 > Up to 100,000 deaths in the US hospitals each yr related to medical errors
> Types of errors 1. Affective Errors - idea that we may treat a patient differently because there is something about them or about the circumstance that evokes either a negative or positive emotion - Positive - more time spent; some literature that we may avoid painful procedures - Negative - premature closure, less time, less care, less analgesia 2. Cognitive errors - Faulty knowledge, faulty data gathering, faulty synthesis, affective errors, external factors - Feedback failure - if you don’t know you screw up you don’t change your thought processes or practices = Confirmation bias; want to avoid over recalibration too - System 1 thinking - Illness script - pattern recognition comes from education and experience > Fast but can be unreliable, dependent on experience and not all illness follows illness scripts - System 2 Thinking - Cognitive Checkpoints - specific tests Cognitive Dispositions
- Premature closure = most common error in acute care medicine
Strategies to avoid error a. Admitting you have a problem is the first step b. Improve accuracy of judgements through cognitive aids c. Simulation d. EVERYTHING around you on any given day will influence how you take care of your next patient e. Metacognition - “thinking about thinking” -requires self awareness, ability to be self critical, & ability to introduc deliberate pause during the decision making process Train yourself to do a diagnostic pause - think about serious or alternative diagnosis, evaluate feelings, make sure there’s no extraneous information you’re missing, evaluate if theres anything today that’s impacting your decisions
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 Myth #1 - "Kids aren't little adults."
- Less a myth and more a good idea gone awry. - We don't need to consider kids to be like aliens. - Just take into account the anatomic and physiologic differences, but don't let them frighten you. - They are a unique patient population (similar to all of your other unique patient populations). Myth #2 - "IVF are faster than ORT." --IVF are effective and often expected, but not always easy. --Painful, makes unhappy parents and unhappy patients. --ED LOS: ORT = 225 vs IVF = 358. Myth #3 - "Lidocaine makes LP worse." -- Neonates do feel pain, have greater sensitivity, and are more susceptible to long term effects. -- EMLA is safe, reduces pain during LP. -- Makes your job easier!! (keeps them from wiggling) Myth #4 - "To hold for LP, bend them into a donut." -- Don't do this. -- Hyperflexed neck leads to SUBOPTIMAL AIRWAY ALIGNMENT. -- Best airway position is sitting up with legs flexed and neck neutral. Myth #5 - You can adjust for RBCs in the "Bloody tap." -- Correct with 1:500 for WBC, etc etc -- these formulas don't work. -- When concerned for meningitis, be conservative WBCs. -- Do not adjust the WBC for the RBC in a traumatic LP. Use the total WBC. Myth #6 - "Nebulizers are better than MDI." -- Evidence shows that MDI are AT LEAST as good as nebs, if not better. -- MDI is faster and reinforces good MDI use, which can help prevent patients from needing to return to the ED. TOA
- Has same risk factors as PID - Multiple sexual partners - 15-25 yrs old - History of prior PID 2 forms - Tobuovarian complexes (agglutination of pelvic organs +/- bowel) - Collection of pus - Often begins with DTD, but once abscess forms it is usually polymicrobial > Think about when you have suspicion for PID but are acutely ill, failure of treatment with normal therapy; diffuse abdominal pain > Imaging = US is 1st choice DDX
- septic hip or osteomyelitis, discitis, transient synovitis; trauma, congenital, neoplastic, SCFE, LCPD > Your goal should be to rule out potential catastrophic disease Physical Exam - undress!! - watch gait (antalgic gait - less time in stance phase on injured limb; trendelenberg, leaning over the side of the affected hip) - Evaluate for point of maximum tenderness - Hip pain > think spine - Knee pain > think hips - Range of motion - logroll thigh - gives good range of motion of hip Imaging - plain films are a good place to start - image everything if hard story or difficult to pinpoint pain Labs - ESR, CRP, CBC with diff, blood cultures Diagnosis - Transient Synovitis - get hip XRay - bony landmakrs are normal; may see widened joint space - may have joint effusion on US > Management = Rest and NSAIDs; f/up with ortho vs peds in 24-48 hrs; > Kids can limp on and off for a month > Can look like septic hip, usually follows URI; usually had normal labs > Kocher Criteria - 4 criteria: non-weight bearing on affected side; ESR > 40, Fever, WBC >12K - All 4 = 99%; 3 criteria 93%; 2 criteria = 40%; 1 criteria,3% chance of septic arthritis - Toddlers Fracture - Common in young kids; accidental - Stable; do above knee cast with knee flexed - The developing Bone - thicker periosteum, bone is more eleastic; avulsion before tendon rupture - Allows for unique fracture type: Torus and Bowing - SCFE - widened physis; Kleins line - should have bone on other line of femoral neck (get AP and frog leg views) > Stable - kid can walk (at all) - 90% - DC home; nonweight bearing; f/up with ortho; > Unstable - unable to walk (10%) - higher rate of avascular necrosis - non weight bearing; admit to ortho - Septic Arthritis - Common in large joints; severe pain; muscle spasms; fever - Staph and think Neiserria in sexually active teens > Be aware that little kids (< 3 months) have adjacent osteomyelitis (need MRI); 6mo-2 yrs - 50% will have associated infection > Aspirate and OR (antbx after debridement) - ortho urgency  Infection
> 2-7 days post abortion - ascending infection; risk factors include operative intervention, retained POC advanced gestation Retained POC = endometrial stripe >5mm on TVUS > Sx - history, fever (though common to not have a fever), abd pain, discharge, vaginal bleeding, tender uterus, adnexa > Antibitoic regimens - Outpatient - levaquin, flagyl; - Inpatient - vanc, zosyn +/- amp/gent vs vanc and meropenam; Remember tetanus Rh immunization - Rh negative mom, Rh positive fetus - with mixing of maternal and fetal blood; not a lot of great clinical evidence out there so unclear if our Rhogam dosage is correct, unclear how much maternal bleeding is required to have alloimmunization  Dens fracture
> Type I: Extends through the tip of the dens > Type II: Extends through the base of the dens - unstable > Type III: Extends through vertebral body of axis - can be unstable Geriatric Trauma - Falls - leading cause of injury - Frequently fail to mount a tachycardic response TB meningitis
> If lymphocytic meningitis, likely not viral if low glucose - LOW GLUCOSE IS NOT NORMAL FOR VIRAL MENINGITIS > Absence of fever doesn't exclude TB > Cranial nerve 6 = most common nerve palsy in meningitis Chronic Acetaminophen Toxicity - Can't use nomagram with chronic ingestions - NAC - replenished and maintains glutathione stores - also thought to have a role in free radical scavenging; IV or PO acceptable - If unknown ingestion time and LFTs or APAP elevated  Intussusception:
-Paucity of gas due to loss of gas in ascending colon
-Age rage 5 mo - 3 yr but typically <1 yr
-Ideal U/S patient: sens 98-100%, spec 88-100% -Must prep patient well for US with good pain control and anxiolysis Bowel obstruction:
Appy: 2007 JAMA RCE - Does my patient have appendicitis
Chronic Abd Pain:
 Impact
- Head injury is the #1 killer the trauma patient To scan or not to scan? Cost Issues - Head CT = $2700 Occult Injury Issues
If GCS = 14, 10-20% + head CT If GCS 13 = 20-30% + head CT So, if GCS is not 15... risk increases substantially. 2 classes of head trauma patients:
New Orleans Head CT rule - goal was to identify all patients with abnormal scan.
Canadian Head CT rule - looking for clinically significant findings - more specific
Use with caution in drunk folks! Anticoagulation is the Enemy! IMAGE ALL ANTICOAGULATED HEAD TRAUMA -- Much higher mortality in anticoagulated patients when compared to age matched controls Plavix vs Coumadin? -- Observational study of adult ED patients with blunt head trauma on coumadin vs plavix -- higher risk of immediate bleed in plavix -- important - 60% of people with bleeds had GCS 15 and 70% had no LOC Delayed Bleeds? -- Risk of delayed bleed relatively small; -- People with negative head CT who are THERAPEUTICALLY anticoagulated can be DC'ed home -- People who are supra-therapeutic likely need observation. Blood in the Brain is Bad. Airway management - want to minimize increased ICP RSI > Lidocaine - theoretically is supposed to attenuate cough reflex but hasn't been proven to change outcomes > Sucyincholine - can use without concern of worsening ICP from fasiculations > Ketamine - is ok to use in ICP - good literature that ketamine can help with ICP and avoids risk of hypotension that can occur with etomidate (don't use if has history of obstructive hydrocephalus) - use 1-2mg/kg Ventilator settings - RR of 12 Mannitol: 1g/kg (0.5g/kg - 1.5g/kg) - some evidence higher doses are more effective. The Primary damage has been done... your job is to Prevent Secondary Injury
IMPENDING HERNIATION (and briefly in conjunction with other measures); endpoint 30 mm Hg d. Steroids, narcan, hypothermia - none has been proven to work * No fantastic evidence in people on ASA with head trauma*  Pericarditis vs. MI
Your goal is not to diagnose pericarditis... it is to not miss MI. Pericarditis = fever, position dependent pain, diffuse elevation, no reciprocal changes, no Q wave MI = focal ST changes, reciprocal changes, Q waves, +/- pulmonary edema {From Dr. Mattu's ECG Lessons} Factors strongly favoring Acute MI: -- ST Depression in any lead other than V1 or aVR -- ST elevation that is Convex upwards (tombstone) or Slant-like/Horizontal. -- ST elevation in III > II If you have none of those, then consider the Factors that favor pericarditis: -- Pronounced PR depression in multiple leads (often only seen early in viral pericarditis) -- Friction rub Spodick's Sign: downsloping of QRS-TP segment in 80% of acute pericarditis When in doubt, check SERIAL ECGs!! What to order? - Consider troponin, CRP, WBC, ESR, CXR - CRP can be used for diagnosis and disease monitoring Treatment: - NSAIDS = mainstay - Colchicine + conventional therapy => decrease in recurrence rate in patients with a first eposide of acute pericarditis - dose is 0.5mg daily (<70kg) or 0.5mg BID (>70kg) x 3months (none of our cardiologists treat for that long) Recurrent pericarditis = symptom-free for 6 weeks and then symptoms recur Caution with Colchicine - elderly, hepatic/renal failure, pregnant patients In refractory cases, consider steroids, chemotherapeutic agents  Acute Mitral Regurgitation - acute vs chronic
Most common cause of acute: 1. Rupture chordae tendinae due to myxomatous disease, infectious endocarditis, rhemuatic heart disease 2. Rupture papillary muscle due to MI (2-7 days prior) Can get pulmonary edema, cardiogenic shock, mimics ARDS, PNA, difficult exam findings Echo enables you to quantify degree of MR; use color flow doppler echo to evalute for acute MR Persistent Tachycardia
Buergers disease
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