Case: A 58 year-old female presents with a one-day history of worsening right lower extremity pain and swelling, and an acute onset of dyspnea. Her past medical history consists of stage IV renal cell carcinoma diagnosed six months previously. Triage vitals are remarkable for a heart rate of 120 beats per minute and a blood pressure of 68/48 mmHg. What is the diagnosis?
There is no shortage of free open access medical education (FOAM) resources available to the current emergency medicine (EM) learner. It seems that no matter what the concept, FOAM has it covered. And radiology is no different. However, with a specialty as vast as radiology, finding educational material pertinent to the emergency practitioner can be overwhelming. The 2016-2017 ALiEM Chief Resident (CRincubator) class also encountered this when attempting to create an organized FOAM radiology curriculum for EM residents. To tackle this challenge, the chief residents have brought together the best online resources to help EM practitioners gain expertise in the field of radiology.
Orthopedic fractures and injuries are commonly managed in the emergency department. Often a quick bedside reference card is needed to remind the clinician about the acute management and follow-up instructions. Thanks to the efforts of a 2015-16 ALiEM Chief Resident Incubator team, we are pleased to announce the first of these reference cards. Ankle and hindfoot fractures covered include ankle malleolar fractures, talus, and calcaneus fractures. These cards were expert reviewed by Dr. Scott Sherman, co-editor of the Emergency Orthopedics textbook and illustrations were created by Dr. Mary Haas.
Pain is the most common reason people seek care in Emergency Departments. In addition to diagnosing the cause of the pain, a major goal of emergency physicians (EPs) is to relieve pain. However, medications that treat pain can have their own set of problems and side effects. The risks of treatment are particularly pronounced in older adults, who are often more sensitive to the sedating effects of medications, and are more prone to side effects such as renal failure. EPs frequently have to find the balance between controlling pain and preventing side effects. Untreated pain has large personal, emotional, and financial costs, and more effective, multi-modal pain management can help reduce the burden that acute and chronic pain place on patients.1 There is evidence that older adults are less likely to receive pain medication in the ED.2,3 The first step to improving, is being aware of the potential tendency to under-treat pain in older adults. Here are 5 tips to help you effectively manage pain in older adults on your next shift.
Case VignetteA 42-year-old female presents at 10 pm with a throbbing right frontal headache associated with nausea, vomiting, photophobia, and phonophobia. The headache is severe, rated as “10” on a 0 to 10 triage pain scale. The headache began gradually while the patient was at work at 2 pm. Since 2 pm, she has taken 2 tablets of naproxen 500 mg and 2 tablets of sumatriptan 100 mg without relief.
The patient has a diagnosis of migraine without aura. She reports 12 attacks per month. The headache is similar to her previous migraine headaches. She is forced to present to an Emergency Department (ED) on average 2 times per month for management of migraine refractory to oral therapy. She reports a history of dystonic reactions and akathisia after receiving IV dopamine antagonists during a previous ED visit. The physical exam is non-contributory including a normal neurological exam, normal visual fields and fundoscopic exam, and no signs of a head or face infection. When you are done evaluating her, the patient reports that she usually gets relief with 3 doses of hydromorphone 2 mg + diphenhydramine 50 mg IM, and asks that you administer her usual treatment. What do you do?
Migraine is a neurological disorder characterized by recurrent painful headaches and abnormal processing of sensory input resulting in symptoms such as photophobia, phonophobia, and osmophobia.1 Central to disease pathogenesis is abnormal activation of nociceptive pathways.2 Disease severity ranges from mild to severe. Patients at one end of the spectrum have rare episodic headaches. On the other end are patients who have headaches on more days than not, patients who are functionally impaired by their headaches, and patients who frequently cannot participate fully in work or social activities. Chronic migraine, a sub-type of migraine defined by ≥15 days with headache for at least 3 consecutive months, is experienced by 1-3% of the general population.3
ED use for treatment of migraine is common. 1.2 million patients present to U.S. ED’s annually for management of this primary headache disorder.4 Parenteral opioids are used to treat the acute headache in slightly more than 50% of all ED visits.4 Multiple authorities have cautioned against the use of opioids for migraine.5,6 However, the frequent use of opioids has continued unabated, despite the publication in the EM, neurology, and headache literature of dozens of randomized controlled trials (RCTs) demonstrating safety and efficacy of parenteral alternatives, most notably dopamine antagonists and non-steroidal anti-inflammatory drugs.7
Opioids have been associated with a variety of poor outcomes in migraine patients including:
In contrast, a high quality, ED-based RCT did not demonstrate more harm from 1 or 2 doses of meperidine than from dihydroergotamine.12 Hydromorphone, the parenteral opioid currently used most commonly in U.S. EDs,4 has never been studied experimentally in migraine patients. However, given the wide range of parenteral alternatives, the possibility that opioids may worsen the underlying migraine disorder, and the fact that they are less efficacious than other treatments, opioids should not be offered as first- or second-line therapy for patients who present de novo to an ED with an acute migraine (assuming no contraindications to alternative medications).
1) Other than opioids, what parenteral therapies can be offered to this patient?
The 3 classes of parenteral therapeutics with the most evidence supporting safety and efficacy for use as first-line therapy for migraine are the following13:
However, this patient has relative contraindications to each of these. Other parenteral medications used for migraine are listed in the following table.
| Agent | Dose | Adverse events | Evidence supporting efficacy | Notes |
|---|---|---|---|---|
| Acetaminophen (APAP)14,15 | 1 gm IV | Well tolerated | In one trial, IV APAP did no better than placebo. In another, IV APAP was comparable to an IV NSAID. | |
| Dihydroergotamine16 | 0.5 mg -1 mg IV infusion | Nausea is common. Pre-treat with anti-emetics. | In one trial, DHE was less effective than sumatriptan at 2 hours but more effective by 4 and 24 hours. | Use cautiously in patients with cardiovascular risk factors. |
| Ketamine17 | 0.08 mg/kg SC | Fatigue, delirium | In one low quality cross-over RCT, ketamine outperformed placebo. | |
| Magnesium18–21 | 1-2 gm IV | Flushing | In RCTs of varying quality, IV mg did not consistently outperform placebo | Efficacy data is most compelling for migraine with aura. |
| Octreotide22 | 0.1 mg SC | Diarrhea, injection site reactions | In a high quality RCT, octreotide did not outperform placebo | |
| Propofol23,24 | 10 mg IV every 10 minutes as needed up to 80 mg Or 30-40 mg IV with 10-20 mg bolus every 3-5 minutes up to 120 mg | Sedation, hypoxia | In a low quality RCT, propofol outperformed dexamethasone. In another low quality trial, propofol outperformed sumatriptan. | It is not clear whether the migraine returns after propofol administration has been completed. Previous ALiEM post on migraines and propofol. |
| Valproic acid28,29 | 1000 mg IV | Well tolerated | In a high quality RCT, valproate was outperformed by metoclopramide and ketorolac. In a lower quality RCT, valproate was comparable to IV aspirin. | |
| APAP= acetaminophen; DHE= dihydroergotamine; Mg= magnesium | ||||
In some patients, greater occipital nerve blocks with a long-acting local anesthetic such as bupivaciane may play a role.25 While the above alternative parenteral therapies may benefit this patient, available evidence regarding risks and benefits does not dictate that these other therapies must be offered prior to use of opioids.
2) Does the fact that this patient makes frequent use of the ED indicate an unmet medical need?
As with congestive heart failure and asthma, frequent use of an ED for migraine is associated with worse underlying disease.26 These frequent users are more likely to have chronic migraines (> 15 headache days per month) and psychiatric co-morbidities.26 Concomitant medication overuse headache, a disorder defined by an upward spiral of increasing headache frequency in the setting of increased usage of analgesic or migraine medication, is also common.27 Management of complicated patients with migraines is exceedingly difficult, particularly during a busy ED shift, and may lead to frustration for both the healthcare practitioner and the patient. Ideally, outpatient healthcare practitioners with appropriate expertise should direct management of complicated patients with migraines.
3) Should the patient be administered 3 doses of hydromorphone 2 mg + diphenhydramine 50 mg IM as she wishes?
Management of chronic pain patients can be trying and demoralizing for emergency physicians because the underlying problem cannot be solved, and all avenues of treatment are flawed. Allowing the patient to suffer without appropriate justification is cruel. Delaying opioid administration during good faith efforts to identify alternative effective therapeutic agents is reasonable. Withholding opioids on principle is problematic because for most patients in most circumstances, published data do not establish that the benefit of pain relief is outweighed by the potential for opioid induced harm. On the other hand, thoughtlessly acquiescing to repeated requests for opioids during multiple ED visits is a violation of good medical practice, because of the concern of exacerbating the underlying migraine disorder, which could result in more ED visits, increased number of headache days, and the potential to cause refractoriness to standard migraine medication. One might compare it to administering antibiotics for bronchitis.
The best solution for the patient in the case vignette is to administer parenteral opioids only as rescue therapy for patients who adhere to an established outpatient plan of care. Acutely, the patient should not be allowed to suffer. However distasteful it may be, the harm arising from 3 isolated doses of parenteral opioids during one ED visit is unlikely to be either long-lasting or severe. But a prerequisite to treatment with opioids during a subsequent visit should be adherence to appropriate outpatient treatment: specifically, patients who require parenteral opioids for migraines should regularly attend outpatient appointments with an appropriate healthcare provider within the ED’s healthcare system.
Department-wide opioid policies are essential, as physician to physician variability in care may undermine a strict approach to opioids. Ideally, a committee with relevant expertise can monitor frequently presenting pain patients and develop patient-specific interventions that will be enforced by all practitioners during subsequent visits. If need be, the terms of treatment can be reinforced with a written document (example in the Appendix). This written document is not meant to be legally binding, but should be used to establish expectations. The last thing a busy emergency physician needs is a battle over opioids with a frequently presenting migraine patient. But before discharge, there should be a conversation about expectations during future ED visits. This will contribute to increased satisfaction for both the provider and the patient.
Top image: (c) Can Stock Photo
In cardiac arrest care it is well accepted that time to defibrillation is closely correlated with survival and outcome.1 There has also been a lot of focus over the years on limiting interruptions in chest compressions during CPR. In fact, this concept has become a major focus of the current AHA Guidelines. Why? Because we know interruptions are bad.2,3 One particular aspect of CPR that has gotten a lot of attention in this regard is the peri-shock period. It has been well established that longer pre- and peri-shock pauses are independently associated with decreased chance of survival.4,5 Can we do better to shock sooner and minimize these pauses?
A 10-year old girl presents with progressively worsening right lower quadrant pain for the last 2 days. She reports having chills and feeling warm. Her review of systems is negative for nausea, vomiting, diarrhea, or urinary symptoms. Her abdominal exam is unremarkable except for some diffuse, mild tenderness with deep palpation in bilateral lower quadrants. Labs: WBC 9 x 10^9/L. Because of radiation exposure concerns, you order an abdominal ultrasound as the initial imaging modality to evaluate for appendicitis. The radiologist’s reading was: “Unable to visualize the appendix.” Now, what do you do?
Appendicitis is one of the most common surgical emergencies and accounts for 5-10% of all abdominal pain among pediatric patients. Diagnosis can be deceptively difficult given that the complaints can be vague and nonspecific among children. Furthermore, this disease can mimic and be mimicked by many other pathologies making the clinical exam challenging. Laboratory tests, as well as clinical decision-making tools can help guide a clinician, but are limited, especially since early in disease progression, there may not be any demonstrated abnormalities.1
The use of some type of imaging modality is now more frequently incorporated to help assess for appendicitis. The sensitivity and specificity for computer tomography (CT) has been quoted as 94 and 95%, respectively, while for ultrasound (US), it is around 88% and 94%, respectively.1 In one particular 2012 study by Trout et al., the sensitivity for US for the diagnosis of acute appendicitis was as low as 66.4%, although the specificity was 95.9%, with a false negative rate of 33.5%.2
While CT/MRI improves diagnostic accuracy, many institutions use US as the initial imaging modality in order to minimize radiation exposure, and need for IV access and sedation.1,3 However, US results can vary for many reasons:2
Often clinicians are left in a quandary when the interpretation for the appendix is “equivocal,” “non-visualized,” “limited,” or “inconclusive.” This occurs 25-73% of the time.4,5 So now what? Many times, we progress to CT/MRI imaging as if the US study was never performed. Some clinicians incorporate other strategies including serial abdominal exams or repeated US studies. These alternative strategies, however, require a much longer ED stay.
New data suggests that an adequately performed US examination has some negative predictive value (NPV) for appendicitis despite the appendix not being seen (“non-visualized”), assuming that there are no other abnormalities present.5,6
A recent Journal of Pediatric Surgery 2015 study reports that an indeterminate abdominal US has some negative predictive power in risk stratifying the patient for appendicitis. From 2004-2013 at a single tertiary academic center, Cohen et al. did a retrospective chart review study of 1,260 patients who underwent abdominal US where appendicitis was suspected. 63% of the initial US findings were deemed non-diagnostic, with 56% of these due to non-visualization of the appendix. The authors then calculated NPV for non-diagnostic and non-visualized US results, as a function US alone, a serum WBC cutoff of 7.5 x 10^9/L, and a serum WBC cutoff of 11.0 x 10^9/L. The results are summarized in the table.6
| US Study Result | Number | NPV for Appendicitis | ||
| US Alone | US + Serum WBC* <7.5 | US + Serum WBC* <11 | ||
| Non-diagnostic** | 876 | 84.5% | 91.7% | 95.6% |
| Non-diagnostic because of non-visualized appendix | 777 | 86.4% | 98.9% | 97.0% |
| * WBC units are in 109/L
** Cases were categorized as non-diagnostic if they were not clearly or mostly conclusive in being a positive or negative ultrasound study for acute appendicitis |
||||
This study, examined the relationship between a non-diagnostic US and a primary outcome measure of appendicitis. With a non-diagnostic US and a serum WBC count of <7.5 x 10^9/L, one might be able to have a shared decision discussion with the family about observing the patient at home or as an inpatient without further immediate imaging. The NPV is 97.1% (or 98.9% if the appendix was not visualized). A limitation of this study is that it is a single-site retrospective study.6
For many clinicians, when we get a “non-visualized appendix” US reading, we still feel pressed to get further imaging, even if our suspicion is low. For those low-risk patients, regardless of the next imaging modality, they will already have a high NPV (86.4% in one study).7
Radiologists will also look for secondary findings suggestive of appendicitis, including the presence of an appendicolith, free fluid or fluid collection, echogenic inflammatory changes or hyperemia. A study by Ross et al. found that those with at least one of these secondary signs had an odds ratio of 6.52 of having appendicitis.4
A major part of the problem is how US findings are reported, because they can wildly vary by institution and by US technician. Providing a standardized and comprehensive report can help minimize confusion and clarify what descriptives mean. Fallon et al, created an “Appy-Score” which helped categorize various findings, though their “equivocal” definition was a catch-all for those that did not fit into the other groups (e.g. periappendiceal inflammatory changes or borderline enlargement with an otherwise normal appendix). They demonstrated that by using their US scoring system, they were able to reduce overall CT use by 38%.8
| Appy-Score Strata | |
| 1 | Completely visualized normal-appearing appendix with no ancillary findings to suggest appendicitis |
| 2 | Partially visualized normal-appearing appendix with no findings to suggest appendicitis |
| 3 | Non-visualized appendix with no ancillary findings to suggest appendicitis |
| 4 | Equivocal |
| 5a | Non-perforated acute appendicitis |
| 5b | Perforated appendicitis |
| Adapted from Larson et al5 Table 1 | |
Larson et al. used 5 specific interpretative categories to provide more description about their US findings. In patients with a non-visualized appendix but with positive secondary findings, the appendicitis rate was 39.3%, while those without any secondary findings, had a rate of 3.8%.5
Given a 50/50 chance of having an equivocal US exam, having a pre-test risk probability based on clinical exam and/or scores (e.g. Alvarado score) may help risk stratify your patients when combined with imaging.
| Clinical Criterion | No. of Points |
| Migration of pain to the right iliac fossa | 1 |
| Anorexia or ketones in the urine | 1 |
| Nausea or vomiting | 1 |
| Right lower quadrant tenderness | 2 |
| Rebound tenderness | 1 |
| Fever of 37.3°C or more | 1 |
| Leukocytosis of > 10,000/µL | 2 |
| Neutrophilia > 75% | 1 |
| Total possible points | 10 |
| Components of the Alvarado Score | |
In a study by Blitman et al., they found a NPV of 99.6% for those patients who had an inconclusive US test, but a low Alvarado score (<5) and 89.7% for those with a score of 5-8.9
Many institutions have created a staged approach where they will use ultrasound first, followed by a CT or MRI, if they are unable to visualize the appendix. Given new evidence, we now might consider avoiding additional imaging in certain low-risk populations. These low risk patients have ALL of the following:
In the hands of a proficient US operator, a nonvisualized appendix without secondary findings on US no longer means an automatic CT or MRI scan.