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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, November 20, 2017

Getting better at diagnosing Delirium


Delirium can be defined as an acute confusional state caused due to medical or pharmacological triggers. Up to 10% of all older patients in EDs have delirium and only about one-third of them are recognizedAs frontline healthcare providers, it is essential to recognize delirium as the symptom of a life-threatening underlying medical or surgical condition. The consequences of a missed delirium can be disastrous as they can bounce back with florid sepsis, trauma, seizures. In elderly, delirium may be the only sign of an underlying infection (Pneumonia, Sepsis, ACS, Abdominal infection, Intra-cerebral event). Delirium is often multifactorial in etiology and each cause should be investigated. 

DSM IV defines delirium as:
  • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
  • Change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia
  • Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day
  • There is evidence from the history, physical exam, or lab findings that the disturbance is caused by the consequences of a general medical condition

This can be remembered as:

A - Acute and fluctuating (Often reported by a family member or carers)
I - Inattention (Inattention is a hallmark feature of delirium - Can test with months of the years backwards, WORLD or serial 7s)
D - Disorganised thinking (incoherent, rambling, circumstantial, or vague. (irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)
A - Altered Mental Status (hyperactive, drowsy, stuporous, comatose)
  
Causes of Delirium:
  • Systemic Diseases (Infections, ACS, Hepatic Enceph, Metabolic - Na/Glucose/Ca disturbances)
  • Medications (Anticholinergic, Antiparkinsonian, Antiemetics)
  • Withdrawal (Discontinuation or overdose of any medication, alcohol, sedative hypnotics)
  • CNS Pathology (CVA, Subdural hematoma, Meningitis, Seizures – non convulsive, Hypertensive encephalopathy)
Infections are the most commonly encountered cause of delirium in elderly and medications are the most common reversible causes of geriatric delirium.

Why is Delirium missed in ED? 
We frequently assume that most older people have baseline cognitive impairment. Collateral History and paying attention to what caregivers say is crucial. Delirium can present in hypoactive, hypoactive or mixed form. Therefore, it does not always present as restlessness or agitation, in fact hypoactive delirium is the commonest. Using formal assessment methods is the best way to avoid such mishaps



Managing Delirium
Most delirious patients need admission unless we find a single, reversible cause and patient has good social support and someone to observe him at home. 

Non-Pharmacologic 

  • Manage pain and avoid unnecessary restraints including catheters and non-essential monitor leads
  • Promote mobility and encourage to eat and drink
  • Address bowel and bladder function
  • Increase sensory stimulation (hearing aid, eye glasses)
  • Enhance orientation and familiar faces (family)
  • Minimize medication changes 
Pharmacologic 
Medications should be used if evaluation is prevented or if the patient gets severely agitated. Haloperidol remains the drug of choice (Not Benzodiazepines). Use BZD only in case of drug withdrawals. Use Haloperidol 0.5mg-1.0mg PO/IM/SC/IV every 30min to 1hr and frequently reassess. Haloperidol is a potent anti-psychotic with limited anti-cholinergic effects though it may cause problems in Parkinsonian patients because of increased extra pyramidal symptom.

Preventing Delirium
ED Stay > 8 hrs itself is a risk factor for delirium. High Risk groups include dehydrated patients, demented and restrained patients, those who were left in the corridor overnight, visually and hearing impaired. 


Further Reading

  • Altered Mental Status in Older Emergency Department Patients - Wilber, Scott T. Emergency Medicine Clinics , Volume 24 , Issue 2 , 299 - 316 
  • The Acutely Confused Elderly Patient

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic

Monday, November 13, 2017

The Crashing Patient Conference: A Must Go!

As I was putting together my slides for the ACEP 2017 Conference, I saw a tweet pop up. It was by Dr. Amal Mattu (@amalmattu) advertising about The Crashing PatientConference in Baltimore in October 2017. It was the very same month I was going to Washington DC for my one month of clinical rotation at George Washington University Hospital. I was super-excited! It became a top priority to register myself for the conference. I was dreaming of meeting my Emergency Medicine gurus in person and this was an excellent opportunity, which I could hardly lose.

The Crashing Patient Conference is an annual one da conference which has many short lectures with ‘to the point’ pearls. This year’s theme was resuscitation and risk management. There were different lectures encompassing critical care, resuscitation, shock, cardiology, endocrine emergencies, orthopaedics, paediatrics, urology, burns and most importantly medico-legal.




I will summarize the pearls here from each session. Dr. Mike Winters reviewed critical care quickies with an interesting case that he had encountered.
1)     Before intubating the patient,  preoxygenate with 40-60L/min by NRBM
2)     RSI drugs: remember TBW for etomidate and IBW for ketamine (Obese patients were found to be dosed inappropriately)
3)     ED ventilator settings matter, especially if there is increased length of stay in ED!
4)     Deep sedation is known to increase mortality. Target lighter level of sedation. Opioids (Fentanyl) are first line!

Dr. Khoujah talked about delirium, which is misdiagnosed most of the time.
1)     In patients with suspected delirium, pay attention to “attention”.
2)     Use modified Richmond Agitation and Sedation Scale to screen delirium.
3)     Delirium = predisposing condition + precipitating insult; treat the underlying cause
4)     Change the environment ie allow relatives to be besides the patient, put a date time and location on wall facing the patient, try to minimize physical restraints.
5)     Most importantly, prevent delirium before you have to treat it!

Dr. Manning discussed on ventilator settings in severe asthmatics.
1)     Stick to the basic asthma medications
2)     Maintain permissive hypercapnia by balancing acidosis and auto-PEEP
3)     Indication for intubation: cardiac arrest, exhaustion, agitation, silent chest and severe hypoxia
4)     Lower the respiratory rate, allow patient time to breathe. Reduce I:E ratio to 1:4.
5)     Increase tidal volume to 8-10ml/kg, lower the PEEP and increase the flow rate 80L/min and gradually taper FiO2.
6)     Trouble shooting : a)Post-intubation hypotension- disconnect from vent, let them exhale then check for pneumo. b) Post-intubation hypoxia- do the above and check the tube c) post-intubation arrest- ACLS, go easy on bagging, needle the chest
7)     When in doubt, disconnect and let the air out!

Dr. Bontempo discussed about deep neck space infection and things to remember.
1)     The most common etiology of deep neck space infection is odontogenic; specifically infections of lower 2nd and 3rd molars.
2)     One should be worried if voice change, shortness of breath, neck pain, DM, CRP >100
3)     Anticipate a difficult airway, start broad spectrum abx, drain the pus out.

Dr. Dubbs discussed about the law suits faced due to missed diagnosis of cancer in ED. She suggested:
1)     Always have a high index of suspicion- prolonged symptoms, weight loss, B symptoms, voice change, stool change, anorectal lesions, post-menopausal bleeding
2)     Watch out for the fine printed reports- incidental findings, abnormal cell counts, etc.
3)     Discuss with the patient
4)     Document your discussion and have a great QA process

Dr. Bond (@Docbond007) talked about spinal epidural abscess and posterior shoulder dislocation.
1)     The incidence of epidural abscess has increased in past 2 decades, keep a high suspicion for patients presenting with spine pain.
2)     In patients with spine pain without any neuro deficit, but with fever, risk factors, then check CRP/ESR; if elevated get an MRI spine.
3)     Get X-ray axillary view in suspected posterior shoulder dislocation. Ensure humeral head is in glenoid cavity.

Dr. Lu discussed the complications of myocarditis. It can be deadly in kids. Hence
1)     Always be wary of subtle signs
2)     Consider myocarditis if dyspnoea, chest discomfort and antecedent viral illness.
3)     Consider myocarditis if persistent unexplained tachycardia.

In the section on ‘Salt, sugar and sex’, Dr. Willis summarized that
1)     Persistently hypoglycemic- think adrenal insufficiency
2)     Hypoglycemia +hypotension – Adrenal insufficiency until proven otherwise
3)     If there is any suspicion give empiric steroids. (Hydrocortisone 100mg iv, Dexamethasone 5mg iv, fludrocortisone 0.1mg iv

During the conference, Dr. Mattu kept the audience engaged by his fun quiz. He was kind to gift me the signed copy of the second edition of ‘Avoiding common errors in Emergency Department’ which I will treasure the most.

Although it was a long day, but due to short engaging presentations in a TEDx like format, it was very fun filled, motivational and interesting conference. A definite must go!


Summary prepared by:

Nikhil N. Tambe - @nikhil16mar
M.B.B.S., ECFMG (USA)


Emergency Medicine Resident 
Masters in Emergency Medicine (GWU)
Kokilaben Dhirubhai Ambani Hospital, Mumbai
Instructor (American Heart Association)
Lifesupporters Institute of Health Sciences, Mumbai






Monday, November 6, 2017

Sternoclavicular joint Injuries

Sternoclavicular joint is an  extremely stable joint, due to the strong surrounding ligaments, and thus fracture/dislocations are rare and most injuries simple sprains. Significant forces are required to disrupt the strong ligamentous stabilizers of this joint. The most common causes are MVCs and injuries sustained in contact sports.
 The joint may be anteriorly or posteriorly dislocated.





Grading on Injury
Injuries to the SCJ can be graded into three types. A grade I injury is a mild sprain secondary to stretching of the sterno-clavicular and costoclavicular ligaments. A grade II injury is associated with subluxation of the joint (anterior or posterior) secondary to rupture of the sternoclavicular ligament. The costoclavicular ligament remains intact. Complete rupture of the sternoclavicular and costoclavicular ligaments results in a grade III injury (dislocation).

Minor trauma may result in a sprain are treated with with ice, sling, and analgesics and follow up with Orthopaedics. 

Anterior and Posterior Dislocation
Results from a direct blow to the shoulder, causing the shoulder to roll forward. Patients present with severe pain which is exacerbated by arm movement and lying supine. The pain will be exacerbated by lateral shoulder compression, arm movements, deep breathing or coughing.The shoulder may appear shortened and rolled forward. 


http://msk-anatomy.blogspot.co.uk/2012/06/sternoclavicular-joint.html

On examination, anterior dislocations have a prominent medial clavicle end that is visible and palpable anterior to the sternum while in posterior dislocations, the medial clavicle end is less visible and often not palpable, and the patient may have signs and symptoms of impingement of the superior mediastinal contents, such as stridor, dysphagia, and shortness of breath. 



Imaging
CXR is needed to exclude a injuries such as a  pneumothorax, pneumomediastinum, and hemopneumothorax. Routine radiographs have a low sensitivity for the detection of dislocation and thus special views and comparison with the other clavicle may be required. CT remains the imaging procedure of choice and is recommended especially in any posterior dislocation with concern for injury to the mediastinal structures. 



Management

Anterior Dislocation
Patients with uncomplicated anterior dislocations may be discharged without an attempted reduction. Look for concomitant Glenohumeral and Acromioclavicular joint injuries. Clavicular splinting, ice, analgesics, sling, and orthopedic referral are required.

Closed reduction may be performed within 10 days of the injury by placing the patient supine with a towel rollin between the shoulder blades. The arm is then abducted to 90 degrees and longitudinal traction is applied with slight extension by moving the arm toward the ground, and pressure is placed over the medial end of the clavicle. The application of direct pressure over the medial end of the clavicle may also reduce the joint. Post reduction, the patient should be placed in a figure of * brace for 4-6 weeks. Despite successful reduction, the joint is usually remains unstable and redislocates in half of the cases.




The use of acute reduction of anterior dislocations is controversial as most end up redislocating and reduction techniques risk injury to mediastinal structures.


Posterior Dislocation
Posterior dislocations may be associated with life-threatening injuries to adjacent structures, including pneumothorax or injury to surrounding great vessels, trachea, or oesophagus.  Orthopedic consultation is necessary for closed or open reduction. Open reduction should be performed in the operating room.


Take Home
  • Posterior dislocations necessitate prompt orthopaedic referral and looking for evidence of compression of retrosternal structures.
  • Anterior dislocations often remains unstable post treatment and thus acute reduction is debatable. 


Further Reading:
  • Rosen's Emergency Medicine - 7th Edition
  • TIntinalli's Emergency Medicine - 8th Edition
  • LIFTL
  • ALiEM
  • Morell, D. J., & Thyagarajan, D. S. (2016). Sternoclavicular joint dislocation and its management: A review of the literature. World Journal of Orthopedics7(4), 244–250. http://doi.org/10.5312/wjo.v7.i4.244

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic