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Don’t get unnecessary radiologic tests. AAA occurs in about 1% of men between 55-64 years old. It
increases 2-4% per decade. Often when patients present with
For AAA over 6 cm, the risk of rupture is 10-50%.
a ruptured AAA, they do not have a previous diagnosis of AAA.
The risk increases with size. At 5 cm, the risk of rupture is 5%.
Over 6 cm, the risk of rupture is 10-50%.
CASE
A 73 year old man with a history of hypertension developed The classic triad is abdominal or back pain, pulsatile ab-
back pain and called his primary care physician. The physician dominal mass and hypotension. This triad is present less
referred him to the emergency department. He arrived at 9:03 than 50% of the time.
PM. He complained of one day of constant abdominal pain How good are we at abdominal palpation? The sensitivity is
radiating to the back with some loose stools. His vital signs
about 67%. We will be able to palpate a pulsatile mass in 2 out
showed he was afebrile, heart rate was 96 and his blood pres-
of 3 patients with AAA. Missing this a third of the time is not
sure was 110/60. The physical exam as documented described
good enough.
him as alert, resting quietly and breathing comfortably. The
exam of the abdomen described a naturally large abdomen Cullen’s sign (bruising around the umbilicus) and Grey
with tenderness to deep palpation in the lower quadrants. Turner’s sign (bruising of the flanks indicating retroperito-
neal hematoma) rarely occur.
Differential diagnosis? Physical exam may be limited by obesity.
Constipation. This is still a common cause of abdominal pain. A bedside ultrasound of the abdominal aorta is thought to be
Lumbosacral sprain or idiopathic low back pain. very sensitive for detection of aneurysm. However, this study
may be limited by body habitus and presence of bowel gas.
Ureteral stone.
The next day, the radiologist reviewed the x-ray and concluded
Acute pancreatitis. Renal cell carcinoma. Pyelonephritis. Pep-
“11 cm calcified abdominal aortic aneurysm without obvious ra-
tic ulcer disease. Perforated gastric or duodenal ulcer. An ex-
diographic evidence of rupture.” An abdominal x-ray was done
panding or ruptured abdominal aortic aneurysm.
on an elderly patient with abdominal pain and had a positive find-
Shingles. ing. Because the physician was likely looking for evidence of bow-
el obstruction or free air, they did not look at the calcifications.
What did they do? An EKG was ordered and was fine. Lab work
was all normal except a slightly decreased hemoglobin at 13.4. If you think you are doing yourself or your patient a favor with
An abdominal series was read by the emergency physician as inappropriate imaging for back pain or abdominal pain, it may
consistent with constipation. place you at significant risk if you do not recognize a serious
process.
The patient was told he was “full of shit.” He was prescribed
suppositories and was discharged at 1:15 am. The plaintiff alleged that the patient’s presentation was con-
cerning for AAA, there was radiologic confirmation and if an ul-
Diagnosis. 1) Abdominal pain – etiology to be determined. 2)
trasound had been performed, it would have confirmed a large
Possible constipation on x-ray 3) Can’t rule out gastroenteritis
AAA. They alleged the patient had greater than a 50% chance of
with pain only represented by abdominal spasm.
survival if this diagnosis had been made. The decedent was the
What happened? The patient returned home and his pain wors- sole financial provider for his immediate family and was active in
ened. At 3:50 am, he returned to the emergency department. the management and operation of the family business.
The claim was for $250,000 and the case was settled prior to What is the deal with angiotensin II? We don’t know yet. It is
trial for $150,000. expensive. The evidence is scant at this point. It potentially rep-
resents a new path in the treatment with persistent hypotension
When patients present to the emergency department, they
due to vasodilation.
ask us a question but what they are really asking may be more
subtle. A 17 year old female who has been amenorrheic for 2 At this point, you will have tried the most conventional agents
months and has left lower quadrant pain may be asking us for first. You can think of vasopressors as a three legged stool; al-
pain medication but she is really asking us if she has a ruptured pha-agents, vasopressin receptor agonists and now angiotensin II.
ectopic pregnancy. This patient in his 70s with a history of hy- You have already tried your alpha-agonist (norepinephrine
pertension and abdominal and back pain was asking if he had a
or phenylephrine). You have already tried vasopressin. An-
AAA. We are required to answer that question.
giotensin II may be your next option.
Physical exam and history do not have sufficient ability to ex- Before you give angiotensin II, Weingart would evaluate the
clude an AAA. If you are concerned about this, you need to get
heart and consider an inotropic issue needing epinephrine,
further testing.
milrinone or dobutamine.
We often talk about the golden hour of trauma. There is a
When should we use angiotensin II? Weingart would not use it
golden 45 minutes for ruptured AAA. This diagnosis needs to
as a first choice for a vasopressor. His first choice would be nor-
be made quickly. In addition to calling the surgeon, anesthesiol-
epinephrine. There is insufficient evidence to use angiotensin II
ogy and nursing need to be involved.
as a first choice. However, there seems to be some indication
In this case, there was a claim of both failure to diagnose and (although this is mostly from people at the company itself) that it
also delay in diagnosis. The defendant claimed that even if the is a better vasopressor for patients with ARDS. If more evidence
diagnosis had been made, the patient likely would have died. accumulates, it may be an option in this patient population.
This is debatable. Weingart will use this solely when a patient has failure to
Don’t get unnecessary radiologic tests. It can only harm. improve with norepinephrine, vasopressin and an inotrope
(or if their heart function looks good).
We probably use doses of alpha-agonists that are too low.
Critical Care Mailbag: Most hospitals have an arbitrary ceiling for norepinephrine
The FDA recently approved a new drug, angiotensin II, for the
treatment of refractory vasodilatory shock.
Pediatric Psych Policy not suspected based on the history and physical exam. This
should only be performed as indicated based on the patient’s
Ilene Claudius MD
symptoms.
Take Home Points We all want patients experiencing their first episode of symp-
toms consistent with schizophrenia to have some findings on
Routine laboratory testing in the medical clearance of the head CT to explain it. But they don’t. Between 0 and 1.2%
psychiatric patients is unlikely to identify any conditions of patients undergoing head CT for new onset psychosis will
not suspected based on the history and physical exam. have some finding. Given the risks of radiation, it probably is
An ACEP policy statement advises laboratory testing and not a worthwhile test unless their symptoms indicate there
imaging should only be performed as indicated based on might be more going on.
the patient’s symptoms. We have known this for a while, but it is nice to have a formal
There are no validated criteria for children and adoles- document supporting our clinical gestalt.
cents to assess the risk of subsequent suicide.
Regarding the suicidal child or adolescent, the AAP provides
Don’t underestimate the power of verbal de-escalation in a policy statement on the evaluation and management of
children. acute mental health or behavioral problems.
They advise a search of the belongings, changing into a
Medical clearance of psychiatric patients is a frequent prob-
hospital gown and placing the child into as safe a setting as
lem. What workup do we need to do? Labs? Imaging?
possible with close staff supervision.
Medical clearance in adults was covered in an ACEP policy Interviewing the adolescent and parents separately is helpful.
statement from 2006.
Reassure the adolescent about confidentiality. However, let
Lukens, TW et al. Clinical policy: critical issues in the diagnosis them know that the limits of confidentiality end if there is a
and management of the adult psychiatric patient in the emer- concern for harm of themselves or others or concern for po-
gency department. Ann Emerg Med. 2006 Jan;47(1):79-99. tential abuse.
PMID: 16387222 There are no validated criteria for children and adolescents
In general, they recommend a focused medical assessment to assess the risk for a subsequent suicide. It will be up to
in ED psychiatric patients and basing laboratory testing on the your clinical gestalt and that of your consultants. Consider
history and physical exam with some high risk features. common risk factors such as gender and impulsivity.
Medical clearance of both adults and children is a topic where Discharge planning is important. Make sure they have fol-
we are odds with most psychiatric facilities. From an emergen- low-up and emergency contact information. It is surprising
cy department standpoint, medical clearance implies we have how few people leaving an emergency department after
evaluated whether the patient’s current psychiatric or behavior- an attempted or considered suicide have been questioned
al problems are due to or exacerbated by an underlying med- about the accessibility of weapons in the home. Many of
ical condition or if there is a concurrent medical condition that these children are impulsive and if there is a weapon or po-
requires acute treatment in the emergency department. It does tentially lethal medication in the home, it could be a significant
not mean we have definitively ruled out everything that could problem. Talking with parents about limiting the availability of
possibly happen to the child. potentially lethal means is important.
To rule out an emergent or contributory condition requires a Important principles of restraint include safety of staff and
very thorough history and physical which can be difficult to patient and using the least restrictive, age appropriate meth-
do in patients with behavioral and psychiatric emergencies. ods possible. Don’t underestimate the power of verbal de-es-
calation in children. Respect their personal space. Don’t be vi-
What about urine toxicology screening, routine laboratory
sually or verbally confrontational with them. Have a 1-2 people
tests or radiographs? Don’t do it.
serve as their verbal contact rather than multiple staff coming
American College of Emergency Physicians. Ten things physi- They chose clinical scenarios that are pretty similar to the
cians and patients should question. October 14, 1013 (1-5) and language in the recommendations. For example, “How often
October 27, 2017 (6-10. PDF Link would you perform a head CT on a 50 year old man who pres-
ents with syncope, has insignificant head trauma and normal
1.
Avoid computed tomography (CT) scans of the head in emer-
neurologic exam? Do you do head CTs frequently, infrequent-
gency department patients with minor head injury who are at
ly, never or always?”
low risk based on validated decision rules.
The next section aimed at the most important reason for pro-
2.
Avoid placing indwelling urinary catheters in the emergency
viding low value or potentially unnecessary care. Are you
department for either urine output monitoring in stable pa-
concerned about serious diagnoses? Is this because of pa-
tients who can void, or for patient or staff convenience.
tient and family expectations? Reduce your malpractice risk?
3. Don’t delay engaging available palliative and hospice care ser-
They asked which of the following options were from Choos-
vices in the emergency department for patients likely to benefit.
ing Wisely.
4.
Avoid antibiotics and wound cultures in emergency depart-
ment patients with uncomplicated skin and soft tissue ab-
scesses after successful incision and drainage and with ade-
quate medical follow-up.
Many clinical decision rules have components that are sub- Pediatric Pearls:
jective. It is important to be aware of that subjectivity and how Cool Peds Tricks
this may change the outcome from one provider to the next. Ilene Claudius MD, Sol Behar MD, Erik Hofmann MD,
The HEART score asks you to assess how suspicious you are Genevieve Santillanes MD and Ariel Bowman MD
for ACS. Two providers talking to the same patient may differ in
their concern for ACS. They will assign a different score for the Take Home Points
same patient with the same history.
Nebulized tranexamic acid may be an option in an unstable
How often are clinical decision rules compared to clinical ge- patient with a post-tonsillectomy bleed.
stalt? Not very often. We don’t want a tool to override our ge-
Pediatric central lines may experience complications.
stalt and result in unnecessary testing.
The central lines guidewire has an inner and outer layer
Clinical decision rules are designed to be more sensitive than
which can result in kinking.
specific because they are designed as screening tools. They
are designed to not miss anything. You don’t want a rule that Moving the wire gently in and out of the dilator itself as it
says someone doesn’t have a heart attack when they really are is being advanced can prevent looping and kinking. The
and you discharged them. When you increase sensitivity, you in- dilator can be rotated as it is advanced.
variably decrease specificity. These tests often tell you to image,
Pulmonary hypertension can be treated similarly to a TET
treat or admit more. They should not replace clinical gestalt. If
spell with treatment to shunt more oxygen to the lungs.
you applied PERC to every patient with shortness of breath or
chest pain, it would clearly result in overtesting. PERC only ap-
One of the scariest events is to have a situation you haven’t
plies to patients less than 50 years. Does this mean that every
been in before with a critical patient and have no idea what to
patient over 50 needs a CTA or d-dimer to evaluate them for
do next. This is especially true in pediatrics.
PE? No. Your clinical gestalt and testing threshold matter.
Compartment Pressures Should you worry about the small amount of saline that is in-
Jess Mason MD, Jenny Farah MD and Kenji Inaba MD jected during the compartment pressure? It is a tiny amount to
clear the bore of the needle. It is unlikely to cause an artificially
Take Home Points elevated pressure. Injection of superficial lidocaine to facilitate
the comfort of insertion won’t affect the compartment pressure.
Compartment pressure greater than 30 mg or a delta
perfusion pressure (diastolic blood pressure – compart- Not everyone has the commercially available product avail-
ment pressure) less than 30 mmHg is concerning for able such as the Stryker. However, there are other ways to
compartment syndrome. check the pressure. Some use an arterial line. If this is the only
thing available, it is worth trying. There are several studies look-
The delta pressure may be helpful in a hypotensive trau-
ing at the validity of the arterial line and the evidence is varied.
ma patient.
Always err on the side of transfer if necessary.
Maintain a high level of suspicion for compartment syn-
drome.
Compartment syndrome is a dynamic process.
Low Dose Ketamine
Checking compartment pressures seems like it should be Matthew DeLaney MD
simple but between the equipment, calibration and anatomy,
it can be intimidating. We recently made a HD video which Take Home Points
demonstrates how to check compartment pressures in the low-
Most of the literature on low dose ketamine for pain stud-
er leg and forearm.
ied it as an adjunct to traditional analgesics.
There are two ways to assess whether the patient is at risk for The subdissociative dose is usually reported between 0.1
developing compartment syndrome. Once you get the mea-
mg/kg and 0.3 mg/kg IV.
surement, you can look at the absolute number of the pressure
in the compartment or the delta pressure. This is a great medication for patients with short term
pain.
Put in the needle and measure the pressure.
Ketamine is a good option in opioid tolerant patients.
If the pressure is over 30 mmHg, it could be compartment
syndrome. Normal pressures are less than 10 mmHg. Nausea is a frequent side effect but true emergence re-
actions are rare with subdissociative dosing.
If you have the diastolic blood pressure, subtract the compart-
ment pressure and if the difference is less than 30 mmHg,
it is also concerning for compartment syndrome. Basically, if Low dose ketamine for pain. DeLaney had to take multiple
the compartment pressure is reaching the diastolic pressure, steps in his department to get this going. They started the pro-
it represents decreased perfusion. The delta pressure can cess two years ago.
be important, especially if you have a hypotensive trauma
Does low dose ketamine work as well as traditional analge-
patient. If the blood pressure is 90 mmHg with a diastolic of
sics such as the opioids? Much of the literature looks at ket-
50 mmHg and the compartment pressure is 25 mmHg, it is
amine as an adjunct to traditional analgesics.
concerning for compartment syndrome.
The best study was by Beaudoin et al.
Inaba is now using the delta perfusion pressure to assess for com-
partment syndrome. You want this value to be at least 30 mmHg. They gave patients with acute pain morphine or morphine
17
along with a dose of 0.15 mg/kg IV of ketamine. A third group 1. Most of the literature categorizes ketamine as a sedative or
received morphine and a dose of 0.3 mg/kg of ketamine. anesthetic. This typically falls under anesthesia’s jurisdiction.
The hospital considered this outside of conscious sedation.
They found that ketamine seemed to be a viable adjunct
They met with hospital administration and the sedation com-
along with morphine.
mittee and provided literature. They received approval to re-
Beaudoin, FL et al. Low-dose ketamine improves pain categorize ketamine at this dose. It was shifted from a seda-
relief in patients receiving intravenous opioids for acute tive to an analgesic. You need to determine the classification
pain in the emergency department: results of a random- of ketamine at your hospital and who makes that decision. It
ized, double-blind, clinical trial. Acad Emerg Med. 2014 is much easier to ask permission to reclassify ketamine than
Nov;21(11):1193-202. to ask forgiveness after the fact.
Motov et al randomized patients to either receive ketamine 2. Who can give this drug and how? This will vary between hos-
at a dose of 0.3 mg/kg or morphine at 0.1 mg/kg. pitals and state. DeLaney’s group had a goal that this be ad-
ministered by nursing staff just like any other pain medication.
They found the results were equivalent in short term pain relief.
However, in their state, the board of nursing was unwilling to
Motov, S et al. Intravenous subdissociative-dose ketamine let nurses push this like an analgesic. Initially, it had to be ad-
versus morphine for analgesia in the emergency depart- ministered by the physician.
ment: a randomized controlled trial. Ann Emerg Med. 2015
3. How is the medication given? They started giving it as a push
Sep;66(3):222-229.
dose or bolus. They found that patients had a quicker effect
There is an emerging body of literature that shows low with pushes but also experienced more altered sensorium.
dose ketamine is a reasonable analgesic. Some literature describes a bolus followed by a drip for a lon-
ger effect. However, this is labor intensive and many of the
Safety doesn’t seem to be an issue. We have years of litera-
nurses were unwilling to do this. They settled on a low dose
ture on ketamine as a sedative and it seems to be really safe
given as a bolus. This is worth discussing with nursing.
in that setting. Most of the studies on low dose ketamine ar-
en’t sufficiently powered to evaluate safety but we know that it Once they started using the medication, it became obvious
preserves blood pressure and protects the airway. There aren’t it was a great medication in a certain subset of patients. This
many issues that arise with its use in sedation and it is likely safe is a great medication for patients with short term pain, such as
at a lower dose. patient who falls and sustains a distal radius fracture. The onset
of action is quick and the offset is quick. The patient with a distal
How do you enact the use of low dose ketamine at your site?
radius fracture is given the medication, then reduced and splint-
What is the optimal dose? The subdissociative dose is re- ed and feels better. The pain stimulus should be decreased at
ported between 0.1 mg/kg and 0.3 mg/kg IV. Unfortunately that point.
there is no good literature to identify the proper dose. Most
They found it does not work as well in patients who will
of the lower doses in the literature were when ketamine was
have a longer period of pain such as multiple rib fractures
used as an adjunct to morphine. The lower doses were not
or hip fractures. These patients would get some initial relief
used alone. Some studies that used ketamine as a sole agent
but then would require additional pain medication.
used a dose of 0.3 mg/kg IV. However, this is a dose when
you start to worry about reaching the limits of subdissociation. There is emerging literature to say that it is a great pain
We do not want to be sedating patients. medication in patients who are opioid tolerant. DeLaney
has found this to be the case. He had a patient with end stage
Patients received a dose of 10 mg of ketamine. DeLaney’s
cancer treated by fentanyl patches and oxycodone. They
group set a target dose of 0.1 mg/kg. If the patient was be-
tried high dose morphine and hydromorphone but nothing
tween 50-150 kg, they would round up or down. Patients at
was working. They gave 10 mg of IV ketamine and the patient
50 kg rounded up to 10 mg would receive a dose of no more
later walked out of the room and said it was the best he had
than 0.2 mg/kg. This is well within the subdissociative dosing
felt in a year.
range. Patients at 150 kg were rounded down to 10 mg which
was a dose of 0.07 mg/kg. Their available formulation was 10 This medication didn’t seem to work for drug seekers.
mg/mL. This was simple for the nurses. Patients were given 1
Ketamine should probably be avoided in patients who are
mL of solution.
acutely psychotic or have a significant psychiatric history.
They identified multiple systems issues. 1) How was the drug Most of these patients have been excluded from the studies.
categorized in the hospital? 2) How was the drug given in the Ketamine should also probably be avoided in pregnant pa-
department? 3) Who was allowed to give the medication? tients or those with obvious increased intracranial or intraoc-
The dose for the treatment of syphilis is 2.4 million units How do you diagnose syphilis? At von Reinhart’s hospital, they
of long-acting penicillin G benzathine. have a syphilis screen cascade. This automatically triggers the
next test in line.
We need to proactively test and treat pregnant women.
The first test is IgG. Has this person’s immune system ever
Warn patients about the Jarisch-Herxheimer reaction.
encountered syphilis? If they return positive and have never
been treated for syphilis before, treat and you are done. This
Why are we talking about syphilis? Syphilis is on the rise, es-
will also be positive if the patient had a prior exposure and
pecially in the South and West in the United States. It is increas-
has been treated.
ing in young men who have sex with men. There is frequent
co-infection with HIV and syphilis as well as gonorrhea and chla- The RPR is a titer and returns as a ratio. This can be con-
mydia. Syphilis is increasing in all populations. There are also fusing. The utility of the RPR is tracking over time. When you
increasing rates of congenital syphilis. have successfully treated syphilis, the RPR decreases four-
fold. For example, a patient presents with syphilis and a RPR
The stages of syphilis. This is clinically relevant in the emer-
of 1:16. They are treated with penicillin. In six months, when it
19
is checked again, the RPR should have decreased four-fold must assume that it is late latent syphilis and err on the side of
to 1:4. If they get a new infection and the RPR is the same or overtreating.
increased, they will need treatment again.
It can be difficult to identify a chancre in women. It is import-
After the RPR is obtained, you need a treponemal confirma- ant to do a thorough speculum exam, check the vaginal mu-
tory study. There are many treponemal confirmatory studies cosa, check the introitus and between the labia. In both men
such as FTA, PCR, EIA, etc, these are beyond the scope of and women, check the perianal area. If there is a chancre and
emergency medicine and should be interpreted by an infec- the patient is positive for syphilis, treatment is a single dose of
tious disease doctor. penicillin.
What is the treatment? 2.4 million units of penicillin G benza- Counseling. What do you say to your patients?
thine long-acting formulation. It is not the continuous release or
The syphilis will be treated with the single dose of penicillin.
CR. This is given intramuscularly. It has a long half-life.
It is extremely important that all sexual partners get tested
Oral penicillin is inadequate.
and treated. Any sexual partners over the last year should be
There is a national shortage of intramuscular penicillin. Don’t informed. Anyone that has had sexual contact with someone
use IM penicillin for other conditions where there are other with known syphilis in the prior 90 days needs to get treated
available treatment options such as strep pharyngitis. regardless of serologies.
If you are treating someone for a recurrent infection, the treat- Warn patients about the Jarisch-Herxheimer reaction.
ment is the same.
Practice safe sex practices.
This is the treatment for primary, secondary and early latent
Jarisch-Herxheimer reaction. This is not that bad but you
syphilis. If you have late latent syphilis, it is the same dose
should warn your patients about it. Some sources cite a rate of
but the patient needs two more doses a week apart over 3
up to 90% in the treatment of primary syphilis. About 24 hours
weeks. The health department can help make sure patients
after the penicillin shot, the patient may develop fever, myalgias,
get adequate treatment.
worsening of the rash on the palms and soles. This is self-limited
If a patient tests positive for syphilis, it is important to do a and lasts about 24 hours. Most patients only require supportive
thorough physical exam to identify primary or secondary care. Warn the patients so they don’t rush back to your ED think-
syphilis. If there are no findings on exam, it is latent and you ing they are dying.