Author: Jule Santos, Brasil

Emergency physician and #FOAMed enthusiast. Head of the Emergency Medicine Resident Program - DF, Brazil. Current professional interest areas are international emergency medicine, medical education, critical care, airway management, physician wellness, Free Open Access to Medical Education. Founding editor of Emergência Rules. Board member of Brazilian Society for Emergency Medicine, regional DF (ABRAMEDE-DF).

Defibrillator: Clear!

Defibrillator clear
~ Jule Santos, Brasil ~ Leave a comment

So, this is your first day at your internship rotation in the Emergency Department. You see some movement in the resuscitation room, and someone shouts: CODE!

Then, you approach the team, excited to learn and help with cardiopulmonary resuscitation (CPR). The attending physician looks at you and asks: Do you know how to use the defibrillator?

What would your answer be?

Knowing the main functions of the defibrillator is essential but not enough; you need to get used to the model in your hospital to be able to help safely with an emergency.

Defibrillators are devices used to apply electrical energy manually or automatically. Their use is indicated for electrical cardioversion, defibrillation or as a transcutaneous pacemaker.

Later that day, another patient presents with unstable atrial fibrillation (AFib).

The attending suggests cardioverting the patient. Do you know how to prepare the defibrillator?

Defibrillation versus cardioversion

Both defibrillation and cardioversion are techniques in which an electrical current is applied to the patient, through a defibrillator, to reverse a cardiac arrhythmia.

Defibrillation

Defibrillation is a non-synchronized electrical discharge applied to the chest, which aims to depolarize all myocardial muscle fibres, thus literally restarting the heart, allowing the sinoatrial node to resume the generation and control of the heart rhythm, and reversing the severe arrhythmias. It is indicated for pulseless ventricular tachycardia and ventricular fibrillation during CPR.

Electrical Cardioversion

Electrical cardioversion is the application of shock in a synchronized way to ensure the electric discharge is released in the R wave, that is, in the refractory period because accidental delivery of the shock during the vulnerable period, that is, the T wave, can trigger VF. It is reserved for severe arrhythmias in unstable patients with a pulse. It can usually be an elective procedure.

Special Situations

Digital Intoxication

Digital intoxication can present with any type of tachyarrhythmia or bradyarrhythmia. Cardioversion in this situation is a relative contraindication, as digital makes the heart sensitive to electrical stimulation. Before considering cardioversion, correct all electrolyte imbalances, otherwise, the cardioversion can degenerate the rhythm to a VF.

Pacemaker / Implantable cardioverter-defibrillator (ICD)

Cardioversion can be performed, but with care. The inadequate technique can damage the generator, the conductive system, or the heart muscle, leading to dysfunction of the device. The blades must be positioned at least 12 cm away from the generator, preferably in the anteroposterior position. The lowest possible electrical charge must be used.

Pregnancy

Cardioversion can be used safely during pregnancy. The fetal beat should be monitored throughout the procedure.

Things To Consider

Keep your devices tested!

Working in the ED is not easy. This is the place where organization and preparation should be routine. Constant checking of materials and operation of the equipment must be the rule because the smallest detail can cause a difference in saving a life.

During adversity, it is necessary to remain calm, trying to not affect the reasoning and disposition of the team. It is an arduous job, it takes practice and a lot of effort. Errors can only be corrected after they are recognized and must have the right time to be exposed. It happens.

There is no time for despair, yelling and stress when it comes to CPR.

No conductive gel, what can we do?

The main guidelines regarding the use of the conductive gel used in the defibrillator paddles are:

  • Using the proper gel for this purpose is essential. The gel is an electrically conductive material that decreases the resistance to the flow of electric current between the paddle and the chest wall. The absence of conductive material can lead to the production of an arc that causes burns in the patient and the risk of explosion if there is an oxygen source very close, among others.
  • Avoid the use of gauze soaked in saline solution, as the excess serum can cause burns on the patient’s skin, but it is a reasonable option, in an emergency
  • Do not use the ultrasound gel
  • The preference is to use adhesive paddles that already come with their own conductive gel (but this is rare in Brazil).

Location recommended by Advanced Cardiac Life Support (ACLS)

Antero-lateral

One paddle is placed on the right side of the sternum, right below the clavicle and the other laterally where the cardiac appendix would be in the anterior or medial axillary line (V5-V6).

Adhesive paddles can also be placed in an anteroposterior position: The anterior one is placed in the cardiac appendage or precordial region, and the posterior one is placed on the back in the right or left infrascapular region.

During the shock, the provider must ensure that no one is in contact with the patient. A force of approximately 8k must be used to increase the contact of the paddles with the chest. Do not allow a continuous flow of oxygen over the patient’s chest to avoid accidents with sparks.

Complications

  • Electric arc (when electricity travels through the air between the electrodes and can cause explosive noises, burns and impair current delivery)
  • Electrical injuries in spectators
  • Risk of explosion if there is a continuous flow of oxygen during the shock
  • Burning of the skin by repeated shocks
  • Myocardial injury and post-defibrillation arrhythmias and myocardial stunning
  • Skeletal muscle injury
  • Fracture of thoracic vertebrae

References and Further Reading

  1. Sunde, K., Jacobs, I., Deakin, C. D., Hazinski, M. F., Kerber, R. E., Koster, R. W., Morrison, L. J., Nolan, J. P., Sayre, M. R., & Defibrillation Chapter Collaborators (2010). Part 6: Defibrillation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation, 81 Suppl 1, e71–e85. https://doi.org/10.1016/j.resuscitation.2010.08.025
  2. Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W., Drennan, I. R., Hirsch, K. G., Kudenchuk, P. J., Kurz, M. C., Lavonas, E. J., Morley, P. T., O’Neil, B. J., Peberdy, M. A., Rittenberger, J. C., Rodriguez, A. J., Sawyer, K. N., Berg, K. M., & Adult Basic and Advanced Life Support Writing Group (2020). Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142(16_suppl_2), S366–S468. https://doi.org/10.1161/CIR.0000000000000916
  3. Ionmhain, U. N. (2020). Defibrillation Basics. Life in The Fastlane. Retrieved April 26, 2020, from https://litfl.com/defibrillation-basics/
  4. Paradis, N. A., Halperin, H. R., Kern, K. B., Wenzel, V., & Chamberlain, D. A. (Eds.). (2007). Cardiac arrest: the science and practice of resuscitation medicine. Cambridge University Press.
  5. Nickson, C. (2020). Defibrillation Pads and Paddles. Life in The Fastlane. Retrieved April 26, 2020, from https://litfl.com/defibrillation-pads-and-paddles/
Cite this article as: Jule Santos, Brasil, "Defibrillator: Clear!," in International Emergency Medicine Education Project, August 9, 2021, https://iem-student.org/2021/08/09/defibrillator-clear/, date accessed: April 1, 2023

Physiologically Difficult Airway – Metabolic Acidosis

Physiologically Difficult Airway - Metabolic Acidosis
~ Jule Santos, Brasil ~ Leave a comment

Case Presentation

A 32-year-old male with insulin-dependent diabetes mellitus came to your emergency department for shortness of breath. He was referred to the suspected COVID-19 area. His vitals were as follows: Blood pressure, 100/55 mmHg; pulse rate, 135 bpm; respiratory rate, 40/min; saturation on 10 liters of oxygen per minute, 91%; body temperature, 36.7 C. His finger-prick glucose was 350 mg/dl.

The patient reported that he had started to feel ill and had an episode of diarrhea 1 week ago. He developed a dry cough and fever in time. He started to feel shortness of breath for 2 days. He sought out the ER today because of the difficulty breathing and abdominal pain.

The patient seemed alert but mildly agitated. He was breathing effortfully and sweating excessively. On physical examination of the lungs, you noticed fine crackles on the right. Despite the patient reported abdominal pain, there were no signs of peritonitis on palpation.

An arterial blood gas analysis showed: pH 7.0, PCO2: 24, pO2: 56 HCO3: 8 Lactate: 3.

The point-of-care ultrasound of the lungs showed B lines and small foci of subpleural consolidations on the right.
At this point, what are your diagnostic hypotheses?

Two main diagnostic hypotheses here are:

  • Diabetic ketoacidosis (Hyperglycemia + metabolic acidosis)
  • SARS-CoV2 pneumonia

We avoid intubating patients with pure metabolic decompensation of DKA if possible, as they respond to hydration + insulin therapy + electrolyte replacement well and quickly. 

But in this scenario, the patient is extremely sick and has complicating medical issues, such as an acute lung disease decompensating the diabetic condition, probably COVID19. Considering these extra issues may complicate the recovery time and increase the risk of respiratory failure, you decide to intubate the patient in addition to the treatment of DKA.

You order lab tests and cultures. You start hydration and empirical antibiotics while starting preoxygenation and preparing for intubation.

Will this be a Difficult Airway?

Evaluating the patient for the predictors of a difficult airway is a part of the preparation for intubation. Based on your evaluation, you should create an intubation plan. 

This assessment is usually focused on anatomical changes that would make it difficult to manage the airway (visualization of the vocal cords, tube passage, ventilation, surgical airway), thereby placing the patient at risk.

“Does this patient have any changes that will hinder opening the mouth, mobilizing the cervical region, or cause any obstruction for laryngoscopy? Does this patient have any changes that hinder the use of Balloon-Valve-Mask properly, such as a large beard? What about the use of the supraglottic device? Does this patient have an anatomical alteration that would hinder emergency cricothyroidotomy or make it impossible, like a radiation scar? ”

So the anatomically difficult airway is when the patient is at risk if you are unable to intubate him due to anatomical problems.

The physiologically difficult airway, however, is when the patient has physiological changes that put him at risk of a bad outcome during or shortly after intubation. Despite intubation. Or because of intubation, because of its physiological changes due to positive pressure ventilation.

These changes need to be identified early and must be mitigated. You need to recognize the risks and stabilize the patient before proceeding to intubation or be prepared to deal with the potential complications immediately if they happen.

5 main physiological changes need attention before intubation are: hypoxemia, hypotension, severe metabolic acidosis, right ventricular failure, severe bronchospasm.

Back to our patient: Does he have physiologically difficult airway predictors?

  • SI (Shock Index): 1.35 (Normal <0.8) – signs of shock
  • P / F: 93 (Normal> 300) – Severe hypoxemia
  • pH: 7.0: Severe metabolic acidosis – expected pCO2: 20 (not compensating)
  • qSOFA: 2 + Lactate: 3 (severity predictor)

Physiologically Difficult Airway

"Severely critical patients with severe physiological changes who are at increased risk for cardiopulmonary collapse during or immediately after intubation."

Sakles JC, Pacheco GS, Kovacs G, Mosier JM. The difficult airway refocused.

Severe Metabolic Acidosis

In this post, we will focus only on the compensation of the metabolic part, but do not forget that this is a patient who needs attention on oxygenation and hemodynamics as well. That is, this is intubation with very difficult predictions.

What happens during the rapid sequence of intubation in severe metabolic acidosis?

To perform the procedure, the patient needs to be in apnea. During an apnea, pulmonary ventilation is decreased and the CO2 is not “washed” from the airway. These generate an accumulation of CO2, an acid, decreasing blood pH. In a patient with normal or slightly altered pH, this can be very well-tolerated, but in a patient with a pH of 7.0, an abrupt drop in this value can be ominous.

We know that the respiratory system is one of the most important compensation mechanisms for metabolic acidosis and it starts its action in seconds, increasing the pH by 50 to 75% in 2 to 3 minutes, guaranteeing the organism time to recover. So, even seconds without your proper actions can be risky for critical patients.

In addition, it must be remembered that increased RF is the very defense for the compensation of metabolic acidosis, and most of the time the organism does this very well. So if after the intubation the NORMAL FR and NORMAL minute volume are placed in the mechanical ventilator parameters, again there is an increase in CO2 and a further decrease in pH.

And what’s wrong? After all, a little bit of acidosis even facilitates the release of oxygen in the tissues because it deflects the oxyhemoglobin curve to the right, right?

Severe metabolic acidosis (pH <7.1) can have serious deleterious effects:

  • Arterial vasodilation (worsening shock)
  • Decreased myocardial contractility
  • Risks of arrhythmias
  • Resistance to the action of DVAs
  • Cellular dysfunction

What to do?

Always the primary initial treatment is: treating the underlying cause! In patients with severe metabolic acidosis, it is best to avoid intubation! Especially in metabolic ketoacidosis, which as hydration and insulin intake improves, there is a progressive improvement in blood pH.

Sodium bicarbonate

The use of sodium bicarbonate to treat metabolic acidosis is controversial, especially in non-critical acidosis values ​​(pH> 7.2). If you have acute renal failure associated, its use may be beneficial by postponing the need for renal replacement therapy (pH <7.2).

As for DKA, where sodium bicarbonate is used to the ketoacidosis formed by erratic metabolism due to the lack of insulin and no real deficiency is present, its use becomes limited to situations with pH <6.9.

The dose is empirical, and dilution requires a lot of attention (avoid performing HCO3 without diluting!)

NaHCO3 100mEq + AD 400ml

Run EV in 2h

If K <5.3: Associate KCl 10% 2amp

I would make this solution and leave it running while proceeding with the intubation preparations.

Attention: Remember, according to the formula below, that HCO3 is converted to CO2, and if done in excess, is associated with progressive improvement of the ketoacidosis and recovery of HCO3 from the buffering molecules. In a patient already with limited ventilation, its increase can cause deviation of the curve for the CO2 increase, which is also easily diffused to the cells and paradoxically decrease the intracellular pH, in addition to carrying K into the cell.

H + + HCO3 – = H2CO3 = CO2 + H2O

Mechanical ventilation

I think the most important part of the management of these patients is the respiratory part.

If you choose the Rapid Sequence Intubation: Prepare for the intubation to be performed as quickly as possible: Use your best material, choose the most experienced intubator, put the patient in ideal positioning, decide and apply medications skillfully, to ensure the shortest time possible apnea.

You will need personnel experienced in Mechanical Ventilation and you must remember to leave the ventilatory parameters adjusted to what the patient needs and not to what would be normal!

I found this practice very interesting: First, you calculate what the expected pCO2 should be for the patient, according to HCO3:

Winter’s Equation (Goal C02) = 1.5 X HCO3 + 8 (+/- 2)

And then, according to this table, you try to reach the VM Volume Minute value.
Goal CO2 Minute Ventilation
40 mmHg
6-8 L
30 mmHg
12-14 L
20 mmHg
18-20 L

These are just initial parameters. With each new blood gas analysis repeated in 30 minutes to an hour, you re-make fine adjustments using the formula below:

Minute volume = [PaCO2 x Minute volume (from VM)] / CO2 Desired

With the treatment of ketoacidosis, new parameters should be adjusted, hopefully for the better.

Another safer option for these patients would be to use the Awake Patient Intubation technique so that you would avoid the apnea period. However, Awake Patient Intubation Technique is contraindicated in suspected or confirmed COVID-19 cases due to the risk of contamination.

That’s it, folks, send your feedback, your experiences, and if you have other sources!

Further Reading

  1. Frank Lodeserto MD, “Simplifying Mechanical Ventilation – Part 3: Severe Metabolic Acidosis”, REBEL EM blog, June 18, 2018. Available at: https://rebelem.com/simplifying-mechanical-ventilation-part-3-severe-metabolic-acidosis/.
  2. Justin Morgenstern, “Emergency Airway Management Part 2: Is the patient ready for intubation?”, First10EM blog, November 6, 2017. Available at: https://first10em.com/airway-is-the-patient-ready/.
  3. Salim Rezaie, “How to Intubate the Critically Ill Like a Boss”, REBEL EM blog, May 3, 2019. Available at: https://rebelem.com/how-to-intubate-the-critically-ill-like-a-boss/.
  4. Salim Rezaie, “RSI, Predictors of Cardiac Arrest Post-Intubation, and Critically Ill Adults”, REBEL EM blog, May 10, 2018. Available at: https://rebelem.com/rsi-predictors-of-cardiac-arrest-post-intubation-and-critically-ill-adults/.
  5. Salim Rezaie, “Critical Care Updates: Resuscitation Sequence Intubation – pH Kills (Part 3 of 3)”, REBEL EM blog, October 3, 2016. Available at: https://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-ph-kills-part-3-of-3/.
  6. Lauren Lacroix, “APPROACH TO THE PHYSIOLOGICALLY DIFFICULT AIRWAY”, https://emottawablog.com/2017/09/approach-to-the-physiologically-difficult-airway/
  7. Scott Weingart. The HOP Mnemonic and AirwayWorld.com Next Week. EMCrit Blog. Published on June 21, 2012. Accessed on July 15th 2020. Available at [https://emcrit.org/emcrit/hop-mnemonic/ ].
  8. IG: @pocusjedi: “Pocus e Coronavirus: o que sabemos até agora?”https://www.instagram.com/p/B-NxhrqFPI1/?igshid=14gs224a4pbff

References

  1. Sakles JC, Pacheco GS, Kovacs G, Mosier JM. The difficult airway refocused. Br J Anaesth. 2020;125(1):e18-e21. doi:10.1016/j.bja.2020.04.008
  2. Mosier JM, Joshi R, Hypes C, Pacheco G, Valenzuela T, Sakles JC. The Physiologically Difficult Airway. West J Emerg Med. 2015;16(7):1109-1117. doi:10.5811/westjem.2015.8.27467
  3. Irl B Hirsch, MDMichael Emmett, MD. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on July 15, 2020.)
  4. Cabrera JL, Auerbach JS, Merelman AH, Levitan RM. The High-Risk Airway. Emerg Med Clin North Am. 2020;38(2):401-417. doi:10.1016/j.emc.2020.01.008
  5. Guyton AC, HALL JE. Tratado de fisiologia medica. 13a ed. Rio de Janeiro(RJ): Elsevier, 2017. 1176 p.
  6. Kraut JA, Madias NE. Metabolic acidosis: pathophysiology, diagnosis and management. Nat Rev Nephrol. 2010;6(5):274-285. doi:10.1038/nrneph.2010.33
  7. Calvin A. Brown III, John C. Sakles, Nathan W. Mick. Manual de Walls para o Manejo da Via Aérea na Emergência. 5. ed. – Porto Alegre: Artmed, 2019.
  8. Smith MJ, Hayward SA, Innes SM, Miller ASC. Point-of-care lung ultrasound in patients with COVID-19 – a narrative review [published online ahead of print, 2020 Apr 10]. Anaesthesia. 2020;10.1111/anae.15082. doi:10.1111/anae.15082
Cite this article as: Jule Santos, Brasil, "Physiologically Difficult Airway – Metabolic Acidosis," in International Emergency Medicine Education Project, November 25, 2020, https://iem-student.org/2020/11/25/physiologically-difficult-airway-metabolic-acidosis/, date accessed: April 1, 2023

More Posts by Dr. Santos

Passion about “Airway Management”

passion about airway management
~ Jule Santos, Brasil ~ Leave a comment

I have been passionate about learning and teaching airway management since I started practicing in the Emergency Department. As I learned more about the airway, I started to see a whole new world of knowledge to be explored. In fact, I felt a little indignant, because my college training had failed to teach me so much information necessary to manage the airway safely and responsibly in the emergency department. To fill the gap I perceived, I went to many national and international courses, and here are a few:

Meanwhile, Dr. George Kovacs has been one of the biggest inspirations in my mission to learn and teach airway management, especially after I watched his spectacular lecture “The Psychologically Dangerous Airway.” 

I learned he ran a course as a part of his “Airway Interventions & Management in Emergencies (AIME)” Project (http://aimeairway.ca). Learning from him became a big dream. And finally, in February, I managed to go to Halifax, Canada, to take the AIME Advanced course! http://aimeairway.ca

passion about airway management 6

What to expect

The course offers some theoretical classes and plenty of space to practice with various devices. Each instructor supervises 5 or 6 trainees. All trainees rotate the stations to practice each skill on varying airway difficulties.

The highlights of the course include:

  • Real-like Practice: “Nothing is closer to the human body than the human body itself.” Even the best mannequins fail to mimic human anatomy and conditions required to practice airway microskills, in terms of space, weight, and pressure. Therefore, participants of the AIME advanced course practice skills on cadavers donated to the Human Body Donation Program at Dalhousie. Learning with cadavers makes all the difference!
  • Awake Intubation: This is one of the greatest works of Dr. Kovacs, who makes a live demonstration -on himself- of his technique and the materials he uses. Awake intubation is a simple technique, but it requires advanced knowledge. The main indication is anticipated anatomically and/or physiologically difficult airway in cooperative patients.
  • Various devices: The course offers training with a spectrum of devices. In addition to hands-on training, instructors discuss the limitations of the devices and how to overcome them. For example, intubation with a fiberscope assisted by a video laryngoscope in the sedated patient.
  • High-quality teaching materials: Case discussions in the course parallel real-life challenges and present viable solutions. The videos are excellent. All facilitate information exchange and learning.

Also, I must mention that all instructors are very receptive and fun, and interactions between students are excellent. 

The only shortcoming of this course is that it lasts only one day.

So you may ask, “But is awake intubation worth learning even if I work in the Emergencies Departments in Brazil (or other resource-limited contexts for that matter)?” Well, reviewing the advanced airway anatomy and indications for interventions always help to improve practice. If where you work has a video device or fiberscope, you will benefit most from the course. If not (Most EDs in Brazil today don’t), taking the course is a good reason to ask your manager for buying affordable alternatives like VividTrac®, King Vision® or Airtraq®. Also, awake intubation may be performed with Direct Laryngoscopy; however, it does not make much sense to me considering the main indication: an anatomically difficult airway.

Finally, I recommend the AIME advanced course to everyone who wants to improve their skills and learn how to manage the airway in the awake patient. 

If you are interested in airway management, here is another course I can recommend: PRACTICAL EMERGENCY AIRWAY MANAGEMENT https://www.ceme.org/content/practical-emergency-airway-management-november-2020

Cite this article as: Jule Santos, Brasil, "Passion about “Airway Management”," in International Emergency Medicine Education Project, March 9, 2020, https://iem-student.org/2020/03/09/passion-about-airway-management/, date accessed: April 1, 2023

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Why Me? The Story of My Burnout – Part 3

Why Me? The Story of My Burnout - Part 3
~ Jule Santos, Brasil ~ 1 Comment

The story continues from link (Part 2).

I must take a deep breath. I must ask for help.

The Self-Knowledge Path

I could go away and work in another hospital. We have many good hospitals in Brazil. Some even employ emergency physicians who are local graduates. I really could. In truth, there would be no shame if I left the hospital. But I decided to give it one more try.

I just want to make clear that there is no single route back from burnout. It is a multifactorial treatment. You need emotional power. Some you may already have, or you can develop with a mental health specialist’s help. Some you will gather alone, or family and friends will help you to recover if you are lucky enough. Read, talk, discuss, and share with your community. You will never be alone because it is the system that is inflicting moral injury and burning you, and everybody, out.

Each person needs different means and tools to recover. We have to acknowledge that not everybody can afford all of them. Not everybody can pay for a therapist or even leave their work. I was one of the lucky ones. I could.

I promised myself and others that I would get better, and I wouldn’t give up. I felt obliged to improve the system that had harmed me. The system that made me afraid; afraid that I would fail.

It was not easy! It wasn’t “just not thinking about it.” It wasn’t “just a phase.” It wasn’t “just yoga.” It wasn’t “just wanting.” It was more than all the above. It took a long journey of self-knowledge: Who was I? What did I want? How could I achieve that?

Gradually, intertwined with relapses,​ the healing process began. I returned to therapy. Thanks to all support from my amazing friends, -virtual friends, present friends, distant friends- mentors, mentees, students, residents, followers, I was overwhelmed with affection and understanding. There were messages of encouragement everywhere I looked and listened. I did not plan this. It happened organically from across our community, and sometimes unintentionally, as I reached out to others, who always found time to help me.

Kindness can save a life! If you feel so, just go around saying how important people are in your life. I assure you that the kindness and positive comments of these people saved me.

I improved gradually in small steps. With empathy and determination, I took one step after another. Each step led me to find new perspectives. With each small victory​, I felt a small but important​ celebration in my heart​. ​

Yet, I wanted to make sense of it all. How to endure the moral injury? How to continue working here? I desperately needed to make sense of my job.

Why Me?

jule santos

In addition to therapy, I went on leave. I flew away and spent time in Mozambique, an LMIC, with many more difficulties, compared to Brazil. They were just beginning to develop the first emergency medicine residency program, and they had a lot more work to do. They were seemingly starting from scratch, and they had fewer resources than we had in Brazil. I found their enthusiasm and resourcefulness more inspiring than I thought possible.

It wasn’t because I could see how lucky we are in Brazil, but they did their best even though they were aware of their problems. I knew that there was no way that I could give up after seeing them.

I returned to Brazil, where people were eager to work with me. I felt they had missed me. They showed me that I made a difference.

I was fortunate to see my work environment improved. The administration had started to ‘get it,’ and now they cared about what we do. They realized that efficient systems saved money, so they were helping us achieve better care for our patients. Our department was renovated. They hired more people, and we got better medications. It all helped. It felt as though they were listening.

So recovering from burnout not only helped me to accept that problems are a part of the system but also made me realize people make the system. Therefore we can change it to accommodate our needs. Not the contrary. We need to END moral injury by addressing it and demanding solutions! We don’t need to be resilient to it!

In the beginning, I understood that I needed to be ​present​ in all my tasks, but that’s a challenge in the hectic world of emergency medicine. In truth, we are not as good at multitasking as we let ourselves think. However, we get better at prioritizing and scheduling tasks as we develop as clinicians. More importantly, we learn to give each task the proper time and attention it deserves.

As time passed, my most challenging feelings diminished. I redefined my responsibilities and my choices, redefined my motivation, my ambition, my purpose. I adjusted my expectations. I found a new power.

Then, ​gradually​, the love for Emergency Medicine and the energy to become the doctor I aspire came back. However, I still had to face my demons and deal with the most painful side of emergency medicine: Delivering bad news.

“Most of the time, the fact that you care is enough”​ is one of the most effective pieces of advice that I ever received. It helped me relieve the intense pain that I didn’t even know it was there. I still remind others and myself of it regularly.

For example, I dealt with the tragic case of pediatric cardiac arrest, brought in by another medical team. We did CPR over an hour, as this was a very delicate situation with a child. At the debriefing, I was careful with both teams from the other hospital and our own. Although I was worried about having the conversation I did, I was shocked and stunned to hear the reply. The doctor shrugged and said:

– Yeah, right. Can I go now?

He was in a rush. He didn’t even want to hear the debriefing. He didn’t appear to care! The disdain broke my spirit, and the whole team felt the same anger. It made everything harder to cope.

I took a deep breath, thanked the team for all the effort, asked them to prepare the body, and went to the waiting room to talk once again with the father. I had been there a lot of times, talking through everything as we were trying to resuscitate, so he already knew me, and immediately recognized my expression of bad news. I sat next to him and told him everything we did. I was trying to remedy the anguish while allowing time for understanding.

– There was nothing more we could do. I’m so sorry, but he died.

The father stared at the floor for a while.

– My wife is eight months pregnant. What should I do now?

He was in despair. Next came tears. I waited. Present. Then, he looked at me with honest:

– Thank you, doctor, for everything you did.

I will never forget them.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Now, when I have to deliver bad news, I try my best to be there and look in the eyes. I patiently wait to make sure until there is no doubt. I don’t try to hide my feelings, ​and I finally feel I’m always telling the truth:

– We are doing everything we can.

I ensure that they know​ we care.​ I make a difference there. My pain eases as theirs alleviates even a little.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Finding My Ikigai

ikigai

Ikigai is a Japanese concept that means “a reason for being.” In English, the word roughly means “thing that you live for” or “the reason for which you wake up in the morning.” Each individual’s ikigai is personal and specific to their lives, ​values​ , and ​beliefs​. It reflects the ​inner self​ and faithfully expresses that, while simultaneously creating a mental state​ in which the individual feels at ease.

The thing I like most about ikigai is that it is for everyone. You have to understand yourself to achieve this deeply. Seeking self-knowledge can be the most challenging part.

– Am I doing something that I love?
– Am I doing something that the world needs?
– Am I doing something that I am good at?
– Am I doing something that I can be paid for?

YES!

So, where am I now?

Well, I still love heart attacks! I love the look of amazement of the interns when we save a life. I love the self-satisfaction of the residents when they can do something correctly for the first time. I love how happy the team gets when we can do perfect resuscitation. I love the peculiarities of each patient, their life, culture, and beliefs. I love to learn something new every day. ​And that’s why Emergency Medicine!

I love heart attacks! But when we can't save, when the system fails, when the patient dies but I feel that I softened the pain, even a little bit, by showing that we care, I know I can endure.

And that's why, me.

Why Me? The Story of My Burnout - Part 1
Why Me? The Story of My Burnout - Part 2
Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 3," in International Emergency Medicine Education Project, January 6, 2020, https://iem-student.org/2020/01/06/emergency-medicine-why-me-the-story-of-my-burnout-part-3/, date accessed: April 1, 2023

Why Me? The Story of My Burnout – Part 2

Why Me? The Story of My Burnout - Part 2
~ Jule Santos, Brasil ~ Leave a comment

The story continues from link (Part 1)

I had already been tired and sad. Now, I was also feeling wronged.

The Dangers of Burnout

It meant that heart attacks stopped being exciting. I started to resent them as they now caused me to suffer. I have nowhere else to refer the patient, or the specialty doctors criticized me. 

They mistreated me, perhaps because of a lack of trust, or they too were damaged by the system. Maybe it was about payments and expenses. I did not know, but the effort of constant fighting was exhausting.

The system hit me hard. It was clear: irritation, stress, discontent, three quarrels with my team and my superiors in one week. I was burned out. That was putting my good work at risk.

Sad person

I felt like everything I was doing was meaningless. I aspired to become the best possible doctor through studying, traveling and sharing, but I always returned to the conditions that made me feel that all was in vain. My stagnant environment was full of burnout people, unjust deaths and endless problems regarding insufficient resources versus higher and higher demand.

That saddest thing in medicine is a doctor without hope.

I felt that each patient brought more pain than joy, even when we had excellent outcomes. It made me sick. I felt like I had unlearned hope. To make matters worse, I could not contain these emotions.

One day a patient asked me, “Am I going to die, doctor?”

I had just seen the results. It suggested cancer, but what would happen now? We wanted an expert to lead him, necessitating an evaluation by the oncologist. Still, the oncologist would not see the patient until the biopsy result, despite the imaging strongly suggested cancer. That meant we had to ask the general surgeon to do the biopsy, but in return, he asked us to refer the patient to another surgical specialty, based on the location of the tumor. So we tried, but this type of specialist did not serve in our region.

The patient’s and our growing stress and conflict eventually led the general surgeon to do the biopsy, but the patient had to wait 30 to 45 more days for the result. Only then, he would be able to go back to the oncologist. When he did, tho oncologist asked us for phenotyping. One more week passed until we finally get the patient to oncology, only to be declared too sick for treatment.

I had experienced this so many times before. Meanwhile, patients were getting more sick, and repeatedly ended up in the emergency department, sometimes got admitted, only to treat infections or pain. In the end, they were sent by the internist to die in our emergency room. They could not do end-of-life care properly. I frequently talked to an enraged family, not because of cancer, but because they were led to believe there was a chance of treatment.

My opinion is that the problem wasn’t lying to the patient about cure cancer, but how often the system don’t even give them this chance of a fight, lying about a chance to treat, but in really being just harmful for everybody because disorganization, corruption, and for didn’t care.

We do not cure death. Ever.

Sometimes we can prolong life. We hope for a good life with meaning, so that they can enjoy some more years, months, weeks or days of celebration, and prepare their wishes for a decent death with their family.

My opinion is that this realization is important not only when we talk about cancer, but any condition, even like a heart attack. We do not cure death, ever.

Coming back to that new patient, the words and the questions bounced in my head:

– Am I going to die, doctor?
– Don’t think about it now. We will take care of you.

I don’t know what the patient saw in me. To me, It felt like lying. When I said we would do our best, it wasn’t me but the system lying. Even if we as emergency physicians or I as an individual did everything possible, I felt the system didn’t care. I knew the system could do better. What could I say when I knew that the journey I want for my patients is so unachievable in the system I work in. I no longer knew what to say under these circumstances, and I felt the patient recognized that in my soul.

I felt hurt, guilty, beaten, and bitter.

That saddest thing in medicine is a doctor without hope.

I never thought this could happen to me. Not with me! How could this happen to me? I was in love with Emergency Medicine! Wasn’t I?

I’d said a billion times how I loved Emergency Medicine and didn’t know how to live without it. I’d shared my passion, convincing others that Emergency Medicine was the answer. Now, it felt like Emergency Medicine was killing me. And worst, I felt that I was not doing good for my patients as my lies were hurting them.

I must take a deep breath. I must ask for help. ...to be continued...

Why Me? The Story of My Burnout - Part 1
Why Me? The Story of My Burnout - Part 3
Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 2," in International Emergency Medicine Education Project, January 3, 2020, https://iem-student.org/2020/01/03/why-me-the-story-of-my-burnout-part-2/, date accessed: April 1, 2023

Why Me? The Story of My Burnout – Part 1

why me - the story of my burnout
~ Jule Santos, Brasil ~ Leave a comment

This story starts like almost every other: I fell in love.

The thing is, I LOVE heart attacks!

I know this is a weird statement, maybe even a little ​overstated. I know that people can get uncomfortable when I say this. When I said it for the first time, full of enthusiasm and with sparkling eyes, my ex-fiance looked at me in a concerned and puzzled way: ‘Can you say that?​’ – He asked, wondering if it was appropriate for a doctor to say that they actually enjoyed the experience of people being so unwell.

Clearly, as a doctor, I have nothing against people. Quite the contrary, I unceasingly fight for them to survive and thrive. Yet the paradox is real, despite my battle to save my patients, I am so in love with heart attacks!

Why? Perhaps I love the puzzle behind it. When the patient arrives, I see the position of the body, the hand on the chest, fingers tightly pressed against the skin, the skin color, the sweating… I consider the nuances of pain types, the comorbidities, the risk factors… All are informing my judgment and decisions even before I get to look at the ECG.

I love knowing the diagnosis as it reveals itself. I love that I can treat it. And when it works, I’m the queen of my craft. The scores of survival game change. 1 for me, 1 for my patient, and 0 for the heart attack!

So that’s why you would see me so happy when a patient arrives in my ED. I love this feeling. I love this adrenaline rush that is emergency medicine and me! I love leading a code, guiding actions, organizing my team to the point of ROSC. I love that roaring energy that runs through the whole team as we effortlessly move to the next stage of resuscitation.

This is why I love Emergency Medicine.

Emergency Medicine is new In Brazil. The general assumption is that ED is where junior physicians serve until they choose another specialty or other specialists work to earn additional income. Until recently, working in the ED was a difficult job with no career advancement. So, when I realized that I was so in love with more than heart attacks that I could not leave my work as an Emergency Physician, people started to ask me, “Are you sure? Do you want to work forever in an ED in Brazil? What about when you get older? Don’t you think you will get tired and burned out?”

jule santos

I don’t think so. I reply, “I love my job. When you love your job, you don’t ever get tired.”

How naive I was.

Emergency medicine is tough, sometimes even painful. Deaths, we can’t help. Diagnoses of incurable diseases. Bad news. The pressure to be good, perfect, productive. Adding to that, many of us work in corrosive health systems: The result? Emergency Medicine can burn you to your core.

Being in love​ with Emergency Medicine is enough to protect us?

Emergency Medicine can burn you to your core.

Leaving the Comfort Zone

I am a curious soul. While I learned more about emergency medicine, I discovered another world with worldwide Emergency Physicians, who could understand my difficulties and help me learn remotely from them. I fell in love again with #FOAMed.

Hearing the experiences of my colleagues from all around the world inspired me to travel and meet those people. I wanted to learn with them and to compare how Emergency Medicine is in those places.

I love #FOAMED

My newly found calling took me to Sydney in Australia, such a lovely country, which had beautiful and polite people, good public transportation, beautiful scenery, and even a public healthcare system too!

I was lucky enough to spend time in an excellent hospital in NSW. I witnessed them receiving a trauma patient and listened to them as they plan patient management. I was speechless. I felt a sudden sadness to the degree that I wanted to crawl back to my mother’s womb.

When I tell this story, people often react, “You don’t need fancy stuff to practice Emergency Medicine,” but it was not what I saw there. What was it? It wasn’t the video laryngoscopy. It wasn’t the infinite bougies and disposable LMAs. That’s true: The facilities in Australia were incredible and so much more were available than back home in Brazil. But it was still the people.

When the paramedic team arrived, the whole team discussed the patient plan. They were so courteous and respectful to each other, focused only on doing the best for the patient. They were excited about the case, energized, and happy for doing their best.

I’m not saying their life is easy. I’m not saying they don’t suffer moral injury. But I’m sure they don’t show ill-will to their peers and most importantly, to their patients. I want so badly to be able to do that kind of medicine, but the realization of this new health system made me feel envious and perhaps even hopeless. Their experience was so positively different from mine.

Teamwork

I spent the next day in my room, lying depressed in bed, staring at the ceiling, trying to figure out what to do now: “How I would love to have that experience in my hospital!”

I thought a lot about what happened there. Why did it hit me so hard? I knew that not all hospitals were the same in Australia as some hospitals had problems and struggles like in Brazil. I already knew that we had hospitals in Brazil better than mine. Why did I feel so hopeless then?

Now, looking back, I can understand better. I was pushing my comfort zone further than I ever did in my entire life. I was discovering a lot about myself and my capabilities. I was achieving success through FOAM. And so, I saw my limitations, I strumbled in a deep Impostor Syndrome and lost some excellent opportunities. I was in such a fragile mindstate that I felt like the system was unfair to me.

Sad Clown

In my hospital, which is always overcrowded, I work with physicians that don’t have the mindset of Emergency Medicine. When a trauma patient arrives, it feels like a battle. Physicians challenge paramedics: ​“Why did you bring this patient here when we don’t have bed enough?”​ or​ ​“​we don’t have enough surgeons!” or “why does nothing here work?”

All too frequently, the team ends up shouting at each other.

I tried hard to spread the ideas and visions I was learning. One time, I asked for an ultrasound machine, my boss laughed in my face: “Where do you think you are?” Everybody seemed so consumed by pessimism and fatigue that they lost all hope.

I had already been tired and sad. Now, I was also feeling wronged. ...to be continued...

Why Me? The Story of My Burnout - Part 2
Why Me? The Story of My Burnout - Part 3
Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 1," in International Emergency Medicine Education Project, December 30, 2019, https://iem-student.org/2019/12/30/why-me-the-story-of-my-burnout-part-1/, date accessed: April 1, 2023

Mozambique Emergency Medicine Is On The Rise

Mozambique Emergency Medicine Is On The Rise
~ Jule Santos, Brasil ~ 1 Comment

Africa is a magical continent. It is filled with unique cultural energy. I promise you will never regret diving into this experience. Whether in a park celebrating a wedding, or simply celebrating life at a night club. Africans are master of this, the magic spreads through the air, and you can feel it.

Image by Idílio Chirindja from Pixabay

I had an incredible opportunity to experience Mozambique. In the middle of many English speaking countries, an island speaking Portuguese language.

The country is in the southeast of Africa. The capital is Maputo, which was invaded by Portugal in 1505 that established dominion until 1975 when Mozambique gained its independence. But after that, the country lived years of intense civil war until 1992. Since then Mozambique has lived in a period of relative political stability.

The official language of Mozambique is Portuguese but is spoken mainly as a second language about half of the population. Among the most common native languages are Macua, Tsonga and Seine. The population of about 29 million people is predominantly made up of Bantu peoples.

My story meeting Mozambique

Every time you have doubts about the work is done on the Internet, which many may think irrelevant, I want to say to you that I owe my medical career as an Emergency Physician to #FOAMed. Emergency Medicine was recognized as a specialty in Brazil only in 2015, after many years of struggle. So, we didn’t have much information about this specialty which is still unknown to many students who are currently choosing the specialty, as it was with me. But the fact that someone writes something down and makes it accessible on the internet can really change lives. What led me to understand who I was and what I wanted to do in medicine was this text by Joe Lex. I found my people. My tribe. I understood who I was and fell in love with Emergency Medicine.

After knowing so many amazing FOAMed blogs (emdoc, emcrit, rebelem, etc.), I was so inspired and wanted to do for emergency medicine in my country. I want to create a FOAMed content so that people like me could discover our specialty earlier. And it has to be in Portuguese.

English is important, but nothing so comforting than reading content in your own language. You can think and retain the new knowledge faster, and you can translate the knowledge better to the patient. Understanding is clearer, more accessible, and also brings a sense of belonging and appreciation.

So when I met Abigail Hankin-Wei, we were committed to producing emergency medicine content in Portuguese for the sake of our emergency medicine training programs. Abigail is an inspiring person, who is an emergency physician from the US working in Mozambique full-time to help build the country’s first emergency medicine training program. The residency program is the first one in the country established in 2016, with six young and passionate residents. So I went there to make our bond stronger.

The thing I love most in our specialty is the tribe feeling — the way we immediately recognize the passion in each other. So when you talk about medicine, you know, you understand, you feel belonging to a place, you know that you aren’t the only one crazy doctor that likes to take care of very sick patients. In my routine daily life, it is difficult to encounter this kind of bound.

So, coming to Mozambique and meeting these residents (Brito Gulela, Dino M. Lopes, Euridxe Barbosa, Maria Augusta Taimo, Hermenegildo de Jesus da Silva Macauze and Ezio Massinga) and two more physicians from US (Patrick Connel and Rodolfo Loureiro) were the same exactly how I felt. I was among friends, equals, and I felt like I was at home.

The Story

In Mozambique, we worked at the Mavalane Hospital. I assumed that it is a secondary level hospital, but with a real lack of support. The patients were respiratory failure, abdominal pain, fever, malaria, tuberculosis, lots of complications of HIV, acute stroke, high hypertensive emergencies, etc. They could only provide oxygen (with limitation), and some basic medications.

In the first week, the x-ray machine was broken, but the show must go on, and they did the best they could, treated the most likely disease in their environment with little room for a thorough investigation. They placed the sickest patients in a separate room, the only room in the department where they could get oxygen therapy, which came in two large cylinders. They transferred the most severe patients (which had to be very sick) with potential for recovery to the Central Hospital. As Patrick used to say, the work of the Emergency Physician is to separate the sheep from the goats, so they have to learn as best as they can.

One brilliant thing was the use of POCUS, which is a great value in this context, and I was able to learn a lot from them as I still developing my skills. In need of a CT imaging, the patient has to be referred to the Central Hospital (level one, but still with many limitations). It has to be really thought through because there are limited spots daily. Some conditions could be done, some conditions not. It should change treatment and outcome in a patient with possible good prognosis.

Sometimes the days were really harder, especially when you achieved a certain level of treatment, and you did not have more options to use. They couldn’t do fancy things like NIMV or intubation, or continuous infusion of drugs. They do what they could with their best, and we wait and hope.

The human body is amazing, they are particularly strong here, and one thing I brought with me from this experience is that some patients really get better despite our limitations.

Of course, it would be a lot better to help all patients get better faster and safer. But really, our job is not the most important part. The body is the king. We need to recognize this as quickly as possible in our careers and understand how much we should hasten an improvement and how much we should just wait from the body, without feeling resentful of ourselves when the body achieve its’ limitations, because, in fact, we (as doctors) don’t have that much power as sometimes we think we have.

The environment is harsh. The team has to be practical. Patients give themselves to care, and the team does what they need to do with what they have. Sometimes it was hard to see that cold reality. But again, I could testify how education and love can save the world! In one week, I could see the work of the residents changing everything, turning everything better, lighter, humanized with meaning. They educate the team; they treat the patients with passion and respect; the team wants to be like them: education is the power.

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You have to celebrate each small victory

From time to time you should remember and appreciate people for the little good things they do, even if seems small in a big context. So, they don’t forget the small victories, that is what gave us fuel to keep going.

When I was about to leave, we set and talk about their expectations. I could not be more inspired by their clear awareness. They know the hard work that is ahead. But they have dreams about a more organized emergency health care system. They have a passion (inherent in the emergency physician). They have a good heart, strong determinations, vision, and they are smart.

They truly have the magic!

Patrick

They know there’s still a lot of uncertainty, will the specialty be recognized someday? Will be a place to work? Will the residency grow? Will they have a spot in the most important hospital? They don’t know yet. But they are studying, traveling, receiving people of around the world with humbleness, willing to learn, to improve, to be able to do the most exciting things for their patient and their country. 

I would like to remind that planting an unprecedented program in such an arid place is work for many people. And this team needs recognition, so my special thanks to Dr. Kevin Lunney, who creates PLeDGE Health ONG, that is helping support the residency program.

Special thanks to Sarah Mondlane to her work at PLeDGE Health, and for being the sweetest, kindest hostess in the world. Her love for this cause is pure inspiration.
And thank Dra Otilia Neves, member of the Ministry of Health, and coordinator of the program, who kindness accepted us in Mozambique.

I hope that the work of this team resonates forever in Mozambique.

Cite this article as: Jule Santos, Brasil, "Mozambique Emergency Medicine Is On The Rise," in International Emergency Medicine Education Project, September 16, 2019, https://iem-student.org/2019/09/16/mozambique-experience/, date accessed: April 1, 2023

Acute Ischemic Stroke Management in the ED – Part 1

Acute Ischemic Stroke Management
~ Jule Santos, Brasil ~ Leave a comment

Your shift has just started, and you received a 56-year-old female patient, brought by her family due to a sudden loss of movement. The patient seems awake; you approach her, introduce yourself, and ask for her name. She does not understand. You ask her to look at you and to raise her arms, then you see: the left side of her body was paralyzed. In your head, a stroke sign lights up: you need to decide whether to activate the stroke protocol immediately or not, after all:

Time Is Brain

Important Hints

  • Know the protocols and references of your hospital and your region for acute stroke management. Your Emergency Department should be prepared to suspect of stroke in any patient presenting with acute neurological deficits and have a pre-established protocol for prioritizing care.

  • The prehospital service (EMS) should provide notification to the receiving hospital that a suspected stroke patient in the therapeutic window is en route and direct the patient to the closest hospital with thrombolytic support.

  • By AHA/ASA recommendations, door-to-needle time <60 minutes should be sought in more than 50% of patients treated with alteplase (tPA) (1)

Neurons are very sensitive to changes in brain flow and die within minutes in the absence of perfusion: thus the urgency in attempting rapid reperfusion. (2)

Do not delay the patient evaluation because the emergency department is overcrowded! Move the patient to a monitored bed as soon as possible.

While the patient is being monitored, continue your focused neurological examination quickly and accurately. Asking for the patient to lift and hold the arms, then the legs, tests sensitivity and strength. Then you should ask her to try to smile, assess the eye movement, pupils, search for nystagmus, and ask her to try to expose the tongue, assessing movement and understanding. You ask her simple questions: full name, date, where she is, point to a cell phone, a mug and a watch and ask if she recognizes them. At the same time, you evaluate strength, orientation and deficits.

VITAL SIGNS
Blood Pressure: 180/110 mmHg
Pulse: 125 bpm
SatO2%: 98
Respiratory Rate: 18 bpm

Do not forget to measure capillary GLUCOSE (135mg/dl). Important to rule out other causes of neurological symptoms that can mimic a stroke.

Hypoglycemia

Hypoglycemia is the first condition we evaluate for when the patient presents with acute neurological deficit, decreased level of consciousness, weakness, syncope, convulsion, etc. Hypoglycemia is defined by a blood glucose level less than 45 mg/dl. Symptoms improve rapidly as soon as corrected in most cases. However, it may take time for a complete improvement, and does not always rule out a stroke. (3)

Seizure

Seizure and post-ictal condition are also conditions that can mimic a stroke. Todd’s Paralysis is a focal weakness localized to one side of the body, which occurs around 13% of seizures. These deficits usually last up to 20 minutes but may last 48 hours. Unfortunately, seizures may present in the setting of acute stroke or patients with a stroke history due to neuronal damage. (3)

Stroke Mimics

Stroke mimics are common, accounting for 5% to 31% of patients with acute focal neurological deficit. (3) Diagnosis is not always simple, and abnormal eye movements, increased diastolic blood pressure greater than 90mmHg, and history of atrial fibrillation or angina are most commonly found in stroke. In the presence of decreased level of consciousness, cognitive dysfunction and normal eye movements are more common in stroke mimics.

Stroke Mimics

Condition

Misdiagnosed as stroke (%)
Brain tumor
7-15
Labyrinthitis
5-6
Metabolic disorder
3-13
Migraine
11-47
Psychiatric disorder
1-40
Seizures
11-40
Sepsis
14-17
Syncope
5-22
Transient global amnesia
3-10
Other
11-37

From Konrad CN, Crocco T, Biola J, Larrabee H. Is it stroke, or something else? The Journal of Family Practice. 2010 Jan; 59 (1): 26-31.

The time is ticking, and you must make critical decisions.

  • Is it a stroke? Or a disease with an acute neurological symptom that mimics a stroke?

  • I need a brain imaging study in less than 20 minutes. (2) Will I need to protect the patient's airway before, or should I go straight to the imaging exam?

  • What brain imaging study do I have and what should I do first? CT or MRI?

  • Is there an indication for IV alteplase? Should I do it in my unit, or should I referral the patient to another center?

  • Are there indications for mechanical thrombectomy? Should I do CT angiography at the same time?

Management of acute stroke will depend on:

  • The support you have.
  • Time of onset of the stroke, that is, duration of symptoms.
  • The severity of symptoms:
    • Physical examination: NIHSS, etc.
    • Signs of a large vessel stroke
    • Area of irreversible ischemia “core” versus penumbra area, salvageable area
  • The desire of the patient/family after being informed of the risks/benefits.

Clinical History

The clinical history must be acquired quickly and directly. Essential points: time of symptoms, associated symptoms, comorbidities, and medications of continuous use.

It is important to note that the time of the symptom is counted from the last time the patient was seen without symptoms and not when someone noticed the deficit. (1) If the patient woke up with the deficit, time counts from when he/she was seen without symptoms (e.g., the day before bedtime).

Laboratory, Imaging, Management

Unnecessary tests should not delay brain imaging. It should be performed within 20 minutes of the patient’s arrival at the hospital!

If you do not have a CT scanner in your hospital, the patient should be referred for a center that has one, preferably with a stroke unit. In this situation, physical examination and accurate data of the clinical history must be passed to the place of reference. A physician should accompany the patient.

Treatment of blood pressure only if BP> 220 x 110mmHg, preferably with easy-to-control intravenous medication (labetalol, nicardipine, sodium nitroprusside, etc.). Avoid oral medications due to bronchospasm risk and unpredictable effect. Not having intravenous options, I would consider tolerating hypertension until the diagnosis is confirmed.

Venous access with the collection of samples such as complete blood count, electrolytes, renal function, TAP, APTT, troponin, and more as needed, according to patient comorbidities and medications.

Do not delay the brain image waiting for the collection of laboratory tests. Do not delay imaging or therapy with tPA expecting laboratory test results, unless it is essential.

Venous access before the examination is essential if there is a decision to perform CT angiography of cervical and intracranial vessels in the possibility of mechanical thrombectomy. However, performing CTA should not delay the performance of chemical thrombolysis if indicated. That is, the radiology sector should be prepared to perform immediately after CT if indicated.

Which imaging test is the best? and Why?

MRI

Weighted MRI diffusion shows a greater positivity than CT in the first 24 hours for ischemic stroke, especially in the vertebrobasilar territory. However, its role in ED is still limited because of its uncertain accuracy for the diagnosis of acute hemorrhage, low immediate availability, patient contraindications (not cooperating, claustrophobia, metal implants, pacemaker, etc.) and cost-effectiveness.

CT

CT without contrast, is relatively accessible in most reference centers. It discards other causes of neurological deficit such as ICH, abscess, brain tumor, etc. It may not diagnose acute stroke. But together with a compatible clinical story, it is the only necessary brain image for performing IV alteplase. (2)

Every patient with acute neurological deficit, independent of time, must perform a brain imaging, mainly to rule out other causes, such as ICH, which completely changes the treatment.

All patients with acute neurological deficits, mainly without a diagnosis, must be accompanied by a physician assistant during transfer to imaging, due to the risk of abrupt change/worsening of the clinical status.

It is important to have communication between the ED areas, to warn the radiology department in advance that the patient is on the way, and that the exam should be prioritized. (2)

You accompany the patient during the CT scan. And this is her exam:

Do the best you can, ask for help when in doubt, study and care with love.

To Be Continued.

References and Further Reading

  1. Tintinalli, Judith E.,, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Eighth edition. New York: McGraw-Hill Education, 2016.
  2. William J. Powers et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. AHA/ASA Guideline. 2018 Mar;49(3):e46-e110. doi: 10.1161/STR.0000000000000158. Epub 2018 Jan 24.
  3. Brit Long, MD, Stroke Mimics: Pearls and Pitfalls, http://www.emdocs.net/stroke-mimics-pearls-and-pitfalls/ em 07/05/2019
Cite this article as: Jule Santos, Brasil, "Acute Ischemic Stroke Management in the ED – Part 1," in International Emergency Medicine Education Project, August 9, 2019, https://iem-student.org/2019/08/09/acute-ischemic-stroke-management-in-the-ed-part-1/, date accessed: April 1, 2023