Emergency - Quality, Education and Safety Teleconference For smaller Eds - Anne Walton
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Emergency - Quality, Education and
Safety Teleconference
For smaller Eds
Anne Walton
Advanced Trainee
Emergency Care Institute
Thanks for joining
House rulesAgenda • 3 Case discussions - Headache • Review clinical context • Learning points and take home messages • Next meeting • We encourage participation, comments or questions throughout – we want to reflect YOUR needs and interests
Case 1 • 46 male, presented to hospital A, on Sunday @1722hrs • PC: Frontal headache, nausea, neck stiffness and vomiting at triage • Nil significant PMHx given at triage • Afebrile, strong regular pulse, assigned ATS Category 3
Case 1 - assessment • Seen by JMO 2055hrs • Mild, gradual onset headache that morning whilst lying down • 1400hours, worsening of headache – ‘agony’ • Vomited at home, associated with photophobia, neck stiffness, post occular pain and subjective fever • Pain 8-9 earlier that day, currently 4-5/10
Case 1 – pmhx/ exam • No history migraines, but recurrent sinusitis reported • No foreign travel/ coryzal symptoms • A headache 1/52 prior, which lasted
Thoughts ??
Case 1 – progress • DW FACEM – need CT +/- LP • “CT showed no obvious abnormalities”. Advised that absence of photophobia means not SAH • Given ibuprofen/ oxycodone, t/f to ESSU for analgesia • 0530, pt wanted to leave – seen by RMO, d/c with panadeine forte and ibuprofen and told to contact GP
Case 1 – re-present • 15 days later, referred by GP to hospital B for ‘acute work up of headaches’ • No abnormal clinical signs, 3/52 history of headache, worse during sexual activity and felt like ‘being hit with a bat’. Radiation to occiput/ lower back • Seen by JMO and DW medical registrar – provisional diagnosis chronic headache on background of overuse of Panadeine forte. • No need for LP. Previous CT ‘normal’ – will not repeat • Discharged
Thoughts ??
Case 1 – catastrophe • 25 days later – collapse/ headache whilst walking • Decorticate positioning and obstructive breathing • Large left frontal ICH • TF to ICU – unsurvivable haemorrhage, declared brain dead. Proceeded to organ donation • Review of first CT scan showed ‘subtle signs of subarachnoid blood and an anterior communicating artery aneurysm’
What contributed to this outcome? System • Diagnostic anchoring • Premature closure Skills • CT reporting • Understanding the literature on SAH Staffing • Senior supervision and review – ‘represent’ = high risk
Would you have
managed this
differently
??The problem • Up to 5% of ED presentations are with headache • Vast majority of pathologies are benign – how do we screen for a identify the sinister ones?
Subarachnoid haemorrhage –
the evidence
• Still controversial – who needs an LP in SAH?
• CT within 6 hours of onset and interpreted by
neuroradiology = up to 100% sensitive
• After 6 hours, sensitivity drops – negative CT under 6
hours, discuss pros/cons with patient
• LP may be helpful in providing alternative diagnosis
• Lack of symptoms/ signs at time of assessment is
NOT predictive for excluding SAHECI clinical tool
Case 2 • 15 year old Aboriginal male to rural ED • Complex psychosocial history • Daily marijuana use, irregular school attendance • Headache/ fever/ nausea/ vomiting/ meningism
Case 2 – initial management • Treated empirically for meningitis – iv ceftriaxone and acyclovir • LP from ED – opening pressure 28.5mmH2O, clear, colourless fluid, negative fungus India Ink stain, Entero- Virus PCR positive • Treated for viral encephalitis – discharged when clinically improved
Thoughts ??
Case 2 - progress • Re-presented 5 more times with ongoing intractable headache, neck stiffness, vomiting • Had one presentation by ambulance with headache and haemoptysis • Haemoptysis not documented • Handed over to adult medical team as deemed unsuitable for paediatric admission given social situation • Repeat LP – no significant findings. ICP pressure within range
Case 2 - progress • Re-presented a further 4 times, eventually admitted under adult cardiologist – t/f care to tertiary paediatric neurologist due to intractable pain • Following t/f – had repeat LP and grew Cryptococcal Gatti • MRI showed cerebellar abscess and evidence of raised ICP • Left lower lung lobe mass was identified with cryptococcal origins
Case 2 – learning points • Cognitive bias - Psychosocial situation – rationale for re-presentations not fully addressed - Found one positive test (enterovirus), diagnostic anchoring • Failure to review all evidence – eg abnormal ICP • Communication failure - Haemoptysis was important clue, confirmation bias • High risk population – high index of suspicion
Case 2 - outcome • TF back to rural hospital and then d/c home 3 days later with outpatient follow up • Represented to rural ED 2 days later with seizures and raised ICP • TF back to tertiary hospital and VP shunt inserted • Uncomplicated recovery • Re-presented to ED once for r/v after trip and fall with minor head injury • No further presentations to any ED facility within LHD
Red flag modules • There are often recurring themes when reviewing adverse events • Not all adverse events or poor outcomes may be predicted or prevented, but there may often be ‘red flags’ • Re-presentation with the same symptom is a ‘red flag’ and the patient should be reviewed carefully, ideally by a senior medical officer and all investigations and results revisited and reviewed
ECI Red flag modules
Case 3 • 32 year old female, 15 weeks pregnant • 0157hrs: BIBA in with sudden onset of severe headache • With ambulance crew, patient was able to walk, equal strength all limbs • No history of headaches • Ambulance officers administered 5mg morphine iv for pain • ATS category 3 and placed in side room • GCS at triage = 14/15
Case 3 - progress • 0215 – HR 75, BP 138/74, RR 10, sats 97% RA • Nursing staff noted patient was pale, rousable to voice but not opening her eyes. Breathing heavily and unable to squeeze hand to command • Transferred to resuscitation room • 0228hrs, RR 7, GCS 7/15 • 0256 – collateral history from husband: patient vomited and complained of blurred vision at home. Examined by medical officer
Differentials at this
point
??Case 3 - progress • 0330: GCS 6/15 • 0356: 400micrograms naloxone administered • 0416: GCS 6/15 and RR 11 • 0514: right pupil more dilated than left. MO aware. 400micrograms naloxone administered • 0530: GCS 5/15 • 0600: CT brain showed large cerebellar haemorrhage
What contributed to this Cognitive error outcome? • IV Morphine attributed as cause for respiratory depression/ drowsiness – diagnostic anchoring • Failure to review all evidence eg husband’s information – information synthesis Patient factors • Pregnancy + radiation – what is best for mother is best for foetus Skills/ staffing • “Ostrich effect” – 0157 arrival CT scan 0600
Summary • Headache is common presentation in ED • High index of suspicion is required • Severity of pathology does not necessarily correlate well with degree of pain or absence of neurological deficit • What processes or pathways do you have in your ED that might help navigate this difficult diagnosis? • ECI clinical tool (neurology headache): https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical- resources/clinical-tools/neurology/headache
E-QuESTs so far • Atypical Chest Pain - ACS • Sepsis in the elderly • Abdominal Pain in the elderly - AAA & Ischaemic gut • Acute scrotum
Suggested future topics • Minor head injury • Paediatrics • Eye emergencies • Transfer/ retrieval issues, including clinical handover • Any feedback on these topics or other suggestions?
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