Back to Basics
2013
Dr. Brian Weitzman
Department of Emergency Medicine
Ottawa Hospital
Review of 14 Common Emergency
Medicine Topics
Today
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Acute Abdominal Pain
Acute Dyspnea
Hypotension/Shock
Syncope
Coma
Cardiac Arrest
Other Emergency Medicine Topics
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Malignant Hypertension
Animal Bites
Burns
Near-drowning
Hypothermia
Poisoning
Urticaria/Anaphylaxis
Abdominal Pain
MCC Objectives
1.
Common causes of pain
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Localized -Upper vs Lower Abdominal
Diffuse
History –list and interpret clinical finding
Physical exam: appropriate-vitals, abd, rectal, pelvic GU
2.
3.
1.
4.
5.
6.
-recognize peritonits
Investigate: order appropriate tests
Interpret clinical and lab data
Management plan:
1.
2.
3.
Who needs immediate attention and treatment/surgery
Non-emergency management
Further investigation or specialized care
Case 1:
Sally is an 18 year old woman who presents with a 2
day history of dull periumbilical pain which now
localizes to the RLQ.
What disease process is this typical for?
What causes the change in the pain pattern?
What other diseases must you consider?
Neurologic Basis of Abdominal Pain
• Visceral
• Somatic
• Referred
Visceral Abdominal Pain
• Stretch receptors in walls of organs
• Stimulated by distention, inflammation
• return to spinal cord: bilateral, multiple
levels
• Brain cannot localize source
Visceral Abdominal Pain
• Pain felt as crampy, dull, achy, poorly
localized
• Associated with autonomic responses of
palor, sweating, nausea, vomiting
• Patients often writhing around
– Movement doesn’t alter pain
Somatic Abdominal Pain
• parietal peritoneum
• Returns to ipsilateral dorsal root ganglion at
1 dermatomal level
• Sharp, localized pain
• Causes tenderness, rebound, and guarding
• Patients lie still, movement increases pain
Referred Pain
• What is it?
• What are some examples?
Referred Pain
• Pain perceived in an area that is distant
from the disease process
• Due to overlapping nerve innervations
Examples of Referred Pain
• Shoulder pain with diaphragm stimulation
– C 3,4,5 stimulation
• Back pain with biliary colic, pancreatitis, or
PID
Differential Diagnosis
• Diffuse vs Localized
Diffuse Abdominal Pain
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Peritonitis
AAA
Ischemic Bowel
Gastroenteritis
Irritable Bowel Syndrome
Causes of Abd Pain - Localized
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
Upper Abdominal

Lower Abdominal
Localized Abdominal Pain
Colic/Cholecystitis Gastritis,GERD/PUD
 Hepatitis / Hepatic Abscess Pancreatitis
 Pneumonia / Pleurisy
MI
 Biliary
 Appendicitis
 Mesenteric lymphadenitis
Incarcerated Hernia
Bowel obstruction
Inflammatory bowel disease
Diverticulitis
Ectopic
Ovarian(torsion or cystA)
Salpingitis/PID
Renal Stones/UTI
Testicular torsion

Splenic Infarction
 Splenic Rupture
 Pneumonia
Case 1:
Sally is an 18 year old woman who presents with a 2
day history of dull periumbilical pain which now
localizes to the RLQ.
Case 1: Questions
1. What further history do you need from the patient?
2. What would you do in your physical exam?
3. What are you looking for on physical examination?
4. What initial stabilization is required?
5. What is your differential diagnosis?
History
 Onset / Duration
 Nature / Character / Severity
 Radiation
 Exacerbating / Relieving Factors
 Location
 Associated Symptoms
 Nausea / Vomiting
 Diarrhea / Constipation / Flatus
 Fever
 Jaundice / other skin changes
 GU (dysuria, freq, urgency, hematuria…)
 Gyne (menses, contraception, STDs,,,)
 PMHx
 Prior Surgery
 Medical Problems
 Medications
High Yield Questions
High Yield Questions
1. Age Advanced age means increased risk.
2. Which came first—pain or vomiting?
1. Pain first is worse (i.e., more likely to be caused by
surgical disease).
3. When did it start? Pain for < 48 hrs is worse.
4. Previous abdominal surgery? Consider obstruction.
5. Is the pain constant or intermittent? Constant pain is worse.
6. Previous hx of pain?
7. Pregnant? consider ectopic.
High Yield Questions cont’d
8. History of serious illness is suggestive of more serious
disease.
9. HIV? Consider occult infection or drug-related pancreatitis.
10. Alcohol? Consider pancreatitis, hepatitis, or cirrhosis.
11. Antibiotics or steroids? These may mask infection.
12. Did the pain start centrally and migrate to the right lower
quadrant? High specificity for appendicitis.
High Yield Questions, cont’d
13. History of vascular or heart disease, hypertension, or
atrial fibrillation? Consider mesenteric ischemia and
abdominal aneurysm.
Physical Examination
Physical Examination
• Vitals
• General appearance: writhing/motionless, diaphoresis,
skin, mental status
• Always do brief cardiac and respiratory exam
• Abdominal exam: Look, listen, feel
• Pelvic, genital and rectal exam in ALL patients with
severe abdominal pain
• Assess pulses!
Abdo Exam: Specifics
• Always palpate from areas of least pain to areas with
maximal pain
• ?Organomegaly, ?ascites
• Guarding: voluntary vs. involuntary
• Bowel sounds: increased/decreased/absent
• Rectal exam: occult/frank blood, ?stool, ?pain, ?masses
• Pelvic exam: discharge, pain, masses
• Peritonitis:
– suggested by: rigidity with severe tenderness, pain with
percussion/deep breath/shaking bed, rebound
Risk Factors for Acute Disease
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Extremes of age
Abnormal vital signs
Severe pain of rapid onset
Signs of dehydration
Skin pallor and sweating
Initial Stabilization
Initial Stabilization
All patients with acute abdominal pain:
Assess vital signs
Oxygen
Cardiac Monitoring/12 lead ECG
Large bore IV (may need 2)
250-500 cc bolus of NS in elderly with low BP
500-1000 cc bolus in younger patients with low BP
Consider NG and Foley catheter
Brief initial examination : history and physical
Consider analgesics
??Do they need immediate surgical consultation?
Pain: ER Management
• Is it OK to give a patient pain medications
before you determine their diagnosis?
Abdominal Pain: ER Management
• Anti-inflammatories (NSAIDs):
– very effective, esp. for MSK or renal colic pain
– Ex. Ketorlac (Toradol) 30 mg IV
• Narcotics
– sc/im/iv
– very effective, esp. for visceral or undifferentiated pain
– Ex. Morphine 2.5-5 mg, hydromorphone 1-2 mg
Nausea/Vomiting: ER Tx
Nausea/Vomiting: ER Tx
• Ondansetron (Zofran) : iv 4-8 mg
– very useful in patients with refractory vomiting
• Dimenhydrinate (Gravol): po/pr/im/iv 25-50 mg
– beware of anticholinergic side effects
– sedating, may cause confusion
• Metoclopramide (Maxeran) 10 mg IV
• Prochlorperazine (Stemetil): 10 mg IV
– beware of possible EPS
– less sedating; may help with pain control
• Domperidone: po/iv
– especially useful with diabetic gastroparesis
Investigations
Investigations
Most patients with acute abdominal pain require:
- CBC, differential; may need type and cross-match
-electrolytes, BUN, creatinine,
-lactate
- liver function tests
- lipase
- beta-hCG
- urinalysis; stool for OB
They may also need: ECG, cardiac enzymes, ABG,
Investigations
Imaging
ultrasound
CT scan
plain Xrays
A 73 y.o. man presents to the ED with left lower abd
pain to left flank x 5 hours. PMH: Hypertension.
Abdomen is diffusely tender. No rebound/ guarding.
P 120
BP 95/70
RR 18
T 37.5
02 95%
• What is the most likely diagnosis?
1) Diverticulitis
2) Renal colic
3) Ischemic bowel
4) Pyelonephritis
5) Other
A 73 y.o. man presents to the ED with left lower abd
pain to left flank x 5 hours. PMH: Hypertension.
Abdomen is diffusely tender. No rebound/ guarding.
P 120
BP 95/70
RR 18
T 37
02 95%
• What is your immediate treatment?
• What investigations will you do?
5.5 cm AAA
A 45 y.o. man presents to the ED with left lower abd
pain to left flank x 5 hours.. Abdomen is mildly
tender L side. No rebound/ guarding.
P 120
BP 130/70
RR 18
T 37
02 98%
• What is your diagnosis?
• What is your immediate treatment?
• What investigations will you do?
What is the cause of this 45 y.o.
man’s LLQ pain?
What is the cause of this 45 y.o.
man’s LLQ pain?
• Renal stone
A 75 y.o. man presents with 6 hours of LLQ pain
which has become more diffuse. T 38, P 120,
BP 130/60
What is the cause of this man’s pain?
What is the cause of this man’s pain?
• Double lumen sign of free air in
abdomen
• Perforated diverticulitis
Why is this woman vomiting?
Small Bowel Obstruction
• Central location, plica circularis (valvulae coniventes)
• Stacked coin appearance
Plica circularis
Air fluid levels
What are the 3 leading causes of
SBO
• 1) adhesions
• 2) hernia
• 3) neoplasm
Why is this woman vomiting?
Large bowel, haustra, air LLQ
3 Leading causes of LBO
• 1) neoplasm
• 2) Diverticulitis
• 3) volvulus
Sigmoid Volvulus
massive
bowel
dilation
single loop
“bent rubber
tube”
34yr female: cerebral palsy, no BM’s, abdo distension
34 y.o. man, alcoholic binge, repeated
vomiting. Now abdominal pain, guarding
rebound.
What is the cause of this man’s abdominal
• Boerhaave syndromeruptured esophagus
• Free air
Summary: Approach to
Abdominal Pain in the ER
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ABC assessment
Stabilize the patient, and refer early if unstable
Careful, detailed history
Focused physical examination
Early, thorough work-up:
– Appropriate laboratory investigation
– Diagnostic imaging where indicated
• Continuous reassessment
• Consider patient circumstances (age, pmhx, reliability,
home situation)
Summary: Common Causes of
Abdominal Pain
MCC Categorization
• Is it diffuse or localized?
• Do they need immediate resuscitation,
referral or surgery?
?
Acute Dyspnea (minutes to hours)
MCC Objectives
• Differentiate cardiac, pulmonary, central
causes
• Assess the A, B, C’s
• Diagnose and manage acute dyspnea
• Identify life threatening dyspnea
• Interpret clinical and lab data
– ECG, ABG, chest xray
• Management: acutely, refer prn, plan longterm Rx if chronic
What drives us to breath?
• Chemoreceptors in medulla, carotid and
aortic bodies:
– High CO2
– High H+ ion
– Low 02.
• Stretch and baroreceptors in lungs
Definitions
• Dyspnea:
– sensation of shortness of breath
Definitions
• Tachypnea:
– rapid, shallowing breathing
• Hyperventilation:
– breathing in excess of metabolic needs of body
lowering C02
– Need to rule out organic disease
• A 55 year old woman comes into the ED in
obvious respiratory distress. She is very
agitated, sitting forward, using her
accessory muscles.
What is her problem?
Most Common Causes of Acute
Dyspnea (MCC)
• Cardiac:
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MI
Valvular heart disease
Pericardial Tamponade
Dysrhythmia
Increased cardiac output (anemia)
Acute Dyspnea-Pulmonary Causes
• Upper airway: Aspiration, anaphylaxis, FB,
• Chest wall and pleura (effusion, pneumothorax)
• Lower airway: COPD, asthma
• Alveolar: pneumonia, CHF
• Vascular Resistance, hypoxia: PE
Acute Dyspnea
– Central causes
• Metabolic: acidosis, ASA toxicity
• Our 55 year old woman is still in respiratory
distress.
What will you do?
Rapid Assessment
• ABC’s : 5 vitals: P, RR, BP, T, 02 sat.
• O2, IV, Monitor, ECG
Rapid Assessment-General
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Ability to speak
Mental status, agitation, confusion
Positioning
Cyanosis:
– Central: Hgb desats by 5 g. Not evident in
anemia
– Peripheral: mottled extremities
Rapid Assessment
• Airway:
– Is the patient protecting it?
• Talking, swallowing, gagging
– Is the patient able to oxygenate and ventilate
adequately?
– Is there stridor
Oxygen
• Nasal prongs max. 4-5l/min
– Increase FIO2 by 4%/L
• Venturi: up to 50%
• 02 reservoir: 90-95%
5 Reasons to Intubate
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Protection
Creation
Oxygenation
Ventilation
Pulmonary toilet
Breathing
• Look, listen, feel, or IPPA
• Wheezes, rales, rubs, decreased air entry
• Is it adequate? O2 sat?
Circulation
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Pulse, BP,
Heart sounds ? Muffled
JVP
Edema
Rapid Assessment
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Does this person need immediate treatment?
Ventolin
Nitroglycerin
ASA
Furosemide
BiPap
Needle decompression
History-What are the key questions?
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Previous hx of similar event
How long SOB
Onset gradual or sudden
What makes it better or worse
Associated symptoms:
– Chest pain, cough, fever, sputum, PND,
orthopnea, SOBOE
History-What are the key questions?
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Medications, home 02
Allergies
What has helped in the past
Past medical history:
– Cardiac, pulmonary, recent surgery
Labs/Investigations
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ABG/VBG
CBC, Lytes, Cardiac enzymes
D dimer
ECG
Pulmonary Function Tests
Imaging
• CXR
• Helical CT
• Pulmonary angiogram
• V/Q –Nuclear ventilation perfusion scan
COPD
hyperlucent
lung fields
increased
retrosternal
air
low set
diaphragm
increased AP
diameter
flat
diaphragm
vertical
heart
72yr female: chronic SOB, worse x few days
Principles of Management
COPD
• Oxygen
– Titrate with 02 sat:
– Monitor pC02, avoid loss of hypoxic drive
• Beta agonists and anticholinergics
– Ventolin 1 cc in 2 cc atrovent or MDI
• Steroids ex. Solumedrol 125 mg IV
• BiPap
• Antibiotics
Status Asthmaticus
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100 % oxygen
continuous ventolin in atrovent
Prednisone P.O. or solumedrol IV
magnesium S04 2 gm over 2 min
• Epinephrine IM or IV has limited role
RML pneumonia
diaphragm
preserved
R heart
border
obscured
lat
confirms
ant
location
46yr male: chills, pleuritic C/P, ant R creps
LLL pneumonia
58yr female: weakness, cough, SOB
LLL pneumonia
diaphragm
obscured
lat confirms
post
location
58yr female: weakness, cough, SOB
Principles of Management
Pneumonia
• Oxygen to maintain 02 sat at 92-94%
• Antibiotics:
– Macrolides
– Fluroquinolones
– 2nd or 3rd generation cephalosporin
• Beta agonists and BiPap as required
• Considering scoring system for disposition
– CURB-65, CRB-65, Pneumonia Severity Index
Pulmonary edema
increased
cephalic
blood flow
increased
periph blood
flow
alveolar
infiltrates
prominent
hilar vessels
Kerley B
lines
cardiomegaly
69yr male: past MI, SOB, orthopnea, PND
Principles of Management
Pulmonary Edema
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LMNOP
Lasix –furosemide 40-160 mg IV
Morphine 2-4 mg IV
Nitroglycerin SL, IV
Oxygen
Position, postive pressure BiPap
ECG-rule out ACS
A 25 year old with dyspnea
Pneumothorax
Principles of Management
Pneumothorax
• Tension: 14 gauge needle 2nd ICS, MCL
• 30 Fr chest tube
• Pigtail catheter
• Small spontaneous pneumothorax: @20%
– May observe, discharge, repeat CXR 24 hrs
Ruptured Aorta
widened
superior
mediastinum
loss of aortic
knuckle
34yr male: MVC hit tree, unrestrained, c/o chest pain
A 75 y.o. with a history of CHF
comes in drowsy, gasping for air. :
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pH
pC02
HCO3
P02
7.15
70
30
60
• Diagnosis
• Acute or Chronic
A 75 y.o. with a history of CHF
comes in drowsy, gasping for air. :
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pH
pC02
HCO3
P02
7.15
70
30
60
• Acute Respiratory Acidosis
– pH is low
– HCO3 has not had time to increase
A 75. y.o. with COPD and dyspnea x
2 days
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pH
pC02
HC03
p02`
7.32
80
40
65
• Acute or Chronic
A 75. y.o. with COPD and dyspnea x
2 days
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pH
pC02
HC03
p02`
7.32
80
40
65
• Chronic Respiratory Acidosis
– HC03 very high therefor pH not that low despite C02 of
80
A 25 y.o. diabetic, vomiting x 2
days, looks dyspneic
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pH
HC03
pC02
P02
7.10
10
18
95
A 25 y.o. diabetic, vomiting x 2
days, looks dyspneic
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pH
HC03
pC02
P02
7.10
10
18
95
• Acute metabolic acidosis, and partially
compensating respiratory alkalosis
An anxious individual
• A 55 y.o. woman, recent fatigue, shortness
of breath, comes in to the ED
hyperventilating. Feels more short of breath
x 1 hour .
• What will you do?
Our 55 year old woman in distress…
Pericarditis or Acute Inferior MI
Acute Inferior MI
Ischemic Symptoms in Women
• Dyspnea
• Weakness
• Fatigue
• Often no chest pain (vs men)
Admission Criteria for Dyspnea
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Older patient
Abnormal vitals including 02 sat
Abnormal level of consciousness
Significant illness ex. Pneumonia
Patient fatigue
No improvement despite treatment
Home situation
?
Syncope
Syncope
• http://www.blogtelevis
ion.net/p/VideosWatch-aVideo___1,2,,59315.ht
ml
Syncope-MCC Objectives
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Definition
Distinguish from Seizure
Causes: serious or not, cardiac or not
‘Targeted’Hx, Px, Investigations
Initial Management Plan
Who needs referral, fitness to drive
Syncope
• A 73 y.o. man collapsed in the bathroom and had a 30
second episode of unresponsiveness at 0430. He awakes
fully, and is brought to the Emergency Department by his
wife.
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Is this a syncopal episode?
What are the causes of syncope?
What is the likelihood he had a cardiac cause of syncope?
What is your workup and management of this patient?
What is syncope?
• Sudden, transient loss of consciousness
• Rapid and complete recovery
• May have minor myoclonic jerks or muscle
twitching
• No postictal state
How is a generalized seizure
different than a syncopal episode?
• SEIZURE
• Aura (parasthesia, noises, light, vertigo)
• Tonic-clonic movements and loss of
consciousness
• Post ictal confusion for minutes-hours
• Tongue biting
• Incontinence bowel or bladder
Syncope
• Prodrome often occurs
– Feeling faint, hot, lightheaded, weak, sweaty
• Brief loss of consciousness
– seconds to 1-2 minutes
• Rapid and complete recovery
• Speaking normally within 1 minute
– No post event confusion
What are the common causes of
syncope? (MCC)
• Cardiovascular (80%)
– Cardiac arrhythmia (20%)
– Decreased cardiac output –MI, Ao. Stenosis
– Reflex/underfill (60%) (vasovagal, orthostatic)
• Cerebrovascular (15%)
• Other
– metabolic
– psychiatric
Cardiovascular Causes of Syncope
• Cardiac arrhythmia (20%)
– Tachy or bradycardia
– Carotid sinus syndrome
• Decreased cardiac output
– Inflow obstruction (to venous return) ex. PE
– Squeeze: Myocardial ischemia (decreased contractility)
– Outflow obstruction (Aortic stenosis, hypertrophic
cardiomyopathy
Cardiovascular Causes of Syncope
• Reflex/Underfill (60% of syncope)
– Vasovagal (common faint)
– orthostatic/postural ex. Blood loss
– Situational (micturition, cough, defecation)
• Cerebrovascular Causes (15%)
– TIA
– vertibral basilar insufficiency
– high ICP
• Metabolic : hypoxia, low BS, drugs, alcohol
• Psychiatric: hyperventilation, panic
What is your initial approach with
your patient with syncope?
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Check ABC,s,
5 vitals -postural
monitor, IV, ECG, blood tests
Bolus fluids if hypotensive 250-1000cc NS
glucosan
give thiamine if giving glucose
consider naloxone if patient not fully awake
history and physical
History
• what happened (witnesses important)
• what were you doing (ex. urination,
standing up quickly etc.)
• prodrome (hot, sweaty, vomiting)
• any tonic-clonic activity
• postural or neck turning
• recovery – long or short
– any confusion
Review of Systems
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volume status (eating, diarrhea, exercise)
recent blood loss
chest pain, palpitations, SOB,
any focal neurologic symptoms
pregnancy
PMH
• previous history of syncope
• ex. occasional episodes over the years vs
several episodes recently (more sinister)
• cardiac disease or medications
• bleeding disorders or PUD
• diabetes
• medications ex. antihypertensives often
cause orthostatic syncope
Physical Exam
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ABC
Orthostatic Vitals
HEENT: trauma, papilledema,
Resp/CVS: S3, AS murmur,
Abd: aorta, pulses, peritoneal, blood PR
Pelvic: bleeding, tenderness
Neurologic: focal findings
Lab Investigations
• CBC
• Type and xmatch
– If suspect acute blood loss AAA, ectopic, GI bleed
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Lytes, BS, BUN, Cr
D dimer
Pregnancy Test
ECG
CT Head if suspect cerebrovascular cause
Holter
EEG
Vasovagal Faint
• Common (60% all syncope)
• Increased parasympathetic tone
• Bradycardia, hypotension
Vasovagal Faint -Predisposing
Factors
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Fatigue
Hunger
Alcohol
Heat
Strong smells
Noxious stimuli
Medical conditions anemia, dehydration
Valsalva (trumpet player)
Vasovagal Faint
Symptoms and signs
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Warm, sweaty
Weak
Nausea
Confused
Unprotected fall
Eye rolling, myoclonic jerks,
Resolves in 1-2 min
Rarely tongue biting or incontinence
Not confused afterward
Cardiac Syncope
• 20% all syncope
• Serious prognosis
• Exertional syncope
– Outflow obstruction AS, IHSS
• Ischemia/MI
• Conduction disorders
• dysrhythmias
Orthostatic
• Decrease in systolic BP by 20-30 or
increase in pulse by 20-30 on standing
• Supine
• Meds -antihypertensives
• Blood loss, dehydration
Syncope-When to Admit
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Uncertain diagnosis
Elderly (more likely cardiac)
Suspected cardiac etiology
Abrupt onset with no prodrome (typical for
dysrhythmia)
• Unstable vitals
• Blood loss
Our 73 y.o. man who collapsed in the
bathroom and had a 30 second episode of
unresponsiveness at 0430.
In the ED, he had another brief syncopal
episode, following by sinus tachycardia
What is his problem?
What would you do?
Our 73 y.o. man who collapsed in the
bathroom and had a 30 second episode of
unresponsiveness at 0430.
• Sick sinus syndrome: need pacer
An 80 y.o. man complains of recurrent
syncope
What is his diagnosis and treatment?
An 80 y.o. man complains of recurrent
syncope
What is his diagnosis and treatment?
• Third degree Heart Block
A 65 y.o. man on diuretics has
recurrent syncope
A 65 y.o. man on diuretics has
recurrent syncope
Long QT
Torsades de Pointes
Treatment of Torsades
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Correct electrolytes
Magnesium 2 gm over 20 min
Isoproterenol 2-20 mcg/min
Overdrive pacing
Cardiac Pacing
When is it required?
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3rd degree (complete HB)
2nd degree type ll
Sick sinus syndrome
Symptomatic bi or trifasicular blocks
– Ex. RBBB + LAH + 1st degree HB
• Symptomatic bradycardia
Fitness to Drive
• CPSO: > 16 yrs old
– Suffering from a condition that may make it
dangerous to operate a motor vehicle
• Single episode of syncope that is easily explained
ie. Simple faint dosen’t need reporting
• Recurrent episodes or suspected cardiac cause
– needs to be reported and the patient shouldn’t
drive til a cause is determined and treated.
?
Break
Coma
Coma
MCC Objectives
• Definition and Causes of coma
• Clinical Assessment
– Know how to examine a patient in a coma
– Assessment tools (GCS)
• Critical Investigations: appropriate lab and imaging
• Management plan
– Who needs immediate treatment; úrgent and emergent
– Who needs specialized treatment
• Management of Incompetent Patients-proxy decisionmaking
What is Coma?
• MCC Defintion:
• state of pathologic unconsciousness
(unarousable)
An 80 y.o. man is comatose 2 weeks
after falling down stairs?
Why is this patient comatose?
Isodense Subdural Hematoma
Enhanced CT Head
A diabetic patient present in a coma and is
found to have a BS of 1.5
Why are they in a coma?
Coma
Can be induced by structural damage or chemical
depression
1) reticular activating system in brainstem, midbrain,
or diencephalon (thalamic area)
• Ex. Pressure from a mass
• Toxins
2) Bilateral cerebral cortices
– Ex. Toxins, hypoxia, hypoglycemia
A 45 y.o. ‘street’ person is brought
into the ED in a coma. What are the
causes?
Causes of Coma
• Structural
– Bleed, CVA, CNS infection,
• Metabolic (medical)
– A,E,I, O, U, TIPS
•
•
•
•
•
•
•
•
•
•
•
A 45 y.o. ‘street’ person is brought
in to the ED in a coma. What are the
causes?
AEIOU TIPS
A - alcohol, anoxia
E – epilepsy, electrolytes (Na, Ca, Mg), encephalopathy (hepatic)
I - insulin (diabetes)
O - overdose
U - uremia, underdose (B12, thiamine)
T- trauma, toxins, temperature, thyroid
I - infection
P - psychiatric
S - stroke (cardiovascular)
What is your initial approach with
this comatose patient?
•
•
•
•
•
•
•
•
•
A-airway protection (and c spine)
B-breathing O2 sat
C-5 vitals (pulse, BP, temp)
D-dextrose Glucoscan
Thiamine (if giving glucose)
Naloxone (should have small pupils)
IV, ECG monitor, foley, labs
Hx, Px
Determine level of consciousness
Why Thiamine if giving a bolus of
glucose
• Precipitate Wernicke’s encephalopathy
• Cranial nerve palsy - ocular
• Confusion
• Ataxia
Level of Consciousness
• AVPU
– Awake, verbal, pain , unresponsive
• Glasgow Coma Scale
GCS
Best Eye Response. (4)
1. No eye opening.
2. Eye opening to pain.
3. Eye opening to verbal command.
4. Eyes open spontaneously.
Best Motor Response. (6)
1. No motor response.
2. Extension to pain.
3. Flexion to pain.
4. Withdrawal from pain.
5. Localising pain.
6. Obeys Commands
Best Verbal Response. (5)
1. No verbal response
2. Incomprehensible sounds.
3. Inappropriate words.
4. Confused
5. Orientated
8 or less = coma
History
•
•
•
•
•
What happened?
Symptoms: depression, Headache
Gradual or sudden LOC
Sudden = intracranial hemorrhage
Gradual more likely metabolic, could be
subdural
• PMH: diabetes, thyroid, hypertension,
substance abuse, alcohol
• Meds,
Physical Exam
• Goal: Try and determine if a
structural lesion is present, or a
metabolic cause.
How do structural lesions present
differently than metabolic causes of
coma?
Physical Exam
• Structural lesions:
– Often have focal findings, abnormal pupils,
evidence of increased ICP
• Metabolic causes:
– No focal findings, pupils equal mid or small, no
evidence of increased ICP
Signs and Symptoms of
Increased ICP
•
•
•
•
•
•
Headache, N, V,
Decreased LOC
Abnormal posturing
Abnormal respiratory pattern
Abnormal cranial nerve findings
Cushing Triad: late sign of high ICP
– high BP, bradycardia, and low RR = high ICP
Physical Exam
•
•
•
•
Vitals
BP > 120 diastolic may cause encephalopathy
Hypotension uncommon with intracranial pathology
Temperature
– Infection, CNS or otherwise
– Neuroleptic malignant syndrome
• antipsychotics, dopaminergic (levadopa) , or
anti-dopamine (metoclopramide)
• Altered mental status, muscle rigidity, and fever
Respirations
• Cheyne stokes
– Fast alternating with slow breathing
• Brain lesions, acidosis
• Apneustic
– Pauses in inspiration
• Pons lesions, CNS infection, hypoxia
Physical Exam
• HEENT:
– Battle’s sign, hemotympanum.
– Breath odour
• Ex. Acetone = DKA
Pupils
• Metabolic:
– pupils usually react
• Structural:
– may be unilateral dilatation Why?
• Uncal herniation presses on CN 111,
• Lose Parasympathetic tone
• Unapposed sympathetic stimulation
• 10% normal people have 1-2 mm difference
Pupils
• Fixed dilated pupils ominous
• Dead, central herniation, hypoxic injury
• Small pinpoint pupils
– Lesion in pons (ischemic or bleed
– Opiate OD
Physical Exam
• Corneal Reflex
– Sensory CN 5, and Blink is CN 7
Extraocular Movements
• Helps determine brainstem function in coma
• Doll’s eyes
– Eyes move in opposite direction to head
movement
– indicates functioning brainstem
Oculocephalic Reflex
Ensure C spine cleared
• Awake person:
– eyes look forward, some nystagmus
• Comatose patient with brainstem function:
Eyes deviate completely in opposite
direction to head movement
• Comatose Patient with no brainstem function
– Eyes follow head movement
Oculovestibular Reflex
Cold Calorics
• Check eardrum
• 50 cc iced saline
• Awake person:
– COWS
– Nytagmus away from cold
– Driving a car, cerebral cortex keeps you on the
road
Oculovestibular Reflex
Cold Calorics
• Comatose patient, intact brainstem
– Eyes deviate to cold side
– Hey who’s putting ice in my ear
• Comatose patient, nonfunctioning brainstem
– No reaction
Physical Exam cont.
•
•
•
•
Disc
Nuchal rigidity
Resp/CVS/Abd/Extrem
Neuro:
level of consciousness, CN, Motor, Sensory,
DTR
Motor Exam
•
•
•
•
Is there asymmetry in response to pain
Evidence for seizures?
Withdrawing: nearly awake pt
Decorticate:
– Abnormal flexion response. Flexes elbow,
wrist, and adducts shoulder
– Cerebral cortex injury
Motor Exam
• Decerebrate posture
– Extends elbow with internal rotation
– Lesions or metabolic effect in midbrain
• Flaccidity
– Ominous sign
– Toxin/OD
Labs ?
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•
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•
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CBC,
Lytes, Bun Cr, BS
LFT, Ca, Mg,
ABG
Alcohol, Osmolality
Tox screen
CO level
Diagnostic Tests/Imaging
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•
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•
CXR
CT Head
LP
ECG
EEG
A 25 y.o. woman presents in a coma.
Pupils pinpoint. RR 8. No focal
findings?
What will you do?
•
•
•
•
ABC’s, vitals
BS
Naloxone 0.4-2 mg IV
What if she is chronically taking narcotics?
A 30 y.o. man, hit on the head,
comatose with a unilateral fixed
dilated pupil?
What would you do?
•
•
•
•
Intubate, pC02 to 30 mmHg
Mannitol .5 gm/kg
CT Head
Stat Neurosurgery consult
Uncal Herniation
Summary COMA
• ABC, Vitals, O2, CO2, BS, Naloxone
• Metabolic vs Structural
• Key to Exam
–
–
–
–
Respiration
Pupils
EOM
Motor response
Competence / Capable
• Understands medical issue
• Understands treatment proposed
• Understands consequences of accepting or
refusing treatment
Substitute Decision Making
Highest of
?
Hypotension Shock – MCC
Objectives
•
•
•
•
•
•
Causes
History
Examine
Diagnose: interpret symptoms and signs
Labs
Management strategy
– Restore tissue perfusion
– Specific therapy for each cause
What Is Shock
• Tissue hypoperfusion or tissue hypoxia
Shock
• Catecholamine surge
• Vasoconstriction, increased CO
• Renin-angiotensin, vasopressin
– Salt and water retention
Shock
• If persists
–
–
–
–
–
Lactic acidois, decreased CO and vasodilation
Cell membrane ion dysfunction,
cell edema
Leakage of cellular contents
Cell and organ death
Shock What are the causes?
Obstructive
Obstructive
Card
iac
Hypovolemic
Distributive
• Obstructive Shock
– PE, tamponade, tension pneumothorax
• Cardiac
– Pump failure: MI, ruptured cordae or septum
• Contutsion, aortic value dysfunction
– Dysrhythmia
• Hypovolemic
– Blood Loss
• Trauma, AAA, aneurysm, GI bleed, ectopic
– Dehydration
• Gastro, DKA, Burns
• Distributive
– Sepsis –most common
– adrenal, neurogenic, anaphylactic
– Toxins (cyanide), CO, acidosis
Initial Management
• ABC’s
• Vitals
• MAP = DBP + 1/3 PP (SBP-DBP)
– MAP <70 = shock (inadequate perfusion)
• IV How much?
– Fill the patient up
• Two, 16 ga, 500-1000cc bolus
• Cardiac shock: bolus 250 cc at a time
Hx and Px
• Ask questions and examine carefully to rule
in or out all of the major causes of shock
• ABC approach
• Head to Toe Survey
Labs
•
•
•
•
•
•
BS
CBC, lytes, liver/renal function
Lipase, fibrinogen, fibrin split products,
Cardiac enzymes, ABG, ECG, urine,
Tox screen
Stool OB
A 75 y.o. comes in confused x 2
days, lethargic
• BP 80/50 P. 130 T 38 RR 25 02 85%
• What is his diagnosis?
• What would you do?
Septic Shock
• Fluids: normal saline 1-2 litres
• Oxygen
• Treat the infection:
– Antibiotics: broad spectrum
– 3rd generation cephalosporins
– Pip-tazo
• BP support: inotropes: dopamine
A 39 y.o. man arrives in the ED having been
stung by a bee 30 minutes ago. He has hives,
facial and tongue swelling and is dyspneic.
• What will you do?
• BP 70/50 P. 140
Anaphylaxis
• 100 % oxygen
• bolus 1-2 litres normal saline
• epinephrine 0.3 mg IM q5min
• or 5-15 microgm/min IV with shock
•
•
•
•
benadryl 50 mg IV
ranitidine 50 mg IV
solumedrol 125 mg IV
Glucagon 1mg IV if on beta blockers
?
Cardiac Arrest – MCC Objectives
• Causes
– Cardiac and noncardiac
• Investigations
• Management plan-CPR and ACLS protocols
• Communicate
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–
–
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DNR
Death
Organ donation
Autopsy request
Cardiac Arrest - Causes
• Cardiac
– Coronary artery
– Conduction
• Metabolic: hypo Ca, Mg, K, anorexia
• Brady or tachydysrhythmia
– Myocardium
• Hereditary: cardiomyopathy
• Acquired: LVH, Valve disease, myocarditis
Cardiac Arrest - Causes
• Non Cardiac
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–
–
–
Tamponade
PE
Tension
Trauma
A 72 y.o. man complains of chest
pain and collapses in the ED
• What are you going to do ?
Sudden Cardiac Arrest
• electrical accident due to ischemia or
reperfusion
• 80%
ventricular fibrillation or
ventricular tachycardia
• 20 %
asystole
pulseless electrical activity
Mechanism of Fibrillation
• ischemia:
slows conduction
• adjacent myocardium in various phases of
excitation and recovery
• multiple depolarizing reentrant wave fronts
Ventricular Fibrillation (V. fib.)
Ventricular Tachycardia (V. tach)
Cardiac Arrest
• What are the key actions that are required to
improve survival from cardiac arrest?
Chain of Survival
Major Changes of BLS
• Change in CPR sequence to :
–C-A-B rather than A-B-C...
• Begin with chest compressions !!!
Major Changes of BLS
• Trained Layperson or Health Care Provider
– 30 compressions, 2 breaths
• Untrained layperson
– Compression only CPR acceptable
– ‘Hands Only’ CPR
Major Changes of BLS
• Elimination of : “Look, Listen & Feel” for
breathing...
• …except for hypoxic arrest
• Pulse check for Health Care Providers < 10
sec.
High Quality C.P.R.
• Compression : Ventilation ratio (30 : 2)
– Until advanced airway
• Minimize interruptions in CPR
• Push Hard & Fast : 2 inches / 100/ min.
• Full chest recoil-lift hands off chest
• Change compressors q2min
Airway Management
• BVM (Bag-Valve-Mask)
– Avoid hyperventilation!
– 8 – 10 breaths / min. interposed with CPR
• Secure Airway & Confirm Placement
– No need to pause compressions!
• Advanced airway: LMA, ETT
– ETCO2 monitoring !
Airway & Adjuncts
• Role of cricoid pressure during cardiac arrest
has not been studied.
• Routine use of cricoid pressure in cardiac
arrest is not recommended.
What are the only things that should
interrupt CPR?
•
•
•
•
Rhythm and pulse check
Ventilation (if advanced airway not present)
Advanced airway and intubation
Defibrillation
A patient you are talking to suddenly
becomes unresponsive
The crash cart arrives, you grab the paddles
and have a quick-look
Is this
A) Normal sinus rhythm
B) Ventricular tachycardia
C) Ventricular fibrillation
D) Can I call a friend?
Would you:
A) Do 2 minutes of CPR then defibrillate
B) Defibrillate immediately
What if the patient had an unwitnessed arrest?
New CPR Guidelines
• Even with unwitnessed arrest….
• Once V fib is recognized…shock ASAP
Shock Protocol
• Shorten interval between compressions and shocking
– improves shock success.
• After shock delivery, resume CPR immediately
– Don’t delay chest compressions for rhythm or pulse check
How many times do you
defibrillate?
No Change in Recommendations
• 1 shock then resume CPR
If you can’t get an IV, what other
route can you give drugs?
• Intraosseus
• Endotrachael: (not a good route)
Intraosseous Access
Your patient is still in this
rhythm !
Cardiac Arrest Medications
No Significant Change in New Guidelines
• Vasopressors
– Epinephrine
• 1 mg q3-5 min
– Vasopressin
• 40 units
• May replace 1st or 2nd dose of epinephrine
Cardiac Arrest Medications
No Significant Change in New Guidelines
• Antiarrythmics
• Don’t revert v fib.
• Work by preventing V.Fib,
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–
–
–
Amiodarone –
Procainamide
Lidocaine
Magnesium Sulfate
Amiodarone
• First line antidysrhymthmic
• 300 mg IV bolus
• May give 2nd dose: 150 mg
Lidocaine
• 1.5 mg/kg
• Repeat x 1 prn.
• The paramedics brings in a 56 y.o. man who
arrested at home, was successfully
defibrillated but remains comatose and
intubated. BP. 100/70, P. 75 NSR
• What other treatment options are available
to you to increase survival?
Therapeutic Hypothermia for Cardiac Arrest
• Cool to 32-34°C x 24 hrs
• Criteria:
– adult patient prehospital cardiac (v.fib) arrest
.
– Spontaneous circulation BP > 90
– Patient remains comatose and intubated
?
A 69 y.o. patient you are assessing
for chest pain suddenly complains of
palpitations
Is this
A) Normal sinus rhythm
B) Ventricular tachycardia
C) Supraventricular tachycardia
D) I don’t know but it looks bad
A 69 y.o. patient you are assessing
for chest pain suddenly complains of
palpitations
Is this
A) Normal sinus rhythm
B) Ventricular tachycardia
C) Supraventricular tachycardia
D) I don’t know but it looks bad
What do you do next?
What do you do next?
Determine if patient stable or unstable!
BP 110/60, no SOB, no chest pain
A) Give lidocaine 100 mg
B) give amiodarone 150 mg IV
C) sedate and cardiovert
D) Adenosine 6 mg IV
Adenosine
• recommended as a safe and potentially
effective therapy in wide-complex tachycardia
• Poor evidence
• Level 11b: Observational retrospective studies
– Critical Care Medicine – Marill, KA Sept 2009
Which medications are useful for
terminating monomorphic VT
• Lidocaine: 6 studies (8-30% effective)
• Procainamide: few studies
– 30% effective
• Amiodarone: small case reports only
• 30%
Amiodarone in V. Tach
• 150 mg over 10 min
• may repeat up to 5-7mg/kg
• infusion: 1 mg/min for 1st 6 hours
»then 0.5 mg/min
Lidocaine in V. Tach
• 1.5 mg/kg bolus
• 2nd and 3rd dose: 0.75 mg/kg q 5 min
• Total maximum: 3 mg/kg
Ventricular Tachycardia
• Do not give multiple antidysrhythmics if
one has failed (pro-arrhythmic effects)
• pick one antidysrhythmic, if it fails, go to
electrical cardioversion.
Ventricular Tachycardia-Summary
• If stable: can try drugs but cardioversion best
choice
• If unstable: cardiovert (synchronized)
• If pulseless: defibrillate
• Drugs rarely effective
An 80 y.o. patient admitted for
pneumonia is found unresponsive
by the medical student
• What is your management
• This is his rhythm on the monitor!!
Asystole
Witnessed Arrest ?
Yes
No
CPR - Intubate - IV access
Confirmation in 2 leads
ACLS futile?

Possible causes
Hypoxia
Hyperkalemia
Hypokalemia

Acidosis
Drug overdoses
Hypothermia
Epinephrine 1 mg IV q 3 - 5 min
(consider 1 dose Vasopressin 40 IU IV may replace 1st or 2nd dose epinephrine)

Consider termination of efforts
Atropine no longer recommended
A 65 y.o. man admitted to the CCU with
chest pain is found unresponsive by the
medical student. He has no pulse.
He has the following rhythm
PEA
• Treatment:
• Find and treat cause
• (Is there a shockable rhythm?)
• Epinephrine 1 mg IV
• (no longer atropine)
PEA
• Consider causes:
– 5 H’s :
– hypovolemia, hypoxia, H ion, hyper/hypo K,
– 5 T’s:
– tamponade, tension pneumo, thrombosiscoronary or pulmonary, tablets OD
A 49 y.o. patient arrives in the ED complaining of
palpitations for 1 hour.
What is this?
A) Atrial fibrillation
B) Atrial flutter
C) Ventricular tachycardia
D) A-V nodal re-entrant tachycardia
E) Sinus tachycardia
What will you do?
SVT
STABLE
UNSTABLE
CARDIOVERSION
VAGAL MANOEUVRES
Class 1
Verapamil 2.5 – 5 MG I.V. over 2 min or Diltiazem 20 mg IV over 2 min)
or
Adenosine 6 mg IV then 12 mg if needed
RAPID PUSH
or
Metoprolol 5 mg IV repeat x 2 prn
A 75 year old woman complains of dizziness.
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
What are the treatment options if:
1) her BP is 120/80 and she looks well
2) her pulse was 45, BP 70/30 and she looks ill
Second degree HB type ll
• Dysfunctional His Purkinje system
can lead to complete heart block
• If stable, send to monitored bed, and
arrange permanent transvenous pacer
• If unstable: external pacing, or dopamine or
epinephrine infusion.
A 70 yo woman complains of dizziness x 3 days
What is this rhythm?
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
A 70 yo woman complains of dizziness x 3 days
What is this rhythm?
A) NSR
B) Second degree HB type 1
C) Second degree HB type 2
D) Third degree HB
Would 1 mg of epinephrine be
appropriate if her BP was 60/40
A) Agree
B) Disagree
Bradycardia
When to Treat ?
• Symptomatic: chest pain, SOB, hypotension
• Therapy:
–
–
–
–
atropine 0.5-1 mg (max total 3 mg)
transcutaneous pacemaker OR
dopamine 5-20 microgm/kg/min OR
epinephrine 2-10 microgm/min
A 72 year old man complains of
persistant retrosternal chest
heaviness
What is your management ?
Is this: A) Pericarditis
B) Benign Early Repolerization
C) STEMI
A) Agree
B) Disagree
Is this: A) Pericarditis
B) Benign Early Repolerization
C) STEMI
A) Agree
B) Disagree
Myocardial Infarction
What can you do?
• MONA
–
–
–
–
ASA 160 mg chew
Oxygen
nitrates sublingual or IV
morphine 2-3 mg prn
Myocardial Infarction
What can you do?
•
•
•
•
Antiplatelets: clopidogrel or ticagrelor
Heparin
Thrombolytics < 30 mins
Primary PTCA <90 mins
– Percutaneous transluminal coronary angioplasty
An 80 year old man is being
treated in hospital for pneumonia.
He is found VSA at 0300. His
rhythm shows asystole.
How long are you required to
perform CPR for?
CPR and ACLS
Purpose: treatment of sudden
unexpected death.
When Not To Initiate CPR
• CPR is inappropriate and ineffective for
medical problems where death is neither
sudden or unexpected
• don’t offer CPR as an option to patients or
families if it is not medically indicated
• communicate openly
When to Discontinue CPR
• Judgement that patient is unresuscitatable
• Variables:
– down time, rhythm, age, premorbid conditions
– advance directives
You have just finished a 45 minute
unsuccessful resuscitation attempt on a
42 y.o. man. His wife is anxiously
waiting.
How do you tell her that her husband has
died?
How do you make it less stressful on the
survivors when a sudden unexpected
death has occurred.
Sudden Unexpected Death
• Develop multidisciplinary approach
• Develop intervention strategy
• Contacting Survivors
– Avoid disclosure on the phone
– meet family at a specific site
CMAJ 1993 149(10) 1445-1451
Sudden Unexpected Death
• Arrival of Survivors
– met by RN, or Social Worker
– updated regularly
Should the family be brought to the bedside
if the resuscitation attempt is ongoing ?
Sudden Unexpected Death
• Notificiation of Death
–
–
–
–
–
–
–
obtain all information prior to meeting
quiet room, have RN also there
sit next or across from closest relative
explain in lay terms sequence of events
use the words dead or died
express condolences
answer questions now or later
Sudden Unexpected Death
• Grief Response
– private time
• Viewing Deceased
– encourage family
– clean patient and remove equipment if possible
• Conclusion
– return valuables, address concerns
– give family permission to leave
?