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IES Clinical Newsletter

Heart Failure Guideline Update
Provided By:
Seamus Lonergan, MD, FACEP
Emergency Department Medical Director, BSWH - Irving

Attention all IES providers:  Hopefully, you are very familiar with our system-wide Heart Failure project by now!  Below is a reminder of goals for the project, and a brief summary of preliminary results. 

Problem: 
The general approach is to automatically admit the symptomatic heart failure patient seeking care in the ED.  Admit rates throughout the country and our system run between 80 and 100%.  This has led to some complacency in ED providers’ assessment and management of these patients. 

Reasons to reconsider this automatic admission plan: 

  • There is no evidence to support that admission decreases morbidity and mortality in this already high mortality population. 
  • We know the dangers of admissions with regards to iatrogenic complications and nosocomial acquired infections. 
Goals of the project:
  • Improve our care of heart failure patients by using a comprehensive heart failure guideline to guide assessment, management, and disposition.  
  • Decrease our overall heart failure admission rate. 

How do we do this?  

  • Recognize that we do not have to admit a heart failure patient just because they have symptoms.
  • Make a proper assessment of fluid overload status of your patient (Look at the neck veins...among other things).
  • Perform new diuretic protocol with liberal Lasix dose (1-2 x  home dose up to 200mg).  *Approved by the heart failure docs and pharmacists.
  • Reassess our patients after 1 hour to evaluate urine output, symptom improvement, and ambulatory O2 saturation as we consider the possibility of home discharge.

Results: 
We are currently showing about a 5% decrease in Heart Failure admissions across the system since we rolled out education in November 2018.  Some sights that have been particularly focused from early on in the project have been able to drop their admission rate by 10%.   


Please join us as we continue to develop this program to take better care of our heart failure patients! 

Heart Failure Algorithm

July Interesting Case Winner
"tPA Troubles"
Provided By:
William Fox, MD
Administrative Fellow, BSWH - Dallas
HPI: 83M PMH CAD, HTN, HLD and is s/p pacemaker placement in for R leg weakness and R facial droop for the past 45 minutes. New-onset, no prior hx of neuro deficits, brought in by daughter who is PT at an outside facility, concerned he may be having a stroke.  

ROS: No headache or speech abnormalities.  No CP/SOB

PMH: STEMI 3 months and 2 days prior to presentation

Medications: No medication changes 

VS: BP 160/83, HR 69, RR 18, Temp 98.3F, SaO2 98% on RA, Weight 92.9kg

Physician Exam:  HEENT/CV/Pulm/Abd/Neck/Skin/MSK unremarkable

NIHSS: 2 (2 for partial facial palsy, no drift or weakness detected though reported)

Labs:
  • CBC- Normal, CMP Normal, Trop 0.02, PT/PTT Normal
  • CT non-contrast head wet read without hemorrhage
  • CTA/CT perfusion pending
  • PacedEKG- AV
Treatment: R&B discussed, pt and family requested TPA. TPA administered at 1725

ED Course: 1820- Called to bedside by RN after patient reporting sore throat, SOB, and voice changes approx.  Noted muffled voice and uvular and right-sided soft palate swelling.


Treatment: Benadryl, steroids, ranitidine, but rapidly progressive  (< 3 minutes), pt intubated under VL.
Case Presentation

Interesting Case of the Month
Congratulations to William Fox, MD, from BSWH - Dallas, for submitting the winning case for the month of July titled, "tPA Troubles."

As a reminder, submissions are due before midnight on the first day of each month and will be reviewed by a committee of judges to select the winning case of that month for the $500 reward.
 
Please see the links below regarding submission requirements, rules and eligibility requirements.
Interesting Case Submission DropBox

Competition Flyer
Amy Ho, MD
Interesting Case of the Month Co-Chair

Joe Young, DO
Interesting Case of the Month Co-Chair

Pediatric Status Epilepticus
Provided by:
Udit Jain, MD
JPS Emergency Medicine Residency Program
Definition
  • “Prolonged” seizure, or recurrent seizures lasting >5 minutes without return to full consciousness
  • Nonconvulsive status epilepticus may present as a prolonged postictal state and must be considered in any patient with altered mental status         
Medication Algorithm
  • Attempt benzos twice and then move on to AEDs (anti-epileptic drugs)
  • Have two doses of benzos drawn up and ready
  • If seizure persists additional medication should be added at 5 minutes intervals
1st Line
  •  IV Access > IM> IO
    • Lorazepam 0.1mg/kg- max dose 4mg
    • Diazepam 0.3mg/kg- max dose 20
  • Buccal/Intranasal (if no access within 5 minutes)
    • Buccal- Midazolam 0.3mg/kg- max dose 10mg (Use IV formulation, open lower lip and place med, then rub into cheek for absorption)
    • Intranasal- Midazolam 0.2mg/kg-0.5 mg/kg (use an atomizer if possible)
2nd Line
  • Choose 2 and use after 5 minutes if no improvement
  • Levetiracetam IV 50mg/kg- max dose 2500mg
  • Phenytoin IV 25mg/kg- max dose 1500mg 
  • e 40mg/kg- max dose 3000mgValproat
3rd Line
  • Ketamine 1-2 mg/kg
  • Propofol infusion 1.5-4.0 mg/kg/h (Controversy regarding propofol infusion. Prolonged use >48hours increases risk of fatal acidosis)
  • Midazolam infusion 0.05-0.4mg/kg/h
  • pentobarbital infusion 0.5-5.0mg/kg/h
Resources
Chop Clinical guidelines- https://www.chop.edu/clinical-pathway/status-epilepticus-clinical-pathway
Anand Swaminathan, "REBEL Core Cast 9.0 – Pediatric Status Epilepticus", REBEL EM blog, April 17, 2019. Available at: https://rebelem.com/rebel-core-cast-9-0-pediatric-status-epilepticus/.

Antihistamines for Urticaria:
Is there an alternative to Benadryl?
Provided by:
Sumera Makhani, PA-C
BSWH - McKinney
I recently took care of a 16-year-old female with food-induced urticaria.  I treated her with the typical cocktail of prednisone, famotidine, and diphenhydramine with improvement in symptoms.  I prescribed the same cocktail for outpatient treatment.  By the end of the visit, the patient was quite drowsy.  Father asked, “How is she going to go to school or to work if she has to take Benadryl (diphenhydramine) every 6 hours.  Can you prescribe something else?”

ED providers frequently prescribe first-generation H1 antihistamines (e.g. diphenhydramine, hydroxyzine) for urticaria. These drugs have drawbacks, such as drowsiness, anticholinergic effects, and frequent q6h dosing.  Second-generation H1 antihistamines (e.g. cetirizine, loratadine) are safe and effective alternatives for the treatment of urticaria, whether is it acute, chronic, food-induced, irritant-induced, or associated with angioedema.  Studies [2] show that they are equally efficacious and have a similar onset of action when compared to diphenhydramine. They also cause less drowsiness, have minimal anticholinergic effects, have fewer drug-to-drug interactions, and require less frequent dosing [1].  In fact, second-generation H1 antihistamines are recommended as first-line treatment for urticaria by both dermatology and allergy expert panels [3].

Several second-generation H1 antihistamines are available over the counter.  Among them, cetirizine appears to be more effective and has a faster onset of action, but can also cause more drowsiness, when compared to loratadine or fexofenadine [2].  Sedative effects are mild and dose-dependent.  These agents are usually dosed once daily, however, if the standard dosage is not effective, the dose can be increased up to four-fold [3].  For e.g., cetirizine is usually given 10 mg once daily but can be increased to 20 mg BID if needed.

So, is it time for ED providers to ditch diphenhydramine? Not quite.  As always, the decision to choose between the two classes depends on the patient in front of you.  Second-generation agents are not available in parenteral form.  Thus, patients who cannot tolerate oral treatment may require parenteral diphenhydramine.  Patients who need some anxiolytic or sedative effects may benefit from first-generation agents.  Some clinicians prefer to use a more sedating agent at bedtime, combined with a less sedating agent during the day.  

I switched my patient to cetirizine at bedtime with an additional day time dose if needed.  At 3-day phone call follow up, the patient was responding well to this treatment and did not have to miss additional school or workdays.  When treating urticaria, if frequent dosing, sedation, or anticholinergic side effects of diphenhydramine are of concern, consider cetirizine or loratadine as an alternative  

Take-home point: Cetirizine is equally efficacious in treating urticaria and has fewer side effects when compared to diphenhydramine.

*Please note, glucocorticoids and H2 antihistamines also play a role in the treatment of urticaria and epinephrine if first-line treatment is anaphylaxis is present.  These topics are not discussed in this article. 


References: 
  • Asero R. New-onset urticaria. Feldweg, A. ed. UpToDate. Waltham MA: UptoDate inc. Accessed May 4, 2019
    https://www.uptodate.com/contents/new-onset-urticaria search=new%20onset%20urticaria&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
  • Banerji A, Long AA, Camargo CA Jr. Diphenhydramine versus nonsedating antihistamines for acute allergic reactions: a literature review.  Allergy Asthma Proc. 2007 Jul-Aug:28(4):418-26
    https://www.ncbi.nlm.nih.gov/pubmed/17883909
  • Zuberbier T, Asero R, Bindslev-Jensen C, Canonica GW, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy. 2009 Oct;64(10):1427-43https://www.ncbi.nlm.nih.gov/pubmed?term=19772513

Telemetry Monitoring...Don’t Silence the Alarm
Provided by:
Samir Shahani, MD

Emergency Department Medical Director, BSWH - Heart Plano
30-year-old healthy female presents with palpitations and near syncope. Vitals are normal. EKG shows occasional unifocal PVC. The patient appears in no distress. You say hello and are ordering labs and go see your next patient. As your walking by hearing a beep on the telemetry station, quickly silenced by the Tech. Everything continues as normal. No one reacts to the alarm….except you happened to see:



Alarm fatigue is real. Telemetry monitoring is often over-ordered and under used in the ED. Over the last few years, I have found that I have gravitated to the computer next to the telemetry terminal. When I am on shift I silence the alarms.

This particular healthy 30 yo F had multiple bouts of NSVT caught on the monitor, and ended up with an ablation from the right coronary cusp of both right and left outflow tracts and now has zero ectopy and symptoms.

PS: To get billing credit for cardiac monitoring, make sure you chart a Rate/Rhythm and Interpretation under Cardiovasc-O2 in MDM section.

JPS Has One of the Busiest ERs
 
in the Country and it's Growing
 
D Healthcare Article

INSPIRE: IES Peer Network is Now Live
Revathi Jyothindran, MD
INSPIRE Program Director
The INSPIRE team has partnered with Baylor Scott and White’s peer support program, SWADDLE, in an effort to create a network of emergency medicine providers who are trained in providing confidential peer support. Whether it be a personal crisis, medical error, malpractice suit or patient complaint, our nominated IES peers are trained in active listening and psychological first aid. All interactions are privileged and will remain confidential. This program is accessible to all IES clinicians and we DO NOT keep records. Many of our peers are themselves experienced in healthcare adversity.
 
PEER SUPPORT
Except for a method of contact, no other information is required. A clinician can fill out our webform for themselves, or if you are concerned about a colleague, you may contact a peer so they can reach out discreetly to your colleague. Alternately, if you are familiar with one of our peers listed below, please do not hesitate to contact them personally. We strive to have a peer of your choice contact you within 24 hours.

TRAUMA RESET
While critical situations continuously surround us, some are particularly traumatic – not just to the providers but also to the rest of the staff. Frequently the aftershocks can be felt for many days. Please contact your site medical director or the INSPIRE team at iescommunications@ies.healthcare if you would like a team to be dispatched to your site for staff support.
IES Peer Network

Important Dates 2019 

JPS EM Resident Networking Reception
Thursday, August 29, 2019 (SMD's only)

IES Patient Safety Conference
Friday, August 30, 2019, BUMC (Click Here for details)

Founder's Luncheon - INSPIRE
Wednesday, September 25, 2019 (Provider of the Quarter winners from 2019 2nd quarter)  


IES APP Intensive Emergency Medicine Symposium
October 3 & 4, 2019 (Click Here for details)

ACEP 
October 27-30, 2019, Denver CO

Fall Clinical Integration Forum: PED's
Wednesday, November 6, 2019 (Click Here for details)

Critical Procedures Course
Friday, November 15, 2019 (Click Here for details)

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Integrative Emergency Services · Heritage Square One 4835 LBJ FWY St. 900 · Dallas, Tx 75244 · USA