Management of Status Epilepticus in ER

References and Further Reading

  1. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48
  2. Joshua G. Kornegay.  Chapter 171. Seizures. In: Tintinalli JE, ed. Tintinalli’s Emergency Medicine A Comprehensive Study Guide. 8th Edition. McGraw-Hill Education; 2016: 1176-1178
  3. Rabin E, Jagoda AS. Chapter 92. Seizures. In: Walls RM, Hockberger RS, Gausche-Hill  M, eds. Rosen’s Emergency Medicine Concepts and Clinical Practice. 9th Edition. Philadelphia: Elsevier Saunders; 2018: 1256-1264
  4. Sharma AN, Hoffman RJ. Toxin-related seizures. Emerg Med Clin North Am. 2011;29(1):125–139. doi:10.1016/j.emc.2010.08.011

 

Cite this article as: Neha Hudlikar, UAE, "Management of Status Epilepticus in ER," in International Emergency Medicine Education Project, June 1, 2020, https://iem-student.org/2020/06/01/management-of-status-epilepticus-in-er/, date accessed: October 23, 2020

SAFE-BBOP! – A mnemonic for anaphylaxis management in the emergency department

anaphylaxis

While recently experiencing eight incredible weeks of Emergency Medicine rotations, I was reviewing my approach to anaphylaxis. Coincidentally, there was a real case a few days later, and I found the following mnemonic useful. If you’re having trouble remembering the different components of management for adult cases of anaphylaxis in the emergency department, think of SAFE-BBOP

This is not the exact order in which anaphylaxis should be approached, but it may facilitate memorizing commonly-used treatment modalities while learning and reviewing the general approach. The ABC algorithm should be applied first (see: https://iem-student.org/abc-approach-critically-ill/). Following the diagnosis of anaphylaxis, epinephrine should be administered promptly, as delayed administration has been associated with increased mortality (1-4).

SAFE BBOP

S - Steroids

Prednisone 50mg PO or methylprednisolone 125mg IV. Glucocorticoids are theoretically used to prevent a possible biphasic reaction; however, there is limited evidence for this.

A - Antihistamines (H1 and H2)

Ranitidine 150mg PO/50mg IV, Diphenhydramine 25-50mg PO/IV. Their use is based on studies of urticaria and should only be used as an adjunct therapy.

F - Fluids

Normal saline or Ringer’s lactate 1-2 L IV.

B - Beta-blocked

If a patient is on a beta-blocker and is refractory to the administered epinephrine, consider glucagon 1-5mg slow IV bolus over 5mins, followed by an infusion at 5-15mcg/min, titrated to effect.

B - Bronchodilators

For persistent bronchospasm despite epinephrine, an inhaled bronchodilator can be considered, such as salbutamol 2.5-5mg nebulized or 4-8 puffs by MDI with spacer q20 mins x 3. This is based on studies of acute asthma exacerbation and should only be used as an adjunct therapy.

O - Oxygen

Every patient, who is critically ill, requires supportive oxygen treatment.

P - Positioning

Recumbent position with lower extremity elevation (consider left lateral decubitus position for pregnant patients to prevent inferior vena cava compression).

As for disposition considerations, the SAFE system below was introduced by Lieberman et al. (2007) to recognize the four basic actions to address with patients prior to discharge from the emergency department (5).

  • Seek support
  • Allergen identification and avoidance
  • Follow-up for specialty care
  • Epinephrine for emergencies

For a detailed review of anaphylaxis definitions, signs and symptoms, refer to this great Life in the Fast Lane article: https://litfl.com/anaphylaxis/

References

  1. Prince, B.T., Mikhail, I., & Stukus, D.R. (2018). Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy, 11, 143-151.
  2. Sheikh, A., Shehata, Y., Brown, S.G., & Simons, F.E. (2009). Adrenaline for the treatment of anaphylaxis: Cochrane systematic review. Allergy, 64(2), 204.
  3. Simons, F.E. (2008). Emergency treatment of anaphylaxis. BMJ, 336(7654), 1141.
  4. McLean-Tooke, A.P., Bethune, C.A., Fay, A.C., & Spickett, G.P. (2003). Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ, 327, 1332.
  5. Lieberman, P.,Decker, W., Camargo, C.A. Jr., Oconnor, R., Oppenheimer, J., & Simons, F.E. (2007). SAFE: a multidisciplinary approach to anaphylaxis education in the emergency department. Ann Allergy Asthma Immunol 98(6), 519-23. 
 

Further Reading

Cite this article as: Nada Radulovic, Canada, "SAFE-BBOP! – A mnemonic for anaphylaxis management in the emergency department," in International Emergency Medicine Education Project, December 11, 2019, https://iem-student.org/2019/12/11/a-mnemonic-for-anaphylaxis-management/, date accessed: October 23, 2020

Clinical examination of the hemodynamically unstable patient

Clinical examination of the hemodynamically unstable patient

Authors: Job Rodríguez Guillén. Chief of Emergency Department. Hospital H+ Querétaro. México and Paola Rivero Castañeda. Medical Intern, Anahuac Querétaro University, Mexico. 

Introduction

Clinical examination accounts as a fundamental part in the management of most critical scenarios. Although there are few publications and it remains controversial, its value considered as limited by 50% of medical practicioners (1). None of the well-known semiology books include any section about the physical examination in the critically ill patient (2). Nonetheless, an adequate clinical evaluation at the patient’s bedside may save lives in the context of a serious situation.

Clinical Examination Objectives

The main objectives are identifying and discerning from types of shock, emphasizing in the identification of life-threatening conditions, clinical signs of organic hypoperfusion, as well as to evaluate treatment response regarding therapies employed, and risk stratifying.

Identify hemodynamic instability

  • Life-threatening conditions (Tension pneumothorax, Cardiac tamponade, Pulmonary thromboembolism, Active hemorrhage, etc.)
  • Organ hypoperfusion
    (Altered mental state, decreased uresis, mottled skin, prolonged CFT, etc.)

Evaluate treatment response

  • Vital signs and normalization of the clinical state
    (Mental state improvement, diminished skin mottling, improved uresis, normalization of prolonged capillary filling time, etc.)

Risk stratifying

  • Scale and prognostic scores calculation. Prognostic scores use a combination of clinical and/or laboratoy variables (SOFA: Squential Organ Failure Assessment; APACHE: Acute Physiology and Chronic Health Evaluation; SAPS: Simplified Acute Physiology Score; MPM: Mortality Probability Models, etc.)

Clinical Exam Systematization

The clinician must be able to do a quick and efficient clinical examination to recognize different states of shock as early as possible, or even situations that may compromise organic perfusion. At a given time, it’s suggested to check out the clinical history, re-interrogate the patient and his/her family members, as well as patient’s family/regular physician (or even look for their previous medical notes), in order to help clinical integration, and so for decision making.

Systematization of the evaluating process, based on the previously proposed objectives, can be identified with the following mnemonic: PROA.

PROA - Summary

P - Probabilistic thinking

  • Think about any probability.
  • Look for intentionally.
  • Analyze clinical context and individualize.

R - Risk of dying

Identify life-threatening causes: Cardiac tamponade, Tensionpneumothorax, Pulmonary thromboembolism, Active hemorrhage, etc.

O - Organic hypoperfusion

Cutaneous perfusion signs: examine mottled skin and capillary filling time.

A - Approach of the clinical examination

Clinical exam by regions. Some components may not be relevant for all patients, even requiring other physical maneuvers. Even though laboratory and imaging are not part of the clinical exam, their interpretation must be integrated with the examination findings.

Probabilistic Thinking

Medicine is a science of uncertainty and an art of probability.

— William Osler

Clinical decision making in the emergency department begins with the estimation of the probability of a determined patient to have or do not have specific conditions (Bayesian reasoning or pretest probability).

Example; the probability of septic shock in a young patient after having a car crash is very low compared to the high probability of presenting with hemorrhagic or obstructive shock.

Proposed decisions related to initial probabilistic thinking vary in clinical relevance depending on the patient’s condition. It should always be re-evaluated through available additional data (posttest probability) (Figure 1).

Relationship between probability thresholds and decision‐making zones
Figure 1: Relationship between probability thresholds and decision‐making zones (3).

Risk of Dying

Shock is a momentary pause in the act of death.

— John Collins Warren

Currently, there are four types of shock, all with a common pathophysiological pathway: acute circulatory insufficiency associated with cell oxygen utilization dysfunction (altered-balance between oxygen input and consumption: DO2/VO2 dysfunction), a central situation that takes part in the development of multiorgan dysfunction (4-5).

Initial physical examination should be directed to the identification of immediate life-threating pathologies such as obstructive shock (Tension pneumothorax, cardiac tamponade, pulmonary thromboembolism), hemorrhagic shock etc.

These pathologies require immediate action. Otherwise, early multi-organ dysfunction and death may occur. The Point of Care Ultrasound (PoCUS), is a fundamental tool used for the evaluation of patients with hemodynamic instability of unknown origin.

Organ Hypoperfusion

When assessing the damage an earthquake or fire has caused inside a building, one looks through the windows. Using this analogy, it would be useful to be able to see inside the body to view the damage caused by the shock process.

— Jean-Louis Vincent

The initial approach to clinical examination begins with the skin. It is essential to remember that microcirculation cannot be globally defined through its dependency with macrocirculation, autoregulation mechanisms and organ interactions. Moreover, the availability of devices to evaluate it remains limited. Therefore, the evaluation is done from clinical, biochemical and hemodynamic data integration (6) (Figure 2)

Figure 2: three windows of shock

The correct way of measuring capillary filling time

Approach of The Clinical Examination

Clinical exam is not an art, is an essential ability.

— Leonel Martínez-Ramírez

During the initial evaluation, multiple situations can affect the accomplishment of a detailed physical examination. Therefore, it is recommended to follow a structured exploration method, looking at every main organ system and region. Documenting its results would allow avoiding the inclusion of essential data, and would permit to identify tendencies or any change in the patient’s clinical status.

Clinical examination approach in the critically-ill patient.

7Clinical examination approach emphasized in the critically-ill patient. This examination is realized based on every region in the body. Some components may not be relevant for all patients, or even some other maneuvers shall be executed in the physical examination. The verification list should be modified to be adapted to each patient’s circumstances. Laboratory and other studies analysis does not conform part of the clinical examination, although, their interpretation should be added to exploration findings (7).

  • General appearance

    Introduce yourself to the patient. Evaluate general appearance, physical state, complexity or the presence of particular face patterns, etc.

  • Head

    Inspect pupils' symmetry and reactiveness to light. Look for facial asymmetry and signs of bleeding in nostrils and oropharynx. Inspect lips, mouth and tongue, searching for lesions or signs of ulceration.

  • Neck

    Evaluate neck symmetry, venous distension and tracheal positioning. Palpate searching for adenopathies, subcutaneous emphysema, etc.

  • Thorax

    Expose the thorax, inspect the use of accessory respiratory muscles, diaphragmatic movement, and type of respiration. Also, look for ecchymosis or hematomas. Palpate searching for subcutaneous emphysema or bone crepitations. Auscultate respiratory sounds bilaterally, as well as heart sounds, noting the physiological splitting of the second heart sound, murmurs, friction and gallop rhythm or third heart sound.

  • Upper extremities

    Evaluate upper extremities symmetry. Inspect all arterial and venous line catheters. Evaluate for presence of mottled skin, peripheral pulses and perfusion through capillary filling time.

  • Abdomen

    Take into consideration the diaphragmatic movement during ventilation. Evaluate distension and tympanic sounds during the percussion of the abdomen. Palpate for any rigidity or involuntary guarding. Evaluate abnormal growth of spleen and liver, palpable masses, murmurs or other intestinal sounds.

  • Lower extremities

    Evaluate all sites of vascular accesses and palpate pulses. Evaluate mottled skin, peripheral perfusion and edema.

  • Central Nervous System and Mental State

    Evaluate if the patient is able to follow orders and if his/her four extremities can move equally. Evaluate plantar response as well as withdrawal to pain stimuli. Check pupils and facial symmetry if they were not previously evaluated.

  • Devices and Incisions

    Every possible surgical site should be evaluated, as well as the entrance of every device, including endotracheal tubes, vascular accesses, thoracic tubes, enteral probes and urinary catheters. It should be taken into consideration the characteristics and quantity of urine in the Foley bag.

  • Monitors and waveforms

    The mode, pressures, ventilation per minute and waveforms, hemodynamic monitor (venous pressure, arterial pressure), telemetry and vital signs, as well as any other type of bedside monitor, should be inspected in order to detect any qualitative or quantitative alteration/abnormality.

  • Posterior region

    Exam executed when the patient is in a prone position. Inspect looking for lesions or penetrating wounds. Pressure ulcer appearance should be evaluated.

  • Environment

    Family’s or visitors' moods should be taken into consideration. Light quality, ambient temperature, etc. should be evaluated.

Conclusions

Clinical integration of initial clinical history and the physical examination should be added to the biochemical complementation as well as advanced hemodynamic monitoring parameters, when these are available. Even so, if clinical examination answers raised questions during the initial evaluating process, the clinician must act according to physiological principles. There is no ideal hemodynamic monitoring, meaning that all parameters have to be individualized for each patient and his/her clinical context. Therefore, clinical examination systematization results are an excellent aid for the clinician regarding his/her clinical practice.  

References and Further Reading

  1. Vazquez R, Vazquez Guillamet C, Adeel Rishi M, Florindez J, Dhawan PS, Allen SE, Manthous CA, Lighthall G.  Physical examination in the intensive care unit: opinions of physicians at three teaching hospitals. Southwest J Pulm Crit Care. 2015;10(1):34-43. DOI: http://dx.doi.org/10.13175/swjpcc165-14
  2. Cook CJ, Smith GB. Do textbooks of clinical examination contain information regarding the assessment of critically ill patients?Resuscitation. 2004;60:129–136.
  3. Zehtabchi S, Kline J.A. The Art and Science of Probabilistic Decision‐making in Emergency Medicine. Academic Emergency Medicine, 17:521-523. DOI: http://doi.org/10.1111/j.1553-2712.2010.00739.x
  4. Weil MH, Shubin H. Proposed reclassification of shock states with special reference to distributive defects. Adv Exp Med Biol.1971 Oct;23(0):13-23.
  5. Ince C. The microcirculation is the motor of sepsis. Crit Care. 2005;9 Suppl 4:S13-9. DOI: 1186/cc3753
  6. Vincent JL, Ince C, Bakker J. Clinical review: Circulatory shock–an update: a tribute to Professor Max Harry Weil.Crit Care. 2012 Nov 20;16(6):239. DOI: 10.1186/cc11510.
  7. Metkus TS, Kim BS. Bedside Diagnosis in the Intensive Care Unit. Is Looking Overlooked?. Ann Am Thorac Soc.2015 Oct;12(10):1447-50. DOI: 10.1513/AnnalsATS.201505-271OI.
Cite this article as: Job Guillen, Mexico, "Clinical examination of the hemodynamically unstable patient," in International Emergency Medicine Education Project, December 6, 2019, https://iem-student.org/2019/12/06/clinical-examination-of-the-hemodynamically-unstable-patient/, date accessed: October 23, 2020

The ABCDE Approach for Medical Students

The ABCDE Approach

Emergency Medicine Is a Dynamic Specialty

Emergency medicine is a dynamic specialty which mainly focuses on the rapid assessment and intervention of life-threatening conditions. It is well known that emergency patients are undifferentiated and mostly they come for unscheduled care. This is usually a new environment for a medical student in clinical years. Facing many undifferentiated patients and understanding the situation requires an initial standardized approach. There is an “ABCDE” approach which is universally accepted and applicable in all clinical emergencies for immediate assessment and intervention (1).

The Summary of ABCDE Approach for Medical Students

ABCDE assessment, which is also called primary survey is all about looking for immediately life-threatening conditions while at the same time doing lifesaving interventions. Rapid intervention usually includes O2 Support, IV access, the fluid challenge with or without specific treatment. The approach should take no longer than 5 min. It can be repeated as many times as necessary, depending on patient condition. During the ABCDE phase, you may recognize that the situation needs much more experience than critical but straightforward life-saving maneuvers. So, get experienced help as soon as you need it. Because resuscitation efforts need a team approach, If you have one, delegating jobs can help to move steps faster and smoother.

A - Airway

Acute Problems

  • Decreased GCS
  • Excessive secretions
  • Foreign body
  • Inflammation
  • Infection
  • Trauma, and so on.

Assessment

  • Unresponsive patient
  • Added sounds
    • Snoring, wheeze, stridor
  • Accessory muscles use
  • Irregular respiratory pattern

Interventions

  • Head tilt chin lift
  • Jaw thrust
  • Suction
  • Oral airway application
  • Nasal airway application
  • Advanced airway interventions (endotracheal intubation, surgical airway, etc.)

B - Breathing

Acute Problems

  • Decreased GCS
  • Respiratory depressions
  • Muscle weakness
  • Exhaustion
  • Asthma/COPD
  • Sepsis
  • Cardiac event
  • Pulmonary edema
  • Pulmonary embolus
  • ARDS
  • Pneumothorax
  • Haemothorax
  • Flail chest

Assessment

Look

  • Respiratory rate (Apnea/Bradypnea/Tachypnea), symmetry, effort, SpO2, color

Listen

  • Talking: sentences, phrases, words
  • Air entry, wheeze, silent chest other added sounds

Feel

  • Central trachea, percussion, expansion

Interventions

  • Consider ventilation with BVM (Bag-Valve-Mask Ventilation)
  • Consider ventilation with BVM
  • Position upright if struggling to breath (be careful in trauma patient)
  • Specific treatment like β agonist for wheeze, chest drain for pneumothorax

C - Circulation

Acute Problems

  • Loss of volume/Hypovolaemia
  • Pump failure (Myocardial & non-myocardial causes)
  • Vasodilatation (Sepsis, anaphylaxis, neurogenic)

Assessment

  • Look at color
  • Examine peripheries
  • Pulse, BP & CRT
  • Hypotension (late sign)
  • Decreased urine output

Interventions

  • Position supine with legs raised (shock position)
  • Left lateral tilt in pregnancy
  • IV access – 16G or larger x2 (+/- bloods if new cannula
  • Fluid challenge
  • ECG Monitoring
  • Specific treatment

D - Disability

Acute Problems

  • Inadequate perfusion of the brain
  • Sedative side effects of drugs
  • Toxins and poisons
  • Cerebrovascular accident (CVA)
  • Increased ICP

Assessment

  • AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) or GCS
  • Pupil size/response
  • Posture
  • Pain relief

Interventions

  • Optimize airway, breathing & circulation
  • Treat underlying cause (i.e., naloxone for opiate toxicity)
  • Control seizures
  • Seek expert help for CVA or high ICP

E - Exposure

  • Remove clothes and examine head to toe, including patients front and back. 
  • Look for hemorrhage, rashes, swelling, sores, syringe drivers, catheter, etc.
  • Keep the patient warm.
  • Maintain dignity

Reference

  1. Thim T, Krarup NH, Grove EL, Rohde CV, Løfgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012;5:117–121. doi:10.2147/IJGM.S28478

Further Reading

Cite this article as: Temesgen Beyene, Ethiopia, "The ABCDE Approach for Medical Students," in International Emergency Medicine Education Project, August 18, 2019, https://iem-student.org/2019/08/18/the-abcde-approach-for-a-medical-students/, date accessed: October 23, 2020

AEIOU TIPS Card

ALTERED MENTAL STATUS