How to Talk Like a Neurologist

**Written by:** Saabir Kaskar, MD (NUEM ‘23) **Edited by:** Nick Wleklinski (NUEM ‘22)
**Expert Commentary by**: Fan Caprio, MD

Neurology Scores: LVO, NIHSS, and ICH

As first line providers, being able to effectively communicate with ancillary services and specialties is key to advancing patient care within the emergency department. When patients present with symptoms concerning for ischemic or hemorrhagic stroke, there are a variety of clinical decision tools available to help direct interventions and predict patient outcomes. Having a basic understanding of these scoring systems helps ED providers communicate more effectively with our neurology colleagues. This post highlights indications, strengths, and limitations of common stroke assessment scales used in the prehospital and hospital setting.

Cincinnati Prehospital Stroke Scale (CPSS)

The Cincinnati Prehospital Stroke Scale is a simple, easy to teach, three-part evaluation and is the most cited scale in statewide EMS protocols. Patients with one of these three findings, as a new event, will have 72% probability of ischemic stroke. If they have three of these deficits, that probability increases to 85%. Further, those scoring higher on this scale are more likely to have a large vessel occlusion (LVO) and warrant transfer to a comprehensive stroke center. One major limitation is that the CPSS does not identify features of posterior circulation strokes.

Figure 1: Cincinnati Prehospital Stroke Scale components

Predicting Large Vessel Occlusion

There are many stroke severity scales that are useful in predicting large vessel occlusion (LVO) in the pre-hospital setting. Early LVO detection is useful as these patients have better outcomes if transported to comprehensive stroke centers (CSCs) which have endovascular interventions, such as thrombectomy, readily available. Such interventions are not available at primary stroke centers (PSC). LVO screening tools include the Rapid Arterial Occlusion Evaluation Scale (RACE), the Cincinnati Prehospital Stroke Severity Scale (CP-SSS/C-STAT), the Los Angeles Motor Scale (LAMS), and the Emergent Large Vessel Occlusion Scale (ELVO). While these scales are good, none have achieved an optimal sensitivity/specificity combination which is why there is no “gold standard” test per the most recent 2019 AHA guidelines (Powers et al. Guidelines for Early Mgmt of Patients with AIS. Stroke 2019).

The Rapid Arterial Occlusion Evaluation Scale (RACE), for example, is one of these severity scales that predicts stroke caused by large vessel occlusion. It is based on the NIHSS but provides quicker assessment in the pre-hospital environment. It focuses on facial palsy, extremity motor function, head deviation, gaze deviation and aphasia or agnosia. The scale ranges from 0-9 with scores ≥ 5 being associated with detection of an LVO. RACE has a sensitivity of 85% and specificity of 68% for LVO at scores ≥ 5.

Another example of a LVO screening tool is the Cincinnati Prehospital Stroke Severity Scale (CP-SSS/CSTAT) which is important to differentiate from the CPSS outlined above. CSTAT focuses on gaze deviation, level of consciousness and arm weakness. Both RACE and CSTAT are validated in the prehospital setting and with external data sets. However, CSTAT is more convenient with fewer items to score.

EMS protocol in Chicago (Region XI), utilizes a two-tier system that first involves the Cincinnati Stroke Scale and finger to nose test. If either aspect is abnormal, then stroke severity is assessed with the 3-Item Stroke Scale (3I-SS) which assesses level of consciousness, gaze preference and motor function, scored from 0-6. If the 3I-SS score is ≥4 and the last known normal is ≤6 hours ago then the patient is transported to the closest CSC instead of the closest primary stroke center (PSC), as long as the added transport time is not >15 minutes.

National Institutes of Health Stroke Scale (NIHSS)

The NIHSS is a 11-part scoring tool and is the gold standard when assessing stroke patients in hospital (figure 3). Higher scores indicate a more severe stroke and usually correlate with infarct size on CT and MRI. Taken within the first 48 hours of acute stroke, the NIHSS helps predict three month and one-year clinical outcomes. For example, patients with a NIHSS of 1-4 have a high likelihood of functional independence and favorable outcome regardless of treatment. The NIHSS does not serve as the primary clinical guide in determining tPA administration. However, given that higher scores correlate with larger infarct size, caution is advised when considering tPA in patients with a NIHSS >22 as there is a higher risk of hemorrhagic conversion (see figure 2 for full tPA exclusion criteria). Analysis from subjects of the NINDS trials show that a NIHSS of >20 was associated with a 17% rate of intracranial hemorrhage with tPA when compared to 3% hemorrhage rate in patients with a score of <10.

Figure 2: Contraindications for tPA administration

Overall, the NIHSS is a reliable scoring tool to quicky assess the effects of stroke. Medical providers and nurses have been shown to have similar levels of accuracy when trained. Limitations include assessing posterior circulation stroke that involve gait abnormality, dizziness, or diplopia.

Figure 3: NIHSS, adopted from the American Stroke Association

Intracerebral Hemorrhage Score (ICH Score)

The ICH score is an important tool when evaluating a hemorrhagic stroke. This score was developed to standardize clinical grading of ICH and to improve communication between providers. This five-component scoring system (Figure 4) helps quantify ICH severity and subsequently 30-day mortality (Figure 6) with a sensitivity of 66%. It is not used to determine treatment modality. This score helps universalize the grading of ICH severity, providing a standardized language that can be used between EM providers, neurologists, and neurosurgeons. Further, this score can help providers guide goals of care conversations with patient’s families and determine appropriate level of care or transfer.

Figure 4: ICH score, adapted from the American Stroke Association

Figure 5: Mortality rates based on ICH score
*No patients in the study scored 6, but estimated 100% mortality

Conclusion

In summary, it is important to understand how to utilize these scoring tools for ischemic and hemorrhagic stroke. Knowing how to interpret pre-hospital stroke scores and how to calculate a NIHSS score accurately and quickly is helpful in not only quantifying severity but also in improving communication between providers. Improved understanding and effective use of these tools can help better advance care of our stroke patients efficiently. These tools can also remind us of the severity of the neurologic deficit we observe on clinical exam. Subsequently, this can be helpful in guiding discussions with patients and their families regarding the severity of their condition.

References

Adams HP Jr, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999; 53:126.

Goldstein, L. (2019). Use and utility of stroke scales and grading systems. Up To Date

Goldstein L, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol 1989; 46:660.

Generalized efficacy of t-PA for acute stroke. Subgroup analysis of the NINDS t-PA Stroke Trial. Stroke 1997; 28:2119.

Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001 Apr;32(4):891-7. PubMed PMID: 11283388.

Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999; 33:373.

Pérez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke 2014; 45:87.

Schlemm L, Ebinger M, Nolte CH, Endres M. Impact of Prehospital Triage Scales to Detect Large Vessel Occlusion on Resource Utilization and Time to Treatment. Stroke 2018; 49:439.

Expert Commentary

Thanks for writing this comprehensive summary of common screening tools used in stroke patients. Having a good handle on these tools will allow you to quickly and effectively communicate with comanaging care providers. It is also important to understand how and why each scale was developed, so they can be used in the appropriate setting to expedite care in extremely time-sensitive neurologic emergencies.

Keep in mind that scales are merely screening tools and are not meant to give a definitive diagnosis. No scale is perfect, but you have highlighted some that yield the highest sensitivity and specificity for identifying a potential stroke patient. In addition to leaning on these scales as decision support tools, always use your clinical judgement. A few things to remember in addition to the neurologic symptoms:

* Strokes are potentially intervenable within the first 24 hours:

1. Up to 4.5 hours – IV-TPA / tenecteplase.

2. Up to 6 hours – Thrombectomy with LVO on vessel imaging.

3. Up to 24 hours – Thrombectomy with LVO + favorable penumbra on perfusion imaging.

* Last known normal (LKN) starts the timer to when stroke patients are eligible for intervention (not to be confused with time of symptom discovery!)

* Strokes typically cause a sudden loss of function (in contrast to positive phenomena such as convulsive movements, tingling sensation, sparkling vision, which can point away from a stroke diagnosis)

* In patients with prior deficits, ask which symptoms are new or different in comparison to their baseline.

The NIHSS is widely accepted as THE stroke severity scale, and it has many strengths and some pitfalls. The NIHSS was initially developed to be used in research, and, as mentioned here, was designed to be reproducible between various groups – physicians, nurses, research staff. Higher scores correlate with bigger infarct volume. The NIHSS is not an accurate scale in that it does not necessarily capture each patient’s deficits, omitting brain functions such as gait, distal limb dexterity, and cognition. It also scores higher for dominant (L) hemispheric functions as many points depend on language function.

When screening for large vessel occlusion, remember key brain structures and functions from the L MCA, R MCA, and posterior circulation. Looking for cortical signs can be very helpful to identify larger stroke syndromes: aphasia, neglect, gaze deviation, visual field deficit.

Last but not least, keep in mind that hemorrhagic strokes (intracerebral hemorrhage, subarachnoid hemorrhage) account for about 15% of all strokes. The same screening tools for acute neurologic symptoms can be used to identify these patients, though they more often have concurrent headache or LOC than ischemic strokes (due to increased ICP and irritation from blood products). For SAH, two scales are commonly used to describe the clinical and radiographic severities: Hunt-Hess (surgical risk index) and modified Fisher scales (risk index for developing vasospasm).

Fan Caprio, MD

Assistant Professor of Neurology (Stroke)

Department of Neurology

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Kaskar, S. Wleklinski, N. (2021, Oct 25). How to Talk Like a Neurologist. [NUEM Blog. Expert Commentary by Caprio, F]. Retrieved from http://www.nuemblog.com/blog/neuro-scores

C-Spine Intubation

Written by: Daniel Levine, MD (NUEM ‘24) Edited by: Zach Schmitz (NUEM ‘21) Expert Commentary by: Matt Levine, MD — **Written by:** Daniel Levine, MD (NUEM ‘24) **Edited by:** Zach Schmitz (NUEM ‘21)
**Expert Commentary by**: Matt Levine, MD

The “Evidence” Behind Manual In-Line Stabilization During Intubation of Trauma Patients

Background

Even in the absence of frank head and neck trauma that may cause bleeding or distortions in usual anatomy, trauma patients present challenging airways because of cervical spine precautions. Standard-of-care technique according to EAST (Eastern Association for the Surgery of Trauma), West (Western Trauma Association), and ATLS (Advanced Trauma Life Support) guidelines for intubating acute trauma patients with known or potential cervical spine injury involves manual in-line stabilization (MILS). (1,2) This is a two-person technique whereby one provider performs laryngoscopy while another holds the patient’s neck in place. The two most common techniques for this procedure are depicted below, one in which the stabilizer crouches down at the head of the bed (A), and the other where the stabilizer approaches from the side of the bed (B). (3)

(photo from Strange and Schafermeyer's Pediatric Emergency Medicine, 4th edition) (3)

Evidence

Like many practices in medicine, MILS has never been studied in randomized controlled trials, and the practice stems more from weak data and expert opinion. (4) The practice of spinal stabilization began during the 1970s after a retrospective review published in 1979 of 300 patients with acute cervical injuries who presented to Johns Hopkins hospital between 1950 and 1972. Although the main focus was on the effects of laminectomy and steroids, the review also found that 11 of the 300 patients developed neurologic deficits after reaching the hospital. Of the 11 patients, 7 developed these deficits “after neck immobilization was not provided”, with no clear comment as to whether immobilization was not provided during intubation or during some other process of the patient’s care. (5) These observations led to concerns that mobilization of the neck during intubation may worsen spinal cord injury, so manual in-line stabilization became standard of care in the 1980s.

Existing data for spinal stabilization comes from trials of cadaveric models, case series, and uninjured patients. Data from cadavers with post-mortem surgically created cervical spine injuries have shown mixed results on the effects of the amount of measured movement at the injured site with versus without MILS. For example, a 1993 study by Donaldson et al. found higher degrees of subluxation and angulation at C5-C6 during orotracheal intubation without MILS compared to with stabilization in five cadaveric specimens with injuries created in that area. (6) On the other hand, a 2001 Lennarson et al. study on cadavers found MILS significantly increased subluxation in C4-C5 during the same movements. (7) While it is somewhat counterintuitive that performing MILS might be associated with increased cervical motion, this may be explained by the laryngoscopist’s need to apply greater force with the laryngoscope in order to obtain an adequate view. This is what Santoni et al. (2009) found in a matched control study of 9 patients undergoing elective surgery. The patients in this study underwent two sequential laryngoscopies and oral intubations with a Macintosh 3 blade. Pressure transducers attached to the end of the blades detected higher maximum pressures at best glottic view with MILS compared to without. (8)

What is more clear in the literature on MILS than its effect on cervical motion is that it impairs glottic visualization and subsequent first pass intubation success. In the aforementioned Donaldson study on cadavers, MILS was shown to have a negative impact on Cormack-Lehane (CL) grade. (6) Similarly, in the aforementioned Santoni et al. study of 9 patients who underwent two sequential intubations with and without MILS, glottic visualization was worse in 6 patients with MILS, and intubation failure occurred in 2 of these 6 patients compared to no intubation failures among these patients when the intubation was performed without MILS. Thiboutot et al. (2008) performed a randomized controlled trial that further demonstrated this effect. In their study, 200 elective surgical patients were randomized to receive MILS or no MILS, and the primary endpoint was rate of failed intubation at 30 seconds with a Mac 3 blade. The rate of failed intubation was half in the MILS group (50%, 47/94), significantly higher compared to the control group (5.7%, 6/105). When they released manual in-line stabilization, they were able to intubate all patients. Secondary outcomes of rate of CL grade 3-4 as well as mean latency to successful intubation were also both significantly higher in the MILS group. (9) Additionally, these data were from patients undergoing elective surgery being intubated in the controlled OR setting by anesthesiologists. It is likely that the rate of failed intubation would be even higher in the chaotic emergency department environment with an acutely injured trauma patient. While 30 seconds is a somewhat arbitrary cutoff for a failed intubation, and it is quite possible many of the patients in the MILS group who “failed” may have been successfully intubated if a longer cut-off time were chosen, hypoxia caused by failed or delayed intubation is associated with poor outcome in central nervous system injury. (10)

Conclusion

In an ideal world, a large-scale randomized controlled trial of trauma patients studying the effects of MILS on mortality and important functional neurologic outcomes would help elucidate the utility of this commonly accepted practice. However realistically, completing such a study has significant obstacles. Cervical spine injuries are relatively rare (4% of trauma injured patients)4 and only a small fraction of those cases involve unstable injuries with potentially salvageable cord function. Thus, a study with sufficient power to detect any meaningful difference in outcomes would take many thousands of patients, many trauma centers, and many years to complete. Perhaps an even larger hurdle is the ethical and medicolegal hurdle of randomizing patients to not getting MILS and possibly putting them at risk of quadriplegia. (4) So what’s a clinician to do when faced with the common scenario of having to intubate a trauma patient? I personally like the approach that Dr. Reuben Strayer discusses in his video “Advanced Airway Management for the Emergency Physician” (link below). (11) To summarize his strategy:

Screen Shot 2021-10-17 at 10.22.17 AM.png

*The exception: in the rare situation where the patient has a highly suspected (e.g. obvious bony deformity, focal neurologic deficit) or known cervical spine injury, Dr. Strayer recommends lowering the threshold to perform a cricothyroidotomy. Additionally, he recommends considering an awake intubation approach in these patients.

Another consideration is intubating using a hyper-angulated video GlideScope, which has been shown to have improved CL views and high rates of intubation success in c-spine immobilized patients. (12) That said, occasionally equipment availability or a bloody airway may preclude the use of video laryngoscopy in the trauma setting.

References

Mayglothling J, Duane TM, Gibbs M, McCunn M, Legome E, Eastman AL, Whelan J, Shah KH; Eastern Association for the Surgery of Trauma. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4).
Brown CVR, Inaba K, Shatz DV, Moore EE, Ciesla D, Sava JA, Alam HB, Brasel K, Vercruysse G, Sperry JL, Rizzo AG, Martin M. Western Trauma Association critical decisions in trauma: airway management in adult trauma patients. Trauma Surg Acute Care Open. 2020 Oct 9;5(1)
Leonard, J et al. "Strange and Schafermeyer's Pediatric Emergency Medicine, 4th edition." Chapter 24: Cervical Spine Injury. https://doctorlib.info/pediatric/schafermeyers-pediatric-emergency-medicine/24.html, accessed 5/7/21.
Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med. 2007 Sep;50(3):236-45.
Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61:1119- 1142.
Donaldson WF 3rd, Towers JD, Doctor A, et al. A methodology to evaluate motion of the unstable spine during intubation techniques. Spine. 1993;18:2020-2023  
Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. J Neurosurg. 2001 Apr;94(2 Suppl):265-70.
Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31.
Thiboutot, F et al. Effect of manual in-line stabilization of the C-spine on the rate of difficult orotracheal intubation by direct laryngoscopy; a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8.
Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993 Feb;34(2):216-22.
“Advanced Airway Management for the Emergency Physician”, uploaded by Reuben Strayer, https://vimeo.com/12440392
Bathory I, Frascarolo P, Kern C, Schoettker P. Evaluation of the GlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar. Anaesthesia. 2009 Dec;64(12):1337-41.

Expert Commentary

So once again a review of a significant body of literature leaves a clinical question unanswered, leaving the practitioner to either follow dogma or make one’s own conclusions. Like most of our medical decision making, this is a risk/benefit analysis. So let’s go through the process.

Some background context to keep in mind:

Most cervical spine injury occurs from the initial traumatic event (primary neurologic injury). Secondary neurologic injury is a cascade of events at the cellular level that worsen primary injury and is exacerbated by hypoxia and hypercarbia, which are frequent events in difficult/prolonged intubations. These must be minimized when the brain or c spine are injured!

The movements of the cervical spine that occur during ED care pale in magnitude to the cervical spine motion that caused the primary injury to occur. These likely contribute less to neurologic outcome than secondary neurologic injury from other events during ED care like hypotension, hypoxia, and hypocarbia.

It’s too difficult to intubate with a collar on. It must be carefully and temporarily removed. As Dr. Levine taught us, MILS impairs glottic visualization and first pass intubation success. Dr. Levine also taught us that we don’t know whether the injured cervical spine actually moves less or more with MILS during intubation attempts.

The synthesis:

These factors all lead me to agree with Dr. Strayer’s approach. It is reasonable to minimize cervical spine motion as much as possible, but not at the expense of adequate glottic visualization. Maybe MILS helps minimize motion during intubation. But abandon MILS when glottic visualization is suboptimal because MILS can be contributing to this, leading to hypoxia, hypercarbia, and secondary neurologic injury. Practice MILS only until it is possibly prolonging airway success, because now it is more likely to be harming than helping.

Even more future questions remain. Much of the prior literature is based on use of traditional orotracheal intubation techniques. How much of that knowledge applies to the now widespread use of fiberoptic video intubations (i.e. Glidescope), which may have better first pass success rates and less neck motion? Do we even need to perform MILS for these intubations? Or can we reliably rapidly intubate with MILS and the Glidecope – so we can have our cake and eat it too?

Matthew Levine, MD

Associate Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Levine, D. Schmitz, Z. (2021, Oct 18). C-Spine. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/cervical-spine-intubation

Managing Minor Thermal Burns in the ED

Expert Commentary

Dr. Blenden and Dr. Karalius provided an excellent handy, high-yield, quick reference of thermal burn considerations in the ED. There are some nuances of thermal burn care that I’d like to provide further commentary:

A pitfall is underestimating the severity of the burn when the patient presents within a few hours of the event. Burn appearance evolves over 24-48 hours. What initially appears as erythematous skin can be covered in bullae the next day. Consider a repeat examination in 24-48 hours, or at least discuss with the patient the possibility that this may occur and what to do if it does. Otherwise, if you initially diagnosed the patient with superficial burns and provided only instructions for superficial burns, which require little treatment or follow-up, the patient can be set up for a worse outcome when these burns subsequently declare themselves to be partial thickness.
For years, most non-facial burns were sent home with instructions to use silver sulfadiazine (AKA Silvadene) cream. This would require teaching of how to apply and remove it. The cream needs to be removed daily before applying a new coat (I always sent the patient home with tongue blades to scrape it off). The benefits of this are that it debrides some nonviable tissue when the cream is removed and provides a moist antimicrobial barrier. The down sides are that removal can be painful and some patients have difficulty performing this procedure, which requires teaching. Silver sulfadiazine can also cause skin staining. There is scant evidence recommending one topical antimicrobial over another. For these reasons, practice (including mine) has evolved in many places to simply prescribe whatever antibiotic ointment is on hand for ease of use and less painful and technically challenging application.
Another controversy is whether to debride blisters and bullae or leave them intact. This is another area without definitive evidence and practice is often guided by gestalt, local custom, or prior teachings. On one hand, intact bullae can be thought of as “sterile” coverings and may be less painful than dermal layers exposed to air and friction. On the other hand, when bullae rupture, the patient is left with dead skin which can be a nidus for infection. My practice has been to leave small blisters intact and debride large bullae if it seems like they will soon rupture and leave the patient with hanging skin fragments. If the patient has reliable follow up burn care then I may choose a less aggressive approach in debriding. Other clinicians are likely to give alternate approaches so ask your attendings what they do in these scenarios so you can develop a practice pattern that makes sense to you.

Matthew Levine, MD

Associate Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Blenden, M. Karalius, V. (2021, Oct 18). Managing Minor Thermal Burns in the ED. [NUEM Blog. Expert Commentary by Levine, M]. Retrieved from http://www.nuemblog.com/blog/managing-minor-thermal-burns

SonoPro Tips and Tricks for Aortic Aneurysm and Dissection

Written by: John Li, MD (NUEM ‘24) Edited by: Andra Farcas, MD (NUEM ‘21) Expert Commentary by: John Bailitz, MD & Shawn Luo, MD (NUEM ‘22) — **Written by:** John Li, MD (NUEM ‘24) **Edited by:** Andra Farcas, MD (NUEM ‘21) **Expert Commentary by**: John Bailitz, MD & Shawn Luo, MD (NUEM ‘22)

SonoPro Tips and Tricks

Welcome to the NUEM Sono Pro Tips and Tricks Series where Sono Experts team up to take you scanning from good to great for a problem or procedure! For those new to the probe, we recommend first reviewing the basics in the incredible FOAMed Introduction to Bedside Ultrasound Book and 5 Minute Sono. Once you’ve got the basics beat, then read on to learn how to start scanning like a Pro!

Aortic ultrasound is a staple in emergency point of care ultrasound. It has incredible sensitivity (97.5-100%) and specificity (94.1-100%) in detecting abdominal aortic aneurysms and can provide a diagnosis for critically ill patients in seconds. [1-4] However, it can often be a technically difficult study for beginner sonographers due to shadowing bowel gas and patient body habitus. Follow along in this installment of our Sono Pro Tips and Tricks Series to become an expert in finding aortas!

Beyond the classic elderly male smoker with abdominal, flank, or back pain, what are other scenarios where you would use aortic ultrasound?

Older patients with limb ischemia - an aortic aneurysm can have atherosclerosis or a mural thrombus which can embolize and cause an arterial occlusion!
“But they fixed my aorta!” Aortic endograft leakage can sometimes present with symptoms that are similar to a AAA rupture, such as back pain, flank pain, or hemodynamic instability.

How to scan like a Pro

Always Start Smart: Aortic ultrasound can be tricky because of factors that seem out of our control, such as bowel gas or patient body habitus.

When scanning for an abdominal aortic aneurysm, start scanning in the epigastric region with a transverse view and apply constant pressure, gently pushing the bowel gas out of the way as you slide the probe down towards the patient’s feet.
Tell your patients to bend their knees! This relaxes the abdominal musculature and can help you move bowel gas or make better contact with the probe.

What if you still can’t see it? Try looking in the right upper quadrant view of the FAST exam!

Start with your probe in the right mix-axillary line and use the liver as your acoustic window. You may need to fan anteriorly or posteriorly depending on the patient’s body habitus and your positioning.
Unfortunately, this view predominantly visualizes the superior aspect of the abdominal aorta, and it can be difficult to visualize the inferior abdominal aorta or the bifurcation.

Here we are looking at a modified RUQ view, where the aorta is visualized on the bottom part of the screen using the liver as an acoustic window. (acep.org)

Pro Pickups!

What’s that weird aneurysm?
- Most people are familiar with the classic fusiform aortic aneurysm, but saccular aneurysms can be easily missed because of shadowing bowel gas obstructing parts of the aorta. Saccular aneurysms actually have a higher risk of rupture and repair is recommended for smaller diameters.

Here you can see two images in the longitudinal axis of the different kinds of abdominal aortic aneurysms. On the left is a saccular aneurysm and on the right is a fusiform one. Be sure to pay attention to the mural thrombus in the walls of both of these aortas - they can embolize and cause arterial occlusions! (med.emory.edu)

2. How big is that aorta anyways?

Be sure to always measure the aorta from outside wall to outside wall!
Many aortic aneurysms have a mural thrombus or intraluminal clot, and it can be very easy to mistake these for extra-luminal contents.
Remember the concerning numbers: >5.5cm for men and >5cm for women!

What the Pros Do Next

Abdominal Aortic Aneurysm

If the patient is hemodynamically unstable (defined as BP <90/60, altered mental status, or other signs of end-organ damage), go straight to the OR!
If the patient is hemodynamically stable (defined as the absence of any of the above), then the next step is to obtain further imaging, such as a CT Angiogram, which is the imaging gold standard.
- If you are concerned about a large AAA that could be a contained leak but the patient is hemodynamically stable, then we recommend an emergent vascular surgery consult
- If you find a small AAA (defined as <5cm in women or <5.5cm in men) that you do not think is actively contributing to the patient’s symptoms, then we recommend outpatient vascular surgery follow up

SonoPro Tips - Where to Learn More

Do you want to review more examples of pathologic images that you may see when you are doing an aortic ultrasound? Be sure to check out The Pocus Atlas by our expert editor Dr. Macias. Aortic pathology is quite rare, and going through these images will help immensely in recognizing this diagnosis in emergent situations. If you’re interested in looking at some of the evidence behind aortic ultrasound, be sure to check out the evidence atlas here as well.

References

Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013 Feb;20(2):128-38. doi: 10.1111/acem.12080. PMID: 23406071.
Hunter-Behrend, Michelle, and Laleh Gharahbaghian. “American College of Emergency Physicians.” ACEP // Home Page, 2016, www.acep.org/how-we-serve/sections/emergency-ultrasound/news/february-2016/tips-and-tricks-big-red---the-aorta-and-how-to-improve-your-image/.
Ma, John, et al. Ma and Mateer's Emergency Ultrasound. McGraw-Hill Education, 2020.
Mallin, Mike, and Matthew Dawson. Introduction to Bedside Ultrasound: Volume 1. Emergency Ultrasound Solutions, 2013.
Macias, Michael. TPA, www.thepocusatlas.com/.

Expert Commentary

Another great Sono Pro Post! Thank you John Li and Andra for helping everyone move from good to great when scanning for Abdominal Aortic Aneurysms. As noted, this application defines Emergency Ultrasound as a fast (pun intended), accurate, and life saving diagnostic tool for every EM physicians tool belt. When consistent probe pressure does not do the trick, consider the RUQ view for a quick look. Since most AAA’s are fusiform, this may quickly confirm your suspicions and prompt the call to get the OR ready. Be sure to visualize the entire abdominal aorta throughout in both short and long axis to identify saccular aneurysms and even the rare aortic occlusion!

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

Shawn Luo, MD

PGY4 Resident Physician

Northwestern University Emergency Medicine

How To Cite This Post:

[Peer-Reviewed, Web Publication] Li, J. Farcas, A. (2021 Oct 11). SonoPro Tips and Tricks for Aortic Aneurysm. [NUEM Blog. Expert Commentary by Bailitz, J. Shawn, L.]. Retrieved from http://www.nuemblog.com/blog/sonopro-tips-and-tricks-for-aortic-aneurysm

SonoPro Tips and Tricks for Pulmonary Embolism

Written by: Megan Chenworth, MD (NUEM ‘24) Edited by: Abiye Ibiebele, MD (NUEM ‘21) Expert Commentary by: John Bailitz, MD & Shawn Luo, MD (NUEM ‘22) — **Written by:** Megan Chenworth, MD (NUEM ‘24) **Edited by:** Abiye Ibiebele, MD (NUEM ‘21) **Expert Commentary by**: John Bailitz, MD & Shawn Luo, MD (NUEM ‘22)

SonoPro Tips and Tricks

Did you know that focused transthoracic cardiac ultrasound (FOCUS) can help identify PE in tachycardic or hypotensive patients? (It has been shown to have a sensitivity of 92% for PE in patients with an HR>100 or SBP<90, and approaches 100% sensitivity in patients with an HR>110 [1]). Have a hemodynamically stable patient with PE and wondering how to risk stratify? FOCUS can identify right heart strain better than biomarkers or CT [2].

Who to FOCUS on?

Patients presenting with chest pain or dyspnea without a clear explanation, or with a clinical concern for PE. The classic scenario is a patient with pleuritic chest pain with VTE risk factors such as recent travel or surgery, systemic hormones, unilateral leg swelling, personal or family history of blood clots, or known hypercoagulable state (cancer, pregnancy, rheumatologic conditions).
Patients presenting with unexplained tachycardia or dyspnea with VTE risk factors
Unstable patients with undifferentiated shock
When PE is suspected but CT is not feasible: such as when the patient is too hemodynamically unstable to be moved to the scanner, too morbidly obese to fit on the scanner, or in resource-limited settings where scanners aren’t available
1. One may argue AKI would be another example of when CT is not feasible (though there is some debate over the risk of true contrast nephropathy - that is a discussion for another blog post!)

How to scan like a Pro

Key is to have the patient as supine as possible - this may be difficult in truly dyspneic patients
If difficulty obtaining views arise, the left lateral decubitus position helps bring the heart closer to the chest wall

FOCUS on these findings

You only need one to indicate the presence of right heart strain (RHS).

Right ventricular dilation
Septal flattening: Highly specific for PE (93%) in patients with tachycardia (HR>100) or hypotension (SBP<90) [1]
Tricuspid valve regurgitation
McConnell’s sign
- Definition: Akinesis of mid free wall and hypercontractility of apical wall (example below)
- The most specific component of FOCUS: 99% specific for patients with HR>100bpm or SBP<90 [1]
Tricuspid annular plane systolic excursion (TAPSE)

The most sensitive single component of FOCUS: TASPE < 2cm is 88% sensitive for PE in tachycardic and hypotensive patients; 93% sensitive when HR > 110 [1]

Where to FOCUS

Apical 4 Chamber (A4C) view: your best shot at seeing it all

Find the A4C view in the 5th intercostal space in the midclavicular line
Optimize your image by sliding up or down rib spaces, sliding more lateral towards the anterior axillary line until you see the apex with the classic 4 chambers - if the TV and MV are out of the plane, rotate the probe until you can see both openings in the same image; if the apex is not in the middle of the screen, slide the probe until the apex is in the middle of the screen. If you are having difficulty with this view, position the patient in the left lateral decubitus.
Important findings:
1. RV dilation: the normal RV: LV ratio in diastole is 0.6:1. If the RV > LV, it is abnormal. (see in the image below)
2. Septal flattening/bowing is best seen in this view
3. McConnell’s sign: akinesis of the free wall with preserved apical contractility

McConnell’s Sign showing akinesis of the free wall with preserved apical contractility

4. Tricuspid regurgitation can be seen with color flow doppler when positioned over the tricuspid valve

Tricuspid regurgitation seen with color doppler flow

5. TAPSE

Only quantitative measurement in FOCUS, making it the least user-dependent measurement of right heart strain [3]
A quantitative measure of how well the RV is squeezing. RV squeeze normally causes the tricuspid annulus to move towards the apex.
Fan to bring the RV as close to the center of the screen as possible
Using M-mode, position the cursor over the lateral tricuspid annulus (as below)
Activate M-mode, obtaining an image as below
Measure from peak to trough of the tracing of the lateral tricuspid annulus
- Normal >2cm

Parasternal long axis (PSLA) view - a good second option if you can’t get A4C

Find the PSLA view in the 4th intercostal space along the sternal border
Optimize your image by sliding up, down, or move laterally through a rib space, by rocking your probe towards or away from the sternum, and by rotating your probe to get all aspects of the anatomy in the plane. The aortic valve and mitral valve should be in plane with each other.
Important findings:
1. RV dilation: the RV should be roughly the same size as the aorta and LA in this view with a 1:1:1 ratio. If RV>Ao/LA, this indicates RHS.
2. Septal flattening/bowing of the septum into the LV (though more likely seen in PSSA or A4C views)

Right heart strain demonstrated by right ventricle dilation

Parasternal Short Axis (PSSA) view: the second half of PSLA

Starting in the PSLA view, rotate your probe clockwise by 90 degrees to get PSSA

Optimize your image by fanning through the heart to find the papillary muscles - both papillary muscles should be in-plane - if they are not, rotate your probe to bring them both into view at the same time
Important findings:
1. Septal flattening/bowing: in PSSA, it is called the “D-sign”.

“D-sign” seen on parasternal short axis view. The LV looks like a “D” in this view, particularly in diastole.

Subxiphoid view: can add extra info to the FOCUS

Start just below the xiphoid process, pointing the probe up and towards the patient’s left shoulder
Optimize your image by sliding towards the patient’s right, using the liver as an echogenic window; rotate your probe so both MV and TV are in view in the same image
Important findings
1. Can see plethoric IVC if you fan down to IVC from RA (not part of FOCUS; it is sensitive but not specific to PE)

What to do next?

Sample algorithm for using FOCUS to assess patients with possible PE. *cannot completely rule out PE, but negative FOCUS makes PE less likely — Sample algorithm for using FOCUS to assess patients with possible PE.
*cannot completely rule out PE, but negative FOCUS makes PE less likely

Limitations to keep in mind:

FOCUS is great at finding heart strain, but the lack of right heart strain does not rule out a pulmonary embolism
1. Systematic review and meta-analysis concluded that the overall sensitivity of FOCUS for PE is 53% (95% CI 45-61%) for all-comers [5]
Total FOCUS exam requires adequate PSLA, PSSA, and A4C views – be careful when interpreting inadequate scans
Can see similar findings in chronic RHS (pHTN, RHF)
1. Global thickening of RV (>5mm) can help distinguish chronic from acute RHS
2. McConell’’s sign is also highly specific for acute RHS, whereas chronic RV failure typically appears globally akinetic/hypokinetic

SonoPro Tips - Where to Learn More

Right Heart Strain at 5-Minute Sono: http://5minsono.com/rhs/
Ultrasound GEL for Sono Evidence: https://www.ultrasoundgel.org/posts/EJHu_SYvE4oBT4igNHGBrg, https://www.ultrasoundgel.org/posts/OOWIk1H2dePzf_behpaf-Q
The Pocus Atlas for real examples: https://www.thepocusatlas.com/echocardiography-2
The Evidence Atlas for Sono Evidence: https://www.thepocusatlas.com/ea-echo

References

Daley JI, Dwyer KH, Grunwald Z, Shaw DL, Stone MB, Schick A, Vrablik M, Kennedy Hall M, Hall J, Liteplo AS, Haney RM, Hun N, Liu R, Moore CL. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. Acad Emerg Med. 2019 Nov;26(11):1211-1220. doi: 10.1111/acem.13774. Epub 2019 Sep 27. PMID: 31562679.
Weekes AJ, Thacker G, Troha D, Johnson AK, Chanler-Berat J, Norton HJ, Runyon M. Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism. Ann Emerg Med. 2016 Sep;68(3):277-91. doi: 10.1016/j.annemergmed.2016.01.027. Epub 2016 Mar 11. PMID: 26973178.
Kopecna D, Briongos S, Castillo H, Moreno C, Recio M, Navas P, Lobo JL, Alonso-Gomez A, Obieta-Fresnedo I, Fernández-Golfin C, Zamorano JL, Jiménez D; PROTECT investigators. Interobserver reliability of echocardiography for prognostication of normotensive patients with pulmonary embolism. Cardiovasc Ultrasound. 2014 Aug 4;12:29. doi: 10.1186/1476-7120-12-29. PMID: 25092465; PMCID: PMC4126908.
Hugues T, Gibelin PP. Assessment of right ventricular function using echocardiographic speckle tracking of the tricuspid annular motion: comparison with cardiac magnetic resonance. Echocardiography. 2012 Mar;29(3):375; author reply 376. doi: 10.1111/j.1540-8175.2011.01625_1.x. PMID: 22432648.
Fields JM, Davis J, Girson L, et al. Transthoracic echocardiography for diagnosing pulmonary embolism: a systematic review and meta‐analysis. J Am Soc Echocardiogr 2017;30:714–23.e4.

Expert Commentary

RV function is a frequently overlooked area on POCUS. Excellent post by Megan looking specifically at RV to identify hemodynamically significant PEs. We typically center our image around the LV, so pay particular attention to adjust your views so the RV is optimized. This may mean moving the footprint more laterally and angle more to the patient’s right on the A4C view. RV: LV ratio is often the first thing you will notice. When looking for a D-ring sign, make sure your PSSA is actually in the true short axis, as a diagonal cross-section may give you a false D-ring sign. TAPSE is a great surrogate for RV systolic function as RV contracts longitudinally. Many patients with pulmonary HTN or advanced chronic lung disease can have chronic RV failure, lack of global RV thickening. Lastly remember, that a positive McConnell’s sign is a great way to distinguish acute RHS from chronic RV failure.

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

Shawn Luo, MD

PGY4 Resident Physician

Northwestern University Emergency Medicine

How To Cite This Post:

[Peer-Reviewed, Web Publication] Chenworth, M. Ibiebele, A. (2021 Oct 4). SonoPro Tips and Tricks for Pulmonary Embolism. [NUEM Blog. Expert Commentary by Bailitz, J. Shawn, L.]. Retrieved from http://www.nuemblog.com/blog/sonopro-tips-and-tricks-for-pulmonary-embolism

SonoPro Tips and Tricks for Pneumothroax

**Written by:** Morgan McCarthy, MD (NUEM ‘24) **Edited by:** Jon Hung, MD (NUEM ‘21) **Expert Commentary by**: John Bailitz, MD & Shawn Luo, MD (NUEM ‘22)

SonoPro Tips and Tricks

Did you know that Lung Ultrasound (LUS) has a higher sensitivity than the traditional upright anteroposterior chest X-ray for the detection of a pneumothorax? (LUS has a reported 90.9 for sensitivity and 98.2 for specificity. CXR were 50.2 for sensitivity and 99.4 for specificity). Busy trauma bay? Ultrasound is faster than calling for X-ray. Critically ill patient? Small pneumothoraces are less likely to be missed with ultrasound. To take your Sono Skills to the next level, read on:

Beyond the classic trauma patient during your E-Fast Exam, who else does the Sono-Pros scan?

Primary spontaneous pneumothorax: the classic scenario is a tall, young adult, with symptoms such as breathlessness, along with potentially those with risk factors of pneumothoraxes such as smoking, male sex, family history of pneumothorax
Secondary spontaneous pneumothorax: those with underlying lung disease including but not limited to COPD, tuberculosis, necrotizing pneumonia, pneumonocystis carini, lung cancer, sarcoma involving the lung, sarcoidosis, endometriosis, cystic fibrosis, acute severe asthma, idiopathic pulmonary fibrosis
Of course, traumatic pneumothorax, especially in penetrating trauma or blunt trauma with broken ribs
Don’t forget iatrogenic causes of pneumothorax including transthoracic needle aspiration, subclavian vessel puncture, thoracentesis, pleural biopsy, and mechanical ventilation

SonoPro Tips - How to scan like a Pro

The key is to have the patient completely supine - air rises! - with the probe in the anterior field in sagittal orientation pointing towards the patient's head.
It is commonly taught to start at the second intercostal space, midclavicular line, and scan down a few lung spaces to at least the 4th intercostal space, however, keep in mind some studies show that trauma supine trauma patients had pneumothoraces seen more commonly in the 5-8 rib spaces.
Important Landmarks

Green = Subcutaneous tissue. Red = Pleural space. Blue = A - lines.

4. Look for lung sliding, improve your image by turning down gain and decrease depth to have lung sliding become clearer

What to Look For:

To Rule-Out a pneumothorax

Lung Sliding - Lung sliding has a negative predictive value of 100% for ruling out a pneumothorax, however only at that interspace
Additional Findings: B-lines and Z lines also help to rule out pneumothorax!

2. To Rule-In a pneumothorax

Lung point - the interface between where lung sliding is happening and where the absence of lung sliding is happening has been shown to have 100% specificity for pneumothorax.
Keep in mind the border of where the heart and lung come in contact and the border where the diaphragm and lung come in contact can cause a false lung point.
The lung point may be hard to find in a larger pneumothorax, and impossible to find in a completely collapsed lung.

3. Next turn on M-mode:

Sandy Beach Shore = Lung sliding (left). Barcode Sign = No lung sliding (right)

What to do next:

Lung sliding = sensitive, Lung point = specific
If you see lung sliding, there is no pneumothorax
If you do not see lung sliding it does not rule in a pneumothorax -> look for a lung point, the interface between where lung sliding is happening and where the absence of lung sliding is happening to rule it in
- Always keep in mind other causes that result in lack of lung sliding before management decisions take place!: atelectasis, main-stem intubation, adhesions, contusions, and arrest or apnea. Check out this great table from 5 - Min Sono.

4. If your patient is apneic or has a mainstem intubation look for lung pulse, when the heart beats if the parietal and visceral pleura are touching (no pneumothorax) it will show a pulse at the interfaces of the pleura

5. Sub-Q emphysema - Always look for E - lines. When there is subcutaneous air above the pleural line it creates a false pleural line above the actual pleural. You may also see B-lines obscuring the actual pleural line. This is most likely subcutaneous air and you can not interpret it for a pneumothorax.

SonoPro Tips - Where to Learn More

American College of Emergency Physicians. Emergency ultrasound imaging criteria compendium. Ann Emerg Med. 2006;48(4):487-510.
Ma, John, et al. Ma and Mateer's Emergency Ultrasound. McGraw-Hill Education, 2020.
Macias, Micheal. TPA, The Pocus Atlas.
Availa, Jacob. 5 minute Sono.
US G.E.L. Podcast
Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest. 2012;141(3):703-708.

Expert Commentary

Morgan went “beyond lung sliding” and dove deep into how to increase your sensitivity & specificity for PTX with POCUS. Supine is ideal to make PTX visible against the anterior chest wall, but if the patient cannot tolerate lying flat, look at the apical pleural superior to the clavicles. First, identify the true pleural line--it should be the bright line just deep to the ribs in your view. SQ emphysema may obscure the view or even mimic the pleura, although its outline is usually more hazy & irregular, a little pressure helps to move the SQ air out of the way can be helpful. Sliding? Great, PTX ruled out. But absent sliding does not automatically mean PTX. Make sure there is no B-line or “lung pulse”, as sometimes pleural adhesion or poor ventilation can cause absent sliding too. Most of the time you don’t need M-mode unless the movement is very subtle and you want to be extra sure. The lung point is pathognomonic for PTX, but don’t waste time digging around for it if the patient is unstable with a good clinical story for PTX > decompress instead!

John Bailitz, MD

Vice Chair for Academics, Department of Emergency Medicine

Professor of Emergency Medicine, Feinberg School of Medicine

Northwestern Memorial Hospital

Shawn Luo, MD

PGY4 Resident Physician

Northwestern University Emergency Medicine

How To Cite This Post:

[Peer-Reviewed, Web Publication] McCarthy, M. Hung J. (2021 Sept 20). SonoPro Tips and Tricks for Pneumothorax. [NUEM Blog. Expert Commentary by Bailitz, J. Shawn, L.]. Retrieved from http://www.nuemblog.com/blog/sonopro-tips-and-tricks-for-pneumothorax

Buprenorphine Use in the ED

Written by: Diana Halloran, MD (NUEM ‘24) Edited by: Sean Watts, MD (NUEM ‘22) Expert Commentary by: Quentin Reuter, MD (NUEM ‘18) — **Written by:** Diana Halloran, MD (NUEM ‘24) **Edited by:** Sean Watts, MD (NUEM ‘22) **Expert Commentary by**: Quentin Reuter, MD (NUEM ‘18)

The United States has been facing a debilitating opioid epidemic, which has been partially fueled by the over-prescription of these medications in the emergency department setting. In addition, the opioid epidemic has grown exponentially during the COVID-19 pandemic. More than 40 states have reported increases in opioid-related mortality, resulting in an increased burden on an already overstrained healthcare system. (1) Prescribing the medication Buprenorphine in the emergency department offers an opportunity to ameliorate these past faults and rising statistics.

The basics:

Buprenorphine, which goes by the trade name Subutex, works by acting as both a partial mu agonist and weak kappa antagonist on opiate receptors in the brain. (2) This mechanism of action enables buprenorphine to exert analgesic effects, as well as antagonistic effects when additional opiates are consumed. In addition, buprenorphine does not carry significant sedative effects, making respiratory depression extremely rare. (3) Buprenorphine is also safe in pregnancy – a 2016 meta-analysis found no difference in pregnant patients given methadone versus buprenorphine when assessing for congenital malformations. (4) The American College of Obstetrics & Gynecology has released a committee position statement, encouraging the use of buprenorphine in pregnant patients with opioid use disorder. (5)

How to prescribe:

While the DEA X-waiver is required to write a prescription for buprenorphine for addiction treatment, withdrawal, or detox, it is not required to order or administer a dose in the hospital or emergency department. (6) This exception, called the “three-day rule”, allows a patient to come to the emergency department for three consecutive days to obtain a dose of buprenorphine if found to be in opioid withdrawal. (7)

In order to dose buprenorphine in the emergency department, the patient must be in mild acute opioid withdrawal, with a Clinical Opiate Withdrawal Score (COWS) of at least 8. (8,9) Administration of buprenorphine should not occur if the patient does not appear to be clinically withdrawing, as administration in this setting could actually precipitate withdrawal.

Dosing: (10)

4mg of sublingual buprenorphine can be given initially, allowing 20-40 minutes for resolution of withdrawal symptoms with repeat dosing every 1-2 hours as needed. (10)
On Day 2, the patient’s response to Day 1 should be assessed. If the patient’s opioid withdrawal symptoms were controlled, the same dose can be continued. If not, the dose should be increased by 2-4mg. (10)
On Day 3, the patient’s response to Day 2 should be assessed. Again, if the patient’s withdrawal symptoms are controlled then the same dose can be continued. If not, the dose can be increased by 2-4mg for Day 3. (10)
After 3 days this dose should be continued for 3-7 days until steady-state levels are achieved (10)
Doses should be decreased by 2mg if the patient experiences opioid intoxication (10)

Use in the emergency department:

While buprenorphine and long-term treatment of opioid use disorder may seem confined to primary care physicians and psychiatrists, emergency medicine physicians have been shown to be successful providers for initiating buprenorphine treatment versus brief intervention and referral with a result of decreased self-reported illicit opioid use. (11) In addition, Dr. Gail D’Onofrio, chair of the Department of Emergency Medicine at Yale, found that emergency department initiated buprenorphine treatment was associated with the increased self-reported engagement of addiction treatment and reduced illicit opioid use within a two-month interval. (12) Increasing evidence demonstrates that the emergency department provides an opportunity to intervene on opioid use disorder, with more and more emergency medicine physicians becoming X-waiver certified.

References

Issue brief: Reports of increases in opioid and other drug-related overdose and other concerns during COVID pandemic. American Medical Association. https://www.ama-assn.org/system/files/2020-12/issue-brief-increases-in-opioid-related-overdose.pdf. Published December 9, 2020.
Wakhlu S. Buprenorphine: a review. J Opioid Manag. 2009 Jan-Feb;5(1):59-64. doi: 10.5055/jom.2009.0007.
Walsh SL, Preston KL, Stitzer ML, Cone EJ, Bigelow GE. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994 May;55(5):569-80. doi: 10.1038/clpt.1994.71.
Zedler BK, Mann AL, Kim MM, Amick HR, Joyce AR, Murrelle EL, Jones HE. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction. 2016 Dec;111(12):2115-2128. doi: 10.1111/add.13462.
Committee Opinion No. 711 Summary: Opioid Use and Opioid Use Disorder in Pregnancy. Obstetrics & Gynecology. 2017;130(2):488-489. doi:10.1097/aog.0000000000002229
Special Circumstances for Providing Buprenorphine. SAMHSA. https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines/special-circumstances. Published August 19, 2020.
Nagel L. Emergency Narcotic Addiction Treatment. https://www.deadiversion.usdoj.gov/pubs/advisories/emerg_treat.htm.
Wesson DR, Ling W. Clinical Opiate Withdrawal Scale. PsycTESTS Dataset. June 2003. doi:10.1037/t48752-000
D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
Dosing Guide For Optimal Management of Opioid Dependence. The National Alliance of Advocates for Buprenorphine Treatment.
D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. 2015;313(16):1636–1644. doi:10.1001/jama.2015.3474
D'Onofrio G, Chawarski MC, O'Connor PG, Pantalon MV, Busch SH, Owens PH, Hawk K, Bernstein SL, Fiellin DA. Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention. J Gen Intern Med. 2017 Jun;32(6):660-666. doi: 10.1007/s11606-017-3993-2.

Expert Commentary

Thanks to Dr. Halloran and Watts for providing an informative discussion on buprenorphine prescribing from the ED. Buprenorphine continues to emerge as the state of the art treatment strategy for opioid use disorder (OUD) and thus, developing a working knowledge for when and how to use it is essential.

While there is little doubt that the medical field fueled the opioid epidemic through the prescribing of pain medications, EM is often given a disproportionate amount of blame for the current situation. In 2012, EM prescriptions made up only 4.3% of all opioids in circulation (1). Furthermore, I anticipate our specialty will continue to lead the fight against the opioid epidemic as practices such as naloxone prescribing, education around safe injecting practices, reduction and optimization of opioid prescribing efforts, and buprenorphine initiation gain further traction in the ED.

Obtaining a DEA X is the first step to prescribing buprenorphine. In April of this year guidelines for the administration of buprenorphine were updated to allow practitioners to treat up to 30 patients at a time with no extra training (2). While these changes will likely expand buprenorphine prescribing from the ED, it is vital that we do not operate in a silo.

To effectively manage this complex patient cohort, a coherent system of addiction medicine services is vital. EDs must partner with local community resources to make rapid addiction medicine appointments available. Our department utilizes specially trained addiction care coordinators, nurses with extensive training in addiction medicine to help evaluate OUD patients and navigate the fractured array of outpatient services.

Prior to the implementation of our Medication for Opioid Use Disorder (MOUD) program, our clinicians had relatively little to offer patients that directly addressed their underlying addiction. While anecdotal, we believe that by utilizing MOUD, we have begun to rebuild trust between OUD patients and the medical system. A once generally negative relationship between OUD patients and our ED staff has been replaced with a hopeful rapport, confident that recovery for these patients is a distinct possibility. This therapeutic relationship continues to grow and we believe will lead to long-term sustained recovery for many of our OUD patients in the surrounding community.

References

Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. Am J Prev Med 2015;49:409-13.
Reuter Q, Smith G, McKinnon J, Varley J, Jouriles N, Seaberg D. Successful Medication for Opioid Use Disorder (MOUD) Program at a Community Hospital Emergency Department. Acad Emerg Med 2020.

Quentin Reuter, MD

Emergency Medicine Physician

Core Faculty at Summa Health

How To Cite This Post:

[Peer-Reviewed, Web Publication] Halloran D., Watts S. (2021, Sept 13). Buprenorphine Use in the ED. [NUEM Blog. Expert Commentary by Reuter Q.]. Retrieved from http://www.nuemblog.com/blog/buprenorphine

Basic Capnography Interpretation

Written by: Shawn Luo, MD (NUEM ‘22) Edited by: Matt McCauley, MD (NUEM ‘21) Expert Commentary by: N. Seth Trueger, MD, MPH — **Written by:** Shawn Luo, MD (NUEM ‘22) **Edited by:** Matt McCauley, MD (NUEM ‘21) **Expert Commentary by**: N. Seth Trueger, MD, MPH

Continuous waveform capnography has increasingly become the gold standard of ETT placement confirmation. However, capnography can provide additional valuable information, especially when managing critically ill or mechanically ventilated patients.

Normal Capnography

Phase I (inspiratory baseline) reflects inspired air, which is normally devoid of CO2.
Phase II (expiratory upstroke) is the transition between dead space to alveolar gas.
Phase III is the alveolar plateau. Traditionally, PCO2 of the last alveolar gas sampled at the airway opening is called the EtCO2. (normally 35-45 mmHg)
Phase 0 is the inspiratory downstroke, the beginning of the next inspiration

EtCO2 is only one component of capnography. Measured at the end-peak of each waveform, it reflects alveolar CO2 content and is affected by alveolar ventilation, pulmonary perfusion, and CO2 production.

Figure 2. Factors affecting ETCO2 (EMSWorld)

EtCO2 - PaCO2 Correlation

Correlating EtCO2 and PaCO2 can be problematic, but in general, PaCO2 is almost always HIGHER than EtCO2. Normally the difference should be 2-5mmHg but the PaCO2-EtCO2 gradient is often increased due to increased alveolar dead space (high V/Q ratio), such as low cardiac output, cardiac arrest, pulmonary embolism, high PEEP ventilation.

Important Patterns

Let’s go through a few cases and learn some of the important capnography waveforms to recognize

Case 1: Capnography with Advanced Airway

An elderly gentleman with a history of COPD, CAD & CKD gets rushed into the trauma bay with respiratory distress and altered mental status. You gave him a trial of BiPAP for a few minutes without improvement.

You swiftly tubed the patient. It was not the easiest view, but you advance the ETT hoping for the best. Upon attaching the BVM to bag the patient, you saw this on capnography:

Oops, the ETT is in the esophagus, as evidenced by the low-level EtCO2 that quickly tapers off.

2. You remove the ETT, bag the patient up, and try again with a bougie. Afterward, you see…

Figure 4. Capnography with ETT in right main bronchus (EMSWorld)

This suggests a problem with ETT position, most often in the right main bronchus. Notice the irregular plateau--the initial right lung ventilation, followed by CO2 escaping from the left lung. Beware that capnography can sometimes still appear normal despite the right main bronchus placement.

3. You pull back the ETT a few cm and the CXR now confirms the tip is now above the carina. The patient’s capnography now looks like this:

Figure 5. Capnography showing obstruction or bronchospasm (SketchyMedicine)

Almost looks normal but notice the “shark fin” appearance, this is due to delayed exhalation, often seen in airway obstruction and bronchospasms such as COPD or asthma exacerbation.

4. You suction the patient and administer several bronchodilator nebs. The waveform now looks more normal:

Figure 6. Capnography showing normal waveform (SketchyMedicine)

5. However, just as you were about to get back to the workstation to call the ICU, the monitor alarms and you see this:

Figure 7. Sudden loss of capnography waveform (SketchyMedical)

Noticing the ETT still in place with good chest rise, you quickly check for a pulse. There is none.

6. You holler, push the code button and start ACLS with a team of clinicians. With CPR in progress, you notice this capnography:

Figure 8. Capnography during CPR (SketchyMedicine)

Initially, your patient’s EtCO2 was only 7, after coaching the compressor and improving CPR techniques, it increased to 14.

You are also aware that EtCO2 at 20min of CPR has prognostic values. EtCO2 <10 mmHg at 20 minutes suggests little chance of achieving ROSC and can be used as an adjunctive data point in the decision to terminate resuscitation.

7. Fortunate for your patient, during the 3rd round of ACLS, you notice the following:

Figure 9. ROSC on capnography (emDOCs.net)

This sudden jump in EtCO2 suggests ROSC. You stop the CPR and confirm that the patient indeed has a pulse.

8. As you are putting in orders for post-resuscitation care, you notice this:

Figure 10. Asynchronous breathing on capnography (SketchyMedical)

This curare cleft comes from the patient inhaling in between ventilator-delivered breaths and is usually a sign of asynchronous breathing. However, in the post-arrest scenario, it is a positive prognostic sign as your patient is breathing spontaneously. You excitedly call your mom, I meant MICU, about the incredible save.

Case 2: Capnography with Non-intubated Patient

You just hung up the phone with MICU when EMS brings you a young woman with a heroin overdose. She already received some intranasal Narcan from EMS but per EMS report patient is becoming sleepy again.

She mumbles a little as you shout her name, and as you put an end-tidal nasal cannula on her, you saw this:

Figure 11. Hypoventilation on capnography (emDOCs.net)

Noticing the low respiratory rate and high EtCO2 value, you recognize this is hypoventilation.

2. But very soon she becomes even less responsive and the waveform changed again:

Figure 12. Airway obstruction on capnography (emDOCs.net)

The inconsistent, interrupted breaths suggest airway obstruction, while the segments without waveform suggest apnea. You have to act fast.

3. By then your nurse has already secured an IV, so you pushed some Narcan. However, in the heat of the moment, you gave the whole syringe. The patient quickly woke up crying and shaking.

Figure 13. Hyperventilating on capnography (emDOCs.net)

She was quite upset and hyperventilating. The waveform reveals a high respiratory rate and relatively low EtCO2.

As much as you are a little embarrassed by putting the patient into florid withdrawal, you know it could have been a lot worse. Walking away from the shift, you think about how many times capnography has assisted you during those critical moments. “Hey, perhaps we should buy a capnography instead of a baby monitor,” you ask your wife at dinner.

Additional Resources

This website provides a tutorial and quiz on some of the basic capnography waveforms.

References

American Heart Association. 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support. Circulation. 2019; 140(24). https://doi.org/10.1161/CIR.0000000000000732
Brit Long. Interpreting Waveform Capnography: Pearls and Pitfalls. emDOCs.net. www.emdocs.net/interpreting-waveform-capnography-pearls-and-pitfalls/, accessed May 12, 2020
Capnography.com, accessed May 12, 2020
Kodali BS. Capnography outside the operating rooms. Anesthesiology. 2013 Jan;118(1):192-201. PMID: 23221867.
Long, Koyfman & Vivirito. Capnography in the Emergency Department: A Review of Uses, Waveforms, and Limitations. Clinical Reviews in Emergency Medicine. 2017; 53(6). https://doi.org/10.1016/j.jemermed.2017.08.026
Nassar & Schmidt, Capnography During Critical Illness. CHEST. 2016; 249(2). https://doi.org/10.1378/chest.15-1369
Sketchymedicine.com/2016/08/waveform-capnography, accessed May 13, 2020
Wampler, D. A. Capnography as a Clinical Tool. EMS World. www.emsworld.com/article/10287447/capnography-clinical-tool. June 28, 2011. Accessed May 13, 2020

Expert Commentary

This is a nice review of many of the intermediate and qualitative uses of ETCO2 in the ED. For novices, I recommend a few basic places to start:

Confirmation of intubation. Color change is good but it’s just litmus paper and gets easily defeated by vomit. Also, in low output states, it may not pick up. Further, colorimetric capnographs require persistent change over 6 breaths, not just a single change. Waveform capnography uses mass spec or IR spec to detect CO2 molecules. There are so many uses, it’s good to have, I don’t see why some are resistant to use this better plastic adapter connected to the monitor vs the other, worse, plastic adapter.

a. The mistake I have seen here is assuming a lack of waveform is due to low cardiac output, ie there’s no waveform because the patient is being coded, not because of esophageal intubation. There is always *some* CO2 coming out if there is effective CPR; if there isn’t, the tube is in the wrong place. If you really don’t believe it, check with good VL but a flatline = esophagus.

2. Procedural sedation. There’s lots of good work and some debate about absolute or relative CO2 changes or qualitative waveform changes that might predict impending apnea, but for me, the best use is that I can just glance at the monitor for a second or two and see yes, the patient is breathing. No more staring at the chest debating whether I see chest rise, etc. It’s like supervising a junior trainee during laryngoscopy with VL: it’s anxiolysis for me.

a. Using ketamine? Chest movement or other signs of respiratory effort without ETCO2 waveform means laryngospasm. Jaw thrust, bag, succinylcholine (stop when better).

3. Cardiac arrest.

a. Quality of CPR. Higher number means more output. Can mean the compressor needs to fix their technique, or more often, is tiring out and needs a swap.

b. ROSC. There can be a big jump (eg from 15 to 40) when ROSC occurs. Very helpful.

c. Ending a code. 20 mins into a code, if it’s <10 during good CPR, the patient is unlikely to survive. I try to view this as confirming what we know – it’s time to end the code. The mistake here is to not end a code that should otherwise end because the ETCO2 is above 10; it doesn’t work like that, it’s a 1-way test.

4. Leak. One waveform shape I wanted to add that I find helpful: if the downstroke kinda dribbles down like a messy staircase, it’s a leak. Can be an incomplete connection (eg tubing to the vent) or the balloon is too empty or full.

Seth Trueger, MD, MPH

Assistant Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern University

How To Cite This Post:

[Peer-Reviewed, Web Publication] Luo, S., McCauley M. (2021, Sept 9). Basic Capnography Interpretation. [NUEM Blog. Expert Commentary by Trueger N.S]. Retrieved from http://www.nuemblog.com/blog/capnography

Droperidol

Expert Commentary

Thanks to Dr. Payne & Dr. Richardson for putting this together! I think this was well done, they’ve presented a concise overview of the safety and efficacy of droperidol.

There’s a lot of utility in droperidol. It’s great for nausea, migraines, and even as an adjunct for chronic pain. It’s also a very good choice for agitation. I use it most often for nausea. It’s been shown to be as effective as odansetron, and more effective than metoclopramide. Anecdotally, I find it works particularly well for gastroparesis and cannabinoid hyperemesis (with some low-concentration topical capsaicin cream), with less sedation than haloperidol. For migraines, it has been shown to be as effective as prochlorperazine. It works well for sedation in agitated patients as well; IV & IM it has a much faster onset than haloperidol, and so benzodiazepines typically do not have to be co-administered, reducing the level and duration of sedation and need for monitoring.

The black box warning significantly limited droperidol’s availability, such that many of our newer graduates have not had any first-hand clinical experience with the medication. If you’re not familiar with its use, don’t let the black box warning completely dissuade you. Subsequent studies looking at emergency department droperidol use have shown it to be safe, and that complications related to QT prolongation are rare in typical doses. As a rule of thumb, the dose of droperidol is about half of the dose of haloperidol for a given indication. For nausea, migraine, or other pain, I usually start with 0.625-2.5mg IV, twice that IM, and can repeat dosing if needed (my most common starting dose is 1.25mg IV). For agitation, usually 2.5-5mg IM, though up to 10mg IM has been shown likely to be safe. Although it is prudent to be cautious, I think the literature supports droperidol’s use at appropriate doses in otherwise healthy patients.

Matt O’Connor, MD

Emergency Medicine Physician

BerbeeWalsh Department of Emergency Medicine

University of Wisconsin Hospitals and Clinics

How To Cite This Post:

[Peer-Reviewed, Web Publication] Payne, A. Richardson, J. (2021, Aug 30). Droperidol. [NUEM Blog. Expert Commentary by O’Connor, M]. Retrieved from http://www.nuemblog.com/blog/droperidol

Awake Intubation

Expert Commentary

Awake intubation can sound imposing but simply means the patient is still breathing on their own. It is mostly just a matter of using topical lidocaine instead of paralyzing, and sedating the patient a bit to tolerate it. It will almost always require some sedation – ketamine procedural sedation works very well as the patient’s protective reflexes will be intact (until we topicalize) as will their respiratory drive.

It does not take long! Just spray lido instead of pushing NMBA. This is the key concept. If time is really a factor, I atomize the larynx, push ketamine, and then reload and spray more lidocaine as I do laryngoscopy; everything else is just like every other ED intubation.

Glycopyrrolate is nice but if it’s not handy, not worth a delay.

I find nebulizing doesn’t add much, mostly just gets the mouth. I still nebulize if I can get it set up quickly while prepping everything else (and it can help tolerate the atomizer).

Small touches of propofol might help relax the ketamine-sedated patient as well, including spontaneous/dissociated movements and tightly closed mouths. Dexmedetomidine might not be fast enough for ED intubations.

I usually use hyperangulated VL (eg Glidescope S3) – we are usually doing this for predicted difficult intubation, and now not optimizing intubating conditions. Fiberoptic requires a fair amount of skill and time. One of the main things that demystified awake intubation for me is it is a medication choice; it doesn’t always mean awake-fiber optic.

In non-COVID times, I would keep the nasal cannula on at 5-15lpm to keep the patient as oxygenated as possible, which is even better than during RSI because they’re still breathing, now with extra oxygen.

The paradox of awake intubation is that we take the patients we predict to be the most difficult anatomically, and then don’t optimize intubating conditions (no NMBA). Part of the beauty of awake intubation is that we also gain a ton of information even if unsuccessful without losing much; if I get a partial view in non-NMBA circumstances I can make a judgment call about proceeding to paralysis (ie RSI) or calling for help, etc.

Sedation-only or ketamine-only intubation can sound like a good idea but neither makes sense to me. It takes a lot of sedation to knock out protective airway reflexes to allow laryngoscopy, i.e. enough to impair respiratory drive. Topicalization is not hard with atomizers. Similarly, ketamine keeps the airway reflexes intact, which is why it is so safe for procedural sedation, so hard to imagine that laryngoscopy won’t be an issue.

Seth Trueger, MD, MPH

Assistant Professor of Emergency Medicine

Department of Emergency Medicine

Northwestern University

How To Cite This Post:

[Peer-Reviewed, Web Publication] Bigach, P. Whipple, T. (2021, Aug 20). Awake Intubation. [NUEM Blog. Expert Commentary by Trueger, S]. Retrieved from http://www.nuemblog.com/blog/awake-intubation

TPA in Frostbite

Written by: Patrick King, MD Edited by: Nery Porras, MD (NUEM ‘21) Expert Commentary by: Anne Lambert Wagner, MD

TPA in Frostbite

Figure 1. What we would like to avoid (Cline et al.)

It’s an early Saturday morning, and EMS brings in one of your ED’s regulars – a schizophrenic, undomiciled gentleman named Jack who finds occasional work as a day laborer. You walk to bed three to greet Jack who is uncomfortable and shivering while nursing collects vitals. His chief complaint is hand and foot pain. You listen to him speak, but you jump right into a cursory exam as he does – and your heart sinks when you see the icy hard, cyanotic, mottled digits across all four extremities. You wonder what else you might be able to offer in addition to the standard cold injury approach we are taught as emergency residents, and you recall that the What’s New in Emergency Medicine section of UpToDate just recognized growing evidence for yet another off-label use for tPA: severe frostbite.

As we head into the winter months, emergency physicians will continue to see frostbite wreck a significant level of morbidity on our most vulnerable patients – patients who are undomiciled, suffering from addictions or mental illness, and those with preexisting conditions that limit blood flow to extremities (Zafren and Crawford Mechem). This post will address the theory, evidence, and logistics behind tPA utilization in severe frostbite.

The proposed efficacy of tPA in frostbite is related to cold-induced thrombosis. Endothelial damage is sustained both as a direct result of cold-related injury and exacerbated by reperfusion injury during the period of rewarming. During rewarming, arachidonic acid cascades promote vasoconstriction, platelet aggregation, leukocyte sludging, and erythrostasis which further promote thrombosis throughout affected tissues. This process is compounded in instances of multiple freeze-thaw cycles (Cline et al).

Research on tPA in frostbite goes back years. In 2005, Twomey et al. demonstrated in an open-label study that technetium (Tc)-99m scintigraphy (i.e., nuclear bone scan) reliably predicts digits/limbs at risk for amputation. Historical control patients with no or minimal flow distal to radiographically identified “cutoff” points of ischemia on bone scans inevitably all required amputations. Untreated historical controls without flow cutoffs were more likely to retain digits. In contrast, 16 of 19 study patients with identified flow cutoffs responded to intra-arterial (IA) or intravenous (IV) tPA with an amputation rate of only 19% of at-risk digits. In 2017, Patel et al. showed a 15% amputation rate for severe frostbite in eight IA tPA patients compared to 77% in their control group.

Figure 2. Pre-tPA and Post-tPA using technetium (Tc)-99m scintigraphy bone scan (Twomey et al.)

While study results have been impressive in instances of small sample sizes such as the above, a paucity of evidence has prevented widespread utilization of tPA for frostbite use amongst emergency physicians. This year, however, What’s New In Emergency Medicine on UpToDate gave special attention to a 2020 systematic review of 16 studies by Lee and Higgins which wielded a sample size of 209 patients with 1109 digits at high amputation risk. The study, entitled “What Interventional Radiologists Need to Know About Managing Severe Frostbite”, ultimately demonstrated a 76% salvage rate amongst IA tPA (222 amputations amongst 926 digits) and 62% salvage rate in IV tPA (24 amputations amongst 63 patients). Importantly, the 16 studies are not randomized, though several such as Patel et al. and Twomey et al. utilize historical controls. There is also no direct comparison of IA vs. IV tPA, and for unclear reasons, the salvage rate for IA is in terms of digits salvaged out of those at risk while IV is expressed as a function of patients who required no amputations. Though there remains additional research to be done, UpToDate’s Frostbite authors Zafren and Crawford Mechem now give an overall grade 2C recommendation for tPA use in severe frostbite for patients otherwise at risk of life-altering amputations.

Figure 3. Grading severity of frostbite after rewarming (Cauchy et al.)

Figure 4. Grade 4 Frostbite, best seen in far right (Pandey et al.)

TPA utilization in frostbite is straightforward. UpToDate authors recommend tPA consideration for any patients with frostbite in multiple digits in a single limb, in multiple limbs, and/or in proximal limb segments who present within 24 hours of injury. The American Burn Association, which has its own guidelines (largely similar), recommends tPA for patients with cyanosis proximal to the distal phalanx after rewarming (i.e. grade 3 or 4). In more simple terms – injuries expected to be life-altering, as revealed following rapid rewarming, are likely to meet inclusion. Contraindications include general tPA contraindications as well as frostbite-specific considerations such as multiple freeze-thaw cycles which destroy tissue viability via repeated reperfusion injury as discussed previously. An additional frostbite-specific quandary with tPA use is the intoxicated frostbite patient, as substance abuse is a strong risk factor for frostbite, but intoxication can preclude tPA consent.

So you suspect you have a candidate – how do you proceed? Advice from UpToDate’s Zafren and Mechem is representative of many experts’ approaches. Early consultation with centers experienced in advanced frostbite therapeutics is recommended. General immediate frostbite care is undertaken on ED arrival, including 15-30 minutes rapid water bath rewarming at 37 to 39 degrees Celsius, at which point the tissue should change from hard and cold to more soft and pliable. Ensure adequate analgesia, as this rewarming process can be painful. Following rapid rewarming, the grade of frostbite can be assessed (fig. 2,3). Clinical suspicion is then confirmed via technetium (Tc)-99m scintigraphy (bone scan) or by angiography at centers with expertise in intra-arterial tPA use. Angiography is utilized only if IA administration is planned. UpToDate recommends IV tPA for most candidates given the ease of administration unless specific institutional protocol differs.

Specific UpToDate dosing regimen is as follows: “Give a bolus dose of 0.15 mg/kg over 15 minutes, followed by a continuous IV infusion of 0.15 mg/kg per hour for six hours. The maximum total dose is 100 mg. After tPA has been given, adjunct treatment can be started with IV heparin or subcutaneous (SC) enoxaparin. The dose of IV heparin is 500 to 1000 units/hour for six hours or targeted to maintain the partial thromboplastin time (PTT) at twice the control value. Enoxaparin can be given at the therapeutic dose (1 mg/kg SC).”

Additional research remains to be done on this topic. At this time, however, it is reasonable to give your patients – a hand – when it comes to severe frostbite. Consider tPA.

Expert Commentary

Background

Skin and soft tissue are readily susceptible to injury at either end of the temperature spectrum. With exposure to cold, unprotected tissues can readily become frostbitten and/or hypothermic (aka Frostnip); two distinct but often linked injuries. In the past, skin, limbs, and digits sustaining severe frostbite injury had predictable outcomes: sloughing or amputation. The only question was how long to wait to amputate. Essentially no progress was made in the treatment of frostbite until the early 1990’s when the development of a treatment protocol for frostbite patients was developed using thrombolytics to restore blood flow to damaged tissue.

Frostbite has two separate mechanisms to the injury itself. The initial insult is the cold injury that leads to direct cellular damage from the actual freezing of the tissues. Rewarming of the affected tissues leads to the second, a reperfusion injury resulting in patchy microvascular thrombosis and tissue death.

Frostbite Classification

First-degree frostbite: Superficial damage to the skin from tissue freezing with redness (erythema), some edema, hypersensitivity, and stinging pain.
Second-degree frostbite: Deeper damage to the skin with a hyperemic or pale appearance, significant edema with clear or serosanguinous fluid-filled blisters, and severe pain. Frostnip, first and second-degree frostbite will generally heal without significant tissue loss.
Third-degree frostbite: Deep damage to the skin and subcutaneous tissue. Cold, pale, and insensate without a lot of tissue edema. Shortly after rewarming, edema rapidly forms along with the presentation of hemorrhagic blisters. Significant pain often occurs after rewarming.
Fourth-degree frostbite: All the elements of a third-degree injury with evidence of damage extending to the muscle, tendon, and bone of the affected area.

Figure 2. 1st and 2nd degree frostbite (left), 3rd and 4th degree frostbite (right)

Pre-hospital or Emergency Department Management

Determining the extent of frostbite injury starts with a detailed history regarding how the affected area appeared on presentation.
The history of a cold, white, and insensate extremity on presentation is consistent with severe frostbite injury (3rd and/or 4th-degree frostbite).
A severe frostbite injury requires emergent therapy with thrombolytics unless the patient meets one of the exclusion criteria.
If in question regarding the depth of the injury, a clinical exam can be supported by a vascular study as indicated. A digital Doppler exam is a simple and quick modality to further Clarify the diagnosis of severe frostbite.
Complete a primary survey to rule out any traumatic injuries.
Correct hypothermia (warm room, remove wet clothing & jewelry, warmed fluids, etc.)
If there are areas of frozen tissue rapid rewarming is preferred (see next section, rapid rewarming is associated with the best outcomes and salvage rates. However, never thaw until the risk of re-freezing has been eliminated. Patients undergoing freeze-thaw cycles do not respond to thrombolytics and are treated with standard supportive frostbite therapy.
Protect affected areas from further trauma with padding, splinting, and immobilization while transporting.
Keep the patient non-weight bearing to avoid incurring additional injury to frozen tissue (ice crystals) and/or disrupting blisters.
Elevate the affected extremities when able to decrease tissue edema.
Obtain a large-bore peripheral IV & start warmed fluids. Most patients will present with dehydration secondary to hypothermia and/or intoxication.
Avoid direct radiant heat to prevent iatrogenic burns to the cold tissue.
Update the patient’s tetanus status
Expect the patient to have increasing pain as the involved tissue is rapidly rewarmed. Pain management should include scheduled Ibuprofen (800 mg if no contraindication) to block the arachidonic cascade, gabapentin (nerve pain), and narcotics as needed.

Figure 4. Rewarming — Figure 3. Rewarming

Rapid rewarming

Circulating water bath when able. Put each affected area in its own water bath to avoid the tissue “knocking” against each other.

Document start & completion time

Try to keep the water temp at 104 ºF (40º C)
It will take 30-45 min for a hand or foot
If the patient has boots, socks, gloves, etc frozen to the skin do not force off. Submerge the entire area as part of the rapid rewarming process
Continue until frostbitten limb becomes flushed red or purple, and tissue soft and pliable to gentle touch

Air Dry

Avoid any aggressive manipulation to decrease tissue loss and injury
Elevate the affected areas to decrease swelling
Dress the affected areas with bulky padded dressings for transfer to avoid trauma to the areas
Avoid rewarming with a direct heat source (heat lamp, warm IV bag, etc.). This will lead to a thermal injury secondary to the lack of blood flow.

Rewarming will be associated with:

A return of sensation, movement, and possible initial flushing of the skin. The vessels in the case of severe frostbite (3rd or 4th degree) quickly become thrombotic (<20 minutes) with mottling or demarcation, however, the demarcation may be subtle at first and requires careful observation.
In the case that the tissues return fully to a normal color and palpable pulses or Doppler digital signals are present, the patient may not need any further intervention other than close observation (inpatient or daily visits in the clinic) and pain management.
If any question exists, an urgent triple-phase bone scan can support perfusion to the affected area.

Figure 4. Early evidence of demarcation and patchy thrombosis

Indications for Thrombolytics

Patient presenting with frozen tissue (severe frostbite, 3rd and/or 4th degree)
Absent or weak Doppler pulses following rewarming
Clinical exam consistent with severe frostbite
< 24 hours of warm ischemia time (time from rewarming)
Time matters significantly. For each hour after rewarming delaying the start of thrombolytics decreased salvage rates even by 28.1%.
With correct training after discussion with a burn center that does a lot of frostbite care, thrombolytics can be safely started at the outside hospital prior to transfer to the center.

Frostbite Thrombolytic Protocol

Examine for any associated injuries or illnesses. If any question of injury the patient will require a head, chest, and abdominal CT to rule out any sources of bleeding.
The dosing of the thrombolytic requires an actual weight and while infusing the thrombolytic requires ICU status and monitoring for 24 hours.
Following completion of the therapy, the patient will immediately be started on treatment dose Enoxaparin for 1-2 weeks.

Figure 5. Patient before and after receiving thrombolytics

Contraindications to the Thrombolytic Protocol

Absolute contraindications:

> 24 hours of warm ischemia time
Repeated freeze/thaw cycles
Concurrent or recent (within 1 month) intracranial hemorrhage, subarachnoid hemorrhage or trauma with active bleeding
Inability to consistently follow a neurologic exam (eg. intubated and sedated, significant dementia)
Severe uncontrollable hypertension

Relative contraindications:

History of GI bleed or stroke within 6 mo.
Recent intracranial or intraspinal surgery or serious head trauma within 3 months
Pregnancy

Figure 6. Clinical guide for the management of frostbite

Frostbite Take-Home Points

Rapid rewarming of frozen tissue in a circulating water bath is the preferred method of rewarming.
Patients that have undergone trauma in conjunction with the frostbite injury are not an absolute contraindication to receiving tPA.
Starting tPA at the outside hospital, prior to transport, results in significantly improved outcomes even compared to those that receive it at UCH.
Frostbite patients, regardless of whether or not they get thrombolytics, do better at a center that has experience and protocols to take care of frostbite.

Anne Lambert Wagner, MD, FACS

Associate Professor

University of Colorado

Medical Director

Burn & Frostbite Center at UC Health

How To Cite This Post…

[Peer-Reviewed, Web Publication] King, P. Porras, N. (2021, Aug 16). TPA in Frostbite. [NUEM Blog. Expert Commentary by Lamber Wagner, A]. Retrieved from http://www.nuemblog.com/blog/TPA-in-frostbite.

Hanging Injuries

Written by: Vytas Karalius, MD, MPH (NUEM ‘22) Edited by: Nery Porras, MD (NUEM ‘21) Expert Commentary by: Kevin Emmerich, MD, MS — **Written by:** Vytas Karalius, MD, MPH (NUEM ‘22) **Edited by:** Nery Porras, MD (NUEM ‘21) **Expert Commentary by**: Kevin Emmerich, MD, MS

Today’s post was inspired by the near-hanging of young gentleman who ended up passing away due to complications related to his near-hanging. His parents decided to donate his organs to Gift of Hope, allowing the passing of his life to extend the lives of others. While we hope to never see cases like these, they are an inevitable part of our job as emergency medicine physicians. As with most rare and complex pathology, preparation and knowledge can help us with the management of these cases when things often get chaotic. Lastly, as emergency medicine physicians who see the sequelae of mental illness daily in their EDs, I encourage us all to advocate for better funding and access to mental health care in the United States.

Hanging Injury

Terms/Classification [1]

“Hanging” is used to describe a death from a form of strangulation that involves hanging from the neck.
“Near-hanging” is a term for patients who have survived an attempted hanging (or at least long enough to reach the hospital).
“Complete hanging” defines when a patient’s legs are fully suspended off the ground and the patient's bodyweight is fully suspended by the neck.
“Incomplete hanging” defines when some part of the patient’s body is still on the ground and the body's full weight is not suspended off the ground.
“Judicial hanging” classically refers to victims who fell at least the height of their body.

Epidemiology:

Hanging is the 2nd most common form of successful suicide in the US after firearms
Accounts for 23% of >34,500 suicides in 2007
In the jail system, hanging is the most common form of successful suicide
Increasing incidence in US
Risk Factors: male, aged 15-44 years, history of drug or alcohol abuse, history of psychiatric illness

Pathophysiology of Injury:

Spine/Spinal Cord:

When the drop is greater than or equal to the height of the victim, as in a judicial hanging, there will almost always be cervical spine injury.
The head hyperextends, leading to fracture of the upper cervical spine ("hangman's fracture” of C2) and transection of the spinal cord.
Cervical injuries are in non-judicial hangings are rare. [2] One retrospective case review of near-hangings over a 10-year period found the incidence of cervical spine fracture to be as low as 5%. [3]

Vascular:

The major pathologic mechanism of death in hanging/strangulation is neck vessel occlusion, not airway obstruction. [1,4]
Death ultimately results from cerebral hypoxia and global ischemia.
There are two mechanisms by which this happens:
- Venous: The most implicated cause of death is actually venous obstruction. Jugular veins are superficial and easily compressible. Obstruction of venous outflow from the brain leads to stagnant hypoxia and loss of consciousness in as little as 15 seconds.
- Arterial: The risk of damage to the major arterial blood flow to the brain (such as carotid artery dissection) is rare, but should suspected in patients. [4]

Cardiac:

Carotid body reflex-mediated cardiac dysrhythmias are reported, and likely a minor mechanism of death.

Pulmonary:

Airway compromise plays less of a role in the immediate death of complete hanging/strangulation. However, it is a major cause of delayed mortality in near-hanging victims. [1,4]
Significant pulmonary edema occurs through two mechanisms:
- Neurogenic: centrally mediated, massive sympathetic discharge; often in association with serious brain injury and a poor prognostic implication.
- Post-obstructive: strangulation causes marked negative intrapleural pressure, generated by forceful inspiratory effort against extra-thoracic obstruction; when the obstruction is removed, there is a rapid onset pulmonary edema leading to ARDS.
Aspiration pneumonia later sequela of near-hanging injury.
Airway edema from mechanical trauma to the airway, which can make intubation difficult.
Tracheal stenosis can develop later in the hospital course.

Other Injuries:

Hyoid bone fracture
Cricoid or thyroid cartilage injury [5]

Physical Examination:

"Ligature marks" or abrasions, lacerations, contusions, bruising, edema of the neck
Tardieu spots of the eyes
Severe pain on gentle palpation of the larynx (laryngeal fracture)
Respiratory signs: cough, stridor, dysphonia/muffled voice, aphonia
Varying levels of respiratory distress
Hypoxia
Mental status changes

Early Management/Stabilization:

ABCs as always
Early endotracheal intubation may become necessary with little warning.
Patients who are unconscious or have symptoms such as odynophagia, hoarseness, neurologic changes, or dyspnea require aggressive airway management.
If ETI unsuccessful, consider cricothyroidotomy; if unsuccessful, percutaneous trans-laryngeal ventilation may be used temporarily.
Judicious and cautious fluid resuscitation - avoid large fluid volume resuscitation and consider early pressors, as fluids increases the risk/severity of ARDS and cerebral edema.
Monitor for cardiac arrhythmias.
The altered/comatose patient should be assumed to have cerebral edema with elevated ICP.

Imaging/Further Testing:

Chest radiograph
CT brain
CT C-spine
CTA head/neck
Can consider soft-tissue neck x-ray, if CT not immediately available

Further Management:

In patients with signs of hanging/strangulation, there should be a low threshold to obtain diagnostic imaging/testing as discussed above.
Expect pulmonary complications early.
- They are a major cause of delayed mortality in near-hanging victims, as stated above.
Early intubation and airway management are important.
Non-intubated patients with pulmonary edema may benefit from positive end-expiratory pressure ventilation.
Patients with symptoms of laryngeal or tracheal injury (e.g. dyspnea, dysphonia, aphonia, or odynophagia), should undergo laryngobronchoscopy with ENT. [4,6]
Tracheal stenosis has been reported during the hospital course. Address cerebral edema from anoxic brain injury, using strategies to reduce intracranial pressure or seizure prophylaxis. [4]
Address vascular complications seen on CTA and coordinate intervention with the appropriate specialty at your institution.
Therapeutic Hypothermia
- There is some evidence for therapeutic hypothermia in those with cardiac arrest from hanging injury [7,8] and those who are comatose from hanging injury. [9-11] While the evidence is weak, in the absence of better evidence, it is reasonable to consider hypothermia treatment in all comatose near-hanging victims. [1,12,13]
When suicide is suspected, evaluate patients for other methods of self-harm (e.g. wrist lacerations, self-stabbing, ingestions). It is also important to consider drug and alcohol intoxication. [4]

Disposition:

Admit critically ill patients to the appropriate ICU-level care.
Admit patients with abnormal radiologic or endoscopic imaging to the appropriate service and level of care.
Even if the initial presentation is clinically benign, all near-hanging victims should be observed for 24 hours, given the high risk of delayed neurologic, airway and pulmonary complications. [14]
Observe asymptomatic patients with normal imaging.
Psychiatry/Crisis Team consult on all suspected intentional cases.
Emphasize strict return precautions as well as education about possible delayed respiratory and neurologic dysfunction when discharging patients.
Some patients may require transfer to a trauma center if the required services are not available at the initial receiving facility. [1]

Prognostication:

GCS 3/GCS 3T is a predictor of very poor outcome, [15-19] but there is mixed evidence on the GCS as a predictor of outcomes in GCS scores greater than 3, especially with regard to neurologic intactness. [3,19]
Recovery of patients with neurology symptoms is unpredictable. [4]
Patients presenting with cardiac arrest have a very poor prognosis, and might be the strongest predictor of poor prognosis. [4,8,16,18,20]
Other predictors of poor clinical outcome include:
- Anoxic brain injury or cerebral edema on head CT [3,19]
- Prolonged hanging time [18]
- Cardiopulmonary arrest [8,11,19]
- Cervical spine injury
- Hypotension on arrival

Expert Commentary

We’ve all certainly been involved with a patient with reported hanging injury at some point in our time in the ED. They are usually unimpressive if a person does it as more of a gesture rather than a true suicide attempt. When they are unfortunately done “correctly,” they usually result in a trip to the morgue instead of the ED. When the swiss cheese holes align and a true hanging attempt results in a serious but not fatal presentation, things can get quite hairy. I’ve been a part of one such case, and will never forget it. Here are my two cents.

Airway

This should undoubtedly be treated as a predicted difficult airway, not only due to likely cervical spine trauma, but also possibly due to airway edema. Get your ducks in a row for this unless this patient is crashing in front of you. Get your consultants/help (if available), preoxygenate, airway adjuncts open and ready, backup airway supplies if your first plan fails. Most importantly, have a plan and discuss this with your team beforehand. Don’t be afraid to take an awake look with a hyperangulated video laryngoscope, especially if this patient presents with stridor. Ketamine can be your friend here. This should be an airway that you do not undertake without a scalpel, finger, and bougie ready just in case. I like to draw a line on the patient’s skin overlying the cricothyroid membrane beforehand.

Trauma

Self explanatory, but don’t be stingy here. Light this patient up from head to pelvis, including the neck angiogram. Document a repeat neuro exam every time you move this patient.

Overdose/psych

Don’t forget your Tylenol and salicylate levels, EKG in this suicide attempt. If you feel the need to add the useless urine drug screen, I suppose this is fine as well.

Kevin Emmerich, MD, MS

Emergency Medicine Physician

Methodist Hospital

Gary, Indiana

How To Cite This Post:

[Peer-Reviewed, Web Publication] Karalius, V. Porras, N. (2021, Aug 9). Hanging Injuries. [NUEM Blog. Expert Commentary by Emmerich, K]. Retrieved from http://www.nuemblog.com/blog/hanging-emergencies

References

1. Walls RM, Hockberger RS, Gausche-Hill M. Rosen's emergency medicine : concepts and clinical practice. Ninth edition. ed. Philadelphia, PA: Elsevier; 2018.

2. Aufderheide TP, Aprahamian C, Mateer JR, et al. Emergency airway management in hanging victims. Ann Emerg Med. 1994;24(5):879-884.

3. Salim A, Martin M, Sangthong B, Brown C, Rhee P, Demetriades D. Near-hanging injuries: a 10-year experience. Injury. 2006;37(5):435-439.

4. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM. Tintinalli's emergency medicine: a comprehensive study guide. 9th. ed. New York: McGraw-Hill Education; 2019.

5. Tugaleva E, Gorassini DR, Shkrum MJ. Retrospective Analysis of Hanging Deaths in Ontario. J Forensic Sci. 2016;61(6):1498-1507.

6. Hackett AM, Kitsko DJ. Evaluation and management of pediatric near-hanging injury. Int J Pediatr Otorhinolaryngol. 2013;77(11):1899-1901.

7. Hsu CH, Haac B, McQuillan KA, Tisherman SA, Scalea TM, Stein DM. Outcome of suicidal hanging patients and the role of targeted temperature management in hanging-induced cardiac arrest. J Trauma Acute Care Surg. 2017;82(2):387-391.

8. Kim MJ, Yoon YS, Park JM, et al. Neurologic outcome of comatose survivors after hanging: a retrospective multicenter study. Am J Emerg Med. 2016;34(8):1467-1472.

9. Jehle D, Meyer M, Gemme S. Beneficial response to mild therapeutic hypothermia for comatose survivors of near-hanging. Am J Emerg Med. 2010;28(3):390.e391-393.

10. Lee BK, Jeung KW, Lee HY, Lim JH. Outcomes of therapeutic hypothermia in unconscious patients after near-hanging. Emerg Med J. 2012;29(9):748-752.

11. Hsu CH, Haac BE, Drake M, et al. EAST Multicenter Trial on targeted temperature management for hanging-induced cardiac arrest. J Trauma Acute Care Surg. 2018;85(1):37-47.

12. Borgquist O, Friberg H. Therapeutic hypothermia for comatose survivors after near-hanging-a retrospective analysis. Resuscitation. 2009;80(2):210-212.

13. Sadaka F, Wood MP, Cox M. Therapeutic hypothermia for a comatose survivor of near-hanging. Am J Emerg Med. 2012;30(1):251.e251-252.

14. McHugh TP, Stout M. Near-hanging injury. Ann Emerg Med. 1983;12(12):774-776.

15. Kao CL, Hsu IL. Predictors of functional outcome after hanging injury. Chin J Traumatol. 2018;21(2):84-87.

16. La Count S, Lovett ME, Zhao S, et al. Factors Associated With Poor Outcome in Pediatric Near-Hanging Injuries. J Emerg Med. 2019;57(1):21-28.

17. Martin MJ, Weng J, Demetriades D, Salim A. Patterns of injury and functional outcome after hanging: analysis of the National Trauma Data Bank. Am J Surg. 2005;190(6):836-840.

18. Matsuyama T, Okuchi K, Seki T, Murao Y. Prognostic factors in hanging injuries. Am J Emerg Med. 2004;22(3):207-210.

19. Nichols SD, McCarthy MC, Ekeh AP, Woods RJ, Walusimbi MS, Saxe JM. Outcome of cervical near-hanging injuries. J Trauma. 2009;66(1):174-178.

20. Gantois G, Parmentier-Decrucq E, Duburcq T, Favory R, Mathieu D, Poissy J. Prognosis at 6 and 12months after self-attempted hanging. Am J Emerg Med. 2017;35(11):1672-1676.

Posted on August 9, 2021 by NUEM Blog and filed under Airway, Critical care, Trauma and tagged trauma difficult airway psychiatry hanging strangulation.

Scalpel Finger Bougie

Expert Commentary

Establishing an airway via a cricothyroidotomy is a stressful and tense experience. In almost all of these cases, experienced airway staff have already attempted advanced airway maneuvers in patients typically at high risk for inability to intubate. As the oxygen saturation drops and the patient becomes unstable, the most adept proceduralist present (whether emergency department physicians or surgeons) are asked to step in to secure a surgical airway.

The scalpel-finger-bougie technique is one proven and reliable method to secure a surgical airway via a cricothyroidotomy. Some additions to the technique described above are:

Use a vertical incision through the skin and soft tissues. If you are too superior or inferior with your initial incision, then this incision can be easily extended as needed. A horizontal incision commits you to that cranial-caudal level. It is often more of a struggle to identify the cranial-caudal orientation of the cricothyroid membrane rather than the medial-lateral orientation.
In a patient with a stable and flexible neck, retract the neck via cranial pressure on the chin to bring the neck structures better into your working field. Insert a shoulder roll if available (unlikely) to augment this positioning.
After the tube is advanced, listen for bilateral breath sounds. It is common, in this adrenaline fueled procedure, to advance the endotracheal tube too far, leading to a right main stem intubation. This can limit your ventilation and oxygenation and can lead to confusion about the airway placement in the neck. If there are no left lung field breath sounds, then pull the tube back until bilateral breath sounds are confirmed with auscultation.
Always verify tube placement with capnography.
Persistent, moderate volume bleeding is often from injury to the anterior jugular vein. Gentle, directed pressure on the area can control this bleeding while the patient is being transported to the operating room for a more definitive airway.

Joseph Posluszny, MD

Assistant Professor of Surgery (Trauma and Critical Care)

Northwestern Memorial Hospital

How To Cite This Post:

[Peer-Reviewed, Web Publication] Wessling, E. Whipple, T. (2021, Aug 2). Scalpel Finger Bougie. [NUEM Blog. Expert Commentary by Posluszny, J]. Retrieved from http://www.nuemblog.com/blog/scalpel-finger-bougie

Seasonal Influenza

Expert Commentary

Thank you for the concise and informative resource guide. Don’t we all yearn for the days when patients with myalgias and fever were typically diagnosed with influenza and sent on their merry way? Believe it or not, there are some interns who may go their entire first winter as physicians without diagnosing influenza.

A large part of our jobs as emergency medicine physicians is reassurance. Patients want to know they are okay, but they always want something to make them feel better faster, which is true for influenza as well as coronavirus. And while most young, healthy patients do not need treatment for influenza, another consideration is time lost from work, even though symptom duration is really only decreased by one day. However, for some individuals, those one to two days of work may be essential, in which case, a prescription should be considered if the patient presents within 48 hours of symptom onset. For all other healthy adults, I discuss the side effects of the medication. Evidence from a Cochrane Review published in 2014 suggests that in healthy adults, the risks of side effects including nausea, vomiting, headaches and psychiatric symptoms likely outweighs any benefit, which again, does NOT include decreased hospitalizations rates or complications. I usually frame it as “yes, your flu symptoms may get better about 16 hours sooner, but you may also have nausea, vomiting and headaches.” Most people, in my experience, will then pass on a prescription for Tamiflu.

Screening for chronic medical conditions, pregnancy, high risk household members is essential in knowing which patients require treatment. High level athletes is another patient population where treatment may be considered to allow them to get back to training faster but also to minimize spread to the rest of the team.

Visits for influenza are also a great time to discuss vaccination with patients, especially during the current pandemic. Emphasis should be placed on how vaccines prevent life threatening complications from influenza and diminish symptom severity. This is a perfect time for vaccine education to hopefully prevent future pandemics.

References

Jefferson T et al. Oseltamivir for Influenza in Adults and Children: Systematic Review of Clinical Study Reports and Summary of Regulatory Comments. BMJ 2014. PMID: 24811411.

Gabrielle Ahlzadeh, MD

Clinical Assistant Professor of Emergency Medicine

University of Southern California

How To Cite This Post:

[Peer-Reviewed, Web Publication] Wedel, L. (2021, May 17). Seasonal Influenza. [NUEM Blog. Expert Commentary by Ahlzadeh, G]. Retrieved from http://www.nuemblog.com/blog/seasonal-influenza

Cocaine Chest Pain

Written by: Maren Leibowitz, MD (NUEM ‘23) Edited by: Zach Schmitz, MD (NUEM ‘21) Expert Commentary by: David Farman, MD — **Written by:** Maren Leibowitz, MD (NUEM ‘23) **Edited by:** Zach Schmitz, MD (NUEM ‘21) **Expert Commentary by**: David Farman, MD

Expert Commentary

Cocaine chest pain was something that was frequently discussed but rarely encountered during my training and during my 11 years practicing in suburban and metropolitan Indiana (we're more of a heroin/meth state). I suspect there is significant regional and local variation in the epidemiology of cocaine chest pain, likely influenced by the economics and local availability or popularity of intoxicants.

When cocaine is more expensive, we tend to see more methamphetamine use. And vice-versa. I was once told by a local sheriff that "people will get high on whatever they can get for less than $20" and I have found that to be true in practice. I wouldn't expect that an emergency physician would be intimately familiar with the local micro-economics of the drug trade, but one should expect there to be a periodic waxing/waning of cocaine chest pain presentations. Similarly, it may be a more frequent complaint dependent on cocaine's local popularity and availability.

When consulting with a Cardiologist about a cocaine chest pain case, it is important for the emergency physician to avoid letting premature closure or psychosocial biases unduly influence the patient's disposition. It is not unheard of for physicians to minimize objective findings (ST segment abnormalities or biomarker elevation) and attribute them to the vasoactive properties of cocaine. I have certainly been tempted to do so myself. However, the article wisely points out the physiologic changes induced by cocaine use, both acutely and chronically. Platelet aggregation and atherogenesis can absolutely promote a scenario that would require PCI in even the most frequent of 'frequent fliers' with cocaine chest pain.

In short, I would have a low threshold to involve Cardiology in a patient who has objective findings regardless of their use of cocaine. Similarly, a Cardiology request for a Urine Drug Screen shouldn't delay a patient's trip to the cath lab if they have a STEMI. An exception to this may be a patient who has had recent coronary angiography that objectively demonstrates normal coronaries. In that scenario I would consider serial markers, conservative management and strong consideration of non-cardiac causes of the pain (dissection, pneumothorax, etc.).

David Farman, MD FACEP

Emergency Medicine Physician

Franciscan Health Lafayette East

How To Cite This Post:

[Peer-Reviewed, Web Publication] Leibowitz, M. Schmitz, Z. (2021, May 10). Cocaine Chest Paine. [NUEM Blog. Expert Commentary by Farman, D]. Retrieved from http://www.nuemblog.com/blog/cocaine-chest-pain

Eliminating health disparities in LGBT individuals begins in the ED

Written by: David Feiger, MD (NUEM ‘22) Edited by: Vidya Eswaran, MD (NUEM ‘20) Expert Commentary by: Will Laplant, MD, MPH '20 — **Written by:** David Feiger, MD (NUEM ‘22) **Edited by:** Vidya Eswaran, MD (NUEM ‘20) **Expert Commentary by**: Will Laplant, MD, MPH '20

Introduction

18% of lesbian, gay, bisexual, transgender, or questioning (LGBTQ) individuals avoided seeking medical attention for fear of discrimination according to a 2017 joint poll conducted by NPR, the Robert Wood Johnson Foundation, and Harvard T.H. Chan School of Public Health [1]. These fears are not unfounded—decades of anti-lesbian, gay, and bisexual (LGB) prejudice in medicine, despite greater social acceptance in the United States have tainted medicine’s perception in the LGB community.

Only in 1987 was “sexual orientation disturbance” removed from the DSM while conversion therapy, the scientifically-unfounded exercise of converting one’s sexual orientation to heterosexual, continues to be legal across much of the United States. In 2015, a pediatrician in Michigan declined to see a child of a lesbian couple which spurred a national debate of refusal of care on the basis of religious freedom [2]. Just this year the Conscience and Religious Freedom Division of the Department of Health and Human Services was established [3]. It is clear why LGB individuals may want to avoid routine medical attention.

As a disclaimer, LGBT individuals are often lumped into one category. We will focus this post on LGB individuals as we believe that the transgender experience, while occasionally overlapping with that of LGB individuals, deserves its own recognition in another post. Many studies and data grouped LGB and transgender individuals as one group and will be cited as such in this post.

Health Disparities

34% of LGBT individuals reported having been a victim of bullying, instituting a fear of discrimination and coming out that can lead to a variety of emotional and psychological consequences [4]. In the National Health Interview Study, 26% and 28% of gay men and women, respectively, and 41% and 47% of bisexual men and women, respectively, reported moderate or severe levels of mental distress compared to 17% of straight men and 22% of straight women [6]. These levels of psychological stress make LGB individuals more prone to emotional disorders leading to suicidal ideation, homelessness, depression, and substance abuse [4].

Furthermore, 18% of LGBT individuals reported having been coerced into sex and 23% sexually assaulted [4]. This victimization increases their risk of unsafe sexual behavior than their peers resulting in a twice greater likelihood of contracting sexually transmitted diseases when compared to straight-identifying men [5]. The fear of seeking medical attention only exacerbates these health disparities.

While much of the focus has been on the modern experience of LGB youth, it is important to be aware the circumstances of LGB seniors that may contribute to health disparities. Due to the social climate in which they grew up, they are less likely to be partnered, have children, or other social supports, increasing their barriers to health care. Furthermore, they often reside in senior communities where they often face continued discrimination [7].

Creating a More Welcoming Environment for All

The emergency department is often the first point of healthcare contact for the vulnerable, and is therefore a prime location to make healthcare more approachable for the LGB community.

The Waiting Room

Patients often spend hours in the waiting room, providing an opportune time to set an inviting tone for LGB patients. LGB individuals constantly seek subtle indications of acceptance in unknown environments [11]. At the most basic level, triage forms can include questions pertaining to sexual orientation and gender identity [7]. In fact, collection of this data has been recommended by the Institute of Medicine and the Joint Commission [8]. These forms can also include the hospital’s non-discrimination policy on the basis of sexual orientation and offer a contact for a patient advocate for those who have been unfairly treated. Staff can wear rainbow flag pins and waiting rooms can offer pamphlets that highlight LGB health among other health topics [7]. These small additions can make LGB individuals feel more welcome.

With the Physician
Despite 78% of emergency physicians believing that patients would refuse to reveal their sexual orientation in the emergency department, only 10% of patient respondents of all sexual orientations (n=1516) to the EQUALITY study reported that they would not answer the question [8]. As summarized by Dr. Adil Haider, the principal investigator of the study, “your patients want to be asked.”

When asking patients about their sexual orientation, it is important to use gender-neutral language. Ask “are you in a relationship?” or “do you have sex with men, women, or both?” to delve into a social history. These types of questions may comfort LGB patients to allow them to expand on details they find relevant [9]. Of course, patients who are not comfortable with their identity may continue to conceal their sexual orientation. Each individual’s coming out experience varies and it is crucial that the physician allows the patient to take his or her own time to reveal their sexual orientation, even if not on this visit. Simply asking the broad questions without judgment may begin to change the patient’s apprehensive attitude towards medicine.

Going Above and Beyond

While important to make the clinical encounter more inviting, more actions can be taken to make a hospital a leader in LGB care.

1. Partner with local LGB organizations

Hospitals can partner with organizations that support the LGB community. Having a presence in health clinics targeting LGB individuals and other local LGB organizations will also allow the hospital to better understand and adapt to the needs specific to the community. Celebrating LGBT awareness months and having staff march in local LGB Pride events is a very public and visible way of showing support for the community [9].

2. Actively recruiting and maintaining LGB staff

Health care providers should actively recruit LGB staff by ensuring equal employment benefits as their heterosexual colleagues by offering supplemental packages that include benefits for both married and unmarried same-sex partners. After hiring, ensure that LGB employees continue to receive support and mentoring by sponsoring LGB employee groups and functions [9].

3. Striving for and achieving a perfect score on the Human Rights Campaign Healthcare Equality Index

The Human Rights Campaign is the largest organization supporting LGBT rights in the United States. Each year, the Human Rights Campaign scores and publishes a list of many hospitals in the United States and grades them on hospitals’ ability to provide inclusive care regardless of sexual orientation. The list evaluates a hospital’s patient and employment non-discrimination policies, visitation rights, LGBT-focused training offering, presence of patient services to LGBT individuals, employee benefits, and commitment to the community for a total score on a scale from 0 to 100.10 For healthcare institutions not achieving a perfect 100 score, this is a great tool to ensure progression to full equity of care for LGB patients.

Summing it Up

Despite rapid social acceptance of the LGB community in the United States within the past decade, remnants of fear and distrust in healthcare remain, exacerbating existing health disparities. While it may take several decades to fully eradicate the apprehension, taking the steps above will certainly make strides to achieve that goal.

Expert Commentary

Thank you for writing about such an important topic. I think we all understand the special position of the emergency department beyond the care of emergencies; it is a point of access for many marginalized communities that have been unable to receive care through other venues. It is our duty as emergency physicians to be able to provide competent and appropriate care for all who walk through our doors.

I think it makes sense to divide the topic of LGBTQ care into two: sexual minorities (those who identify as lesbian/gay/bisexual/queer, etc) and gender minorities (those who identify as trans, genderqueer or otherwise gender nonconforming). While they have much in common, the barriers and healthcare disparities they face are unique and different, and they each warrant a lengthy discussion. I look forward to your article on the care of gender minorities!

Normalizing Care in the Emergency Department

Identifying Those in the Room

Asking “how are the two of you related?” to figure out who else is in the room can prevent mishaps of assuming someone is with their friend, when really they are with their partner. As a major support system after discharge, it’s important to include a patient’s partner in the discussion and plan.

Taking a Sexual History

It’s important to not conflate sexual orientation with sexual behaviors. For example, there is a well defined subsect of men who have sex with men (MSM) but do not identify as gay/bisexual. By asking “do you have sex with men, women, or both?” you ensure that you capture the data you need to treat the patient appropriately. Some people get hung up on the follow up questions to further identify how to treat a patient:

“Do you have anal intercourse?”

“Do you have receptive, penetrative, or both?”

The same model can be used for oral and vaginal intercourse.

Addressing the Sexual Health of Sexual Minorities

If you are addressing sexual health needs in the emergency room, either because of chief complaint (eg. sore throat, rectal pain, vaginal discharge, abdominal pain) or exposure, try and be as comprehensive as possible. The majority of syphilis cases in the US are amongst MSM [1], making it an important consideration. I suppose this blog is also as good a place as any to highlight the recent CDC recommendations for treatment of STIs, including [2]:

Monotherapy with ceftriaxone for confirmed gonorrhea given increasing azithromycin resistance
Increased dosing of ceftriaxone (500mg from 250mg) for gonorrhea treatment, and 1g of ceftriaxone for those >150kg
Doxycycline 100mg BID for 7 days for chlamydia infections
*Notably, compliance with a 7 day course of treatment should be addressed and factored into the decision (with regards to the previous standard of azithromycin 1g as a single dose).

Identifying Bias

Bias comes in two forms: explicit biases, which we are cognizant of, and implicit, which we are not. Implicit bias stems from the confluence of your life experiences and the society you are a part of. If you have been raised in a society entrenched in systemic racism, sexism, ableism and heteronormativity, you have been exposed to stereotypes and prejudices which may subconsciously shape the way you make decisions. Healthcare professionals have been shown to have a similar level of implicit bias compared to the general population [3], and this implicit bias has been correlated with significant patient outcomes. [4] What shapes your decision in who receives narcotic pain medication or who stays in the hospital for observation? I highly recommend taking at least a few tests of implicit bias which are freely available and, in my opinion, highly informative: https://implicit.harvard.edu/implicit/takeatest.html

References

CDC. Sexually transmitted disease surveillance 2013. Atlanta: US Department of Health and Human Services; 2014.
St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon.
FitzGerald, C., Hurst, S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 18, 19 (2017). https://doi.org/10.1186/s12910-017-0179-8
William J. Hall et al. “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review”, American Journal of Public Health 105, no. 12 (December 1, 2015): pp. e60-e76.

Will Laplant MD, MPH

Emergency Medicine Physician

Good Samaritan Medical Center

Brockton, MA

How To Cite This Post:

[Peer-Reviewed, Web Publication] Feiger, D. Eswaran, V. (2021, May 2). Eliminating health disparities in LGBT individuals begins in the ED. [NUEM Blog. Expert Commentary by Laplant, W]. Retrieved from http://www.nuemblog.com/blog/lgbt-disparities

References

“Discrimination in America: Experiences and Views of LGBTQ Americans.” www.npr.org, National Public Radio, Nov. 2017, www.npr.org.
Pear, Robert, and Jeremy W. Peters. “Trump Gives Health Workers New Religious Liberty Protections.” The New York Times, 18 Jan. 2018.
Phillip, Abby. “Pediatrician Refuses to Treat Baby with Lesbian Parents and There’s Nothing Illegal about It.” The Washington Post, 19 Feb. 2015.
Hafeez, Hudaisa, et al. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review.” Cureus, 2017, doi:10.7759/cureus.1184.
Robinson, Joseph P., and Dorothy L. Espelage. “Peer Victimization and Sexual Risk Differences Between Lesbian, Gay, Bisexual, Transgender, or Questioning and Nontransgender Heterosexual Youths in Grades 7–12.” American Journal of Public Health, vol. 103, no. 10, 2013, pp. 1810–1819., doi:10.2105/ajph.2013.301387.
Gonzales, Gilbert, et al. “Comparison of Health and Health Risk Factors Between Lesbian, Gay, and Bisexual Adults and Heterosexual Adults in the United States.” JAMA Internal Medicine, vol. 176, no. 9, 2016, p. 1344., doi:10.1001/jamainternmed.2016.3432.
Understanding the Health Needs of LGBT People. Understanding the Health Needs of LGBT People, National LGBT Health Education Center, 2016.
Haider, Adil H., et al. “Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity.” JAMA Internal Medicine, vol. 177, no. 6, 2017, p. 819., doi:10.1001/jamainternmed.2017.0906.
Ten Things: Creating Inclusive Health Care Environments for LGBT People. Ten Things: Creating Inclusive Health Care Environments for LGBT People, National LGBT Health Education Center, 2015.
Human Rights Campaign. “Healthcare Equality Index 2018.” Human Rights Campaign, Human Rights Campaign, 2018, www.hrc.org/hei.
Eliason, Michele J., and Robert Schope. “Does ‘Don't Ask Don't Tell’ Apply to Health Care? Lesbian, Gay, and Bisexual People's Disclosure to Health Care Providers.” Journal of the Gay and Lesbian Medical Association, vol. 5, no. 4, Dec. 2001.

Posted on May 3, 2021 by NUEM Blog and filed under Advocacy and tagged health disparities LGBT advocacy health policy.

Bariatric Emergencies

Written by: Maurice Hajjar, MD, MPH (NUEM ‘22) Edited by: Philip Jackson(NUEM ‘20) Expert Commentary by: Gabby Ahlzadeh, MD — **Written by:** Maurice Hajjar, MD, MPH (NUEM ‘22) **Edited by:** Philip Jackson(NUEM ‘20) **Expert Commentary by**: Gabby Ahlzadeh, MD

Expert Commentary

Thanks for this great post. Being familiar with the anatomy of these various procedures is essential to understanding the complications and why you cannot be reassured by a benign abdominal examination.

With laparoscopic band procedures, complications are more common early on and are more related to band erosion or migration. Migration of the lap-band is best evaluated with an upper GI series with Gastrografin. Another important question to ask patients is if their lap band has been inflated recently. This is typically done in a progressive manner, where normal saline is instilled within the subcutaneous port. This can also be a source of obstruction, and if emergent, the band can be deflated by aspirating fluid from the port. This should be done under the guidance of a surgeon, if possible.

Asking about dietary indiscretions can also sometimes clue you in to why a person is having abdominal pain or nausea. Especially immediately post-op, these patients have specific dietary guidelines and are often limited to liquids or pureed foods. Dumping syndrome can also occur in this patient population, more common with gastric bypass surgery, due to rapid gastric emptying. Typically, these patients have bloating, sweating, facial flushing, diarrhea, nausea, early satiety about 30 to 60 minutes after a meal. Dumping syndrome is typically diagnosed clinically, though laboratory testing should be performed to rule out electrolyte derangements. Dumping syndrome is typically treated with dietary modifications and should be discussed with the patient’s surgical team.

As these procedures become more common and advanced, some are also performed endoscopically, which comes with its own set of complications. Another newer procedure is the intragastric balloon, which is a saline filled silicone balloon that is inflated in the stomach. In the first few days after placement, patients may experience abdominal pain, nausea, and vomiting. Other complications include balloon rupture, bowel obstruction, gastric outlet obstruction, gastric ulcer, pancreatitis, nonalcoholic steatohepatitis and cholecystitis.

Overall, management of these patients in the emergency department should be done in consultation with the surgeon.

Gabrielle Ahlzadeh, MD

Clinical Assistant Professor of Emergency Medicine

University of Southern California

How To Cite This Post:

[Peer-Reviewed, Web Publication] Hajjar, M. Jackson, P. (2021, Apr 26). Bariatric Emergencies. [NUEM Blog. Expert Commentary by Ahlzadeh, G]. Retrieved from http://www.nuemblog.com/blog/bariatric-emergencies

Thyroid Storm ED Diagnosis and Management

Expert Commentary

For those of you who have not yet cared for a patient in Thyroid Storm, I guarantee that the experience will humble you. As far as endocrine emergencies go, this one is (quite literally) a killer. In 1993, Burch and Wartofsky cited mortality rates as high as 20 to 50% [1]. In more recent literature, the mortality rate of this condition is still at a whopping 10% [2]. As you can see from the beautifully presented infographic above, there are a number of complexities that factor into the diagnosis and treatment of Thyroid Storm. This is in part due to the fact that thyroid hormone affects all organ systems, with clinical manifestations of disease involving everything from cardiac dysrhythmia to profound GI losses secondary to vomiting and diarrhea to acute psychosis. To ground this infographic in clinical reality, where we know that diagnoses are not always easy to make and the decision between one therapeutic option versus another is not always clear, I offer you just a few additional points:

1. Making this diagnosis requires that you actually think about it in the first place. There is no single diagnostic test or image that will clinch this diagnosis for you. The Burch and Wartofsky criteria are clinical findings that you as the provider must use in the correct context for them to be useful. This is a rare condition, and your availability bias will be working against you here. Patient presentations can be vague and there is incredible overlap with other disease processes, with chief complaints ranging from anxiety to vomiting and abdominal pain to leg swelling.

2. Once this diagnosis has been considered or made, understand that these patients have incredibly complex hemodynamics, with multiple potential factors in play at any given time: hypovolemia from profound GI losses, concomitant sepsis, high output cardiac failure, and cardiac systolic dysfunction. With regards to this last point, there is a high incidence of decompensated heart failure in patients with thyroid storm, and those with cardiogenic shock are at some of the greatest risk of mortality [2, 3, 4]. As such, it behooves you to re-assess these patients’ volume status frequently. Examine them closely, and then re-examine them. Use your bedside ultrasound to assess their cardiac output, IVC, and lung windows. While they may be profoundly hypertensive when you first administer a beta blocker, concomitant sepsis and hypovolemia may surface very quickly as the patient’s blood pressure plummets.

3. This leads to my next point: when given the choice between propranolol and esmolol in managing tachydysrhythmia (whether profound sinus tachycardia or atrial fibrillation) in the context of Thyroid Storm, strongly consider esmolol. The Japan Thyroid Association and Japan Endocrine Society Task Force specifically cites increased mortality rates in patients for whom propranolol was used versus esmolol or landiolol (super short-acting beta blocker used in Japan) [3]. Much of the benefit to using esmolol over propranolol is in its much shorter half-life. The alpha and beta half-life for propranolol are 10 minutes and 2.3 hours, respectively, whereas the alpha and beta half-life for esmolol are 2 minutes and 9 minutes, respectively. Once the infusion is stopped, the effect of esmolol will have completely disappeared by 18 minutes [3].

4. When asked during oral boards how you would manage a patient with Thyroid Storm, a response involving antithyroid agents, inorganic iodide, corticosteroids, and beta blockers would score you full marks. However, I would encourage you to also consider thoughtful administration of IV fluids (with frequent re-assessment of volume status), early empiric antibiotics, inotropic agents for patients in cardiogenic shock, and psychotropic medications as needed for restlessness/delirium/psychosis (with olanzapine preferred over haldol) [3].

Diagnosis and management of Thyroid storm in the Emergency Department requires us to draw upon so many of our expert skills in approaching undifferentiated and critically ill patients. I hope that these points help to provide you with just a few more tools to include in your arsenal as you go forth.

References

[1] Burch, HB, Wartofsky, L. (1993). Life-threatening thyrotoxicosis: Thyroid storm. Endocrinology and Metabolism Clinics of North America, 22(2): 263-77.

[2] Akamizu, T. (2018). Thyroid Storm: A Japanese Perspective. Thyroid, 28:1.

[3] Satoh, T, et al. (2016). 2016 Guidelines for the Management of Thyroid Storm from The Japan Thyroid Association and Japan Endocrine Society (First edition). Endocrine Journal, 63: 12 (1025-1064).

[4] Bourcier, S, et al. (2020). Thyroid Storm in the ICU: A Retrospective Multicenter Study. Critical Care Medicine, 48:1 (83-90).

Samia Farooqi, MD

Assistant Professor

Department of Emergency Medicine

UT Southwestern

How To Cite This Post:

[Peer-Reviewed, Web Publication] Luo, S. Chukwuelebe, S. (2021, April 19). Thyroid Storm ED Diagnosis and Management. [NUEM Blog. Expert Commentary by Farooqi, S]. Retrieved from http://www.nuemblog.com/blog/thyroid-storm.

ED Clinical Decision Making Units

Written by: Mitchell Blenden, MD (NUEM ‘24) Edited by: Em Wessling (NUEM ‘22) Expert Commentary by: Tim Loftus, MD, MBA — **Written by:** Mitchell Blenden, MD (NUEM ‘24) **Edited by:** Em Wessling (NUEM ‘22) **Expert Commentary by**: Tim Loftus, MD, MBA

Expert Commentary

Thank you to Dr’s Blenden and Wessling for the excellent overview of ED CDUs including some background and indications for their use.

Several points to highlight and elaborate upon include the following:

The background of the utility of CDUs mostly stems from their early function as rapid diagnostic and treatment centers (RDTCs) for chest pain. The function and utility of CDUs have since grown to demonstrate clinical benefits well-established across a variety of conditions as Dr’s Blenden and Wessling have mentioned, including not only chest pain (rule out acute coronary syndrome) but also TIA, CHF, asthma, COPD, cellulitis, pyelonephritis, pneumonia, etc.

Value and Benefits

The utility and value of ED CDUs will continue to expand. The percentage of all hospital admissions that start in the ED continues to grow -- 67% in 2019, up from 58% in 2004 according to the ED Benchmarking Alliance. Additionally, EDs cared for approximately 158M people as of 2018 (EMNet/NEDI-USA), up 32% over a 10 year period. As the number of admissions continues to grow, and considering that some of these inpatient stays are short, it follows that many of these short inpatient admissions are subject to recovery audit contractors and payor denials. Many clinical conditions which are often subject to short inpatient stays can be cared for in dedicated short stay observation units without adversely affecting, and for the most part improving, the quality of care delivery, safety, satisfaction, cost savings, and reducing subsequent inpatient LOS.

All stakeholders in the health care system benefit from CDU use: patients are more accurately diagnosed before leaving the ED and are discharged home faster, payors avoid costly inpatient admission charges, hospitals keep scarce inpatient bed capacity open for more appropriate patients and avoid audits and denials, and providers deliver care in a setting that more appropriately matches patient needs to resources.

Dedicated Units with Protocolized Care

Observation patients can be managed in a variety of settings and contexts, but best practice that leads to best outcomes would be in dedicated observation units adherent to protocols tailored to the patients’ conditions, the best available evidence, and local institutional resources.

Shorter hospitalizations are more likely to occur in dedicated observation units under protocols than with unstructured hospitalization on inpatient teams and simply billing status changes to observation.

Financial Considerations

Much of the existing evidence has demonstrated that CDUs can provide care that efficiently utilizes resources and results in shorter hospital lengths of stay relative to other projects to expand capacity. Further, hospitals may realize decreased operating expenses for those patients subsequently discharged home from the CDU who have diagnoses or clinical conditions that are not as profitable for the hospital to manage in the inpatient setting - for example, CHF, which can often create a loss for the hospital. That being said, hospitals should be careful about shifting too much acute care into CDUs, because any CDU stay that subsequently results in inpatient admission (about 20% or so) are only paid by a single DRG, which includes that care provided for in the ED, CDU, and hospital unit. Thus, you can risk incurring additional costs without additional revenue. Finally, the duration of observation should exceed 8 hours only to justify the added expense of operating the CDU, because payors, including Medicare, generally do not pay clinical or facility fees for observation stays less than 8 hours.

Another consideration when estimating value created by a CDU is the increasing use by those who would have otherwise been discharged from the ED. It is important to consider the value of a CDU not only by the cost savings to the hospital and patient but also the possible supply-induced demand of health care services and overutilization of those services to a detriment.

CMS, and other payors, do not necessarily exclude payment from observation status patients whose stay lasted longer than 24 or even 48 hours. However, the profit margin and efficiency are reduced when patients are staying in the CDU that long, highlighting an opportunity to evaluate your particular unit’s effectiveness, efficiency, and patient selection.

Final Considerations

CDUs are not appropriate for all EDs, as only about 5-10% of ED patients have been found to be appropriate for a CDU, and in order to optimize operational and financial efficiency, a certain minimum number of beds and fixed costs would need to be overcome.

It is worth mentioning that protocol-driven CDUs in proximity to an ED with dedicated diagnostic and treatment algorithms, patient selection criteria, predetermined outcomes and end points have demonstrated the best outcomes with respect to cost savings, patient satisfaction, safety, and reduction in hospital LOS. For administrative and clinical operations leaders, tracking process and outcome metrics such as LOS, occupancy rate, discharge rate, and bed turns in addition to other clinical and quality outcomes will enable ongoing continuous optimization of the CDU.

Depending on the resources and throughout considerations of each hospital and health system, at times CDUs provide great benefit in being able to flexibly accommodate inpatient holds, pre or postoperative patients, or additional acute ED treatment space as the need allows. Design and construction with this in mind may enable the hospital to best accommodate ever changing dynamics - COVID being one example.

References

Emergency Medicine Network (EMNet). National Emergency Department Inventory – USA. https://www.emnet-usa.org/research/studies/nedi/nedi2018/. Accessed 1 Jan 2021.
Emergency Department Benchmarking Alliance (EDBA). Before there was COVID - 2019 Emergency Department Performance Measures Report. Accessed 1 Jan 2021.
Baugh CW, Liang L-J, Probst MA, Sun BC. National Cost Savings From Observation Unit Management of Syncope. Academic Emergency Medicine. 2015;22(8):934-941. doi: 10.1111/acem.12720.
Baugh, C. W., Venkatesh, A. K., & Bohan, J. S. (2011). Emergency department observation units: a clinical and financial benefit for hospitals. Health care management review, 36(1), 28-37.
Baugh and Granovsky - ACEP Now - https://www.acepnow.com/article/new-cms-rules-introduce-bundled-payments-for-observation-care/?singlepage=1
Making Greater Use Of Dedicated Hospital Observation Units For Many Short-Stay Patients Could Save $3.1 Billion A Year. Health Affairs. 2012;31(10):2314-2323. doi: 10.1377/hlthaff.2011.0926.
Ross MA, Hockenberry JM, Mutter R, Barrett M, Wheatley M, Pitts SR. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Aff (Millwood). 2013;32(12):2149-2156. doi: 10.1377/hlthaff.2013.0662.
Rydman RJ, Zalenski RJ, Roberts RR, et al. Patient satisfaction with an emergency department chest pain observation unit. Ann Emerg Med. 1997;29(1):109-115. doi: 10.1016/s0196-0644(97)70316-0.

Timothy Loftus, MD, MBA

Assistant Professor

Department of Emergency Medicine

Northwestern University

How To Cite This Post:

[Peer-Reviewed, Web Publication] Blenden, M. Wessling, E. (2021, Apr 12). ED Clinical Decision Making Units. [NUEM Blog. Expert Commentary by Loftus, T]. Retrieved from http://www.nuemblog.com/blog/ed-clinical-decision-making-units.

Pelvic Inflammatory Disease

Written by: Niki Patel, MD, MD (NUEM ‘22) Edited by: Luke Neill, MD (NUEM ‘20) Expert Commentary by: Gabby Ahlzadeh, MD — **Written by:** Niki Patel, MD, MD (NUEM ‘22) **Edited by:** Luke Neill, MD (NUEM ‘20) **Expert Commentary by**: Gabby Ahlzadeh, MD

Expert Commentary

Thanks for this clear and succinct post. The differential diagnosis of lower abdominal and pelvic pain is extremely broad in both premenopausal and post-menopausal women. This is when the sexual history becomes important. A question we often overlook as part of the sexual history is asking about dyspareunia, which may help differentiate gynecological from intra-abdominal causes of abdominal pain, specifically in the case of PID.

Patients with PID are frequently misdiagnosed with a urinary tract infection because they may have urinary symptoms, but the urinalysis often shows sterile pyuria, which should raise your suspicion for PID.

And while the utility of the pelvic exam is constantly scrutinized and questioned in patients with vaginal bleeding, it is impossible to diagnose PID without it. Having said that, the clinical diagnosis is only 65-90% specific so even minimal symptoms with no other explanation warrant antibiotic therapy to reduce further complications.

Underdiagnosis is even more significant in the adolescent patient population, who are at highest risk for developing PID. Over 70% of PID diagnoses among adolescents are made in the ED, with approximately 200,000 adolescents diagnosed annually. If the patient is accompanied by a family member or friend, having them step out to better elicit a sexual history is essential. HIV and syphilis testing should also be considered while these patients are in the ED.

Ensuring follow-up for these patients within 48-72 hours is essential and must be emphasized. Patients should understand the complications of PID and the importance of antibiotic compliance prior to discharge, especially in younger patients.

Gabrielle Ahlzadeh, MD

Clinical Assistant Professor of Emergency Medicine

University of Southern California

How To Cite This Post:

[Peer-Reviewed, Web Publication] Patel, N. Neill, L. (2021, Apr 5). Pelvic Inflammatory Disease. [NUEM Blog. Expert Commentary by Ahlzadeh, G]. Retrieved from http://www.nuemblog.com/blog/pelvic-inflammatory-disease

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