High-risk Emergencies

Educational Objectives

The goal of this program is to improve diagnosis of appendicitis and to evaluate the decision-making processes in managing airways. After hearing and assimilating this program, the clinician will be better able to:

1.   Determine the cause of abdominal pain, based on history, physical examination, laboratory tests, and imaging.

2.   Compare the efficacy of computed tomography and ultrasonography in the diagnosis of abdominal pain.

3.   Use symptoms, laboratory tests, and imaging to establish the diagnosis of appendicitis.

4.   Explain the decision-making process in managing difficult airways.

5.   Summarize the medicolegal responsibilities of emergency physicians, attending physicians, and consultants in the management of patients with difficult airways.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of inter­est. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a propri­etary business or commercial interest. For this program, the faculty and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Vissers was recorded at Clinical Decision Making in Emergency Medicine, sponsored by Mount Sinai Medical Center, University of Florida, Jacksonville, Mayo Clinic College of Medicine, the George Washington University, Brigham and Women’s Hospital, the Foundation for Education and Research in Neurologic Emergencies, Best Prac­tices, Inc, and Emergency Medicine Practice, and held June 26-28, 2008, in Ponte Vedra Beach, FL. Dr. Walls was re­corded at High Risk Emergency Medicine, sponsored by the Division of Emergency Services, San Francisco General Hospital, and the Department of Medicine, University of California, San Francisco, School of Medicine, and held May 21-23, 2008, in San Francisco. The Audio-Digest Foundation thanks the speakers and the sponsors for their co­operation in the production of this program.

Pitfalls in Appendicitis

Robert Vissers, MD, Adjunct Associate Professor, Oregon Health Sciences University, and Director, Emergency Department, and Chief Medical Officer, Legacy Emanuel Hospital, Portland, OR

Pinpointing causes of abdominal pain: time- and resource-intensive; “black box” of possible pathologies (eg, ap­pendicitis, cholecystitis), depending on patient’s age and sex; uncertain in »50% of cases (based on history and physical examination [PE]); take-home message  —  do not guess on diagnosis; make patient comfortable; admit or arrange follow-up (£ 24 hr)

Patient management: try to have some justification for sending patient home; many patients undiagnosed at dis­charge; supplement history and PE with laboratory tests or observation; re-examine within short time

Diagnosing Appendicitis

Case example: man 25 yr of age; symptoms  —  pain for 1.5 days, nausea and anorexia, loose stools, vomiting, and ten­derness in right lower quadrant (relatively specific sign); normal bowel and rectal sounds; no peritoneal signs; nor­mal white blood cell (WBC) count and slight hematuria; laboratory tests  —  should not change actions; allow surgeon to participate in decision-making; options  —  evaluate for probable appendicitis, order renal protocol, order computed tomography (CT) for appendix, or admit to observe (rare, but appropriate if concerned); result  —  appendicitis revealed on CT; note — intravenous (IV) contrast alone or no contrast adequate and accurate for diag­nosis of appendicitis

Risk and diagnosis: 12% to 28% of patients with abdominal pain (33% if >50 yr of age); diagnosis  —  history and PE; no pathognomonic or historical finding to diagnosis appendicitis; some factors more revealing than others; lab­oratory tests  —  not helpful; imaging  —  helpful when used rationally and correctly; likelihood ratio (LR)  —  eg, pre­dicting appendicitis based on response to right lower quadrant test; LR >10 or <0.1 should change action (if between 0.1 and 10, do not use in isolation); lower right quadrant pain best available (LR=7); anorexia (LR=1.27); nausea or vomiting too ubiquitous; features somewhat helpful but not definitive; palpation  —  nonspecific in ab­dominal pain (still worthwhile); unreliable in immunocompromised, elderly, and very young; rebound tenderness  —  false-positive rate »25%; specific findings  —  include rigidity, psoas sign, fever, rebound tenderness, guarding, and rectal tenderness; rectal examination  —  often unnecessary; need good reason (eg, perirectal pain, bleeding); WBC testing  —  nonspecific (normal WBC in some patients with appendicitis); waiting (6 hr) and repeat­ing WBC test  —  no change in outcome and no diagnostic value; C-reactive protein (CRP)  —  low sensitivity and specificity; pain for 3 days  —  pyuria or hematuria in »50%;  more common in elderly; make sure test results ex­plain symptoms; pyuria and hematuria often accompany ruptured appendix

CT vs Ultrasonography (US)

Overview: 1994 comparative prospective trial  —  CT more accurate, sensitive, and specific than US and better at de­tection of other pathologies; US techniques  —  operators and technology improving in adults and children; CT  —  increasing concerns about cost, time, and radiation exposure; look for distended appendix, fecalith, thickened wall, and periappendiceal inflammation; to reduce radiation exposure and cost, request focused noncontrast CT of ap­pendix

CT without oral contrast: 1999 study  —  300 patients without oral contrast; of 5 missed cases of appendicitis, 3 oc­curred early in study (learning curve for radiologists); remaining 2 cases  —  young slender women (easier to find appendicitis in obese patients); bottom line  —  educate patient on possibility of false negatives; analysis of noncon­trast CT (23-article review)  —  on all parameters, CT without contrast as good or better than with contrast; can pre­vent unnecessary laparoscopy, laparotomy (or negative laparotomy), and admissions; negative laparotomy rate remains high (8%-12% range, even using CT); lower cost; helps pick up another diagnosis (approximately two-thirds of time); broad differential (eg, 60-yr-old with right lower quadrant pain) or atypical features  —  discuss use of contrast or less focused study with radiologist

Who needs CT? study (New England Journal of Medicine)  —  if classic signs using history and PE, call surgeon; if equivocal, consider CT and discuss with surgeon; who needs US  —pregnant women and children; if positive, send to surgery; if negative, or equivocal CT results, consider observation and follow-up; limitations of US  —  false negatives; operator-dependent

Case A: child with intermittent abdominal pain for 2 days; no fever; tenderness in right lower quadrant; US shows no appendicitis; patient still uncomfortable; overnight observation  —  patient recovered by next day; US accuracy  —  sensitivity and specificity »90% in children (may improve with addition of color Doppler methods)

Case B: boy 2 yr of age; fussy; acute episodes of pain that suddenly disappear; intussusception  —  most common cause of abdominal pain in children <2 yr of age; US sensitivity for intussception »100%

Case C: child 12 yr of age; symptoms for 2 days, including decreased appetite, low-grade fever, pain, and tender­ness in right lower quadrant (worse when walking); classic symptoms of appendicitis  —  patient can go straight to operating room without CT

CT in pediatric patients: pain for extended periods; before laparotomy, check for ruptured appendicitis (much higher false-negative rate than with US); duration of symptoms suggests ruptured appendix (uncomfortable, worsens, then gets better)

CT in elderly patients: appendicitis comprises »10% of abdominal emergencies (>50 yr of age); population ac­counts for »50% of deaths from appendicitis; be aggressive about CT

Troubling Airway Cases in Rapid-sequence Intubation (RSI)

Ron M. Walls, MD, Professor of Medicine (Emergency Medicine), Harvard University School of Medicine, and Chair, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA

Background

Common themes in troubling cases: pattern of practice  —making repeated errors in one patient and across many cases; lack of preparation  —  consequential when working with difficult rather than easy airways; textbook teachings  —  can be used against physicians in court

Elements of medical malpractice lawsuit: plaintiff must establish  —  duty to treat; breach of duty (usually negli­gence); injury, and cause of injury on “balance of probability,” ie, “more likely than not”; different from criminal cases in which establishment “beyond reasonable doubt”; establish negligence  —  actions failed to meet standard of care (SOC); “trier of fact” (usually jury)  —  determines facts based on evidence (documents and fact witnesses), SOC, and causation; trier of fact advised by expert witnesses; fact witness gives facts; expert witness gives opinion; if documenting others’ actions, give facts only; damages  —  amount awarded; expenses and lost earnings meticu­lously determined by actuaries; other considerations, eg, pain and suffering, then added; SOC  —  can differ by locale (eg, small vs large hospitals), but not location; failure to perform actions reasonable person would perform; reason­able person  —  practitioner with similar experience and of same specialty in same circumstances; can involve omis­sion or commission; negligent action  —  anything you do or fail to do (eg, consult too late, consult wrong person, fail to admit)

Case 1: Status Epilepticus (SE)

Facts: girl 3 yr of age with SE; events  —  patient starts seizing too long; parents bring her to ED; cared for by ED di­rector (physician neither board-certified nor trained in EM); seizures continue; director calls large pediatric hospital (LPH); LPH recommends 0.5 mg lorazepam; director follows advice but seizures continue; another physician at LPH advises additional 0.5 mg; nurses documented giving child 2 doses; patient becoming deeply cyanotic; oxygen applied, patient continues to seize; patient arrests and receives bag-mask ventilation (BMV) and tracheal intuba­tion; patient stops seizing; survives and lives with severe brain injury; lawsuit  —  against ED physician; claims neg­ligent management of SE

Discovery: ED director  —  admits to having no training or standing in EM; did not intubate before arrest because of unfamiliarity with drug-assisted intubation; other providers in ED  —“pretty sure” about presence of pediatric equipment in ED, but did not know nature or location of equipment; care for children regularly

1) True or false: SOC to which ED director held is that of non-emergency physician working in ED, and not a board-certified emergency physician

Answer: false; for physicians who provide emergency care, SOC that of trained and board-certified ED physician

2) True or false: when physician fails to provide accurate or complete information to referral center, that center held responsible only for decisions made based on information provided

Answer: false; providers working in referral centers must perform actions of reasonable person (ie, ask for details)

Expert testimony: inadequate treatment; inadequate information conveyed to referral center; referral center did not seek adequate information; brain injury preventable by timely intubation; improper and/or inadequate equipment in ED; hospital deliberately staffing ED with non-board-certified emergency physicians; result  —  case indefensible; director and hospital both settled; did not involve referral center

Lessons: any physician working in ED must meet SOC of board-certified emergency physician; if physician working in referral center and giving medical advice, he or she should document it; EDs must have adequate equipment for pediatric patients; hospital can be held liable for providing inadequately qualified physicians

Case 2: Postoperative Crisis

Facts: man 56 yr of age; day after open gallbladder surgery; patient morbidly obese and had sleep apnea; extubation 8 hr after surgery; 4 hr after extubation, patient develops progressive respiratory distress and desaturation (in inten­sive care unit [ICU]); supplemental oxygen applied, but patient grows restless; oxygen increased and nonrebreather (NRB) mask placed; oxygen saturation (Pao₂) drops to 86%; on-duty emergency physician (family practitioner [FP] working in ED) called to ICU, and observes patient obtunded and cyanotic with Pao₂ of 80% on NRB; heart rate 66 bpm; FP checks intravenous (IV) line, oxygen source, and suction, and gives 200 mg of succinylcholine IV (low dose for obese patient); fails 3 attempts at intubation; tries bag-mask ventilation (BMV) but result poor; makes 2 more unsuccessful attempts at laryngoscopy; pages anesthesia; makes 2 more attempts at intubation; certified reg­istered nurse anesthetist (CRNA) arrives and immediately pages attending physician and surgeon (advisable); pa­tient in full cardiac arrest; cardiopulmonary resuscitation (CPR) in progress; CRNA tries oral intubation 3 times; ED physician makes 2 more attempts; surgeon performs tracheostomy; patient dies; lawsuit  —  early extubation by anesthesiologist (second most common claim in anesthesiology malpractice); failure of ICU nurses to note deterio­ration (did note, but failed to take effective measures); failure of ED physician to manage airway properly or call for help early enough; ED physician should have performed cricothyrotomy early on

1) Agree or disagree: FP had no choice but to proceed directly to succinylcholine and intubation

Answer: disagree; too short time between FP arrival and administration of succinylcholine; FP did not consider or note difficulty of intubation, of BMV, of cricothyrotomy (desaturation occurs 3 times faster in obese patients); clas­sic difficult airway

Expert opinions: premature tracheal extubation; should have followed protocol for difficult airway (ie, extubate over guide and leave guide in place); do not leave patient or move patient to different department, eg, ICU

Lessons: ED physician  —  improve oxygenation before intubation; if oxygenation does not improve, make “the next best call” (eg, bilevel positive airway pressure using modern ICU ventilators); position obese patient to oxygenate between failed attempts, eg, reverse Trendelenburg position; call for help on first arrival; abandon attempts to intu­bate after third time; proceed to cricothyrotomy early enough; CRNA  —  proceed to rescue airway quickly; appropri­ate to call for help immediately; make serious attempts at oxygenating patient; BMV  —  if done carefully, almost always possible to ventilate patient (keep repositioning, get bigger airway in, 2-handed, 2-person technique); oral intubation  —difficult to defend 12 attempts

Case 3: Sore Throat

Facts: man 19 yr of age with sore throat; febrile and has trouble swallowing secretions; voice abnormal; lateral neck x-ray confirms epiglottitis; emergency physician pages ear, nose, and throat (ENT) surgeon; patient remains un­changed (IV line placed, oxygen started, and patient monitored); emergency physician sees other patients; ENT resident arrives 2 hr after initial page; patient cannot swallow; ENT resident removes patient to other side of ED and performs laryngoscopy (unmonitored); after 10 min, resident calls code blue; staff tries CPR, BMV  laryngos­copy (no visibility and laryngospasm), and cricothyrotomy; patient dies; lawsuit alleges  —  improper care of pa­tient’s epiglottitis; failure to protect and secure airway; failure to obtain timely ENT consultation; negligent ENT department; inadequate supervision of ENT resident

1) True or false: if ED physician makes reasonable and usual attempts to obtain consultation but consultant not re­sponsive or timely, ED physician generally not liable

Answer: false; ED physician bears responsibility for patient’s care; ENT claims ED physician never informed him of urgency

2) True or false: ED physician in teaching hospital can expect that consulting system capable and that he or she should not have to supervise ENT resident

Answer: false; ED physician responsible for patient; cases should not be assigned to residents (trainees)

Expert testimony: ED physician  —  did not inform ENT surgeon of urgency (if ENT response not timely, emergency physician should insist on timely consultation or assess and treat patient); did not adequately supervise care; resident  —responsible for not communicating plan to his attending or ED physician; level of supervision indefensi­ble

Result: case settled by ED physician and hospital on resident’s behalf; attending ENT released

Lesson: ED physician responsible for patients during consultation, before admission, and before formal transfer to admitting service

Suggested Reading

Brennan GD: Pediatric appendicitis: pathophysiology and appropriate use of diagnostic imaging. CJEM 8:425, 2006; Cheung CS et al: Adult epiglottitis: 6 years experience in a university teaching hospital in Hong Kong. Eur J Emerg Med March 6, 2009 [Epub ahead of print]; Fry M et al: A 12 month retrospective study of airway management practices. Int Emerg Nurs 17:108, 2009; Kharbanda AB et al: A clinical decision rule to identify children at low risk for appendicitis. Pediatrics 116:709, 2005; Melnick ER et al: Pelvic ultrasound in acute appendicitis. J Emerg Med June 18, 2008 [Epub ahead of print]; Old JL et al: Imaging for suspected appendicitis. Am Fam Physician 71:71, 2005; Peterson GN et al: Management of the difficult airway: a closed claims analysis. Anesthesiology 103:33, 2005; Poortman P et al: Improving diagnosis of acute appendicitis: results of a diagnostic pathway with standard use of ultrasonography followed by selective use of CT. J Am Coll Surg 208:434, 2009; Rosengren D et al: Radiological imaging to improve the emergency department diagnosis of acute appendicitis. Emerg Med Australas 16:410, 2004; Sakles JC: Airway Management in Emergencies. Acad Emerg Med Feb 7, 2009 [Epub ahead of print]; Young N et al: Economic impact of additional radiographic studies af­ter registered diagnostic medical sonographer (RDMS)-certified emergency physician-performed identification of cholecys­titis by ultrasound. J Emerg Med Feb 27, 2009 [Epub ahead of print].