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High‐risk Cases in Emergency Medicine: Part 1
Kevin M. Klauer, DO, EJD, FACEPChief Medical Officer, EMP, Ltd.Medical Editor‐in‐Chief, ACEP NowSpeaker, ACEP CouncilAsst. Clinical Professor, MSU College of Osteopathic Medicine
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Thursday, November 6th, 2014
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SpeakerDr. Kevin Klauer is the Director of the Center for Emergency Medical Education and the Chief Medical Officer for Emergency Medicine Physicians, Ltd., based in Canton, Ohio. He also is the Director of EMP’s Patient Safety Organization. He serves on the Board of Directors for Physicians Specialty Limited Risk Retention Group. He is an Assistant Clinical Professor at Michigan State University College of Osteopathic Medicine. He has received the EMRA Robert Dougherty ACEP/EMF Teaching Fellowship and also the ACEP's National Emergency Medicine Faculty Teaching Award. He was most recently recognized by the Ohio Chapter ACEP with the Bill Hall Award for service. Dr. Klauer is the co‐author of two risk management books: Emergency Medicine Bouncebacks: Medical and Legal and Risk Management and the Emergency Department: Executive Leadership for Protecting Patients and Hospitals.
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1. Discuss strategies to identify high-risk features of clinical entities in emergency medicine.
2. Develop strategies to improve patient safety.
3. Review ways to reduce professional liability in the practice of emergency medicine.
Learning Objectives
Diederich Healthcare
The Current Malpractice Climate
• Claims Frequency• 1/26,800 ED visits• Indemnity
2002: $80,0002013: $163,000
2013 ASHRM Hospital ProfessionalLiability Benchmark Analysis
Future claim severity expected to increase 4% annuallyLoss Rate for 2014: $6.16
The Genesis of Risk
Unhappy PatientsUnhappy Patients
Bad Outcomes
Bad Outcomes
+
Important Tools
• Stop Diagnosing• Scheduled ED re‐evaluations
• Discuss testing limitations
• Testing responsibility
• No Fly Zone• Atypical Chest Pain• Anxiety• Constipation• Gastroenteritis• Atypical Migraine• Teething?
Important Tools
• Stop Diagnosing• Scheduled ED re‐evaluations
• Discuss testing limitations
• Testing responsibility
• No Fly Zone• Atypical Chest Pain• Anxiety• Constipation• Gastroenteritis• Atypical Migraine• Teething?
High Risk Entities
• Pulmonary Embolism• TIA• tPA for Stroke and Consent • Appendicitis• Intussusception• Thoracic Aortic Dissection• Interruptions
Pulmonary Embolism
Case History
• CC: “Chest Pain”• HPI: 34 y/o female presents to the ED
complaining of right sided chest pain which began 3 hours prior to arrival. No trauma.
• PMHx: None• Meds: None• No cough. No SOB. Pain is pleuritic
Exam
• VS: BP: 118/78, RR: 20, HR: 76, T: 98.7, Pox: 97%
• LS: Clear to auscultation“Right Inframammary tenderness”
• Legs: No clubbing, cyanosis or edema• Neuro: Normal
ED Course
• Chest radiograph: Normal• ECG: Normal• Ibuprofen 600 mg PO• Oxycodone/Acet PO
Impression/Plan
• Dx: Musculoskeletal chest pain• Rx: Ibuprofen and Oxycodone/Acet• 7 day follow up with PCP• Discharge
Outcome
• PCP follow up in 7 daysNo change in treatment
• Consult 3 days later
Outcome
• PCP follow up in 7 daysNo change in treatment
• Consult 3 days later
Pathology
Outcome of Claim
• Emergency Physician released• Hospital and PCP remain
THE PULMONARY EMBOLISM RULE‐OUT CRITERIA (PERC) RULE DOES NOT SAFELY EXCLUDE PULMONARY EMBOLISM Hugli, O.,
et al, J Thromb Haemost 9(2):300, February 2011
• 1,675 Pts (outpts) being evaluated for PE• 13.2%: PERC Negative• 85.1%: Low pretest probability per Geneva• PE: 21.3%• 5.4% of the PERC Negative Group• 6.4% of PERC Negative and Low probability
Incidence, Timing & Vulnerability of Pregnancy
• VTE: 0.76‐1.72 per 1,000 pregnancies• 4X risk of non pregnant population• 2/3rd DVT: Antepartum (evenly distributed)• 43‐60% of pregnancy related PE occur in puerperium
• PE is the leading cause of maternal death in developed nations1.1‐1.5 per 100,000 deliveries
Incidence, Timing & Vulnerability of Pregnancy
• VTE: 0.76‐1.72 per 1,000 pregnancies• 4X risk of non pregnant population• 2/3rd DVT: Antepartum (evenly distributed)• 43‐60% of pregnancy related PE occur in puerperium
• PE is the leading cause of maternal death in developed nations1.1‐1.5 per 100,000 deliveries
50% of events occur in the first 20 weeksPuerperium
RR = 20
PERC
• < 50 years• HR < 100 beats per minute• Room air oxygen saturations greater than 94%• No prior deep venous thrombosis [DVT] or PE• No recent surgery or hemoptysis • No exogenous estrogen • No clinical signs suggestive of DVT
No D‐dimer!Pregnant Patients Were Excluded From Their Derivation Study
Clinical Features of Patients With PulmonaryEmbolism and a Negative PERC Rule ResultJ. Kline, D. Slattery1880 with PE: All 8 (parameters) Neg in 6%None of these died at 30 days (v. 108)3 Factors Associated with PERC Neg PE
Pleuritic CP, Pregnancy, Post Partum
TIAs
Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA.
2000 Dec 13;284(22):2901-6.
• Patients discharged with Dx of TIA• At 90 days 10.5% returned with a stroke• 50% of those were within the first 48 hours• Predictive factors
Age > 60 DMSpeech Sx > 10 minutesWeakness
Uchiyama S. Brain Nerve. 2009 Sep;61(9):1013‐22.Transient ischemic attack, a medical emergency
• “A medical emergency”• Acute Cerebrovascular Syndrome (ACVS)
Stead, L.G., et al. An Assessment of The Incremental Value of The ABCD2Score In The Emergency Department Evaluation of Transient IschemicAttack, Ann Emerg Med 57(1):46, January 2011.
• 637 TIA Pts• ECG, CT, Labs and Carotid Doppler, Observation Unit
• ABCD2 Score• 2.4% at 90 days• 7 days: 1.1,% 0.3%, 2.7%• 90 days: 2.1%, 2.1%, 3.6%
Mullins et al. CT and Conventional and Diffusion‐weighted MR Imaging in Acute Stroke:Study in 691 Patients at Presentation to the Emergency Department Radiology August2002
• Imaging < 6 hrs after ED Presentation• CT: 40% Sens• DW MRI: 97% Sens
The National Jury Verdict Review and Analysis (48725) Massachusetts
20-year-old plaintiff to suffer permanent and severe cognitive dysfunctions.Series of TIAsAphasia/Difficulty understanding/Difficulty in movingED in BostonCT and LP NormalNeurologist: Consulted by phoneDx: Atypical Migraine2 days later: Primary care physician Dx Migraines2 days later: Aphasia and Rt sided hemiplegia1 day later: Massive strokeDx: Carotid dissectionLawsuit: Neurologist and Primary care physician
The National Jury Verdict Review and Analysis (48725) Massachusetts
20-year-old plaintiff to suffer permanent and severe cognitive dysfunctions.Series of TIAsAphasia/Difficulty understanding/Difficulty in movingED in BostonCT and LP NormalNeurologist: Consulted by phoneDx: Atypical Migraine2 days later: Primary care physician Dx Migraines2 days later: Aphasia and Rt sided hemiplegia1 day later: Massive strokeDx: Carotid dissectionLawsuit: Neurologist and Primary care physician
$1,000,000 Judgment
Standard of Care ArgumentIs Informed Consent Required?
Incapacitated Patients
Likelihood of Litigation
• 95%: Lawsuits from not giving tPA or not diagnosing stroke
• 5%: From complications
• Just as likely to get sued for giving it as you are for not giving itMany more are not given the drug Much larger pool% tPA = % no tPA will result in lawsuits
Community Hospital/EP/Hospital
Appendicitis
Case History
• 5 yr old male with 3 hours of generalized abd pain since 1 hour after dinner tonight, V x 2 twice, no fever, no diarrhea. No assocsymptoms.
• VS‐ 99.1/110/24 BP‐ 101/58• PE‐Abd‐ +BS, mild epigastric tenderness, no rebound
Case History
• Diagnosis: Gastroenteritis• Instructions:
Vomiting SheetFlu sheetFollow up with PMD tomorrow
Case History
• Day 2‐ To the PMD’s office• “Pt with abd pain for 15 hours, V X 2, seen in the ED last night diagnosed with the flu”
• No vitals at PMD office• Exam‐ “abd slightly tender, pt appears ill”• Plan‐ CBC, 3 way abdominal films
Case #9
• Day 2‐ To the PMD’s office• “Pt with abd pain for 15 hours, V X 2, seen in the ED last night diagnosed with the flu”
• No vitals at PMD office• Exam‐ “abd slightly tender, pt appears ill”• Plan‐ CBC, 3 way abdominal films
Case History
• Day 2 evening‐ Back to the ED• Resident exam‐ pt here last night, PMD today, abd pain for 24 hours, x‐rays and labs done today, V X 3 today, felt warm today, taking sips of fluid, no BM today, points to belly button as area of tenderness.
• VS‐ 100.5/130/28/ 105/51
Case History
• Resident exam• Pt sitting on bed, appears tired, but in no distress
• Abd‐ some tenderness in epigastrium, no HSM, no masses, dec BS noted, no CVA tenderness
• Attending note‐ “Agree with above”
Case History
• Disposition• Diagnosis‐ Gastroenteritis• Plan‐ vomiting sheet, clear fluids for 24 hours, F/U PMD 3 days
Case History
• The next AM• Pt has a restless night, c/o pain all night, at 11am the pt is unable to be aroused, parents call 911, the pt codes on the way to the ED
• Autopsy shows perforated appendix and blood CXs grew Strep
• Case settles after depositions, but before trial
Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000
• The most common non‐traumatic surgical disorder in children > 2 yrs
• Dx: 1‐8% of children presenting to pediatric EDs with CC of Abd pain
• Perforation: <15% in adolescents, but nearly 100% in children < 3 yrs
• 11% more: May‐August: Association with enteric infections
Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000
• Genetic Predisposition (1st degree): RR 3.5‐10.0• 50th percentile for fiber intake = 30% reduction in likelihood
• 10%‐36%: Report prior similar symptoms• Diarrhea: 9‐16%• Constipation: 5‐28%• Dysuria: 4‐20%
Pain with Movement1. Cough sign 95% 2. Cat’s eye sign 80%3. Heel drop sign 93%
Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000
• Increased IncidenceViral outbreaks (Mumps, Coxsackie and Adenovirus)AmebiasisBacterial enteritis
• Infectious etiology for appendicitis?• Extended Breast Feedings
Milk‐induced alteration of the immune responseLymphoid tissue at the base of the appendix less reactiveMay limit exposure to other dietary risks
Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000
• Initial misdiagnosis rates range from 28% to 57% for children 12 years old or younger
• Nearly 100% for those 2 years or youngerTable 1.Initial misdiagnoses in childhood appendicitis.Misdiagnosis % of CasesGastroenteritis 42 Upper respiratory tract infection* 18 Pneumonia 4 Sepsis 4 Urinary tract infection 4Encephalitis/encephalopathy 2 Febrile seizure 2 Blunt abdominal trauma 2 Unknown 22*Includes diagnoses of otitis media, sinusitis, pharyngitis, and upper respiratory tract infection. From Rothrock SG, Skeoch G, Rush JJ, et al. Clinical features of
misdiagnosed appendicitis in children. Ann Emerg Med. 1991;20:45‐50.
Gastroenteritis?!
• McKerzie v. Barnes Hospital 1995 MO• Wozniuk v. Kitchin 1997 GA• Klug v. Ramirez 1992 TX• Birkett v. Kasulke 1983 NY• Green v. Dupre 1987 LA• Granbury Minor Emergency Clinic v. Thiel
2009 LA• Stringer v. Trapp 2010 MS
Medical MythA digital rectal examination should be performed on all individuals withpossible appendicitis West J Med. 2000 September; 173(3): 207–208.
• Children: 1/3 Severe Discomfort“Major crying and screaming”Another 1/3: “Mild discomfort” Facial grimacing or crying
• 1979 (Bonello): 46% False – and 53% False +• 1991 (Dixon, largest study)
1204: 85% rectal examinationsNo difference in management
Intussusception
Case History
• HPI15‐yr‐old maleLower abdominal pain, cramps and vomiting for 3 hours
• Physical examinationBP: 120/64; HR: 122; RR: 24; T: 100.1Abdominal: Soft, right mid abdominal tenderness, hyperactive bowel sounds
Case History• Diagnostics
Laboratory: WBC 12.5, BMP, Lipase, UA all normal• ED Course
IV fluidsPhenergan 12.5 mg IVPMorphine sulfate 4 mgCondition improved but not abd reassessmentDischarged after 4 hoursDx: Gastroenteritis and Dehydration
Case History
• OutcomeReturn visit at 1130 pm (approx 18 hours after discharge)Cardiopulmonary arrest and pronounced at 1145
Case #11
• OutcomeReturn visit at 1130 pm (approx 18 hours after discharge)Cardiopulmonary arrest and pronounced at 1145
Intussusception
• Leading cause of intestinal obstruction in infants3 – 12 mo
• Ileocolic is most commonSmall bowel: ileoileal via the ileocecal valve and continues into the colon (poss rectum)Sausage shaped mass in Rt Abd 2/3
• Colocolic: Rare• Infants: Hypertrophied Peyer’s Patches
Lead Point
Intussusception• > 2 yrs: Alternative lead point
Meckel’s, Polyp, Duplication or Tumor• Frequently preceded by days
Diarrheal illnessViral Syndrome/URIHenoch‐Schönlein Purpura
• Classic triad (20%)1. Colicky abd pain 2. Vomiting3. Rectal bleeding
Intussusception• Colicky/Episodic abdominal pain• Gradual irritability, anorexia and may vomit• May appear well • May be lethargic/listless• Partial or complete SBO with gen distension• Mass may be noted in RUQ• 50%‐75%: occult blood• Lack of blood does not exclude the Dx• Four classic x‐ray findings / target sign, crescent sign,
absent liver edge sign, bowel obstruction
Currant Jelly Stool 50%• Mesenteric vein compression• Arterial supply preserved• Increased pressure = Currant jelly stool
Spontaneous; orRectal exam
• Increased pressure = Arterial compromise• Bleeding reduces• Bowel ischemia occurs
Perforation
Intussusception
Med‐Challenger • EM
CT Scan -- Intussusception
US Study -- Intussusception
Sensitivity for ileocolic intussusception = 98% / Specificity, 98%
Management
Diagnosis: plain x-ray, ultrasound, barium enema (“coiled spring” sign)Treatment: air contrast enema, surgery
Thoracic Aortic Dissection
Case #12Aortic Dissection Mimicking SAH
Nohe Anesth Analg 2005
• Case report 63 y.o. female with sudden onset excruciating headache, severe arterial hypertension, syncope, and coma.
• Initial head CT and angiography normal• Intubated, ICU, neurology consult, anticoagulation• 8 hrs later, 2nd CXR showed widening of the mediastinum
• Immediate surgical aneurysm repair with good recovery without sequelae.
NeurologicalGaul C, et al. Neurological symptoms in aortic dissection: a challenge for neurologists. Cerebrovasc Dis. 2008;26(1):1‐8.
• Neuro Sxs at Onset: 17%‐40%• Pain Free Dissection: 5%‐15%Stroke. 2007 Feb;38(2):292‐7.• Type A• 102 Consecutive Pts• 29% had Neurological Sxs• Only 2/3s had Chest Pain
Neuro Sxs?+ Diastolic Murmur = Dissection
Hansen M, et al. Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection. Am J Cardiol. 2007 Mar 15;99(6):852‐6.
• 66 Consecutive Cases• Misdiagnosis: 39%• ACS Most Common Misdiagnosis
ASA 100%Plavix 4%Heparin 85%Thrombolytics 12%
• Major Bleeding: 38% v. 13%• Mortality: 27% v. 13%
INTERRUPTIONS
Chisholm CD, Collison EK, Nelson DR, Cordell WH Emergency department workplace interruptions: are emergency physicians "interrupt‐driven" and "multitasking"? Acad Emerg Med. 2000 Nov;7(11):1239‐43. 30.9 & 20.7
Case History
• 48 year old white female• CC: Left upper back pain• HPI: 3 hours, acute onset, non‐reproducible to palpation but slightly worsened by ROM
• Assoc: Pleuritic• PSHx: No ETOH, ½ ppd Tobacco history
Case History
• CBC, Urinalysis, BMP, Troponin I negative• ECG SR without ectopy or ischemic changes• CT Pulmonary angiogram: Negative
Case History
• Disposition• Discharged • 3‐5 Day follow up• Rx: Ibuprofen and Vicodin
Case History
• Died 26 hours after discharge
Case History
• Claim Filed• Settlement on behalf of the physician• $750,000
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