT : equal  IV contrast : highlight inflammed tissue.  Oral Contrast : better differentiate the appendix from surrounding tissue.
  56. 56.  High sensitivity as CT in some studies  Lower NPV than CT (specificity 83%)  Finding : non-compressible lumen, diameter > 6mm, absence gas in lumen and appendicoliths (some center use 7mm)  Doppler US – increased flow in an inflammed appendix, but limit in necrotic or ruptured appendix.  Limitations : Obese, Bowel gas, Operator dependent  US best use as an initial study in children, women, pregnant patients.
  57. 57. A 43y Female, Lower abdominal Pain, no fever, no nausea/vomiting  Vaginalbleeding : spotting for 20 days  Refused probability of pregnancy  No contraception • UPT + • PV : OS closed, minimal bloody mucoid • Treated as Threatened abortion, D/C
  58. 58. 3 DAYS LATER  The patient came to ED, with abdominal pain with spotting.  V/S : BP 100/80, PR 110
  59. 59.  1:30000 pregnancies  4 common signs abdominal pain, adnexal mass, peritoneal irritation, enlarged uterus (absent in 1st Tri.)  Consider heterotropic pregnancies in women receiving ART : 1:100 Pregnancies
  60. 60.  8% of Unstable angina presented with epigastric pain  Painless ulcer was found 35% of Pt > 60 yr  Elderly Pt with Acute cholecystitis  50% has afebrile. 33% absent leukocytosis and normal LFT  Pancreatitis  incident 200 folds in > 65y  Higher risk of necrotizing pancreatitis in >80y  Early CT in Elderly
  61. 61.  Low incidence (1/1000 Hospital admission)  High Mortality (80%), with immediate angiogram (mortality reduced to 54%)  Severe Abdominal Pain (out of proportion to exam)  Risk Factors for mesenteric ischemia
  62. 62. Type of Mesenteric Risk Factors Special Notes Ischemia SMA Embolus Cardiac Disease 1/3 have Hx of Embolic •AF and other arrhythmias event •Valvular diasease •Ventricular aneurysm •Cardiomyopathy SMA Thrombosis Vascular Disease Risks Acute event may be •HT preceded by period of •Hypercholesterolemia “intestinal angina” and •DM prolonged period of •Smoking significant weight loss Mesenteric Venous Hypercoagulable State Women > Men Thrombosis •Inherited ½ have personal or •Acquired (Malignancy, Oral family Hx of DVT/PE contrceptions) Subacute presentation NOMI Low-flow state (Non-Occlusive Mesenteric •Sepsis Heart Failure Ischemia) •Volume depletion Hemodialysis Drugs •Digitalis Ergot derivatives •Cocaine Norepinephrine
  63. 63.  Misdiagnosis of cardiac ischemia  Over-reliance on “classic” presentations and laboratory results of appendicitis  Over-reliance on laboratory values and ancillary testing in suspected mesenteric ischemia.  Failure to consider heterotopic pregnancy in women receiving reproductive assistance  Failure to appreciate atypical signs and symptoms in the elderly
  64. 64.  Do Not over-reliance on the classic signs, symptoms, diagnostic tools.  Know Limitations of Test and Scoring system  Negative test does not mean no disease.  Use Evidence-Based in decision making  Do not “ Guard Down”

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