Volume 32 Number 9 September 2018

Age Restrictions Emergency department visits and hospital admissions are on the rise in patients older than 65, who comprise the fastest growing segment of the US population. Preparation is the key to providing age-appropriate care, avoiding iatrogenic harm, decreasing the risk of morbidity and mortality, and averting unnecessary hospitalizations. Simple modifications to emergency department design, triage and discharge protocols, medication reconciliation, and targeted educational initiatives can pay big dividends for geriatric patients.

In Too Deep While pediatric drowning is more prevalent in regions populated by large numbers of swimming pools, lakes, rivers, and beaches, younger children are also at risk in poorly controlled situations that involve bathtubs and even buckets of liquid. An estimated 85% of drownings are preventable with adequate supervision and public safety initiatives. Because early resuscitation is vital to a good outcome, emergency clinicians must be prepared to recognize and manage drowning and submersion-related injuries without hesitation.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS IN THIS ISSUE Lesson 17 n The Geriatric Emergency Department ...... 3 Critical Procedure ...... 13 Critical Decisions in Emergency Medicine is the official CME publication of the American College of Emergency LLSA Literature Review ...... 14 Physicians. Additional volumes are available. Critical Image ...... 16 EDITOR-IN-CHIEF Critical ECG ...... 18 Michael S. Beeson, MD, MBA, FACEP Northeastern Ohio Universities, Lesson 18 n Pediatric Drowning and Submersion Injuries . . . . 19 Rootstown, OH CME Questions ...... 30 SECTION EDITORS Drug Box/Tox Box ...... 32 Joshua S. Broder, MD, FACEP Duke University, Durham, NC Andrew J. Eyre, MD, MHPEd Brigham & Women’s Hospital/Harvard Medical School, Contributor Disclosures. In accordance with the ACCME Standards for Commercial Boston, MA Support and policy of the American College of Emergency Physicians, all individuals with control over CME content (including but not limited to staff, planners, reviewers, and Frank LoVecchio, DO, MPH, FACEP authors) must disclose whether or not they have any relevant financial relationship(s) to Maricopa Medical Center/Banner Phoenix Poison learners prior to the start of the activity. These individuals have indicated that they have and Drug Information Center, Phoenix, AZ a relationship which, in the context of their involvement in the CME activity, could be Amal Mattu, MD, FACEP perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants, University of Maryland, Baltimore, MD honoraria, or consulting fees), but these individuals do not consider that it will influence the CME activity. Joshua S. Broder, MD, FACEP; GlaxoSmithKline; his wife is employed by Lynn P. Roppolo, MD, FACEP GlaxoSmithKline as a research organic chemist. All remaining individuals with control over UT Southwestern Medical Center, CME content have no significant financial interests or relationships to disclose. Dallas, TX

This educational activity consists of two lessons, a post-test, and evaluation questions; Christian A. Tomaszewski, MD, MS, MBA, FACEP as designed, the activity should take approximately 5 hours to complete. The participant University of California Health Sciences, should, in order, review the learning objectives, read the lessons as published in the print San Diego, CA or online version, and complete the online post-test (a minimum score of 75% is required) Steven J. Warrington, MD, MEd and evaluation questions. Release date September 1, 2018. Expiration August 31, 2021. Orange Park Medical Center, Orange Park, FL

Accreditation Statement. The American College of Emergency Physicians is accredited ASSOCIATE EDITORS by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Wan-Tsu W. Chang, MD University of Maryland, Baltimore, MD The American College of Emergency Physicians designates this enduring material for a Walter L. Green, MD, FACEP maximum of 5 AMA PRA Category 1 Credits™. Physicians should claim only the credit UT Southwestern Medical Center, commensurate with the extent of their participation in the activity. Dallas, TX Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for 5 ACEP John C. Greenwood, MD Category I credits. Approved by the AOA for 5 Category 2-B credits. University of Pennsylvania, Philadelphia, PA Commercial Support. There was no commercial support for this CME activity. Danya Khoujah, MBBS University of Maryland, Baltimore, MD Target Audience. This educational activity has been developed for emergency physicians. Sharon E. Mace, MD, FACEP Cleveland Clinic Lerner College of Medicine/ Critical Decisions in Emergency Medicine is a trademark owned and published monthly by the American Case Western Reserve University, Cleveland, OH College of Emergency Physicians, PO Box 619911, Dallas, TX 75261-9911. Send address changes and Nathaniel Mann, MD comments to Critical Decisions in Emergency Medicine, PO Box 619911, Dallas, TX 75261-9911, or to Massachusetts General Hospital, Boston, MA [email protected]; call toll-free 800-798-1822, or 972-550-0911. Jennifer L. Martindale, MD, MSc Copyright 2018 © by the American College of Emergency Physicians. All rights reserved. No part of this Mount Sinai St. Luke’s/Mount Sinai West, publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, New York, NY including storage and retrieval systems, without permission in writing from the Publisher. Printed in the USA. David J. Pillow, Jr., MD, FACEP The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its UT Southwestern Medical Center, Dallas, TX publications are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this publication are provided as the contributors’ recommendations at the time George Sternbach, MD, FACEP of publication and should not be construed as official College policy. ACEP recognizes the complexity of Stanford University Medical Center, Stanford, CA emergency medicine and makes no representation that this publication serves as an authoritative resource Joseph F. Waeckerle, MD, FACEP for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of or standard of care that should be practiced by all health care providers at any particular University of Missouri-Kansas City School of Medicine, time or place. Drugs are generally referred to by generic names. In some instances, brand names are added Kansas City, MO for easier recognition. Device manufacturer information is provided according to style conventions of the American Medical Association. ACEP received no commercial support for this publication. EDITORIAL STAFF To the fullest extent permitted by law, and without Rachel Donihoo, Managing Editor limitation, ACEP expressly disclaims all liability for [email protected] errors or omissions contained within this publication, Suzannah Alexander, Publishing Assistant and for damages of any kind or nature, arising out of use, reference to, reliance on, or performance of such ISSN2325-0186(Print) ISSN2325-8365(Online) information. Age Restrictions The Geriatric Emergency Department

LESSON 17

By Nicole E. Cimino-Fiallos, MD; and Danya Khoujah, MBBS Dr. Cimino-Fiallos is an attending physician in the Department of Emergency Medicine at Carroll Hospital Center in Westminster, Maryland. Dr. Khoujah is an assistant professor in the Department of Emergency Medicine at the University of Maryland School of Medicine in Baltimore. Reviewed by Amal Mattu, MD, FACEP OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. Describe the unique challenges that geriatric patients face n How should elderly patients be triaged? in the emergency department. 2. Recognize the shortcomings of current triage systems for n What early interventions should be considered geriatric patients. when managing geriatric patients? 3. Implement simple emergency department improvements to enhance the care of elderly patients. n What are the specialized needs of geriatric patients, 4. Summarize strategies and resources to develop personal and how should they be addressed? and department knowledge of geriatric emergency care. 5. Use evidence-based strategies to safely discharge n What is the best way to prevent returns to the geriatric patients from the emergency department. emergency department or rehospitalization?

FROM THE EM MODEL n How can emergency providers increase their 20.0 Other Core Competencies of the Practice knowledge of age-specific problems in geriatric of Emergency Medicine patients? 20.4 Systems-Based Practice

Emergency department visits and hospital admissions are on the rise for geriatric patients, who comprise the fastest growing segment of the US population.1,2 Preparation is the key to providing age-appropriate care, avoiding iatrogenic harm, decreasing the risk of morbidity and mortality, and averting unnecessary hospitalizations. Simple modifications to emergency department design, triage and discharge protocols, medication reconciliation, and targeted educational initiatives for emergency clinicians can pay big dividends for older patients.

September 2018 n Volume 32 Number 9 3 CASE PRESENTATIONS ■ CASE ONE ■ CASE TWO evaluates him and orders x-rays. When the patient requests pain medication, A 79-year-old man presents While out driving his classic the nurse relays that the doctor did not Corvette, an 85-year-old man is with weakness and a cough. He is order anything because of the patient’s T-boned at an intersection. The diagnosed with pneumonia, started age. driver of the other car is taken to a on antibiotics, and admitted to the level 1 trauma center by helicopter, hospital. Because a room is not ■ CASE THREE and the elderly man is transported A 67-year-old woman presents with immediately available, he waits to the local emergency department. vomiting for the past 2 hours. She on a stretcher in the emergency He has chest and hip pain but no is well appearing, her vital signs are department’s hallway for 6 hours. loss of consciousness or head injury. stable, and she has a benign abdominal By the time an inpatient bed On arrival, his vital signs are blood examination. Her laboratory values becomes available, he is confused, pressure 110/70, heart rate 98, are normal. During her visit, she does respiratory rate 20, and oxygen agitated, and tachycardic. not vomit and is able to tolerate saltine saturation 98% on room air. He is crackers. She is discharged home The hospitalist no longer feels afebrile but appears uncomfortable. with written instructions and return comfortable managing him with a He complains of localized tenderness precautions. The patient lives by floor level of care, so he requests on palpation to the right lower chest herself and promises that she will read a step-down unit or intensive care wall; his examination is otherwise the instructions as soon as she finds unit (ICU) admission. normal. The emergency physician her glasses at home.

In 2010, 15% of the 130 million complications, and loss of functional quality improvement and enhancements patients who visited a US emergency status. With Medicare deducting of the physical environment — a safer department were over 65 years of reimbursements for iatrogenic layout — and geriatric-focused supplies. age.1 Extra care must be taken when complications, such as catheter and Geriatric emergency departments provide managing this special population, which wound infections, the need to take special education and interdisciplinary suffers from high rates of cognitive better care of admitted elderly patients staffing, including specially trained 6 impairment, functional impairment, has a financial incentive. Geriatric providers and case managers. depression, and polypharmacy.3 patients also require more services after Standardized protocols are implemented Geriatric patients have more emergent discharge to prevent their immediate to address common age-related issues, problems, need more diagnostic tests, return to the hospital. Even if these improve safety, decrease admissions, and are more likely to be admitted to services are provided, they are still at optimize discharges, and decrease higher risk for bouncing back to the 6 the hospital or ICU than those in any moribund outcomes. emergency department and requiring Geriatric emergency departments other age group.4 Every emergency readmission than younger patients.7 focus on older patients as a whole, rather department visit should be considered Most patients over the age of than on the acute chief complaint, as is a high-risk event that puts the elderly 75 years are affected by functional the model with traditional emergency at increased risk of medical errors problems and geriatric syndromes. care (Figure 1). These facilities may and adverse drug interactions when Approximately 50% are dependent on also be better equipped to address compared to the general population.5 others for personal activities of daily comorbidities, such as depression, Although the number of older adults living, a number that increases to 75% cognitive impairment, and medication presenting to emergency departments after presentation to an emergency interactions. In addition, they strive has been increasing steadily, the department. About 25% of elderly to optimize transitions to inpatient, number of those admitted to the emergency department patients exhibit home, community-based, rehabilitation, hospital has increased more than those one form of cognitive impairment, and and long-term care settings. To learn who were discharged, with an almost 50% cannot walk unsupervised.8 more, visit the American College of 2 doubling of the use of ICU services. The unique challenges facing this Emergency Physicians (ACEP) website These changes may indicate a more population and the successes of prior for the geriatric emergency department critically ill population but could initiatives focused on disease entities accreditation program at https://www. also be due to the overutilization of (eg, stroke) and patient populations acep.org/geda. services. Hospitalization itself can be (eg, pediatrics) have contributed to the Although studies have not yet proven dangerous for geriatric patients: They birth of accredited geriatric emergency whether geriatric-focused emergency are susceptible to delirium, hospital- departments. These facilities are departments can achieve all the goals acquired infections, falls, iatrogenic designed for older patients, including set out above,9 this new approach has

4 Critical Decisions in Emergency Medicine already been associated with a decreased signs makes it less sensitive, as vital increasing the sensitivity of vital signs rate of hospital admission.5 Fellowships signs can be deceptively normal for this (Table 1) and the level of consciousness, in geriatric emergency care and population.12 Specifically, a trigger for which follows the logic of pediatric- specially designated geriatric emergency the “danger zone” in the ESI is a heart specific parameters. Research is still departments are two approaches that rate of 100 beats per minute (bpm), required to validate this approach. enhance the delivery of age-appropriate but tachycardia is not easily mounted Another important intervention is care to older patients, but neither option by older patients. In addition, altered to encourage the involvement of a is available to all providers. Regardless, mental status or “disorientation” family member or care provider in the emergency physicians should be warrants a higher acuity triage level, process,6 especially for patients who are cognizant of the differences in the care yet delirium is frequently missed on cognitively impaired. required for older patients. evaluation of geriatric patients.13 Even when geriatric patients are Other vital signs that are not accurately triaged, they are less likely CRITICAL DECISION explicitly addressed in the ESI, but to be seen within the appropriate time How should elderly patients be that are used for consideration of frame for their assigned urgency.17 It is triage level by nursing staff, are blood unclear why the elderly wait longer for triaged? pressure and fever, both of which care, even though they are more likely to The most common triage system have different normal ranges in older be sicker and to require admission and in the United States is based on the patients. Thus, older adults without critical care. Emergency Severity Index (ESI), which grossly abnormal vital signs, those with Triage for geriatric trauma patients risk stratifies patients according to the dementia or other cognitive disorders, is a robust area of interest. As injuries severity of their presentation and how patients with nonfocal complaints and to elderly people increase in frequency, quickly they should be seen.10 In a 2010 atypical presentations, and seniors so do the associated rates of morbidity study that focused on older patients, the with less apparent illness, in general, and mortality. These increases are not third iteration of the ESI algorithm can be easily assigned to lower triage limited to major traumatic injuries; they (ESI-3) demonstrated validity, as it acuities.14 Under-triage leads to increased also occur among people with seemingly correlates with hospitalization, length of wait times, with subsequently worse minor injuries, such as those sustained stay, resource utilization, and survival.11 outcomes; a more negative patient in falls. One obvious reason for the This is important from a patient experience; discomfort, nervousness, two- to five-fold increase in mortality is safety standpoint, as it ensures that mistrust, and confusion; and feelings of the abundance of comorbidities in this sicker patients are seen first. However, abandonment and anxiety.15,16 population; under-triage becomes an when addressing individual outcomes These challenges have led many additional complicating factor.18 in older patients, the ESI has many experts to propose geriatric-specific An estimated one-third of older shortcomings. Its dependence on vital modifications to the ESI, specifically trauma patients are under-triaged,

FIGURE 1. The Central Role of the Emergency Department in Geriatric Care

Medical Home Surgicalists Outpatient Management Patient Entry

Anesthesia Transition/ Home/Skilled Telemedicine (perioperative) Urgent Care Nursing Facility Systems

Urgent Care Nurse Systems Hospital Hospital Hospital Medical Emergency Medicine Medicine Medicine Call Center Department (Admit (Inpatient (Discharge Primary Care Process) Management) Process) Primary Care Office Office

Skilled Nursing Nurse Facility Medical Laborists Call Center Hospital Home Care Nonemergent Admissions

REPRODUCED WITH PERMISSION FROM TEAMHEALTH’S PATIENT CARE CONTINUUM MODEL

September 2018 n Volume 32 Number 9 5 the Geriatric Emergency Department TABLE 1. Suggested Thresholds for Vital Signs in Older Patients Guidelines compiled by ACEP, the Current Abnormal American Geriatrics Society (AGS), the Vital Sign Threshold Proposed Abnormal Threshold Emergency Nurses Association (ENA), Heart rate >10 0 bpm >90 bpm and the Society for Academic Emergency Blood pressure <90 mm Hg <110 mm Hg Medicine (SAEM), available online at Temperature >38°C (100.4°F) (oral) >37.4°C (99.3°F) (oral) https://www.acep.org/geda/resources/ pdfs/GEDA-Guidelines.pdf.6,21 which are hot commodities in an era CRITICAL DECISION TABLE 2. Risk-Stratification of decreased federal funding for health Tools for Geriatric Patients care.6 What are the specialized needs Identification of Seniors at Risk (ISAR) A recent meta-analysis21 evaluated of geriatric patients, and how Triage Risk Screening Tool (TRST) a variety of screening tools (Table 2) should they be addressed? Silver Code with regard to their ability to identify Variables Indicative of Placement (VIP) at-risk patients during triage and, Physical Environment risk thereby, improve care through targeted Building a geriatric emergency Mortality Risk Index management. By definition, screening department with amenities specifically Rowland tools should be sensitive, have a good designed to accommodate elderly Runciman negative predictive value, and be simple patients seems difficult for many Score Hospitalier d’Evaluation du Risque and reproducible. Unfortunately, providers working in small community de Perte d’Autonomie (SHERPA) none of the screening tools evaluated hospitals or crowded academic centers. yielded “compelling evidence” to However, not all changes require a with the rate climbing to almost 60% justify recommendation of their use.21,22 contractor or a large budget (Table 3). for patients 90 years and older, which An earlier review article evaluated a When seniors were asked what they negatively affects both mortality rates targeted screening process, in which would like to see in an emergency and costs.18,19 A unique initiative in geriatric patients underwent a brief department, they reported that they Ohio, started in 2009, used an evidence- evaluation. Patients identified as high wanted their independence, mobility, based triage protocol in the field for risk then underwent a comprehensive and safety prioritized.23 injured patients older than 70 years geriatric assessment. In this review, Ideally, hallways should be clear to determine destination, utilizing evidence supported the two-step process from clutter and easily accessible by lower thresholds for transfer to a to identify at-risk patients in need of someone using a walker or a wheelchair. trauma center. This protocol improved further intervention and to decrease Handrails should be installed, and the sensitivity of identifying injury emergency department readmissions.22 signage with easy-to-read graphics severity and increased the proportion While the meta-analysis could should be clearly visible to direct of individuals discharged home, but it not advocate a specific screening patients to amenities such as the failed to change the mortality rate.19,20 test, given the lack of statistical bathroom, the waiting room, and the CRITICAL DECISION evidence, it did emphasize the need exit to parking. Orientation in each for a focused, evidence-based tool patient’s room, including an easy-to- What early interventions should that can identify high-risk populations read clock and a sign denoting the date be considered when managing at the time of triage and positively and day of the week, would also help geriatric patients? influence management decisions. This patients at high risk for delirium In addition to applying the classic recommendation is consistent with (Figure 2).23 triage model to identify patients’ ESI levels, emergency department visits TABLE 3. Emergency Department Interventions to Improve Outcomes are used as opportunities to screen for Geriatric Patients6 patients for a variety of conditions, Physical Environment Staffing Patient Care Initiatives including depression, suicide, abuse, and Handrails Pharmacist Frailty assessment substance abuse, and direct them toward Clutter-free hallways Volunteers Delirium detection appropriate resources. Clinicians should Large clocks Social worker/case manager Pain management also assess for those at high risk for an Signage indicating date Physical therapist Palliative care adverse event after discharge, such as Ambient light hospital readmission, another emergency Lower-level beds Even walking surfaces department visit, institutionalization, Bedside interventions functional decline, or death. An Avoidance of medical tape awareness of these events can help focus Thick, soft mattresses the use of time, personnel, and resources,

6 Critical Decisions in Emergency Medicine Improved lighting is a simple way to decrease the risk of adverse events, such FIGURE 2. Delirium Screening Instruments as falls and delirium. Patients should be Step 1. Delirium Triage Screen able to control the light in their rooms; Rule-Out Screen: Highly Sensitive older adults require three times as much light as younger adults for visual clarity. Altered Level of In addition, they should be able to turn Consciousness off the lights in their rooms at night, RASS Yes DTS Posititive which can lessen the disruption to their No circadian rhythms and subsequently Confirm with bCAM decrease the risk of delirium. Indirect Inattention >1 error light is preferred to spot lighting, which “Can you spell the word increases glare and makes it more ‘LUNCH’ backwards?” difficult for elderly people to see.6 Elderly patients are at significant 0 or 1 errors risk for falls. While some interventions such as fall-risk bracelets do not ED-DTS Negative improve outcomes, others can No Delirium decrease complications and should be implemented. Bed rails should not be used. They do not reduce fall risk and Step 2. Brief Confusion Assessment Method actually increase the risk of injury if Confirmation: Highly Specific the patient does fall.6 Beds should be kept at low levels to allow patients to Feature 1 — Altered Mental Status No bCAM Negative stand more easily. Elevated thresholds or Fluctuating Course No Delirium in room doorways should be removed. Uneven walking surfaces, textured Yes tiles, rugs, and carpets should be eliminated. Reducing the number of Feature 2 — Inattention 0 or 1 bCAM Negative “Can you name the months backwards patient transfers during the emergency errors No Delirium department stay also decreases the risk from December to July?” 6 of falls. Bedside radiological studies >1 error and portable laboratory equipment for bedside blood draws limit the number Feature 3 — Altered Level bCAM Positive of transports and decrease the risk of of Consciousness Yes Delirium Present disorientation by keeping the patients in RASS one treatment space for the entirety of No their stay.6 Geriatric patients are also at high Any Feature 4 — Disorganized Thinking errors risk for skin breakdown while in the 1. Will a stone float on water? hospital. Simple changes in practice 2. Are there fish in the sea? can limit this complication. The use of 3. Does 1 pound weigh more than 2 medical tape and adhesive should be pounds? No bCAM Negative limited because it can injure frail skin.5 4. Can you use a hammer to pound a nail? errors No Delirium Extra-thick, soft mattresses are usually Command: “Hold up this many fingers.” (Hold up two fingers.) “Now do the available in the hospital and should same thing with the other hand.” be requested for geriatric patients who (Do not demonstrate.) are expected to have an extended stay in the emergency department. Patients should be given the option to use a soft Interventions that decrease the risk of be encouraged to use their glasses reclining chair, instead of a stretcher, delirium include frequently orienting and hearing aids to help them remain if it does not interfere with treatment. patients to the time and place, using signs oriented and engaged. Furniture should be easy to clean and or sitters, avoiding unnecessary tethering soft to protect frail skin. Staffing The emergence of delirium in the in the form of monitor leads or urinary The role of emergency department emergency department is common and catheters, and turning the lights off in pharmacists in managing the geriatric may have an iatrogenic component. patients’ rooms at night.6 Patients should population is unclear. Polypharmacy

September 2018 n Volume 32 Number 9 7 is prevalent in older patients, making suitable for the emergency department. Introducing the concept of palliative them prone to medication errors, Alternatives include the Quick care early and correctly is essential in adverse events, and drug interactions. Confusion Scale, the Brief Confusion the care of all patients, but even more In addition, given the physiological Assessment Method (bCAM), and the so in those with multiple comorbidities. changes and comorbidities typical Modified Richmond Agitation and It is important to recognize that among the elderly, some medications Sedation Scale (mRASS), specifically palliative care and hospice care are not are inappropriate for older patients and because each takes less than 1 minute to one and the same. Palliative care is an have been identified in several initiatives, administer. The Quick Confusion Scale is interdisciplinary approach focused on including Beers list and the Screening a shorter version of the MMSE and is the improving the quality of life for persons Tool of Older Persons’ potentially test with the best performance-to-time of any age who are living with serious inappropriate Prescriptions (STOPP) ratio in the emergency department.22 The illness and their families. Hospice criteria.24,25 It therefore seems reasonable bCAM is derived from the Confusion care, on the other hand, provides that the presence of an emergency Assessment Method (CAM) used in ICUs palliative care to dying patients in department pharmacist, who could for the detection of delirium. their final months of life. Clarifying address this population specifically, Undertreatment of pain is also this distinction helps to enable patients could improve outcomes. One study a common problem for geriatric and their families to accept a referral reported that an emergency department– patients. One study showed that older to palliative care, if appropriate, and based pharmacist or clinical pharmacy patients are 20% less likely than their to improve the quality of life for the specialist identified at least one younger counterparts to receive pain patient, reduce hospital stays, and medication-related problem in almost medication.28 This difference probably decrease the cost of care.29 half of those in an elderly patient cohort; stems from concerns about the use of however, the presence of a pharmacist opioids in the elderly population. It is CRITICAL DECISION was not associated with improved important to consider alternatives to What is the best way to prevent clinical outcomes in previous studies.26 opioids for pain management, such returns to the emergency Although many emergency as acetaminophen, topical anesthetic department or rehospitalization? departments have limited budgets and treatments like lidocaine patches, staff, they often have access to a plethora and nerve blocks. The use of low- Prior to discharge, consider that of hospital volunteers. Engaging this dose opioids, with titration, is safe as many as 80% of elderly patients supplemental workforce in efforts to in older patients; however, increased who are discharged from the improve geriatric outcomes can pay bioavailability and medication emergency department have at least off with improved patient experiences. interactions must be factored into dosing one unrecognized geriatric problem On patient satisfaction surveys, many decisions. Uncontrolled pain, especially — delirium, dementia, depression, seniors report not receiving enough after an injury, increases the risk of undernutrition, or an unmet social attention and reassurance during their delirium in susceptible patients and is service need.30 Emergency providers visit. They describe the emergency frequently associated with functional should take the time to look for insidious department as busy and chaotic and feel decline, disability, and an increased risk diagnoses, while determining a safe that their basic needs (eg, hunger or use of falls. discharge plan. of the toilet) are addressed insufficiently. A robust volunteer service can fill many of these gaps and support a strained clinical staff.23 Patient Care Initiatives Several specific aspects of care should be addressed when managing any elderly n Reduce bounce-back visits by making follow-up phone calls to high-risk patient in the emergency department. elderly patients. For example, delirium screening can be n Geriatric patients typically want more information about advance very effective in decreasing in-hospital care directives, elder services in the community, and the compilation morbidity and can detect patients of medication lists. Include this material in your standard discharge at heightened risk of death, thereby paperwork. prompting appropriate interventions. n Make small physical changes to the emergency department — hang a When health care professionals do not clock with large numerals, display a calendar with the day and date, ensure use a dedicated screening tool, they miss patients can control the light settings in their room — to help prevent the diagnosis of delirium more than 50% complications such as delirium. 27 of the time. n Make educational resources on geriatric care readily available. Staff The Mini-Mental State Examination members want to know more about how to care for elderly patients. (MMSE) is cumbersome and not

8 Critical Decisions in Emergency Medicine A multidisciplinary approach is physicians by emergency care providers hospice or an assisted living facility. necessary for a safe discharge and was infrequent and that telephone Other placement considerations should can improve patient outcomes. An follow-up after discharge was rare.32 As include the need for rehabilitation or emergency department pharmacist expressed in the Geriatric Emergency observation.5 should review the medication list; a Department Guidelines,6 emergency If a patient is discharged home, geriatric life specialist should conduct department personnel should contact follow-up phone calls can reduce the screenings for depression, neglect, abuse, the patient’s outpatient care provider to likelihood of bounce-backs and improve and other geriatric-specific topics; a relay information about the complaints outcomes. In a 2014 study, nurses social worker should create a safety that precipitated the visit, the available with training in geriatric emergency plan; and a physical therapist should test results, the treatment administered, medicine made follow-up calls 1 to 3 assess the patient’s needs.5 One barrier the patient’s response to treatment, any days after discharge and again at 10 to the safe discharge of elderly patients consultations obtained, the discharge to 14 days after discharge.33 The calls from the emergency department is the diagnosis, any new prescriptions, and a aimed to assess pain, answer medication limited availability of ancillary staff, concrete follow-up plan. questions, confirm the scheduling of such as social workers, who typically The discharge instructions handed outpatient follow-up appointments, and work during usual business hours. to an elderly patient should be in a inquire about home health-care status. Expanding the resources that are already large font. As applicable, they can Rates of return visits to the emergency in place can improve the process. also be shared with family members department within 3 days and hospital Prior to discharge, a few other things in accordance with the parameters of admissions were lower in the group should be assessed. One is the patient’s the Health Insurance Portability and that received the follow-up consultation mobility, which affects safety and fall Accountability Act (HIPAA). Best than in the group that did not. Follow- risk at home.6 Interestingly, older adults practice is for the emergency physician up phone calls are an easy, inexpensive overestimate their ability to perform to personally review the discharge way to reduce admissions and bounce- simple tasks — like getting out of bed, instructions with the patient. Emergency backs to the emergency department. walking 10 feet, and then returning to department staff can improve the bed — up to 20% of the time, even more discharge experience by providing CRITICAL DECISION so if they are cane or walker dependent. additional information about geriatric How can emergency providers Therefore, a member of the emergency topics to patients and families. Popular increase their knowledge care team should observe the patient’s topics in a geriatric patient survey mobility directly prior to discharge. The included information about advance of age-specific problems in timed “Get Up and Go Test” is used care directives, elder services in the geriatric patients? in inpatient settings and in emergency community, and how to create a list In an ideal geriatric emergency departments as a predictor of return of medications.23 If written in general department, physicians would be visits and hospitalizations.31 terms in an easy-to-read style, patients fellowship-trained geriatric emergency The importance of discharge and families appreciate this relevant physicians with a support staff that protocols that enhance communication information. includes geriatric life specialists and between the emergency department The most appropriate disposition for nurses with special training in elder team and outpatient care providers has a patient might not be the place they left care.5 While these standards may not be been supported by various specialty to come to the emergency department. possible for all emergency departments, societies.6 However, one study found For example, a patient who lives at physicians and nurses can pursue that communication with community home might be better served by entering education in geriatric topics with minimal extra effort. In surveys about geriatric care, providers often report moral angst about the quality of care and cite a lack of education as the main reason for their discomfort.23 When surveyed about their comfort level in caring for geriatric n Ignoring age-specific factors when triaging geriatric patients. patients in the emergency department, n Making elderly patients wait longer for care than is appropriate for their staff cited a need for education and acuity level. training on geriatric-specific issues — the health problems associated with n Failing to recognize that 80% of elderly patients have one of the following undiagnosed conditions at the time of discharge: delirium, dementia, aging, communication with elders, depression, undernutrition, or an unmet social service need. elder abuse, and cultural sensitivity.23 n Neglecting to look for signs of elder abuse. Have a system in place to fully Clinicians also wanted to learn more evaluate every elderly patient. about appropriately managing patients with dementia and about responding to

September 2018 n Volume 32 Number 9 9 CASE RESOLUTIONS ■ CASE ONE progressed. He then developed a fever He suffered significant delays in and superinfection, which significantly care and pain control. The 79-year-old man with lengthened his hospital stay. pneumonia responded well to ■ CASE THREE antibiotics and started to improve. ■ CASE TWO When the elderly woman returned When his family arrived in the The 85-year-old man’s x-rays home, she was unable to find her emergency department, their showed a sternal fracture, left glasses and she could not read familiar faces, plus some rest, hemothorax, and grade II pelvic her discharge instructions. When helped resolve his delirium. He fracture. He was under-triaged by the her vomiting resumed, she called was eventually admitted to an paramedics at the scene when they an ambulance, which took her to inpatient floor, but his stay in the decided not to transport him to the the emergency department across emergency department had been trauma center for evaluation. In the town. A CT scan of her abdomen prolonged significantly. Once he emergency department, the patient revealed diverticulitis complicated got to his hospital room, his nurse was stabilized with a pelvic binder by an abscess. She was treated noticed a stage 1 decubitus ulcer and a left-sided chest tube. Given with intravenous antibiotics and on the left side of his sacrum. In the patient’s age, the physician was a percutaneous drain and was his hospital bed, the patient was afraid to prescribe opioids, so he was discharged home from the hospital adequately turned, but the ulcer transferred without pain medication. 5 days later.

confusion, aggression, and agitation.23 focus on continuing medical education in department guidelines. Ann Emerg Med. 2014 May; 63(5):e7-e25. Other topics of interest to emergency geriatric care to improve the experience 7. Di Bari M, Salvi F, Roberts AT, et al. Prognostic department staff include living wills and outcomes of the oldest and most stratification of elderly patients in the emergency department: a comparison between the and the community services available vulnerable patients. “Identification of Seniors at Risk” and the “Silver Code.” J Gerontol A Biol Sci Med Sci. 2012 May; to elders. For those who wish to learn more 67(5):544-550. The Geriatric Emergency about creating dedicated geriatric 8. Gray LC, Peel NM, Costa AP, et al. Profiles of older patients in the emergency department: findings from Department Guidelines are presented emergency departments, email the the interRAI Multinational Emergency Department as a consensus publication of ACEP, ACEP Geriatric Emergency Department Study. Ann Emerg Med. 2013 Nov;62(5):467-474. 9. Keyes DC, Singal B, Kropf CW, Fisk A. Impact of a AGS, ENA, and SAEM. While not a Accreditation (GEDA) program at new senior emergency department on emergency [email protected] or visit https://www. department recidivism, rate of hospital admission, mandate or requirement, they provide and hospital length of stay. Ann Emerg Med. 2014 evidence-based material that is relevant acep.org/geda to learn more about the May;63(5):517-524. accreditation levels, application process, 10. Gilboy N, Tanabe P, Travers D, Rosenau AM. to the acute care of geriatric patients. Emergency Severity Index (ESI): A Triage Tool Topics include atypical presentations GEDA guidelines, GEDA criteria, news, for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. Rockville, of disease, pain management and events, articles, podcasts, and more on MD: Agency for Healthcare Research and Quality; the evolving trends in geriatric care and November 2011. palliative care, the effect of comorbid 11. Baumann MR, Strout TD. Triage of geriatric patients conditions on current presentation, emergency medicine. in the emergency department: validity and survival with the Emergency Severity Index. Ann Emerg Med. common complaints that prompt 2007 Feb;49(2):234-240. REFERENCES older patients to seek emergency 12. Platts-Mills TF, Travers D, Biese K, et al. Accuracy of 1. US Department of Health and Human Services; the Emergency Severity Index triage instrument for care, and the logistics of making an Centers for Disease Control and Prevention; National identifying elder emergency department patients Center for Health Statistics. Health, United States, receiving an immediate life-saving intervention. emergency department more geriatric 2014: with special feature on adults aged 55-64. Acad Emerg Med. 2010 Mar;17(3):238-243. http://www.cdc.gov/nchs/data/hus/hus14.pdf#086. 13. Han JH, Zimmerman EE, Cutler N, et al. Delirium in friendly. These high-yield topics Published May 2015. Accessed September 25, 2017. older emergency department patients: recognition, can help practitioners target areas 2. Pines JM, Mullins PM, Cooper JK, Feng LB, Roth KE. risk factors, and psychomotor subtypes. Acad Emerg National trends in emergency department use, care Med. 2009 Mar;16(3):193-200. where geriatric patients have been patterns, and quality of care of older adults in the 14. Tucker G, Clark NK, Abraham I. Enhancing ED triage United States. J Am Geriatr Soc. 2013 Jan;61(1):12-17. shown to have delays in diagnosis or to accommodate the special needs of geriatric 3. Hwang U, Shah MN, Han JH, Carpenter CR, Siu patients. J Emerg Nurs. 2013 May;39(3):309-314. worse outcomes than their younger AL, Adams JG. Transforming emergency care for 15. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. older adults. Health Aff (Millwood). 2013 Dec; counterparts. Association between waiting times and short term 32(12):2116-2121. mortality and hospital admission after departure 4. Platts-Mills TF, Glickman SW. Measuring the value from emergency department: population based Summary of a senior emergency department: making sense of cohort study from Ontario, Canada. BMJ. 2011 health outcomes and health costs. Ann Emerg Med. Jun 1;342:d2983. Geriatric patients require careful 2014 May;63(5):525-527. 16. Shankar KN, Bhatia BK, Schuur JD. Toward patient- consideration. They are at high risk 5. Burton J, Young J, Bernier C. The geriatric ED: centered care: a systematic review of older adults’ for complications and have increased structure, patient care, and considerations for the views of quality emergency care. Ann Emerg Med. emergency department geriatric unit. Int J Gerontol. 2014 May;63(5):529-550.e1. 2014;8:56-59. morbidity and mortality after they 17. Freund Y, Vincent-Cassy C, Bloom B, et al. 6. American College of Emergency Physicians; Association between age older than 75 years and present to an emergency department. American Geriatrics Society; Emergency Nurses exceeded target waiting times in the emergency All providers can make small changes Association; Society for Academic Emergency department: a multicenter cross-sectional survey in Medicine; Geriatric Emergency Department the Paris metropolitan area, France. Ann Emerg Med. to their emergency departments and can Guidelines Task Force. Geriatric emergency 2013 Nov;62(5):449-456.

10 Critical Decisions in Emergency Medicine 18. Staudenmayer KL, Hsia RY, Mann NC, Spain Physicians, American Geriatrics Society, Emergency DA, Newgard CD. Triage of elderly trauma patients: a Nurses Association, and Society for Academic population-based perspective. J Am Coll Surg. 2013 Emergency Medicine. J Am Geriatr Soc. 2014 Jul; Oct;217(4):569-576. 62(7):1360-1363. 19. Ichwan B, Darbha S, Shah MN, et al. Geriatric-specific 3. Rosenberg M, Rosenberg L. The geriatric emergency triage criteria are more sensitive than standard department. Emerg Med Clin North Am. 2016 Aug; adult criteria in identifying need for trauma center 34(3):629-648. care in injured older adults. Ann Emerg Med. 2015 4. Samaras N, Chevalley T, Samaras D, Gold G. Older Jan;65(1):92-100.e3. patients in the emergency department: a review. 20. Caterino JM, Brown NV, Hamilton MW, et al. Effect Ann Emerg Med. 2010 Sep;56(3):261-269. of geriatric-specific trauma triage criteria on outcomes in injured older adults: a statewide retrospective cohort study. J Am Geriatr Soc. 2016 Oct;64(10):1944-1951. 21. Carpenter CR, Shelton E, Fowler S, et al. Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta- analysis. Acad Emerg Med. 2015 Jan;22(1):1-21. 22. Graf CE, Zekry D, Giannelli S, Michel JP, Chevalley T. Efficiency and applicability of comprehensive geriatric assessment in the emergency department: a systematic review. Aging Clin Exp Res. 2011 Aug; 23(4):244-254. 23. Kelley ML, Parke B, Jokinen N, Stones M, Renaud D. Senior-friendly emergency department care: an environmental assessment. J Health Serv Res Policy. 2011 Jan;16 (1):6-12. 24. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015 Nov;63(11):2227-2246. 25. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015 Mar;44(2):213-218. 26. Shaw PB, Delate T, Lyman A Jr, et al. Impact of a clinical pharmacy specialist in an emergency department for seniors. Ann Emerg Med. 2016 Feb;67(2):177-188. https://www.annemergmed.com/ article/S0196-0644(15)00528-4/fulltext. Accessed October 2, 2017. 27. Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013 Nov;62(5):457-465. 28. Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US emergency department patients are less likely to receive pain medication than younger patients: results from a national survey. Ann Emerg Med. 2012 Aug;60(2): 199-206. 29. Kahn JH, Magauran BG Jr, Olshaker JS, Shankar KN. Current trends in geriatric emergency medicine. Emerg Med Clin North Am. 2016 Aug;34(3):435-452. 30. Rosted E, Wagner L, Hendriksen C, Poulsen I. Geriatric nursing assessment and intervention in an emergency department: a pilot study. Int J Older People Nurs. 2012 Jun;7(2):141-151. 31. Roedersheimer KM, Pereira GF, Jones CW, Braz VA, Mangipudi SA, Platts-Mills TF. Self-reported versus performance-based assessments of a simple mobility task among older adults in the emergency department. Ann Emerg Med. 2016 Feb;67(2): 151-156. 32. McCusker J, Verdon J, Vadeboncoeur A, et al. The elder-friendly emergency department assessment tool: development of a quality assessment tool for emergency department-based geriatric care. J Am Geriatr Soc. 2012 Aug;60(8):1534-1539. 33. Aldeen AZ, Courtney DM, Lindquist LA, Dresden SM, Gravenor SJ. Geriatric emergency department innovations: preliminary data for the geriatric nurse liaison model. J Am Geriatr Soc. 2014 Sep;62(9): 1781-1785.

ADDITIONAL READING 1. Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department — The DEED II study. J Am Geriatr Soc. 2004 Sep;52(9):1417-1423. 2. Carpenter CR, Bromley M, Caterino JM, et al. Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency

September 2018 n Volume 32 Number 9 11 A 67-year-old man with palpitations. The Critical ECG

Accelerated junctional tachycardia, rate 115, bifascicular block (right By Amal Mattu, MD, FACEP bundle branch block [RBBB] and left anterior fascicular block [LAFB]), Dr. Mattu is a professor, vice chair, and director of the Emergency Cardiology prolonged QT-interval. Subtle P waves are noted on the rhythm strip. Fellowship in the Department of However, the PR interval is too short (<120 msec) for normal sinus rhythm, Emergency Medicine at the University unless an accessory pathway were present. (There is no evidence of an of Maryland School of Medicine in Baltimore. accessory pathway.) The most likely alternative cause of such a short PR interval is a junctional rhythm. A normal atrioventricular junctional rate is 40 to 60 beats/min; thus, this is referred to as an accelerated junctional tachycardia. An RBBB (QRS duration >120 msec, rsR’ pattern in

lead V1, wide S waves in the lateral leads) and LAFB (leftward axis, rS pattern in lead III and qR in I and aVL) are also present.

This patient was initially misdiagnosed as having sinus tachycardia. He was treated for several hours with intravenous fluids with the assumption that the tachycardia was due to hypovolemia. When his rate showed no evidence of improvement, the proper diagnosis was finally made. He then received a small dose of a beta-blocker medication and immediately converted to sinus rhythm with a rate of 75.

From Mattu A, Brady W. ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008. Reprinted with permission.

12 Critical Decisions in Emergency Medicine The Critical Procedure Regional Anesthesia of the Median Nerve at the Wrist By Vytautas Vaicys, MD Baylor Scott & White Medical Center, Dallas, Texas Reviewed by Steven Warrington, MD, MEd

Regional anesthesia of the median nerve at the wrist is a simple and effective pain management tool when treating complex trauma or performing procedures involving multiple fingers and/or the palm.

Contraindications achieve more consistent anesthesia while the injected volume can increase the n Allergy to anesthetic minimizing the rate of complications. compartment pressure. Patients with a n Infection overlying the site of The use of a sterile technique can further history of carpal tunnel syndrome may injection reduce the risk of infection. experience neurapraxia in the medial n Suspected risk of compartment Special Considerations nerve distribution. Additionally, it is syndrome Special consideration should be used important to avoid systemic toxicity by n Upper-extremity trauma to the area in patients with obvious anatomical considering maximum doses based on proximal to the wrist (such injuries irregularities and those who report the patient’s medical history. Because of may be better managed by more prior injuries and surgeries to the wrist. the superficial location of the nerve, care proximal regional anesthesia) This procedure is also contraindicated should be taken to avoid inserting the Benefits and Risks in severely injured patients at risk for needle and anesthetic too deep, which The procedure can anesthetize a large compartment syndrome; in such cases, can cause the procedure to fail. area of the hand with a single injection. This allows for proper irrigation, a thorough motor examination, the TECHNIQUE debridement of tissues, and laceration 1. Select the anesthetic based on the slightly proximal to the volar wrist repairs. The technique can also be used clinical situation (eg, ideal duration crease. Advance until a puncture of in conjunction with other nerve blocks of block), and prepare the anesthetic the retinaculum is felt (likely within and local infiltration, as indicated. (5 mL) and needle (23-27 gauge). the first cm of insertion), and deposit Risks are relatively limited and 2. Identify the injection site and 3-5 mL of anesthetic. Resistance and include infection, bleeding, the vascular confirm laterality. severe pain can indicate intraneural or intraneural administration of 3. Position the patient’s wrist on a tray injection; in such cases, withdraw anesthetic, vascular trauma, hematoma, table, dorsiflexed at 30 degrees. the needle 1-2 mm. and allergic reaction. 4. Clean and drape the area. If using Note: Full anesthesia is achieved in Alternatives ultra­sound, identify the injection site about 10 minutes. Regional anesthesia of the median prior to this step. For ultrasound-guided administration: nerve may be done more proximally 5. Locate the median nerve, which lies 1. Place the probe on the volar side of at the elbow, depending on the within the carpal tunnel and runs the wrist, setting the depth to 2-3 cm. clinical picture. Other options include along the palmaris longus and flexor 2. Locate the median nerve by noting a operative care, local anesthetic only, and carpi radialis. These can be located lack of movement, with flexion and procedural sedation. by asking the patient to flex the middle finger, or by approximating extension of the phalanges. When Reducing Side Effects the thumb with the fifth digit. sliding the probe proximally, tendons Proper patient positioning is 6. Insert the needle at a 45-degree become thicker and eventually important to achieve easy access to the angle, aimed proximally on the muscular in appearance, while the injection site. The use of ultrasound radial side of the palmaris longus nerve remains solid and round. guidance can also help the clinician

September 2018 n Volume 32 Number 9 13 The Critical Image A 78-year-old man presents after an unwitnessed ground-level fall By Joshua S. Broder, MD, FACEP at home. His son reports that the patient previously suffered a remote Dr. Broder is an associate professor and the traumatic brain injury and has recently developed progressive dementia, residency program director in the Division of Emergency Medicine at Duke University with several falls in the past week. He says the patient’s mental status Medical Center in Durham, North Carolina. today appears to be at his recent baseline. The patient complains of a mild Case contributor: Amanda Wessel, MD headache. Clear fluid is draining from his nares, and his son suggests that the patient may have an upper-respiratory infection. His vital signs are blood pressure 132/64, heart rate 60, respiratory rate 18, temperature 36.8°C (98.2°F), and oxygen saturation 100% on room air. The patient is awake and alert, but dried blood is visible on his posterior scalp. A cervical collar is in place. The remainder of the examination shows no evidence of trauma. He has no epistaxis or fluid from his nose at this time. He does not recall falling and is unable to provide the date or his location. An ECG shows sinus bradycardia. His laboratory tests are notable for a WBC count of 18.3. The nurse reports that the patient’s pillow is now soaked with watery fluid. A noncontrast CT scan of the head below( ) and cervical spine (not shown) are performed.

A Separation of frontal lobes by wide Intracranial interhemispheric fissure air, creating mass effect on brain Air outside of patient

Intracranial Intracranial air air

A. Noncontrast head CT, axial images, brain and bone windows. Extensive pneumocephalus (black) is present; it compresses the bilateral frontal lobes, giving a mass effect similar to that seen with intracranial hemorrhage. The interhemispheric fissure is widened by air. The appearance of flattened and separated frontal lobes, known as the “Mount Fuji sign,” can indicate elevated intracranial pressure (ICP) from accumulated air — tension pneumocephalus. When accompanied by clinical signs of high ICP, this finding is considered a neurosurgical emergency.1

KEY POINTS evaluation to identify the source of spaces (cisterns, ventricles, and leak is essential. Surgical repair may subarachnoid space); contrast n Pneumocephalus is a common be necessary for persistent found outside of these expected finding on head CT following (>7 days) or high-volume leaks. locations can indicate the leak site. trauma and may indicate air n An examination of a brain or facial n Provocative maneuvers (eg, prone entering the skull through an open CT using bone windows and a positioning) can accentuate a CSF fracture, or air communicating with bone reconstruction algorithm can leak and assist with localization. the intracranial space from facial identify bony discontinuities that A fluorescein injection into the airspaces (eg, frontal, ethmoid, may accompany a tear in the dura lumbar thecal sac can aid the sphenoid, or maxillary sinuses). mater. When uncertainty persists, intraoperative identification of a In many cases, pneumocephalus CT cisternogram (injection of leak. requires no specific intervention, iodinated contrast into the lumbar n A CSF leak can predispose patients but when extensive and thecal sac to enhance intracranial to meningitis, but prophylactic accompanied by clinical signs of CSF spaces) can be performed to antibiotics are controversial, with a cerebrospinal fluid (CSF) leak identify the site of a CSF leak. no systematic evidence supporting such as CSF rhinorrhea, additional n Contrast normally fills all CSF their use.2

14 Critical Decisions in Emergency Medicine B Defect in posterior wall of frontal sinus Intracranial may connect with air, creating intracranial space mass effect on brain

B. Noncontrast head CT, sagittal images, brain and bone windows (same scan as in A and B). Again, mass effect on the brain is seen, with a concave surface of the frontal lobe. A defect in the posterior wall of the frontal sinus appears to communicate with the intracranial space.

C Defect in posterior wall of frontal sinus Hardware from may connect with prior surgery intracranial space

Injected contrast partially fills the subarachnoid space

C. A CT cisternogram performed after the injection of iodinated contrast (white) into the lumbar thecal sac. From there, the contrast is expected to diffuse into the intracranial CSF spaces, and then to the site of any persisting leak. In this patient, no leak was identified by this maneuver, but he continued to have a CSF leak on clinical examination. Hardware from prior facial surgery is seen, and a communication is present between the frontal sinus and intracranial space — potentially the leak site.

CASE RESOLUTION Although the patient’s CSF WBC count was 41, his RBC count was more than 15,000 (therefore, not suggestive of infection). He remained afebrile, and his CSF culture showed no bacterial growth. Endoscopic surgery was performed by otolaryngology and showed multiple defects of the skull base, which were repaired.

1. Sweni S, Senthilkumaran S, Balamurugan N, Thirumalaikolundusubramanian P. Tension pneumocephalus: a case report with review of literature. Emerg Radiol. 2013 Dec;20(6):573-578. 2. Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015 Apr 28;(4):CD004884.

September 2018 n Volume 32 Number 9 15 The LLSA Literature Review Pelvic Inflammatory Disease By Elizabeth Harmon, MD; and Laura Welsh, MD University of Washington School of Medicine, Department of Emergency Medicine, Seattle Reviewed by Andrew J. Eyre, MD, MHPEd

Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med. 2015 May 21;372(21):2039-2048.

Pelvic inflammatory disease (PID) is an on all patients with suspected PID. inability to tolerate oral medications, inflammatory disorder of the female Ultrasonography can be helpful to or complications such as a tubo- upper-reproductive tract, including identify an alternative diagnosis. ovarian abscess. Inpatient treatment the endometrium, fallopian tubes, However, while imaging might be involves doxycycline and a parenteral and ovaries. The disease is caused by specific in identifying thickened, fluid- second-generation cephalosporin infection-induced inflammation that filled fallopian tubes indicative of with anaerobic coverage (eg, cefoxitin ascends from the vagina or cervix to the salpingitis, ultrasound lacks sufficient or cefotetan), or a combination of upper-genital tract. sensitivity. clindamycin and gentamicin. Acute pelvic inflammatory disease The treatment of PID involves Long-term complications of (lasting ≤30 days) is most often caused combination antibiotic regimens that PID include tubal infertility and an by the sexually transmitted cervical empirically treat the likely pathogens; increased risk of ectopic pregnancy pathogens Chlamydia trachomatis and N. gonorrhoeae and C. trachomatis due to tubal epithelial inflammation, Neisseria gonorrhoeae, but Mycoplasma should always be covered. Outpatient scarring, and adhesions. Short-term genitalium and bacterial vaginosis- regimens include a 2-week course of complications include tubo-ovarian associated pathogens are also common doxycycline and a one-time dose of a abscesses and Fitz-Hugh-Curtis culprits. Approximately 15% of cases parenteral third-generation cephalosporin syndrome, a rare complication that are caused by respiratory or enteric (eg, intramuscular ceftriaxone). causes liver capsule inflammation and pathogens that colonize in the lower Metronidazole can be added to this adhesion formation. Early diagnosis genital tract. regimen to cover anaerobic pathogens. and treatment is necessary to prevent PID can be difficult to diagnose Indications for hospitalization include both short-term and long-term due to the wide variation in signs pregnancy, severe illness with the complications of PID. and symptoms, including lower abdominal pain, abnormal vaginal KEY POINTS discharge, intermenstrual bleeding, n and dyspareunia. The clinical diagnosis PID is caused by an ascending infection from the lower female genital tract to the endometrium, fallopian tubes, and pelvis. is based on findings of pelvic organ n tenderness, including cervical motion The most common causes of PID are C. trachomatis and N. gonorrhoeae; other culprits include bacterial vaginosis-associated anaerobes and tenderness, adnexal tenderness, or respiratory or enteric pathogens. uterine tenderness, with associated signs n The clinical diagnosis is based on pelvic organ tenderness with cervical of lower genital tract inflammation, such discharge or friability. Nucleic acid amplification tests for N. gonorrhoeae as cervical mucopurulent discharge or and C. trachomatis should be performed in all patients with suspected PID. friability. Cervical or vaginal nucleic acid n Early treatment is essential to prevent both short- and long-term amplification tests for N. gonorrhoeae complications. and C. trachomatis should be performed

Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2018 Lifelong Learning and Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.

16 Critical Decisions in Emergency Medicine In Too Deep Pediatric Drowning and Submersion Injuries

LESSON 18

By Christina Long, MD, FACEP Dr. Long is an emergency physician at Loyola University Medical Center and a clinical assistant professor in the Department of Emergency Medicine at the Stritch School of Medicine in Maywood, Illinois. Reviewed by Sharon E. Mace, MD, FACEP

OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. Define drowning and use acceptable terminology. n What condition determines whether an incident 2. Recognize risk factors for drowning. is defined as drowning? 3. List the steps involved in rescuing and resuscitating a n What steps should you take to rescue and pediatric drowning patient. resuscitate a pediatric patient after drowning? 4. Manage hypothermia in a drowning patient. n 5. Recognize different end-organ complications that result What is the pathophysiology of drowning? from drowning. n What end-organ complications coincide with 6. Determine the appropriate disposition for a drowning drowning? patient. n What is the appropriate disposition for a pediatric 7. Identify poor prognostic indicators after drowning. patient after drowning? FROM THE EM MODEL n What factors indicate a poor prognosis for a 6.0 Environmental Disorders pediatric drowning patient? 6.5 Submersion Incidents

While pediatric drowning is more prevalent in regions populated by large numbers of swimming pools, lakes, rivers, and beaches, younger children are also at risk in poorly controlled situations that involve bathtubs and even buckets of liquid (Figure 1).1,2 An estimated 85% of these cases are preventable with adequate supervision, swimming lessons, and public safety initiatives. Because early rescue and resuscitation are vital to a good outcome, emergency clinicians must be prepared to recognize and manage drowning and submersion-related injuries without hesitation.

September 2018 n Volume 32 Number 9 17 CASE PRESENTATIONS ■ CASE ONE ■ CASE TWO prepares oxygen, suction, an end-tidal CO2 monitor, a pediatric bag valve mask, A 9-month-old girl arrives via EMS notifies a Florida hospital that and a ventilator. On arrival, she is cool ambulance after a frantic babysitter a 4-year-old girl is being transported and apneic, with thready pulses. called Emergency Medical Services to the emergency department in critical (EMS) with a report of drowning. condition after being found unresponsive ■ CASE THREE The babysitter told the medics that in the family’s pool. EMS states that A 16-year-old boy arrives via rescue she was giving the child a bath the family was having a party, when the helicopter after a drowning injury. His when she stepped away briefly to child slipped away unnoticed. An adult friends admit that they were drinking get her a towel. When she returned, found her in the pool and pulled her out alcohol and were taking turns diving off the infant was face down in the tub, of the water, but she was unresponsive. a nearby cliff into the river. The patient Nobody at the party knows how long flailing. She quickly pulled her out jumped into the river but did not resurface. she was down. A family friend, a nurse, and gave her a few back blows; the His friends were unable to rescue him started cardiopulmonary resuscitation child began to cry. and called 911. Medics recovered his (CPR) immediately. On arrival, the child is alert, unresponsive body after about 20 minutes Attempts to intubate were and pulled him to shore. Signs of head is breathing spontaneously, and unsuccessful in the field, so she was trauma were noted. appears well perfused. Her vital bagged. Attempts at IV were also The patient was pulseless and apneic; signs are blood pressure 82/40, unsuccessful. CPR was continued en an automated external defibrillator (AED) heart rate 172, respiratory rate 40, route to the emergency department. showed asystole. A cervical collar was rectal temperature 37.1°C (98.8°F), The emergency physician prepares the applied, and cervical spine precautions oxygen saturation 99% on room trauma bay, crash cart, and airway were maintained as CPR was initiated. air, and weight 7 kg. Her exam cart. The on-call pediatric intensive The medics were unable to intubate the reveals normal heart sounds and care unit (PICU) physician is also boy in the field. A peripheral IV was normal lung sounds. The secondary notified in advance, and puts ECMO established and epinephrine (0.8 mg IV) exam does not reveal any bruises or on standby. The nurse prepares the was administered prior to emergency signs of trauma. Her neurological Broselow chart and PALS resuscitation department arrival, based on an estimated examination is normal. medications. The respiratory therapist weight of 80 kg.

According to the Centers for Disease seizure disorders, and behavioral/ American Heart Association (AHA) Control and Prevention, approximately developmental disorders.1,2,3 recommends using the definitions set by 10 victims die every day from accidental the Utstein Style guidelines, which were drowning; 1 in 5 of these victims are CRITICAL DECISION formed by an international group of children 14 years or younger.3 These What condition determines researchers with scientific expertise in injuries have a bimodal age distribution, whether an incident is defined the field of drowning.1,5 with a peak incidence in those under as drowning? According to these guidelines 4 years old and another peak in and the World Health Organization Nonfatal drowning and submersion- adolescence.4 Children between the (WHO), drowning is defined “as a related injuries are frequent and ages of 1 and 4 years have the highest process resulting in primary respiratory significant causes of pediatric drowning rates; the majority of these impairment from submersion in a liquid morbidity and mortality. Nonfatal medium.”1,5 Fatal drowning, as the incidents occur in home swimming drowning is hallmarked by survival 3 pools. Older children, particularly males after a temporary submersion in water name implies, is a submersion injury older than 15 years, are more likely to or other liquid medium. Drownings leading to respiratory impairment drown in natural water (eg, rivers, lakes, were previously divided into two that results in death. Any submersion 1,2 or beaches). categories: “wet” (in which fluid was or immersion incident that does not Risk factors (Table 1) for fatal and aspirated into the lungs) and “dry” result in respiratory impairment nonfatal drowning include inadequate (indicating a period of asphyxia should not be considered a drowning childproofing barriers around secondary to laryngospasm).1 This injury; it should be considered a water pools, the inability to swim, lack of terminology, and other terms such rescue. Therefore, drowning is either appropriate adult supervision, failure as “near drowning,” “secondary classified as nonfatal or fatal. Drowning to use life jackets, alcohol or drug use, drowning,” and “delayed drowning,” outcomes have been simplified to death, risk-taking behavior, cardiac events, should no longer be used. The morbidity, and no morbidity.4

18 Critical Decisions in Emergency Medicine CRITICAL DECISION in pediatric patients (“ABC” [airway, On arrival to the emergency breathing, circulation], not “CAB” department, high-quality CPR should What steps should you take to [circulation, airway, breathing]). be continued. Indications for intubation rescue and resuscitate a pediatric If the patient does not respond to include apnea, an inability to maintain patient after drowning? two rescue breaths, high-quality chest a PaO2 above 60 mm Hg or oxygen Prehospital care is paramount to a compressions at a rate of 100 to 120 bpm saturation below 90% on high-flow drowning child. Immediate rescue and should be started. CPR is also indicated oxygen, a PaCO2 above 50 mm Hg, resuscitation, including initiation of for any pediatric patient with bradycardia signs of neurological deterioration, or bystander CPR, improves the outcome. (heart rate <60 bpm) and signs of poor an inability to protect the airway.1 If the The patient should be brought to land in perfusion. When available, an AED patient requires intubation, a nasogastric the supine position, and then checked for should be placed. Most patients with tube (or orogastric tube) should also responsiveness and breathing. In-water cardiac arrest due to drowning present be placed to decompress the stomach. resuscitation, consisting of ventilation in asystole or pulseless electrical activity Resuscitation medications should only, should only be attempted by a (PEA); however, they can also present be given according to the AHA and highly trained rescuer. The Heimlich with fatal arrhythmias such as ventricular pediatric advanced life support (PALS) maneuver is not a beneficial technique in fibrillation, especially when hypothermic.7 guidelines; refer to the Broselow chart if drowning and should not be performed.6 Wet clothing should be removed, and a weight is not available. Patients who If the patient is unconscious but passive rewarming should be initiated are bradycardic (heart rate <60 bpm) and breathing, the patient should be placed in the field. A decreased response showing signs of poor perfusion should in the lateral decubitus position.7 If the to defibrillation and resuscitation be given atropine 0.02 mg/kg IV or IO, patient is not breathing, two rescue medications can occur in a hypothermic up to two doses, with a maximum dose breaths should be given. Respiratory patient, but should still be used when of 0.5 mg, followed by epinephrine 0.01 arrest usually precedes cardiac arrest, indicated. Cervical spine injuries are rare mg/kg every 3 to 5 minutes (1:10,000 making ventilation essential. Unlike in drowning patients, and cervical spine concentration). Any pediatric patient in the adult cardiac arrest patient, precautions are not indicated unless there cardiac arrest should be given epinephrine immediate ventilation is emphasized is an associated high-risk mechanism 0.01mg/kg IV or IO (1:10,000 over uninterrupted chest compressions involved, such as diving or water sports.1,7 concentration) every 3 to 5 minutes.

FIGURE 1. Distribution of Fatal and Nonfatal Drownings by Location and Age Group 100

80

60

40 PERCENTAGE

20

0 0–4 years 5–14 years ≥15 years 0–4 years 5–14 years ≥15 years FATAL NONFATAL TYPE OF DROWNING n All other and unspecified n Unspecified pool n Private pool n Natural water, including boating n Public pool n Bathtub

Derived from the National Vital Statistics System and National Electronic Injury Surveillance System — All Injury Program

September 2018 n Volume 32 Number 9 19 Having a high suspicion for is performed, the trunk should be its use in pediatric cardiac arrest has hypothermia is crucial. A low-reading rewarmed first. In a patient with not been definitively proven to improve rectal thermometer or, ideally, a central moderate to severe hypothermia, active outcomes, perhaps due to a lack of core probe should be used to assess for internal rewarming measures should be reporting of outcome improvement, the hypothermia. Hypothermia is defined instituted. Active internal rewarming known harmful effects of hypothermia, as a core body temperature below measures include warmed humidified or a lack of standardized measures for 35°C (95°F). It can be categorized as oxygen via endotracheal tube, warmed inducing hypothermia in children.9 mild (32°C to 35°C [89.6°F to 95°F]), IV fluids, warmed fluid irrigation or In particular, one study looked at moderate (28°C to 32°C [82.4°F to lavage of body cavities such as the pleura therapeutic hypothermia versus 8 89.6°F]), or severe (<28°C [<82.4°F]). or peritoneum, and extracorporeal therapeutic normothermia in pediatric If not already started in the field, cardiopulmonary resuscitation (ECPR) comatose survivors of out-of-hospital passive rewarming should be initiated using extracorporeal membrane cardiac arrest due to drowning. It did immediately. If the patient remains oxygenation (ECMO), when available. not show a statistically significant benefit hypothermic with a core temperature Resuscitative efforts should be in survival with a good functional of <32°C (<89.6°F), active rewarming continued in a hypothermic patient until outcome or mortality at 1 year in those should be started with a target core the core temperature reaches 34°C to treated with hypothermia compared temperature of 34°C to 35°C (93.2°F 35°C (93.2°F to 95°F) or spontaneous to normothermia.10 Therefore, current to 95°F).8 Active external rewarming circulation returns to the patient.8 recommendations are to continue measures include applying warm blankets Survival has occurred in patients with prolonged resuscitative efforts until or using external heating devices that hypothermia and cardiac arrest, even use radiant heat, convection, or forced after prolonged resuscitation, hence the the patient is rewarmed to at least a 8 air rewarming. In a patient with signs of saying “not dead until warm and dead.” core temperature of 32°C (89.6°F). poor perfusion and moderate to severe This may be due to the neuroprotective Once the patient has reached a core hypothermia, the benefits of external effects of hypothermia. temperature of 34°C to 35°C (93.2°F to rewarming may be limited and could Whether an emergency physician 95°F), without return of spontaneous potentiate circulatory compromise; should use targeted or induced circulation, efforts can be stopped.8 external rewarming in such cases has therapeutic hypothermia in a cardiac Children who suffer cardiac arrest and been associated with afterdrop (further arrest patient depends on the patient’s hypothermia, who do not have return cooling), hypotension (rewarming age. Targeted therapeutic hypothermia of spontaneous circulation within 30 shock), ventricular fibrillation, and after cardiac arrest has been very minutes of resuscitation, experience asystole.8 If active external rewarming successful in adult patients; however, extremely poor outcomes.11

FIGURE 2. The Osborn Wave

The Osborn wave (commonly called the J wave) is typically seen when body temperature falls below 32°C (89.6°F). This finding is a positive deflection at the J point, seen between the QRS and ST segments.

20 Critical Decisions in Emergency Medicine neurological, cardiovascular, hepatic, precordial leads. The Osborn wave is FIGURE 3. Chest Radiograph 12 hematologic, and renal systems. All negative in leads aVR and V1 and can of Child With Noncardiogenic children studied who experienced severe occur when temperature falls below Pulmonary Edema, With neurological impairment or died suffered 30°C to 32°C (86°F to 89.6°F), though it Progression to ARDS cardiorespiratory arrest.1 is not pathognomonic for hypothermia. Pulmonary injury results from fluid Neurological impairment can occur aspiration, which can lead to hypoxemia, due to cerebral edema and elevated noncardiogenic pulmonary edema, and intracranial pressure, or also as a result acute respiratory distress syndrome of hypoxemia and hypoxia.1 Metabolic (ARDS). The hallmarks of ARDS and respiratory acidosis are also seen, include diffuse alveolar injury leading to though less likely in nonfatal drowning decreased permeability, inflammation, victims.1 Electrolyte abnormalities impaired gas exchange, and decreased are not common. Renal failure can pulmonary compliance. The classic chest also occur, usually as a result of acute x-ray for ARDS finds diffuse pulmonary tubular necrosis, but it is rare.1 Hepatic opacities, consistent with noncardiogenic impairment and coagulopathies are also pulmonary edema. Patients have rare complications.1 Courtesy of Critical Care; used with permission. impaired oxygenation with high oxygen requirements, most often requiring CRITICAL DECISION intubation. Signs and symptoms of CRITICAL DECISION What is the appropriate pulmonary insufficiency after drowning disposition for a pediatric What is the pathophysiology can present acutely or insidiously, and patient after drowning? of drowning? include dyspnea, tachypnea, hypoxia, For a symptomatic, unstable, Fatal and nonfatal drownings crackles, and wheezing. Clinically or critical drowning patient, the begin with primary respiratory significant pulmonary derangements can disposition is obvious — admission. Any impairment due to submersion in a be seen with as little as 1 mL/kg to 13 liquid medium, followed by breath- 3 mL/kg of fluid aspiration. symptomatic patient should receive an holding and a struggle to stay above Cardiac effects are usually secondary ECG, an arterial blood gas test, a basic water, if concscious.1,12 Eventual reflex to hypoxemia or hypothermia. PEA or complete metabolic panel, a complete inspiratory efforts lead to aspiration or and asystole are the most frequently blood count, coagulation studies, drug laryngospasm. If laryngospasm occurs, encountered rhythms in drowning and alcohol testing (when indicated), it is often rapidly terminated by brain victims who are in cardiac arrest. and a chest x-ray. All symptomatic tissue hypoxia.7 Regardless of freshwater Abnormal cardiac rhythms seen patients should be admitted to a or seawater aspiration, fluid in the after drowning include tachycardia, monitored bed. But what about the alveoli causes surfactant dysfunction, bradycardia, atrial fibrillation, and asymptomatic, stable patient? which affects the osmotic gradient in the even ventricular dysrhythmias.1 In a In recent years, media have given a lot alveolar-capillary membrane. This leads hypothermic patient, notable ECG of attention to “delayed drowning” and to pulmonary edema, which decreases the changes can include the Osborn wave, or “secondary drowning” cases, which has exchange of oxygen and carbon dioxide.7 J wave (Figure 2) — a positive deflection instilled fear in parents (and physicians) If the patient is not rescued, aspiration seen at the J point between the QRS and everywhere, even after minor submersion leads to hypercapnea, hypoxia, and ST segments, which is best seen in the injuries. Historically, these patients eventual respiratory arrest. This usually results in cardiac deterioration, starting TABLE 1. Important Facts and Predictors of Outcome in Resuscitation with tachycardia, then bradycardia, PEA, of a Drowned Patient and asystole.7 Early basic life support and advanced life support improve outcomes. CRITICAL DECISION During drowning, a reduction of brain temperature of 10°C decreases ATP consumption by approximately 50%, doubling the duration of time that the brain can survive. What end-organ complications Duration of submersion and risk of death or severe neurological impairment after coincide with drowning? hospital discharge Systemic hypoxemia can affect 0-5 minutes: 10% 6-10 minutes: 56% virtually all organs and lead to 11-25 minutes: 88% multisystem organ dysfunction or >25 minutes: nearly 100% failure. In one study that reviewed Signs of brain-stem injury predict death or severe neurologic sequelae. multiorgan dysfunction after pediatric Prognostic factors are important in the counseling of family members and are crucial in drowning, the respiratory system was informing decisions regarding more aggressive cerebral resuscitation therapies. most frequently affected, followed by the

September 2018 n Volume 32 Number 9 21 than 5 minutes, time to basic life support longer than 10 minutes, a resuscitation duration greater than 25 minutes, an age older than 14 years, a Glasgow Coma Scale score below 5, persistent apnea and requirement of CPR in the emergency n Rescue breaths (ventilation) should be the first step to resuscitating a pediatric department, or an arterial blood pH drowning patient (“ABC,” not “CAB”). 1 n Evaluate all drowning patients for hypothermia and initiate rewarming measures. below 7.1 on presentation. n Admit all symptomatic drowning patients. The survival outcome following n Consider discharge for an asymptomatic, stable patient after a period of 8 hours pediatric cardiac arrest is poor. Survival of observation in the emergency department. to hospital discharge ranges from 0% to 38% when factoring for both out- of-hospital and in-hospital arrests, were admitted due to the fear that they (with a score of 0 to 5). A score of 4 with up to half of the survivors having could later develop ARDS or respiratory or higher in the emergency department neurological impairment.9 For children arrest. Current literature suggests that suggests a safe discharge from the who do not need resuscitation or who emergency department monitoring or emergency department at 8 hours. In recover quickly after basic life support, observation may be sufficient to safely this study, a total of 278 patients were the neurological outcome is typically discharge these patients.14 A recent study, ultimately reviewed, and 50% were excellent. The prognosis is much worse published in The American Journal of deemed safe for discharge. None of the in those children who require advanced Emergency Medicine, focused on the patients who were determined to be safe life support. safe discharge of pediatric drowning for discharge at 8 hours had abnormal In one retrospective study of children patients from the emergency department vital signs requiring hospital admission with cardiac arrest and hypothermia and showed that very few patients at 24 hours. Outcomes were verified after drowning, absence of return had clinical deterioration after a well- through fatality records and electronic of spontaneous circulation within appearing presentation.14 health record review.15 30 minutes was associated with an Most of the patients who developed In conclusion, the asymptomatic extremely poor outcome. Survival complications had abnormal age- patient should be observed for 8 hours in with good overall outcome or mild to adjusted vital signs on presentation. the emergency department and admitted moderate disability occurred in 11% Only 34% of patients presented if there are any signs of deterioration. If of children with cardiac arrest who with normal age-adjusted vital signs. the vital signs, exam, and all studies are required advanced life support.11 Induced Despite the low number of patients normal, and remain normal, the patient therapeutic hypothermia has not been with subsequent clinical deterioration, can be safely discharged with clear proven to improve outcomes following more than half were admitted to the 1 discharge and follow-up instructions. pediatric cardiac arrest, though case hospital. Reasons included an abnormal reports with good neurological outcomes temperature, respiratory rate, oxygen CRITICAL DECISION do exist.7 saturation, physical examination finding, What factors indicate a poor or chest x-ray. The researchers concluded Summary prognosis for a pediatric that initial age-adjusted vital signs and Drowning is a leading cause of injury- physical exam in stable, well-appearing drowning patient? related death in children, and is largely drowning patients do not completely Factors associated with a poor preventable. An adult should constantly exclude the possibility of delayed prognosis for a pediatric drowning supervise infants and toddlers during complications. However, they are rare patient include submersion for longer bath time and while swimming, and events.14 Another study, published in the Society for Academic Emergency Medicine, used a scoring system called the Pediatric Submersion Score to identify children at low risk of submersion-related injury who could be n Using the terms “near drowning,” “delayed drowning,” “secondary drowning,” safely discharged from the emergency “wet drowning,” or “dry drowning.” department after a period of observation. n Performing the Heimlich maneuver. Five factors generated a safe discharge n Performing chest compressions before ventilation on a drowning cardiac arrest score at 8 hours: normal mentation, patient. normal respiratory rate, absence of n Failing to recognize and treat hypothermia. dyspnea, absence of need for airway n Admitting every patient with a water-submersion injury. support, and absence of hypotension

22 Critical Decisions in Emergency Medicine CASE RESOLUTIONS

■ CASE ONE 0.4 mg IO. The physician intubates her physician intubates the patient using using a 5.0-cuffed endotracheal tube. video laryngoscopy. Large volumes The babysitter calls the parents, A 12-French nasogastric tube is also of pink, frothy fluid are suctioned who arrive shortly after the arrival from his airways. A size 7.0-cuffed of the patient to the emergency placed. A large amount of frothy pink endotracheal tube is placed and department. An ECG, chest x-ray, sputum is suctioned from her airway, confirmed. An orogastric tube is then and basic labs are obtained, all of as well as fluid from her stomach. She placed to decompress his stomach. which are normal. The emergency continues to have weak pulses and is Despite tube placement confirmation, physician consults a social worker. bradycardic; epinephrine 0.2 mg is After the social worker interviews given IO. breath sounds remain diminished both the parents and the babysitter, During the patient’s next pulse bilaterally, and oxygen saturation is abuse is ruled out. The social and rhythm check, the physician finds poor. Epinephrine 0.8 mg is given IV, worker then explains water-related that she has stronger pulses and a and a second large bore IV is placed safety precautions and reiterates the heart rate of 84 bpm, in sinus rhythm. by the nurse. CPR is continued, and importance of supervision at all times Chest compressions are stopped, epinephrine is given every 3 minutes. when a child is in the bathtub. The and a complete set of vitals show A low-reading thermometer child is observed for 8 hours in the blood pressure 84/42, heart rate 84, shows a rectal temperature of 30°C emergency department. Her vital signs, respiratory rate 22 (with ventilator), (86°F). A brief secondary trauma respiratory status, and mental status rectal temperature 32°C (89.6°F), exam is performed and shows a remain unchanged and stable. She and oxygen saturation 88% on scalp hematoma to the right frontal- temporal region, facial abrasions, is discharged home with the parents 100% FiO2. An ECG reveals Osborn with clear instructions and follow-up waves. The chest x-ray shows diffuse dilated and nonreactive pupils, and recommendations. noncardiogenic pulmonary edema, and absent reflexes. No obvious trauma ARDS is suspected (Figure 3). to the chest, abdomen, back, or ■ CASE TWO Laboratory tests show show normal extremities is found. Active external On arrival, the child’s condition is electrolytes, renal function, blood and internal rewarming measures are unchanged. She is unresponsive and counts, liver function, and coagulation implemented. apneic, and her pulses are weak. Her studies. The arterial blood gas test An extended focused assessment heart rate is 30 bpm. The respiratory shows mild metabolic acidosis. Active with sonography for trauma is done therapist takes over bagging the internal rewarming measures are and is negative for free fluid. A brief child, and the technician resumes started. She is admitted to the PICU, pause in chest compressions to perform chest compressions. where she may require ECMO. bedside cardiac ultrasound shows The emergency physician prepares a lack of cardiac activity after 45 for intubation. The nurse is not able ■ CASE THREE minutes of high-quality CPR in the to establish a peripheral IV after On arrival, an assessment of the emergency department, with a total two attempts, so she is instructed teenager’s ABCs reveals he is still in downtime estimated at 75 minutes. He to place an intraosseous line in the full cardiac arrest. The monitor shows remains in asystole, despite rewarming child’s right tibia. Once the line is asystole. CPR is resumed, and cervical to 34°C (93.2°F), and is pronounced established, the child is given atropine spine precautions are maintained. The dead. should not rely on floatation devices important first step in resuscitation patient is rewarmed to at least a core to substitute for supervision. Pools after rescue is ventilation by giving two temperature of 32°C (89.6°F). Cervical and other bodies of water around the rescue breaths. In most cases of early spine injuries are rare in drowning home should have adequate childproof rescue, two rescue breaths are all that is cases, but should be considered if the barriers. Buckets of water or other needed. If a patient does not respond, mechanism suggests otherwise, such liquids should not be left unattended, CPR should be initiated. Medics and as diving. Prolonged submersion time, as these also pose a drowning risk for physicians should have a high suspicion delay of rescue and resuscitation, and children. In addition, public safety for hypothermia in every drowning cardiac arrest are indicators of poor measures should be emphasized, such patient, and rewarming measures prognosis. as using life jackets and avoiding risk- should be taken. The role of therapeutic Stable, asymptomatic patients can taking behavior, especially while under hypothermia remains controversial potentially be discharged from the the influence of alcohol or drugs. in pediatric patients, so current emergency department after a period Early rescue and resuscitation are recommendations are to continue of observation of 8 hours. Frequent vital to a good outcome. The most prolonged resuscitative efforts until the assessment of vital signs and re-

September 2018 n Volume 32 Number 9 23 examination are necessary, in addition to obtaining an ECG, a chest x-ray, and labs. All symptomatic patients should be admitted. Complications can include noncardiogenic pulmonary edema, ARDS, cardiac dysrhythmias, neurological impairment, and multisystem organ failure. When referring to cases of drowning, only the terms nonfatal drowning and fatal drowning should be used. To be considered a drowning, respiratory impairment must have occurred after a period of submersion.1,5 It is otherwise considered a water rescue. Do not use terms like “near drowning.” Respiratory insufficiency can occur insidiously, but should not be referred to as a “delayed drowning” or “secondary drowning.”

REFERENCES 1. Chandy D, Weinhouse GL. Drowning (submersion injuries). UpToDate. https://www.uptodate.com/ contents/drowning-submersion-injuries. Accessed February 24, 2018. 2. Cohen N, Scolnik D, Rimon A, Balla U, Glatstein M. Childhood drowning: review of patients presenting to the emergency departments of 2 large tertiary care pediatric hospitals near and distant from the sea coast. Pediatr Emerg Care. 2018 Feb 5. 3. Unintentional drowning: get the facts. Centers for Disease Control and Prevention. https://www.cdc.gov/ homeandrecreationalsafety/water-safety/waterinjuries- factsheet.html. 2016. Accessed February 24, 2018. 4. Conover K, Romero S. Drowning prevention in pediatrics. Pediatr Ann. 2018 Mar 1;47(3):e112-e117. 5. Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation, an ILCOR advisory statement. Circ Cardiovasc Qual Outcomes. 2017 Jul;10(7). 6. Best RR, Harris BHL, Walsh JL, Manfield T. Pediatric drowning: a standard operating procedure to aid the prehospital management of pediatric cardiac arrest resulting from submersion. Pediatr Emerg Care. 2017 May 8. 7. Corneli HM. Hypothermia in children: management. UpToDate. https://www.uptodate.com/contents/ hypothermia-in-children-management. Accessed March 24, 2018. 8. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012 May 31;366(22): 2102-2110. 9. Schlunt ML, Wang L. Hypothermia and pediatric cardiac arrest. J Emerg Trauma Shock. 2010 Jul;3(3):277-281. 10. Moler FW, Hutchison JS, Nadkarni VM, et al. Targeted temperature management after pediatric cardiac arrest due to drowning: outcomes and complications. Pediatr Crit Care Med. 2016 Aug;17(8):712-720. 11. Kieboom JK, Verkade HJ, Burgerhof JG, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. BMJ. 2015 Feb 10;350:h418. 12. Mtaweh H, Kochanek PM, Carcillo JA, Bell MJ, Fink EL. Patterns of multiorgan dysfunction after pediatric drowning. Resuscitation. 2015 May;90:91-96. 13. Terry SH, Kaplan LJ. Near-drowning. In: Wilson WC, Grande CM, Hoyt DB, eds. Trauma. Boca Raton, FL: CRC Press; 2007:685-694. 14. Brennan CE, Hong TKF, Wang VJ. Predictors of safe discharge for pediatric drowning patients in the emergency department. Am J Emerg Med. 2018 Jan 31. 15. Shenoi RP, Allahabadi S, Rubalcava DM, Camp EA. The pediatric submersion score predicts children at low risk for injury following submersions. Acad Emerg Med. 2017 Dec;24(12):1491-1500.

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September 2018 n Volume 32 Number 9 25 Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers toCritical Decisions in Emergency Medicine may receive CME certificates for up to 5 ACEP Category I credits, 5AMA PRA Category 1 CME Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety. Submit your answers online at acep.org/cdem; a score of 75% or better QUESTIONS is required. You may receive credit for completing the CME activity any time within 3 years of its publication date. Answers to this month’s questions will be published in next month’s issue.

Which of the following strategies has failed to improve Which of the following interventions decreases the risk 1 geriatric patient safety? 6 of delirium in susceptible patients? A. Bedside radiological studies A. Haloperidol B. Fall-risk bracelets B. Regular meal times C. Flat, even floors C. Use of a cardiac monitor D. Recliners or soft mattresses D. Use of a clock What strategy can make the discharge process safer for Which of the following is an inaccurate statement 2 older patients? 7 concerning the triage of elderly patients? A. Ask the patient to schedule a follow-up appointment A. Even when triaged appropriately, geriatric patients wait with a primary care provider within 1 month longer to be seen than expected, given their assigned B. Exclude family members from the process because triage level their presence violates HIPAA B. Heart rate is the most sensitive vital sign for the C. Present all instructions in simple language and appropriate triage of elderly patients personally review them with the patient C. Inappropriate field triage can direct elderly trauma D. Streamline discharge instructions to one piece of paper patients away from level 1 trauma centers and put Which of the following presentations warrants assigning them at greater risk for delays in appropriate care 3 an older patient to a higher acuity level? D. The ESI triage system is not always accurate when A. Blood pressure 130/90 triaging elderly adults B. Disorientation Which of the following should be considered before C. Heart rate 85 8 prescribing opioids to a geriatric patient? D. Oral temperature 37.2°C (99°F) A. Acetaminophen and topical anesthetics should not be Which of the following tactics could make the discharge used in lieu of more effective opioids 4 process safer? B. Palliative care can help to create safe, effective pain A. Discouraging the patient from seeing a primary care management plans for elderly patients physician until next week C. Palliative care is appropriate for terminally ill patients B. Excluding the patient’s family from the process to D. Regional nerve blocks should not be used routinely protect the patient’s privacy A 70-year-old woman presents with new-onset gout. C. Making a follow-up phone call in 2 weeks 9 While waiting for her radiology results, her physician D. Using large type for all discharge instructions prescribes 6 mg of morphine. After receiving it, she An 86-year-old woman presents after a fall. She reports becomes delirious. As she tries to get off the stretcher, 5 a burning sensation while urinating. Her urinalysis is she falls and sustains a femoral neck fracture. Which positive for leukocytes, >50 WBCs, large bacteria, and action might have prevented this series of events? nitrates. What step should be taken prior to discharging A. Application of a fall-risk bracelet her? B. Consideration of alternatives to opioids A. Arrange for the patient to be taken to her car in a C. Evaluation of her vital signs and re-evaluation by the wheelchair so that she doesn’t have to walk and risk nurse falling D. Placement of a Foley catheter B. Discuss the planned antibiotic therapy with the Which of the following tasks is outside the scope of emergency department pharmacist or look at the Beers 10 practice for an emergency department pharmacist? list for potentially harmful drug interactions A. Completing a medication reconciliation C. Explain to the patient that another antibiotic cannot be B. Confirming appropriate dosing for emergency added to her medication regimen because it would be department–prescribed medications dangerous C. Identifying a potential medication-medication D. Prescribe an antibiotic without checking the patient’s interaction home medication list D. Modifying the patient’s home medication dosages

26 Critical Decisions in Emergency Medicine What age group is at the highest risk for drowning? Which of the following should be considered when 11 A. 4 years of age and under 17 performing diagnostic tests after a drowning? B. 5 to 8 years of age A. Arterial blood gas, if abnormal, usually shows a C. 8 to 12 years of age respiratory alkalosis D. Over 15 years of age B. Chest x-ray findings often include cardiomegaly Which of the following is an acceptable term to use and diffuse pulmonary edema 12 when referring to drowning? C. ECG is usually not necessary because drowning A. Dry drowning results primarily in pulmonary insufficiency and B. Near drowning cardiac abnormalities are not common C. Nonfatal drowning D. Renal function is rarely affected D. Secondary drowning Which chest x-ray finding suggests ARDS? An 11-month-old girl is left unattended in the 18 A. Bilateral, patchy, perihilar opacities and 13 bathtub. Her mother returns to find her submerged peribronchial cuffing face down. What should the mother do first? B. Consolidation in the left lower lobe A. Get in the tub and start resuscitation C. Diffuse pulmonary edema with cardiomegaly B. Pull the girl out of the tub, check for breathing, D. Diffuse pulmonary edema without cardiomegaly and give her two rescue breaths if she is not A 3-year-old child has been rescued from breathing 19 drowning. He is unresponsive and apneic, has C. Pull the girl out of the tub and immediately start weak pulses, and has a heart rate of 40. What is chest compressions the best approach? D. Pull the girl out of the tub and perform the A. Use a bag valve mask, give oxygen for Heimlich maneuver ventilation, and administer a 20-mL/kg fluid bolus Which of the following is associated with a poor B. Give two rescue breaths, followed by chest 14 prognosis after drowning? compressions if he does not respond; continue A. Apnea and CPR required in the emergency CPR and give atropine, as well as epinephrine; department and intubate, if possible B. Basic life support provided on scene C. Begin immediate chest compressions, followed C. Duration of submersion of less than 5 minutes by atropine every 3 to 5 minutes, and intubate, if D. Return of spontaneous circulation within 30 possible minutes D. Since he is not pulseless and does not require Which of the following should be considered when chest compressions, perform the Heimlich 15 managing hypothermia in a drowning patient? maneuver, give two rescue breaths, and then A. Active rewarming should be initiated in the intubate, if possible emergency department Which of the following should be considered when B. ECG changes include the “delta wave” 20 managing a drowning patient? C. Induced or targeted therapeutic hypothermia A. All drowning patients should be admitted should be performed, as it has been proven to due to the risk of delayed respiratory distress, improve survival and neurologic outcomes in hypoxemia, ARDS, and respiratory arrest pediatric patients B. Hypothermia associated with drowning should D. Patients should be rapidly rewarmed until they not be aggressively treated, as it has been shown reach a core body temperature of 37°C (98.6°F) to have neuroprotective effects and to improve Which of the following is a risk factor for drowning? the outcome in pediatric cardiac arrest patients 16 A. Constant adult supervision during bath time C. The most common rhythm in a drowning patient B. Multiple adults hanging out around a pool who has suffered cardiac arrest is ventricular socializing, while children are swimming in the fibrillation pool D. Submersion or drowning injuries that result in C. No use of alcohol or drugs when in the water pulmonary insufficiency and hypoxemia can D. Using life safety vests, while boating or swimming potentially lead to multiorgan dysfunction

ANSWER KEY FOR AUGUST 2018, VOLUME 32, NUMBER 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 C D D A B C B C D D B A D D D C B B D C

September 2018 n Volume 32 Number 9 27 Drug Box Tox Box

OCTREOTIDE BACLOFEN POISONING By Anthony Kraus, MD; and Frank LoVecchio, DO, MPH, By Tony Gao, MD; and Christian A. Tomaszewski, MD, MS, MBA, FACEP, Maricopa Medical Center, Phoenix, AZ FACEP, University of California, San Diego Octreotide is a broad polypeptide hormone that Baclofen is a centrally acting GABA-B receptor agonist prescribed to treat vasoconstricts vessels, reduces portal vessel pressure, and spasticity and chronic neuropathic pain syndromes. It is also used to decreases insulin release. It provides more potent inhibition treat alcohol withdrawal. There are oral and intrathecal formulations. of growth hormone, glucagon, and insulin than endogenous Presentation somatostatin. Toxic dose Mechanism of Action >150 mg — symptomatic The drug mimics natural somatostatin by inhibiting >300 mg — significant complications serotonin release and the secretion of gastrin, VIP, Acute overdose insulin, glucagon, secretin, motilin, and pancreatic • CNS depression to coma polypeptide. In addition, it decreases growth hormone • Respiratory depression, resulting in coma and decreased muscle and IGF-1 in acromegaly, suppresses LH response to tone GnRH and the secretion of thyroid-stimulating hormone, • Hypotension with bradycardia and decreases splanchnic blood flow. • Hypothermia Emergent Indications Seizures Bleeding esophageal varices — Decreases portal vessel • Seen in both baclofen overdose and withdrawal pressure and may reduce the rate of upper-GI bleeding. • Inhibition of both presynaptic and postsynaptic receptors of Sulfonylurea toxicity — Reduces the incidence of GABA-B recurrent hypoglycemia versus therapy with dextrose Management alone. • Provide supportive care and maintain airway. Dosing • The first-line treatment for seizures is benzodiazepines, which act Bleeding esophageal varices (off label): (IVB) 25 to 100 on GABA-A receptors. mcg (usual bolus dose: 50 mcg) followed by continuous IV • Hemodialysis can be used in ill patients with end-stage renal infusion of 25 to 50 mcg/hour for 2 to 5 days; may repeat disease or acute kidney injury. bolus in first hour if hemorrhage is not controlled. • Consider EEG for persistent symptoms to rule out nonconvulsive Sulfonylurea toxicity (off label): (SubQ) 50 mcg every status epilepticus. 6 hours, when necessary. Subcutaneous administration Disposition is preferred; however, repeat dosing, dose escalation, • Symptomatic patients should be admitted (effects can last 2-3 days). or initiation of a continuous infusion may be required in • Asymptomatic patients can be discharged after brief cases of recurrent hypoglycemia. Treatment for >24 hours (4-6 hours) observation (symptom-onset is quick). may be necessary; observation is recommended. Intrathecal Pumps Precautions Because <10% of baclofen crosses the blood-brain barrier, intrathecal Common adverse reactions include bradycardia pumps are used to treat severe spasticity. Excess drug delivery arrhythmia (19%-25%), hyperglycemia (16%-27%), and or abrupt cessation can cause coma or status epilepticus. Pump fatigue (1%-10%). Patients should also be monitored for interrogation may help distinguish the two, and benzodiazepines can increased biliary disease due to decreased gallbladder treat both. In some cases of intrathecal overdose, the withdrawal of motility and increased sludging. 30 mL of CSF has been advocated.