escaping from emergency department pitfalls

Montinee Sangtian, MDEmergency PhysicianBUMRUNGRAD INTERNATIONAL HOSPITAL

INTRODUCTION

high-risk specialty

not purely due to a lack of knowledge but rather to simply “letting one’s guard down.”

Did not use the evidence-based in clinical decision.

COMMON PRESENTING SYMPTOMS IN ED

Abdominal Pain

Chest Pain

Dyspnea, Shortness of Breath

CHEST PAIN

5% of all ED visits

Ranging from benigh to life-threatening.

ACS is 20% of all deaths in US.

Fear of being sued : increased hospital cost and admit non-cardiac caused in IPD or CCU

IMMEDIATE LIFE THREATENING CAUSED OF CHEST PAIN

FINAL DIAGNOSIS OF CHEST PAIN FROM ED

i*trACS registry data, Jun1, 1999- Aug1, 2001

BUT, MORE OVER…

Missed Cardiac Ischemia 2-4%, with mortality rate 10-25%

It means : every 100 chest pain patients

- 4/100 : Missed Cardiac Ischemia

- 1/100 : dead from missed diagnosis.

Characteristics associated with inadvertent discharge of a patient with missed cardiac ischemia

• Younger patient

• Atypical symptoms

• Women

• Nonwhite

• Physician inexperiences

• Lower-volume EDs

• Failure to detect ischemia on initial ECG

• Failure to obtain an ECG

(Ann. Emerg Med 1989;18(10):1029-34)

CLINICAL QUESTIONS

How to rule out or rule in life-threatening chest pain?

Characteristics of pain, History, Risk factors, Physical exam, ECG, Lab, CXR

Outcome.

CHARACTERISTICS OF CHEST PAIN

NRMI2 – 1/3 of MI – no chest pain

20% of MI – with presenting symptoms other than chest pain

Risk Factors % Without chest pain

Prior Heart Failure 51

Prior Stroke 47

Age > 75 yr 45

DM 38

Non-White 34

Woman 39

ATYPICAL CHEST PAIN

7% of ACS : chest wall tenderness

6% of costochondritis dx : enz - proven MI ( Arch. Intern Med 1994; 154(21):2466-9)

To define low-risk group : use combination of 3

1. sharping or stabbing pain

2. no history of angina

3. pain reproduced by palpation

Without these combination – 5% were MI.( Arch. Intern Med 1985; 145(1):65-9)

HISTORY

Burning, Indigestion complaints – as strong as chest pressure (QJM 2003;96(12);893-9)

Precipatating factors : physical activities 35%, eating 8.2%, emotional stress 6.8% (Int. J. Cardiol.; 117(2):260-9)

Relieving factor : GI cocktail, antacids, NTG –not reliable. (Ann. Emerg Med 1996;26(6):687-90)

Features that increased the probability of an acute MI

Jama 1998;280:1256

• CLINICAL FEATURES Likelihood ratio (95% CI)

• Pain in chest or left arm 2.7

• Chest pain radiation : Rt shoulder 2.9(1.4-6.0)

• Chest pain radiation : Lt arm 2.3(1.7-3.1)

• Chest pain radiation : Both Lt and Rt arm 7.1(3.6-14.2)

• Nausea or vomiting 1.9(1.7-2.3)

• Diaphoreis 2.0(1.9-2.2)

• 3rd Heart sound on ausculation 3.2(1.6-6.5)

• Hypotension (SBP < 80 mmHg) 3.1(1.8-5.2)

• Pulmonary crackles 2.1(1.4-3.1)Features that decreased the probability of an acute MI

• Pleuritic Chest Pain 0.2(0.2-0.3)

• Sharp or Stabbing Chest Pain 0.3(0.2-0.5)

• Positioning Chest Pain 0.3(0.2-0.4)

• Chest Pain reproduced by palpation 0.2

Classic or traditional Risk Factors

• Advanced age

• Male

• Hypertension

• DM

• Hypercholesterolemia

• Premature CAD in 1st degree relatives

• Cigarette smoking

Non-traditional

Risk Factors

• HIV

• SLE

• ESRD

• Cocaine

• Type A Personality

• Genetic and Acquired thrombophilias

4 RISK FACTOR : DM, HT, HYPERCHOL, FAMILY HX OF CAD

Group No Risk Factors

LR –

≥ 4 Risk Factors

LR +

Age < 40 yr 0.17(95% CI 0.04-0.66)

7.39(95% CI 3.09-17.67)

40 – 65 yr 0.53(95% CI 0.40-0.71)

2.13(95% CI 1.66-2.73)

65 yr 0.96(95% CI 0.74-1.09)

1.09(95% CI 0.64-1.62)

i*trACS registry data analysis

RISK STRATIFICATION : TIMI, GRACE, ETC.

Don’t be confuse !

TIMI, GRACE, ESSENCE – for predicting outcome, adverse events.

Not for rule out Acute Coronary Syndrome.

Can not use for discharge decision making.

Even TIMI score = 0, rate of adverse events

in 30 days = 1.7% (95% CI 1-4%)

ECG AND CARDIAC BIOMARKERS

Single initial normal EKG and Cardiac Enz can not be used for rule out ACS.

7.8% of MI : normal initial ECG

35.3% of MI : non-specific finding on initial ECG

Be careful in LBBB and Ventricular Pacing Rhythm (VPR) ECG.

LBBB

• Widened QRS complex > 0.12s• Monophasic notch R-wave in the lateral leads Lead I, V5 • Absent of Q-wave in Lateral leads.• There is discordant between the major vector of QRS complex and the major vector of ST-segment/ T-wave complex that follows

ACUTE MI IN THE PRESENCE OF LBBB

•There is concordant ST-segment elevation in lead I, aVL, V5, V6•Concordant ST-segment depression in leads V1-V3

Scarbossa’s criteria for STEMI in the presence of LBBB

ST-segment elevation ≥ 1 mm concordant with QRS complex

Score 5

ST-segment elevation ≥ 1 mm in lead V1, V2 or V3

Score 3

ST-segment elevation ≥ 5 mm discordant to QRS complex

Score 2

Score ≥ 3 : likely to experience STEMIScore < 3 : indetermined

VPR

•Small amplitude spikes before the widened QRS cpx•Predominate negative QRS cpx (9/12), less opportunity for Concordant ST-segment elevation

ACUTE MI IN THE PRESENCE OF VPR

Concordant ST-segment elevation in leads II, III, aVF and Reciprocal ST-segment depression in leads I and aVL

Only 1 useful to detect STEMI in VPR :

ST-segment elevation ≥ 5 mm discordant to QRS complex.

The ECG in VPR is more likely to rule in the diagnosis of acute MI than to rule it out.

PRIOR NEGATIVE CARDIAC WORKUP :

Stress test (Am J Cardiol 1997; 80(8): 1086-7)

• 3 yr Event rate for prior negative stress test is 5-15%.

• A Stress test can be considered to rule out coronary disease during that visit only.

Cardiac Cath. (Arch Intern Med 2006; 166(13): 1391-5)

• 1 yr Event rates for prior negative C.Cath

• 3.3% : mild CAD (< 50% stenosis)

• 1.2% : serious event rate.

• Normal angiogram equals to no short-term risk of ACS

OTHERS CAUSES OF ACUTE LIFE-THREATENING CHEST PAIN

Aortic Dissection

Pulmonary embolism

Pericarditis with cardiac tamponade

Tension pneumothorax

Esophageal ruptured.

AORTIC DISSECTION OF THORACIC AORTA

Chest pain (sensitivity 67%), Back Pain (32%), Abd. Pain (23%), ANY PAIN (90%)

Other symptoms : syncope (4-13%), stroke (6%), other neuro deficit (17%)

In AD patients : 62% Widening mediastinum , 50% Abn. Aortic contour, 12% normal CXR

PERICARDITIS

Failure to differentiate Pericarditis from other chest syndrome

Classic symptoms : progressive, central, pleuriticshest pain that worse in supine

PE : friction rub, heard best in sitting up and leaning forward.

ECG : diffuse ST elevation , PR depression

( except lead aVR)

35-50% of Patients : elevated Troponin level

Always look for Signs of Pericardial tamponade!

a. Acute Pericarditis : Concave ST segment Elevationb. Acute MI : Convex ST segment Elevation

Ratio of the ST segment and T wave amplitudes, Lead V6a. ratio ≥ 0.25 : Pericarditisb. ratio < 0.25 : BER (Benign Early Repolarized)

BOERHAAVE’S SYNDROME

Classic Triad: forceful emesis, chest pain, subcutaneous emphysema.

CXR abnormalities usual on the Left : 90% tear in the left posterolateral wall of lower 1/3 esophagus

pneumomediastinum, hydropneumothorax

20% of case : no vomiting

Other caused : swallowing sandwich, violent cough, weight lifing, seizures, blunt abdomen.

Diagnosis : CXR, CT, Esophagogram

SUMMARY : PITFALLS IN CHEST PAIN

Over-reliance on the classic presence of chest pain for the diagnosis of acute myocardial infarction (MI)

Exclusion of cardiac ischemia based on reproducible chest wall tenderness

Assumption that acute MI cannot be diagnosed with a 12-lead ECG in the presence of pre-existing left bundle branch block or ventricular paced rhythm

STEMI can be diagnosed on an ECG with LBBB … the ECG is more useful in ruling in the diagnosis than in excluding it.

Use of a “GI cocktail” to distinguish between cardiac versus non-cardiac chest pain

Assumption that a normal ECG rules out cardiac ischemia

Single determinations of cardiac markers at the time of presentation appear to be inadequate to exclude the diagnosis of acute MI and provide no information about the possibility of cardiac ischemia

Over-reliance on a “classic” presentation.

Use of the chest X-ray to exclude AD

The use of ECG findings to rule in or rule out PE

Failure to differentiate pericarditis from other chest syndromes

Assumption that the standard chest X-ray completely rules out pneumothorax

Excluding the diagnosis of Boerhaave’s syndrome due to an absence of antecedent retching or vomiting

Failure to evaluate a patient with chest tenderness for herpes zoster

Frequent chief complaint in ED

Common associated with hospital admission

Subjective symptom

Crucial for EPs to consider related underlying disease.

Delayed diagnosis and treatment can lead to increase morbidity and mortality.

Pericardial Effusion and Cardiac Tamponade

Pneumothorax

Pulmonary Embolism

Asthma, COPD

Anemia, etc.

Ausculation in Hemothorax, Pneumothorax : sensitivity 50-82%, PPV 97-98%

Normal ausculatory exam : up to 800 cc of hemothorax, 28% of pneumothorax

Pneumonia : sensitivity 47-69%, specificity 58-75%

Pulse oximetry : useful for detect hypoxia,

Not for hypercarbia, hypoventilation

Anxiety and depressive are common in elderly and more likely with non-specific symptoms.

< 50% of Pt with cardiac tamponade have the classic finding.

Doppler Echocardiography : sensitivity 96%

Classic symptoms: pleuritic chest pain and SOB

20% asymptomatic or minor symptoms

23% missed pneumothorax in standard CXR in ICU patients. 26% missed in severe injured patients

CXR Upright 80% sensitivity, Supine 50% Sens.

Others options : expiratory CXR, lateral decubitusfilm, US, Chest CT

Bedside US : up to 98% sensitivities

CXR and US cannot diff. Bullous and Pneumothorax

Not including pulmonary embolism in the differential diagnosis of the patient with dyspnea

Use objective criteria to assess pretest probrobility.

Over-reliance on the D-dimer, ABG, CXR, or EKG to exclude PE

CXR, EKG should not be used alone to exclude PE.

A D-dimer test should not be used to exclude PE in patients with moderate or high clinic pre-test probability.

Only 20% present with classic triad of chest pain, dyspnea, hemoptysis

In PE patients only 44% has pleuric chest pain

80-92% of PE patients presented with dyspnea.

67% of Pt : rapid onset of dyspnea over sec to min.

Classic S1Q3T3 ECG only 12-50% of PE.

Precordial T-wave inversion was the most common finding in ECG of PE (68%)

Sinus tachycardia : 8-69% of PE

Low risk Wells score + Negative D-Dimer : NPV 96-100% (Ann Intern Med 2001;135(2):98-107)

PERC : can exclude PE in low pretest prob.(Am J Emerg Med 2008;26(2):181-5)

D-Dimer

normal D-Dimer level (ELISA): 95% likelihood of not having PE

Poor PPV, Good NPV (Mayo Clin Proc 2003;78(11):1385-91)

CXR : poor diagnostic tool for PE (Chest 1991;100(3):598-03)

ECG : neither sensitive nor specific for PE

(Emerg Med Clinic North Am 2006;24(1):133-43)

CXR, EKG should not be used alone to exclude PE

Bedside US : sensitivity 51-93%, specificity 82-90% ( Int J Cardiol 1998;65(1):101-9)

V/Q Scan :

normal, low, intermediate, high probability of PE

High Probability : PPV 85-90%

Normal and High Prob : powerful prognostic tool.

CONTRAST-ENHANCED HELICAL, SPIRAL, OR

ELECTRON-BEAM CT

Pulmonary Computed Tomography Angiography (PTCA) : Senstivity 53-70%

PTCA + Scoring System: 83-96%(N Engl J Med 2006;354(22):2317-27)

Gold standard : Pulmonary angiography

Disadvantage : Invasive

Identifying asthmatics at risk

Assessing asthma severity

Clinical presentation : slow or fast onset

Some Pt. have low perception of dyspnea

Overly or underly aggressive oxygen administration in patients with COPD

Do not withhold oxygen from a hypoxic COPD patient; however, be cautious with its use and follow PCO2 levels.

Initial Goal : SaO2 > 90%, PaO2 60-70 mmHg

Cutoff at Sao2 92%, detect hypoxia : sensitivity 100%, specificity 86%

Not considering non-invasive positive pressure ventilation; that is, CPAP/BiPAP as an alternative to intubation in selected patients

Data support for using NPPV is strongest for COPD.

Decreased Intubation Rate (RR 0.42, 95%CI 0.31-0.59)

Decreased Mortality (RR 0.41, 95%CI 0.26-0.64)

5-10% of all ED visits.

18-25% admitted for investigation

10% : operation

Challenge for emergency physician (EP):

About 1/3 have an atypical presentation.

If misdiagnosis, mortality rate 2.5 times higher than

correct diagnosis in the elderly.

Problematic : Women (child-bearing age), HIV, Elderly.

A 65 yr Male, DM,HT with epigastric pain, nausea, no fever

A 43 yr Female, Lower abdominal pain, vaginal bleeding

A 25 yr Male: fever with RLQ pain

A 78 yr Male, ESRD on HD : abdominal pain

Who is the patient of acute abdomen?

What are the probable diagnoses you have in

mind?

Why do you consider such diagnosis?

How do you prove it?

When will you consult surgeon for operation?

Common, lifetime risk 7%

Only 20% of elderly pt have classic findings.

MANTRELS (Alvarado) Score : less suited for elderly, women

Missed Appendicitis in score < 5 : age 60-80 yr

High score in women has a lower PPV

Score > 7 in women : 1/3 were normal appendix

No lab test specific for appendicitis.

Scoring system : MANTRELS, Ohmann score : none of these are accurate enough to predict appendicitis.

CT : sensitivity 94%, specificity 94%

CT : appendix > 6 mm, wall thickening, RLQ inflammatory changes, appendicoliths.

Contrast CT vs NonContrast CT : equal

IV contrast : highlight inflammed tissue.

Oral Contrast : better differentiate the appendix from surrounding tissue.

High sensitivity as CT in some studies Lower NPV than CT (specificity 83%) Finding : non-compressible lumen, diameter >

6mm, absence gas in lumen and appendicoliths(some center use 7mm)

Doppler US – increased flow in an inflammedappendix, but limit in necrotic or ruptured appendix.

Limitations : Obese, Bowel gas, Operator dependent

US best use as an initial study in children, women, pregnant patients.

A 43y Female, Lower abdominal Pain, no fever, no nausea/vomiting

Vaginal bleeding : spotting for 20 days

Refused probability of pregnancy

No contraception

• UPT +

• PV : OS closed, minimal bloody mucoid• Treated as Threatened abortion, D/C

3 DAYS LATER

The patient came to ED, with abdominal pain with spotting.

V/S : BP 100/80, PR 110

1:30000 pregnancies

4 common signs

abdominal pain, adnexal mass, peritoneal irritation, enlarged uterus (absent in 1st Tri.)

Consider heterotropic pregnancies in women receiving ART : 1:100 Pregnancies

8% of Unstable angina presented with epigastric pain

Painless ulcer was found 35% of Pt > 60 yr

Elderly Pt with Acute cholecystitis

50% has afebrile. 33% absent leukocytosis and normal LFT

Pancreatitis

incident 200 folds in > 65y

Higher risk of necrotizing pancreatitis in >80y

Early CT in Elderly

Low incidence (1/1000 Hospital admission)

High Mortality (80%), with immediate angiogram (mortality reduced to 54%)

Severe Abdominal Pain (out of proportion to exam)

Risk Factors for mesenteric ischemia

Type of Mesenteric Ischemia

Risk Factors Special Notes

SMA Embolus Cardiac Disease•AF and other arrhythmias•Valvular diasease•Ventricular aneurysm•Cardiomyopathy

1/3 have Hx of Embolic event

SMA Thrombosis Vascular Disease Risks•HT•Hypercholesterolemia•DM•Smoking

Acute event may be preceded by period of “intestinal angina” and prolonged period of significant weight loss

Mesenteric Venous Thrombosis

Hypercoagulable State•Inherited•Acquired (Malignancy, Oral contrceptions)

Women > Men½ have personal or family Hx of DVT/PESubacute presentation

NOMI(Non-Occlusive MesentericIschemia)

Low-flow state•Sepsis Heart Failure•Volume depletion Hemodialysis

Drugs•Digitalis Ergot derivatives•Cocaine Norepinephrine

Misdiagnosis of cardiac ischemia

Over-reliance on “classic” presentations and laboratory results of appendicitis

Over-reliance on laboratory values and ancillary testing in suspected mesenteric ischemia.

Failure to consider heterotopic pregnancy in women receiving reproductive assistance

Failure to appreciate atypical signs and symptoms in the elderly

Do Not over-reliance on the classic signs, symptoms, diagnostic tools.

Know Limitations of Test and Scoring system

Negative test does not mean no disease.

Use Evidence-Based in decision making

Do not “ Guard Down”