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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, June 29, 2015

The story of Kayexalate!

Hyperkalemia is a life-threatening emergency that can cause arrhythmias and cardiovascular collapse. As Emergency Physicians, we must be able to anticipate and treat Hyperkalemia better than anyone else. No surprise, why we have been about the management of Hyperkalemia “n” number of times. Lets look at the evidence behind one of the treatment modalities for Hyperkalemia;  “Kayexylate” aka “K-Bind/SPS”.

Sodium polystyrene sulfonate (SPS, Kayexalate) is a cation-exchange resin that has a higher affinity for potassium than sodium. In the lumen of the colon, it exchanges sodium for secreted potassium. It can cause severe constipation; therefore sorbitol/mannitol is added to it as a cathartic. FDA approved K Bind in 1958. This was based in two studies done with very limited number of patients were published in NEJM, 1961 supported the use of SPS. There were potential flaws with these studies like no control group; patients were fed with sugar (which causes insulin release and decreases potassium) and poor statistical analysis.

1. Scherr et al. 32 patients with hyperkalemia and renal failure, various doses of SPS were given with various dosing schedules and courses of treatment. Reduction of serum K by 0.4 in 66% pts after 24 hours. Not a RCT, no controls, patients in the study were also on: low potassium diets, many received bicarb/insulin/glucose

2. Flinn et al, 10 patients, 5 kayexalate/sorbitol PO, 3 sorbitol, 2 kayexalate/sorbitol enema. All on low potassium diets and diuretics. 5 days QID dosing, steady decrease in potassium.

In addition to the questionable benefit, now there is mounting evidence describing constipation and colonic necrosis with the use of SPS. In 2011, FDA issued a warning with the use of SPS. There is more and more literature coming up against the use of SPS. Evidence Based Medicine has come a long way over last 50 years and we need to review this practice.


So, SPS is a potentially harmful therapy to treat hyperkalemia, it has a slow onset action (if at all) and  doubtful efficacy. It also carries risk of life threatening gastrointestinal complications. There is no convincing evidence that SPS increases fecal potassium losses.

So next time, ask yourself if SPS (K-Bind) is really required !

References:
1.  Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: Are they safe and effective? J Am Soc Nephrol 21: 733-5, 2010
2.   Gruy-Kapral C, Emmett M, Santa Ana CA, et al. Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease. J Am Soc Nephrol 9: 1924–30, 1998.
3.  Bomback A, Woosley JT, Kshirsagar AV. Colonic necrosis due to sodium polystyrene sulfate (kayexalate). Am J of EM 27: 753.e1-753.e2, 2009.
4.   Welsberg LS. Management of severe hyperkalemia. Crit Care Med 36: 3246-51, 2008.
5.  Rogers BR, LI SC. Acute colonic necrosis associated with sodium polystyrene sulfonate (kayexalate) enemas in a critically ill patient: Case report and review of the literature. J Trauma 51: 395-7, 2001.
6. Systematic review of adverse events caused by kayexalate (The American Journal of Medicine Volume 126, Issue 3 , Pages 264.e9-264.e24, March 2013)
7.  http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/011287s023lbl.pdf


Monday, June 22, 2015

Monday, June 15, 2015

For people who think ED is a cocoon - Think again!!


As emergency physicians we need to speak a lot to different people in the ED and the fact that people are so different from each other makes the task very challenging. Communication plays an important role in the smooth running of the ED. Since ED is an emotionally charged area, where patient’s attenders constantly look up to the doctor for his next words about the condition of the patient and next course of action, conflicts sprout up very easily when we lack effective communication skills.  The words we speak, thus makes a (huge) difference! We are what we speak!



General rules:

1. Recognize there’s something called ‘Transference and countertransference’:  Some patients don’t like you without any seemingly obvious explanations or reasons and the vice versa also sometimes holds good. Have you thought why?




           
Transference is the phenomenon whereby we unconsciously transfer feelings and attitudes from a person or situation in the past on to a person or situation in the present. The process is at least partly inappropriate to the present” (patient might think ‘this doc seems to be an idiot’)

“Countertransference is the response that is elicited in the recipient (therapist) by the other's (patient's) unconscious transference communications” (Might make you think ‘this guys is such a pain in the a**)

Awareness of the transference–countertransference allows reflection and thoughtful response rather than unproductive reaction from the doctor.


2. Introduce yourself: Does that require more introductions? May be yes! Often we have seen doctors who just jump in and start checking for abdominal tenderness without even uttering a word while the patient stares at the doctor thinking “Who the heck is this guy?”


 Often we think this isn’t important (especially in India!)  . This often is the first step towards building a good rapport.  Say who you are. How do you expect the patient to know that you are the emergency physician who’s gonna treat him now?!

3. When there’s a crowd/mob of relatives, try to keep only 1-2 attenders inside the ED.





Make them understand that crowding will hinder the progress of treatment in the ED and will add to unnecessary confusion. Tell this in a convincing way rather than a paternalistic manner.

4. Find out to whom you are speaking to? How’s he related to the patient? When asking history, LISTEN before you speak

 (Interrupt only when you think he’s describing how USA captured Osama when asked about chest pain of the patient)




5. Don’t be Judgmental: Never ever judge a person before you get to know the complete story. Don’t get carried away by your biases (Yes, each one of us is biased). Put yourself in other person’s shoes (‘Chappals’?! Ok that will also do) before you judge someone!




6. Use Please, Thank you and Sorry SOS




7. Be confident about what you speak. Most of the scuttle in the ED starts when we are not confident of what we are speaking.





It’s always good to mentally prepare ourselves before we speak to the relatives about the patient. Be clear about the present condition and next plan of action. Brief them if you have any concerns. One of the most common questions we encounter is “Is he out of danger?” Be very (you can add few more VERYs) cautious when you answer this question. The answer usually cannot be a mere YES or NO. Explain that to the relatives and make sure they understand the gravity of the situation.

Before we look at how to speak to the attenders, let’s try to classify different types of attenders we see in the ED commonly followed by Dos and DONTs in communication wrt each groups.

1. Parents of a sick child:
These are a special population and would require special care as they are genuinely concerned about the health of the child (No, we aren’t talking about Munchausen’s) and most of the times very anxious.







DO'S
  • Reassure them: Say everything has been in place for the wellbeing of the child. Update them about the general condition of the child. Quickly give an overview of differential diagnoses after the initial assessment and the next plan of action.
  • Make sure you address the primary ‘cause of concern’ – It’s not uncommon to hear ‘’Head of the child becomes hotter than the rest of the body’’ being the primary concern of the parents while you are more worried about the pneumonia and low SpO2. Make sure you address the primary concern by suitable explanation as you discus your concerns.
  • When parents say something is abnormal about child’s behavior, BELIEVE! (Yes, they know better)
  • ANALGESIA IN KIDS IS AS IMPORTANT AS IN ADULTS. Discuss regarding analgesia in detail with parents. Provide good analgesia. Involve senior on the shift, ED consultant, Pediatrics/Pediatric EM consultants when in doubt about dosages. (It’s not always half tablet Paracetamol)
  • Try non-pharmacological modalities for relieving pain/anxiety. Distraction often really works as an adjunct to the medicines for pain.
  • Read this article about pediatric specific techniques that can be adopted in the ED on REBEL EM: http://rebelem.com/7-pediatric-hacks-for-your-ed/

DON’T
  • Don’t be judgmental about the parents or the child (Not all kids complaining pain abdomen are malingering)
  • Don’t be rude / cruel to the kid or parents. If the kid is not cooperating that shows your inability to deal with the kid and not kid’s issues with coping.


2. Angry attender: Angry people are a common finding in EDs. The reason for anger could be multiple; ranging from waiting time in the ED to grief reaction upon the death of a patient. (Sometimes even the non-functional Air conditioner)




DOs and DONTs
  • Find out the reason for the anger and offer him help.
  • Be gentle in your approach. Taking him to a room and offering him some water would help. Put possible practical solutions before him if the reason for the anger is genuine.
  • Be safe when speaking to such attenders. Involve senior on the shift or keep him informed. Don’t put yourself at risk of physical harm.  Keep the security informed about the situation if you sense that the person is a ‘trouble maker’.
  • Never raise your voice or be angry. Don’t lose your cool.


3. Overtly anxious attender


   This problem is commonly encountered when dealing with kids. But a good conversation with the parents would solve the problem. 
    When there’s anxiousness ‘out of proportion’ to the existing problem despite being explained about the condition would say two things: 1) The person is generally over anxious (Type A personalities) 2) Case of abuse, troubled relationships, harassment, etc. Always keep the later in mind and offer help to the patient in every possible way.

4. Unruly Crowd / Mob
This is a serious problem especially if you are working in India. Even though there are tough laws dealing with violence against healthcare providers, there are serious lapses when it comes to implementation of these laws. So it has become a regular menace to the doctors and emergency physicians are undoubtedly the most susceptible group when compared to other specialties. Some hospitals have even gone to the extent of hiring private bodyguards (bouncers) as a safety measure. (Read: http://www.ndtv.com/india-news/indian-hospitals-hire-bouncers-to-deter-attacks-498923)



Your safety is of prime importance when you work in the ED. Most of these incidences occur when there is presumed negligence by the doctor / hospital staff.

  • All the general rules apply in this situation as well.        
  • Keep the security informed.
  • Keep the local police informed about the situation
  • Let the ED Head and the hospital administration know about the situation.
  • Try to calm down the situation by whatever means you can. (If you can’t do this, at least don’t add fuel to the fire)
5. ‘Obsessive compulsive googler with internet based diagnosing skills’.


Ah! You know what I’m talking about!
‘I know everything-I have diagnosed myself with ABC variant of XYZ disease-Just came here to check how good doctor’s knowledge of the condition is-I already self-medicated with PQR drug-Would like to undergo 123 test-I will never be happy if the test results are negative or if you tell me I’m wrong-I will find problems with all your advices and prescriptions-Your Paracetamol will damage my liver and you are still giving it to me-I don’t need solutions at all’ types.
Dealing with this kind of people is indeed a very tough job.
-        Be PATIENT while they check your patience.
-        Like the great men said – “Use individualized approach” 

6. Attenders with ‘VIP-syndrome’
Again this seems more to be an India-specific problem.
An unknown person wearing white shirt and white pant enters the ED from nowhere and almost inserts his mobile phone into doctor’s mouth saying “Baat karo…Baat karo..Saab se baat karo” (Speak…Speak…Speak to the master) before you even take a glimpse at the patient.



Keep your calm. Make them understand that you would speak to whoever it is on the
phone once you see and assess the patient.

Involve senior on shift and administrative staff early in case you sense some trouble.

These are some of the tips that are helpful for an effective communication in the ED. I hope this would have helped you just like a revision tool for the communication course (Your ED rotations) you have undergone all through these years. 

Thank you!


References:
  1. “Transference and countertransference in communication between doctor and patient”
  2. Patricia Hughes, Ian Kerr Advances in Psychiatric Treatment Jan 2000, 6 (1) 57-64; DOI: 10.1192/apt.6.1.57
  3. Oxford handbook of emergency medicine: General approach.
  4. Emergency department violence http://www.acep.org/workarea/DownloadAsset.aspx?id=81782
  5. “Doctor-Patient Communication: A Review” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096184/ PMCID: PMC3096184
  6. “Effective physician-patient communication and health outcomes: a review.” http://www.ncbi.nlm.nih.gov/pubmed/7728691



                 
                 Author 


                 Dr. Apoorva Chandra
                 Resident, Emergency medicine         
                 Apollo health city, Hyderabad                                                         
                 Twitter: @apoorvamagic    
                 apoorvamagic@gmail.com
                

Monday, June 8, 2015

Corrosive Poisoning

Corrosive poisoning is a common emergency as corrosive agents are easily available for household use. Corrosives can injure the GI tract by causing tissue necrosis, perforation, fibrosis, stricture formation and malignancy years after the exposure. These compounds include acids, bases, salts, heavy metals, iodine tincture etc. 




Acids
  • Car battery fluid (sulfuric acid)
  • Descalers (hydrochloric acid)
  • Metal cleaners (nitric acid)
  • Rust removers (hydrogen fluoride) 
Alkalis
  • Bleach (hypochlorite)
  • Sodium hydroxide (liquid lye) 

Pathophysiology
Alkali ingestion: Causes liquefaction necrosis. This process includes protein dissolution, collagen destruction, fat saponification, cell membrane emulsification, submucosal vascular thrombosis and cell death.

Acid ingestion: Causes coagulation necrosis. In this process, hydrogen (H+) ions desiccate epithelial cells producing an eschar. This process leads to edema, erythema, mucosal sloughing, ulceration and necrosis of tissues.

Both acids and alkalis cause fibrosis and stricture formation 



Signs and Symptoms

Clinical presentation varies and depends on the type/quantity of the agent ingested, timing of ingestion, presence of food in the stomach. Burns to the lips, mouth, and oropharyx may be seen but this does not necessarily correlate to the degree of injury tothe esophagus or stomach. Patients with airway deem may present with stridor, aphonia, hoarseness, or dyspnea. Other presenting symptoms include abdominal or chest pain, nausea/vomiting, GI bleed, dysphagia, odynophagia, drooling. 

If there is GI perforation, it may result in fluid loss causing renal failure, altered mental status, lethargy, arrythmias, respiratory distress and seizures.

Investigations
CBP
Basic Metabolic Profile
ABG
CXR (look for free air)
Type and Cross Match 
CT Scan (for suspected perforation despite negative X-Rays and to assess oesophageal wall thickness)
Endoscopy (for direct evaluation and management of strictures)

Esophagogastroduodenoscopy should be performed in the first 12 to 24 hours post-ingestion with great care, to avoid iatrogenic perforation. The grade and extent of the lesions of the upper gastrointestinal tract can be determined and classified according to the Zargar’s modified endoscopic classification of burns due to corrosive ingestion

Grade Description
  1. 0  Normal mucosa
  2. 1  Erythema/Hyperemia
  1. 2a  Superficial ulcer/erosion/friability/hemorrhage/ exudates
  2. 2b  Findings in 2a + deep discrete/circumferential ulcers
  1. 3a  Scattered necrosis (black/grey discoloration)
  2. 3b  Extensive/circumferential necrosis of mucosa 

Severe hypopharyngeal burns are an absolute contraindication for esophagogastroduodenoscopy.

Management 

1. If only a small amount is ingested: Observe and discharge from the ED if tolerating orallly, asymptomatic and normal intra oral examination. 

2. Major Ingestion
  • Pay special attention to the Airway/Oxygenation
  • IV Fluids
  • Add PPIs (reduce exposure of injured esophagus to gastric acid, which may result in decreased stricture formation.)
  • Antibiotics if there is evidence of perforation
  • Don't forget to add pain relief 
  • Keep Nil by Mouth 
Activated charcoal is relatively contraindicated in caustic ingestions because of poor adsorption and endoscopic interference. Emergency surgical intervention is indicated in case of perforation or peritonitis, or if uncontrolled massive hematemesis occurs. 

DO NOT
  • Induce Emesis (risk of mucosal injury and perforation)
  • Insert NG Tube (may cause esophageal perforation and increase the risk of aspiration)
  • Do Lavage (risk of damage to oesophagus and aspiration)
  • Try to neutralise the substance (risk of heat production resulting from this exothermic reaction
  • Administer systemic steroids


Nutrition: Endoscopic grade of lesions needs to be assessed for planning nutritional support in patients with caustic ingestion. Patients with Grade 1/2a lesions on endoscopy can tolerate oral feeds, while those with Grade 2b/3a lesions will need nasoenteral feeding. Patients with Grade 3b lesions require gastrostomy for enteral feeding and rarely need total parenteral nutrition (TPN). 

Acute presentation 
Within 48-72 hours of corrosive ingestion: Upper GI endoscopy should be performed on Day 1-2. (ideally between 12-24 hours of ingestion). If endoscopy reveals only mild lesions, then the patient can be discharged and clinical follow-up should be done at one month. If severe lesions are found on endoscopy, then surgical gastrostomy is indicated, which should be followed by repeat endoscopy and dilatation after three weeks.

Delayed Admission
Within 72 hours to three weeks of corrosive ingestion: No endoscopy is indicated here. Gastrostomy should be done if there is severe dysphagia. Endoscopy and dilatation of stricture (if present) should be done three weeks after ingestion.


Late Admission
More than three weeks of ingestion: Requires endoscopy and dilatation of stricture. If the procedure is successful, then follow-up endoscopy should be done at one month. If the procedure is unsuccessful, then surgical gastrostomy is performed, which is followed by retrograde dilatation of stricture after 10 days of operation.


Complications of the Disease and/or Management
Aspiration of corrosive substances into the respiratory tree may cause endotracheal or bronchial necrosis with mediastinitis. Acute kidney injury, disseminated intravascular coagulation, acid-base disturbances and pneumonia. Oesophageal stricture formation is the most feared long-term complication; stenosis gastric antrum or pylorus may also occur, as may fistula formation.

Stricture formation begins weeks to months after injury and is the most important consequence of corrosive poisoning. Procedures used for prevention and treatment of strictures are:

  1. Dilatation therapy: This is done 3-6 weeks after injury, progressively larger bougies are passed over endoscopically placed guide wires for dilatation. 
  2. Surgery: Esophageal strictures resistant to dilatation therapy may require surgery that includes resection of stricture surgically and esophageal bypass surgery. 
Key Points:
1. Both acids and Alkalis can cause strictures.
2. Endoscopy performed in the first 12 to 24 hours following ingestion is the gold standard  to assess the GI tract.
3. Pay attention to Airway, Hydration, Nutrition.
4. Say no to NG tube, gastric lavage, emetics, dilution and neutralisation, systemic steroids and activated charcoal.


For further reading:


  1. In: Critical Care Toxicology: Diagnosis and Management of the Critically Poisoned Patient. 1st edition, Brent, Wallace, Burkhart, Phillips, Donovan (Eds.) 2005:p. 1035-44.
  2. Caustics. In: Goldfrank’s Toxicologic Emergencies. 8th edition.
  3. Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991;37(2):165-9.
  4. Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 1990;323(10):637-40.
  5. Acids and alkalis. The Poisoning and Toxicology Handbook. 4th edition, Jerrold B. Leikin, Frank P. Paloucek Informa Healthcare, USA 2007:p.713-9.
  6. Alkali injury. In: Clinical Management of Poisoning and Drug Overdose. 3rd edition, Lester M. Haddad, Michael W. Shannon, and James F. Winchester (Eds.) 1998: p.817-20. 
  7. http://medind.nic.in/iaa/t12/i8/iaat12i8p131.pdf