Asynchrony EM

Asynchrony EM: Dementia and Delirium in the ED

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

You see them every shift. Could you be taking better care of them?

You see them every shift. Could you be taking better care of them?

This week, we start our Neurology block. There are lots of 'sexy' neuro topics we could be starting off with, but we're starting with care of elderly patients with dementia and delirium in the emergency department. We'll look at how to differentiate between the two diagnoses (which can co-exist), talk about best practices for caring for these patients in the ED, about the burden on caregivers, and some of the more 'humanistic' aspects of dementia. 

No theme song this week; a theme movie trailer instead.  Julianne Moore won the Oscar for her portrayal of 'Alice' in 'Still Alice' (the book is worth a read but I haven't seen the movie.)  


Now, before I forget, let's hit it. 

1)From EM Docs, Sept 2016. "Dementia in the Emergency Department: Can You Do Anything About It?" 


2)  In 2013, Geriatric ED Guidelines were jointly approved by ACEP, SAEM, the American Geriatric Society, and the Emergency Nurses Association.  But why would these guidelines not apply to the treatment of the elderly in any ED when possible?

Please read starting on page 26 the section entitled "Delirium and Dementia in the Geriatric Emergency Department". Also read the brief Palliative Care section immediately following.  (It's somewhat telling that the Palliative Care section is so short. See our discussion section.)


3) Did looking at all those screening tools make you crazy?  Think you can pick up delirium on your own without a screening tool? Well, maybe you can, Superdoc, but most of your colleagues can't: check out this Annals of EM 4 minute podcast about the May 2014 article, "Screening for Delirium in the Emergency Department." The podcast is assigned; reading the article is OPTIONAL.  The take-home point from both is that we stink at identifying delirium, and it's a dangerous thing to miss.


4) Now we're going to get a little more...humanistic.

It is difficult sometimes to imagine an elderly, frail, confused patient as the person they might have been once upon a time. We see these patients as a snapshot, without the benefit of knowing them "before,"and without the inherent compassion that comes with that knowing. When the snapshot is a screeching, drooling, vacant, shrunken being, it's easy to restrain or oversedate or ignore. But maybe, the next time (which will of course, be tomorrow) that you see this patient, imagine them as Pam (in this mini-documentary) or Alice, or someone you may have known in your own life that you have watched fall slowly into the abyss. You will find that it does wonders for your patience. 

Not a medical video, but worth watching. An eight minute, beautiful Op-Doc video called "A Marriage to Remember," from the New York Times. This very short film was made by a son documenting his mother's dementia and his father's efforts to care for her over a four year period.

"A Marriage to Remember"


5)  As the video above highlights, patients who are cared for at home create a heavy burden on families, even on families with means (as the family in the op-doc appears to have). Caregiver fatigue and burnout is increasingly recognized, and you will see and treat patients with depression and stress-related illness that stems directly from caregiver burnout.  And when caregivers burn out, where do the patients with dementia wind up?

With the silver tsunami gathering strength, it's time for us to learn to 'help the helpers', because they are the ones who will determine how much of an overall burden patients with dementia present to emergency departments.

True story: a few years ago, I treated a man with advanced dementia whose wife called 911 after she knowingly gave him an overdose of his pain medication. She then could not go through with her plan, which was to kill him, and then kill herself. (Both of them became my patients--she was admitted to psychiatry.)  The wife had no previous history of mental illness or depression; her symptoms stemmed entirely from caregiver burnout, and the stress of the promise she had made to her husband to 'never put him in a home.' 

This is an area that is only beginning to be addressed, and is ripe for research. In September 2016, the National Academies of Sciences, Engineering, and Medicine (NASEM, formerly known as the Institute of Medicine) released a very long report on "Families Caring for an Aging America." For our purposes, read this Geri Tech Blog Post. 


6) Because it's more prevalent among cognitively impaired patients: Elder Abuse, a quick reminder from LITFL.


7) Three quick news blurbs: lots of mainstream news attention on dementia and anti-psychotics/benzo use.  The immediate implications are for long term prescriptions, but you will find that (as in the Geriatric ED guidelines) there is counsel to avoid them even in the ED if non-pharmacologic methods can curb behaviors instead. You should also consider this when sending dementia patients back from whence they came after they are sedated for behaviors in the ED. 

a) From a March 5th, 2015 NPR post:  'Behavioral Therapy Helps More than Drugs' in dementia

b) From the March 1, 2015 NY Times: "Investigators are recommending that Medicare officials take immediate action to reduce unnecessary prescriptions to older Americans with dementia."  This is mostly about anti-psychotic drugs.

c) Couple those with the February 2015 JAMA Psychiatry article "Benzodiazepine Use in the US" (abstract/scroll through is enough) -- and you will find there is a lot of pressure to de-prescribe the elderly, maybe with good reason. 


The OPTIONAL (but really worth the time) blurbs:

a) Nursing homes that eschew the use of antipsychotics: from NPR.

b) A recent series from NPR, "Inside Alzheimer's" -- perspective from caregivers and afflicted. 

c) Speaking of non-pharmacologic methods, do you have a working iPod you don't use?  Music and Memory NEEDS IT. Check them out: awesome stuff.

d) If you didn't see the documentary Alive Inside (featuring the work Music and Memory does: won the Audience award at the 2014 Sundance film festival), this stuff is pure genius, and so, so simple.  (I'd love to see a trial of using music to calm and comfort  patients with dementia.)


 e) Finally, because the Music and Memory videos above feature the wonderful Dr. Oliver Sacks, who died in 2015, I'm throwing this in: very much worth the short time it takes to read. Not dementia related, but we're in the Neuro block, and he was the world's sweetheart neurologist/writer. If I haven't gotten you teared up yet, keep reading.  "My Own Life: Oliver Sacks on Learning He Has Terminal Cancer."  "Above allI have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure."

That's all for this week. Share any thoughts or other #FOAMed resources you'd like us to know about in the comments. 

Asynchrony EM: 'Oh Sugar!'

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.
Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

Endocrine: DKA and HHS

Sugar overload!

Sugar overload!

Here's our next stop in the Endocrine block: managing DKA (in adults and kids --because it's not the same) and hyperosmolar hyperglycemic state (HHS). We've got core content and controversy (especially on the pediatric DKA front!) -- sweet!

Our theme song: "Sugar, We're Going Down" by Fall Out Boy. (Because, you know, you want the sugar to go down?...right? You get it.)

Let's go!

1) First, the basics of adult DKA. This is a long-ish review but it covers all the bases. You may know a lot of this, so just scan through, click through the sections, and pick up any pointers you may have missed along the way. Also, ignore the pediatric DKA stuff -- more to follow on that. Medscape Practice Essentials: DKA (7/20/16). 

2) Now some finer points. EM Lyceum (11/2014), with four DKA Questions (on adult DKA):

1. When you are suspicious for DKA do you get a VBG or an ABG? How good is a VBG for determining acid/base status? 
2. Do you use serum or urine ketones to guide your diagnosis and treatment of DKA?
3. Do you use IV bicarbonate for the treatment of severe acidosis in DKA? If so, when?
4. When do you start an insulin infusion in patients with hypokalemia? Bolus or no bolus?

And their answers: DKA Answers

After reading that, know that the bicarb issue is still controversial. There is no clear role for bicarb -- however if you look at the ADA Guidelines, or in Up to Date, you'll still see a recommendation to use it (on Up to Date, they recommend it for a pH of 6.9 or lower, although they do make clear there is no good evidence to support this practice and that there is potential, it's clear as mud.) And remember, we are talking about ADULTS here. More on kids to follow (spoiler: never bicarb!)


3) Now: Hyperosmolar Hyperglycemic State (HHS). Another quick click-through review from Medscape (August 2016). 


4) Something these patients might have, and you might need to learn a little more about. From ALiEM: Insulin Pumps and what you need to know about them (12/2013).  Read the comments, as they are helpful.


5) PEDIATRIC DKA. Lots and lots of controversy surrounding management, especially regarding fluids. Why? Because of the DKA complication of cerebral edema, which happens almost exclusively in kids -- and is often devastating. 

We will have some real answers about fluids in about four months, when the PECARN DKA FLUID study results are released (and our Hasbro Children's Hospital was a site in this study). I picked the brain of our Hasbro expert Dr. Aris Garro for DKA management pearls based on this changing landscape. His answers to my questions are as follows (and please note the differences from the FOAM resources that follow): 

Fluid management is very controversial but the lead investigators out of UC Davis argue that most cerebral injury occurs because we underperfuse the brain (their data supports a hypoperfusion / reperfusion phenomenon). Therefore they do not advocate limiting fluid administration. That teaching unfortunately came after horribly flawed studies in the 90's that did not take into account that sicker children (aka more likely to get cerebral edema) got more fluid by indication. 

To address your points:

1. Children with DKA definitely need a fluid bolus as they are intravascularly volume depleted initially and perfusion needs to be restored. Most of us start with 10 mL/kg and reassess peripheral perfusion, HR, MS. Most children's intravascular volume is adequately replaced with 10-20 mL/kg.

2. After that you can start your long-term fluid resuscitation. Easy way to calculate is 1.5 x maintenance rate. Verdict is out on NS vs. 1/2NS but stay tuned for FLUID study results...

2. Yes, give some fluid before starting insulin drip (the initial fluid bolus is generally sufficient)

3. Never give Insulin boluses! 

4. All kids are whole body potassium depleted. Don't need serum K back from lab to start insulin (unlike in adults). Need to start K replacement as soon as you know the child is not anuric (i.e., they pee.)

5. Never give bicarb boluses!

6. Everything we need for DKA is on the VBG since it is not a primary respiratory problem

One last teaching point that eludes some trainees is that the dreaded cerebral edema from DKA is almost exclusively a pediatric problem. Therefore the lessons about treating pediatric DKA should not be applied to adults and vice versa.

GOT THAT? (For the thousandth time, kids are not little adults.)

Now, with that in mind, here's what's out there in the FOAM world about it -- and remember that all of this will need updating once the FLUID data is out in public. But you've got to know where we've been to understand better where we're going, and this is the way a lot of docs still manage pedi DKA.

a)FOAMCast Episode 29 (June 2015): summarizing an EM Cases podcast about pedi DKA and then some "Rosenalli" core content from the textbooks. Does have a nice review of the differences in current treatment between adult DKA and HHS.

b) From Pediatric EM Morsels: Cerebral Edema and DKA  (2014).

c) From PEMGeek, the Pediatric DKA Guideline 2015: What's New?  The links/summary neatly show what many folks are doing currently, but remember, this will all be changing soon! (see Dr Garro's commentary above.)


a) From EM:RAP (remember you have a subscription through EMRA): a recent "Paper Chase" segment (August 2016) on a study about fluid boluses in pediatric DKA  and that more volume might be OK (again, just wait until FLUID is out.) 

b) From EMedHome: a DKA Case discussion(click through to EM Cast, use the little dropdown menu to find Archived EMCast episodes, pick the August 2015 EM Cast, and choose the DKA chapter). 

c) There are some good resources out there that you can direct patients to for more information on managing their diabetes, especially new onset adults who may be discharged from the ED. Check out the American Diabetes Association  page.

d) Hot off the press (January 10, 2017): "Enterovirus may predict Type 1 Diabetes in Kids" (Very intriguing.)

e) Also intriguing: Hope for Reversing Type 2 Diabetes (NYT, 4/18/16).

That's it for this week! Keep tuned for our next module.

**Brown EM Residents, remember you have to complete your modules in Canvas (hit the discussion board, and pass the quiz) to claim credit.**

Let us know in the comment section:

  • Other #FOAMed resources you find helpful
  • About your current practice in pediatric DKA and how it may differ from what's discussed here
  • Interesting DKA/HHS cases you'd like to discuss!


Asynchrony EM: The Difficult Delivery

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.



Here in Asynchrony EM --being asynchronous and all -- we're a little late for Halloween. So we're serving up the scariest stuff we can think of now, as we enter our new curricular block (OB/Gyn.)


Happy Ending! But how do we get here?

Happy Ending! But how do we get here?

It's all terrifying. Even more so if you wind up working somewhere where OB isn't in house 24/7. And the delivery doesn't even need to be 'difficult' per se -- any unexpected delivery in the ED is a pulse-quickening event (and we'll discuss normal deliveries, too.)

But before we start, as always: this week's theme song! Here's Motown queen Diana Ross and -- "I'm Coming Out."  

(You got other theme song ideas? Tweet me at @GitaPensaMD.)


OK, no more pun and games -- back to the scary stuff at hand. 

1) Let's start with the mother of all procedures (fine, one more pun) -- the peri-mortem C-section -- also now known as resucitative hysterotomy. (Disclosure: I have never done one. Never even seen one. In fact, just thinking about it makes me twitch, especially working community single-doc-coverage nights with no in-house OB or peds. Murphy's law dictates that if it's gonna happen, it's gonna happen when you have the fewest hands available to help.)

Peri-Mortem C-Section: from EM:Crit. The actual videocast (at the very bottom, the "Wee") is 10 minutes. Watch it. The St Emelyn's link is no longer working, but do click through and read Dr. Press's posts on his personal experiences doing PMCS. (You'll see he doesn't set much store by the numbers 24 or 4.) The more times you read about it, think about it, envision it, list the steps out loud, do it in SIM--the more ready you will be. (Me too.)  Also, WATCH the 3-minute life-identical simulation video, because it's AWESOME--just remember they do not demonstrate the mother being bounced around with CPR while they spend forever closing the uterus, which is why Dr. Press, in his post, suggests just packing it all with towels and moving on. 

Now one more: From Mayo Clic EM, A New Mindset: From Peri-mortem C-Section to Resuscitative Hysterotomy (August 2015). The proposed algorithm (published in Am J Obstet Gynecol, July 2015) is both reasonable and helpful. 


2a) Now that I've got your attention with a rare and horrible event, let's do a review of what will undoubtedly happen to you at some point in your career, if it hasn't happened yet: the precipitous delivery in the ED (or in the parking lot, a car backseat, or -- I swear, it really did happen, and it was quite problematic--a revolving door.)  Unlike the peri-mortem C-Section, this usually ends with a good outcome and a nice story to tell over a beer. Usually... (Cue scary soundtrack....)

- First an overview: First 10 EM: Precipitous Delivery in the ED

- Now, as much detail as you want -- peruse this Medscape article to fill in your gaps, but what I really want you to do is click on "Multimedia Library" at the bottom of the left-hand menu, and then go through the slide show. Watch the video at Image 6. Take note that once the shoulder is coming, you better be ready to catch! If you're lucky, it happens fast.

Medscape: Normal Delivery of the Infant

b) And what if it doesn't happen fast? What if the shoulder is stuck?

-First 10 EM: Shoulder Dystocia 

-That's the overview. Now read this for more detail: CoreEM: Shoulder Dystocia

c) And what if the presenting part is....a butt?!

If you see the butt coming out first...butt out. Meaning: be as hands-off as you can (see below).

-Start with this video. You can skip the end bit with the forceps, as you will not be using them (unless you have had significant training.)

Vaginal Breech Birth


-Then read some more detail here: Jacobi EM: Breech Delivery

-Then back to First 10 EM for the step by step. (He does a nice, concise job with these. Save them in your phone somewhere...)  First 10 EM: Breech Presentation

(Aside: Not covering footling/incomplete breech presentations today. Those are even scarier!)


3) A five minute review video of postpartum hemorrhage from EM in 5 Because sometimes it happens.


4) Lastly: important, but somewhat fuzzy stuff. How do we best train for these situations? What the heck is 'metacompetence'? Read a Resus M.E. post about it. Then let's talk about it (hit the comment section below.)


5) The OPTIONAL (slightly tangential) EXTRAS:

a) Because you also have to worry about the baby...In October 2015, the AHA updated their Neonatal Resuscitation guidelines. The Full Text of this update is available here: Neonatal Resusciation  

b) Aspiration of Neonatal Pneumothorax -- In case you didn't know it was a thing.

c) I've had to play clean-up crew in the ED after a nasty home birth gone wrong, and would never have considered trying to give birth at home myself-- but home births are apparently en vogue again. Here's a well known OB blogger's take on it:

2015: This year in homebirth deaths and disasters from The Skeptical OB

d) Did you know there's a whole TV series called "I Didn't Know I Was Pregnant?" (O.M.G.)


That's it for this week! Keep tuned for our next module in OB/Gyn.

**Brown EM Residents, remember you have to complete your modules in Canvas (hit the discussion board, and pass the quiz) to claim credit.**

Other EM Readers, let us know in the comment section:

  • Are there other #FOAMed resources about these topics that you would recommend?
  • Have you performed a resucitative hysterotomy? Tell us about it, and give us some pointers.
  • Done a breech delivery in triage? Brag about it here--and leave us some teaching points.
  • Discussion regarding the concept of metacompetence: how do you summon the courage to do what needs to be done when a rare procedure (cricothyrotomy, resuscitative hysterotomy, burr hole, etc.) is needed? What advice do you have for residents?